1
|
Mulder MJHL, Cras TY, Shay J, Dippel DWJ, Burke JF. Comparison of American and European Guideline Recommendations for Diagnostic Workup and Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack. Circulation 2024; 150:806-815. [PMID: 39226381 DOI: 10.1161/circulationaha.124.069651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
Guidelines help to facilitate treatment decisions based on available evidence, and also to provide recommendations in areas of uncertainty. In this paper, we compare the recommendations for stroke workup and secondary prevention of ischemic stroke and transient ischemic attack of the American Heart Association (AHA)/American Stroke Association (ASA) with the European Stroke Organization (ESO) guidelines. The primary aim of this paper is to offer clinicians guidance by identifying areas where there is consensus and where consensus is lacking, in the absence or presence of high-level evidence. We compared AHA/ASA with the ESO guideline recommendations for 7 different topics related to diagnostic stroke workup and secondary prevention. We categorized the recommendations based on class and level of evidence to determine whether there were relevant differences in the ratings of evidence that the guidelines used for its recommendations. Finally, we summarized major topics of agreement and disagreement, while also prominent knowledge gaps were identified. In total, we found 63 ESO and 82 AHA/ASA recommendations, of which 38 were on the same subject. Most recommendations are largely similar, but not all are based on high-level evidence. For many recommendations, AHA/ASA and ESO assigned different levels of evidence. For the 10 recommendations with Level A evidence (high quality) in AHA/ASA, ESO only labeled 4 of these as high quality. There are many remaining issues with either no or insufficient evidence, and some topics that are not covered by both guidelines. Most ESO and AHA/ASA Guideline recommendations for stroke workup and secondary prevention were similar. However not all were based on high-level evidence and the appointed level of evidence often differed. Clinicians should not blindly follow all guideline recommendations; the accompanying level of evidence informs which recommendations are based on robust evidence. Topics with lower levels of evidence, or those with recommendations that disagree or are missing, may be an incentive for further clinical research.
Collapse
Affiliation(s)
- Maxim J H L Mulder
- Departments of Neurology, Erasmus University Medical Center (M.J.H.L.M., T.Y.C., D.W.J.D.), Rotterdam, The Netherlands
| | - Tim Y Cras
- Departments of Neurology, Erasmus University Medical Center (M.J.H.L.M., T.Y.C., D.W.J.D.), Rotterdam, The Netherlands
- Sint Franciscus Gasthuis (T.Y.C.), Rotterdam, The Netherlands
| | - James Shay
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus (J.S., J.F.B.)
| | - Diederik W J Dippel
- Departments of Neurology, Erasmus University Medical Center (M.J.H.L.M., T.Y.C., D.W.J.D.), Rotterdam, The Netherlands
| | - James F Burke
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus (J.S., J.F.B.)
| |
Collapse
|
2
|
Ebbesen BH, Modrau B, Rathleff MS, Johnsen SP, Andreasen J. 'There are things I have learned the hard way' Patient experiences on lasting challenges 4 months after Transient Ischemic Attack: A qualitative study. J Clin Nurs 2024. [PMID: 39128965 DOI: 10.1111/jocn.17399] [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: 03/20/2024] [Revised: 07/12/2024] [Accepted: 07/25/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND Fatigue, depression, anxiety and cognitive difficulties are reported by 1/3 of patients following transient ischemic attack (TIA). AIMS To explore the timeline and how the diagnosis impacts individuals experiencing lasting challenges after TIA. Furthermore, to identify what they believed facilitated return to everyday life. DESIGN Qualitative exploratory study with a phenomenological-hermeneutic approach. METHODS Individual semi-structured interviews and thematic analysis. RESULTS Fifteen patients were included. Four themes were identified; (1) 'They say it is transient - no, not for me' where all participants described lasting challenges emphasizing invalidating fatigue and impaired social participation, (2) 'I am a changed person; how does this impact my future?' which reflects altered identity and elevated alertness to symptoms, (3) 'Time has been my ally and new perspectives have evolved' where most participants described improvement over time and a few considered the diagnosis a wake-up call to change lifestyle. Lastly (4) 'What would have helped me recover?' which unfolds that close, trustful relations influence positively. In addition, the system often failed to support. Participants described pressure to return to work and lack of trust and negative experiences when involving their general practitioner. CONCLUSIONS During the 4 months since diagnosis, participants experienced limitations impacting physical, psychological and social domains. They felt uninformed that lasting challenges could affect them. Different coping strategies were activated, and participants with close, supportive relations managed better. A pressure to return to work and a lack of trust in the general practitioner affected their recovery negatively. Overall, return to everyday life after TIA was considered stressful and appropriate support lacking. RELEVANCE TO CLINICAL PRACTICE To be able to support patients with challenges following TIA, we as healthcare professionals need to understand the identified impact and life changing circumstances. Currently the system seemingly is not able to provide timely, sufficient and competent support. IMPACT (ADDRESSING) WHAT PROBLEM DID THE STUDY ADDRESS?: We know from the literature that up to 1/3 of patients following transient ischemic attack experience lasting challenges measured on a variety of questionnaires. This is paradoxical to a diagnosis defined by focal neurological symptoms that resolve within 24 h. It is unknown how patients with lasting challenges experience the timeline from diagnosis and until 4 months after, how the diagnosis impacts the lives of these individuals, and what they believe as beneficial in returning to their everyday life. WHAT WERE THE MAIN FINDINGS?: These participants with self-reported lasting challenges experienced substantial impacts on physical, psychological and social domains. Further, they felt alone with their struggles and when in need of support from the healthcare system, it failed to provide this. A pressure to return to work and a lack of trust in the general practitioner affected return to everyday life negatively, whereas close and supportive relations facilitated positively. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: This study will have an impact on the healthcare professionals that provide support and the (limited) follow-up services to patients after TIA. These healthcare professionals are often specialized nurses who need to know what these patients experience and need in order to act upon their struggles and provide timely support. REPORTING METHOD The Standards of Reporting Qualitative Research (SRQR). PATIENT OR PUBLIC CONTRIBUTION Patients with TIA was involved in planning this study. They participated in a panel to plan a prospective observational cohort study and emphasized the importance of exploring the subjective perspectives of impact and prognosis for those patients struggling in a longer term (through qualitative interviews).
Collapse
Affiliation(s)
- Birgitte Hede Ebbesen
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Boris Modrau
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Michael Skovdal Rathleff
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jane Andreasen
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Aalborg Centre of Health and Rehabilitation, Aalborg Municipality, Aalborg, Denmark
| |
Collapse
|
3
|
Caruso P, Prandin G, Rossi L, Cegalin M, Lugnan C, Pasquin F, Sisto UG, Furlanis G, Naccarato M, Cominotto F, Manganotti P. Epidemiology and management of transient ischemic attack in Trieste district, how day hospital assessment improves outcomes: a five-year retrospective study. Neurol Sci 2024; 45:3861-3867. [PMID: 38467952 DOI: 10.1007/s10072-024-07443-6] [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: 01/19/2024] [Accepted: 03/03/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Transient ischemic attack (TIA) is defined as a transient episode of neurologic dysfunction, without acute infarction or tissue injury lasting less than 24 h. Previous data suggest TIA precedes 15% of ischemic strokes, with a higher risk in the first week. Current practice guidelines advise evaluation through rapid neurological visit or admission to hospital. We provide data on TIA incidence in Trieste, and we compare three different types of assessment: day hospital (DH), stroke unit (SU), and emergency department/outpatients (ED). METHODS This is a 5-year retrospective study of transient cerebrovascular events admitted in the University Hospital of Trieste (230.623 inhabitants), between 2016 and 2020. We calculated TIA prevalence in Trieste district's general population. Our primary endpoint is ischemic recurrences within 90 days, and we evaluate the possible association between different types of management. RESULTS TIA incidence rate was 0.54/1000 inhabitants. In the multivariate analysis remained significantly associated with primary endpoint: ABCD2 (OR 1.625, CI 95% 1.114-2.369, p = 0.012) and DH evaluation (OR 0.260, CI 95% 0.082-0.819, p = 0.021). CONCLUSIONS Incidence of TIA in Trieste district is in line with previous data. We demonstrate the crucial role of DH evaluation over the outpatient/ED in reducing overall mortality and recurrence rate. Prompt recognition of patients at high risk for cerebrovascular events and specialist follow-up may reduce the incidence of major vascular events and death.
Collapse
Affiliation(s)
- Paola Caruso
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Gabriele Prandin
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy.
| | - Lucrezia Rossi
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Matteo Cegalin
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Carlo Lugnan
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Fulvio Pasquin
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Ugo Giulio Sisto
- Emergency Department, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Marcello Naccarato
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Franco Cominotto
- Emergency Department, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, ASUGI, University of Trieste, Strada Di Fiume 447, 34100, Trieste, Italy
| |
Collapse
|
4
|
Salafia G, Carandina A, Sacco RM, Ferri E, Montano N, Arosio B, Tobaldini E. Soluble Triggering Receptors Expressed on Myeloid Cells (sTREM) in Acute Ischemic Stroke: A Potential Pathway of sTREM-1 and sTREM-2 Associated with Disease Severity. Int J Mol Sci 2024; 25:7611. [PMID: 39062850 PMCID: PMC11277504 DOI: 10.3390/ijms25147611] [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: 05/07/2024] [Revised: 06/28/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
In 2022, stroke emerged as the most significant cerebrovascular disorder globally, causing 6.55 million deaths. Microglia, crucial for CNS preservation, can exacerbate brain damage in ischemic stroke by triggering neuroinflammation. This process is mediated by receptors on microglia, triggering receptors expressed on myeloid cells (TREM-1 and TREM-2), which have contrasting roles in neuroinflammation. In this study, we recruited 38 patients within 4.5 h from the onset of ischemic stroke. The degree of severity was evaluated by means of the National Institutes of Health Stroke Scale (NIHSS) at admission (T0) and after one week of ischemic events (TW) and the Modified Rankin Scale (mRS) at three months. The plasma concentration of TREMs (sTREM) was analyzed by next-generation ELISA at T0 and TW. The sTREM-1 concentrations at T0 were associated with mRS, while the sTREM-2 concentrations at T0 were associated with both the NIHSS at T0 and the mRS. A strong correlation between sTREM-1 and sTREM-2 was observed, suggesting a dependent modulation of the levels. This study provides insights into the potential pathway of TREM-1 and TREM-2 as a future biomarker for stratifying high-risk patients with ischemic stroke.
Collapse
Affiliation(s)
- Greta Salafia
- Department of Clinical Sciences and Community Health, Dipartimento di Eccellenza 2023–2027, University of Milan, 20122 Milan, Italy; (G.S.); (A.C.); (N.M.); (B.A.)
| | - Angelica Carandina
- Department of Clinical Sciences and Community Health, Dipartimento di Eccellenza 2023–2027, University of Milan, 20122 Milan, Italy; (G.S.); (A.C.); (N.M.); (B.A.)
| | - Roberto Maria Sacco
- Emergency Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Evelyn Ferri
- Geriatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Nicola Montano
- Department of Clinical Sciences and Community Health, Dipartimento di Eccellenza 2023–2027, University of Milan, 20122 Milan, Italy; (G.S.); (A.C.); (N.M.); (B.A.)
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Beatrice Arosio
- Department of Clinical Sciences and Community Health, Dipartimento di Eccellenza 2023–2027, University of Milan, 20122 Milan, Italy; (G.S.); (A.C.); (N.M.); (B.A.)
| | - Eleonora Tobaldini
- Department of Clinical Sciences and Community Health, Dipartimento di Eccellenza 2023–2027, University of Milan, 20122 Milan, Italy; (G.S.); (A.C.); (N.M.); (B.A.)
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| |
Collapse
|
5
|
De Matteis E, Ornello R, De Santis F, Foschi M, Romoli M, Tassinari T, Saia V, Cenciarelli S, Bedetti C, Padiglioni C, Censori B, Puglisi V, Vinciguerra L, Guarino M, Barone V, Zedde M, Grisendi I, Diomedi M, Bagnato MR, Petruzzellis M, Mezzapesa DM, Di Viesti P, Inchingolo V, Cappellari M, Zenorini M, Candelaresi P, Andreone V, Rinaldi G, Bavaro A, Cavallini A, Moraru S, Querzani P, Terruso V, Mannino M, Pezzini A, Frisullo G, Muscia F, Paciaroni M, Mosconi MG, Zini A, Leone R, Palmieri C, Cupini LM, Marcon M, Tassi R, Sanzaro E, Paci C, Viticchi G, Orsucci D, Falcou A, Diamanti S, Tarletti R, Nencini P, Rota E, Sepe FN, Ferrandi D, Caputi L, Volpi G, Spada SL, Beccia M, Rinaldi C, Mastrangelo V, Di Blasio F, Invernizzi P, Pelliccioni G, De Angelis MV, Bonanni L, Ruzza G, Caggia EA, Russo M, Tonon A, Acciarri MC, Anticoli S, Roberti C, Manobianca G, Scaglione G, Pistoia F, Fortini A, De Boni A, Sanna A, Chiti A, Barbarini L, Caggiula M, Masato M, Del Sette M, Passarelli F, Roberta Bongioanni M, Toni D, Ricci S, Sacco S. Beyond RCTs: Short-term dual antiplatelet therapy in secondary prevention of ischemic stroke and transient ischemic attack. Eur Stroke J 2024:23969873241255250. [PMID: 38869034 DOI: 10.1177/23969873241255250] [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: 06/14/2024] Open
Abstract
BACKGROUND AND PURPOSE Randomized controlled trials (RCTs) proved the efficacy of short-term dual antiplatelet therapy (DAPT) in secondary prevention of minor ischemic stroke or high-risk transient ischemic attack (TIA). We aimed at evaluating effectiveness and safety of short-term DAPT in real-world, where treatment use is broader than in RCTs. METHODS READAPT (REAl-life study on short-term Dual Antiplatelet treatment in Patients with ischemic stroke or Transient ischemic attack) (NCT05476081) was an observational multicenter real-world study with a 90-day follow-up. We included patients aged 18+ receiving short-term DAPT soon after ischemic stroke or TIA. No stringent NIHSS and ABCD2 score cut-offs were applied but adherence to guidelines was recommended. Primary effectiveness outcome was stroke (ischemic or hemorrhagic) or death due to vascular causes, primary safety outcome was moderate-to-severe bleeding. Secondary outcomes were the type of ischemic and hemorrhagic events, disability, cause of death, and compliance to treatment. RESULTS We included 1920 patients; 69.9% started DAPT after an ischemic stroke; only 8.9% strictly followed entry criteria or procedures of RCTs. Primary effectiveness outcome occurred in 3.9% and primary safety outcome in 0.6% of cases. In total, 3.3% cerebrovascular ischemic recurrences occurred, 0.2% intracerebral hemorrhages, and 2.7% bleedings; 0.2% of patients died due to vascular causes. Patients with NIHSS score ⩽5 and those without acute lesions at neuroimaging had significantly higher primary effectiveness outcomes than their counterparts. Additionally, DAPT start >24 h after symptom onset was associated with a lower likelihood of bleeding. CONCLUSIONS In real-world, most of the patients who receive DAPT after an ischemic stroke or a TIA do not follow RCTs entry criteria and procedures. Nevertheless, short-term DAPT remains effective and safe in this population. No safety concerns are raised in patients with low-risk TIA, more severe stroke, and delayed treatment start.
