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Bax F, Greenberg SM. Cerebral Amyloid Angiopathy and Nontraumatic Subdural Hemorrhage. JAMA Neurol 2024; 81:888. [PMID: 38856979 DOI: 10.1001/jamaneurol.2024.1595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Affiliation(s)
- Francesco Bax
- Hemorrhagic Stroke Research Program, J Philip Kistler Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, J Philip Kistler Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
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Samarasekera N, Ferguson K, Parry-Jones AR, Rodrigues M, Loan J, Moullaali TJ, Hughes J, Shoveller L, Wardlaw J, McColl B, Allan SM, Selim M, Norrie J, Smith C, Al-Shahi Salman R. Perihaematomal Oedema Evolution over 2 Weeks after Spontaneous Intracerebral Haemorrhage and Association with Outcome: A Prospective Cohort Study. Cerebrovasc Dis 2024:1-10. [PMID: 38952101 DOI: 10.1159/000540099] [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: 02/20/2024] [Accepted: 06/21/2024] [Indexed: 07/03/2024] Open
Abstract
INTRODUCTION We know little about the evolution of perihaematomal oedema (PHO) >24 h after ICH onset. We aimed to determine the trajectory of PHO after ICH onset and its association with outcome. METHODS We did a prospective cohort study using a pre-specified scanning protocol in adults with first-ever spontaneous ICH and measured absolute PHO volumes on CT head scans at ICH diagnosis and 3 ± 2, 7 ± 2, and 14 ± 2 days after ICH onset. We used the largest ICH if ICHs were multiple. The primary outcomes were (a) the trajectory of PHO after ICH onset and (b) the association between PHO (absolute volume at the time when most repeat CT head scans were obtained, and change in PHO volume at this time compared with the first CT head scan) and poor functional outcome (modified Rankin scale 3-6 at 90 days). We pre-specified multivariable logistic regression models of this association adjusting analyses for potential confounders: age, GCS, infratentorial ICH location, and intraventricular extension. RESULTS In 106 participants of whom 49 (46%) were female, with a median ICH volume 7 mL (interquartile range [IQR] 2-22 mL), the trajectory of median PHO volume increased from 14 mL (IQR: 7-26 mL) at diagnosis to 18 mL (IQR: 8-40 mL) at 3 ± 2 days (n = 87), 20 mL (IQR: 8-48 mL) at 7 ± 2 days (n = 93) and 21 mL (IQR: 10-54 mL) at 14 ± 2 days (n = 78) (p = <0.001). PHO volume at each time point was collinear with ICH volume at diagnosis (│r│ >0.7), but the change in PHO volume between diagnosis and each time point was not. Given collinearity, we used total lesion (i.e., ICH + PHO) volume instead of PHO volume in a logistic regression model of its association at each time point with outcome. Increasing total lesion (ICH + PHO) volume at day 7 ± 2 was associated with poor functional outcome (adjusted OR per mL 1.02, 95% CI: 1.00-1.03; p = 0.036), but the increase in PHO volume between diagnosis and day 7 ± 2 was not associated with poor functional outcome (adjusted OR per mL 1.03, 95% CI: 0.99-1.07; p = 0.132). CONCLUSION PHO volume increases throughout the first 2 weeks after onset of mild to moderate ICH. Total lesion (ICH + PHO) volume at day 7 ± 2 was associated with poor functional outcome, but the change in PHO volume between diagnosis and day 7 ± 2 was not. Prospective cohort studies with larger sample sizes are needed to investigate these associations and their modifiers.
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Affiliation(s)
| | - Karen Ferguson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Adrian Robert Parry-Jones
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal National Health Service Foundation Trust, University of Manchester, Manchester, UK
| | - Mark Rodrigues
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - James Loan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Tom J Moullaali
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jeremy Hughes
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Laura Shoveller
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Barry McColl
- UK Dementia Research Institute Centre, Centre for Discovery Brain Sciences University of Edinburgh, Edinburgh, UK
| | - Stuart M Allan
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - John Norrie
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Colin Smith
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Boe NJ, Hald SM, Kristensen AR, Möller S, Bojsen JA, Elhakim MT, Rodrigues MA, Al-Shahi Salman R, Hallas J, García Rodríguez LA, Selim M, Goldstein LB, Gaist D. Association of Antithrombotic Drug Use With Incident Intracerebral Hemorrhage Location. Neurology 2024; 102:e209442. [PMID: 38771998 PMCID: PMC11226324 DOI: 10.1212/wnl.0000000000209442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/01/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Few population-based studies have assessed associations between the use of antithrombotic (platelet antiaggregant or anticoagulant) drugs and location-specific risks of spontaneous intracerebral hemorrhage (s-ICH). In this study, we estimated associations between antithrombotic drug use and the risk of lobar vs nonlobar incident s-ICH. METHODS Using Danish nationwide registries, we identified cases in the Southern Denmark Region of first-ever s-ICH in patients aged 50 years or older between 2009 and 2018. Each verified case was classified as lobar or nonlobar s-ICH and matched to controls in the general population by age, sex, and calendar year. Prior antithrombotic use was ascertained from a nationwide prescription registry. We calculated odds ratios (aORs) for associations between the use of clopidogrel, aspirin, direct oral anticoagulants (DOACs) or vitamin K antagonists (VKA), and lobar and nonlobar ICH in conditional logistic regression analyses that were adjusted for potential confounders. RESULTS A total of 1,040 cases of lobar (47.9% men, mean age [SD] 75.2 [10.7] years) and 1,263 cases of nonlobar s-ICH (54.2% men, mean age 73.6 [11.4] years) were matched to 41,651 and 50,574 controls, respectively. A stronger association with lobar s-ICH was found for clopidogrel (cases: 7.6%, controls: 3.5%; aOR 3.46 [95% CI 2.45-4.89]) vs aspirin (cases: 22.9%, controls: 20.4%; aOR 2.14 [1.74-2.63; p = 0.019). Corresponding estimates for nonlobar s-ICH were not different between clopidogrel (cases: 5.4%, controls: 3.4%; aOR 2.44 [1.71-3.49]) and aspirin (cases: 20.7%, controls: 19.2%; aOR 1.77 [1.47-2.15]; p = 0.12). VKA use was associated with higher odds of both lobar (cases: 14.3%, controls: 6.1%; aOR 3.66 [2.78-4.80]) and nonlobar (cases: 15.4%, controls: 5.5%; aOR 4.62 [3.67-5.82]) s-ICH. The association of DOAC use with lobar s-ICH (cases: 3.5%, controls: 2.7%; aOR 1.66 [1.02-2.70]) was weaker than that of VKA use (p = 0.006). Corresponding estimates for nonlobar s-ICH were not different between DOACs (cases: 5.1%, controls: 2.4%; aOR 3.44 [2.33-5.08]) and VKAs (p = 0.20). DISCUSSION Antithrombotics were associated with higher risks of s-ICH, but the strength of the associations varied by s-ICH location and drug, which may reflect differences in the cerebral microangiopathies associated with lobar vs nonlobar hemorrhages and the mechanisms of drug action.
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Affiliation(s)
- Nils Jensen Boe
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Stine Munk Hald
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Alexandra Redzkina Kristensen
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Sören Möller
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jonas A Bojsen
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Mohammad Talal Elhakim
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Mark A Rodrigues
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Rustam Al-Shahi Salman
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jesper Hallas
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Luis A García Rodríguez
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Magdy Selim
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Larry B Goldstein
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - David Gaist
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
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Huang B, Chen A, Sun Y, He Q. The Role of Aging in Intracerebral Hemorrhage. Brain Sci 2024; 14:613. [PMID: 38928613 PMCID: PMC11201415 DOI: 10.3390/brainsci14060613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/10/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Intracerebral hemorrhage (ICH) is the cerebrovascular disease with the highest disability and mortality rates, causing severe damage to the health of patients and imposing a significant socioeconomic burden. Aging stands as a foremost risk factor for ICH, with a significant escalation in ICH incidence within the elderly demographic, highlighting a close association between ICH and aging. In recent years, with the acceleration of the "aging society" trend, exploring the intricate relationship between aging and ICH has become increasingly urgent and worthy of in-depth attention. We have summarized the characteristics of ICH in the elderly, reviewing how aging influences the onset and development of ICH by examining its etiology and the mechanisms of damage via ICH. Additionally, we explored the potential impacts of ICH on accelerated aging, including its effects on cognitive abilities, quality of life, and lifespan. This review aims to reveal the connection between aging and ICH, providing new ideas and insights for future ICH research.
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Affiliation(s)
| | | | | | - Quanwei He
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Tseng WC, Wang YF, Chen HS, Wang TG, Hsiao MY. Spot sign score is associated with hematoma expansion and longer hospital stay but not functional outcomes in primary intracerebral hemorrhage survivors. Jpn J Radiol 2024:10.1007/s11604-024-01597-1. [PMID: 38833105 DOI: 10.1007/s11604-024-01597-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/16/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE The computed tomography angiography (CTA) spot sign is a validated predictor of 30-day mortality in intracerebral hemorrhage (ICH). However, its role in predicting unfavorable functional outcomes remains unclear. This study explores the frequency of the spot sign and its association with functional outcomes, hematoma expansion, and length of hospital stay among survivors of ICH. MATERIALS AND METHODS This was a retrospective analysis of consecutive patients with primary ICH who received CTA within 24 h of admission to two medical centers between January 2007 and August 2022. Patients who died before discharge and those referred from other hospitals were excluded. Spot signs were assessed by an experienced neuroradiologist. Functional outcomes were determined by modified Rankin Scale (mRS) scores and the Barthel Index (BI). RESULTS In total, 98 patients were included; 14 (13.64%) had a spot sign. No significant differences were observed in the baseline characteristics between the patients with and without a spot sign. Higher spot sign scores were associated with higher odds of experiencing hematoma expansion (p = 0.013, 95% CI = 1.16-3.55), undergoing surgery (p = 0.012, 95% CI = 0.19-1.55), and having longer hospital stay (p = 0.02, 95% CI = 1.22-13.92). However, higher spot sign scores were not associated with unfavorable functional outcomes (p = 0.918 for BI, and p = 0.782 for mRS). CONCLUSION Spot signs are common findings among patients with ICH, and higher spot sign scores were associated with subsequent hematoma expansion and longer hospital stays but not unfavorable functional outcomes.
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Affiliation(s)
- Wen-Che Tseng
- Department of Physical Medicine and Rehabilitation, Yunlin Rd, National Taiwan University Hospital Yunlin Branch, Yunlin County, Sec. 2, 579, Douliu City, Taiwan
| | - Yu-Fen Wang
- Department of Medical Imaging, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei, Taiwan
| | - Hsin-Shui Chen
- Department of Physical Medicine and Rehabilitation, Yunlin Rd, National Taiwan University Hospital Yunlin Branch, Yunlin County, Sec. 2, 579, Douliu City, Taiwan
| | - Tyng-Guey Wang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei, Taiwan
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, 7, Zhongshan S. Rd, Taipei, Taiwan
| | - Ming-Yen Hsiao
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei, Taiwan.
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, 7, Zhongshan S. Rd, Taipei, Taiwan.
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van Veluw SJ, Benveniste H, Bakker ENTP, Carare RO, Greenberg SM, Iliff JJ, Lorthois S, Van Nostrand WE, Petzold GC, Shih AY, van Osch MJP. Is CAA a perivascular brain clearance disease? A discussion of the evidence to date and outlook for future studies. Cell Mol Life Sci 2024; 81:239. [PMID: 38801464 PMCID: PMC11130115 DOI: 10.1007/s00018-024-05277-1] [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: 11/14/2023] [Revised: 04/20/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024]
Abstract
The brain's network of perivascular channels for clearance of excess fluids and waste plays a critical role in the pathogenesis of several neurodegenerative diseases including cerebral amyloid angiopathy (CAA). CAA is the main cause of hemorrhagic stroke in the elderly, the most common vascular comorbidity in Alzheimer's disease and also implicated in adverse events related to anti-amyloid immunotherapy. Remarkably, the mechanisms governing perivascular clearance of soluble amyloid β-a key culprit in CAA-from the brain to draining lymphatics and systemic circulation remains poorly understood. This knowledge gap is critically important to bridge for understanding the pathophysiology of CAA and accelerate development of targeted therapeutics. The authors of this review recently converged their diverse expertise in the field of perivascular physiology to specifically address this problem within the framework of a Leducq Foundation Transatlantic Network of Excellence on Brain Clearance. This review discusses the overarching goal of the consortium and explores the evidence supporting or refuting the role of impaired perivascular clearance in the pathophysiology of CAA with a focus on translating observations from rodents to humans. We also discuss the anatomical features of perivascular channels as well as the biophysical characteristics of fluid and solute transport.
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Affiliation(s)
- Susanne J van Veluw
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Helene Benveniste
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, USA
| | - Erik N T P Bakker
- Department of Biomedical Engineering, Amsterdam University Medical Center, Location AMC, Amsterdam Neuroscience Research Institute, Amsterdam, The Netherlands
| | - Roxana O Carare
- Clinical Neurosciences, University of Southampton, Southampton, UK
| | - Steven M Greenberg
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey J Iliff
- VA Puget Sound Health Care System, University of Washington, Seattle, WA, USA
| | - Sylvie Lorthois
- Institut de Mécanique Des Fluides de Toulouse, IMFT, Université de Toulouse, CNRS, Toulouse, France
| | - William E Van Nostrand
- Department of Biomedical and Pharmaceutical Science, George & Anne Ryan Institute for Neuroscience, University of Rhode Island, Kingston, RI, USA
| | - Gabor C Petzold
- German Center for Neurodegenerative Disease, Bonn, Germany
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Andy Y Shih
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, University of Washington, Seattle, WA, USA
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Kapapa T, Jesuthasan S, Schiller F, Schiller F, Oehmichen M, Woischneck D, Mayer B, Pala A. Outcome after Intracerebral Haemorrhage and Decompressive Craniectomy in Older Adults. Neurol Int 2024; 16:590-604. [PMID: 38804483 PMCID: PMC11130851 DOI: 10.3390/neurolint16030044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/11/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE There is a relationship between the incidence of spontaneous intracerebral haemorrhage (ICH) and age. The incidence increases with age. This study aims to facilitate the decision-making process in the treatment of ICH. It therefore investigated the outcome after ICH and decompressive craniectomy (DC) in older adults (>65 years of age). METHODS Retrospective, multicentre, descriptive observational study including only consecutive patients who received DC as the consequence of ICH. Additive evacuation of ICH was performed after the individual decision of the neurosurgeon. Besides demographic data, clinical outcomes both at discharge and 12 months after surgery were evaluated according to the Glasgow Outcome Scale (GOS). Patients were divided into age groups of ≤65 and >65 years and cohorts with favourable outcome (GOS IV-V) and unfavourable outcome (GOS I to III). RESULTS 56 patients were treated. Mean age was 53.3 (SD: 16.13) years. There were 41 (73.2%) patients aged ≤65 years and 15 (26.8%) patients aged >65 years. During hospital stay, 10 (24.4%) patients in the group of younger (≤65 years) and 5 (33.3%) in the group of older patients (>65 years) died. Mean time between ictus and surgery was 44.4 (SD: 70.79) hours for younger and 27.9 (SD: 41.71) hours for older patients. A disturbance of the pupillary function on admission occurred in 21 (51.2%) younger and 2 (13.3%) older patients (p = 0.014). Mean arterial pressure was 99.9 (SD: 17.00) mmHg for younger and 112.9 (21.80) mmHg in older patients. After 12 months, there was no significant difference in outcome between younger patients (≤65 years) and older patients (>65 years) after ICH and DC (p = 0.243). Nevertheless, in the group of younger patients (≤65 years), 9% had a very good and 15% had a good outcome. There was no good recovery in the group of older patients (>65 years). CONCLUSION Patients >65 years of age treated with microsurgical haematoma evacuation and DC after ICH are likely to have a poor outcome. Furthermore, in the long term, only a few older adults have a good functional outcome with independence in daily life activities.
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Affiliation(s)
- Thomas Kapapa
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Stefanie Jesuthasan
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Frederike Schiller
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Franziska Schiller
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Marcel Oehmichen
- Department of Neurosurgery, Military Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Dieter Woischneck
- Department of Neurosurgery, Hospital Landshut, Robert-Koch-Strasse 1, 84034 Landshut, Germany
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Schwabstrasse 13, 89075 Ulm, Germany
| | - Andrej Pala
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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8
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Senff JR, Singh SD, Pasi M, Jolink WM, Rodrigues MA, Schreuder FH, Staals J, Schreuder T, Douwes JP, Talsma J, McKaig BN, Kourkoulis C, Yechoor N, Anderson CD, Puy L, Cordonnier C, Wermer MJ, Rothwell PM, Rosand J, Klijn CJ, Al-Shahi Salman R, Rinkel GJ, Viswanathan A, Goldstein JN, Brouwers HB. Long-Term Outcomes in Patients With Spontaneous Cerebellar Hemorrhage: An International Cohort Study. Stroke 2024; 55:1210-1217. [PMID: 38487876 PMCID: PMC11045548 DOI: 10.1161/strokeaha.123.044622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/28/2023] [Accepted: 12/13/2023] [Indexed: 04/19/2024]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) in the cerebellum has a poor short-term prognosis, whereas data on the long-term case fatality and recurrent vascular events are sparse. Herewith, we aimed to assess the long-term case fatality and recurrence rate of vascular events after a first cerebellar ICH. METHODS In this international cohort study, we included patients from 10 hospitals (the United States and Europe from 1997 to 2017) aged ≥18 years with a first spontaneous cerebellar ICH who were discharged alive. Data on long-term case fatality and recurrence of vascular events (recurrent ICH [supratentoria or infratentorial], ischemic stroke, myocardial infarction, or major vascular surgery) were collected for survival analysis and absolute event rate calculation. RESULTS We included 405 patients with cerebellar ICH (mean age [SD], 72 [13] years, 49% female). The median survival time was 67 months (interquartile range, 23-100 months), with a cumulative survival rate of 34% at 10-year follow-up (median follow-up time per center ranged: 15-80 months). In the 347 patients with data on vascular events 92 events occurred in 78 patients, after initial cerebellar ICH: 31 (8.9%) patients had a recurrent ICH (absolute event rate, 1.8 per 100 patient-years [95% CI, 1.2-2.6]), 39 (11%) had an ischemic stroke (absolute event rate, 2.3 [95% CI, 1.6-3.2]), 13 (3.7%) had a myocardial infarction (absolute event rate, 0.8 [95% CI, 0.4-1.3]), and 5 (1.4%) underwent major vascular surgery (absolute event rate, 0.3 [95% CI, 0.1-0.7]). The median time to a first vascular event during follow-up was 27 months (interquartile range, 8.7-50 months), with a cumulative hazard of 47% at 10 years. CONCLUSIONS The long-term prognosis of patients who survive a first spontaneous cerebellar ICH is poor and comparable to that of patients who survive a first supratentorial ICH. Further identification of patients at high risk of vascular events following the initial cerebellar ICH is needed. Including patients with cerebellar ICH in randomized controlled trials on secondary prevention of patients with ICH is warranted.
