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Woodhouse LJ, Appleton JP, Christensen H, Dineen RA, England TJ, James M, Krishnan K, Montgomery AA, Ranta A, Robinson TG, Sprigg N, Bath PM. Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia. Sci Rep 2023; 13:11717. [PMID: 37474599 PMCID: PMC10359249 DOI: 10.1038/s41598-023-38474-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 07/09/2023] [Indexed: 07/22/2023] Open
Abstract
Intensive antiplatelet therapy did not reduce recurrent stroke/transient ischaemic attack (TIA) events as compared with guideline treatment in the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial, but did increase the frequency and severity of bleeding. In this pre-specified analysis, we investigated predictors of bleeding and the association of bleeding with outcome. TARDIS was an international prospective randomised open-label blinded-endpoint trial in participants with ischaemic stroke or TIA within 48 h of onset. Participants were randomised to 30 days of intensive antiplatelet therapy (aspirin, clopidogrel, dipyridamole) or guideline-based therapy (either clopidogrel alone or combined aspirin and dipyridamole). Bleeding was defined using the International Society on Thrombosis and Haemostasis five-level ordered categorical scale: fatal, major, moderate, minor, none. Of 3,096 participants, bleeding severity was: fatal 0.4%, major 1.5%, moderate 1.2%, minor 11.4%, none 85.5%. Major/fatal bleeding was increased with intensive as compared with guideline therapy: 39 vs. 17 participants, adjusted hazard ratio 2.21, 95% CI 1.24-3.93, p = 0.007. Bleeding events diverged between treatment groups in the 8-35 day period but not in the 0-7 or 36-90 day epochs. In multivariate analysis more, and more severe, bleeding events were seen with increasing age, female sex, pre-morbid dependency, increased time to randomisation, prior major bleed, prior antiplatelet therapy and in those randomised to triple vs guideline antiplatelet therapy. More severe bleeding was associated with worse clinical outcomes across multiple physical, emotional and quality of life domains.Trial registration ISRCTN47823388 .
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Affiliation(s)
- Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Hanne Christensen
- Bispebjerg and Frederiksberg Hospital, Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - Rob A Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, School of Medicine, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Derby Stroke Centre, University Hospitals of Derby and Burton, Derby, DE22 3NE, UK
| | - Marilyn James
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
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Soo Y, Zietz A, Yiu B, Mok VCT, Polymeris AA, Seiffge D, Ambler G, Wilson D, Leung TWH, Tsang SF, Chu W, Abrigo J, Cheng C, Lee KJ, Lim JS, Shiozawa M, Koga M, Chabriat H, Hennerici M, Wong YK, Mak H, Collet R, Inamura S, Yoshifuji K, Arsava EM, Horstmann S, Purrucker J, Lam BYK, Wong A, Kim YD, Song TJ, Lemmens R, Eppinger S, Gattringer T, Uysal E, Demirelli DS, Bornstein NM, Assayag EB, Hallevi H, Molad J, Nishihara M, Tanaka J, Coutts SB, Kappelle LJ, Al-Shahi Salman R, Jager R, Lip GYH, Goeldlin MB, Panos LD, Mas JL, Legrand L, Karayiannis C, Phan T, Bellut M, Chappell F, Makin S, Hayden D, Williams D, van Dam-Nolen DHK, Nederkoorn PJ, Barbato C, Browning S, Wiegertjes K, Tuladhar AM, Mendyk AM, Köhler S, van Oostenburgge R, Zhou Y, Xu C, Hilal S, Gyanwali B, Chen C, Lou M, Staals J, Bordet R, Kandiah N, de Leeuw FE, Simister R, Hendrikse J, Wardlaw J, Kelly P, Fluri F, Srikanth V, Calvet D, Jung S, Kwa VIH, Smith EE, Hara H, Yakushiji Y, Orken DN, Fazekas F, Thijs V, Heo JH, Veltkamp R, Ay H, Imaizumi T, Lau KK, Jouvent E, Toyoda K, Yoshimura S, Bae HJ, Martí-Fàbregas J, Prats-Sánchez L, Lyrer P, Best J, Werring D, Engelter ST, Peters N. Impact of Cerebral Microbleeds in Stroke Patients with Atrial Fibrillation. Ann Neurol 2023; 94:61-74. [PMID: 36928609 DOI: 10.1002/ana.26642] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVES Cerebral microbleeds are associated with the risks of ischemic stroke and intracranial hemorrhage, causing clinical dilemmas for antithrombotic treatment decisions. We aimed to evaluate the risks of intracranial hemorrhage and ischemic stroke associated with microbleeds in patients with atrial fibrillation treated with vitamin K antagonists, direct oral anticoagulants, antiplatelets, and combination therapy (i.e. concurrent oral anticoagulant and antiplatelet). METHODS We included patients with documented atrial fibrillation from the pooled individual patient data analysis by the Microbleeds International Collaborative Network. Risks of subsequent intracranial hemorrhage and ischemic stroke were compared between patients with and without microbleeds, stratified by antithrombotic use. RESULTS A total of 7,839 patients were included. The presence of microbleeds was associated with an increased relative risk of intracranial hemorrhage (adjusted hazard ratio [aHR] = 2.74, 95% confidence interval = 1.76-4.26) and ischemic stroke (aHR = 1.29, 95% confidence interval = 1.04-1.59). For the entire cohort, the absolute incidence of ischemic stroke was higher than intracranial hemorrhage regardless of microbleed burden. However, for the subgroup of patients taking combination of anticoagulant and antiplatelet therapy, the absolute risk of intracranial hemorrhage exceeded that of ischemic stroke in those with 2 to 4 microbleeds (25 vs 12 per 1,000 patient-years) and ≥ 11 microbleeds (94 vs 48 per 1,000 patient-years). INTERPRETATION Patients with atrial fibrillation and high burden of microbleeds receiving combination therapy have a tendency of higher rate of intracranial hemorrhage than ischemic stroke, with potential for net harm. Further studies are needed to help optimize stroke preventive strategies in this high-risk group. ANN NEUROL 2023;94:61-74.