Collapse
Affiliation(s)
- Eleonora De Matteis
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Department of Brain Sciences, Imperial College London, London, UK
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Federico De Santis
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Michele Romoli
- Department of Neuroscience, Maurizio Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Tiziana Tassinari
- Department of Neurology, Santa Corona Hospital, Pietra Ligure, Italy
| | - Valentina Saia
- Department of Neurology, Santa Corona Hospital, Pietra Ligure, Italy
| | - Silvia Cenciarelli
- Department of Neurology, Città di Castello Hospital, Città di Castello, Italy
| | - Chiara Bedetti
- Department of Neurology, Città di Castello Hospital, Città di Castello, Italy
| | - Chiara Padiglioni
- Department of Neurology, Città di Castello Hospital, Città di Castello, Italy
| | - Bruno Censori
- Department of Neurology, ASST Cremona Hospital, Cremona, Italy
| | | | | | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Valentina Barone
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Ilaria Grisendi
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marina Diomedi
- Department of Systems Medicine, Tor Vergata University Hospital, Rome, Italy
| | | | - Marco Petruzzellis
- Department of Neurology and Stroke Unit, "F. Puca" AOU Consorziale Policlinico, Bari, Italy
| | | | - Pietro Di Viesti
- Department of Neurology, Fondazione IRCCS Casa sollievo della sofferenza, San Giovanni Rotondo, Italy
| | - Vincenzo Inchingolo
- Department of Neurology, Fondazione IRCCS Casa sollievo della sofferenza, San Giovanni Rotondo, Italy
| | - Manuel Cappellari
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona
| | - Mara Zenorini
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona
| | - Paolo Candelaresi
- Department of Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | - Vincenzo Andreone
- Department of Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | | | | | - Anna Cavallini
- UO Neurologia d'Urgenza e Stroke Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Stefan Moraru
- UO Neurologia d'Urgenza e Stroke Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Pietro Querzani
- Department of Neuroscience, S.Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Valeria Terruso
- Department of Neurology, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - Marina Mannino
- Department of Neurology, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - Alessandro Pezzini
- Department of Medicine and Surgery, University of Parma, Stroke Care Program, Department of Emergency, Parma University Hospital, Parma, Italy
| | - Giovanni Frisullo
- Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | | | - Maurizio Paciaroni
- Department of Internal and Cardiovascular Medicine - Stroke Unit, University Hospital Santa Maria della Misericordia, Perugia, Italy
| | - Maria Giulia Mosconi
- Department of Internal and Cardiovascular Medicine - Stroke Unit, University Hospital Santa Maria della Misericordia, Perugia, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Ruggiero Leone
- Department of Neurology and Stroke Unit, "M. R. Dimiccoli" General Hospital, Barletta, ASL BT, Italy
| | - Carmela Palmieri
- Medical Department, E. Agnelli Hospital - Local Health Company (ASL) TO3, Pinerolo, Italy
| | | | - Michela Marcon
- Department of Neurology, Cazzavillan Hospital Arzignano, Vicenza, Italy
| | - Rossana Tassi
- Stroke Unit, Urgency and Emergency Department, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Enzo Sanzaro
- Department of Neurology, Umberto I Hospital, Siracusa, Italy
| | - Cristina Paci
- UOC Neurologia, Ospedale "Madonna del Soccorso", San Benedetto del Tronto, Italy
| | - Giovanna Viticchi
- Experimental and Clinical Medicine Department, Marche Polytechnic University, Ancona
| | - Daniele Orsucci
- Unit of Neurology-San Luca Hospital, Lucca and Castelnuovo Garfagnana, Italy
| | - Anne Falcou
- Stroke Unit, Emergency Department, Policlinico Umberto I Hospital, Rome, Italy
| | - Susanna Diamanti
- Department of Neurology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Roberto Tarletti
- SCDU Neurologia - Stroke Unit, Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
| | | | - Eugenia Rota
- Department of Neurology, San Giacomo Hospital, Novi Ligure, Italy
| | | | - Delfina Ferrandi
- Stroke Unit-Department of Neurology, SS. Biagio e Arrigo Hospital, Alessandria, Italy
| | - Luigi Caputi
- Department of Cardiocerebrovascular diseases, Neurology-Stroke Unit-ASST Ospedale Maggiore di Crema, Crema, Italy
| | - Gino Volpi
- Department of Neurology, San Jacopo Hospital, Pistoia, Italy
| | | | - Mario Beccia
- Department of Neurology, Sant'Andrea Hospital, Rome, Italy
| | - Claudia Rinaldi
- Neurology Unit, "Infermi" Hospital, AUSL Romagna, Rimini, Italy
| | | | | | - Paolo Invernizzi
- Departiment of Neurology, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | | | - Maria Vittoria De Angelis
- Stroke Unit, "S.Spirito" Hospital, Pescara, Italy
- Department of Neurology and Stroke Unit, SS Annunziata Hospital, Chieti, Italy
| | - Laura Bonanni
- Dipartimento di Medicina e Scienze dell'Invecchiamento, Università G. d'Annunzio di Chieti-Pescara e Clinica Neurologica e Stroke Unit Ospedale Clinicizzato SS. Annunziata di Chieti, Chieti, Italy
| | | | | | - Monia Russo
- Department of Neurology, St Misericordia Hospital, Rovigo, Italy
| | - Agnese Tonon
- Department of Neurology, Ospedale Civile Ss. Giovanni e Paolo, Venice, Italy
| | | | | | - Cinzia Roberti
- Department of Neurology, San Filippo Neri Hospital, Rome, Italy
| | - Giovanni Manobianca
- Department of Neurology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Gaspare Scaglione
- Department of Neurology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Alberto Fortini
- Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | | | | | - Alberto Chiti
- Unit of Neurology, Apuane Hospital, Massa Carrara, Italy
| | | | | | - Maela Masato
- Department of Neurology, Mirano Hospital, Mirano, Italy
| | - Massimo Del Sette
- Department of Neuroscience, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | - Danilo Toni
- Department of Human neurosciences, University of Rome La Sapienza, Rome, Italy
| | - Stefano Ricci
- Department of Neurology, Città di Castello Hospital, Città di Castello, Italy
- Coordinatore Comitato Scientifico ISA-AII
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| |
Collapse
|
6
|
Ozdemir H, Sagris D, Abdul-Rahim AH, Lip GYH, Shantsila E. Management of ischaemic stroke survivors in primary care setting: the road to holistic care. Intern Emerg Med 2024; 19:609-618. [PMID: 37875703 PMCID: PMC11039521 DOI: 10.1007/s11739-023-03445-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/26/2023] [Indexed: 10/26/2023]
Abstract
The management of ischaemic stroke survivors is multidisciplinary, necessitating the collaboration of numerous medical professionals and rehabilitation specialists. However, due to the lack of comprehensive and holistic follow-up, their post-discharge management may be suboptimal. Achieving this holistic, patient-centred follow-up requires coordination and interaction of subspecialties, which general practitioners can provide as the first point of contact in healthcare systems. This approach can improve the management of stroke survivors by preventing recurrent stroke through an integrated post-stroke care, including appropriate Antithrombotic therapy, assisting them to have a Better functional and physiological status, early recognition and intervention of Comorbidities, and lifestyles. For such work to succeed, close interdisciplinary collaboration between primary care physicians and other medical specialists is required in a holistic or integrated way.
Collapse
Affiliation(s)
- Hizir Ozdemir
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Azmil Husin Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Gregory Yoke Hong Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Eduard Shantsila
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK.
| |
Collapse
|
7
|
Chen PL, Wu YH, Huang JA, Liao NC, Chao YT, Wang CS. Dual antiplatelet therapy is associated with favorable outcome in acute minor stroke with an onset-to-door time beyond 24 h. J Formos Med Assoc 2024; 123:501-509. [PMID: 37838539 DOI: 10.1016/j.jfma.2023.09.017] [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: 05/07/2023] [Revised: 08/05/2023] [Accepted: 09/26/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND/PURPOSE In patients with noncardioembolic acute minor ischemic stroke (AMIS), dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel within 24 h after stroke onset was more effective than aspirin alone. This study investigated the efficacy and safety of DAPT in AMIS patients with an onset-to-door time (OTDT) of more than 24 h. METHODS This was a retrospective analysis of a prospective stroke registry from 2015 to 2021. Patients with AMIS and an OTDT within seven days were classified into the Early (≤24 h) and Late groups (>24 h) according to the time of antiplatelet administration after stroke onset. RESULTS In total, 691 patients were identified. Of these, 446 (64.5%) and 245 (35.5%) patients were classified into the Early and Late groups, respectively. The rates of recurrent infarction and symptomatic intracranial hemorrhage at 90 days were similar between the single antiplatelet therapy (SAPT) and DAPT subgroups in both the Early and Late groups. More patients in the DAPT subgroup had a favorable outcome (modified Rankin scale of 0-1) at 90 days in both Early (84.2% versus 75.0%, p = 0.016) and Late (88.2% versus 76.9%, p = 0.040) groups. DAPT was independently associated with a favorable outcome in both the Early (odds ratio, 1.95; 95% CI, 1.15-3.32; p = 0.013) and Late (odds ratio, 2.72; 95% CI, 1.14-6.48; p = 0.024) groups. CONCLUSION In patients with AMIS and an OTDT of more than 24 h, DAPT was associated with a favorable outcome at 90 days.
Collapse
Affiliation(s)
- Po-Lin Chen
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Yu-Hsuan Wu
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taiwan
| | - Jin-An Huang
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan; Department of Health Business Administration, Hungkuang University, Taichung, Taiwan
| | - Nien-Chen Liao
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Ting Chao
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taiwan; Center of Geriatrics & Gerontology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chi-Sheng Wang
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taiwan.
| |
Collapse
|
8
|
Wardlaw JM, Chabriat H, de Leeuw FE, Debette S, Dichgans M, Doubal F, Jokinen H, Katsanos AH, Ornello R, Pantoni L, Pasi M, Pavlovic AM, Rudilosso S, Schmidt R, Staals J, Taylor-Rowan M, Hussain S, Lindgren AG. European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke. Eur Stroke J 2024; 9:5-68. [PMID: 38380638 PMCID: PMC10916806 DOI: 10.1177/23969873231219416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/22/2023] [Indexed: 02/22/2024] Open
Abstract
A quarter of ischaemic strokes are lacunar subtype, typically neurologically mild, usually resulting from intrinsic cerebral small vessel pathology, with risk factor profiles and outcome rates differing from other stroke subtypes. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist with clinical decisions about management of lacunar ischaemic stroke to prevent adverse clinical outcomes. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We addressed acute treatment (including progressive lacunar stroke) and secondary prevention in lacunar ischaemic stroke, and prioritised the interventions of thrombolysis, antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle, and other interventions and their potential effects on the clinical outcomes recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, or mood disorders. We systematically reviewed the literature, assessed the evidence and where feasible formulated evidence-based recommendations, and expert concensus statements. We found little direct evidence, mostly of low quality. We recommend that patients with suspected acute lacunar ischaemic stroke receive intravenous alteplase, antiplatelet drugs and avoid blood pressure lowering according to current acute ischaemic stroke guidelines. For secondary prevention, we recommend single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines. We recommend smoking cessation, regular exercise, other healthy lifestyle modifications, and avoid obesity for general health benefits. We cannot make any recommendation concerning progressive stroke or other drugs. Large randomised controlled trials with clinically important endpoints, including cognitive endpoints, are a priority for lacunar ischaemic stroke.
