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Lee M, Oh MS, Yu KH, Kim C, Sohn JH, Mo HJ, Kim Y, Lee SH. Optimal use of antithrombotic agents in recent small subcortical strokes accompanied by atrial fibrillation. Eur Stroke J 2024:23969873241253958. [PMID: 38804237 DOI: 10.1177/23969873241253958] [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: 05/29/2024] Open
Abstract
BACKGROUND This study aimed to evaluate the efficacy and safety of anticoagulants (AC) and antiplatelets (APT) in patients with recent small subcortical infarctions (RSSI) and atrial fibrillation (AF). METHODS We utilized a prospective multicenter stroke registry database to identify patients with RSSI with a concurrent diagnosis of AF. Propensity score matching analysis was used to balance baseline differences among the AC-only, APT-only, and their combination groups. The main outcomes of interest were time to occurrence of minor and major bleeding, stroke recurrence, and all-cause mortality. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for each outcome were calculated using the multivariable Cox proportional hazard regression analysis. RESULTS Of the 404 eligible patients, 28.2% received APT only, 53.0% received AC only, and 18.9% received a combination of both. Notable differences were observed between these groups in terms of the 1-year stroke recurrence (APT, 32.5%; AC, 5.6%; APT + AC, 9.2%) and all-cause mortality (APT, 21.9%; AC, 6.1%; APT + AC, 14.5%), whereas the rates of bleeding events were comparable. The multivariable analysis indicated a significant association of AC alone with reduced risks of severe bleeding, stroke recurrence, and all-cause mortality compared with APT alone (aHR 0.64, 95% CI 0.41-0.98; aHR 0.11, 95% CI 0.06-0.22; aHR 0.22, 95% CI 0.11-0.44, respectively). The combination group showed a reduced risk of stroke recurrence compared to APT alone (aHR 0.19, 95% CI 0.08-0.46). These findings remained consistent with the propensity score-matched analysis. CONCLUSION AC showed better clinical outcomes than APT in patients with RSSI and AF. Additionally, combination therapy with AC and APT was associated with a lower risk of stroke recurrence than APT alone.
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Affiliation(s)
- Minwoo Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, Korea
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Chulho Kim
- Institute of New Frontier Research Team, Hallym University, Chuncheon, Korea
- Department of Neurology, Chuncheon Sacred Heart Hospital, Chuncheon, Korea
| | - Jong-Hee Sohn
- Institute of New Frontier Research Team, Hallym University, Chuncheon, Korea
- Department of Neurology, Chuncheon Sacred Heart Hospital, Chuncheon, Korea
| | - Hee-Jung Mo
- Department of Neurology, Dongtan Sacred Heart Hospital, Seoul, Korea
| | - Yerim Kim
- Department of Neurology, Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Sang-Hwa Lee
- Institute of New Frontier Research Team, Hallym University, Chuncheon, Korea
- Department of Neurology, Chuncheon Sacred Heart Hospital, Chuncheon, Korea
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Koohi F, Harshfield EL, Shatunov A, Markus HS. Does Thrombosis Play a Causal Role in Lacunar Stroke and Cerebral Small Vessel Disease? Stroke 2024; 55:934-942. [PMID: 38527140 PMCID: PMC10962440 DOI: 10.1161/strokeaha.123.044937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/02/2023] [Accepted: 12/05/2023] [Indexed: 03/27/2024]
Abstract
BACKGROUND The importance of thromboembolism in the pathogenesis of lacunar stroke (LS), resulting from cerebral small vessel disease (cSVD), is debated, and although antiplatelets are widely used in secondary prevention after LS, there is limited trial evidence from well-subtyped patients to support this approach. We sought to evaluate whether altered anticoagulation plays a causal role in LS and cSVD using 2-sample Mendelian randomization. METHODS From a recent genome-wide association study (n=81 190), we used 119 genetic variants associated with venous thrombosis at genome-wide significance (P<5*10-8) and with a linkage disequilibrium r2<0.001 as instrumental variables. We also used genetic associations with stroke from the GIGASTROKE consortium (62 100 ischemic stroke cases: 10 804 cardioembolic stroke, 6399 large-artery stroke, and 6811 LS). In view of the lower specificity for LS with the CT-based phenotyping mainly used in GIGASTROKE, we also used data from patients with magnetic resonance imaging-confirmed LS (n=3199). We also investigated associations with more chronic magnetic resonance imaging features of cSVD, namely, white matter hyperintensities (n=37 355) and diffusion tensor imaging metrics (n=36 533). RESULTS Mendelian randomization analyses showed that genetic predisposition to venous thrombosis was associated with an increased odds of any ischemic stroke (odds ratio [OR], 1.19 [95% CI, 1.13-1.26]), cardioembolic stroke (OR, 1.32 [95% CI, 1.21-1.45]), and large-artery stroke (OR, 1.41 [95% CI, 1.26-1.57]) but not with LS (OR, 1.07 [95% CI, 0.99-1.17]) in GIGASTROKE. Similar results were found for magnetic resonance imaging-confirmed LS (OR, 0.94 [95% CI, 0.81-1.09]). Genetically predicted risk of venous thrombosis was not associated with imaging markers of cSVD. CONCLUSIONS These findings suggest that altered thrombosis plays a role in the risk of cardioembolic and large-artery stroke but is not a causal risk factor for LS or imaging markers of cSVD. This raises the possibility that antithrombotic medication may be less effective in cSVD and underscores the necessity for further trials in well-subtyped cohorts with LS to evaluate the efficacy of different antithrombotic regimens in LS.