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Affiliation(s)
- Yannie Soo
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Annaelle Zietz
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Brian Yiu
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Vincent C T Mok
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
- Gerald Choa Neuroscience Institute, Margaret K. L. Cheung Research Centre for Management of Parkinsonism, Therese Pei Fong Chow Research Centre for Prevention of Dementia, Lui Che Woo Institute of Innovative Medicine, Li Ka Shing Institute of Health Science, Lau Tat-chuen Research Centre of Brain Degenerative Diseases in Chinese, The Chinese University of Hong Kong, Hong Kong SAR, Hong Kong
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK, New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Thomas Wai Hong Leung
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Suk Fung Tsang
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Winnie Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jill Abrigo
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cyrus Cheng
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Keon-Joo Lee
- Department of Neurology, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Jae-Sung Lim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Hugues Chabriat
- APHP, Lariboisière Hospital, Translational Neurovascular Centre, F-75475 Paris, France, FHU NeuroVasc, Université de Paris and INSERM U1141, Paris, France
| | - Michael Hennerici
- Department of Neurology, University of Heidelberg/Mannheim Hospital, Mannheim, Germany
| | - Yuen Kwun Wong
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Henry Mak
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong, Hong Kong
| | - Roger Collet
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Shigeru Inamura
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Kazuhisa Yoshifuji
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Ethem Murat Arsava
- Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Solveig Horstmann
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bonnie Y K Lam
- Division of Neurology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
- Gerald Choa Neuroscience Institute, Margaret K. L. Cheung Research Centre for Management of Parkinsonism, Therese Pei Fong Chow Research Centre for Prevention of Dementia, Lui Che Woo Institute of Innovative Medicine, Li Ka Shing Institute of Health Science, Lau Tat-chuen Research Centre of Brain Degenerative Diseases in Chinese, The Chinese University of Hong Kong, Hong Kong SAR, Hong Kong
| | - Adrian Wong
- Gerald Choa Neuroscience Institute, Margaret K. L. Cheung Research Centre for Management of Parkinsonism, Therese Pei Fong Chow Research Centre for Prevention of Dementia, Lui Che Woo Institute of Innovative Medicine, Li Ka Shing Institute of Health Science, Lau Tat-chuen Research Centre of Brain Degenerative Diseases in Chinese, The Chinese University of Hong Kong, Hong Kong SAR, Hong Kong
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Robin Lemmens
- Experimental Neurology, Department of Neurosciences, KU Leuven-University of Leuven, Leuven, Belgium
- VIB Center for Brain & Disease Research, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Sebastian Eppinger
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Ender Uysal
- Antalya Teaching and Research Hospital, Department of Radiology, University of Health Sciences Turkey, Antalya, Turkey
| | - Derya Selçuk Demirelli
- Sisli Hamidiye Etfal Teaching and Research Hospital, Department of Neurology, University of Health Sciences Turkey, Antalya, Turkey
| | - Natan M Bornstein
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Einor Ben Assayag
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hen Hallevi
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jeremy Molad
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Masashi Nishihara
- Department of Radiology, Saga University Faculty of Medicine, Saga, Japan
| | - Jun Tanaka
- Department of Cerebrovascular Medicine, St. Mary's Hospital, Kurume, Japan
| | - Shelagh B Coutts
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Rolf Jager
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Martina B Goeldlin
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Leonidas D Panos
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jean-Louis Mas
- GHU-Paris Psychiatrie et Neurosciences, Neurology Department and Stroke Unit, Sainte-Anne Hospital, and Université de Paris Cité, INSERM U1266, Institute of Psychiatry and Neuroscience of Paris, Paris, France
| | - Laurence Legrand
- GHU-Paris Psychiatrie et Neurosciences, Neuroradiology Department, Sainte-Anne Hospital, and Université Paris Cité, INSERM U1266, Institute of Psychiatry and Neuroscience of Paris, Paris, France
| | - Chris Karayiannis
- Peninsula Clinical School, Peninsula Health, Monash University, Melbourne, Australia
| | - Thanh Phan
- Stroke and Ageing Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Maximilian Bellut
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, Edinburgh Imaging, Edinburgh, UK
- UK Dementia Institute at the University of Edinburgh, Edinburgh, UK
| | - Stephen Makin
- Centre for Rural Health, Institute for Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Derek Hayden
- Acute Medical Unit and Department of Age-related Healthcare, Tallaght University Hospital, Dublin, Ireland