Collapse
Affiliation(s)
- Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Hugues Chabriat
- CNVT and Department of Neurology, Hopital Lariboisière, Paris, France
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Stéphanie Debette
- Bordeaux Population Health Research Center; University of Bordeaux – Inserm U1219; Bordeaux; Department of Neurology, Institute for Neurodegenerative Diseases, Bordeaux University Hospital, Bordeaux, France
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Medical Center, Munich; Munich Cluster for Systems Neurology (SyNergy), Munich; German Center for Neurodegenerative Diseases (DZNE, Munich), Munich; German Centre for Cardiovascular Research (DZHK, Munich), Munich, Germany
| | - Fergus Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor’s Building, Edinburgh, UK
| | - Hanna Jokinen
- Neurocenter, Helsinki University Hospital and University of Helsinki, HUS, Helsinki, Finland
| | - Aristeidis H Katsanos
- Neurology, McMaster University & Population Health Research Institute, Hamilton, ON, Canada
| | - Raffaele Ornello
- Neurology/Department of Biotechnological ad Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | | | - Marco Pasi
- Department of Neurology, University of Tours, Tours, France
| | - Aleksandra M Pavlovic
- University of Belgrade, Faculty of Special Education and Rehabilitation, Belgrade, Serbia
| | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neurology, Hospital Clínic of Barcelona, Barcelona, Spain
| | | | - Julie Staals
- Department of Neurology and CARIM School for cardiovascular diseases, MUMC+, Maastricht, The Netherlands
| | - Martin Taylor-Rowan
- School of Health and Wellbeing; General Practice and Primary Care, Clarice Pears Building, University of Glasgow, Glasgow, UK
| | | | - Arne G Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University; Department of Neurology, Skåne University Hospital, Lund, Skånes Universitetssjukhus, Lund, Sweden
| |
Collapse
|
9
|
Prendes CF, Rantner B, Hamwi T, Stana J, Feigin VL, Stavroulakis K, Tsilimparis N. Burden of Stroke in Europe: An Analysis of the Global Burden of Disease Study Findings From 2010 to 2019. Stroke 2024; 55:432-442. [PMID: 38252754 DOI: 10.1161/strokeaha.122.042022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 09/21/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND While most European Regions perform well in global comparisons, large discrepancies within stroke epidemiological parameters exist across Europe. The objective of this analysis was to evaluate the stroke burden across European regions and countries in 2019 and its difference to 2010. METHODS The GBD 2019 analytical tools were used to evaluate regional and country-specific estimates of incidence, prevalence, deaths, and disability-adjusted life years of stroke for the European Region as defined by the World Health Organization, with its 53 member countries (EU-53) and for European Union as defined in 2019, with its 28 member countries (EU-28), between 2010 and 2019. Results were analyzed at a regional, subregional, and country level. RESULTS In EU-53, the absolute number of incident and prevalent strokes increased by 2% (uncertainty interval [UI], 0%-4%), from 1 767 280 to 1 802 559 new cases, and by 4% (UI, 3%-5%) between 2010 and 2019, respectively. In EU-28, the absolute number of prevalent strokes and stroke-related deaths increased by 4% (UI, 2%-5%) and by 6% (UI, 1%-10%), respectively. All-stroke age-standardized mortality rates, however, decreased by 18% (UI, -22% to -14%), from 82 to 67 per 100 000 people in the EU-53, and by 15% (UI, -18% to -11%), from 49.3 to 42.0 per 100 000 people in EU-28. Despite most countries presenting reductions in age-adjusted incidence, prevalence, mortality, and disability-adjusted life year rates, these rates remained 1.4×, 1.2×, 1.6×, and 1.7× higher in EU-53 in comparison to the EU-28. CONCLUSIONS EU-53 showed a 2% increase in incident strokes, while they remained stable in EU-28. Age-standardized rates were consistently lower for all-stroke burden parameters in EU-28 in comparison to EU-53, and huge discrepancies in incidence, prevalence, mortality, and disability-adjusted life-year rates were observed between individual countries.
Collapse
Affiliation(s)
- Carlota F Prendes
- Department of Vascular Surgery, Ludwig Maximilians University, Munich, Germany (C.F.P., B.R., T.H., J.S., K.S., N.T.)
| | - Barbara Rantner
- Department of Vascular Surgery, Ludwig Maximilians University, Munich, Germany (C.F.P., B.R., T.H., J.S., K.S., N.T.)
| | - Tarek Hamwi
- Department of Vascular Surgery, Ludwig Maximilians University, Munich, Germany (C.F.P., B.R., T.H., J.S., K.S., N.T.)
| | - Jan Stana
- Department of Vascular Surgery, Ludwig Maximilians University, Munich, Germany (C.F.P., B.R., T.H., J.S., K.S., N.T.)
| | - Valery L Feigin
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, New Zealand (V.L.F.)
- Institute for Health Metrics and Evaluation, University of Washington, Seattle (V.L.F.)
- Research Center of Neurology, Moscow, Russia (V.L.F.)
| | - Konstantinos Stavroulakis
- Department of Vascular Surgery, Ludwig Maximilians University, Munich, Germany (C.F.P., B.R., T.H., J.S., K.S., N.T.)
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig Maximilians University, Munich, Germany (C.F.P., B.R., T.H., J.S., K.S., N.T.)
| |
Collapse
|
10
|
Zhou J, Li G, Meng Y, Hu F, Wang W, Chen X. Analysis of the posterior cerebral perfusion status and clinical prognostic value in chronic unilateral middle cerebral artery occlusion using SWAN combined with 3D-ASL. Medicine (Baltimore) 2023; 102:e35836. [PMID: 37960815 PMCID: PMC10637506 DOI: 10.1097/md.0000000000035836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/06/2023] [Indexed: 11/15/2023] Open
Abstract
To investigate the predictive value of T2 star-weighted angiography (SWAN) combined with 3-dimensional (3D) arterial spin labeling (3D-ASL) to assess cerebral perfusion status and clinical prognosis in chronic unilateral middle cerebral artery (MCA) M1 occlusion. This study included 55 patients diagnosed with chronic unilateral MCA M1 occlusion using 3D time-of-flight magnetic resonance angiography between January 2018 and July 2022. Based on the prominent vessel sign (PVS) shown in the SWAN sequence, the patients were divided into PVS-positive (n = 26) and PVS-negative (n = 29) groups. Cerebral blood flow (CBF) was selected in the affected regions of the frontal, parietal, and temporal lobes (regions of interest = 200 ± 20 mm2) using pseudo-color maps in the 3D-ASL sequence. Each patient was followed up for ischemic cerebrovascular disease within 12 months of diagnosis. The collected data were statistically analyzed to evaluate the predictive value of SWAN and 3D-ASL for the clinical prognosis of patients with chronic unilateral MCA M1 occlusion. Patients were divided into 2 groups based on the occurrence of an ischemic cerebrovascular event within 12 months (ischemic cerebrovascular event [acute ischemic stroke + transient ischemic attack] and non-ischemic cerebrovascular event groups, including 30 and 25 cases, respectively). The incidence of ischemic cerebrovascular events within 12 months was significantly higher in the PVS-positive group than in the PVS-negative group (92.31% vs 20.69%). Furthermore, the CBF values of the affected frontal, parietal, and temporal lobes were significantly lower in the ischemic cerebrovascular event group than in the non-ischemic cerebrovascular event group (P < .05). According to the receiver operating characteristic curve, the CBF values of the affected frontal, parietal, and temporal lobes in patients with chronic unilateral MCA M1 occlusion strongly correlated with ischemic cerebrovascular disease within 12 months. PVS-negative display and good collateral circulation were closely related to clinical prognosis in patients with chronic unilateral MCA M1 occlusion.
Collapse
Affiliation(s)
- Jianguo Zhou
- Department of Radiology, Lianyungang City Chinese Medicine Hospital, Lianyungfang, Jiangsu, China
| | - Guifen Li
- Department of Radiology, The Second People’s Hospital of Lianyungang City, Lianyungfang, Jiangsu, China
| | - Yun Meng
- Department of Radiology, Lianyungang City Chinese Medicine Hospital, Lianyungfang, Jiangsu, China
| | - Fangyun Hu
- Department of Radiology, Lianyungang City Chinese Medicine Hospital, Lianyungfang, Jiangsu, China
| | - Wei Wang
- Department of Radiology, The Peoples Hospital of Xuyi County, Huaian, Jiangsu, China
| | - Xunjun Chen
- Department of Radiology, The Peoples Hospital of Xuyi County, Huaian, Jiangsu, China
| |
Collapse
|
11
|
Casani AP, Gufoni M, Ducci N. Episodic Vertigo: A Narrative Review Based on a Single-Center Clinical Experience. Audiol Res 2023; 13:845-858. [PMID: 37987332 PMCID: PMC10660529 DOI: 10.3390/audiolres13060074] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/17/2023] [Accepted: 10/27/2023] [Indexed: 11/22/2023] Open
Abstract
(1) Background: Usually, the majority of patients suffering from vertigo and dizziness can be identified in four major categories: acute spontaneous vertigo, episodic (recurrent) vertigo, recurrent positional vertigo, and chronic imbalance. Our purpose is to retrospectively evaluate the main causes of episodic vertigo and to find indications for a reliable clinical suspicion useful for a definitive diagnosis, comparing patients affected by different presenting symptomatology (acute vertigo, recurrent episodic vertigo, and imbalance). (2) Methods: we retrospectively evaluated the clinical records in a population of 249 consecutive patients observed for vertigo in our tertiary referral center in the period 1 January 2019-31 January 2020. On the basis of the reported clinical history, patients were divided into three groups: patients with their first ever attack of vertigo, patients with recurrent vertigo and dizziness, and patients with chronic imbalance. (3) Results: On the basis of the results of the instrumental examination, we arbitrarily divided (for each type of symptoms) the patients in a group with a normal vestibular instrumental examination and a group of patients in which the clinical-instrumental evaluation showed some pathological results; a highly significant difference (p: 0.157) was found between recurrent and acute vertigo and between recurrent vertigo and imbalance. (4) Conclusions: Patients with recurrent vertigo more frequently exhibit a negative otoneurological examination since they are often examined in the intercritical phase. A precise and in-depth research of the patient's clinical history is the key to suspect or make a diagnosis together with the search for some instrumental or clinical hallmark, especially in cases where the clinical picture does not fully meet the international diagnostic criteria.
Collapse
Affiliation(s)
- Augusto Pietro Casani
- ENT Section, Medical, Molecular and Critical Area, Department of Surgical Pathology, Pisa University Hospital, 56122 Pisa, Italy; (M.G.); (N.D.)
| | | | | |
Collapse
|
12
|
Alstadhaug KB, Tronvik E, Aamodt AH. Transient ischemic attack or migraine with aura? TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2023; 143:23-0225. [PMID: 37874053 DOI: 10.4045/tidsskr.23.0225] [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: 10/25/2023] Open
Abstract
Migraine or migraine-like symptoms can contribute to a delayed stroke diagnosis. However, migraine with aura is a common stroke mimic and often the basis for acute thrombolytic therapy. It is probably also the reason why many patients are misdiagnosed with a transient ischemic attack. In this clinical review, we explain the factors that could differentiate a transient ischemic attack from a migraine with aura.
Collapse
|
13
|
Greco A, Occhipinti G, Giacoppo D, Agnello F, Laudani C, Spagnolo M, Mauro MS, Rochira C, Finocchiaro S, Mazzone PM, Faro DC, Landolina D, Ammirabile N, Imbesi A, Raffo C, Capodanno D. Antithrombotic Therapy for Primary and Secondary Prevention of Ischemic Stroke: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1538-1557. [PMID: 37793752 DOI: 10.1016/j.jacc.2023.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 10/06/2023]
Abstract
Stroke is a devastating condition with significant morbidity and mortality worldwide. Antithrombotic therapy plays a crucial role in both primary and secondary prevention of stroke events. Single or dual antiplatelet therapy is generally preferred in cases of large-artery atherosclerosis and small-vessel disease, whereas anticoagulation is recommended in conditions of blood stasis or hypercoagulable states that mostly result in red thrombi. However, the benefit of antithrombotic therapies must be weighed against the increased risk of bleeding, which can pose significant challenges in the pharmacological management of this condition. This review provides a comprehensive summary of the currently available evidence on antithrombotic therapy for ischemic stroke and outlines an updated therapeutic algorithm to support physicians in tailoring the strategy to the individual patient and the underlying mechanism of stroke.
Collapse
Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy. https://twitter.com/AGrecoMD
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Daniele Giacoppo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carmelo Raffo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy.
| |
Collapse
|
14
|
Al-Sabbagh MQ, Thirunavukkarasu S, Eswaradass P. Advances in Cardiac Workup for Transient Ischemic Attack: Improving Diagnostic Yield and Reducing Recurrent Stroke Risk. Cardiol Rev 2023:00045415-990000000-00155. [PMID: 37750739 DOI: 10.1097/crd.0000000000000607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Transient ischemic attack (TIA) is a warning sign for an impending stroke, with a 10-20% chance of a stroke occurring within 90 days of the initial event. Current clinical practice for cardiac workup in TIA includes cardiac enzymes, with 12-lead electrocardiogram, transthoracic echocardiography, and 24-hour Holter monitoring. However, the diagnostic yield of these investigations is variable, and there is a need for better diagnostic approaches to increase the detection of cardiac abnormalities in a cost-effective way. This review article examines the latest research on emerging diagnostic tools and strategies and discusses the potential benefits and challenges of using these advanced diagnostic approaches in clinical practice. Novel biomarkers, imaging techniques, and prolonged rhythm monitoring devices have shown great promise in enhancing the diagnostic yield of cardiac workup in TIA patients. Echocardiography, Transcranial Doppler ultrasound, cardiac MRI, and cardiac CT are among the promising diagnostic tools being studied. We conclude the article with a suggested diagnostic algorithm for cardiac workup in TIA. Further research is necessary to enhance their usefulness and to outline future directions for research and clinical practice in this field.
Collapse
Affiliation(s)
- Mohammed Q Al-Sabbagh
- From the Department of Neurology, University of Kansas Medical Center, Kansas City, KS
| | | | - Prasanna Eswaradass
- From the Department of Neurology, University of Kansas Medical Center, Kansas City, KS
| |
Collapse
|
15
|
Amoura Z, Bader-Meunier B, Bal Dit Sollier C, Belot A, Benhamou Y, Bezanahary H, Cohen F, Costedoat-Chalumeau N, Darnige L, Drouet L, Elefant E, Harroche A, Lambert M, Martin T, Martin-Toutain I, Mathian A, Mekinian A, Pineton De Chambrun M, de Pontual L, Wahl D, Yelnik C, Zuily S. French National Diagnostic and Care Protocol for antiphospholipid syndrome in adults and children. Rev Med Interne 2023; 44:495-520. [PMID: 37735010 DOI: 10.1016/j.revmed.2023.08.004] [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: 08/21/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023]
Abstract
Antiphospholipid syndrome (APS) is a chronic autoimmune disease involving vascular thrombosis and/or obstetric morbidity and persistent antibodies to phospholipids or certain phospholipid-associated proteins. It is a rare condition in adults and even rarer in children. The diagnosis of APS can be facilitated by the use of classification criteria based on a combination of clinical and biological features. APS may be rapidly progressive with multiple, often synchronous thromboses, resulting in life-threatening multiple organ failure. This form is known as "catastrophic antiphospholipid syndrome" (CAPS). It may be primary or associated with systemic lupus erythematosus (associated APS) and in very rare cases with other systemic autoimmune diseases. General practitioners and paediatricians may encounter APS in patients with one or more vascular thromboses. Because APS is so rare and difficult to diagnosis (risk of overdiagnosis) any suspected case should be confirmed rapidly and sometimes urgently by an APS specialist. First-line treatment of thrombotic events in APS includes heparin followed by long-term anticoagulation with a VKA, usually warfarin. Except in the specific case of stroke, anticoagulants should be started as early as possible. Any temporary discontinuation of anticoagulants is associated with a high risk of thrombosis in APS. A reference/competence centre specialised in autoimmune diseases must be urgently consulted for the therapeutic management of CAPS.