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Affiliation(s)
- Fatemeh Koohi
- Department of Clinical Neurosciences, Stroke Research Group, University of Cambridge, United Kingdom
| | - Eric L. Harshfield
- Department of Clinical Neurosciences, Stroke Research Group, University of Cambridge, United Kingdom
| | - Alexey Shatunov
- Department of Clinical Neurosciences, Stroke Research Group, University of Cambridge, United Kingdom
| | - Hugh S. Markus
- Department of Clinical Neurosciences, Stroke Research Group, University of Cambridge, United Kingdom
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3
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Zietz A, Polymeris AA, Helfenstein F, Schaedelin S, Hert L, Wagner B, Seiffge DJ, Traenka C, Altersberger VL, Dittrich T, Kaufmann J, Ravanelli F, Fladt J, Fisch U, Thilemann S, De Marchis GM, Gensicke H, Bonati LH, Katan M, Fischer U, Lyrer P, Engelter ST, Peters N. The impact of competing stroke etiologies in patients with atrial fibrillation. Eur Stroke J 2023; 8:703-711. [PMID: 37401394 PMCID: PMC10472960 DOI: 10.1177/23969873231185220] [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: 04/20/2023] [Accepted: 06/12/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Data on the impact of competing stroke etiologies in stroke patients with atrial fibrillation (AF) are scarce. METHODS We used prospectively obtained data from an observational registry (Novel-Oral-Anticoagulants-in-Ischemic-Stroke-Patients-(NOACISP)-LONGTERM) of consecutive AF-stroke patients treated with oral anticoagulants. We compared the frequency of (i) the composite outcome of recurrent ischemic stroke (IS), intracerebral hemorrhage (ICH) or all-cause death as well as (ii) recurrent IS alone among AF-stroke patients with versus without competing stroke etiologies according to the TOAST classification. We performed cox proportional hazards regression modeling adjusted for potential confounders. Furthermore, the etiology of recurrent IS was assessed. RESULTS Among 907 patients (median age 81, 45.6% female), 184 patients (20.3%) had competing etiologies, while 723 (79.7%) had cardioembolism as the only plausible etiology. During 1587 patient-years of follow-up, patients with additional large-artery atherosclerosis had higher rates of the composite outcome (adjusted HR [95% CI] 1.64 [1.11, 2.40], p = 0.017) and recurrent IS (aHR 2.96 [1.65, 5.35 ], p < 0.001), compared to patients with cardioembolism as the only plausible etiology. Overall 71 patients had recurrent IS (7.8%) of whom 26.7% had a different etiology than the index IS with large-artery-atherosclerosis (19.7%) being the most common non-cardioembolic cause. CONCLUSION In stroke patients with AF, causes other than cardioembolism as competing etiologies were common in index or recurrent IS. Concomitant presence of large-artery-atherosclerosis seems to indicate an increased risk for recurrences suggesting that stroke preventive means might be more effective if they also address competing stroke etiologies in AF-stroke patients. CLINICAL TRIAL REGISTRATION NCT03826927.
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Affiliation(s)
- Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | - Sabine Schaedelin
- Department of Clinical Research, University Hospital Basel and University of Basel, Switzerland
| | - Lisa Hert
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Intensive Care Medicine, University Hospital Basel, Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David J Seiffge
- Department of Neurology and Stroke Center, Inselspital, Bern, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland
| | - Valerian L Altersberger
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland
| | - Tolga Dittrich
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Josefin Kaufmann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland
| | - Flavia Ravanelli
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland
| | - Joachim Fladt
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Urs Fisch
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department for Neurology, University Hospital Zurich, Switzerland
| | - Urs Fischer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland
- Stroke Center, Klinik Hirslanden, Zürich, Switzerland
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Dimaras T, Merkouris E, Tsiptsios D, Christidi F, Sousanidou A, Orgianelis I, Polatidou E, Kamenidis I, Karatzetzou S, Gkantzios A, Ntatsis C, Kokkotis C, Retsidou S, Aristidou M, Karageorgopoulou M, Psatha EA, Aggelousis N, Vadikolias K. Leukoaraiosis as a Promising Biomarker of Stroke Recurrence among Stroke Survivors: A Systematic Review. Neurol Int 2023; 15:994-1013. [PMID: 37606397 PMCID: PMC10443317 DOI: 10.3390/neurolint15030064] [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: 06/29/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 08/23/2023] Open
Abstract
Stroke is the leading cause of functional disability worldwide, with increasing prevalence in adults. Given the considerable negative impact on patients' quality of life and the financial burden on their families and society, it is essential to provide stroke survivors with a timely and reliable prognosis of stroke recurrence. Leukoaraiosis (LA) is a common neuroimaging feature of cerebral small-vessel disease. By researching the literature of two different databases (MEDLINE and Scopus), the present study aims to review all relevant studies from the last decade, dealing with the clinical utility of pre-existing LA as a prognostic factor for stroke recurrence in stroke survivors. Nineteen full-text articles published in English were identified and included in the present review, with data collected from a total of 34,546 stroke patients. A higher rate of extended LA was strongly associated with stroke recurrence in all stroke subtypes, even after adjustment for clinical risk factors. In particular, patients with ischemic stroke or transient ischemic attack with advanced LA had a significantly higher risk of future ischemic stroke, whereas patients with previous intracerebral hemorrhage and severe LA had a more than 2.5-fold increased risk of recurrent ischemic stroke and a more than 30-fold increased risk of hemorrhagic stroke. Finally, in patients receiving anticoagulant treatment for AF, the presence of LA was associated with an increased risk of recurrent ischemic stroke and intracranial hemorrhage. Because of this valuable predictive information, evaluating LA could significantly expand our knowledge of stroke patients and thereby improve overall stroke care.