| | - David Williams
- Department of Geriatric and Stroke Medicine, RCSI University of Medicine and Health Sciences Dublin, Ireland and Beaumont Hospital Dublin, Dublin, Ireland
| | - Dianne H K van Dam-Nolen
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Carmen Barbato
- Department of Neurology, University of Florence, Firenze, Italy
| | - Simone Browning
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Kim Wiegertjes
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anil Man Tuladhar
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anne-Marie Mendyk
- University of Lille, Inserm, CHU de Lille. Lille Neuroscience & Cognition, Lille, France
| | - Sebastian Köhler
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Maastricht University, Maastricht, The Netherlands
| | - Robert van Oostenburgge
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ying Zhou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Chao Xu
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Saima Hilal
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Bibek Gyanwali
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christopher Chen
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Julie Staals
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Regis Bordet
- University of Lille, Inserm, CHU de Lille. Lille Neuroscience & Cognition, Lille, France
| | - Nagaendran Kandiah
- Dementia Research Centre (Singapore), Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert Simister
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Jeroen Hendrikse
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joanna Wardlaw
- Division of Neuroimaging Sciences, Edinburgh Imaging, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh and NHS Lothian, Edinburgh, UK
| | - Peter Kelly
- The Neurovascular Research Unit and Health Research Board, Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - Felix Fluri
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Velandai Srikanth
- Peninsula Clinical School, Peninsula Health, Monash University, Melbourne, Australia, National Centre for Healthy Ageing, Melbourne, Australia
| | - David Calvet
- GHU-Paris Psychiatrie et Neurosciences, Neurology Department and Stroke Unit, Sainte-Anne Hospital, and Université de Paris Cité, INSERM U1266, Institute of Psychiatry and Neuroscience of Paris, Paris, France
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Yusuke Yakushiji
- Department of Neurology, Kansai Medical University, Hirakata, Japan
| | | | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
- A.A. Martinos Center for Biomedical Imaging, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Austin Health, Heidelberg, Australia
| | - Hakan Ay
- Department of Brain Sciences, Imperial College London, London, UK
| | - Toshio Imaizumi
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Kui Kai Lau
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Shatin, Hong Kong
| | - Eric Jouvent
- Université de Paris-Assistance Publique Hôpitaux de Paris, Paris, France
- Département de Neurologie, Hôpital Lariboisière, FHU NeuroVasc, INSERM NeuroDiderot U1141, Paris, France
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Joan Martí-Fàbregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Luis Prats-Sánchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Philippe Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Jonathan Best
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - David Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
- Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
- Stroke Center, Klinik Hirslanden, Zürich, Switzerland
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Role of cerebral microbleeds in acute ischemic stroke and atrial fibrillation. J Thromb Thrombolysis 2022; 55:553-565. [PMID: 36571659 DOI: 10.1007/s11239-022-02761-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2022] [Indexed: 12/27/2022]
Abstract
Cerebral microbleeds (CMBs) are commonly detected in the brains of patients with acute ischemic stroke (AIS). With the development of neuroimaging, clinicians are paying more attention to the presence of CMBs. CMBs were found to significantly increase the risk of intracranial hemorrhagic transformation and hemorrhage in patients with AIS, especially in patients with concurrent atrial fibrillation (AF). Additionally, the presence of CMBs is thought to be a symbol of a high risk of recurrent ischemic stroke (IS). A few researchers have found that the presence of CMBs has no significant effect on the prognosis of patients with AIS. Therefore, the current views on the role of CMBs in the prognoses of patients with IS are controversial. The use of anticoagulants and other drugs has also become a dilemma due to the special influence of CMBs on the prognosis of these patients. Due to the large number of patients with AF and CMBs, many studies have been conducted on the effects of CMBs on these patients and subsequent pharmacological treatments. However, at present, there are no relevant guidelines to guide the secondary preventive treatment of patients with stroke, CMBs, and AF. In this paper, we summarized the role of CMBs in AIS combined with AF and relevant preventive measures against the recurrence of stroke and the occurrence of intracerebral hemorrhage to help clarify the specifics of drug therapies for this group of patients.