Collapse
Affiliation(s)
- Z Amoura
- Department of Internal Medicine, Institut E3M, CIMI-Paris, Faculty of medicine, National Reference Centre of Systemic Lupus, antiphospholipid syndrome, and other autoimmune diseases, Sorbonne University, AP-HP, Pitié Salpêtrière, boulevard de l'Hôpital, 75013 Paris, France.
| | - B Bader-Meunier
- Laboratory of Immunogenetics of Paediatric Autoimmune Diseases, Institute Imagine, University Paris Cité, Paris, France
| | - C Bal Dit Sollier
- Thrombosis and atherosclerosis research unit, vessels and blood institute (IVS), anticoagulation clinic (CREATIF), Lariboisière hospital, AP-HP, 75010 Paris, France
| | - A Belot
- Department of Pediatric Nephrology, Rheumatology, Dermatology, Reference Centre for Rheumatic, AutoImmune and Systemic diseases in children (RAISE), hôpital femme mère enfant, CHU de Lyon, Bron, France
| | - Y Benhamou
- National Reference Centre of MicroAngiopathies Thrombotic, Paris, France; Department of Internal Medicine, University Hospital of Rouen, Normandie University, Rouen, France
| | - H Bezanahary
- Department of Internal Medicine and Clinical Immunology, centre hospitalier universitaire de Limoges, Limoges, France
| | - F Cohen
- Department of Internal Medicine, Institut E3M, CIMI-Paris, Faculty of medicine, National Reference Centre of Systemic Lupus, antiphospholipid syndrome, and other autoimmune diseases, Sorbonne University, AP-HP, Pitié Salpêtrière, boulevard de l'Hôpital, 75013 Paris, France
| | - N Costedoat-Chalumeau
- Department of Internal Medicine, Referral Centre for Rare Autoimmune and Systemic Diseases of Île-de-France, AP-HP, Cochin Hospital, Paris, France; Centre for Epidemiology and Statistics, Institut national de la santé et de la recherche médicale, French National Institute for Agricultural Research, University Paris Cité, Paris, France
| | - L Darnige
- Biological Hematology Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, Inserm, UMR-S1140, Innovative Therapies in Haemostasis, Paris, France
| | - L Drouet
- Thrombosis and atherosclerosis research unit, vessels and blood institute (IVS), anticoagulation clinic (CREATIF), Lariboisière hospital, AP-HP, 75010 Paris, France
| | - E Elefant
- Reference Center for Teratogenic Agents, hôpital Armand-Trousseau centre de référence sur les agents tératogènes, Île-de-France, Paris, France
| | - A Harroche
- Department of Hematology, Haemophilia Treatment Centre, University Hospital Necker Enfants Malades, Paris, France
| | - M Lambert
- Department of Internal Medicine and Clinical immunology, Reference Centre of Autoimmune Systemic Rare Diseases Of North And North-West of France (CeRAINO), U1167 RID-AGE, Lille University, Inserm, University hospital of Lille, 59000 Lille, France
| | - T Martin
- Department of Internal Medicine and Clinical Immunology, Strasbourg University Hospital, Strasbourg, France
| | - I Martin-Toutain
- Resource and Competence Centre for Haemorrhagic Diseases, Hospital Center of Versailles André-Mignot, Le Chesnay, France
| | - A Mathian
- Department of Internal Medicine, Institut E3M, CIMI-Paris, Faculty of medicine, National Reference Centre of Systemic Lupus, antiphospholipid syndrome, and other autoimmune diseases, Sorbonne University, AP-HP, Pitié Salpêtrière, boulevard de l'Hôpital, 75013 Paris, France
| | - A Mekinian
- Department of Internal Medicine and Inflammation-Immunopathology-Biotherapy (DMU i3), Saint-Antoine Hospital, Sorbonne University, AP-HP, 75012 Paris, France
| | - M Pineton De Chambrun
- Department of Internal Medicine, Institut E3M, CIMI-Paris, Faculty of medicine, National Reference Centre of Systemic Lupus, antiphospholipid syndrome, and other autoimmune diseases, Sorbonne University, AP-HP, Pitié Salpêtrière, boulevard de l'Hôpital, 75013 Paris, France
| | - L de Pontual
- Department of Paediatrics, Jean-Verdier Hospital, AP-HP, HUPSSD, 93140 Bondy, France
| | - D Wahl
- Vascular Medicine Division and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, CHRU de Nancy, Nancy, France
| | - C Yelnik
- Department of Internal Medicine and Clinical immunology, Reference Centre of Autoimmune Systemic Rare Diseases Of North And North-West of France (CeRAINO), U1167 RID-AGE, Lille University, Inserm, University hospital of Lille, 59000 Lille, France
| | - S Zuily
- Vascular Medicine Division and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, CHRU de Nancy, Nancy, France
| |
Collapse
|
16
|
Fumagalli C, Bonanni F, Beltrami M, Ruggieri R, Zocchi C, Tassetti L, Maurizi N, Berteotti M, Zampieri M, Argirò A, Lovero F, Tomberli A, di Bari M, Marchionni N, Pieragnoli P, Ricciardi G, Checchi L, Cappelli F, Fumagalli S, Olivotto I. Incidence of stroke in patients with hypertrophic cardiomyopathy in stable sinus rhythm during long-term monitoring. Int J Cardiol 2023; 381:70-75. [PMID: 37061097 DOI: 10.1016/j.ijcard.2023.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 04/17/2023]
Abstract
INTRODUCTION Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of stroke, but the incidence and factors associated with cardioembolic events in HCM patients without atrial fibrillation (AF) remain unresolved. We determined the incidence of stroke in patients in sinus rhythm (SR) monitored with a cardiac implantable electronic device (CIED). METHODS All consecutive patients diagnosed with HCM and referred to CIED implantation with >16 years at diagnosis and ≥ 1 year follow-up post CIED implantation were retrospectively reviewed. Severe LA dilatation was defined as ≥48 mm. Patients were stratified by rhythm as: Pre-existing AF (AF present prior to CIED); De novo AF (AF present after CIED implantation); SR: no episodes of AF. RESULTS Of 1651 patients, 185 (11.2%) implanted with a CIED were included (57% men, age: 54 ± 17 years). Baseline, pre-existing AF was present in 73 (39%) patients. Ischemic stroke was reported in 19 (10.3%, 1.78%/year) patients and was similar across the three groups (2.3%/year vs 1.1%/year vs 0.6%/year in patients in SR vs pre-existing AF vs de novo AF, respectively, p = 0.235). In SR patients, a LAD≥48 mm posed the greatest risk of stroke (Hazard Ratio: 10.03,95% Confidence-Interval 2.79-16.01). At Cox multivariable analysis, after adjustment for oral anticoagulation, LA was independently associated with stroke while rhythm was not. CONCLUSIONS in HCM patients with CIED long-term monitoring and no prior history of AF, stroke rates were similar in those with de novo AF or stable SR. Severe LA dilatation was a powerful risk factor, irrespective of AF.
Collapse
Affiliation(s)
- Carlo Fumagalli
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Francesca Bonanni
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Matteo Beltrami
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Roberta Ruggieri
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Chiara Zocchi
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Luigi Tassetti
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Niccolò Maurizi
- University Hospital of Lausanne, Cardiology Department, Lausanne, Switzerland
| | - Martina Berteotti
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Mattia Zampieri
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Alessia Argirò
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Fabrizio Lovero
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Alessia Tomberli
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Mauro di Bari
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paolo Pieragnoli
- Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Giuseppe Ricciardi
- Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Luca Checchi
- Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloid Center, Careggi University Hospital, Florence, Italy; Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Stefano Fumagalli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| |
Collapse
|
17
|
Mead GE, Sposato LA, Sampaio Silva G, Yperzeele L, Wu S, Kutlubaev M, Cheyne J, Wahab K, Urrutia VC, Sharma VK, Sylaja PN, Hill K, Steiner T, Liebeskind DS, Rabinstein AA. A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization. Int J Stroke 2023; 18:499-531. [PMID: 36725717 PMCID: PMC10196933 DOI: 10.1177/17474930231156753] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/13/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines. AIMS To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced). SUMMARY OF REVIEW Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited. CONCLUSION The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.
Collapse
Affiliation(s)
- Gillian E Mead
- Usher Institute, University of Edinburgh and Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
- Heart & Brain Lab, Western University, London, ON, Canada
- Robarts Research Institute, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Laetitia Yperzeele
- Antwerp NeuroVascular Center and Stroke Unit, Antwerp University Hospital, Antwerp, Belgium
- Research Group on Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mansur Kutlubaev
- Department of Neurology, Bashkir State Medical University, Ufa, Russia
| | - Joshua Cheyne
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin, Ilorin, Nigeria
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, University Medicine Cluster, National University Health System, Singapore
| | - PN Sylaja
- Neurology and Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Kelvin Hill
- Stroke Treatment, Stroke Foundation, Melbourne, VIC, Australia
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst and Heidelberg University Hospital, Frankfurt, Germany
| | - David S Liebeskind
- UCLA Department of Neurology, Neurovascular Imaging Research Core, UCLA Comprehensive Stroke Center, Los Angeles, CA, USA
| | | |
Collapse
|
18
|
Schutgens RE, Jimenez-Yuste V, Escobar M, Falanga A, Gigante B, Klamroth R, Lassila R, Leebeek FW, Makris M, Owaidah T, Sholzberg M, Tiede A, Werring DJ, van der Worp HB, Windyga J, Castaman G. Antithrombotic Treatment in Patients With Hemophilia: an EHA-ISTH-EAHAD-ESO Clinical Practice Guidance. Hemasphere 2023; 7:e900. [PMID: 37304933 PMCID: PMC10256340 DOI: 10.1097/hs9.0000000000000900] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Cardiovascular disease is an emerging medical issue in patients with hemophilia (PWH) and its prevalence is increasing up to 15% in PWH in the United States. Atrial fibrillation, acute and chronic coronary syndromes, venous thromboembolism, and cerebral thrombosis are frequent thrombotic or prothrombotic situations, which require a careful approach to fine-tune the delicate balance between thrombosis and hemostasis in PWH when using both procoagulant and anticoagulant treatments. Generally, PWH could be considered as being naturally anticoagulated when clotting factors are <20 IU/dL, but specific recommendations in patients with very low levels according to the different clinical situations are lacking and mainly based on the anecdotal series. For PWH with baseline clotting factor levels >20 IU/dL in need for any form of antithrombotic therapy, usually treatment without additional clotting factor prophylaxis could be used, but careful monitoring for bleeding is recommended. For antiplatelet treatment, this threshold could be lower with single-antiplatelet agent, but again factor level should be at least 20 IU/dL for dual antiplatelet treatment. In this complex growing scenario, the European Hematology Association in collaboration with the International Society on Thrombosis and Haemostasis, the European Association for Hemophilia and Allied Disorders, the European Stroke Organization, and a representative of the European Society of Cardiology Working Group on Thrombosis has produced this current guidance document to provide clinical practice recommendations for health care providers who care for PWH.
Collapse
Affiliation(s)
- Roger E.G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Victor Jimenez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Miguel Escobar
- University of Texas Health Science Center at Houston, TX, USA
| | - Anna Falanga
- University of Milano Bicocca, School of Medicine, Monza, Italy
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solna, Sweden
- Department of Clinical Science, Danderyd Hospital, Karolinska institutet, Stockholm, Sweden
| | - Robert Klamroth
- Department of Internal Medicine Angiology and Coagulation Disorders at the Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Germany
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit, and Research Program Unit in Systems Oncology Oncosys, Medical Faculty, University of Helsinki, Finland
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Michael Makris
- Haemophilia and Thrombosis Centre, University of Sheffield, United Kingdom
| | - Tarek Owaidah
- King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Michelle Sholzberg
- Division of Hematology-Oncology, Departments of Medicine, and Laboratory Medicine and Pathobiology, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Canada
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
| | - David J. Werring
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom
| | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
| |
Collapse
|
19
|
Gonçalves M, Lima MJ, Fonseca Â, Duque C, Costa AR, Cruz VT. Study protocol for a pilot randomised controlled trial evaluating the feasibility and effectiveness of non-pharmacological interventions to recover functionality after a transient ischaemic attack or a minor stroke: the 'Back to Normal' trial. BMJ Open 2023; 13:e069593. [PMID: 37117001 PMCID: PMC10151926 DOI: 10.1136/bmjopen-2022-069593] [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] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION Transient ischaemic attack (TIA) and minor stroke are frequently assumed as temporary or non-disabling events. However, evidence suggests that these patients can experience relevant impairment and functional disability. Therefore, the present study aims to evaluate the feasibility and effectiveness of a 3-month multidomain intervention programme, composed of five non-pharmacological strategies, aimed at accelerating return to pre-event level of functionality in patients with TIA or minor stroke. METHODS AND ANALYSIS Patients diagnosed with a TIA or a minor stroke are being recruited at the emergency or neurology departments of the Hospital Pedro Hispano, located in Matosinhos, Portugal (n=70). Those who accept to participate will be randomly allocated to two groups (1:1): (a) Intervention-receives a 3 months combined approach, initiating early post-event, composed of cognitive training, physical exercise, nutrition, psychoeducation and assessment/correction of hearing loss; (b) Control-participants will not be subject to any intervention. Both groups will receive the usual standard of care provided to these diseases. Recruitment began in May 2022 and is expected to continue until March 2023. Socio-demographic characteristics, lifestyles, health status, cognitive function, symptoms of anxiety and depression and quality of life will be assessed; as well as anthropometry, blood pressure and physical condition. Time to complete or partial recovery of instrumental activities of daily living will be assessed using an adapted version of the Frenchay Activities Index. All participants will be evaluated before the intervention and after 3 months. ETHICS AND DISSEMINATION This study was approved by the Ethics Committee of the Local Health Unit of Matosinhos (Ref. 75/CES/JAS). Written informed consent will be required from all the participants; data protection and confidentiality will be also ensured. The findings of this project are expected to be submitted for publication in scientific articles, and the main results will be presented at relevant scientific meetings. TRIAL REGISTRATION NUMBER NCT05369637.