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Affiliation(s)
- Jasper R. Senff
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (J.R.S., S.D.S., J.P.J.D., J.T., G.J.E.R., H.B.B.)
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston (J.R.S., S.D.S., C.K., N.Y., C.D.A., J.R.)
- Department of Neurology (J.R.S., S.D.S., C.K., N.Y., J.R.), Massachusetts General Hospital, Boston
- Center for Genomic Medicine (J.R.S., C.K., N.Y., C.D.A., S.D.S., J.R.), Massachusetts General Hospital, Boston
- Broad Institute, Cambridge (J.R.S., S.D.S., J.R.S., C.K., N.Y., C.D.A., J.R.)
| | - Sanjula D. Singh
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (J.R.S., S.D.S., J.P.J.D., J.T., G.J.E.R., H.B.B.)
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston (J.R.S., S.D.S., C.K., N.Y., C.D.A., J.R.)
- JPK Stroke Center (S.D.S., M.P., A.V.), Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
- Department of Neurology (J.R.S., S.D.S., C.K., N.Y., J.R.), Massachusetts General Hospital, Boston
- Center for Genomic Medicine (J.R.S., C.K., N.Y., C.D.A., S.D.S., J.R.), Massachusetts General Hospital, Boston
- Broad Institute, Cambridge (J.R.S., S.D.S., J.R.S., C.K., N.Y., C.D.A., J.R.)
| | - Marco Pasi
- JPK Stroke Center (S.D.S., M.P., A.V.), Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
- University Lille, Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, France (M.P., L.P., C.C.)
- Neurology Department, University Hospital of Tours, INSERM U1253 iBrain, France (M.P.)
| | - Wilmar M.T. Jolink
- Department of Neurology, Isala Hospital, Zwolle, the Netherlands (W.M.T.J.)
| | - Mark A. Rodrigues
- Centre for Clinical Brain Sciences, The University of Edinburgh, United Kingdom (M.A.R., R.A.-S.S.)
- Department of Neuroradiology, NHS Lothian, United Kingdom (M.A.R.)
| | - Floris H.B.M. Schreuder
- Department of Neurology, Donders Institute for Brain Cognition & Behavior, Radboud University Medical Center, Nijmegen, the Netherlands (F.H.B.M.S., C.J.M.K.)
| | - Julie Staals
- Department of Neurology and School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands (J.S.)
| | - Tobien Schreuder
- Department of Neurology, Zuyderland Medical Center, Heerlen, the Netherlands (T.S.)
| | - Jules P.J. Douwes
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (J.R.S., S.D.S., J.P.J.D., J.T., G.J.E.R., H.B.B.)
| | - Jelmer Talsma
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (J.R.S., S.D.S., J.P.J.D., J.T., G.J.E.R., H.B.B.)
| | - Brenna N. McKaig
- Department of Emergency Medicine (B.N.M., J.N.G.), Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Christina Kourkoulis
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston (J.R.S., S.D.S., C.K., N.Y., C.D.A., J.R.)
- Department of Neurology (J.R.S., S.D.S., C.K., N.Y., J.R.), Massachusetts General Hospital, Boston
- Center for Genomic Medicine (J.R.S., C.K., N.Y., C.D.A., S.D.S., J.R.), Massachusetts General Hospital, Boston
- Broad Institute, Cambridge (J.R.S., S.D.S., J.R.S., C.K., N.Y., C.D.A., J.R.)
| | - Nirupama Yechoor
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston (J.R.S., S.D.S., C.K., N.Y., C.D.A., J.R.)
- Department of Neurology (J.R.S., S.D.S., C.K., N.Y., J.R.), Massachusetts General Hospital, Boston
- Center for Genomic Medicine (J.R.S., C.K., N.Y., C.D.A., S.D.S., J.R.), Massachusetts General Hospital, Boston
- Broad Institute, Cambridge (J.R.S., S.D.S., J.R.S., C.K., N.Y., C.D.A., J.R.)
| | - Christopher D. Anderson
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston (J.R.S., S.D.S., C.K., N.Y., C.D.A., J.R.)
- Center for Genomic Medicine (J.R.S., C.K., N.Y., C.D.A., S.D.S., J.R.), Massachusetts General Hospital, Boston
- Broad Institute, Cambridge (J.R.S., S.D.S., J.R.S., C.K., N.Y., C.D.A., J.R.)
- Department of Neurology, Brigham and Women’s Hospital, Boston (C.D.A.)
| | - Laurent Puy
- University Lille, Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, France (M.P., L.P., C.C.)
| | - Charlotte Cordonnier
- University Lille, Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, France (M.P., L.P., C.C.)
| | | | - Peter M. Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (P.M.R.)
| | - Jonathan Rosand
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston (J.R.S., S.D.S., C.K., N.Y., C.D.A., J.R.)
- Department of Neurology (J.R.S., S.D.S., C.K., N.Y., J.R.), Massachusetts General Hospital, Boston
- Center for Genomic Medicine (J.R.S., C.K., N.Y., C.D.A., S.D.S., J.R.), Massachusetts General Hospital, Boston
- Broad Institute, Cambridge (J.R.S., S.D.S., J.R.S., C.K., N.Y., C.D.A., J.R.)
| | - Catharina J.M. Klijn
- Department of Neurology, Donders Institute for Brain Cognition & Behavior, Radboud University Medical Center, Nijmegen, the Netherlands (F.H.B.M.S., C.J.M.K.)
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, The University of Edinburgh, United Kingdom (M.A.R., R.A.-S.S.)
| | - Gabriël J.E. Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (J.R.S., S.D.S., J.P.J.D., J.T., G.J.E.R., H.B.B.)
| | - Anand Viswanathan
- JPK Stroke Center (S.D.S., M.P., A.V.), Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Joshua N. Goldstein
- Department of Emergency Medicine (B.N.M., J.N.G.), Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - H. Bart Brouwers
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (J.R.S., S.D.S., J.P.J.D., J.T., G.J.E.R., H.B.B.)
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands (H.B.B.)
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9
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Al-Shahi Salman R, Greenberg SM. Antiplatelet Agent Use After Stroke due to Intracerebral Hemorrhage. Stroke 2023; 54:3173-3181. [PMID: 37916459 DOI: 10.1161/strokeaha.123.036886] [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] [Indexed: 11/03/2023]
Abstract
This focused update about antiplatelet agents to reduce the high risk of major adverse cardiovascular events after stroke due to spontaneous (nontraumatic) intracerebral hemorrhage (ICH) complements earlier updates about blood pressure-lowering, lipid-lowering, and oral anticoagulation or left atrial appendage occlusion for atrial fibrillation after ICH. When used for secondary prevention in people without ICH, antiplatelet agents reduce the risk of major adverse cardiovascular event (rate ratio, 0.81 [95% CI, 0.75-0.87]) and might increase the risk of ICH (rate ratio, 1.67 [95% CI, 0.97-2.90]). Before 2019, guidance for clinical decisions about antiplatelet agent use after ICH has focused on estimating patients' predicted absolute risks and severities of ischemic and hemorrhagic major adverse cardiovascular event and applying the known effects of these drugs in people without ICH to estimate whether individual ICH survivors in clinical practice might be helped or harmed by antiplatelet agents. In 2019, the main results of the RESTART (Restart or Stop Antithrombotics Randomized Trial) randomized controlled trial including 537 survivors of ICH associated with antithrombotic drug use showed, counterintuitively, that antiplatelet agents might not increase the risk of recurrent ICH compared to antiplatelet agent avoidance over 2 years of follow-up (12/268 [4%] versus 23/268 [9%]; adjusted hazard ratio, 0.51 [95% CI, 0.25-1.03]; P=0.060). Guidelines in the United States, Canada, China, and the United Kingdom and Ireland have classified the level of evidence as B and indicated that antiplatelet agents may be considered/reasonable after ICH associated with antithrombotic agent use. Three subsequent clinical trials have recruited another 174 participants with ICH, but they will not be sufficient to determine the effects of antiplatelet therapy on all major adverse cardiovascular events reliably when pooled with RESTART. Therefore, ASPIRING (Antiplatelet Secondary Prevention International Randomized Study After Intracerebral Hemorrhage) aims to recruit 4148 ICH survivors to determine the effects of antiplatelet agents after ICH definitively overall and in subgroups.
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Affiliation(s)
| | - Steven M Greenberg
- Massachusetts General Hospital and Harvard Medical School, Boston (S.M.G.)
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10
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Eilertsen H, Menon CS, Law ZK, Chen C, Bath PM, Steiner T, Desborough MJ, Sandset EC, Sprigg N, Al-Shahi Salman R. Haemostatic therapies for stroke due to acute, spontaneous intracerebral haemorrhage. Cochrane Database Syst Rev 2023; 10:CD005951. [PMID: 37870112 PMCID: PMC10591281 DOI: 10.1002/14651858.cd005951.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Outcome after acute spontaneous (non-traumatic) intracerebral haemorrhage (ICH) is influenced by haematoma volume. ICH expansion occurs in about 20% of people with acute ICH. Early haemostatic therapy might improve outcome by limiting ICH expansion. This is an update of a Cochrane Review first published in 2006, and last updated in 2018. OBJECTIVES To examine 1. the effects of individual classes of haemostatic therapies, compared with placebo or open control, in adults with acute spontaneous ICH, and 2. the effects of each class of haemostatic therapy according to the use and type of antithrombotic drug before ICH onset. SEARCH METHODS We searched the Cochrane Stroke Trials Register, CENTRAL (2022, Issue 8), MEDLINE Ovid, and Embase Ovid on 12 September 2022. To identify further published, ongoing, and unpublished randomised controlled trials (RCTs), we scanned bibliographies of relevant articles and searched international registers of RCTs in September 2022. SELECTION CRITERIA We included RCTs of any haemostatic intervention (i.e. procoagulant treatments such as clotting factor concentrates, antifibrinolytic drugs, platelet transfusion, or agents to reverse the action of antithrombotic drugs) for acute spontaneous ICH, compared with placebo, open control, or an active comparator. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was death/dependence (modified Rankin Scale (mRS) 4 to 6) by day 90. Secondary outcomes were ICH expansion on brain imaging after 24 hours, all serious adverse events, thromboembolic adverse events, death from any cause, quality of life, mood, cognitive function, Barthel Index score, and death or dependence measured on the Extended Glasgow Outcome Scale by day 90. MAIN RESULTS We included 20 RCTs involving 4652 participants: nine RCTs of recombinant activated factor VII (rFVIIa) versus placebo/open control (1549 participants), eight RCTs of antifibrinolytic drugs versus placebo/open control (2866 participants), one RCT of platelet transfusion versus open control (190 participants), and two RCTs of prothrombin complex concentrates (PCC) versus fresh frozen plasma (FFP) (47 participants). Four (20%) RCTs were at low risk of bias in all criteria. For rFVIIa versus placebo/open control for spontaneous ICH with or without surgery there was little to no difference in death/dependence by day 90 (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.05; 7 RCTs, 1454 participants; low-certainty evidence). We found little to no difference in ICH expansion between groups (RR 0.81, 95% CI 0.56 to 1.16; 4 RCTs, 220 participants; low-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 0.81, 95% CI 0.30 to 2.22; 2 RCTs, 87 participants; very low-certainty evidence; death from any cause: RR 0.78, 95% CI 0.56 to 1.08; 8 RCTs, 1544 participants; moderate-certainty evidence). For antifibrinolytic drugs versus placebo/open control for spontaneous ICH, there was no difference in death/dependence by day 90 (RR 1.00, 95% CI 0.93 to 1.07; 5 RCTs, 2683 participants; high-certainty evidence). We found a slight reduction in ICH expansion with antifibrinolytic drugs for spontaneous ICH compared to placebo/open control (RR 0.86, 95% CI 0.76 to 0.96; 8 RCTs, 2866 participants; high-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 1.02, 95% CI 0.75 to 1.39; 4 RCTs, 2599 participants; high-certainty evidence; death from any cause: RR 1.02, 95% CI 0.89 to 1.18; 8 RCTs, 2866 participants; high-certainty evidence). There was little to no difference in quality of life, mood, or cognitive function (quality of life: mean difference (MD) 0, 95% CI -0.03 to 0.03; 2 RCTs, 2349 participants; mood: MD 0.30, 95% CI -1.98 to 2.57; 2 RCTs, 2349 participants; cognitive function: MD -0.37, 95% CI -1.40 to 0.66; 1 RCTs, 2325 participants; all high-certainty evidence). Platelet transfusion likely increases death/dependence by day 90 compared to open control for antiplatelet-associated ICH (RR 1.29, 95% CI 1.04 to 1.61; 1 RCT, 190 participants; moderate-certainty evidence). We found little to no difference in ICH expansion between groups (RR 1.32, 95% CI 0.91 to 1.92; 1 RCT, 153 participants; moderate-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 1.46, 95% CI 0.98 to 2.16; 1 RCT, 190 participants; death from any cause: RR 1.42, 95% CI 0.88 to 2.28; 1 RCT, 190 participants; both moderate-certainty evidence). For PCC versus FFP for anticoagulant-associated ICH, the evidence was very uncertain about the effect on death/dependence by day 90, ICH expansion, all serious adverse events, and death from any cause between groups (death/dependence by day 90: RR 1.21, 95% CI 0.76 to 1.90; 1 RCT, 37 participants; ICH expansion: RR 0.54, 95% CI 0.23 to 1.22; 1 RCT, 36 participants; all serious adverse events: RR 0.27, 95% CI 0.02 to 3.74; 1 RCT, 5 participants; death from any cause: RR 0.49, 95% CI 0.16 to 1.56; 2 RCTs, 42 participants; all very low-certainty evidence). AUTHORS' CONCLUSIONS In this updated Cochrane Review including 20 RCTs involving 4652 participants, rFVIIa likely results in little to no difference in reducing death or dependence after spontaneous ICH with or without surgery; antifibrinolytic drugs result in little to no difference in reducing death or dependence after spontaneous ICH, but result in a slight reduction in ICH expansion within 24 hours; platelet transfusion likely increases death or dependence after antiplatelet-associated ICH; and the evidence is very uncertain about the effect of PCC compared to FFP on death or dependence after anticoagulant-associated ICH. Thirteen RCTs are ongoing and are likely to increase the certainty of the estimates of treatment effect.