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Affiliation(s)
- Theofanis Dimaras
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Ermis Merkouris
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Dimitrios Tsiptsios
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Foteini Christidi
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Anastasia Sousanidou
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Ilias Orgianelis
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Efthymia Polatidou
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Iordanis Kamenidis
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Stella Karatzetzou
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Aimilios Gkantzios
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Christos Ntatsis
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Christos Kokkotis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (M.A.); (M.K.); (N.A.)
| | - Sofia Retsidou
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Maria Aristidou
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (M.A.); (M.K.); (N.A.)
| | - Maria Karageorgopoulou
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (M.A.); (M.K.); (N.A.)
| | - Evlampia A. Psatha
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
| | - Nikolaos Aggelousis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (M.A.); (M.K.); (N.A.)
| | - Konstantinos Vadikolias
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (T.D.); (E.M.); (F.C.); (A.S.); (E.P.); (I.K.); (S.K.); (A.G.); (C.N.); (S.R.); (E.A.P.); (K.V.)
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Pedreira BB, Zachrison KS, Singhal A, Yan Z, Oliveira-Filho J, Schwamm LH. Outcomes of recurrent stroke in patients with atrial fibrillation according to presumed etiology. ARQUIVOS DE NEURO-PSIQUIATRIA 2023. [PMID: 37336506 PMCID: PMC10371407 DOI: 10.1055/s-0043-1769124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a potent risk factor for stroke. The presence of competing etiologies can modify disease outcomes and demand different treatment strategies. OBJECTIVES The primary purpose of the study was to examine the differences in outcomes for patients with AF admitted with a recurrent stroke, stratified according to the presumed etiology of the stroke. METHODS We analyzed AF patients admitted for a recurrent ischemic stroke in an academic comprehensive stroke center. Recurrent strokes were categorized as "Cardioembolic", meaning AF without any competing mechanism, versus "Undetermined" etiology due to competing mechanisms. We used logistic regression to test the association between recurrent stroke etiology and favorable outcome (discharge home), after accounting for important covariates. RESULTS We included 230 patients, with a mean age 76.9 (SD ± 11.3), 52.2% male, median National Institute of Health Stroke Scale (NIHSS) score of 7 (IQR 2-16). Patients with cardioembolic stroke (65.2%) had higher median NIHSS 8.5 (3-18) versus 3 (1-8) and were more likely to be treated with reperfusion therapies. The favorable outcome was reached by 64 patients (27.8%), and in-hospital mortality was 15.2% overall. After adjustment, there was no difference in outcome between patients with cardioembolic versus undetermined stroke etiology (odds ratio for discharge home: 1.41; 95% CI: 0.65-3.15). CONCLUSIONS In this single-center sample of AF patients with history of stroke, there was no difference in discharge outcomes between those with cardioembolic and those with undetermined stroke etiology. This question warrants examination in larger samples to better understand the importance of the stroke mechanism and secondary prophylaxis.
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Affiliation(s)
- Bruno Bacellar Pedreira
- Harvard Medical School, Massachusetts General Hospital, Department of Neurology, Boston, United States
- Universidade Federal da Bahia, Hospital Universitario Professor Edgard Santos, Programa de Pós-Graduação em Ciências da Saúde, Salvador BA, Brazil
| | - Korilyn Sauser Zachrison
- Harvard Medical School, Massachusetts General Hospital and Boston, Department of Emergency Medicine, Boston, United States
| | - Aneesh Singhal
- Harvard Medical School, Massachusetts General Hospital, Department of Neurology, Boston, United States
| | - Zhiyu Yan
- Harvard Medical School, Massachusetts General Hospital, Department of Neurology, Boston, United States
| | - Jamary Oliveira-Filho
- Universidade Federal da Bahia, Hospital Universitario Professor Edgard Santos, Programa de Pós-Graduação em Ciências da Saúde, Salvador BA, Brazil
| | - Lee H Schwamm
- Harvard Medical School, Massachusetts General Hospital, Department of Neurology, Boston, United States
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6
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Exploring the Impact of Cerebral Microbleeds on Stroke Management. Neurol Int 2023; 15:188-224. [PMID: 36810469 PMCID: PMC9944881 DOI: 10.3390/neurolint15010014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/17/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023] Open
Abstract
Stroke constitutes a major cause of functional disability and mortality, with increasing prevalence. Thus, the timely and accurate prognosis of stroke outcomes based on clinical or radiological markers is vital for both physicians and stroke survivors. Among radiological markers, cerebral microbleeds (CMBs) constitute markers of blood leakage from pathologically fragile small vessels. In the present review, we evaluated whether CMBs affect ischemic and hemorrhagic stroke outcomes and explored the fundamental question of whether CMBs may shift the risk-benefit balance away from reperfusion therapy or antithrombotic use in acute ischemic stroke patients. A literature review of two databases (MEDLINE and Scopus) was conducted to identify all the relevant studies published between 1 January 2012 and 9 November 2022. Only full-text articles published in the English language were included. Forty-one articles were traced and included in the present review. Our findings highlight the utility of CMB assessments, not only in the prognostication of hemorrhagic complications of reperfusion therapy, but also in forecasting hemorrhagic and ischemic stroke patients' functional outcomes, thus indicating that a biomarker-based approach may aid in the provision of counseling for patients and families, improve the selection of more appropriate medical therapies, and contribute to a more accurate choice of patients for reperfusion therapy.