Collapse
Affiliation(s)
- Micaela Gonçalves
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
| | - Maria João Lima
- Serviço de Neurologia, Unidade Local de Saúde de Matosinhos EPE, Matosinhos, Portugal
| | - Ângelo Fonseca
- Serviço de Neurologia, Unidade Local de Saúde de Matosinhos EPE, Matosinhos, Portugal
| | - Cristina Duque
- Serviço de Neurologia, Unidade Local de Saúde de Matosinhos EPE, Matosinhos, Portugal
| | - Ana Rute Costa
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Vitor Tedim Cruz
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Serviço de Neurologia, Unidade Local de Saúde de Matosinhos EPE, Matosinhos, Portugal
| |
Collapse
|
20
|
Eren OE, Straube A. [Temporary and persistent visual phenomena in neurology]. DER NERVENARZT 2023; 94:344-352. [PMID: 37039876 DOI: 10.1007/s00115-023-01466-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 04/12/2023]
Abstract
Temporary and persistent visual phenomena are a frequent reason for a neurological presentation. The diagnosis can usually be made with the help of a structured anamnesis with determination of the time of onset, the course and symptoms as well as the monocular vs. binocular manifestation. The visual aura in migraine is certainly the most frequent entity to be differentiated. In particular, persistent visual phenomena such as visual snow syndrome, hallucinogen persisting perception disorder and the Charles Bonnet syndrome (CBS) seem to be underdiagnosed in clinical practice for various reasons and are probably not that rare. Instrumental diagnostics are mostly used for exclusion diagnostics and are a component of a complete patient education, but can be indicative for certain questions (CBS, epilepsy). This article presents the most frequent visual phenomena from the neurological practice and their differential diagnoses, guided by a case history.
Collapse
Affiliation(s)
- Ozan E Eren
- Neurologie, München Klinik Bogenhausen, München, Deutschland
- Neurologie, Klinikum der Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - Andreas Straube
- Neurologie, Klinikum der Universität München, Marchioninistraße 15, 81377, München, Deutschland.
| |
Collapse
|
21
|
Tsigkas G, Vakka A, Apostolos A, Bousoula E, Vythoulkas-Biotis N, Koufou EE, Vasilagkos G, Tsiafoutis I, Hamilos M, Aminian A, Davlouros P. Dual Antiplatelet Therapy and Cancer; Balancing between Ischemic and Bleeding Risk: A Narrative Review. J Cardiovasc Dev Dis 2023; 10:135. [PMID: 37103014 PMCID: PMC10144375 DOI: 10.3390/jcdd10040135] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/15/2023] [Accepted: 03/19/2023] [Indexed: 04/28/2023] Open
Abstract
Cardiovascular (CV) events in patients with cancer can be caused by concomitant CV risk factors, cancer itself, and anticancer therapy. Since malignancy can dysregulate the hemostatic system, predisposing cancer patients to both thrombosis and hemorrhage, the administration of dual antiplatelet therapy (DAPT) to patients with cancer who suffer from acute coronary syndrome (ACS) or undergo percutaneous coronary intervention (PCI) is a clinical challenge to cardiologists. Apart from PCI and ACS, other structural interventions, such as TAVR, PFO-ASD closure, and LAA occlusion, and non-cardiac diseases, such as PAD and CVAs, may require DAPT. The aim of the present review is to review the current literature on the optimal antiplatelet therapy and duration of DAPT for oncologic patients, in order to reduce both the ischemic and bleeding risk in this high-risk population.
Collapse
Affiliation(s)
- Grigorios Tsigkas
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece; (A.V.); (A.A.); (N.V.-B.); (E.-E.K.); (G.V.); (P.D.)
| | - Angeliki Vakka
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece; (A.V.); (A.A.); (N.V.-B.); (E.-E.K.); (G.V.); (P.D.)
| | - Anastasios Apostolos
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece; (A.V.); (A.A.); (N.V.-B.); (E.-E.K.); (G.V.); (P.D.)
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Eleni Bousoula
- Department of Cardiology, Tzaneio General Hospital, 185 36 Piraeus, Greece;
| | - Nikolaos Vythoulkas-Biotis
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece; (A.V.); (A.A.); (N.V.-B.); (E.-E.K.); (G.V.); (P.D.)
| | - Eleni-Evangelia Koufou
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece; (A.V.); (A.A.); (N.V.-B.); (E.-E.K.); (G.V.); (P.D.)
| | - Georgios Vasilagkos
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece; (A.V.); (A.A.); (N.V.-B.); (E.-E.K.); (G.V.); (P.D.)
| | - Ioannis Tsiafoutis
- First Department of Cardiology, Red Cross Hospital, 115 26 Athens, Greece;
| | - Michalis Hamilos
- Department of Cardiology, Heraklion University Hospital, 715 00 Heraklion, Crete, Greece;
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, 6042 Charleroi, Belgium;
| | - Periklis Davlouros
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece; (A.V.); (A.A.); (N.V.-B.); (E.-E.K.); (G.V.); (P.D.)
| |
Collapse
|
22
|
Comparison of Adverse Events between Isolated Left Atrial Appendage Closure and Combined Catheter Ablation. J Clin Med 2023; 12:jcm12051824. [PMID: 36902610 PMCID: PMC10003199 DOI: 10.3390/jcm12051824] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/19/2023] [Accepted: 02/23/2023] [Indexed: 02/26/2023] Open
Abstract
(1) Background: This study aimed to investigate the effect of an additional catheter ablation (CA) procedure on the risk of post-procedure adverse events during CA combined with left atrial appendage closure (LAAC). (2) Methods: From July 2017 to February 2022, data from 361 patients with atrial fibrillation who underwent LAAC at our center were analyzed retrospectively. The adverse events were compared between CA + LAAC and LAAC-only groups. (3) Results: The incidence of device-related thrombus (DRT) and embolic events was significantly lower in the CA + LAAC group than in the LAAC-only group (p = 0.01 and 0.04, respectively). A logistic regression analysis revealed that the combined procedure served as a protective factor for DRT (OR = 0.09; 95% confidence interval: 0.01-0.89; p = 0.04). Based on a Cox regression analysis, the risk of embolism marginally increased in patients aged ≥65 years (HR = 7.49, 95% CI: 0.85-66.22 p = 0.07), whereas the combined procedure was found to be a protective factor (HR = 0.25, 95% CI: 0.07-0.87 p = 0.03). Further subgroup and interaction analyses revealed similar results. (4) Conclusions: The combined procedure may be associated with a lower rate of post-procedure DRT and embolization without a higher occurrence of other adverse events after LAAC. A risk-score-based prediction model was conducted, showing a good prediction performance.
Collapse
|
23
|
Rizos T, Jenetzky E, Nabavi DG, Haeusler KG, Wachter R, Ossenbrink M, Ringleb PA, Busse O. Echocardiography in acute stroke patients: a nationwide analysis in departments with certified stroke units in Germany. Neurol Res Pract 2023; 5:3. [PMID: 36653887 PMCID: PMC9850591 DOI: 10.1186/s42466-022-00229-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 12/19/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Echocardiography is highly relevant in patients with ischemic stroke or TIA. Utilization of routine echocardiographic examinations [transthoracic (TTE) or transesophageal (TEE)] on stroke units remains however unknown. To representatively examine echocardiographic rates on stroke units in Germany and to evaluate structural factors that may influence the decision to conduct echocardiography. METHODS A nationwide analysis was performed by using certification audit data of all primary and comprehensive stroke centers (pSC and cSC) in Germany. RESULTS Structural and organizational requirements of 310 departments (cSCs: 42.6%) were extracted. Median TTE rate was 63.3% (IQR 39.3-80.8), median TEE rate 21.3% (IQR 16.4-29.5). A cardiological department on site was present in 74.2%, and they were associated with higher TEE rates. TTE rates decreased with increasing numbers of patients (p = 0.026). Likewise, TEE rates decreased with increasing numbers of patients (p = 0.006), mediated by departments with cSCs (p = 0.008 for cSCs vs p = 0.230 for pSCs). TTE rates were far more inhomogeneously distributed than TEE rates and higher in pSCs (p = 0.011). Overall, 12.9% of centers did not perform any echocardiographic examination in at least 50% of all stroke patients. CONCLUSION More detailed recommendations regarding echocardiography should be included in future guidelines. Moreover, evaluating the impact of echocardiographic examinations on long-term prognosis in stroke patients should be focus of further evaluations.
Collapse
Affiliation(s)
- Timolaos Rizos
- grid.7700.00000 0001 2190 4373Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Ekkehart Jenetzky
- grid.412581.b0000 0000 9024 6397Faculty of Health/School of Medicine, Witten/Herdecke University, Witten, Germany ,grid.5802.f0000 0001 1941 7111Department for Child and Adolescent Psychiatry, Johannes Gutenberg-University, Mainz, Germany
| | - Darius Günther Nabavi
- grid.433867.d0000 0004 0476 8412Department of Neurology, Vivantes Klinikum Neukölln, Rudower Str 48, 12351 Berlin, Germany
| | - Karl Georg Haeusler
- grid.8379.50000 0001 1958 8658Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Rolf Wachter
- grid.411339.d0000 0000 8517 9062Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Martin Ossenbrink
- grid.469884.f0000 0001 2034 2604LGA InterCert GmbH, Nuremberg, Germany
| | - Peter Arthur Ringleb
- grid.7700.00000 0001 2190 4373Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Otto Busse
- Deutsche Schlaganfall Gesellschaft, Berlin, Germany
| |
Collapse
|
24
|
Jensen M, Suling A, Metzner A, Schnabel RB, Borof K, Goette A, Haeusler KG, Zapf A, Wegscheider K, Fabritz L, Diener HC, Thomalla G, Kirchhof P. Early rhythm-control therapy for atrial fibrillation in patients with a history of stroke: a subgroup analysis of the EAST-AFNET 4 trial. Lancet Neurol 2023; 22:45-54. [PMID: 36517170 DOI: 10.1016/s1474-4422(22)00436-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with atrial fibrillation and a history of stroke are at high risk of recurrent stroke and cardiovascular complications. In the EAST-AFNET 4 trial we showed that a systematic strategy of early rhythm control was associated with a lower risk of cardiovascular outcomes than usual care in patients with atrial fibrillation diagnosed in the past 12 months. In this pre-specified subgroup analysis we aimed to assess whether a strategy of early rhythm control is safe and can prevent adverse cardiovascular outcomes compared with usual care in such patients. METHODS EAST-AFNET 4 was a randomised, open-label trial with blinded-outcome assessment done at 135 hospitals and secondary care practices in 11 European countries. Adults with early atrial fibrillation (ie, diagnosed ≤12 months before enrolment) were randomly assigned (1:1) to either early rhythm control or usual care, with stratification according to site and variable block lengths used for concealment. The first primary outcome was time to first occurrence of the composite of cardiovascular death, ischaemic or haemorrhagic stroke, or hospital admission with worsening of heart failure or acute coronary syndrome. The second primary outcome was the number of nights spent in hospital in 1 year. The primary safety outcome was the composite of any death, stroke, or serious adverse events related to rhythm-control therapy. Here we present the results of these outcomes in patients with a history of stroke. Analyses were done in the intention-to-treat population. EAST-AFNET 4 is registered with ClinicalTrials.gov (NCT01288352), EudraCT (2010-021258-20), and ISRCTN (ISRCTN04708680). FINDINGS Between July 28, 2011, and Dec 30, 2016, 2789 patients were randomly assigned in the EAST-AFNET 4 trial to either early rhythm control (n=1395) or usual care (n=1394). Of these patients, five had no information on history of stroke and were excluded from this subgroup analysis. 217 (8%) patients had a history of stroke, of whom 110 were assigned to early rhythm control and 107 to usual care. The median age of participants with a history of stroke was 72·0 years (IQR 66·0-76·0). 95 (44%) participants were female and 122 (56%) were male. During a median follow-up of 4·7 years (3·5-6·4) for patients with a history of stroke, a first primary outcome event occurred in 18 (16%) of 110 patients in the early rhythm-control group (3·7 per 100 person-years) and 33 (31%) of 107 in the usual care group (7·4 per 100 person-years; hazard ratio [HR] 0·52, 95% CI 0·29-0·93). The mean number of nights spent in hospital per year was 5·1 (SD 13·2) for patients with a history of stroke assigned to early rhythm control and 6·6 (10·1) for those assigned to usual care (incidence rate ratio 0·87, 95% CI 0·55-1·38). Among patients with a history of stroke, primary safety events occurred in 17 (15%) patients in the early rhythm-control group versus 30 (28%) in the usual care group. INTERPRETATION In this prespecified subgroup analysis in patients with recently diagnosed atrial fibrillation and a history of stroke, the effects of early rhythm control were consistent with the findings of the primary analysis. As the evidence from this subgroup analysis is considered supportive and exploratory, further research is needed to confirm the safety and efficacy of this approach in patients with a history of stroke. FUNDING German Ministry of Education and Research, German Center for Cardiovascular Research (DZHK), Atrial Fibrillation Network (AFNET), European Heart Rhythm Association, St Jude Medical-Abbott, Sanofi, and the German Heart Foundation.