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Siepen BM, Seiffge DJ, Fischer U. Anticoagulation after stroke: persistent uncertainties. Curr Opin Neurol 2022; 35:55-61. [PMID: 34812748 DOI: 10.1097/wco.0000000000001009] [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: 11/26/2022]
Abstract
PURPOSE OF REVIEW Direct oral anticoagulants (DOAC) are the mainstay of anticoagulant therapy for stroke prevention in patients with nonvalvular atrial fibrillation. Persistent uncertainties remain in different areas, and this review discusses current dilemmas based on selected studies. RECENT FINDINGS Optimal timing of DOAC initiation after a recent ischaemic stroke in patients with atrial fibrillation is currently unknown and subject of ongoing randomized controlled trials. Ischaemic stroke despite anticoagulant therapy in patients with atrial fibrillation is frequent, constitutes heterogeneous causes (competing stroke cause, medication error and cardioembolism despite anticoagulation) and optimal treatment is currently unknown. Thorough etiological work-up is justified. Recent randomized controlled trials found no beneficial effect of DOAC therapy in unselected patients with embolic stroke of undetermined source (ESUS). Currently ongoing trials targeting subgroup of ESUS patients with additional atrial cardiopathy will provide novel data. Cerebral mircobleeds combined in a novel risk score (MICON score) provide good predictive value to stratify the risk of intracranial haemorrhage in patients taking anticoagulants. Use of DOAC after intracerebral haemorrhage in patients with atrial fibrillation is subject of ongoing trials. SUMMARY There are still significant uncertainties in anticoagulant management in patients with stroke. Ongoing trials will soon provide novel data to improve management of these patients.
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Affiliation(s)
- Bernhard M Siepen
- Department of Neurology, Inselspital University Hospital Bern and University of Bern
- Graduate School of Health Sciences, University of Bern, Bern
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital Bern and University of Bern
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Bern and University of Bern
- Department of Neurology, University Hospital Basel and University of Basel, Switzerland
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Ha ACT, Bhatt DL, Rutka JT, Johnston SC, Mazer CD, Verma S. Intracranial Hemorrhage During Dual Antiplatelet Therapy: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:1372-1384. [PMID: 34556323 DOI: 10.1016/j.jacc.2021.07.048] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/19/2022]
Abstract
Dual antiplatelet therapy (DAPT) with acetylsalicylic acid and a P2Y12 inhibitor is an established therapy for a broad spectrum of patients with cardiovascular disease. The ischemic benefit of DAPT is partially offset by its increased bleeding risk, with intracranial hemorrhage (ICH) being the most serious complication. Although uncommon (0.2%-0.3% annually), its cumulative burden can be substantial given the number of patients afflicted by cardiovascular disease worldwide. Patients with a history of stroke or transient ischemic attack harbor a particularly high risk for ICH when treated with DAPT. Prediction rules may assist clinicians when weighing the risk/benefit ratio of prescribing DAPT for patients with stroke/transient ischemic attack in the nonacute, ambulatory setting. Currently, there are no reversal agents that can rapidly and effectively reverse the effect of P2Y12 inhibitors in routine practice, although a reversal agent for ticagrelor is under clinical investigation.
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Affiliation(s)
- Andrew C T Ha
- University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA.