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Nagata K, Inoue H, Yamashita T, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Suzuki S, Tsutsui H, Toyoda K, Hirayama A, Yamaguchi T, Teramukai S, Kimura T, Morishima Y, Takita A, Yasaka M. Impact of cognitive impairment on clinical outcomes in elderly patients with atrial fibrillation: ANAFIE Registry. BMJ Neurol Open 2023; 5:e000370. [PMID: 36727104 PMCID: PMC9884865 DOI: 10.1136/bmjno-2022-000370] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/22/2022] [Indexed: 01/26/2023] Open
Abstract
Background This subcohort study of All Nippon AF In the Elderly (ANAFIE) Registry based on 33 275 elderly patients (aged ≥75 years) with non-valvular atrial fibrillation (NVAF) investigated the relationship between cognitive function and 2-year clinical outcomes. Methods A total of 2963 (mean age, 81.4 years) patients participated in this subcohort study and were classified as having normal cognition (Mini-Mental State Examination (MMSE) score ≥24/30) or cognitive impairment (score ≤23/30) at baseline. Patients with a decrease of >2 points after 24 months were classified as having cognitive decline. Results At baseline, 586 (19.8%) patients had cognitive impairment. These patients tended to be older and had poorer general conditions than patients with normal cognition. The 2-year probability of stroke/systemic embolic events (SEEs), major bleeding and intracranial haemorrhage was numerically higher; those of cardiovascular death, all-cause death and net clinical outcome (composite of stroke/SEE, major bleeding and all-cause death) were significantly higher (all p<0.001) in patients with cognitive impairment versus normal cognition. In multivariate analysis, the risks of cardiovascular death (p=0.021), all-cause death (p<0.001) and net clinical outcome (p<0.001) were higher in patients with cognitive impairment versus those with normal cognition. After 24 months, 642 of 1915 (33.5%) patients with repeated MMSE determination had cognitive decline. Educational background <9 years, older age and concomitant cerebrovascular disorders were significant risk factors of cognitive decline at the 2-year follow-up. Conclusions Elderly patients with NVAF with cognitive impairment have a higher mortality risk than those with normal cognition. Several significant risk factors of cognitive decline were identified at 2-year follow-up. Trial registration number UMIN000024006 (http://www.umin.ac.jp/).
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Affiliation(s)
- Ken Nagata
- Clinical Research Institute, Yokohama General Hospital, Yokohama, Japan
| | | | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co, Chuo-ku, Japan
| | | | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd, Tokyo, Japan
| | - Masahiro Yasaka
- National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
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Kubacka M, Zietz A, Schaedelin S, Polymeris AA, Hert L, Lieb J, Wagner B, Seiffge D, Traenka C, Altersberger VL, Dittrich T, Fladt J, Fisch U, Thilemann S, De Marchis GM, Gensicke H, Bonati LH, Lyrer P, Engelter ST, Peters N. Global Cortical Atrophy Is Associated with an Unfavorable Outcome in Stroke Patients on Oral Anticoagulation. Cerebrovasc Dis 2022; 52:495-502. [PMID: 36513036 PMCID: PMC10627484 DOI: 10.1159/000527739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/17/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Measures of cerebral small vessel disease (cSVD), such as white matter hyperintensities (WMH) and cerebral microbleeds (CMB), are associated with an unfavorable clinical course in stroke patients on oral anticoagulation (OAC) for atrial fibrillation (AF). Here, we investigated whether similar findings can be observed for global cortical atrophy (GCA). METHODS Registry-based prospective observational study of 320 patients treated with OAC following AF stroke. Patients underwent magnetic resonance imaging (MRI) allowing assessment of GCA. Using the simplified visual Pasquier scale, the severity of GCA was categorized as follows: 0: no atrophy, 1: mild atrophy; 2: moderate atrophy, and 3: severe atrophy. Using adjusted logistic and Cox regression analysis, we investigated the association of GCA using a composite outcome measure, comprising: (i) recurrent acute ischemic stroke (IS); (ii) intracranial hemorrhage (ICH); and (iii) death. RESULTS In our time to event analysis after adjusting for potential confounders (i.e., WMH, CMB, age, sex, diabetes, arterial hypertension, coronary heart disease, hyperlipidemia, and antiplatelet use), GCA was associated with an increased risk for the composite outcome in all three degrees of atrophy (grade 1: aHR 3.95, 95% CI 1.34-11.63, p = 0.013; grade 2: aHR 3.89, 95% CI 1.23-12.30, p = 0.021; grade 3: aHR 4.16, 95% CI 1.17-14.84, p = 0.028). CONCLUSION GCA was associated with our composite outcome also after adjusting for other cSVD markers (i.e., CMB, WMH) and age, indicating that GCA may potentially serve as a prognostic marker for stroke patients with atrial fibrillation on oral anticoagulation.
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Affiliation(s)
- Marta Kubacka
- Stroke Center, Klinik Hirslanden, Zürich, Switzerland
- University of Basel, Basel, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland,
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lisa Hert
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Johanna Lieb
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David Seiffge
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Inselspital, Bern, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Valerian L Altersberger
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Tolga Dittrich
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Joachim Fladt
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Urs Fisch
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, 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
- Stroke Center, Klinik Hirslanden, Zürich, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
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9
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Christidi F, Tsiptsios D, Sousanidou A, Karamanidis S, Kitmeridou S, Karatzetzou S, Aitsidou S, Tsamakis K, Psatha EA, Karavasilis E, Kokkotis C, Aggelousis N, Vadikolias K. The Clinical Utility of Leukoaraiosis as a Prognostic Indicator in Ischemic Stroke Patients. Neurol Int 2022; 14:952-980. [PMID: 36412698 PMCID: PMC9680211 DOI: 10.3390/neurolint14040076] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
Stroke constitutes a major cause of functional disability with increasing prevalence among adult individuals. Thus, it is of great importance for both clinicians and stroke survivors to be provided with a timely and accurate prognostication of functional outcome. A great number of biomarkers capable of yielding useful information regarding stroke patients' recovery propensity have been evaluated so far with leukoaraiosis being among them. Literature research of two databases (MEDLINE and Scopus) was conducted to identify all relevant studies published between 1 January 2012 and 25 June 2022 that dealt with the clinical utility of a current leukoaraiosis as a prognostic indicator following stroke. Only full-text articles published in English language were included. Forty-nine articles have been traced and are included in the present review. Our findings highlight the prognostic value of leukoaraiosis in an acute stroke setting. The assessment of leukoaraiosis with visual rating scales in CT/MRI imaging appears to be able to reliably provide important insight into the recovery potential of stroke survivors, thus significantly enhancing stroke management. Yielding additional information regarding both short- and long-term functional outcome, motor recovery capacity, hemorrhagic transformation, as well as early neurological deterioration following stroke, leukoaraiosis may serve as a valuable prognostic marker poststroke. Thus, leukoaraiosis represents a powerful prognostic tool, the clinical implementation of which is expected to significantly facilitate the individualized management of stroke patients.