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Affiliation(s)
- Helle Eilertsen
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Zhe Kang Law
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Chen Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, Australia
- The George Institute for Global Health, Beijing, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Philip M Bath
- Stroke Medicine, University of Nottingham, Nottingham, UK
| | - Thorsten Steiner
- Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Jr Desborough
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital Ullevål, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Nikola Sprigg
- Stroke Medicine, University of Nottingham, Nottingham, UK
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11
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Albakr A, Almatar A, AlFajri A, Zafar A, Nazish S, Shahid R, AlJaafari D, Soltan N, Alarfaj Z, Al Ghamdi O, Alfilw S, Abdelhady A, Albaker W. Important Factors to Expect the Outcome After Intracerebral Hemorrhage: An Observational Study From a University Hospital in Saudi Arabia. Neurologist 2023; 28:310-315. [PMID: 37027177 DOI: 10.1097/nrl.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) has worse clinical outcomes than other stroke types. The risk factors contributing to ICH outcomes are not entirely understood, and published literature from Saudi Arabia on ICH outcomes is limited. Our goal was to study the specific clinical and imaging determinants of ICH outcomes. METHODS We retrospectively retrieved all patients with spontaneous ICH (SICH) from a prospective King Fahd Hospital University registry between 2017 and 2019. The clinical characteristics of ICH events and data on clinical outcomes (6 to 12 mo) were recorded. Groups of patients with a favorable modified Rankin Scale of 0 to 2 and nonfavorable outcomes of a modified Rankin Scale of 3 to 6 were investigated. The relationship between the clinical characteristics of the SICH event and its outcomes was assessed using linear and logistic regression analyses. RESULTS A total of 148 patients with a mean age of 60.3 years (±15.2) and a median follow-up of 9 months were included. Unfavorable outcomes were reported in 98 patients (66.2%). The ICH event variables associated with unfavorable outcomes were impaired renal function, Glasgow Coma Score <8, hematoma volume, hematoma expansion, and intraventricular extension (IVE). CONCLUSIONS Our study demonstrated important clinical and radiologic features in patients with ICH that may affect their clinical long-term functional outcomes. A larger multicenter study is required to validate our results and evaluate the methods to improve health care in patients with SICH.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Suad Alfilw
- Department of Neurology, College of Nursing, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia
| | - Ahmed Abdelhady
- Department of critical care, College of Medicine, Alexandria University, Egypt
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12
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Yan Y, Ren H, Luo B, Fan W, Zhang X, Huang Y. Clinical characteristics of spontaneous intracranial basal ganglia hemorrhage and risk factors for hematoma expansion in the plateaus of China. Front Neurol 2023; 14:1183125. [PMID: 37396776 PMCID: PMC10313382 DOI: 10.3389/fneur.2023.1183125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Background and purpose The clinical features of intracranial cerebral hemorrhage (ICH) and the risk factors for hematoma expansion (HE) have been extensively studied. However, few studies have been performed in patients who live on a plateau. The natural habituation and genetic adaptation have resulted in differences in disease characteristics. The purpose of this study was to investigate the differences and consistency of clinical and imaging characteristics of patients in the plateaus of China compared with the plains, and to analyze the risk factors for HE of intracranial hemorrhage in the plateau patients. Methods From January 2020 to August 2022, we undertook a retrospective analysis of 479 patients with first-episode spontaneous intracranial basal ganglia hemorrhage in Tianjin and Xining City. The clinical and radiologic data during hospitalization were analyzed. Univariate and multivariate logistic regression analyzes were used to assess the risk factors for HE. Results HE occurred in 31 plateau (36.0%) and 53 plain (24.2%) ICH patients, and HE was more likely to occur in the plateau patients compared with the plain (p = 0.037). The NCCT images of plateau patients also showed heterogeneity of hematoma imaging signs, and the incidence of blend signs (23.3% vs. 11.0%, p = 0.043) and black hole signs (24.4% vs. 13.2%, p = 0.018) was significantly higher than in the plain. Baseline hematoma volume, black hole sign, island sign, blend sign, and PLT and HB level were associated with HE in the plateau. Baseline hematoma volume and the heterogeneity of hematoma imaging signs were independent predictors of HE in both the plain and plateau. Conclusion Compared with the plain, ICH patients in the plateau were more prone to HE. The patients showed the same heterogeneous signs on the NCCT images as in the plain, and also had predictive value for HE.
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Affiliation(s)
- Yujia Yan
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Hecheng Ren
- Department of Neurosurgery, Third People’s Hospital of Xining City, Xining, China
| | - Bin Luo
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Wanpeng Fan
- Department of Neurosurgery, Third People’s Hospital of Xining City, Xining, China
| | - Xiqiang Zhang
- Department of Neurosurgery, Third People’s Hospital of Xining City, Xining, China
| | - Ying Huang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
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13
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Teo KC, Fong SM, Leung WCY, Leung IYH, Wong YK, Choi OMY, Yam KK, Lo RCN, Cheung RTF, Ho SL, Tsang ACO, Leung GKK, Chan KH, Lau KK. Location-Specific Hematoma Volume Cutoff and Clinical Outcomes in Intracerebral Hemorrhage. Stroke 2023; 54:1548-1557. [PMID: 37216445 DOI: 10.1161/strokeaha.122.041246] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/17/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Major intracerebral hemorrhage (ICH) trials have largely been unable to demonstrate therapeutic benefit in improving functional outcomes. This may be partly due to the heterogeneity of ICH outcomes based on their location, where a small strategic ICH could be debilitating, thus confounding therapeutic effects. We aimed to determine the ideal hematoma volume cutoff for different ICH locations in predicting ICH outcomes. METHODS We retrospectively analyzed consecutive ICH patients enrolled in the University of Hong Kong prospective stroke registry from January 2011 to December 2018. Patients with premorbid modified Rankin Scale score >2 or who underwent neurosurgical intervention were excluded. ICH volume cutoff, sensitivity, and specificity in predicting respective 6-month neurological outcomes (good [modified Rankin Scale score 0-2], poor [modified Rankin Scale score 4-6], and mortality) for specific ICH locations were determined using receiver operating characteristic curves. Separate multivariate logistic regression models were also conducted for each location-specific volume cutoff to determine whether these cutoffs were independently associated with respective outcomes. RESULTS Among 533 ICHs, the volume cutoff for good outcome according to ICH location was 40.5 mL for lobar, 32.5 mL for putamen/external capsule, 5.5 mL for internal capsule/globus pallidus, 6.5 mL for thalamus, 17 mL for cerebellum, and 3 mL for brainstem. ICH smaller than the cutoff for all supratentorial sites had higher odds of good outcomes (all P<0.05). Volumes exceeding 48 mL for lobar, 41 mL for putamen/external capsule, 6 mL for internal capsule/globus pallidus, 9.5 mL for thalamus, 22 mL for cerebellum, and 7.5 mL for brainstem were at greater risk of poor outcomes (all P<0.05). Mortality risks were significantly higher for volumes that exceeded 89.5 mL for lobar, 42 mL for putamen/external capsule, and 21 mL for internal capsule/globus pallidus (all P<0.001). All receiver operating characteristic models for location-specific cutoffs had good discriminant values (area under the curve >0.8), except in predicting good outcome for cerebellum. CONCLUSIONS ICH outcomes differed with location-specific hematoma size. Location-specific volume cutoff should be considered in patient selection for ICH trials.
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Affiliation(s)
- Kay-Cheong Teo
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Sze-Man Fong
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - William C Y Leung
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Ian Y H Leung
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Yuen-Kwun Wong
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Olivia M Y Choi
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital (O.M.Y.C., A.C.O.T., G.K.K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Ka-Keung Yam
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Rachel C N Lo
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Raymond T F Cheung
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- Research Center of Heart, Brain, Hormone and Healthy Aging (R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR (R.T.F.C., K.-H.C., K.-K.L.)
| | - Shu-Leong Ho
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- Research Center of Heart, Brain, Hormone and Healthy Aging (R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Anderson C O Tsang
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital (O.M.Y.C., A.C.O.T., G.K.K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Gilberto K K Leung
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital (O.M.Y.C., A.C.O.T., G.K.K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Koon-Ho Chan
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- Research Center of Heart, Brain, Hormone and Healthy Aging (R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR (R.T.F.C., K.-H.C., K.-K.L.)
| | - Kui-Kai Lau
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- Research Center of Heart, Brain, Hormone and Healthy Aging (R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR (R.T.F.C., K.-H.C., K.-K.L.)
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14
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Lucà F, Colivicchi F, Oliva F, Abrignani M, Caretta G, Di Fusco SA, Giubilato S, Cornara S, Di Nora C, Pozzi A, Di Matteo I, Pilleri A, Rao CM, Parlavecchio A, Ceravolo R, Benedetto FA, Rossini R, Calvanese R, Gelsomino S, Riccio C, Gulizia MM. Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation. Front Cardiovasc Med 2023; 10:1061618. [PMID: 37304967 PMCID: PMC10249073 DOI: 10.3389/fcvm.2023.1061618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/14/2023] [Indexed: 06/13/2023] Open
Abstract
Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, ASL Roma 1, Roma, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | | | - Giorgio Caretta
- Cardiology Unit, Sant'Andrea Hospital, ASL 5 Liguria, La Spezia, Italy
| | | | | | - Stefano Cornara
- Cardiology Division San Paolo Hospital, ASL 2, Savona, Italy
| | | | - Andrea Pozzi
- Cardiology Division, Maria della Misericordia di Udine, Italy
| | - Irene Di Matteo
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | - Anna Pilleri
- Cardiology Division, Brotzu Hospital, Cagliari, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Antonio Parlavecchio
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Roberto Ceravolo
- Cardiology Division, Giovanni Paolo II Hospital, Lamezia Terme, Italy
| | - Francesco Antonio Benedetto
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | | | | | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University, Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, A.O.R.N. Sant'Anna e San Sebastiano, Caserta, Italy
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15
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Scholte M, Marchau VAWJ, Kwakkel JH, Klijn CJM, Rovers MM, Grutters JPC. Dealing With Uncertainty in Early Health Technology Assessment: An Exploration of Methods for Decision Making Under Deep Uncertainty. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:694-703. [PMID: 36253242 DOI: 10.1016/j.jval.2022.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/18/2022] [Accepted: 08/31/2022] [Indexed: 05/03/2023]
Abstract
OBJECTIVES In early stages, the consequences of innovations are often unknown or deeply uncertain, which complicates early health economic modeling (EHEM). The field of decision making under deep uncertainty uses exploratory modeling (EM) in situations when the system model, input probabilities/distributions, and consequences are unknown or debated. Our aim was to evaluate the use of EM for early evaluation of health technologies. METHODS We applied EM and EHEM to an early evaluation of minimally invasive endoscopy-guided surgery (MIS) for acute intracerebral hemorrhage and compared these models to derive differences, merits, and drawbacks of EM. RESULTS EHEM and EM differ fundamentally in how uncertainty is handled. Where in EHEM the focus is on the value of technology, while accounting for the uncertainty, EM focuses on the uncertainty. EM aims to find robust strategies, which give relatively good outcomes over a wide range of plausible futures. This was reflected in our case study. EHEM provided cost-effectiveness thresholds for MIS effectiveness, assuming fixed MIS costs. EM showed that a policy with a population in which most patients had severe intracerebral hemorrhage was most robust, regardless of MIS effectiveness, complications, and costs. CONCLUSIONS EHEM and EM were found to complement each other. EM seems most suited in the very early phases of innovation to explore existing uncertainty and many potential strategies. EHEM seems most useful to optimize promising strategies, yet EM methods are complex and might only add value when stakeholders are willing to consider multiple solutions to a problem and adopt flexible research and adoption strategies.
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Affiliation(s)
- Mirre Scholte
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | - Jan H Kwakkel
- Faculty of Technology, Policy and Management, Delft, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke P C Grutters
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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16
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Boe NJ, Hald SM, Jensen MM, Kristensen LMB, Bojsen JA, Elhakim MT, Clausen A, Möller S, Hallas J, García Rodríguez LA, Selim M, Goldstein LB, Al-Shahi Salman R, Gaist D. Major Cardiovascular Events After Spontaneous Intracerebral Hemorrhage by Hematoma Location. JAMA Netw Open 2023; 6:e235882. [PMID: 37017964 PMCID: PMC10077102 DOI: 10.1001/jamanetworkopen.2023.5882] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/23/2023] [Indexed: 04/06/2023] Open
Abstract
Importance Survivors of spontaneous (ie, nontraumatic and with no known structural cause) intracerebral hemorrhage (ICH) have an increased risk of major cardiovascular events (MACEs), including recurrent ICH, ischemic stroke (IS), and myocardial infarction (MI). Only limited data are available from large, unselected population studies assessing the risk of MACEs according to index hematoma location. Objective To examine the risk of MACEs (ie, the composite of ICH, IS, spontaneous intracranial extra-axial hemorrhage, MI, systemic embolism, or vascular death) after ICH based on ICH location (lobar vs nonlobar). Design, Setting, and Participants This cohort study identified 2819 patients in southern Denmark (population of 1.2 million) 50 years or older hospitalized with first-ever spontaneous ICH from January 1, 2009, to December 31, 2018. Intracerebral hemorrhage was categorized as lobar or nonlobar, and the cohorts were linked to registry data until the end of 2018 to identify the occurrence of MACEs and separately recurrent ICH, IS, and MI. Outcome events were validated using medical records. Associations were adjusted for potential confounders using inverse probability weighting. Exposure Location of ICH (lobar vs nonlobar). Main Outcomes and Measures The main outcomes were MACEs and separately recurrent ICH, IS, and MI. Crude absolute event rates per 100 person-years and adjusted hazard ratios (aHRs) with 95% CIs were calculated. Data were analyzed from February to September 2022. Results Compared with patients with nonlobar ICH (n = 1255; 680 [54.2%] men and 575 [45.8%] women; mean [SD] age, 73.5 [11.4] years), those with lobar ICH (n = 1034; 495 [47.9%] men and 539 [52.1%] women, mean [SD] age, 75.2 [10.7] years) had higher rates of MACEs per 100 person-years (10.84 [95% CI, 9.51-12.37] vs 7.91 [95% CI, 6.93-9.03]; aHR, 1.26; 95% CI, 1.10-1.44) and recurrent ICH (3.74 [95% CI, 3.01-4.66] vs 1.24 [95% CI, 0.89-1.73]; aHR, 2.63; 95% CI, 1.97-3.49) but not IS (1.45 [95% CI, 1.02-2.06] vs 1.77 [95% CI, 1.34-2.34]; aHR, 0.81; 95% CI, 0.60-1.10) or MI (0.42 [95% CI, 0.22-0.81] vs 0.64 [95% CI, 0.40-1.01]; aHR, 0.64; 95% CI, 0.38-1.09). Conclusions and Relevance In this cohort study, spontaneous lobar ICH was associated with a higher rate of subsequent MACEs than nonlobar ICH, primarily due to a higher rate of recurrent ICH. This study highlights the importance of secondary ICH prevention strategies in patients with lobar ICH.
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Affiliation(s)
- Nils Jensen Boe
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Stine Munk Hald
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Mie Micheelsen Jensen
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Line Marie Buch Kristensen
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Jonas Asgaard Bojsen
- Department of Radiology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Mohammad Talal Elhakim
- Department of Radiology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Anne Clausen
- Open Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Sören Möller
- Open Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Department of Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
| | | | - Magdy Selim
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Larry B. Goldstein
- Department of Neurology and Kentucky Neuroscience Institute, University of Kentucky, Lexington
| | | | - David Gaist
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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17
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Boe NJ, Hald SM, Jensen MM, Bojsen JA, Elhakim MT, Florisson S, Saleh A, Clausen A, Möller S, Harbo FSG, Graumann O, Hallas J, García Rodríguez LA, Al-Shahi Salman R, Goldstein LB, Gaist D. Association Between Statin Use and Intracerebral Hemorrhage Location: A Nested Case-Control Registry Study. Neurology 2023; 100:e1048-e1061. [PMID: 36878720 PMCID: PMC9990851 DOI: 10.1212/wnl.0000000000201664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/24/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES A causal relationship between statin use and intracerebral hemorrhage (ICH) is uncertain. We hypothesized that an association between long-term statin exposure and ICH risk might vary for different ICH locations. METHODS We conducted this analysis using linked Danish nationwide registries. Within the Southern Denmark Region (population 1.2 million), we identified all first-ever cases of ICH between 2009 and 2018 in persons aged ≥55 years. Patients with medical record-verified diagnoses were classified as having a lobar or nonlobar ICH and matched for age, sex, and calendar year to general population controls. We used a nationwide prescription registry to ascertain prior statin and other medication use that we classified for recency, duration, and intensity. Using conditional logistic regression adjusted for potential confounders, we calculated adjusted ORs (aORs) and corresponding 95% CIs for the risk of lobar and nonlobar ICH. RESULTS We identified 989 patients with lobar ICH (52.2% women, mean age 76.3 years) who we matched to 39,500 controls and 1,175 patients with nonlobar ICH (46.5% women, mean age 75.1 years) who we matched to 46,755 controls. Current statin use was associated with a lower risk of lobar (aOR 0.83; 95% CI, 0.70-0.98) and nonlobar ICH (aOR 0.84; 95% CI, 0.72-0.98). Longer duration of statin use was also associated with a lower risk of lobar (<1 year: aOR 0.89; 95% CI, 0.69-1.14; ≥1 year to <5 years aOR 0.89; 95% CI 0.73-1.09; ≥5 years aOR 0.67; 95% CI, 0.51-0.87; p for trend 0.040) and nonlobar ICH (<1 year: aOR 1.00; 95% CI, 0.80-1.25; ≥1 year to <5 years aOR 0.88; 95% CI 0.73-1.06; ≥5 years aOR 0.62; 95% CI, 0.48-0.80; p for trend <0.001). Estimates stratified by statin intensity were similar to the main estimates for low-medium intensity therapy (lobar aOR 0.82; nonlobar aOR 0.84); the association with high-intensity therapy was neutral. DISCUSSION We found that statin use was associated with a lower risk of ICH, particularly with longer treatment duration. This association did not vary by hematoma location.
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Affiliation(s)
- Nils Jensen Boe
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Stine Munk Hald
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Mie Micheelsen Jensen
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jonas Asgaard Bojsen
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Mohammad Talal Elhakim
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Sandra Florisson
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Alisa Saleh
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Anne Clausen
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Sören Möller
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Frederik Severin Gråe Harbo
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Ole Graumann
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jesper Hallas
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Luis Alberto García Rodríguez
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Rustam Al-Shahi Salman
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Larry B Goldstein
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - David Gaist
- From the Research Unit for Neurology (N.J.B., S.M.H., M.M.J., S.F., A.S., D.G.), Departments of Radiology (J.A.B., M.T.E., F.S.G.H., O.G.) and Clinical Research (S.M.), and the Open Patient Data Explorative Network (OPEN) (A.C., S.M.), Odense University Hospital, University of Southern Denmark; Department of Clinical Pharmacology (D.M.), Pharmacy and Environmental Medicine, University of Southern Denmark; Centro Espanõl Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Centre for Clinical Brain Sciences (R.A.-S.S.), University of Edinburgh, United Kingdom; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington.