| | - James T Rutka
- University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - S Claiborne Johnston
- The Dean's Office, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - C David Mazer
- University of Toronto, Toronto, Ontario, Canada; St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Subodh Verma
- University of Toronto, Toronto, Ontario, Canada; St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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Hilkens NA, Algra A, Diener HC, Bath PM, Csiba L, Hacke W, Kappelle LJ, Koudstaal PJ, Leys D, Mas JL, Sacco RL, Greving JP. Balancing Benefits and Risks of Long-Term Antiplatelet Therapy in Noncardioembolic Transient Ischemic Attack or Stroke. Stroke 2021; 52:3258-3265. [PMID: 34304604 PMCID: PMC8478107 DOI: 10.1161/strokeaha.120.031755] [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: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Lifelong treatment with antiplatelet drugs is recommended following a transient ischemic attack or ischemic stroke. Bleeding complications may offset the benefit of antiplatelet drugs in patients at increased risk of bleeding and low risk of recurrent ischemic events. We aimed to investigate the net benefit of antiplatelet treatment according to an individuals' bleeding risk. METHODS We pooled individual patient data from 6 randomized clinical trials (CAPRIE [Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events], ESPS-2 [European Stroke Prevention Study-2], MATCH [Management of Atherothrombosis With Clopidogrel in High-Risk Patients], CHARISMA [Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance], ESPRIT [European/Australasian Stroke Prevention in Reversible Ischemia Trial], and PRoFESS [Prevention Regimen for Effectively Avoiding Second Strokes]) investigating antiplatelet therapy in the subacute or chronic phase after noncardioembolic transient ischemic attack or stroke. Patients were stratified into quintiles according to their predicted risk of major bleeding with the S2TOP-BLEED score. The annual risk of major bleeding and recurrent ischemic events was assessed per quintile for 4 scenarios: (1) aspirin monotherapy, (2) aspirin-clopidogrel versus aspirin or clopidogrel monotherapy, (3) aspirin-dipyridamole versus clopidogrel, and (4) aspirin versus clopidogrel. Net benefit was calculated for the second, third, and fourth scenario. RESULTS Thirty seven thousand eighty-seven patients were included in the analyses. Both risk of major bleeding and recurrent ischemic events increased over quintiles of predicted bleeding risk, but risk of ischemic events was consistently higher (eg, from 0.7%/y (bottom quintile) to 3.2%/y (top quintile) for major bleeding on aspirin and from 2.5%/y to 10.2%/y for risk of ischemic events on aspirin). Treatment with aspirin-clopidogrel led to more major bleedings (0.9%-1.7% per year), than reduction in ischemic events (ranging from 0.4% to 0.9/1.0% per year) across all quintiles. There was no clear preference for either aspirin-dipyridamole or clopidogrel according to baseline bleeding risk. CONCLUSIONS Among patients with a transient ischemic attack or ischemic stroke included in clinical trials of antiplatelet therapy, the risk of recurrent ischemic events and of major bleeding increase in parallel. Antiplatelet treatment cannot be individualized solely based on bleeding risk assessment.
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Affiliation(s)
- Nina A Hilkens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, The Netherlands. (N.A.H., A.A., J.P.G.).,Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands (N.A.H.)
| | - Ale Algra
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, The Netherlands. (N.A.H., A.A., J.P.G.).,Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands. (A.A., L.J.K.)
| | | | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.)
| | - László Csiba
- Department of Neurology, University of Debrecen Medical and Health Science Center, Hungary (L.C.)
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Germany (W.H.)
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands. (A.A., L.J.K.)
| | - Peter J Koudstaal
- Department of Neurology, Erasmus Medical Center, Rotterdam, the Netherlands (P.J.K.)
| | - Didier Leys
- Department of Neurology, University of Lille, INSERM U 1171, CHU l, Lille, France (D.L.)
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris Descartes, France (J.-L.M.)
| | - Ralph L Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, FL (R.L.S.)
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, The Netherlands. (N.A.H., A.A., J.P.G.)
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7
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Best JG, Ambler G, Wilson D, Lee KJ, Lim JS, Shiozawa M, Koga M, Li L, Lovelock C, Chabriat H, Hennerici M, Wong YK, Mak HKF, Prats-Sanchez L, Martínez-Domeño A, Inamura S, Yoshifuji K, Arsava EM, Horstmann S, Purrucker J, Lam BYK, Wong A, Kim YD, Song TJ, Lemmens R, Eppinger S, Gattringer T, Uysal E, Tanriverdi Z, Bornstein NM, Ben Assayag E, Hallevi H, Molad J, Nishihara M, Tanaka J, Coutts SB, Polymeris A, Wagner B, Seiffge DJ, Lyrer P, Algra A, Kappelle LJ, Al-Shahi Salman R, Jäger HR, Lip GYH, Fischer U, El-Koussy M, Mas JL, Legrand L, Karayiannis C, Phan T, Gunkel S, Christ N, Abrigo J, Leung T, Chu W, Chappell F, Makin S, Hayden D, Williams DJ, Mess WH, Nederkoorn PJ, Barbato C, Browning S, Wiegertjes K, Tuladhar AM, Maaijwee N, Guevarra AC, Yatawara C, Mendyk AM, Delmaire C, Köhler S, van Oostenbrugge R, Zhou Y, Xu C, Hilal S, Gyanwali B, Chen C, Lou M, Staals J, Bordet R, Kandiah N, de Leeuw FE, Simister R, Hendrikse J, Kelly PJ, Wardlaw J, Soo Y, Fluri F, Srikanth V, Calvet D, Jung S, Kwa VIH, Engelter ST, Peters N, Smith EE, Hara H, Yakushiji Y, Orken DN, Fazekas F, Thijs V, Heo JH, Mok V, Veltkamp R, Ay H, Imaizumi T, Gomez-Anson B, Lau KK, Jouvent E, Rothwell PM, Toyoda K, Bae HJ, Marti-Fabregas J, Werring DJ. Development of imaging-based risk scores for prediction of intracranial haemorrhage and ischaemic stroke in patients taking antithrombotic therapy after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies. Lancet Neurol 2021; 20:294-303. [PMID: 33743239 DOI: 10.1016/s1474-4422(21)00024-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Balancing the risks of recurrent ischaemic stroke and intracranial haemorrhage is important for patients treated with antithrombotic therapy after ischaemic stroke or transient ischaemic attack. However, existing predictive models offer insufficient performance, particularly for assessing the risk of intracranial haemorrhage. We aimed to develop new risk