Collapse
Affiliation(s)
- Märit Jensen
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
| | - Anna Suling
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany
| | - Katrin Borof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Goette
- St Vincenz Hospital Paderborn, Paderborn, Germany; Atrial Fibrillation Network, Münster, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation Network, Münster, Germany; Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany
| | - Larissa Fabritz
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; University Center of Cardiovascular Sciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
25
|
Grimley RS, Collyer T, Dewey HM, Andrew N, Cadilhac DA. Stroke and emergency department re-presentation after outpatient TIA management: An interrupted time series study. J Stroke Cerebrovasc Dis 2023; 32:106900. [PMID: 36427470 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106900] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/24/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess the effects of a non-admitted management pathway following emergency department (ED) presentation with suspected TIA on: 90-day stroke and ED re-presentations, overnight admission, length of stay (LOS) and costs. METHODS We implemented a management pathway across an Australian regional health service (4 hospitals; 2 rural, 10,000 km2) including ED protocols followed by urgent outpatient review or telemedicine consultation to one rural hospital. Interrupted time series analysis was conducted on linked hospital administrative datasets for all ED TIA diagnoses 5 years before and 2 years after intervention (2015). We assessed whether pathway introduction was associated with immediate change (level) or subsequent rate of change (slope) in outcomes. RESULTS There were 2031 presentations: 1,467 before, 564 after implementation. Against background declining trends, overnight admissions decreased by 12.4% (95%CI 5.0, 19.7) and total LOS decreased 6 hours (95%CI 1.5, 10.4). Hospital costs reduced by AUD683 per patient with implementation. Outpatient review occurred for 36% at median 5 days (IQR 3, 9), including 19/87 (22%) telemedicine reviews. Pathway adherence was incomplete: 29% had no specialist review. Recurrent stroke increased by 1.3/100 presentations (95%CI 0.6, 2.1) with implementation, then returned to baseline of 0.9/100. ED re-presentations rose at a significant rate after implementation (extra 1.69/100 patients re-presenting/quarter; 95%CI 0.8, 2.6) reaching 32/100. CONCLUSIONS An ED TIA management pathway designed to avoid hospital admission resulted in decreased hospital use and costs; but an initial increase in recurrent stroke and sustained rise in ED re-presentation, possibly related to delayed and incomplete follow-up.
Collapse
Affiliation(s)
- Rohan S Grimley
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia; Griffith University, School of Medicine, Birtinya, Australia; Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.
| | - Taya Collyer
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Australia.
| | - Helen M Dewey
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Box Hill, Australia.
| | - Nadine Andrew
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia; Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Australia.
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia; Florey Institute of Neuroscience and Mental Health, Heidelberg, University of Melbourne, Vic, Australia.
| |
Collapse
|
26
|
Palaiodimou L, Kargiotis O, Katsanos AH, Kiamili A, Bakola E, Komnos A, Zisimopoulou V, Natsis K, Papagiannopoulou G, Theodorou A, Zompola C, Safouris A, Psychogios K, Ntais E, Plomaritis P, Karamatzianni G, Mavriki A, Koutsokera M, Lykou C, Koutroulou I, Gourbali V, Skafida A, Roussopoulou A, Kourtesi G, Papamichalis P, Papagiannopoulos S, Gryllia M, Tavernarakis A, Kazis D, Karapanayiotides T, Magoufis G, Giannopoulos S, Tsivgoulis G. Quality metrics in the management of acute stroke in Greece during the first 5 years of Registry of Stroke Care Quality (RES-Q) implementation. Eur Stroke J 2023; 8:5-15. [PMID: 36793743 PMCID: PMC9923128 DOI: 10.1177/23969873221103474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 05/09/2022] [Indexed: 02/12/2023] Open
Abstract
Introduction Establishment of a prospective stroke registry may promote the documentation and improvement of acute stroke care. We present the status of stroke management in Greece using the Registry of Stroke Care Quality (RES-Q) dataset. Methods Consecutive patients with acute stroke were prospectively registered in RES-Q registry by contributing sites in Greece during the years 2017-2021. Demographic and baseline characteristics, acute management, and clinical outcomes at discharge were recorded. Stroke quality metrics, with a specific interest in the association between acute reperfusion therapies and functional recovery in ischemic stroke patients are presented. Results A total of 3590 acute stroke patients were treated in 20 Greek sites (61% men, median age 64 years; median baseline NIHSS 4; 74% ischemic stroke). Acute reperfusion therapies were administered in almost 20% of acute ischemic stroke patients, with a door to needle and door to groin puncture times of 40 and 64 min, respectively. After adjustment for contributing sites, the rates of acute reperfusion therapies were higher during the time epoch 2020-2021 compared to 2017-2019 (adjusted OR 1.31; 95% CI 1.04-1.64; p < 0.022; Cochran-Mantel-Haenszel test). After propensity-score-matching, acute reperfusion therapies administration was independently associated with higher odds of reduced disability (one point reduction across all mRS scores) at hospital discharge (common OR 1.93; 95% CI 1.45-2.58; p < 0.001). Conclusions Implementation and maintenance of a nationwide stroke registry in Greece may guide the stroke management planning, so that prompt patient transportation, acute reperfusion therapies, and stroke unit hospitalization become more widely accessible, improving the functional outcomes of stroke patients.
Collapse
Affiliation(s)
- Lina Palaiodimou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Lina Palaiodimou, Second Department of
Neurology, “Attikon” University Hospital, School of Medicine, National and
Kapodistrian University of Athens, Rimini 1, Chaidari, Athens 12462, Greece.
| | | | - Aristeidis H Katsanos
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, School of
Medicine, University of Ioannina, Ioannina, Greece
| | - Argyro Kiamili
- Department of Neurology,
Korgialenio-Benakio Greek Red Cross General Hospital of Athens, Athens, Greece
| | - Eleni Bakola
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Apostolos Komnos
- Intensive Care Unit, General Hospital
of Larissa, Larissa, Greece
| | - Vaso Zisimopoulou
- Stroke Unit, Athens Euroclinic, Athens,
Greece
- Department of Neurology, 251 Hellenic
Air Force & VA General Hospital, Athens, Greece
| | | | - Georgia Papagiannopoulou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Aikaterini Theodorou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Christina Zompola
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | | | | | - Evangelos Ntais
- Department of Neurology, School of
Medicine, University of Ioannina, Ioannina, Greece
| | - Panagiotis Plomaritis
- Department of Neurology,
Korgialenio-Benakio Greek Red Cross General Hospital of Athens, Athens, Greece
| | - Georgia Karamatzianni
- Department of Neurology,
Korgialenio-Benakio Greek Red Cross General Hospital of Athens, Athens, Greece
| | - Andriana Mavriki
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Maria Koutsokera
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Christina Lykou
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Ioanna Koutroulou
- Second Department of Neurology,
Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital,
Thessaloniki, Greece
| | | | | | - Andromachi Roussopoulou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, Tzaneio
General Hospital, Pireaus, Greece
| | - Georgia Kourtesi
- Department of Neurology, General
Hospital of Serres, Serres, Greece
| | | | - Sotirios Papagiannopoulos
- Third Department of Neurology,
Aristotle University of Thessaloniki, Papanikolaou Hospital, Thessaloniki,
Greece
| | - Maria Gryllia
- Department of Neurology, Athens
General Hospital G. Gennimatas, Athens, Greece
| | | | - Dimitrios Kazis
- Third Department of Neurology,
Aristotle University of Thessaloniki, Papanikolaou Hospital, Thessaloniki,
Greece
| | - Theodoros Karapanayiotides
- Second Department of Neurology,
Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital,
Thessaloniki, Greece
| | | | - Sotirios Giannopoulos
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, School of
Medicine, University of Ioannina, Ioannina, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| |
Collapse
|
27
|
Himmelreich JCL, Lucassen WAM, Coutinho JM, Harskamp RE, de Groot JR, CPM van Weert H. 14-day Holter monitoring for atrial fibrillation after ischemic stroke: The yield of guideline-recommended monitoring duration. Eur Stroke J 2022; 8:157-167. [PMID: 37021150 PMCID: PMC10069211 DOI: 10.1177/23969873221146027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/29/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction: Current European Stroke Organisation (ESO) guidelines recommend >48 h of continuous electrocardiographic monitoring for atrial fibrillation (AF) in all patients with ischemic stroke or transient ischemic attack (TIA) with undetermined origin. We assessed the yield of the guideline-recommended monitoring for AF, as well as of extending monitoring up to 14 days. Patients and methods: We included consecutive patients with stroke/TIA without AF in an academic hospital in The Netherlands. We reported AF incidence and number needed to screen (NNS) in the overall sample after 48 h and 14 days of Holter monitoring. Results: Among 379 patients with median age 63 years (IQR 55–73), 58% male, Holter monitoring detected 10 cases of incident AF during a median of 13 (IQR 12–14) days of monitoring. Seven AF cases were detected within the first 48 hours (incidence 1.85%, 95% CI 0.74–3.81; NNS 54), and three additional AF cases were recorded among the 362 patients with >48 h of monitoring and without AF ⩽ 48 h (incidence 0.83%, 95% CI: 0.17–2.42; NNS 121). All AF cases were detected within the first 7 days of monitoring. Our sample was subject to sampling bias favoring inclusion of participants with low AF risk. Discussion: Strengths of this work were the broad inclusion criteria as recommended by ESO guidelines, and high Holter adherence among participants. The analysis was limited by inclusion of lower-risk cases and a relatively small sample size. Conclusion: In low-risk patients with recent stroke or TIA, ESO guideline-recommended screening for AF resulted in a low AF yield, with limited additional value of monitoring up to 14 days. Our results underline the need for a personalized approach in determining a patient’s optimum duration for post-stroke non-invasive ambulatory monitoring.
Collapse
Affiliation(s)
- Jelle CL Himmelreich
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands
| | - Wim AM Lucassen
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Ralf E Harskamp
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands
| | - Joris R de Groot
- Department of Cardiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure & Arrhythmias, Amsterdam, The Netherlands
| | - Henk CPM van Weert
- Department of General Practice, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands
| |
Collapse
|
28
|
Popa MA, Bourier F, Lengauer S, Krafft H, Bahlke F, Förschner LV, Dorfmeister S, Kathan S, Telishevska M, Englert F, Lennerz C, Reents T, Hessling G, Deisenhofer I, Kottmaier M. Safety profile and long-term efficacy of very high-power short-duration (60-70 W) catheter ablation for atrial fibrillation: results of a large comparative analysis. Europace 2022; 25:408-416. [PMID: 36504120 PMCID: PMC9935037 DOI: 10.1093/europace/euac215] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 09/30/2022] [Indexed: 12/14/2022] Open
Abstract
AIMS This retrospective study sought to compare complication rates and efficacy of power-controlled very high-power short-duration (vHPSD) and conventional catheter ablation in a large cohort of patients with atrial fibrillation (AF). METHODS AND RESULTS We analyzed 1115 consecutive patients with AF (38.7% paroxysmal, 61.3% persistent) who received first-time catheter ablation at our centre from 2015 to 2021. Circumferential pulmonary vein isolation ± additional substrate ablation using an irrigated-tip catheter was performed with vHPSD (70 W/5-7 s or 60 W/7-10 s) in 574 patients and with conventional power (30-35 W/15-30 s) in 541 patients. Baseline characteristics were well-balanced between groups (mean age 65.1 ± 11.2 years, 63.4% male). The 30-day incidence of cardiac tamponade [2/574 (0.35%) vs. 1/541 (0.18%), P = 0.598], pericardial effusion ≥ 10 mm [2/574 (0.35%) vs. 1/541 (0.18%), P = 0.598] and transient ischaemic attack [1/574 (0.17%) vs. 2/541 (0.37%), P = 0.529] was not significantly different between vHPSD and conventional ablation. No stroke, atrio-esophageal fistula, cardiac arrest or death occurred. Procedure (122.2 ± 46.8 min vs. 155.0 ± 50.5 min, P < 0.001), radiofrequency (22.4 ± 19.3 min vs. 52.9 ± 22.0 min, P < 0.001), and fluoroscopy (8.1 ± 7.2 vs. 9.2 ± 7.4, P = 0.016) duration were significantly shorter in the vHPSD group. At 12 months follow-up, freedom of any atrial arrhythmia was 44.1% vs. 34.2% (P = 0.010) in persistent AF and 78.1% vs. 70.2% in paroxysmal AF (P = 0.068). CONCLUSION vHPSD ablation is as safe as conventional ablation and is associated with an improved long-term efficacy in persistent AF.
Collapse
Affiliation(s)
- Miruna A Popa
- Corresponding author. Tel: +49 89 1218 2020, Fax: +49 89 1218 4593. E-mail address:
| | - Felix Bourier
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Sarah Lengauer
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Hannah Krafft
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Fabian Bahlke
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Leonie V Förschner
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Stephan Dorfmeister
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Susanne Kathan
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Marta Telishevska
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Florian Englert
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Carsten Lennerz
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Tilko Reents
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Gabriele Hessling
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Isabel Deisenhofer
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| | - Marc Kottmaier
- German Heart Center Munich, Department of Electrophysiology, Lazarettstraße 36, 80636 Munich, Germany,Munich Arrhythmia Research and Study Center (MARS), Lazarettstraße 36, 80636 Munich, Germany
| |
Collapse
|
29
|
Yeh CY, Lee HH, Islam MM, Chien CH, Atique S, Chan L, Lin MC. Development and Validation of Machine Learning Models to Classify Artery Stenosis for Automated Generating Ultrasound Report. Diagnostics (Basel) 2022; 12:diagnostics12123047. [PMID: 36553056 PMCID: PMC9776545 DOI: 10.3390/diagnostics12123047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/24/2022] [Accepted: 11/30/2022] [Indexed: 12/07/2022] Open
Abstract
Duplex ultrasonography (DUS) is a safe, non-invasive, and affordable primary screening tool to identify the vascular risk factors of stroke. The overall process of DUS examination involves a series of complex processes, such as identifying blood vessels, capturing the images of blood vessels, measuring the velocity of blood flow, and then physicians, according to the above information, determining the severity of artery stenosis for generating final ultrasound reports. Generation of transcranial doppler (TCD) and extracranial carotid doppler (ECCD) ultrasound reports involves a lot of manual review processes, which is time-consuming and makes it easy to make errors. Accurate classification of the severity of artery stenosis can provide an early opportunity for decision-making regarding the treatment of artery stenosis. Therefore, machine learning models were developed and validated for classifying artery stenosis severity based on hemodynamic features. This study collected data from all available cases and controlled at one academic teaching hospital in Taiwan between 1 June 2020, and 30 June 2020, from a university teaching hospital and reviewed all patients' medical records. Supervised machine learning models were developed to classify the severity of artery stenosis. The receiver operating characteristic curve, accuracy, sensitivity, specificity, and positive and negative predictive value were used for model performance evaluation. The performance of the random forest model was better compared to the logistic regression model. For ECCD reports, the accuracy of the random forest model to predict stenosis in various sites was between 0.85 and 1. For TCD reports, the overall accuracy of the random forest model to predict stenosis in various sites was between 0.67 and 0.86. The findings of our study suggest that a machine learning-based model accurately classifies artery stenosis, which indicates that the model has enormous potential to facilitate screening for artery stenosis.