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Cochrane A, Chen C, Stephen J, Rønning OM, Anderson CS, Hankey GJ, Al-Shahi Salman R. Antithrombotic treatment after stroke due to intracerebral haemorrhage. Cochrane Database Syst Rev 2023; 1:CD012144. [PMID: 36700520 PMCID: PMC9878977 DOI: 10.1002/14651858.cd012144.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND This is an update of the Cochrane Review last published in 2017. Survivors of stroke due to intracerebral haemorrhage (ICH) are at risk of major adverse cardiovascular events (MACE). Antithrombotic (antiplatelet or anticoagulant) treatments may lower the risk of ischaemic MACE after ICH, but they may increase the risk of bleeding. OBJECTIVES To determine the overall effectiveness and safety of antithrombotic drugs on MACE and its components for people with ICH. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (5 October 2021). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL: the Cochrane Library 2021, Issue 10), MEDLINE Ovid (from 1948 to October 2021) and Embase Ovid (from 1980 to October 2021). The online registries of clinical trials searched were the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (5 October 2021). We screened the reference lists of included randomised controlled trials (RCTs) for additional, potentially relevant RCTs. SELECTION CRITERIA We selected RCTs in which participants with ICH of any age were allocated to a class of antithrombotic treatment as intervention or comparator. DATA COLLECTION AND ANALYSIS In accordance with standard methodological procedures recommended by Cochrane, two review authors assessed each selected RCT for its risk of bias and extracted data independently. The primary outcome was a composite of MACE, and secondary outcomes included death, individual components of the MACE composite, ICH growth, functional status and cognitive status. We estimated effects using the frequency of outcomes that occurred during the entire duration of follow-up and calculated a risk ratio (RR) for each RCT. We grouped RCTs separately for analysis according to 1) the class(es) of antithrombotic treatment used for the intervention and comparator, and 2) the duration of antithrombotic treatment use (short term versus long term). We pooled the intention-to-treat populations of RCTs using a fixed-effect model for meta-analysis, but used a random-effects model if RCTs differed substantially in their design or there was considerable heterogeneity (I2 ≥ 75%) in their results. We applied GRADE to assess the certainty of the evidence. MAIN RESULTS We identified seven new completed RCTs for this update, resulting in the inclusion of a total of nine RCTs based in secondary care, comprising 1491 participants (average age ranged from 61 to 79 years and the proportion of men ranged from 44% to 67%). The proportion of included RCTs at low risk of bias, by category was: random sequence generation (67%), allocation concealment (67%), performance (22%), detection (78%), attrition (89%), and reporting (78%). For starting versus avoiding short-term prophylactic dose anticoagulation after ICH, no RCT reported MACE. The evidence is very uncertain about the effect of starting short-term prophylactic dose anticoagulation on death (RR 1.00, 95% CI 0.59 to 1.70, P = 1.00; 3 RCTs; very low-certainty evidence), venous thromboembolism (RR 0.84, 95% CI 0.51 to 1.37, P = 0.49; 4 RCTs; very low-certainty evidence), ICH (RR 0.24, 95% CI 0.04 to 1.38, P = 0.11; 2 RCTs; very low-certainty evidence), and independent functional status (RR 2.03, 95% CI 0.78 to 5.25, P = 0.15; 1 RCT; very low-certainty evidence) over 90 days. For starting versus avoiding long-term therapeutic dose oral anticoagulation for atrial fibrillation after ICH, starting long-term therapeutic dose oral anticoagulation probably reduces MACE (RR 0.61, 95% CI 0.40 to 0.94, P = 0.02; 3 RCTs; moderate-certainty evidence) and probably reduces all major occlusive vascular events (RR 0.27, 95% CI 0.14 to 0.53, P = 0.0002; 3 RCTs; moderate-certainty evidence), but probably results in little to no difference in death (RR 1.05, 95% CI 0.62 to 1.78, P = 0.86; 3 RCTs; moderate-certainty evidence), probably increases intracranial haemorrhage (RR 2.43, 95% CI 0.88 to 6.73, P = 0.09; 3 RCTs; moderate-certainty evidence), and may result in little to no difference in independent functional status (RR 0.98, 95% CI 0.78 to 1.24, P = 0.87; 2 RCTs; low-certainty evidence) over one to three years. For starting versus avoiding long-term antiplatelet therapy after ICH, the evidence is uncertain about the effects of starting long-term antiplatelet therapy on MACE (RR 0.89, 95% CI 0.64 to 1.22, P = 0.46; 1 RCT; moderate-certainty evidence), death (RR 1.08, 95% CI 0.76 to 1.53, P = 0.66; 1 RCT; moderate-certainty evidence), all major occlusive vascular events (RR 1.03, 95% CI 0.68 to 1.55, P = 0.90; 1 RCT; moderate-certainty evidence), ICH (RR 0.52, 95% CI 0.27 to 1.03, P = 0.06; 1 RCT; moderate-certainty evidence) and independent functional status (RR 0.95, 95% CI 0.77 to 1.18, P = 0.67; 1 RCT; moderate-certainty evidence) over a median follow-up of two years. For adults within 180 days of non-cardioembolic ischaemic stroke or transient ischaemic attack and a clinical history of prior ICH, there was no evidence of an effect of long-term cilostazol compared to aspirin on MACE (RR 1.33, 95% CI 0.74 to 2.40, P = 0.34; subgroup of 1 RCT; low-certainty evidence), death (RR 1.65, 95% CI 0.55 to 4.91, P = 0.37; subgroup of 1 RCT; low-certainty evidence), or ICH (RR 1.29, 95% CI 0.35 to 4.69, P = 0.70; subgroup of 1 RCT; low-certainty evidence) over a median follow-up of 1.8 years; all major occlusive vascular events and functional status were not reported. AUTHORS' CONCLUSIONS We did not identify beneficial or hazardous effects of short-term prophylactic dose parenteral anticoagulation and long-term oral antiplatelet therapy after ICH on important outcomes. Although there was a significant reduction in MACE and all major occlusive vascular events after long-term treatment with therapeutic dose oral anticoagulation for atrial fibrillation after ICH, the pooled estimates were imprecise, the certainty of evidence was only moderate, and effects on other important outcomes were uncertain. Large RCTs with a low risk of bias are required to resolve the ongoing dilemmas about antithrombotic treatment after ICH.
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Affiliation(s)
| | - Chen Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, Australia
- The George Institute for Global Health, Beijing, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Ole Morten Rønning
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
- Perron Institute for Neurological and Translational Science, Perth, Australia
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Wang YH, Chen YJ, Yang Y, Zhang KY, Chen XZ, Yang CY, Wang J, Lei XJ, Quan YL, Chen WX, Zhao HL, Yang LK, Feng H. Cyclophilin D-induced mitochondrial impairment confers axonal injury after intracerebral hemorrhage in mice. Neural Regen Res 2023; 18:849-855. [PMID: 36204853 PMCID: PMC9700082 DOI: 10.4103/1673-5374.353495] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The mitochondrial permeability transition pore is a nonspecific transmembrane channel. Inhibition of mitochondrial permeability transition pore opening has been shown to alleviate mitochondrial swelling, calcium overload, and axonal degeneration. Cyclophilin D is an important component of the mitochondrial permeability transition pore. Whether cyclophilin D participates in mitochondrial impairment and axonal injury after intracerebral hemorrhage is not clear. In this study, we established mouse models of intracerebral hemorrhage in vivo by injection of autologous blood and oxyhemoglobin into the striatum in Thy1-YFP mice, in which pyramidal neurons and axons express yellow fluorescent protein. We also simulated intracerebral hemorrhage in vitro in PC12 cells using oxyhemoglobin. We found that axonal degeneration in the early stage of intracerebral hemorrhage depended on mitochondrial swelling induced by cyclophilin D activation and mitochondrial permeability transition pore opening. We further investigated the mechanism underlying the role of cyclophilin D in mouse models and PC12 cell models of intracerebral hemorrhage. We found that both cyclosporin A inhibition and short hairpin RNA interference of cyclophilin D reduced mitochondrial permeability transition pore opening and mitochondrial injury. In addition, inhibition of cyclophilin D and mitochondrial permeability transition pore opening protected corticospinal tract integrity and alleviated motor dysfunction caused by intracerebral hemorrhage. Our findings suggest that cyclophilin D is used as a key mediator of axonal degeneration after intracerebral hemorrhage; inhibition of cyclophilin D expression can protect mitochondrial structure and function and further alleviate corticospinal tract injury and motor dysfunction after intracerebral hemorrhage. Our findings provide a therapeutic target for preventing axonal degeneration of white matter injury and subsequent functional impairment in central nervous diseases.
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Liu T, Mai J, Pang L, Huang Y, Han J, Su W, Chen K, Qin P. Effects of subarachnoid extension following intracerebral hemorrhage: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e32225. [PMID: 36626509 PMCID: PMC9750540 DOI: 10.1097/md.0000000000032225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The effects of subarachnoid extension (SAHE) following intracerebral hemorrhage (ICH) have not yet been fully understood. We conducted a systematic review and meta-analysis of published literature on this topic to better understand the effects of SAHE. METHODS PubMed, Embase, and Cochrane databases were thoroughly searched from inception to October 16, 2022 to identify studies that evaluated the association between SAHE and mortality and worse functional outcomes in primary ICH. Crude odds ratios (cOR) and adjusted odds ratios (aOR) with 95% confidence interval (CI) were calculated to compare the endpoints. RESULTS Three studies with 3368 participants were eventually included in the analysis. In the short-term follow-up of the primary endpoint, no association was observed between SAHE and mortality (cOR: 0.51, 95% CI: 0.01-28.19; aOR: 2.31, 95% CI: 0.72-7.45). In the long-term follow-up of the primary endpoint, SAHE was associated with a significantly increased mortality of patients with primary ICH (cOR: 3.00, 95% CI: 2.27-3.98); however, only 1 study provided the values of aOR and 95% CI and showed that SAHE was not associated with increased mortality (aOR: 1.14, 95% CI: 0.71-1.83). For the secondary endpoint, the data of only 1 study on major disability (modified Rankin Scale = 3-5) were available, and the results revealed that SAHE increased the probability of major disability, but not after adjusting for baseline hematoma volume. CONCLUSION There is insufficient evidence to demonstrate the correlation between SAHE and mortality and worse functional outcomes in primary ICH. The validation of this correlation requires further studies as the potential effect and mechanisms of SAHE remain unclear.
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Affiliation(s)
- Tingzhi Liu
- Department of Neurology, the Second People’s Hospital of Qinzhou, Qinzhou, Guangxi Zhuang Autonomous Region, China
| | - Jilin Mai
- Department of Neurology, Beihai People’s Hospital, the Ninth Affiliated Hospital of Guangxi Medical University, Beihai, Guangxi Zhuang Autonomous Region, China
| | - Linlin Pang
- Department of Neurology, Minzu Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Ya Huang
- Department of Neurology, the Second People’s Hospital of Qinzhou, Qinzhou, Guangxi Zhuang Autonomous Region, China
| | - Jing Han
- Department of Neurology, the Second People’s Hospital of Qinzhou, Qinzhou, Guangxi Zhuang Autonomous Region, China
| | - Weixiang Su
- Department of Neurology, the Second People’s Hospital of Qinzhou, Qinzhou, Guangxi Zhuang Autonomous Region, China
| | - Kaichang Chen
- Department of Neurology, the Second People’s Hospital of Qinzhou, Qinzhou, Guangxi Zhuang Autonomous Region, China
| | - Peiying Qin
- Department of Neurology, the Second People’s Hospital of Qinzhou, Qinzhou, Guangxi Zhuang Autonomous Region, China
- * Correspondence: Peiying Qin, Department of Neurology, the Second People’s Hospital Medical Group of Qinzhou, Wenfeng South Road, Qinnan District, Qinzhou, 535000, China (e-mail: )
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Mair G, White P, Bath PM, Muir KW, Al‐Shahi Salman R, Martin C, Dye D, Chappell FM, Vacek A, von Kummer R, Macleod M, Sprigg N, Wardlaw JM. External Validation of e-ASPECTS Software for Interpreting Brain CT in Stroke. Ann Neurol 2022; 92:943-957. [PMID: 36053916 PMCID: PMC9826303 DOI: 10.1002/ana.26495] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 07/08/2022] [Accepted: 08/29/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The purpose of this study was to test e-ASPECTS software in patients with stroke. Marketed as a decision-support tool, e-ASPECTS may detect features of ischemia or hemorrhage on computed tomography (CT) imaging and quantify ischemic extent using Alberta Stroke Program Early CT Score (ASPECTS). METHODS Using CT from 9 stroke studies, we compared software with masked experts. As per indications for software use, we assessed e-ASPECTS results for patients with/without middle cerebral artery (MCA) ischemia but no other cause of stroke. In an analysis outside the intended use of the software, we enriched our dataset with non-MCA ischemia, hemorrhage, and mimics to simulate a representative "front door" hospital population. With final diagnosis as the reference standard, we tested the diagnostic accuracy of e-ASPECTS for identifying stroke features (ischemia, hyperattenuated arteries, and hemorrhage) in the representative population. RESULTS We included 4,100 patients (51% women, median age = 78 years, National Institutes of Health Stroke Scale [NIHSS] = 10, onset to scan = 2.5 hours). Final diagnosis was ischemia (78%), hemorrhage (14%), or mimic (8%). From 3,035 CTs with expert-rated ASPECTS, most (2084/3035, 69%) e-ASPECTS results were within one point of experts. In the representative population, the diagnostic accuracy of e-ASPECTS was 71% (95% confidence interval [CI] = 70-72%) for detecting ischemic features, 85% (83-86%) for hemorrhage. Software identified more false positive ischemia (12% vs 2%) and hemorrhage (14% vs <1%) than experts. INTERPRETATION On independent testing, e-ASPECTS provided moderate agreement with experts and overcalled stroke features. Therefore, future prospective trials testing impacts of artificial intelligence (AI) software on patient care and outcome are required before widespread implementation of stroke decision-support software. ANN NEUROL 2022;92:943-957.
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Affiliation(s)
- Grant Mair
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Philip White
- Translational and Clinical Research InstituteNewcastle University and Newcastle upon Tyne Hospitals NHS TrustNewcastle upon TyneUK
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical NeuroscienceUniversity of NottinghamNottinghamUK
| | - Keith W. Muir
- School of Psychology & NeuroscienceUniversity of GlasgowGlasgowUK
| | | | - Chloe Martin
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - David Dye
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | | | - Adam Vacek
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Rüdiger von Kummer
- Department of NeuroradiologyUniversity Hospital, Technische Universität DresdenDresdenGermany
| | - Malcolm Macleod
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Nikola Sprigg
- Translational and Clinical Research InstituteNewcastle University and Newcastle upon Tyne Hospitals NHS TrustNewcastle upon TyneUK
| | - Joanna M. Wardlaw
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
- UK Dementia Research Institute Centre at the University of EdinburghEdinburghUK
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Wang S, Zou XL, Wu LX, Zhou HF, Xiao L, Yao T, Zhang Y, Ma J, Zeng Y, Zhang L. Epidemiology of intracerebral hemorrhage: A systematic review and meta-analysis. Front Neurol 2022; 13:915813. [PMID: 36188383 PMCID: PMC9523083 DOI: 10.3389/fneur.2022.915813] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 08/16/2022] [Indexed: 12/03/2022] Open
Abstract
Background Intracerebral hemorrhage (ICH) is associated with high mortality and disability rates. This study aimed to investigate the relationship between sex, age, study year, risk factors, bleeding site, median year of study, and the incidence of ICH. Method Literature on the incidence of ICH published on 1 January 1980 and 1 January 2020, was systematically retrieved from PubMed and Embase databases. The random-effects model and subgroup analysis were used to explore the relationship between the incidence of ICH and different ages, sex, bleeding sites, and risk factors. Results We summarized the epidemiological changes in ICH in the past 40 years according to 52 studies and found that the total incidence of ICH is 29.9 per 100,000 person-years (95% CI: 26.5–33.3), which has not decreased worldwide. The incidence of ICH in the Asian population is much higher than in other continents. In addition, the incidence of ICH increases with age and differs at the 85-year-old boundary. Men are more likely to develop ICH than women, and the basal ganglia region is the most common area for ICH. Of the 10 risk factors examined in this study, those with hypertension had the highest incidence of ICH, followed by those with excessive alcohol consumption and heart disease. Conclusion The prevention and treatment of ICH still need to be improved continuously according to age, sex, risk factors, and other factors, and targeted and normative strategies should be gradually developed in the future.