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Affiliation(s)
- Foteini Christidi
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Dimitrios Tsiptsios
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
- Correspondence:
| | - Anastasia Sousanidou
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Stefanos Karamanidis
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Sofia Kitmeridou
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Stella Karatzetzou
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Souzana Aitsidou
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Konstantinos Tsamakis
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London, London SE5 8AF, UK
| | - Evlampia A. Psatha
- Department of Radiology, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Efstratios Karavasilis
- Medical Physics Laboratory, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Christos Kokkotis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece
| | - Nikolaos Aggelousis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece
| | - Konstantinos Vadikolias
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
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10
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Wagner B, Hert L, Polymeris AA, Schaedelin S, Lieb JM, Seiffge DJ, Traenka C, Thilemann S, Fladt J, Altersberger VL, Zietz A, Dittrich TD, Fisch U, Gensicke H, De Marchis GM, Bonati LH, Lyrer PA, Engelter ST, Peters N. Impact of type of oral anticoagulants in patients with cerebral microbleeds after atrial fibrillation-related ischemic stroke or TIA: Results of the NOACISP-LONGTERM registry. Front Neurol 2022; 13:964723. [PMID: 36203998 PMCID: PMC9531011 DOI: 10.3389/fneur.2022.964723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCerebral microbleeds (CMBs) may have a differential impact on clinical outcome in stroke patients with atrial fibrillation (AF) treated with different types of oral anticoagulation (OAC).MethodsObservational single-center study on AF-stroke-patients treated with OAC. Magnetic-resonance-imaging was performed to assess CMBs. Outcome measures consisted of recurrent ischemic stroke (IS), intracranial hemorrhage (ICH), death, and their combined analysis. Functional disability was assessed by mRS. Using adjusted logistic regression and Cox proportional-hazards models, we assessed the association of the presence of CMBs and OAC type (vitamin K antagonists [VKAs] vs. direct oral anticoagulants [DOACs]) with clinical outcome.ResultsOf 310 AF-stroke patients treated with OAC [DOACs: n = 234 (75%); VKAs: n = 76 (25%)], CMBs were present in 86 (28%) patients; of these, 66 (77%) received DOACs. In both groups, CMBs were associated with an increased risk for the composite outcome: VKAs: HR 3.654 [1.614; 8.277]; p = 0.002; DOACs: HR 2.230 [1.233; 4.034]; p = 0.008. Patients with CMBs had ~50% higher absolute rates of the composite outcome compared to the overall cohort, with a comparable ratio between treatment groups [VKAs 13/20(65%) vs. DOACs 19/66(29%); p < 0.01]. The VKA-group had a 2-fold higher IS [VKAs:4 (20%) vs. DOACs:6 (9%); p = 0.35] and a 10-fold higher ICH rate [VKAs: 3 (15%) vs. DOACs: 1 (1.5%); p = 0.038]. No significant interaction was observed between type of OAC and presence of CMBs. DOAC-patients showed a significantly better functional outcome (OR 0.40 [0.17; 0.94]; p = 0.04).ConclusionsIn AF-stroke patients treated with OAC, the presence of CMBs was associated with an unfavorable composite outcome for both VKAs and DOACs, with a higher risk for recurrent IS than for ICH. Strokes were numerically higher under VKAs and increased in the presence of CMBs.Clinical trial registrationhttp://www.clinicaltrials.gov, Unique identifier: NCT03826927.