Collapse
Affiliation(s)
- Chih-Yang Yeh
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan
| | - Hsun-Hua Lee
- Department of Neurology, Taipei Medical University Hospital, Taipei Medical University, Taipei 11031, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Dizziness and Balance Disorder Center, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
| | - Md. Mohaimenul Islam
- International Center for Health Information Technology, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan
| | - Chiu-Hui Chien
- Division of Operation Performance, Center for Management and Development, Taipei Medical University, Taipei 11031, Taiwan
| | - Suleman Atique
- Department of Public Health Science, Faculty of Landscape and Society, Norwegian University of Life Sciences, 1430 Ås, Norway
- Department of Health Informatics, College of Public Health and Health Informatics, University of Hail, Hail 55476, Saudi Arabia
| | - Lung Chan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
- Correspondence: (L.C.); (M.-C.L.)
| | - Ming-Chin Lin
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Correspondence: (L.C.); (M.-C.L.)
| |
Collapse
|
30
|
Southey CC, Birns J, Sommerville P, Bhalla A. Transient unilateral weakness: is it a transient ischaemic attack? Br J Hosp Med (Lond) 2022; 83:1-7. [DOI: 10.12968/hmed.2022.0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transient ischaemic attack is an emergency medical condition that causes brief negative focal neurological symptoms such as unilateral weakness. The symptoms herald a high risk of stroke and hence require urgent assessment. The challenge lies in the brevity and compendium of associated symptoms that can ‘mimic’ a plethora of other conditions. The result is a high rate of referrals to transient ischaemic attack clinics for these stroke mimics. This article highlights the diagnostic challenges in transient ischaemic attack with relevance to unilateral weakness.
Collapse
Affiliation(s)
- Charles C Southey
- Department of Ageing and Health, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Jonathan Birns
- Department of Ageing and Health, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Peter Sommerville
- Department of Ageing and Health, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Ajay Bhalla
- Department of Ageing and Health, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| |
Collapse
|
31
|
When Can an Emergency CTA Be Dispensed with for TIA Patients? J Clin Med 2022; 11:jcm11195686. [PMID: 36233554 PMCID: PMC9573404 DOI: 10.3390/jcm11195686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/31/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Transient ischemic attacks (TIAs) and minor strokes are often precursors of a major stroke. Therefore, diagnostic work-up of the TIA is essential to reduce the patient’s risk of further ischemic events. Purpose: With the help of this retrospective study, we aim to determine for which TIA patients a CT angiography (CTA) is not immediately necessary in order to reduce radiation exposure and nephrotoxicity. Material and Methods: Clinical and imaging data from patients who presented as an emergency case with a suspected diagnosis of TIA at a teaching hospital between January 2016 and December 2021 were evaluated. The included 1526 patients were divided into two groups—group 1, with major pathologic vascular findings in the CTA, and group 2, with minor vascular pathologies. Results: Out of 1821 patients with suspected TIA on admission, 1526 met the inclusion criteria. In total, 336 (22%) had major vascular pathologies on CTA, and 1190 (78%) were unremarkable. The majority of patients with major vascular pathologies were male and had a history of arterial hypertension, coronary heart disease, myocardial infarction, ischemic stroke, TIA, atherosclerotic peripheral vascular disease, smoking, antiplatelet medication, had a lower duration of TIA symptoms, and had lower ABCD2 scores. Conclusions: We were able to demonstrate a direct correlation between major CTA pathologies and a history of smoking, age, hyperlipidemia, history of peripheral arterial disease, and a history of stroke and TIA. We were able to prove that the ABCD2 score is even reciprocal to CTA pathology. This means that TIA patients without described risk factors do not immediately require a CTA and could be clarified in the course of treatment with ultrasound or MRI.
Collapse
|
32
|
Sojka M, Drelich-Zbroja A, Kuczyńska M, Cheda M, Dąbrowska I, Kopyto E, Halczuk I, Zbroja M, Cyranka W, Jargiełło T. Ischemic and Hemorrhagic Cerebrovascular Events Related to COVID-19 Coagulopathy and Hypoxemia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11823. [PMID: 36142094 PMCID: PMC9517511 DOI: 10.3390/ijerph191811823] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 06/16/2023]
Abstract
Since the very beginning of the COVID-19 pandemic, numerous researchers have made an effort to determine the molecular composition of the SARS-CoV-2 virus, and the exact pathomechanism through which the virus exerts such a devastating effect on the host/infected organism. Recent scientific evidence highlights the affinity of the virus towards ACE2 receptors, which are widespread in multiple human systems, including the central nervous system (CNS) and cerebral vessels. Such an affinity may explain endothelial dysfunction and damage that is observed in COVID-positive patients in histopathological studies, with subsequent dysregulation of the cerebral circulation leading to transient or acute cerebrovascular accidents. In this paper, we aimed to evaluate the effects of COVID-related hypoxemia and direct viral invasion on the cerebral circulation, with special respect to the postulated pathomechanism, vulnerable groups of patients, clinical course and outcomes, as well as diagnostic imaging findings.
Collapse
Affiliation(s)
- Michał Sojka
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Anna Drelich-Zbroja
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Maryla Kuczyńska
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Mateusz Cheda
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Izabela Dąbrowska
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Ewa Kopyto
- Students’ Scientific Society at the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Izabela Halczuk
- Students’ Scientific Society at the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Monika Zbroja
- Students’ Scientific Society at the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Weronika Cyranka
- Students’ Scientific Society at the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Tomasz Jargiełło
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-090 Lublin, Poland
| |
Collapse
|
33
|
Chen PL, Chen YJ, Chung CP, Seak CJ, Jeng JS, Hsieh MJ, Lien LM, Chen JH, Chen YW, Chiu TF, Lee JT, Ng CJ. Dual Antiplatelet Therapy in the Management of Acute Minor Ischemic Stroke and High-Risk Transient Ischemic Attack: An Expert Consensus Statement From Taiwan Stroke Society and Taiwan Society of Emergency Medicine. J Acute Med 2022; 12:85-95. [PMID: 36313610 PMCID: PMC9561483 DOI: 10.6705/j.jacme.202209_12(3).0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 07/24/2022] [Indexed: 06/16/2023]
Abstract
The aim of this review is to achieve a consensus between Taiwan Stroke Society (TSS) and Taiwan Society of Emergency Medicine (TSEM) to manage acute non-cardioembolic minor ischemic stroke (MIS) and high-risk transient ischemic attack (TIA). The methodology is to review the recent findings from clinical trials of dual antiplatelet therapy (DAPT) from 2010 to 2021 and updates in clinical practice guidelines from 2018 to 2022 for non-cardioembolic MIS/TIA management at the acute stage. Four leading clinical studies, CHANCE, POINT, THALES, and CHANCE-2 along with other relevant studies introducing DAPT, are discussed in this review. The risk-benefit profile between stroke recurrence reduction and major bleeding increase is also elucidated. TSS and TSEM concluded that for patients presenting with non-cardioembolic MIS or high-risk TIA who did not receive intravenous alteplase, initiation of DAPT within 24 hours after stroke onset and continued up to 21 days, followed by antiplatelet monotherapy, is effective in reducing recurrent ischemic stroke for a period of up to 90 days.
Collapse
Affiliation(s)
- Po-Lin Chen
- Neurological Institute Division of Neurology Taichung Veterans General Hospital, Taichung Taiwan
| | - Ying-Ju Chen
- Taipei Veterans General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Chih-Ping Chung
- Neurological Institute Department of Neurology Taipei Veterans General Hospital, Taipei Taiwan
| | - Chen-June Seak
- New Taipei Municipal Tucheng Hospital Department of Emergency Medicine New Taipei City Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
| | - Jiann-Shing Jeng
- National Taiwan University Hospital Department of Neurology and Stroke Center Taipei Taiwan
| | - Ming-Ju Hsieh
- National Taiwan University Hospital Department of Emergency Medicine Taipei Taiwan
| | - Li-Ming Lien
- Shin Kong Wu Ho-Su Memorial Hospital Department of Neurology Taipei Taiwan
| | - Jiann-Hwa Chen
- Cathay General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Yu-Wei Chen
- Landseed International Hospital Department of Neurology Taoyuan Taiwan
| | - Te-Fa Chiu
- China Medical University Hospital Department of Emergency Medicine Taichung Taiwan
| | - Jiunn-Tay Lee
- Tri-Service General Hospital Department of Neurology National Defense Medical Center, Taipei Taiwan
| | - Chip-Jin Ng
- Chang Gung University College of Medicine Taoyuan Taiwan
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
| |
Collapse
|
34
|
Dawson J, Béjot Y, Christensen LM, De Marchis GM, Dichgans M, Hagberg G, Heldner MR, Milionis H, Li L, Pezzella FR, Taylor Rowan M, Tiu C, Webb A. European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack. Eur Stroke J 2022; 7:I-II. [PMID: 36082250 PMCID: PMC9446324 DOI: 10.1177/23969873221100032] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022] Open
Abstract
Recurrent stroke affects 9% to 15% of people within 1 year. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations on pharmacological management of blood pressure (BP), diabetes mellitus, lipid levels and antiplatelet therapy for the prevention of recurrent stroke and other important outcomes in people with ischaemic stroke or transient ischaemic attack (TIA). It does not cover interventions for specific causes of stroke, including anticoagulation for cardioembolic stroke, which are addressed in other guidelines. This guideline was developed through ESO standard operating procedures and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified clinical questions, selected outcomes, performed systematic reviews, with meta-analyses where appropriate, and made evidence-based recommendations, with expert consensus statements where evidence was insufficient to support a recommendation. To reduce the long-term risk of recurrent stroke or other important outcomes after ischaemic stroke or TIA, we recommend: BP lowering treatment to a target of <130/80 mmHg, except in subgroups at increased risk of harm; HMGCoA-reductase inhibitors (statins) and targeting a low density lipoprotein level of <1.8 mmol/l (70 mg/dl); avoidance of dual antiplatelet therapy with aspirin and clopidogrel after the first 90 days; to not give direct oral anticoagulant drugs (DOACs) for embolic stroke of undetermined source and to consider pioglitazone in people with diabetes or insulin resistance, after careful consideration of potential risks. In addition to the evidence-based recommendations, all or the majority of working group members supported: out-of-office BP monitoring; use of combination treatment for BP control; consideration of ezetimibe or PCSK9 inhibitors when lipid targets are not achieved; consideration of use of low-dose DOACs in addition to an antiplatelet in selected groups of people with coronary or peripheral artery disease and aiming for an HbA1c level of <53 mmol/mol (7%) in people with diabetes mellitus. These guidelines aim to standardise long-term pharmacological treatment to reduce the burden of recurrent stroke in Europe.
Collapse
Affiliation(s)
- Jesse Dawson
- Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow,
Glasgow, UK
| | - Yannick Béjot
- Dijon Stroke Registry, Department of
Neurology, University Hospital of Dijon, Dijon, France
- Pathophysiology and Epidemiology of
Cardio-Cerebrovascular disease (PEC2), University of Burgundy, Dijon, France
| | - Louisa M Christensen
- Dept of Neurology, Copenhagen
University Hospital Bispebjerg, Kobenhavn, Denmark
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Martin Dichgans
- Institute for Stroke and Dementia
Research (ISD), University Hospital, LMU Munich, Munich, Germany
- Munich Cluster for Systems Neurology
(SyNergy), Munich, Germany
| | - Guri Hagberg
- Oslo Stroke Unit, Department of
Neurology, Oslo University Hospital, Ullevål, Norway
- Department of medical research, Bærum
Hospital Vestre Viken Hospital Trust, Drammen, Norway
| | - Mirjam R Heldner
- Stroke Research Center Bern,
Department of Neurology, University and University Hospital Bern, Bern,
Switzerland
| | - Haralampos Milionis
- Department of Internal Medicine,
School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina,
Greece
| | - Linxin Li
- Wolfson Centre for Prevention of
Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
| | | | - Martin Taylor Rowan
- Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow,
Glasgow, UK
| | - Cristina Tiu
- Department of Clinical Neurosciences,
University of Medicine and Pharmacy ‘Carol Davila’, Bucuresti, Romania
- Department of Neurology, University
Hospital Bucharest, Bucharest, Romania
| | - Alastair Webb
- Wolfson Centre for Prevention of
Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
| |
Collapse
|
35
|
Ortiz-Garcia J, Gomez CR, Schneck MJ, Biller J. Recent advances in the management of transient ischemic attacks. Fac Rev 2022; 11:19. [PMID: 35949262 PMCID: PMC9340656 DOI: 10.12703/r/11-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Transient ischemic attack (TIA) constitutes an important clinical condition, indicating the presence of considerable risk for a subsequent ischemic stroke. Its prompt diagnosis and management have the potential for reducing the risk of neurologic disability, highlighting the critical need to prioritize the care of patients with TIA. The risk of ischemic stroke following a TIA is directly related to its etiopathogenesis, and recognizable causes are commonly categorized within one of three domains: cerebrovascular pathology, cardiac dysfunction, and hematologic disorders. Therefore, the clinical approach to patients suspected of having suffered a TIA demands a comprehensive evaluation, including testing of possible etiologic conditions in all three of these domains, best carried out in an expedited fashion since the stroke risk is greatest in the hours and days that follow the index event. The present is a review of the existing literature addressing the diagnosis, evaluation, prioritization, and management strategies available to clinicians who provide care to patients with TIA.