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Affiliation(s)
- Sai Wang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Xue-Lun Zou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Lian-Xu Wu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Hui-Fang Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Linxiao Xiao
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Tianxing Yao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yupeng Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Junyi Ma
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Zeng
- Department of Geriatrics, Second Xiangya Hospital, Central South University, Changsha, China
| | - Le Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Multi-Modal Monitoring Technology for Severe Cerebrovascular Disease of Human Engineering Research Center, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Le Zhang
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Cliteur MP, Sondag L, Wolsink A, Rasing I, Meijer FJA, Jolink WMT, Wermer MJH, Klijn CJM, Schreuder FHBM. Cerebral small vessel disease and perihematomal edema formation in spontaneous intracerebral hemorrhage. Front Neurol 2022; 13:949133. [PMID: 35968312 PMCID: PMC9372363 DOI: 10.3389/fneur.2022.949133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/07/2022] [Indexed: 12/02/2022] Open
Abstract
Objective Blood-brain barrier (BBB) dysfunction is implicated in the pathophysiology of cerebral small vessel disease (cSVD)-related intracerebral hemorrhage (ICH). The formation of perihematomal edema (PHE) is presumed to reflect acute BBB permeability following ICH. We aimed to assess the association between cSVD burden and PHE formation in patients with spontaneous ICH. Methods We selected patients with spontaneous ICH who underwent 3T MRI imaging within 21 days after symptom onset from a prospective observational multicenter cohort study. We rated markers of cSVD (white matter hyperintensities, enlarged perivascular spaces, lacunes and cerebral microbleeds) and calculated the composite score as a measure of the total cSVD burden. Perihematomal edema formation was measured using the edema extension distance (EED). We assessed the association between the cSVD burden and the EED using a multivariable linear regression model adjusting for age, (log-transformed) ICH volume, ICH location (lobar vs. non-lobar), and interval between symptom onset and MRI. Results We included 85 patients (mean age 63.5 years, 75.3% male). Median interval between symptom onset and MRI imaging was 6 days (IQR 1–19). Median ICH volume was 17.0 mL (IQR 1.4–88.6), and mean EED was 0.54 cm (SD 0.17). We found no association between the total cSVD burden and EED (B = −0.003, 95% CI −0.003–0.03, p = 0.83), nor for any of the individual radiological cSVD markers. Conclusion We found no association between the cSVD burden and PHE formation. This implies that mechanisms other than BBB dysfunction are involved in the pathophysiology of PHE.
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Affiliation(s)
- Maaike P. Cliteur
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Axel Wolsink
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Ingeborg Rasing
- Department of Neurology & Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - F. J. A. Meijer
- Department of Medical Imaging, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Marieke J. H. Wermer
- Department of Neurology & Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Catharina J. M. Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Floris H. B. M. Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
- *Correspondence: Floris H. B. M. Schreuder
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Best JG, Cardus B, Klijn CJM, Lip G, Seiffge DJ, Smith EE, Werring DJ. Antithrombotic dilemmas in stroke medicine: new data, unsolved challenges. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2020-325249. [PMID: 35728935 DOI: 10.1136/jnnp-2020-325249] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 05/16/2022] [Indexed: 11/04/2022]
Abstract
Antithrombotic therapy is a key element of secondary prevention in patients who have had an ischaemic stroke or transient ischaemic attack. However, its use in clinical practice is not always straightforward. This review provides an update on certain difficult scenarios in antithrombotic management, with a focus on recent clinical trials and large observational studies. We discuss the approach to patients with an indication for antithrombotic treatment who also have clinical or radiological evidence of previous intracranial bleeding, patients with indications for both anticoagulant and antiplatelet treatment, and patients in whom antithrombotic treatment fails to prevent stroke. We also review the timing of anticoagulation initiation after cardioembolic stroke, and the use of antithrombotics in patients with asymptomatic cerebrovascular disease. Despite a wealth of new evidence, numerous uncertainties remain and we highlight ongoing trials addressing these.
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Affiliation(s)
- Jonathan G Best
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Beatrix Cardus
- Royal Surrey County Hospital, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Catharina J M Klijn
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Gregory Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital, Bern, Switzerland
| | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
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Schreuder FHBM, Scholte M, Ulehake MJ, Sondag L, Rovers MM, Dammers R, Klijn CJM, Grutters JPC. Identifying the Conditions for Cost-Effective Minimally Invasive Neurosurgery in Spontaneous Supratentorial Intracerebral Hemorrhage. Front Neurol 2022; 13:830614. [PMID: 35720058 PMCID: PMC9200972 DOI: 10.3389/fneur.2022.830614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIn patients with spontaneous supratentorial intracerebral hemorrhage (ICH), open craniotomy has failed to improve a functional outcome. Innovative minimally invasive neurosurgery (MIS) may improve a health outcome and reduce healthcare costs.AimsBefore starting phase-III trials, we aim to assess conditions that need to be met to reach the potential cost-effectiveness of MIS compared to usual care in patients with spontaneous supratentorial ICH.MethodsWe used a state-transition model to determine at what effectiveness and cost MIS would become cost-effective compared to usual care in terms of quality-adjusted life-years (QALYs) and direct healthcare costs. Threshold and two-way sensitivity analyses were used to determine the minimal effectiveness and maximal costs of MIS, and the most cost-effective strategy for each combination of cost and effectiveness. Scenario and probabilistic sensitivity analyses addressed model uncertainty.ResultsGiven €10,000 of surgical costs, MIS would become cost-effective when at least 0.7–1.3% of patients improve to a modified Rankin Scale (mRS) score of 0–3 compared to usual care. When 11% of patients improve to mRS 0–3, surgical costs may be up to €83,301–€164,382, depending on the population studied. The cost-effectiveness of MIS was mainly determined by its effectiveness. In lower mRS states, MIS needs to be more effective to be cost-effective compared to higher mRS states.ConclusionMIS has the potential to be cost-effective in patients with spontaneous supratentorial ICH, even with relatively low effectiveness. These results support phase-III trials to investigate the effectiveness of MIS.
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Affiliation(s)
- Floris H. B. M. Schreuder
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Floris H. B. M. Schreuder
| | - Mirre Scholte
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marike J. Ulehake
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lotte Sondag
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Maroeska M. Rovers
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, Netherlands
| | - Catharina J. M. Klijn
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Janneke P. C. Grutters
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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Zhang X, Zhang Y, Wang F, Liu Y, Yong VW, Xue M. Necrosulfonamide Alleviates Acute Brain Injury of Intracerebral Hemorrhage via Inhibiting Inflammation and Necroptosis. Front Mol Neurosci 2022; 15:916249. [PMID: 35721316 PMCID: PMC9201046 DOI: 10.3389/fnmol.2022.916249] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/06/2022] [Indexed: 11/29/2022] Open
Abstract
Objective Intracerebral hemorrhage (ICH) is the most lethal subtype of stroke, without effective treatment. Necrosulfonamide (NSA), a specific inhibitor for mixed lineage kinase domain-like protein, has been reported to exert neuroprotective effects in neurological diseases by ameliorating neuroinflammation and necroptosis. We hypothesized that NSA would alleviate acute brain injury and improve behavioral outcomes after ICH. Materials and Methods Male adult C57BL/6 mice were assigned randomly into three groups. In vehicle and treatment groups, animals were injected with collagenase VII to induce ICH. The solvent (0.25% DMSO) and NSA (5 mg/kg) were administrated intraperitoneally twice a day, respectively. The sham group was injected with saline and administrated with DMSO. The brain hematoma volume, inflammatory factors, and blood-brain barrier permeability were measured on day 3 after the operation. Fluorescent double immunostaining was performed to evaluate the neuronal death. Neurological functions were assessed. Results In the NSA group, the hematoma size was significantly reduced, inflammatory cells and cytokines were suppressed, and the blood-brain barrier was protected compared to vehicle controls. NSA dramatically reduced the death of neurons and improved the performance of neurological functions after ICH. Conclusion Necrosulfonamide has a neuroprotective role in alleviating acute brain injury in a mouse ICH model, and this is associated with reduced neuroinflammation and necroptosis.
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Affiliation(s)
- Xiangyu Zhang
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
| | - Yan Zhang
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
| | - Fei Wang
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
| | - Yang Liu
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
| | - V. Wee Yong
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- *Correspondence: V. Wee Yong,
| | - Mengzhou Xue
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
- Mengzhou Xue,
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27
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Cheng Z, Zhang W, Zhan Z, Xia L, Han Z. Cerebral Small Vessel Disease and Prognosis in Intracerebral Hemorrhage: A Systematic Review and Meta-analysis of Cohort Studies. Eur J Neurol 2022; 29:2511-2525. [PMID: 35435301 DOI: 10.1111/ene.15363] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND To investigate whether cerebral small vessel disease (CSVD) markers and the total CSVD burden are associated with functional outcome, mortality, stroke recurrence, and hematoma expansion in patients with spontaneous intracerebral hemorrhage (ICH). METHODS Following a previously registered protocol (PROSPERO protocol: CRD42021287743), we systematically searched PubMed, Web of Science, and EMBASE to identify relevant literature up to November 2021. Cohort studies that examined the association between CSVD markers (white matter hyperintensity [WMH], lacune, enlarged perivascular space [EPVS], cerebral microbleed [CMB], and brain atrophy) or CSVD burden and prognosis in patients with ICH were included. The pooled estimates were calculated using random effects models. RESULTS Forty-one studies with 19,752 ICH patients were pooled in the meta-analysis. WMH (OR=1.50, 95% CI=1.32 to 1.70), lacune (OR=1.32, 95% CI=1.18 to 1.49), CMB (OR=2.60, 95% CI=1.13 to 5.97) and brain atrophy (OR=2.22, 95% CI=1.48 to 3.31) were associated with worse functional outcome. CSVD markers concerning increased risk of mortality were WMH (OR=1.57, 95% CI=1.38 to 1.79) and brain atrophy (OR=1.84, 95% CI=1.11 to 3.04), while concerning increased risk of stroke recurrence were WMH (OR=1.62, 95% CI=1.28 to 2.04) and lacune (OR=3.00, 95% CI=1.68 to 5.37). EPVS was not related to prognosis. There was a lack of association between CSVD markers and hematoma expansion. CSVD burden increased the risk of worse functional outcome, mortality, and stroke recurrence by 57%, 150%, and 44%, respectively. CONCLUSIONS In patients with spontaneous ICH, WMH, lacune, CMB, brain atrophy, and the total CSVD burden are associated with substantially increased risk of worse functional outcome, mortality, or stroke recurrence.
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Affiliation(s)
- Zicheng Cheng
- Department of Neurology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Wenyuan Zhang
- Department of Neurology, Affiliated Yueqing Hospital, Wenzhou Medical University, Yueqing, China
| | - Zhenxiang Zhan
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lingfan Xia
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhao Han
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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28
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Magid-Bernstein J, Girard R, Polster S, Srinath A, Romanos S, Awad IA, Sansing LH. Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions. Circ Res 2022; 130:1204-1229. [PMID: 35420918 PMCID: PMC10032582 DOI: 10.1161/circresaha.121.319949] [Citation(s) in RCA: 135] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.
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Affiliation(s)
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sean Polster
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Abhinav Srinath
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sharbel Romanos
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Issam A. Awad
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Lauren H. Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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29
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Minhas JS, Moullaali TJ, Rinkel GJE, Anderson CS. Blood Pressure Management After Intracerebral and Subarachnoid Hemorrhage: The Knowns and Known Unknowns. Stroke 2022; 53:1065-1073. [PMID: 35255708 DOI: 10.1161/strokeaha.121.036139] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blood pressure (BP) elevations often complicate the management of intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage, the most serious forms of acute stroke. Despite consensus on potential benefits of BP lowering in the acute phase of intracerebral hemorrhage, controversies persist over the timing, mechanisms, and approaches to treatment. BP control is even more complex for subarachnoid hemorrhage, where there are rationales for both BP lowering and elevation in reducing the risks of rebleeding and delayed cerebral ischemia, respectively. Efforts to disentangle the evidence has involved detailed exploration of individual patient data from clinical trials through meta-analysis to determine strength and direction of BP change in relation to key outcomes in intracerebral hemorrhage, and which likely also apply to subarachnoid hemorrhage. A wealth of hemodynamic data provides insights into pathophysiological interrelationships of BP and cerebral blood flow. This focused update provides an overview of current evidence, knowledge gaps, and emerging concepts on systemic hemodynamics, cerebral autoregulation and perfusion, to facilitate clinical practice recommendations and future research.
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Affiliation(s)
- Jatinder S Minhas
- Department of Cardiovascular Sciences (J.S.M.), University of Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre (J.S.M.), University of Leicester, United Kingdom
| | - Tom J Moullaali
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (T.J.M.)
- Department of Clinical Neurosciences, NHS Lothian, United Kingdom (T.J.M.)
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (T.J.M., C.S.A.)
| | - Gabriel J E Rinkel
- Department of Neurology & Neurosurgery, University Medical Centre Utrecht, University of Utrecht, the Netherlands (G.J.E.R.)
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Germany (G.J.E.R.)
| | - Craig S Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (T.J.M., C.S.A.)
- The George Institute China at Peking University Health Sciences Centre, Beijing, P.R. China (C.S.A.)
- Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, Australia (C.S.A.)
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30
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Li X, Zhang L, Wolfe CDA, Wang Y. Incidence and Long-Term Survival of Spontaneous Intracerebral Hemorrhage Over Time: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:819737. [PMID: 35359654 PMCID: PMC8960718 DOI: 10.3389/fneur.2022.819737] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/20/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose Recent epidemiological data indicate that the absolute number of hemorrhagic stroke cases increased by 47% between 1990 and 2010 and continued to cause high rates of death and disability. The last systematic review and meta-analysis of incidence and long-term survival of intracerebral hemorrhage (ICH) were published 11 and 7 years ago, respectively, and lacked comparison between different income groups, therefore, a more up to date analysis is needed. We aim to investigate the ICH incidence and long-term survival data in countries of different income groups. Materials Methods We systematically searched Ovid Medline for population-based longitudinal studies of first-ever spontaneous ICH published from January 2000 to December 2020. We performed meta-analyses on the incidence and survival rate in countries of 4 different income groups with random-effects models (severe inconsistency). The I2 was used to measure the heterogeneity. Heterogeneity was further investigated by conducting the meta-regression on the study mid-year. Time trends of the survival rate were assessed by weighted linear regression. Results We identified 84 eligible papers, including 68 publications reporting incidence and 24 publications on the survival rate. The pooled incidence of ICH per 100,000 per person-years was 26.47 (95% CI: 21.84–32.07) worldwide, 25.9 (95% CI: 22.63–29.63) in high-income countries (HIC), 28.45 (95% CI: 15.90–50.88) in upper-middle-income countries, and 31.73 (95% CI: 18.41–54.7) in lower-middle-income countries. The 1-year pooled survival rate was from 50% (95% CI: 47–54%; n = 4,380) worldwide to 50% (95% CI: 47–54%) in HIC, and 46% (95% CI: 38–55%) in upper-middle income countries. The 5-year pooled survival rate was 41% (95% CI: 35–48%; n = 864) worldwide, 41% (95% CI: 32–50%) in high-income and upper-middle countries. No publications were found reporting the long-term survival in lower-middle-income and low-income countries. No time trends in incidence or survival were found by meta-regression. Conclusion The pooled ICH incidence was highest in lower-middle-income countries. About half of ICH patients survived 1 year, and about two-fifths survived 5 years. Reliable population-based studies estimating the ICH incidence and long-term survival in low-income and low-middle-income countries are needed to help prevention of ICH. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=170140, PROSPERO CRD42020170140.
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Affiliation(s)
- Xianqi Li
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
- *Correspondence: Xianqi Li
| | - Li Zhang
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
| | - Charles D. A. Wolfe
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
- NIHR Applied Research Collaboration (ARC) South London, London, United Kingdom
| | - Yanzhong Wang
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
- NIHR Applied Research Collaboration (ARC) South London, London, United Kingdom
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31
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Ferroptosis in oligodendrocyte progenitor cells mediates white matter injury after hemorrhagic stroke. Cell Death Dis 2022; 13:259. [PMID: 35318305 PMCID: PMC8941078 DOI: 10.1038/s41419-022-04712-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/17/2022] [Accepted: 03/03/2022] [Indexed: 11/24/2022]
Abstract
Oligodendrocyte progenitor cells (OPCs) differentiate to myelin-producing mature oligodendrocytes and enwrap growing or demyelinated axons during development and post central nervous diseases. Failure of remyelination owing to cell death or undifferentiation of OPCs contributes to severe neurologic deficits and motor dysfunction. However, how to prevent the cell death of OPCs is still poorly understood, especially in hemorrhagic diseases. In the current study, we injected autologous blood into the mouse lateral ventricular to study the hemorrhage-induced OPC cell death in vivo. The integrity of the myelin sheath of the corpus callosum was disrupted post intraventricular hemorrhage (IVH) assessed by using magnetic resonance imaging, immunostaining, and transmission electron microscopy. Consistent with the severe demethylation, we observed massive cell death of oligodendrocyte lineages in the periventricular area. In addition, we found that ferroptosis is the major cell death form in Hemin-induced OPC death by using RNA-seq analysis, and the mechanism was glutathione peroxidase 4 activity reduction-resulted lipid peroxide accumulation. Furthermore, inhibition of ferroptosis rescued OPC cell death in vitro, and in vivo attenuated IVH-induced white matter injury and promoted recovery of neurological function. These data demonstrate that ferroptosis is an essential form of OPC cell death in hemorrhagic stroke, and rescuing ferroptotic OPCs could serve as a therapeutic target for stroke and related diseases.