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Affiliation(s)
- Benjamin Wagner
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lisa Hert
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Intensive Care Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alexandros A. Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sabine Schaedelin
- Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Johanna M. Lieb
- Department of Diagnostic and Interventional Neuroradiology, Clinic for Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David J. Seiffge
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter and Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Joachim Fladt
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Valerian L. Altersberger
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tolga D. Dittrich
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Urs Fisch
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter and Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H. Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Philippe A. Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Stefan T. Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter and Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter and Department of Clinical Research, University of Basel, Basel, Switzerland
- Stroke Center, Klinik Hirslanden Zurich, Zurich, Switzerland
- *Correspondence: Nils Peters
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11
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Polymeris AA, Zietz A, Schaub F, Meya L, Traenka C, Thilemann S, Wagner B, Hert L, Altersberger VL, Seiffge DJ, Lyrer F, Dittrich T, Piot I, Kaufmann J, Barone L, Dahlheim L, Flammer S, Avramiotis NS, Peters N, De Marchis GM, Bonati LH, Gensicke H, Engelter ST, Lyrer PA. Once versus twice daily direct oral anticoagulants in patients with recent stroke and atrial fibrillation. Eur Stroke J 2022; 7:221-229. [PMID: 36082252 PMCID: PMC9446322 DOI: 10.1177/23969873221099477] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/20/2022] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Data on the safety and effectiveness of once-daily (QD) versus twice-daily (BID) direct oral anticoagulants (DOAC) in comparison to vitamin K antagonists (VKA) and to one another in patients with atrial fibrillation (AF) and recent stroke are scarce. PATIENTS AND METHODS Based on prospectively obtained data from the observational registry Novel-Oral-Anticoagulants-in-Ischemic-Stroke-Patients(NOACISP)-LONGTERM (NCT03826927) from Basel, Switzerland, we compared the occurrence of the primary outcome - the composite of recurrent ischemic stroke, major bleeding, and all-cause death - among consecutive AF patients treated with either VKA, QD DOAC, or BID DOAC following a recent stroke using Cox proportional hazards regression including adjustment for potential confounders. RESULTS We analyzed 956 patients (median age 80 years, 46% female), of whom 128 received VKA (13.4%), 264 QD DOAC (27.6%), and 564 BID DOAC (59%). Over a total follow-up of 1596 patient-years, both QD DOAC and BID DOAC showed a lower hazard for the composite outcome compared to VKA (adjusted HR [95% CI] 0.69 [0.48, 1.01] and 0.66 [0.47, 0.91], respectively). Upon direct comparison, the hazard for the composite outcome did not differ between patients treated with QD versus BID DOAC (adjusted HR [95% CI] 0.94 [0.70, 1.26]). Secondary analyses focusing on the individual components of the composite outcome revealed no clear differences in the risk-benefit profile of QD versus BID DOAC. DISCUSSION AND CONCLUSION The overall benefit of DOAC over VKA seems to apply to both QD and BID DOAC in AF patients with a recent stroke, without clear evidence that one DOAC dosing regimen is more advantageous than the other.
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Affiliation(s)
- Alexandros A Polymeris
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Fabian Schaub
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Louisa Meya
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lisa Hert
- Department of Intensive Care Medicine,
University Hospital Basel and University of Basel, Basel, Switzerland
| | - Valerian L Altersberger
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital,
University Hospital and University of Bern, Bern, Switzerland
| | - Flurina Lyrer
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tolga Dittrich
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ines Piot
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Josefin Kaufmann
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Lea Barone
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | | | - Sophie Flammer
- Medical Faculty, University of Basel,
Basel, Switzerland
| | - Nikolaos S Avramiotis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke
Center, 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
Zurich, Zurich, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation,
University Department of Geriatric Medicine Felix Platter, University of Basel,
Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
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12
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Corica B, Romiti GF, Raparelli V, Cangemi R, Basili S, Proietti M. Epidemiology of cerebral microbleeds and risk of adverse outcomes in atrial fibrillation: a systematic review and meta-analysis. Europace 2022; 24:1395-1403. [PMID: 35244694 DOI: 10.1093/europace/euac028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 02/18/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS The aim of this study is to perform a systematic review and meta-analysis on the epidemiology of cerebral microbleeds (CMBs) and the risk of intracranial haemorrhage (ICH) and ischaemic stroke (IS) in patients with atrial fibrillation (AF). METHODS AND RESULTS PubMed and EMBASE databases were systematically searched from inception to 6 March 2021. All studies reporting the prevalence of CMBs and incidence of ICH and IS in AF patients with and without CMBs were included. Meta-analysis was conducted using random-effect models; odds ratios (ORs), 95% confidence intervals (CIs), and prediction intervals (PIs) were calculated for each outcome. Subgroup analyses were performed according to the number and localization of CMBs. A total of 562 studies were retrieved, with 17 studies finally included in the meta-analysis. Prevalence of CMBs in AF population was estimated at 28.3% (95% CI: 23.8-33.4%). Individuals with CMBs showed a higher risk of ICH (OR: 3.04, 95% CI: 1.83-5.06, 95% PI 1.23-7.49) and IS (OR: 1.78, 95% CI: 1.26-2.49, 95% PI 1.10-2.87). Patients with ≥5 CMBs showed a higher risk of ICH. Metaregression showed how higher of prevalence of diabetes mellitus in AF cohort is associated with higher prevalence of CMBs. CONCLUSIONS Cerebral microbleeds are common in patients with AF, found in almost one out of four subjects. Cerebral microbleeds were associated with both haemorrhagic and thromboembolic events in AF patients. Moreover, the risk of ICH increased consistently with the burden of CMBs. Cerebral microbleeds may represent an important overlooked risk factor for both ICH and IS in adults with AF.