scores incorporating clinical variables and cerebral microbleeds, an MRI biomarker of intracranial haemorrhage and ischaemic stroke risk. METHODS We did a pooled analysis of individual-patient data from the Microbleeds International Collaborative Network (MICON), which includes 38 hospital-based prospective cohort studies from 18 countries. All studies recruited participants with previous ischaemic stroke or transient ischaemic attack, acquired baseline MRI allowing quantification of cerebral microbleeds, and followed-up participants for ischaemic stroke and intracranial haemorrhage. Participants not taking antithrombotic drugs were excluded. We developed Cox regression models to predict the 5-year risks of intracranial haemorrhage and ischaemic stroke, selecting candidate predictors on biological relevance and simplifying models using backward elimination. We derived integer risk scores for clinical use. We assessed model performance in internal validation, adjusted for optimism using bootstrapping. The study is registered on PROSPERO, CRD42016036602. FINDINGS The included studies recruited participants between Aug 28, 2001, and Feb 4, 2018. 15 766 participants had follow-up for intracranial haemorrhage, and 15 784 for ischaemic stroke. Over a median follow-up of 2 years, 184 intracranial haemorrhages and 1048 ischaemic strokes were reported. The risk models we developed included cerebral microbleed burden and simple clinical variables. Optimism-adjusted c indices were 0·73 (95% CI 0·69-0·77) with a calibration slope of 0·94 (0·81-1·06) for the intracranial haemorrhage model and 0·63 (0·62-0·65) with a calibration slope of 0·97 (0·87-1·07) for the ischaemic stroke model. There was good agreement between predicted and observed risk for both models. INTERPRETATION The MICON risk scores, incorporating clinical variables and cerebral microbleeds, offer predictive value for the long-term risks of intracranial haemorrhage and ischaemic stroke in patients prescribed antithrombotic therapy for secondary stroke prevention; external validation is warranted. FUNDING British Heart Foundation and Stroke Association.
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Affiliation(s)
- Jonathan G Best
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, Gower Street, London, UK
| | - Duncan Wilson
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Keon-Joo Lee
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Jae-Sung Lim
- Department of Neurology, Hallym Neurological Institute, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Caroline Lovelock
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Hugues Chabriat
- Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital, Department of Neurology, Paris, France; Federation Hospitalo-Universitaire NeuroVasc, Université de Paris, Paris, France; INSERM U1141, Paris, France
| | - Michael Hennerici
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Yuen Kwun Wong
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Henry Ka Fung Mak
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Luis Prats-Sanchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Alejandro Martínez-Domeño
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Shigeru Inamura
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Kazuhisa Yoshifuji
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Ethem Murat Arsava
- A A Martinos Center for Biomedial Imaging, Department of Neurology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Solveig Horstmann
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bonnie Yin Ka Lam
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Adrian Wong
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Robin Lemmens
- Experimental Neurology, Department of Neurosciences, Katholieke Universiteit Leuven, Leuven, Belgium; Vlaams Instituut voor Biotechnologie, Center for Brain & Disease Research; Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Ender Uysal
- Department of Radiology, Saglık Bilimleri University, Sisli Etfal Education and Research Hospital, Istanbul, Turkey
| | - Zeynep Tanriverdi
- Department of Neurology, İzmir Katip Çelebi University Atatürk Education and Research Hospital, İzmir Turkey
| | - Natan M Bornstein
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Einor Ben Assayag
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hen Hallevi
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jeremy Molad
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Masashi Nishihara
- Department of Radiology, Saga University Faculty of Medicine, Saga, Japan
| | - Jun Tanaka
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Shelagh B Coutts
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Alexandros Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland
| | - David J Seiffge
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland; Department of Neurology, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland
| | - Ale Algra
- Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, The Netherlands; Department of Neurology and Neurosurgery, Utrecht University, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Utrecht University, Utrecht, The Netherlands
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Hans R Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK; Liverpool Heart & Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Urs Fischer
- Department of Neurology, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Jean-Louis Mas
- Department of Neurology, Sainte-Anne Hospital, Institut de Psychiatrie et Neurosciences de Paris, INSERM, Université de Paris, Paris, France
| | - Laurence Legrand
- Department of Neuroradiology, Sainte-Anne Hospital, Institut de Psychiatrie et Neurosciences de Paris, INSERM, Université de Paris, Paris, France
| | | | - Thanh Phan
- Stroke and Ageing Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Sarah Gunkel
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Nicolas Christ
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Jill Abrigo
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Thomas Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Winnie Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, Edinburgh Imaging, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Stephen Makin
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Derek Hayden
- The Neurovascular Research Unit and Health Research Board, Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland; Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - David J Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences Dublin, Ireland; Department of Geriatric and Stroke Medicine, Beaumont Hospital Dublin, Ireland