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32
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Christopher E, Loan JJM, Samarasekera N, McDade K, Rose J, Barrington J, Hughes J, Smith C, Al-Shahi Salman R. Nrf2 activation in the human brain after stroke due to supratentorial intracerebral haemorrhage: a case–control study. BMJ Neurol Open 2022; 4:e000238. [PMID: 35265844 PMCID: PMC8860052 DOI: 10.1136/bmjno-2021-000238] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/17/2022] [Indexed: 01/05/2023] Open
Abstract
Aims Pharmacological activation of the antioxidative transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2) improves outcomes in experimental models of intracerebral haemorrhage (ICH). However, the Nrf2 pathway has not been previously studied in humans after ICH. Our study aims to address this gap. Methods We selected cases with fatal ICH from a prospective community-based inception cohort study and age-matched and sex-matched controls who died suddenly of non-neurological disease. We used immunohistochemistry to quantify Nrf2 (% total area stained overall and % of nuclei stained) and CD68 expression in controls and perihaematomal, ipsilateral and contralateral brain tissue from cases. We measured downstream haem oxygenase-1 (HMOX1) and NAD(P)H dehydrogenase quinone 1 [NQO1] expression using RNA in situ hybridisation. Results 26 ICH cases (median age: 82 (IQR 76–86); 13 (50%) male) and eight controls (median age: 79 (IQR 77–80); 3 (37.5%) male) were included. We found no significant differences in overall % of Nrf2 staining between ICH cases and controls. However, the mean % of nuclei staining for Nrf2 seemed higher in perihaematomal compared with contralateral regions, although this was only statistically significant >60 days after ICH (25% (95% CI 17% to 33%) vs 14% (95% CI 11% to 17%), p=0.029). The percentage of perihaematomal tissue staining for CD68 was higher >60 days after ICH (6.75%, 95% CI 2.78% to 10.73%) compared with contralateral tissue (1.45%, 95% CI 0.93% to 1.96%, p=0.027) and controls (1.08%, 95% CI 0.20% to 1.97%, p=0.0008). RNA in situ hybridisation suggested increased abundance of HMOX1 and NQO1 transcripts in perihaematomal versus distant ipsilateral brain tissue obtained <7 days from onset of ICH. Conclusions We found evidence of Nrf2 activation in human brain tissue after ICH. Pharmacological augmentation of Nrf2 activation after ICH might be a promising therapeutic approach.
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Affiliation(s)
- Edward Christopher
- The University of Edinburgh College of Medicine and Veterinary Medicine, Edinburgh, UK
| | - James J M Loan
- Division of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Neshika Samarasekera
- Division of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Karina McDade
- Academic Neuropathology, The University of Edinburgh, Edinburgh, UK
| | - Jamie Rose
- Academic Neuropathology, The University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Jack Barrington
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Jeremy Hughes
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, UK
| | - Colin Smith
- Academic Neuropathology, The University of Edinburgh, Edinburgh, UK
| | - Rustam Al-Shahi Salman
- Division of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
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Jensen MM, Hald SM, Kristensen LMB, Boe NJ, Harbo FSG, Gaist D. Validity of Simple Algorithms to Identify Recurrence of Intracerebral Hemorrhage in Two Danish Nationwide Registries. Clin Epidemiol 2021; 13:949-958. [PMID: 34675683 PMCID: PMC8517414 DOI: 10.2147/clep.s333624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/20/2021] [Indexed: 02/03/2023] Open
Abstract
Purpose Danish registries could be an attractive resource for studies of recurrent intracerebral hemorrhage (re-ICH). We developed and validated algorithms to identify re-ICH in the Danish Stroke Registry (DSR) and the Danish National Patient Registry (DNPR). Patients and Methods Using multiple sources, we followed-up an inception cohort with verified first-ever spontaneous ICH (n = 2528) for their first re-ICH in 2009-2018 (study period). We used verified cases of re-ICH (n = 124) as the gold standard to assess the performance of register-based algorithms for identifying re-ICH. For each cohort member, we traced events of re-ICH (ICD-10-code I61) in the study period according to DSR and DNPR, respectively. For each registry, we tested algorithms with a blanking period (BP) - ie, a period immediately following the index ICH during which outcome events were ignored - of varying length (7 days-360 days). The algorithm with the shortest BP that returned a positive predictive value (PPV) of ≥80% was considered optimal. We also calculated negative predictive value (NPV), sensitivity, and specificity of each algorithm and [95% confidence intervals] for all proportions. Results The optimal algorithm for DSR (BP 30 days) had a PPV of 89.5% [82.2-94.0], NPV 98.8% [98.2-99.1], sensitivity 75.8% [67.6-82.5], and specificity 99.5% [99.2-99.7]. The optimal algorithm for DNPR (BP 120 days) had a PPV of 80.6% [71.7-87.2], NPV 98.1% [97.5-98.6], sensitivity 63.7% [55.0-71.6], and specificity 99.2% [98.8-99.5]. Conclusion Simple algorithms accurately identified re-ICH in DSR and DNPR. Compared with DNPR, DSR achieved higher PPV and sensitivity with a shorter BP. The proposed algorithms could facilitate valid use of DSR and DNPR for studies of re-ICH.
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Affiliation(s)
| | - Stine Munk Hald
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Neurology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Nils Jensen Boe
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Neurology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - David Gaist
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Neurology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Open Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
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Shen J, Guo F, Yang P, Xu F. Influence of hypertension classification on hypertensive intracerebral hemorrhage location. J Clin Hypertens (Greenwich) 2021; 23:1992-1999. [PMID: 34608743 PMCID: PMC8630601 DOI: 10.1111/jch.14367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/17/2021] [Accepted: 09/03/2021] [Indexed: 01/01/2023]
Abstract
The authors sought to explore whether hypertension classification was risk factor for lobar and non‐lobar hypertensive intracerebral hemorrhage (HICH) and the prognosis in patients with hematoma. This retrospective cohort study was conducted on HICH patients admitted at the First Affiliated Hospital of Soochow University. Observations with first‐ever intracerebral hemorrhage (ICH) were recruited. The authors divided the brain image into three groups according to the location of ICH to predict whether there were significant differences between lobar and non‐lobar ICH. A Mann‐Whitney U test was used and this retrospective trial also compared the operation and mortality rates. Our cohort included 209 patients (73.7% male; median age:60.5±16.7). The overall incidence of lobar HICH was less than non‐lobar HICH (24.4% vs. 68.4%), 7.2% cases of mixed HICH was included in this analysis. In a Mann‐Whitney U test analyze, it indicated that there were significant differences in hypertension classification between lobar and non‐lobar HICH (Z = ‐3.3, p<.05). And the percentage of hematoma in lobar areas with relatively slightly high blood pressure (BP) (high normal and grade 1 hypertension) accounts for 52.9% versus 30.1% in non‐lobar areas. The increasing trends of the prevalent rate of lobar ICH with BP rising were not remarkable. The non‐lobar HICH showed a sharper increase in the condition of grade 3 hypertension compared with lobar HICH. During the period of research, the fatality of lobar hemorrhage was 2.9% versus 7.7% (non‐lobar). Besides, the fatality incidence of HICH with relatively slightly high BP (high normal and grade 1 hypertension) was lower than poorly controlled hypertensive patients (grade 2 and grade 3 hypertension). (8.0% vs. 15.7%). The increase of hypertension classification will aggravate the occurrence of non‐lobar ICH and positively corrected with BP, but not in lobar areas. It is essential to understand the distinction influence of hypertension classification between lobar and non‐lobar ICH.
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Affiliation(s)
- Jun Shen
- Department of Emergency Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - FengBao Guo
- Department of Emergency Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Peng Yang
- Department of Emergency Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Feng Xu
- Department of Emergency Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
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Loan JJM, Gane AB, Middleton L, Sargent B, Moullaali TJ, Rodrigues MA, Cunningham L, Wardlaw J, Salman RAS, Samarasekera N. Association of baseline hematoma and edema volumes with one-year outcome and long-term survival after spontaneous intracerebral hemorrhage: A community-based inception cohort study. Int J Stroke 2021; 16:828-839. [PMID: 34165016 PMCID: PMC8521378 DOI: 10.1177/1747493020974282] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Hospital-based studies have reported variable associations between outcome after spontaneous intracerebral hemorrhage and peri-hematomal edema volume. AIMS In a community-based study, we aimed to investigate the existence, strength, direction, and independence of associations between intracerebral hemorrhage and peri-hematomal edema volumes on diagnostic brain CT and one-year functional outcome and long-term survival. METHODS We identified all adults, resident in Lothian, diagnosed with first-ever, symptomatic spontaneous intracerebral hemorrhage between June 2010 and May 2013 in a community-based, prospective inception cohort study. We defined regions of interest manually and used a semi-automated approach to measure intracerebral hemorrhage volume, peri-hematomal edema volume, and the sum of these measurements (total lesion volume) on first diagnostic brain CT performed at ≤3 days after symptom onset. The primary outcome was death or dependence (scores 3-6 on the modified Rankin Scale) at one-year after intracerebral hemorrhage. RESULTS Two hundred ninety-two (85%) of 342 patients (median age 77.5 y, IQR 68-83, 186 (54%) female, median time from onset to CT 6.5 h (IQR 2.9-21.7)) were dead or dependent one year after intracerebral hemorrhage. Peri-hematomal edema and intracerebral hemorrhage volumes were colinear (R2 = 0.77). In models using both intracerebral hemorrhage and peri-hematomal edema, 10 mL increments in intracerebral hemorrhage (adjusted odds ratio (aOR) 1.72 (95% CI 1.08-2.87); p = 0.029) but not peri-hematomal edema volume (aOR 0.92 (0.63-1.45); p = 0.69) were independently associated with one-year death or dependence. 10 mL increments in total lesion volume were independently associated with one-year death or dependence (aOR 1.24 (1.11-1.42); p = 0.0004). CONCLUSION Total volume of intracerebral hemorrhage and peri-hematomal edema, and intracerebral hemorrhage volume alone on diagnostic brain CT, undertaken at three days or sooner, are independently associated with death or dependence one-year after intracerebral hemorrhage, but peri-hematomal edema volume is not. DATA ACCESS STATEMENT Anonymized summary data may be requested from the corresponding author.
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Affiliation(s)
- James JM Loan
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK,UK Dementia Research Institute at Edinburgh, University of Edinburgh, UK,James JM Loan, Centre for Clinical Brain Sciences, The University of Edinburgh, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.
| | - Angus B Gane
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | | | - Brendan Sargent
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Tom James Moullaali
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Mark A Rodrigues
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK,Department of Neuroradiology NHS Lothian, Edinburgh, UK
| | - Laura Cunningham
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK,UK Dementia Research Institute at Edinburgh, University of Edinburgh, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Neshika Samarasekera
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
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Wagner A, Groetsch C, Wilfling S, Schebesch KM, Kilic M, Nenkov M, Wendl C, Linker RA, Schlachetzki F. Index event of cerebral amyloid angiopathy (CAA) determines long-term prognosis and recurrent events (retrospective analysis and clinical follow-up). Neurol Res Pract 2021; 3:51. [PMID: 34565480 PMCID: PMC8474746 DOI: 10.1186/s42466-021-00152-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/17/2021] [Indexed: 11/25/2022] Open
Abstract
Background The modified Boston criteria (mBC) define the probability for the diagnosis of cerebral amyloid angiopathy (CAA). Its initial clinical presentation differs from asymptomatic cerebral microbleedings (cMBs), acute ischemic stroke (AIS), cortical hemosiderosis (cSS), to lobar ICH (lICH). Methods Retrospective analyses and clinical follow-ups of individuals with at least mBC “possible” CAA from 2005 to 2018. Results 149 patients were classified in subgroups due to the index event: lICH (n = 91), AIS (n = 32), > 3 cMBs only (n = 16) and cSS (n = 10). Patients in the lICH subgroup had a significantly higher percentage of single new lICHs compared to other groups, whereas patients in the AIS-group had a significantly higher percentage of multiple new AIS. cMBs as index event predisposed for AIS during follow up (p < 0.0016). Patients of the cMBs- or cSS-group showed significantly more TFNEs (transient focal-neurological episodes) and lower numbers of asymptomatic patients (for epilepsy and TFNEs) at the index event than patients with lICH or AIS (p < 0.0013). At long-term follow-up, the cMBs- and cSS-group were characterized by more TFNEs and fewer asymptomatic patients. Conclusions A new classification system of CAA should add subgroups according to the initial clinical presentation to the mBCs allowing individual prognosis, acute treatment and secondary prophylaxis. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00152-x.
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Affiliation(s)
- Andrea Wagner
- Department of Neurology, University of Regensburg, Bezirksklinikum, Universitätsstraße 84, 93053, Regensburg, Germany.
| | - Christiane Groetsch
- Department of Neurology, University of Regensburg, Bezirksklinikum, Universitätsstraße 84, 93053, Regensburg, Germany
| | - Sibylle Wilfling
- Department of Neurology, University of Regensburg, Bezirksklinikum, Universitätsstraße 84, 93053, Regensburg, Germany
| | - Karl-Michael Schebesch
- Department of Neurosurgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Mustafa Kilic
- Department of Neurology, University of Regensburg, Bezirksklinikum, Universitätsstraße 84, 93053, Regensburg, Germany
| | - Marjan Nenkov
- Department of Neurology, University of Regensburg, Bezirksklinikum, Universitätsstraße 84, 93053, Regensburg, Germany
| | - Christina Wendl
- Institute for Neuroradiology, University Hospital Regensburg and Bezirksklinikum, Universitätsstraße 84, 93053, Regensburg, Germany
| | - Ralf A Linker
- Department of Neurology, University of Regensburg, Bezirksklinikum, Universitätsstraße 84, 93053, Regensburg, Germany
| | - Felix Schlachetzki
- Department of Neurology, University of Regensburg, Bezirksklinikum, Universitätsstraße 84, 93053, Regensburg, Germany
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Xu TQ, Lin WZ, Feng YL, Shen FX, Chen J, Wu WW, Zhu XD, Gu L, Fu Y. Leukoaraiosis is associated with clinical symptom severity, poor neurological function prognosis and stroke recurrence in mild intracerebral hemorrhage: a prospective multi-center cohort study. Neural Regen Res 2021; 17:819-823. [PMID: 34472481 PMCID: PMC8530112 DOI: 10.4103/1673-5374.322469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Leukoaraiosis (LA) results from ischemic injury in small cerebral vessels, which may be attributable to decreased vascular density, reduced cerebrovascular angiogenesis, decreased cerebral blood flow, or microcirculatory dysfunction in the brain. In this study, we enrolled 357 patients with mild intracerebral hemorrhage (ICH) from five hospitals in China and analyzed the relationships between LA and clinical symptom severity at admission, neurological function prognosis at 3 months, and 1-year stroke recurrence. Patients were divided into groups based on Fazekas scale scores: no LA (n = 83), mild LA (n = 64), moderate LA (n = 98) and severe LA (n = 112). More severe LA, larger hematoma volume, and higher blood glucose level at admission were associated with more severe neurological deficit. More severe LA, older age and larger hematoma volume were associated with worse neurological function prognosis at 3 months. In addition, moderate-to-severe LA, admission glucose and symptom-free cerebral infarction were associated with 1-year stroke recurrence. These findings suggest that LA severity may be a potential marker of individual ICH vulnerability, which can be characterized by poor tolerance to intracerebral attack or poor recovery ability after ICH. Evaluating LA severity in patients with mild ICH may help neurologists to optimize treatment protocols. This study was approved by the Ethics Committee of Ruijin Hospital Affiliated to Shanghai Jiao Tong University (approval No. 12) on March 10, 2011.
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Affiliation(s)
- Tian-Qi Xu
- Department of Neurology, Ruijin Hospital/Luwan Branch, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei-Zhi Lin
- The Third Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian Province, China
| | - Yu-Lan Feng
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, China
| | - Fan-Xia Shen
- Department of Neurology, Ruijin Hospital/Luwan Branch, School of Medicine, Shanghai Jiao Tong University; Department of Neurology, Ruijin North Hospital, Shanghai, China
| | - Jie Chen
- Department of Neurology, Ruijin Hospital/Luwan Branch, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei-Wen Wu
- Department of Neurology, Zhongshan Hospital Qingpu Branch, Fudan University, Shanghai, China
| | - Xiao-Dong Zhu
- Department of Neurology, The First Hospital of Jiaxing, Jiaxing, Zhejiang Province, China
| | - Lin Gu
- Department of Rehabilitation, Shanghai Ruijin Rehabilitation Hospital, Shanghai, China
| | - Yi Fu
- Department of Neurology, Ruijin Hospital/Luwan Branch, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Wiegertjes K, Dinsmore L, Drever J, Hutchison A, Stephen J, Valdés Hernández MC, Bhatnagar P, Minks DP, Rodrigues MA, Werring DJ, de Leeuw FE, Klijn CJ, Al-Shahi Salman R, White PM, Wardlaw JM. Diffusion-weighted imaging lesions and risk of recurrent stroke after intracerebral haemorrhage. J Neurol Neurosurg Psychiatry 2021; 92:950-955. [PMID: 34103345 DOI: 10.1136/jnnp-2021-326116] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/07/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether the presence of diffusion-weighted imaging-positive (DWI+) lesions is associated with recurrent stroke after intracerebral haemorrhage (ICH). METHODS The REstart or STop Antithrombotics Randomised Trial (RESTART) assessed the effect of restarting versus avoiding antiplatelet therapy after ICH on major vascular events for up to 5 years. We rated DWI sequences of MRI done before randomisation for DWI+ lesion presence, masked to outcome and antiplatelet use. Cox proportional hazards regression models were used to quantify associations. RESULTS Of 537 participants in RESTART, 247 (median (IQR) age 75.7 (69.6-81.1) years; 170 men (68.8%); 120 started vs 127 avoided antiplatelet therapy) had DWI sequences on brain MRI at a median of 57 days (IQR 19-103) after ICH, of whom 73 (30%) had one or more DWI+ lesion. During a median follow-up of 2 years (1-3), 18 participants had recurrent ICH and 21 had ischaemic stroke. DWI+ lesion presence was associated with all stroke, (adjusted HR 2.2 (95% CI 1.1 to 4.2)) and recurrent ICH (4.8 (95% CI 1.8 to 13.2)), but not ischaemic stroke (0.9 (95% CI 0.3 to 2.5)). DWI+ lesion presence (0.5 (95% CI 0.2 to 1.3)) vs absence (0.6 (95% CI 0.3 to 1.5), pinteraction=0.66) did not modify the effect of antiplatelet therapy on a composite outcome of recurrent stroke. CONCLUSIONS DWI+ lesion presence in ICH survivors is associated with recurrent ICH, but not with ischaemic stroke. We found no evidence of modification of effects of antiplatelet therapy on recurrent stroke after ICH by DWI+ lesion presence. These findings provide a new perspective on the significance of DWI+ lesions, which may be markers of microvascular mechanisms associated with recurrent ICH. TRIAL REGISTRATION NUMBER ISRCTN71907627.