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Affiliation(s)
- Bernadette Corica
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Roberto Cangemi
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Via Camaldoli, 64, 20138 Milan, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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13
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Koh YH, Lew LZW, Franke KB, Elliott AD, Lau DH, Thiyagarajah A, Linz D, Arstall M, Tully PJ, Baune BT, Munawar DA, Mahajan R. Predictive role of atrial fibrillation in cognitive decline: a systematic review and meta-analysis of 2.8 million individuals. Europace 2022; 24:1229-1239. [PMID: 35061884 PMCID: PMC9435641 DOI: 10.1093/europace/euac003] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/04/2022] [Indexed: 12/31/2022] Open
Abstract
Aims To systematic review and meta-analyse the association and mechanistic links between atrial fibrillation (AF) and cognitive impairment. Methods and results PubMed, EMBASE, and Cochrane Library were searched up to 27 March 2021 and yielded 4534 citations. After exclusions, 61 were analysed; 15 and 6 studies reported on the association of AF and cognitive impairment in the general population and post-stroke cohorts, respectively. Thirty-six studies reported on the neuro-pathological changes in patients with AF; of those, 13 reported on silent cerebral infarction (SCI) and 11 reported on cerebral microbleeds (CMB). Atrial fibrillation was associated with 39% increased risk of cognitive impairment in the general population [n = 15: 2 822 974 patients; hazard ratio = 1.39; 95% confidence interval (CI) 1.25–1.53, I2 = 90.3%; follow-up 3.8–25 years]. In the post-stroke cohort, AF was associated with a 2.70-fold increased risk of cognitive impairment [adjusted odds ratio (OR) 2.70; 95% CI 1.66–3.74, I2 = 0.0%; follow-up 0.25–3.78 years]. Atrial fibrillation was associated with cerebral small vessel disease, such as white matter hyperintensities and CMB (n = 8: 3698 patients; OR = 1.38; 95% CI 1.11–1.73, I2 = 0.0%), SCI (n = 13: 6188 patients; OR = 2.11; 95% CI 1.58–2.64, I2 = 0%), and decreased cerebral perfusion and cerebral volume even in the absence of clinical stroke. Conclusion Atrial fibrillation is associated with increased risk of cognitive impairment. The association with cerebral small vessel disease and cerebral atrophy secondary to cardioembolism and cerebral hypoperfusion may suggest a plausible link in the absence of clinical stroke. PROSPERO CRD42018109185.
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Affiliation(s)
- Yu Han Koh
- The University of Adelaide, Adelaide, Australia
| | | | | | | | - Dennis H Lau
- The University of Adelaide, Adelaide, Australia
- Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Margaret Arstall
- The University of Adelaide, Adelaide, Australia
- Lyell McEwin Hospital, Adelaide, Australia
| | | | - Bernhard T Baune
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Victoria, Australia
- Department of Psychiatry, University of Münster, Münster, Germany
| | - Dian A Munawar
- The University of Adelaide, Adelaide, Australia
- Royal Adelaide Hospital, Adelaide, Australia
- Department of Cardiology and Vascular Medicine, University of Indonesia, Jakarta, Indonesia
| | - Rajiv Mahajan
- The University of Adelaide, Adelaide, Australia
- Lyell McEwin Hospital, Adelaide, Australia
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Schaub F, Polymeris AA, Schaedelin S, Hert L, Meya L, Thilemann S, Traenka C, Wagner B, Seiffge D, Gensicke H, De Marchis GM, Bonati L, Engelter ST, Peters N, Lyrer P. Differences Between Anticoagulated Patients With Ischemic Stroke Versus Intracerebral Hemorrhage. J Am Heart Assoc 2021; 11:e023345. [PMID: 34935409 PMCID: PMC9075191 DOI: 10.1161/jaha.121.023345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Data on the relative contribution of clinical and neuroimaging risk factors to acute ischemic stroke (AIS) versus intracerebral hemorrhage (ICH) occurring on oral anticoagulant treatment are scarce. Methods and Results Cross-sectional study was done on consecutive oral anticoagulant-treated patients presenting with AIS, transient ischemic attack (TIA), or ICH from the prospective observational NOACISP (Novel-Oral-Anticoagulants-In-Stroke-Patients)-Acute registry. We compared clinical and neuroimaging characteristics (small vessel disease markers and atherosclerosis) in ICH versus AIS/TIA (reference) using logistic regression. Among 734 patients presenting with stroke on oral anticoagulant treatment (404 [55%] direct oral anticoagulants, 330 [45%] vitamin K antagonists), 605 patients (82%) had AIS/TIA and 129 (18%) had ICH. Prior AIS/TIA, coronary artery disease, dyslipidemia, and worse renal function were associated with AIS/TIA (adjusted odds ratio [aOR] [95% CI] 0.51 [0.32-0.82], 0.48 [0.26-0.86], 0.55 [0.34-0.89], and 0.82 [0.75-0.90] per 10 mL/min). Prior ICH, older age, higher admission blood pressure, and statin treatment were associated with ICH (aOR [95% CI] 6.33 [2.87-14.04], 1.37 [1.04-1.81] per 10 years, 1.19 [1.10-1.29] per 10 mm Hg, and 1.81 [1.09-3.03]). Cerebral microbleeds and moderate-to-severe white matter hyperintensities contributed more to ICH (aOR [95% CI] 2.77 [1.34-6.18], and 2.62 [1.28-5.63]). Aortic arch, common and internal carotid artery atherosclerosis, and internal carotid artery stenosis ≥50% contributed more to AIS/TIA (aOR [95% CI] 0.54 [0.31-0.90], 0.29 [0.05-0.97], 0.48 [0.30-0.76], and 0.32 [0.13-0.67]). Conclusions In patients presenting with stroke on oral anticoagulant, AIS/TIA was 5 times more common than ICH. A high atherosclerotic burden (indicated by cardiovascular comorbidities and extracranial atherosclerosis) and prior AIS/TIA contributed more to AIS/TIA, while small vessel disease markers and prior ICH were stronger determinants for ICH. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02353585.