| | - Werner H Mess
- Department of Clinical Neurophysiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Centres, Netherlands
| | - Carmen Barbato
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Simone Browning
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Kim Wiegertjes
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anil M Tuladhar
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Noortje Maaijwee
- Department for Neurology and Neurorehabilitation, Neurocenter, Lucerne State Hospital, Lucerne, Switzerland
| | | | | | - Anne-Marie Mendyk
- Degenerative and vascular cognitive disorders, University of Lille, INSERM, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Christine Delmaire
- Degenerative and vascular cognitive disorders, University of Lille, INSERM, Centre Hospitalier Universitaire de Lille, Lille, France; Department of Radiology, Fondation A de Rothschild, Paris, France
| | - Sebastian Köhler
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, The Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | - Ying Zhou
- Department of Neurology, The 2nd affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Chao Xu
- Department of Neurology, The 2nd affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Saima Hilal
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bibek Gyanwali
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christopher Chen
- Memory Aging & Cognition Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Min Lou
- Department of Neurology, The 2nd affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Julie Staals
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | - Régis Bordet
- Degenerative and vascular cognitive disorders, University of Lille, INSERM, Centre Hospitalier Universitaire de Lille, Lille, France
| | | | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert Simister
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Peter J Kelly
- The Neurovascular Research Unit and Health Research Board, Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, Edinburgh Imaging, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Yannie Soo
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Special Administrative Region, China
| | - Felix Fluri
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Velandai Srikanth
- Peninsula Clinical School, Peninsula Health, Monash University, Melbourne, Australia
| | - David Calvet
- Department of Neurology, Sainte-Anne Hospital, Institut de Psychiatrie et Neurosciences de Paris, INSERM, Université de Paris, Paris, France
| | - Simon Jung
- Department of Neurology, University Hospital Inselspital Bern, University of Bern, Bern, Switzerland
| | - Vincent I H Kwa
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland; Neurology and Neurorehabilitation, Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Switzerland; Neurology and Neurorehabilitation, Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland
| | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan; Department of Neurology, Kansai Medical University, Osaka, Japan
| | | | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia; Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Vincent Mok
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany; Department of Brain Sciences, Imperial College London, London, UK
| | - Hakan Ay
- A A Martinos Center for Biomedial Imaging, Department of Neurology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA; Takeda, Cambridge, MA, USA
| | - Toshio Imaizumi
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Beatriz Gomez-Anson
- Unit of Neuroradiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Kui Kai Lau
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Eric Jouvent
- Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital, Department of Neurology, Paris, France; Federation Hospitalo-Universitaire NeuroVasc, Université de Paris, Paris, France; INSERM U1141, Paris, France
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Joan Marti-Fabregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - David J Werring
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK.
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Xu YY, Gu HQ, Li ZX, Xiong YY, Zhou Q, Liu LP, Zhao XQ, Wang YL, Meng X, Wang YJ. In-hospital prognosis of first-ever noncardiogenic ischemic stroke in patients with and without indication for prestroke antiplatelet therapy: Chinese Stroke Center Alliance. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:626. [PMID: 33987324 PMCID: PMC8106102 DOI: 10.21037/atm-20-7902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background It is unknown about the influence of prestroke antiplatelet use on early outcomes in patients with and without the indication. We aimed to evaluate the in-hospital prognosis of first-ever noncardiogenic ischemic stroke patients with and without indications of antiplatelet use for primary prevention. Methods This was a retrospective, observational study based on a prospective hospital-based registry (Chinese Stroke Center Alliance). Using the data with 436,660 first-ever noncardiogenic acute ischemic strokes recorded from Aug 1, 2015, to July 31, 2019, from 1,453 hospitals in China, we examined the associations between the indication for prestroke antiplatelet use and in-hospital clinical outcomes. Results Among 436,660 first-ever noncardiogenic ischemic stroke patients, 42,409 patients (9.7%) had a documented previous vascular indication and 394,251 (90.3%) did not. Compared to those without, patients with the indication were associated with increased prevalence of in-hospital morbid conditions, including stroke severity (OR 2.71; 95% CI: 2.62–2.81; P<0.0001), length of stay >14 days (OR 1.16; 95% CI: 1.13–1.19; P<0.0001), mortality (OR 2.20; 95% CI: 1.96–2.46, P<0.0001), and recurrence of ischemic stroke and transient ischemic attack (TIA) (OR 1.5; 95% CI: 1.43–1.59, P<0.0001). Among patients without indication, prestroke antiplatelet use was associated with lower mortality (OR 0.73, 95% CI: 0.56–0.96; P=0.0221); while among patients with indication, those receiving prestroke antiplatelet had lower odds ratios in stroke severity (P<0.0001) and disability (P=0.0003) than those who not. Conclusions Patients with indications of prestroke antiplatelet use were more likely to have unfavorable outcomes than those without. Prestroke antiplatelet might be associated with lower mortality, less disability, and less stroke severity in certain population groups. Future studies to improve risk prediction rules are needed to guide effective primary prevention for ischemic stroke.