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Affiliation(s)
- Kim Wiegertjes
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lynn Dinsmore
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Jonathan Drever
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Aidan Hutchison
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Maria C Valdés Hernández
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK.,Row Fogo Centre for Research into Ageing and the Brain, The University of Edinburgh, Edinburgh, UK.,Edinburgh Imaging, The University of Edinburgh, Edinburgh, UK
| | - Priya Bhatnagar
- Department of Neuroradiology, Newcastle-upon-Tyne Hospitals NHS Trust, Newcastle-upon-Tyne, UK
| | - David P Minks
- Department of Neuroradiology, Newcastle-upon-Tyne Hospitals NHS Trust, Newcastle-upon-Tyne, UK
| | - Mark A Rodrigues
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK.,Edinburgh Imaging, The University of Edinburgh, Edinburgh, UK
| | - David J Werring
- Stroke Research Centre, Queen Square Institute of Neurology, University College London, London, UK
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Catharina Jm Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK .,Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Phillip M White
- Translational and Clinical Research Institute, The University of Newcastle, Newcastle-upon-Tyne, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK.,Row Fogo Centre for Research into Ageing and the Brain, The University of Edinburgh, Edinburgh, UK.,Edinburgh Imaging, The University of Edinburgh, Edinburgh, UK.,Dementia Research Institute, The University of Edinburgh, Edinburgh, UK
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Yang Y, Chen X, Feng Z, Cai X, Zhu X, Cao M, Yang L, Chen Y, Wang Y, Feng H. MEC17-induced α-tubulin acetylation restores mitochondrial transport function and alleviates axonal injury after intracerebral hemorrhage in mice. J Neurochem 2021; 160:51-63. [PMID: 34407220 DOI: 10.1111/jnc.15493] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/25/2021] [Accepted: 08/09/2021] [Indexed: 02/01/2023]
Abstract
Injury to long axonal projections is a central pathological feature at the early phase of intracerebral hemorrhage (ICH). It has been reported to contribute to persistent functional disability following ICH. However, the molecular mechanisms that drive axonal degeneration remain unclear. Autologous blood was injected into the striatum to mimic the pathology of ICH. Observed significant swollen axons with characteristic retraction bulbs were found around the striatal hematoma at 24 h after ICH. Electronic microscopic examination revealed highly disorganized microtubule and swollen mitochondria in the retraction bulbs. MEC17 is a specific α-tubulin acetyltransferase, ablation of acetylated α-tubulin in MEC17-/- mice aggravated axonal injury, axonal transport mitochondria dysfunction, and motor dysfunction. In contrast, treatment with tubastatin A (TubA), which promotes microtubule acetylation, significantly alleviated axonal injury and protected the integrity of the corticospinal tract and fine motor function after ICH. Moreover, results showed that 41% mitochondria were preferentially bundled to the acetylated α-tubulin in identifiable axons and dendrites in primary neurons. This impaired axonal transport of mitochondria in primary neurons of MEC17-/- mice. Given that opening of mitochondrial permeability transition pore (mPTP) induces mitochondrial dysfunction and impairs ATP supply thereby promoting axonal injury, we enhanced the availability of acetylated α-tubulin using TubA and inhibited mPTP opening with cyclosporin A. The results indicated that this combined treatment synergistically protected corticospinal tract integrity and promoted fine motor control recovery. These findings reveal key intracellular mechanisms that drive axonal degeneration after ICH and highlight the need to target multiple factors and respective regulatory mechanisms as an effective approach to prevent axonal degeneration and motor dysfunction after ICH.
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Affiliation(s)
- Yang Yang
- Department of Neurosurgery, The 904th Hospital of PLA, School of Medicine of Anhui Medical University, Wuxi, Jiangsu Province, China.,Department of Neurosurgery and State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University, Chongqing, China.,Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Third Military Medical University (Army Medical University, Chongqing, China.,Wuxi Translational Medicine Center, Wuxi, Jiangsu, China
| | - Xuezhu Chen
- Department of Neurosurgery and State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University, Chongqing, China.,Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Third Military Medical University (Army Medical University, Chongqing, China
| | - Zhizhong Feng
- Department of Neurosurgery, The 904th Hospital of PLA, School of Medicine of Anhui Medical University, Wuxi, Jiangsu Province, China
| | - Xianfeng Cai
- Department of Neurosurgery, The 904th Hospital of PLA, School of Medicine of Anhui Medical University, Wuxi, Jiangsu Province, China
| | - Xiaoming Zhu
- Department of Neurosurgery, The 904th Hospital of PLA, School of Medicine of Anhui Medical University, Wuxi, Jiangsu Province, China
| | - Ming Cao
- Department of Neurosurgery, The 904th Hospital of PLA, School of Medicine of Anhui Medical University, Wuxi, Jiangsu Province, China
| | - Likun Yang
- Department of Neurosurgery, The 904th Hospital of PLA, School of Medicine of Anhui Medical University, Wuxi, Jiangsu Province, China.,Wuxi Translational Medicine Center, Wuxi, Jiangsu, China
| | - Yujie Chen
- Department of Neurosurgery and State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University, Chongqing, China.,Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Third Military Medical University (Army Medical University, Chongqing, China
| | - Yuhai Wang
- Department of Neurosurgery, The 904th Hospital of PLA, School of Medicine of Anhui Medical University, Wuxi, Jiangsu Province, China.,Wuxi Translational Medicine Center, Wuxi, Jiangsu, China
| | - Hua Feng
- Department of Neurosurgery and State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University, Chongqing, China.,Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Third Military Medical University (Army Medical University, Chongqing, China
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40
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Forti P, Maioli F, Zoli M. Association of early glycemic change with short-term mortality in lobar and non-lobar intracerebral hemorrhage. Sci Rep 2021; 11:16059. [PMID: 34373518 PMCID: PMC8352939 DOI: 10.1038/s41598-021-95453-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022] Open
Abstract
The association between early glycemic change and short-term mortality in non-diabetic patients with acute intracerebral hemorrhage (ICH) is unclear. We retrospectively investigated non-diabetic patients with lobar (n = 262) and non-lobar ICH (n = 370). Each patient had a random serum glucose test on hospital admission and a fasting serum glucose test within the following 48 h. Hyperglycemia was defined as serum glucose ≥ 7.8 mmol/l. Four patterns were determined: no hyperglycemia (reference category), persistent hyperglycemia, delayed hyperglycemia, and decreasing hyperglycemia. Associations with 30-day mortality were estimated using Cox models adjusted for major features of ICH severity. Persistent hyperglycemia was associated with 30-day mortality in both lobar (HR 3.00; 95% CI 1.28–7.02) and non-lobar ICH (HR 4.95; 95% CI 2.20–11.09). In lobar ICH, 30-day mortality was also associated with delayed (HR 4.10; 95% CI 1.77–9.49) and decreasing hyperglycemia (HR 2.01, 95% CI 1.09–3.70). These findings were confirmed in Cox models using glycemic change (fasting minus random serum glucose) as a continuous variable. Our study shows that, in non-diabetic patients with ICH, early persistent hyperglycemia is an independent predictor of short-term mortality regardless of hematoma location. Moreover, in non-diabetic patients with lobar ICH, both a positive and a negative glycemic change are associated with short-term mortality.
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Affiliation(s)
- Paola Forti
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
| | - Fabiola Maioli
- Medical Department of Integrated Care Models, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Marco Zoli
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
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3D-Printed Endoport vs. Open Surgery for Evacuation of Deep Intracerebral Hemorrhage. Can J Neurol Sci 2021; 49:636-643. [PMID: 34321123 DOI: 10.1017/cjn.2021.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Robinson D, Van Sanford C, Kwon SY, Coleman E, Sekar P, Murphy R, Flaherty ML, Demel SL, Aziz Y, Moomaw CJ, Haverbusch M, Khoury J, Adeoye O, Walsh KB, Broderick JP, Woo D. What is the median volume of intracerebral hemorrhage and is it changing? Int J Stroke 2021; 17:576-582. [PMID: 34190652 DOI: 10.1177/17474930211032594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Population-level estimates of the median intracerebral hemorrhage (ICH) volume would allow for the evaluation of clinical trial external validity and determination of temporal trends. We previously reported the median ICH volume in 1988. However, differences in risk factor management, neuroimaging, and demographics may have affected ICH volumes. The goal of this study is to determine the median volume of ICH within a population-based cross-sectional study, including whether it has changed over time. METHODS The Genetic and Environmental Risk Factors for Hemorrhagic Stroke study was a population-based study of ICH among residents of the Greater Cincinnati/Northern Kentucky region from 2008 through 2012. This study utilizes those data and compares with ICH cases from the same region in 1988. Initial computed tomography images of the head were reviewed, and ICH volumes were calculated using consistent methodology. RESULTS From 2008 through 2012, we identified 1117 cases of ICH. The median volume of ICH was 14.0 mL and was lower in black (11.6) than in white (15.5) patients. Median volumes of lobar and deep ICH were 28.8 mL and 9.8 mL, respectively. Median ICH volume changed significantly from 1988 to 2008-2012, with age-and-race-adjusted volume decreasing from 18.3 mL to 13.76 mL (p = 0.025). CONCLUSIONS Median volume of ICH was 13.76 mL, and this should be considered in clinical trial design. Median ICH volume has apparently decreased from 1988 to 2008-2012.
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Affiliation(s)
- David Robinson
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Carson Van Sanford
- Department of Neurology, Providence Regional Medical Center, Everett, WA, USA
| | - Soo Young Kwon
- Department of Neurology, University of Alabama, Birmingham, Birmingham, AL, USA
| | - Elisheva Coleman
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Padmini Sekar
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ryan Murphy
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Matthew L Flaherty
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stacie L Demel
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Yasmin Aziz
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Charles J Moomaw
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mary Haverbusch
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jane Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Opeolu Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Kyle B Walsh
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Chung J, Hamilton G, Kim M, Marini S, Montgomery B, Henry J, Cho AE, Brown DL, Worrall BB, Meschia JF, Silliman SL, Selim M, Tirschwell DL, Kidwell CS, Kissela B, Greenberg SM, Viswanathan A, Goldstein JN, Langefeld CD, Rannikmae K, Sudlow CLM, Samarasekera N, Rodrigues M, Al-Shahi Salman R, Prendergast JGD, Harris SE, Deary I, Woo D, Rosand J, Van Agtmael T, Anderson CD. Rare Missense Functional Variants at COL4A1 and COL4A2 in Sporadic Intracerebral Hemorrhage. Neurology 2021; 97:e236-e247. [PMID: 34031201 PMCID: PMC8302151 DOI: 10.1212/wnl.0000000000012227] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/19/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To test the genetic contribution of rare missense variants in COL4A1 and COL4A2 in which common variants are genetically associated with sporadic intracerebral hemorrhage (ICH), we performed rare variant analysis in multiple sequencing data for the risk for sporadic ICH. METHODS We performed sequencing across 559 Kbp at 13q34 including COL4A1 and COL4A2 among 2,133 individuals (1,055 ICH cases; 1,078 controls) in United States-based and 1,381 individuals (192 ICH cases; 1,189 controls) from Scotland-based cohorts, followed by sequence annotation, functional impact prediction, genetic association testing, and in silico thermodynamic modeling. RESULTS We identified 107 rare nonsynonymous variants in sporadic ICH, of which 2 missense variants, rs138269346 (COL4A1I110T) and rs201716258 (COL4A2H203L), were predicted to be highly functional and occurred in multiple ICH cases but not in controls from the United States-based cohort. The minor allele of rs201716258 was also present in Scottish patients with ICH, and rs138269346 was observed in 2 ICH-free controls with a history of hypertension and myocardial infarction. Rs138269346 was nominally associated with nonlobar ICH risk (p = 0.05), but not with lobar ICH (p = 0.08), while associations between rs201716258 and ICH subtypes were nonsignificant (p > 0.12). Both variants were considered pathogenic based on minor allele frequency (<0.00035 in European populations), predicted functional impact (deleterious or probably damaging), and in silico modeling studies (substantially altered physical length and thermal stability of collagen). CONCLUSIONS We identified rare missense variants in COL4A1/A2 in association with sporadic ICH. Our annotation and simulation studies suggest that these variants are highly functional and may represent targets for translational follow-up.
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Affiliation(s)
- Jaeyoon Chung
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Graham Hamilton
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Minsup Kim
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Sandro Marini
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Bailey Montgomery
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Jonathan Henry
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Art E Cho
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Devin L Brown
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Bradford B Worrall
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - James F Meschia
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Scott L Silliman
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Magdy Selim
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - David L Tirschwell
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Chelsea S Kidwell
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Brett Kissela
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Steven M Greenberg
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Anand Viswanathan
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Joshua N Goldstein
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Carl D Langefeld
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Kristiina Rannikmae
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Catherine L M Sudlow
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Neshika Samarasekera
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Mark Rodrigues
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Rustam Al-Shahi Salman
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - James G D Prendergast
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Sarah E Harris
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Ian Deary
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Daniel Woo
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Jonathan Rosand
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Tom Van Agtmael
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Christopher D Anderson
- From the Center for Genomic Medicine (J.C., S.M., B.M., J.H., J.R., C.D.A.), Department of Neurology (B.M., J.H., S.M.G., A.V., J.R., C.D.A.), McCance Center for Brain Health (J.H., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (J.C., J.R., C.D.A.), Broad Institute, Boston, MA; Glasgow Polyomics, Wolfson Wohl Cancer Research Centre, Garscube Campus (G.H.), and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (G.H., T.V.A.), University of Glasgow, Bearsden, UK; Department of Bioinformatics (M.K., A.E.C.), Korea University, Sejong, South Korea; Stroke Program, Department of Neurology (D.L.B.), University of Michigan, Ann Arbor; Department of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (J.F.M.), Mayo Clinic Jacksonville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Department of Neurology, Stroke Division (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology, Harborview Medical Center (D.L.T.), University of Washington, Seattle; Department of Neurology (C.S.K.), The University of Arizona, Tucson; Department of Neurology and Rehabilitation Medicine (B.K., D.W.), University of Cincinnati, OH; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; Centre for Medical Informatics, Usher Institute (K.R., C.L.M.S.), Centre for Clinical Brain Sciences (N.S., M.R., R.A.-S.S.), The Roslin Institute (J.G.D.P.), and Lothian Birth Cohorts Group, Department of Psychology (S.E.H., I.D.), University of Edinburgh; and British Heart Foundation Data Science Centre (K.R.), London, UK. Dr. Anderson is currently at the Department of Neurology, Brigham and Women's Hospital, Boston, MA
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Li L, Poon MTC, Samarasekera NE, Perry LA, Moullaali TJ, Rodrigues MA, Loan JJM, Stephen J, Lerpiniere C, Tuna MA, Gutnikov SA, Kuker W, Silver LE, Al-Shahi Salman R, Rothwell PM. Risks of recurrent stroke and all serious vascular events after spontaneous intracerebral haemorrhage: pooled analyses of two population-based studies. Lancet Neurol 2021; 20:437-447. [PMID: 34022170 PMCID: PMC8134058 DOI: 10.1016/s1474-4422(21)00075-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 12/11/2020] [Accepted: 02/25/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with stroke due to spontaneous (non-traumatic) intracerebral haemorrhage (ICH) are at risk of recurrent ICH, ischaemic stroke, and other serious vascular events. We aimed to analyse these risks in population-based studies and compare them with the risks in RESTART, which assessed antiplatelet therapy after ICH. METHODS We pooled individual patient data from two prospective, population-based inception cohort studies of all patients with an incident firs-in-a-lifetime ICH in Oxfordshire, England (Oxford Vascular Study; April 1, 2002, to Sept 28, 2018) and Lothian, Scotland, UK (Lothian Audit of the Treatment of Cerebral Haemorrhage; June 1, 2010, to May 31, 2013). We quantified the absolute and relative risks of recurrent ICH, ischaemic stroke, or any serious vascular event (non-fatal stroke, non-fatal myocardial infarction, or vascular death), stratified by ICH location (lobar vs non-lobar) and comorbid atrial fibrillation (AF). We compared pooled event rates with those after allocation to avoid antiplatelet therapy in RESTART. FINDINGS Among 674 patients (mean age 74·7 years [SD 12·6], 320 [47%] men) with 1553 person-years of follow-up, 46 recurrent ICHs (event rate 3·2 per 100 patient-years, 95% CI 2·0-5·1) and 25 ischaemic strokes (1·7 per 100 patient-years, 0·8-3·3) were reported. Patients with lobar ICH (n=317) had higher risk of recurrent ICH (5·1 per 100 patient-years, 95% CI 3·6-7·2) than patients with non-lobar ICH (n=355; 1·8 per 100 patient-years, 1·0-3·3; hazard ratio [HR] 3·2, 95% CI 1·6-6·3; p=0·0010), but there was no evidence of a difference in the risk of ischaemic stroke (1·8 per 100 patient-years, 1·0-3·2, vs 1·6 per 100 patient-years, 0·6-4·4; HR 1·1, 95% CI 0·5-2·8). Conversely, there was no evidence of a difference in recurrent ICH rate in patients with AF (n=147; 3·3 per 100 patient-years, 95% CI 1·0-10·7) compared with those without (n=526; 3·2 per 100 patient-years, 2·2-4·7; HR 0·9, 95% CI 0·4-2·1), but the risk of ischaemic stroke was higher with AF (6·3 per 100 patient-years, 3·7-10·9, vs 0·7 per 100 patient-years, 0·1-5·6; HR 8·2, 3·3-20·3; p<0·0001), resulting in patients with AF having a higher risk of all serious vascular events than patients without AF (15·5 per 100 patient-years, 10·0-24·1, vs 6·8 per 100 patient-years, 3·6-12·5; HR 1·78, 95% CI 1·16-2·74; p=0·0090). Only for patients with lobar ICH without comorbid AF was the risk of recurrent ICH greater than the risk of ischaemic stroke (5·2 per 100 patient-years, 95% CI 3·6-7·5, vs 0·9 per 100 patient-years, 0·2-4·8; p=0·00034). Comparing data from the pooled population-based studies with that from patients allocated to not receive antiplatelet therapy in RESTART, there was no evidence of a difference in the rate of recurrent ICH (3·5 per 100 patient-years, 95% CI 1·9-6·0, vs 4·4 per 100 patient-years, 2·6-6·1) or ischaemic stroke (3·4 per 100 patient-years, 1·9-5·9, vs 5·3 per 100 patient-years, 3·3-7·2). INTERPRETATION The risks of recurrent ICH, ischaemic stroke, and all serious vascular events after ICH differ by ICH location and comorbid AF. These data enable risk stratification of patients in clinical practice and ongoing randomised trials. FUNDING UK Medical Research Council, Stroke Association, British Heart Foundation, Wellcome Trust, and the National Institute for Health Research Oxford Biomedical Research Centre.