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Affiliation(s)
- Fabian Schaub
- Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland
| | | | - Lisa Hert
- Department of Intensive Care Medicine University Hospital Basel Basel Switzerland
| | - Louisa Meya
- Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland
| | - David Seiffge
- Department of Neurology and Stroke Center University Hospital Bern Bern Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland.,Neurology and Neurorehabilitation University Department of Geriatric Medicine Felix Platter University of Basel Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland
| | - Leo Bonati
- Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland.,Neurology and Neurorehabilitation University Department of Geriatric Medicine Felix Platter University of Basel Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland.,Neurology and Neurorehabilitation University Department of Geriatric Medicine Felix Platter University of Basel Switzerland.,Stroke Center Klinik Hirslanden Zurich Zurich Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center University Hospital Basel and University of Basel Basel Switzerland
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Peters N. Neurofilament Light Chain as a Biomarker in Cerebral Small-Vessel Disease. Mol Diagn Ther 2021; 26:1-6. [PMID: 34825310 DOI: 10.1007/s40291-021-00566-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 03/26/2024]
Abstract
Neurofilament light chain is part of the neuroaxonal cytoskeleton and upon disease-related neuroaxonal damage, it is released to the extracellular space and, based on modern highly sensitive assays, can also be detected in the peripheral blood. Thus, neurofilament light chain in the blood is an emerging marker of neurological disease, including age-related conditions, such as neurodegenerative but also neurovascular diseases. Recently, blood neurofilament light chain has been shown to serve as a potentially interesting marker of disease burden and prognostication also in cerebral small-vessel disease, a condition that is highly prevalent in elderly subjects. Small-vessel disease is a progressive condition, often related to common vascular risk factors such as arterial hypertension and is an important cause of stroke, vascular cognitive impairment, and dementia. As an age-dependent condition, small-vessel disease may occur concomitantly with neurodegenerative diseases, with both conditions having a potential impact on clinical status or cognitive performance. The aim of the present article is to give an overview on the current knowledge on neurofilament light chain as a disease or progression marker in small-vessel disease.
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Affiliation(s)
- Nils Peters
- Stroke Center, Klinik Hirslanden, Zurich, Switzerland. .,Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland. .,Neurorehabilitation Unit, Felix Platter Hospital, University of Basel and University Center for Medicine of Aging, Basel, Switzerland.
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16
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Meya L, Polymeris AA, Schaedelin S, Schaub F, Altersberger VL, Traenka C, Thilemann S, Wagner B, Fladt J, Hert L, Yoshimura S, Koga M, Zietz A, Dittrich T, Fisch U, Toyoda K, Seiffge DJ, Peters N, De Marchis GM, Gensicke H, Bonati LH, Lyrer PA, Engelter ST. Oral Anticoagulants in Atrial Fibrillation Patients With Recent Stroke Who Are Dependent on the Daily Help of Others. Stroke 2021; 52:3472-3481. [PMID: 34311567 DOI: 10.1161/strokeaha.120.033862] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND PURPOSE Data on the effectiveness and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients with stroke attributable to atrial fibrillation (AF) who were dependent on the daily help of others at hospital discharge are scarce. METHODS Based on prospectively obtained data from the observational Novel-Oral-Anticoagulants-in-Ischemic-Stroke-Patients-longterm registry from Basel, Switzerland, we compared the occurrence of the primary outcome-the composite of recurrent ischemic stroke, major bleeding, and all-cause death-among consecutive patients with AF-stroke treated with either VKAs or DOACs between patients dependent (defined as modified Rankin Scale score, 3-5) and patients independent at discharge. We used simple, adjusted, and weighted Cox proportional hazards regression to account for potential confounders. RESULTS We analyzed 801 patients (median age 80 years, 46% female), of whom 391 (49%) were dependent at discharge and 680 (85%) received DOACs. Over a total follow-up of 1216 patient-years, DOAC- compared to VKA-treated patients had a lower hazard for the composite outcome (hazard ratio [HR], 0.58 [95% CI, 0.42-0.81]), as did independent compared to dependent patients (HR, 0.54 [95% CI, 0.40-0.71]). There was no evidence that the effect of anticoagulant type (DOAC versus VKA) on the hazard for the composite outcome differed between dependent (HRdependent, 0.68 [95% CI, 0.45-1.01]) and independent patients (HRindependent, 0.44 [95% CI, 0.26-0.75]) in the simple model (Pinteraction=0.212). Adjusted (HRdependent, 0.74 [95% CI, 0.49-1.11] and HRindependent, 0.51 [95% CI, 0.30-0.87]; Pinteraction=0.284) and weighted models (HRdependent, 0.79 [95% CI, 0.48-1.31] and HRindependent, 0.46 [95% CI, 0.26-0.81]; Pinteraction=0.163) yielded concordant results. Secondary analyses focusing on the individual components of the composite outcome were consistent to the primary analyses. CONCLUSIONS The benefits of DOACs in patients with atrial fibrillation with a recent stroke were maintained among patients who were dependent on the help of others at discharge. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03826927.
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Affiliation(s)
- Louisa Meya
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.).,Department of Intensive Care Medicine, University Hospital Basel and University of Basel, Switzerland. (L.H.)
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.)
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel and University of Basel, Switzerland. (S.S.)
| | - Fabian Schaub
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.)
| | - Valerian L Altersberger
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.)
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.).,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland (L.M., C.T., H.G., S.T.E.)
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.)
| | - Benjamin Wagner
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.)
| | - Joachim Fladt
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.)
| | - Lisa Hert
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland (L.M., C.T., H.G., S.T.E.)
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (S.Y., M.K., K.T.)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (S.Y., M.K., K.T.)
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.)
| | - Tolga Dittrich
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.)
| | - Urs Fisch
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.)
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (S.Y., M.K., K.T.)
| | - David J Seiffge
- Department of Neurology, Inselspital, University Hospital and University of Bern, Switzerland (D.J.S.)
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.).,Department of Neurology and Stroke Center, Hirslanden Hospital, Zurich, Switzerland (N.P.)
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.)
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.).,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland (L.M., C.T., H.G., S.T.E.)
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.)
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.)
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland. (L.M., A.A.P., F.S., V.L.A., C.T., S.T., B.W., J.F., A.Z., T.D., U.F., N.P., G.M.D.M., H.G., L.H.B., P.A.L., S.T.E.).,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland (L.M., C.T., H.G., S.T.E.)
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