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Affiliation(s)
- Yu-Yuan Xu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zi-Xiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yun-Yun Xiong
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qi Zhou
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li-Ping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xing-Quan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi-Long Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong-Jun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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9
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Bleeding risk assessment for stroke patients on antithrombotic therapy. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2019; 31:282-288. [PMID: 31005341 DOI: 10.1016/j.arteri.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/04/2019] [Accepted: 01/27/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION After an ischemic cerebrovascular event the risk of new ischemic events is high, therefore antithrombotic therapy are indicated to prevent stroke recurrence. DISCUSSION Despite its clear benefit, these therapies increase the risk of bleeding. Therefore, it is essential to identify high hemorrhagic risk patients. There are different predictive models of hemorrhage, in particular of intracranial hemorrhage, associated with the use of antiaggregants in patients who have presented an ischemic stroke or TIA, such as the CCSC, intracranial scales -B2LEED3S score or S2TOP-BLEED. However, though main international guidelines recommend the use of scales, in particular, the HAS-BLED score, to assess the risk of bleeding in anticoagulated patients, there is no specific recommendation in the case of the use of antiplatelet drugs. CONCLUSIONS In this review we present the main models currently available for the prediction of bleeding of antithrombotic therapy in patients who have had a stroke or TIA.
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10
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Buchtele N, Schwameis M, Gilbert JC, Schörgenhofer C, Jilma B. Targeting von Willebrand Factor in Ischaemic Stroke: Focus on Clinical Evidence. Thromb Haemost 2018; 118:959-978. [PMID: 29847840 PMCID: PMC6193403 DOI: 10.1055/s-0038-1648251] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite great efforts in stroke research, disability and recurrence rates in ischaemic stroke remain unacceptably high. To address this issue, one potential target for novel therapeutics is the glycoprotein von Willebrand factor (vWF), which increases in thrombogenicity especially under high shear rates as it bridges between vascular sub-endothelial collagen and platelets. The rationale for vWF as a potential target in stroke comes from four bodies of evidence. (1) Animal models which recapitulate the pathogenesis of stroke and validate the concept of targeting vWF for stroke prevention and the use of the vWF cleavage enzyme ADAMTS13 in acute stroke treatment. (2) Extensive epidemiologic data establishing the prognostic role of vWF in the clinical setting showing that high vWF levels are associated with an increased risk of first stroke, stroke recurrence or stroke-associated mortality. As such, vWF levels may be a suitable marker for further risk stratification to potentially fine-tune current risk prediction models which are mainly based on clinical and imaging data. (3) Genetic studies showing an association between vWF levels and stroke risk on genomic levels. Finally, (4) studies of patients with primary disorders of excess or deficiency of function in the vWF axis (e.g. thrombotic thrombocytopenic purpura and von Willebrand disease, respectively) which demonstrate the crucial role of vWF in atherothrombosis. Therapeutic inhibition of VWF by novel agents appears particularly promising for secondary prevention of stroke recurrence in specific sub-groups of patients such as those suffering from large artery atherosclerosis, as designated according to the TOAST classification.
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Affiliation(s)
- Nina Buchtele
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - James C Gilbert
- Band Therapeutics, LLC, Boston, Massachusetts, United States
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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11
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Labovitz DL, Dhamoon MS. Charting the Course. Stroke 2018; 49:513. [DOI: 10.1161/strokeaha.118.020235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel L. Labovitz
- From the Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (D.L.L.); and Mount Sinai School of Medicine, New York, NY (M.S.D.)
| | - Mandip S. Dhamoon
- From the Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (D.L.L.); and Mount Sinai School of Medicine, New York, NY (M.S.D.)
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