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Affiliation(s)
- Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Michael T C Poon
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Luke A Perry
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Tom J Moullaali
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; The George Institute for Global Health, Sydney, NSW, Australia
| | - Mark A Rodrigues
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; Department of Neuroradiology, NHS Lothian, Edinburgh, UK
| | - James J M Loan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; Centre for Discovery Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Maria A Tuna
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sergei A Gutnikov
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Wilhelm Kuker
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Louise E Silver
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; Usher Institute, University of Edinburgh, Edinburgh, UK.
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Humphreys CA, Smith C, Wardlaw JM. Correlations in post-mortem imaging-histopathology studies of sporadic human cerebral small vessel disease: A systematic review. Neuropathol Appl Neurobiol 2021; 47:910-930. [PMID: 34037264 DOI: 10.1111/nan.12737] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/29/2021] [Accepted: 05/02/2021] [Indexed: 11/30/2022]
Abstract
AIMS Sporadic human cerebral small vessel disease (SVD) commonly causes stroke and dementia but its pathogenesis is poorly understood. There are recognised neuroimaging and histopathological features. However, relatively few studies have examined the relationship between the radiological and pathological correlates of SVD; better correlation would promote greater insight into the underlying biological changes. METHODS We performed a systematic review to collate and appraise the information derived from studies that correlated histological with neuroimaging-defined SVD lesions. We searched for studies describing post-mortem imaging and histological tissue examination in adults, extracted data from published studies, categorised the information and compiled this narrative. RESULTS We identified 38 relevant studies, including at least 1146 subjects, 342 of these with SVD: 29 studies focussed on neuroradiological white matter lesions (WML), six on microinfarcts and three on dilated perivascular spaces (PVS) and lacunes. The histopathology terminology was diverse with few robust definitions. Reporting and methodology varied widely between studies, precluding formal meta-analysis. PVS and 'oedema' were frequent findings in WML, being described in at least 94 and 18 radiological WML, respectively, in addition to myelin pallor. Histopathological changes extended beyond the radiological lesion margins in at least 33 radiological WML. At least 43 radiological lesions not seen pathologically and at least 178 histological lesions were not identified on imaging. CONCLUSIONS Histopathological assessment of human SVD is hindered by inconsistent methodological approaches and unstandardised definitions. The data from this systematic review will help to develop standardised definitions to promote consistency in human SVD research.
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Affiliation(s)
| | - Colin Smith
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,UK Dementia Research Institute at The University of Edinburgh, Edinburgh, UK.,Row Fogo Centre for Research into Ageing and the Brain, Edinburgh, UK
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Ye X, Li G, Liu X, Song G, Jia Y, Wu C, Wang X, Huang S, Zhu S. Apolipoprotein E genotype predicts subarachnoid extension in spontaneous intracerebral haemorrhage. Eur J Neurol 2021; 28:1992-1999. [PMID: 33738891 DOI: 10.1111/ene.14830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/12/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracerebral haemorrhage (ICH) with subarachnoid extension (SAHE) predicts poor outcomes and haematoma expansion in spontaneous ICH and is also a potential predictor of the severity of vascular amyloid deposition. The biological underpinnings of SAHE remain elusive. A study was conducted to identify risk factors associated with SAHE. METHODS A retrospective analysis was performed of an ongoing prospective cohort of primary spontaneous supratentorial ICH patients admitted to Tongji Hospital. SAHE was rated on baseline noncontrast computed tomography images by investigators blinded to the clinical data. RESULTS A total of 189 patients were enrolled. Apolipoprotein E (APOE) ε2 copies (p = 0.020), but not APOE ε4 copies (p > 0.2), were more common in patients with SAHE in univariate analysis. After controlling for confounding factors in multiple logistic regression, lobar haematoma (odds ratio [OR] 14.21, 95% confidence interval [CI] 5.89-34.33; p < 0.001), large haematoma volume (OR 1.04, 95% CI 1.02-1.06; p < 0.001) and APOE ε2 copies (OR 3.07, 95% CI 1.05-8.97; p = 0.041) were three independent predictors of SAHE. For subgroup analysis stratified by location, APOE ε2 showed a possible association with SAHE in lobar ICH (p = 0.026) but not in deep ICH (p > 0.2). No significant association was found between APOE ε4 copies and either lobar (p > 0.2) or deep ICH (p > 0.2). CONCLUSIONS The APOE ε2 allele predicts SAHE in spontaneous supratentorial ICH. The association may predominantly apply to lobar ICH. Given the established relationship between the APOE ε2 allele and pathological cerebrovascular changes, our findings suggest that SAHE involves genetically driven vessel pathology.
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Affiliation(s)
- Xiaodong Ye
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guo Li
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyan Liu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guini Song
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuchao Jia
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunmei Wu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiong Wang
- Department of Laboratory Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shanshan Huang
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Tseng WC, Wang YF, Wang TG, Hsiao MY. Early spot sign is associated with functional outcomes in primary intracerebral hemorrhage survivors. BMC Neurol 2021; 21:131. [PMID: 33743639 PMCID: PMC7980675 DOI: 10.1186/s12883-021-02146-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 03/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The computed tomography angiography (CTA) spot sign is a validated predictor of hematoma expansion and 30-day mortality in intracerebral hemorrhage (ICH). However, whether the spot sign predicts worse functional outcomes among ICH survivors remains unclear. This study investigated the frequency of the spot sign and its association with functional outcomes and length of hospital stay among ICH survivors. METHODS This was a retrospective analysis of consecutive patients with primary ICH who received CTA within 24 h from presentation to admission to the emergency department of a single medical center between January 2007 and December 2017. Patients who died before discharge and those referred from other hospitals were excluded. CTAs with motion artifacts were excluded from the analysis. The presence of a spot sign was examined by an experienced neuroradiologist. Functional outcomes were determined based on the modified Rankin Scale (mRS) score and Barthel Index (BI). Severe dependency in activities of daily living (ADL) was defined as BI of ≤60 and severe disability as an mRS score of ≥4. Odds ratio (OR) and multiple linear regression were used as measures of association. RESULTS In total, 66 patients met the inclusion criteria, of whom 9 (13.64%) were positive for a spot sign. No significant differences were observed in baseline characteristics between patients with and without a spot sign. Patients with a spot sign tended to be severely dependent in ADL at discharge (66.67% vs 41.07%; OR = 2.87; p = 0.15) and were more likely to require ICH-related surgery (66.67% vs 24.56%; OR = 6.14; p = 0.01). In multiple linear regression, patients with a higher spot sign score had a significantly longer hospital stay (coefficient = 9.57; 95% CI = 2.11-17.03; p = 0.013). CONCLUSIONS The presence of a spot sign is a common finding and is associated with longer hospital stay and possibly worse functional outcomes in ICH survivors.
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Affiliation(s)
- Wen-Che Tseng
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd., Taipei, Taiwan
| | - Yu-Fen Wang
- Department of Medical Imaging, National Taiwan University Hospital, 7, Zhongshan S. Rd., Taipei, Taiwan
| | - Tyng-Guey Wang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd., Taipei, Taiwan.,Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, 7, Zhongshan S. Rd., Taipei, Taiwan
| | - Ming-Yen Hsiao
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd., Taipei, Taiwan. .,Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, 7, Zhongshan S. Rd., Taipei, Taiwan.
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Deep versus Superficial Spontaneous Cerebellar Hemorrhages: Separated Vascular Etiologies with Different Clinical Consequences. World Neurosurg 2021; 150:e436-e444. [PMID: 33727202 DOI: 10.1016/j.wneu.2021.03.035] [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: 02/15/2021] [Revised: 03/05/2021] [Accepted: 03/06/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Spontaneous cerebellar hemorrhage (CH) is a critical neurosurgical event. It is usually categorized as a homogenous group under the general term of deep/nonlobar intracerebral hemorrhage. However, increasing evidence suggests it is composed of 2 subgroups, separated from each other by their anatomic location (deep vs. superficial), as well as by their vascular etiology (small vessel disease vs. cerebral amyloid angiopathy). OBJECTIVE To identify any clinically significant differences between anatomically separated subgroups of CHs: deep versus superficial. METHODS This is a retrospective study on patients who were diagnosed with spontaneous CHs at a single tertiary center. On the basis of the radiologic location of the hematoma, patients were divided into 2 groups: deep (group 1) and superficial (group 2). Computerized medical records were extracted for multiple variables. RESULTS A total of 69 patients fulfilled the inclusion criteria. Fifty-three (77%) were in group 1, and 16 (23%) were in group 2. Having any vascular risk factor was associated with the highest odds ratio for having a deep CH. Morbid obesity (body mass index ≥30) and the use of antiplatelets were also associated with increased odds ratios. Group 1 is also associated with high prevalence of intraventricular hemorrhage, acute hydrocephalus, and less favorable outcome. CONCLUSIONS This study supports the notion that CH is most likely a heterogenous condition, composed of 2 subgroups, separated from each other in terms of anatomic location, vascular etiologies, and clinical consequences. Further studies on large cohort of patients are needed in order to accurately define the subgroups of this life-threatening event.
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Hostettler IC, Schwarz G, Ambler G, Wilson D, Banerjee G, Seiffge DJ, Shakeshaft C, Lunawat S, Cohen H, Yousry TA, Al-Shahi Salman R, Lip GYH, Brown MM, Muir KW, Houlden H, Jäger HR, Werring DJ. Cerebral Small Vessel Disease and Functional Outcome Prediction After Intracerebral Hemorrhage. Neurology 2021; 96:e1954-e1965. [PMID: 33627495 DOI: 10.1212/wnl.0000000000011746] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 01/08/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether CT-based cerebral small vessel disease (SVD) biomarkers are associated with 6-month functional outcome after intracerebral hemorrhage (ICH) and whether these biomarkers improve the performance of the preexisting ICH prediction score. METHODS We included 864 patients with acute ICH from a multicenter, hospital-based prospective cohort study. We evaluated CT-based SVD biomarkers (white matter hypodensities [WMH], lacunes, brain atrophy, and a composite SVD burden score) and their associations with poor 6-month functional outcome (modified Rankin Scale score >2). The area under the receiver operating characteristic curve (AUROC) and Hosmer-Lemeshow test were used to assess discrimination and calibration of the ICH score with and without SVD biomarkers. RESULTS In multivariable models (adjusted for ICH score components), WMH presence (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.12-2.06), cortical atrophy presence (OR 1.80, 95% CI 1.19-2.73), deep atrophy presence (OR 1.66, 95% CI 1.17-2.34), and severe atrophy (either deep or cortical) (OR 1.94, 95% CI 1.36-2.74) were independently associated with poor functional outcome. For the revised ICH score, the AUROC was 0.71 (95% CI 0.68-0.74). Adding SVD markers did not significantly improve ICH score discrimination; for the best model (adding severe atrophy), the AUROC was 0.73 (95% CI 0.69-0.76). These results were confirmed when lobar and nonlobar ICH were considered separately. CONCLUSIONS The ICH score has acceptable discrimination for predicting 6-month functional outcome after ICH. CT biomarkers of SVD are associated with functional outcome, but adding them does not significantly improve ICH score discrimination. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT02513316.
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Affiliation(s)
- Isabel C Hostettler
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Ghil Schwarz
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Gareth Ambler
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Duncan Wilson
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Gargi Banerjee
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - David J Seiffge
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Clare Shakeshaft
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Surabhika Lunawat
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Hannah Cohen
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Tarek A Yousry
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Rustam Al-Shahi Salman
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Gregory Y H Lip
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Martin M Brown
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Keith W Muir
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Henry Houlden
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Hans Rolf Jäger
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - David J Werring
- From the Stroke Research Centre (I.C.H., G.S., D.W., G.B., D.J.S., C.S., S.L., M.M.B., D.J.W.), University College London, Queen Square Institute of Neurology; Department of Neurology (G.S.), Stroke Unit, San Raffaele Hospital, Milan, Italy; Department of Statistical Science (G.A.), University College London, Gower Street, UK; Department of Neurology and Stroke Center (D.J.S.), Inselspital, Bern, Switzerland; Haemostasis Research Unit (H.C.), Department of Haematology, University College London, Chenies Mews; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (T.A.Y., H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London; Centre for Clinical Brain Sciences (R.A.-S.S.), School of Clinical Sciences, University of Edinburgh; Liverpool Centre for Cardiovascular Science (G.Y.H.L.), Liverpool Heart and Chest Hospital, University of Liverpool; Institute of Neuroscience & Psychology (K.W.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow; and Department of Molecular Neuroscience (H.H.), UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London.
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Schuss P, Bode C, Borger V, Coch C, Güresir Á, Hadjiathanasiou A, Hamed M, Kuchelmeister K, Lehmann F, Müller M, Schneider M, Solymosi L, Vatter H, Velten M, Güresir E. MR-Imaging and Histopathological Diagnostic Work-Up of Patients with Spontaneous Lobar Intracerebral Hemorrhage: Results of an Institutional Prospective Registry Study. Diagnostics (Basel) 2021; 11:diagnostics11020368. [PMID: 33671532 PMCID: PMC7926429 DOI: 10.3390/diagnostics11020368] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/15/2021] [Accepted: 02/19/2021] [Indexed: 02/06/2023] Open
Abstract
Intracerebral hemorrhage (ICH) is a frequently disabling or fatal disease. The localization of ICH often allows an etiological association. However, in atypical/lobar ICH, the cause of bleeding is less obvious. Therefore, we present prospective histopathological and radiological studies which were conducted within the diagnostic workup to identify causes for lobar ICH other than hypertension. From 2016 to 2018, 198 patients with spontaneous, non-traumatic ICH requiring neurosurgical monitoring were enrolled in an institutional prospective patient registry. Patients with deep-seated ICH and/or hemorrhagically transformed cerebral infarcts were excluded from further analysis. Data to evaluate the source of bleeding based on histopathological and/or radiological workup were prospectively evaluated and analyzed. After applying the inclusion criteria and excluding patients with incomplete diagnostic workup, a total of 52 consecutive patients with lobar ICH were further analyzed. Macrovascular disease was detected in 14 patients with lobar ICH (27%). In 11 patients, diagnostic workup identified cerebral amyloid angiopathy-related ICH (21%). In addition, five patients with tumor-related ICH (10%) and six patients with ICH based on infectious pathologies (11%) were identified. In four patients, the cause of bleeding remained unknown despite extensive diagnostic workup (8%). The present prospective registry study demonstrates a higher probability to identify a cause of bleeding other than hypertension in patients with lobar ICH. Therefore, a thorough diagnostic work-up in patients with ICH is essential to accelerate treatment and further improve outcome or prevent rebleeding.
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Affiliation(s)
- Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (V.B.); (Á.G.); (A.H.); (M.H.); (M.S.); (H.V.); (E.G.)
- Correspondence:
| | - Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (C.B.); (F.L.); (M.V.)
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (V.B.); (Á.G.); (A.H.); (M.H.); (M.S.); (H.V.); (E.G.)
| | - Christoph Coch
- Study Center Bonn (SZB), Clinical Study Core Unit, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany;
| | - Ági Güresir
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (V.B.); (Á.G.); (A.H.); (M.H.); (M.S.); (H.V.); (E.G.)
| | - Alexis Hadjiathanasiou
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (V.B.); (Á.G.); (A.H.); (M.H.); (M.S.); (H.V.); (E.G.)
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (V.B.); (Á.G.); (A.H.); (M.H.); (M.S.); (H.V.); (E.G.)
| | - Klaus Kuchelmeister
- Institute of Neuropathology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany;
| | - Felix Lehmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (C.B.); (F.L.); (M.V.)
| | - Marcus Müller
- Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany;
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (V.B.); (Á.G.); (A.H.); (M.H.); (M.S.); (H.V.); (E.G.)
| | - László Solymosi
- Department of Neuroradiology, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany;
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (V.B.); (Á.G.); (A.H.); (M.H.); (M.S.); (H.V.); (E.G.)
| | - Markus Velten
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (C.B.); (F.L.); (M.V.)
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (V.B.); (Á.G.); (A.H.); (M.H.); (M.S.); (H.V.); (E.G.)
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