Collapse
Affiliation(s)
- Jorge Ortiz-Garcia
- Department of Neurology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri Columbia, Columbia, MO, USA
| | - Michael J Schneck
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - José Biller
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| |
Collapse
|
36
|
Weng JX, Gu HQ, Wang S, Yang KX, Yang X, Wang CJ, Meng X, Zhao XQ, Wang YJ, Li ZX. External validation of ABCD series scores for predicting early stroke events following transient ischemic attack in a large nationwide registry. Eur Stroke J 2022; 7:439-446. [DOI: 10.1177/23969873221113145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/23/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: In the context of modern guideline-based strategies, new validations of prognostic scores for predicting early stroke risk are needed. We aimed to compare the validity of the ABCD series scores and assess the incremental values of risk components for predicting in-hospital stroke events in patients with transient ischemic attack (TIA). Patients and methods: We abstracted data from the Chinese Stroke Center Alliance (CSCA), a nationwide registry with 68,433 TIA patients admitted within 7 days of symptom onset from 1476 hospitals. TIA was defined by time-based criteria according to the World Health Organization (WHO). The discrimination of ABCD, ABCD2, ABCD2-I, and ABCD3 scores for predicting in-hospital stroke events was assessed by the area under the receiver-operating characteristics curves (AUC). The incremental predictive values of added risk predictor were determined by net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Results: A total of 29,286 TIA patients were included, of whom 1466 (5.0%) had in-hospital stroke events. Compared with ABCD2-I score (AUC 0.79, 95% confidence interval [CI] 0.77–0.80), ABCD (AUC 0.58, 95% CI 0.57–0.60), ABCD2 (AUC 0.58, 95% CI 0.56–0.59), and ABCD3 (AUC 0.58, 95% CI 0.56–0.60) had lower predictive utility. An incremental value was observed when adding infarction on DWI (IDI = 0.0597, NRI = 1.1036) into ABCD2 score to be ABCD2-I. Conclusion: The traditional scales utilizing medical history (ABCD, ABCD2, and ABCD3 scores) show fair ability for predicting in-hospital stroke events after TIA, but the ABCD2-I score, which adds infarction on DWI, improves the predictive ability.
Collapse
Affiliation(s)
- Jia-Xu Weng
- Vascular Neurology, Department of Neurology, 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
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shang Wang
- Neurocardiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kai-Xuan Yang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Yang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chun-Juan Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xing-Quan Zhao
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Center for Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Yong-Jun Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Center for Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Zi-Xiao Li
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Center for Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
37
|
Pomero F, Galli E, Bellesini M, Maroni L, Squizzato A. P2Y12 inhibitors plus aspirin for acute treatment and secondary prevention in minor stroke and high-risk transient ischemic attack: A systematic review and meta-analysis. Eur J Intern Med 2022; 100:46-55. [PMID: 35331593 DOI: 10.1016/j.ejim.2022.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Aspirin is a cornerstone of preventive treatment for stroke recurrence, but during the last few years the role of dual antiplatelet therapy (DAPT) is much more emerging. OBJECTIVE This systematic review aimed to compare early use of P2Y12 inhibitors (clopidogrel/ticagrelor) plus aspirin to aspirin alone for acute treatment and secondary prevention in acute non-cardioembolic minor ischemic stroke or TIA. METHODS A systematic search on MEDLINE and EMBASE was performed. Treatment effects were estimated with RRs and 95% CI. We used RevMan 5.4 for data analyses. We assessed methodological quality of selected studies according to Rob2 tools and quality of evidence with GRADE approach. RESULTS Four RCTs were included, enrolling 21,459 patients. Compared to aspirin alone, DAPT was superior in reducing stroke recurrence (RR 0.74, 95% CI 0.67-0.82, P <0.00001, absolute risk difference by 2%, NNT 50) and disabling stroke defined as mRS>2 (RR 0.84, 95% CI 0.75-0.95, P = 0.004), with no impact on all causes of mortality (RR 1.30, 95% CI 0.90-1.89, P = 0.16). An increased risk of major bleeding was emerged (RR 2.54, 95% CI 1.65-3.92, P <0.0001, absolute risk difference by 0,4%, NNH 250), in particular with ticagrelor, but there was no correlation between therapy duration and bleeding risk, as appeared from one-month (RR 3.06, 95% CI 1.64 to 5.69) and three-month (RR 2.09, 95% CI 1.18 to 3.69) follow-up analysis. CONCLUSIONS Early administration of P2Y12 inhibitors plus aspirin in patients with acute non-cardioembolic minor ischemic stroke or TIA reduced the incidence of ischemic stroke recurrence, impacting more significantly than the increased bleeding risk and influencing patients' quality of life by reducing disabling stroke.
Collapse
Affiliation(s)
- Fulvio Pomero
- Department of Internal Medicine, Michele and Pietro Ferrero Hospital, Via Tanaro 7, 12060 Verduno, CN, Italy
| | - Eleonora Galli
- Department of Internal Medicine, Michele and Pietro Ferrero Hospital, Via Tanaro 7, 12060 Verduno, CN, Italy; Department of Internal Medicine, University of Turin, Corso Dogliotti 14, 10126 Torino, Italy.
| | - Marta Bellesini
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| | - Lorenzo Maroni
- Department of General Medicine, Hypertension Dyslipidemia and Cardiovascular Risk Clinic, ASST Valle Olona, Sant'Antonio Abate Hospital, Via Eusebio Pastori, 21013 Gallarate, VA, Italy; Ospedale di Circolo, Via Arnaldo da Brescia 1, 21052 Busto Arsizio, VA, Italy
| | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| |
Collapse
|
38
|
Jourdi G, Marquis-Gravel G, Martin AC, Lordkipanidzé M, Godier A, Gaussem P. Antiplatelet Therapy in Atherothrombotic Diseases: Similarities and Differences Across Guidelines. Front Pharmacol 2022; 13:878416. [PMID: 35571090 PMCID: PMC9092185 DOI: 10.3389/fphar.2022.878416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/29/2022] [Indexed: 12/24/2022] Open
Abstract
Antiplatelet therapy, mainly consisting of aspirin and P2Y12 receptor antagonists, is the cornerstone of the pharmacological treatment and prevention of atherothrombotic diseases. Its use, especially in secondary cardiovascular prevention, has significantly improved patient clinical outcomes in the last decades. Primary safety endpoint (i.e., bleeding complications) remain a major drawback of antiplatelet drugs. National and international societies have published and regularly updated guidelines for antiplatelet therapy aiming to provide clinicians with practical recommendations for a better handling of these drugs in various clinical settings. Many recommendations find common ground between international guidelines, but certain strategies vary across the countries, particularly with regard to the choice of molecules, dosage, and treatment duration. In this review, we detail and discuss the main antiplatelet therapy indications in the light of the different published guidelines and the significant number of recently published clinical trials and meta-analyses and highlight the areas that deserve further investigation in order to improve antiplatelet therapy in patients with atherothrombotic diseases.
Collapse
Affiliation(s)
- Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Guillaume Marquis-Gravel
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Anne-Céline Martin
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France.,Service de Cardiologie, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Marie Lordkipanidzé
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Anne Godier
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France.,Service d'Anesthésie Réanimation, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Pascale Gaussem
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France.,Service d'Hématologie Biologique, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| |
Collapse
|
39
|
Ihle-Hansen H, Kelly P, Bladin C, Chaturvedi S. Editorial: Emerging Areas in Extracranial Carotid Stenosis Evaluation and Management. Front Neurol 2022; 13:891883. [PMID: 35463131 PMCID: PMC9020826 DOI: 10.3389/fneur.2022.891883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/15/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Hege Ihle-Hansen
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
- *Correspondence: Hege Ihle-Hansen
| | - Peter Kelly
- HRB Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
- Stroke Service, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Christopher Bladin
- Department of Neurosciences, Monash University, Melbourne, VIC, Australia
| | - Seemant Chaturvedi
- School of Medicine, University of Maryland, Baltimore, MD, United States
| |
Collapse
|
40
|
Low-dose aspirin for the prevention of atherothrombosis across the cardiovascular risk continuum. CARDIOLOGY PLUS 2022. [DOI: 10.1097/cp9.0000000000000017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
41
|
Mbonde AA, O'Carroll CB, Dulamea OA, Anghel D, Chong BW, Dumitrascu OM. Current Guidelines on Management of Amaurosis Fugax and Transient Ischemic Attacks. Asia Pac J Ophthalmol (Phila) 2022; 11:168-176. [PMID: 35213421 DOI: 10.1097/apo.0000000000000511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
ABSTRACT Transient ischemic attack (TIA) is defined as a transient episode of neurological dysfunction resulting from focal brain, spinal cord, or retinal ischemia, without associated infarction. Consequently, a TIA encompasses amaurosis fugax (AF) that is a term used to denote momentary visual loss from transient retinal ischemia. In this review, we use the word TIA to refer to both cerebral TIAs (occurring in the brain) and AF (occurring in the retina). We summarize the key components of a comprehensive evaluation and management of patients presenting with cerebral and retinal TIA.All TIAs should be treated as medical emergencies, as they may herald permanent disabling visual loss and devastating hemispheric or vertebrobasilar ischemic stroke. Patients with suspected TIA should be expeditiously evaluated in the same manner as those with an acute stroke. This should include a detailed history and examination followed by specific diagnostic studies. Imaging of the brain and extracranial and intracranial blood vessels forms the cornerstone of diagnostic workup of TIA. Cardiac investigations and serum studies to evaluate for etiological risk factors are also recommended.The management of all TIAs, whether cerebral or retinal, is similar and should focus on stroke prevention strategies, which we have categorized into general and specific measures. General measures include the initiation of appropriate antiplatelet therapy, encouraging a healthy lifestyle, and managing traditional risk factors, such as hypertension, dyslipidemia, and diabetes. Specific management measures require the identification of a specific TIA etiology, such as moderate-severe (greater than 50% of stenosis) symptomatic extracranial large vessel or intracranial steno-occlusive atherosclerotic disease, aortic arch atherosclerosis, and atrial fibrillation.
Collapse
Affiliation(s)
- Amir A Mbonde
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| | - Cumara B O'Carroll
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| | - Octaviana A Dulamea
- Department of Neurology, Fundeni Clinical institute and University of Medicine Carol Davila, Bucharest, Romania
| | - Daniela Anghel
- Department of Neurology, Fundeni Clinical institute and University of Medicine Carol Davila, Bucharest, Romania
| | - Brian W Chong
- Department of Neuroradiology, Mayo Clinic College of Medicine and Science, Phoenix, AZ, US
| | - Oana M Dumitrascu
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
- Department of Ophthalmology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, US
| |
Collapse
|
42
|
Nouri-Vaskeh M, Khalili N, Sadighi A, Yazdani Y, Zand R. Biomarkers for Transient Ischemic Attack: A Brief Perspective of Current Reports and Future Horizons. J Clin Med 2022; 11:jcm11041046. [PMID: 35207321 PMCID: PMC8877275 DOI: 10.3390/jcm11041046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 02/05/2023] Open
Abstract
Cerebrovascular disease is the leading cause of long-term disability in the world and the third-leading cause of death in the United States. The early diagnosis of transient ischemic attack (TIA) is of great importance for reducing the mortality and morbidity of cerebrovascular diseases. Patients with TIA have a high risk of early subsequent ischemic stroke and the development of permanent nervous system lesions. The diagnosis of TIA remains a clinical diagnosis that highly relies on the patient's medical history assessment. There is a growing list of biomarkers associated with different components of the ischemic cascade in the brain. In this review, we take a closer look at the biomarkers of TIA and their validity with a focus on the more clinically important ones using recent evidence of their reliability for practical usage.
Collapse
Affiliation(s)
- Masoud Nouri-Vaskeh
- Tropical and Communicable Diseases Research Centre, Iranshahr University of Medical Sciences, Iranshahr 7618815676, Iran;
- Network of Immunity in Infection, Malignancy and Autoimmunity, Universal Scientific Education and Research Network, Tehran 1419733151, Iran
| | - Neda Khalili
- School of Medicine, Tehran University of Medical Sciences, Tehran 1449614535, Iran;
- Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Tehran 1419733151, Iran
| | - Alireza Sadighi
- Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA;
| | - Yalda Yazdani
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5165665931, Iran;
| | - Ramin Zand
- Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA;
- Neuroscience Institute, Pennsylvania State University, State College, PA 16801, USA
- Correspondence: or ; Tel.: +1-570-808-7330; Fax: +1-570-808-3209
| |
Collapse
|
43
|
Duloquin G, Crespy V, Jakubina P, Giroud M, Vergely C, Béjot Y. Large Vessel Occlusion in Patients With Minor Ischemic Stroke in a Population-Based Study. The Dijon Stroke Registry. Front Neurol 2022; 12:796046. [PMID: 35095739 PMCID: PMC8795366 DOI: 10.3389/fneur.2021.796046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Strategy for the acute management of minor ischemic stroke (IS) with large vessel occlusion (LVO) is under debate, especially the benefits of mechanical thrombectomy. The frequency of minor IS with LVO among overall patients is not well established. This study aimed to assess the proportion of minor IS and to depict characteristics of patients according to the presence of LVO in a comprehensive population-based setting. METHODS Patients with acute IS were prospectively identified among residents of Dijon, France, using a population-based registry (2013-2017). All arterial imaging exams were reviewed to assess arterial occlusion. Minor stroke was defined as that with a National Institutes of Health Stroke Scale (NIHSS) score of <6. Proportion of patients with LVO was estimated in the minor IS population. The clinical presentation of patients was compared according to the presence of an LVO. RESULTS Nine hundred seventy-one patients were registered, including 582 (59.9%) patients with a minor IS. Of these patients, 23 (4.0%) had a LVO. Patients with minor IS and LVO had more severe presentation [median 3 (IQR 2-5) vs. 2 (IQR 1-3), p = 0.001] with decreased consciousness (13.0 vs. 1.6%, p<0.001) and cortical signs (56.5 vs. 30.8%, p = 0.009), especially aphasia (34.8 vs. 15.4%, p = 0.013) and altered item level of consciousness (LOC) questions (26.1 vs. 11.6%, p = 0.037). In multivariable analyses, only NIHSS score (OR = 1.45 per point; 95% CI: 1.11-1.91, p = 0.007) was associated with proximal LVO in patients with minor IS. CONCLUSION Large vessel occlusion (LVO) in minor stroke is non-exceptional, and our findings highlight the need for emergency arterial imaging in any patients suspected of acute stroke, including those with minor symptoms because of the absence of obvious predictors of proximal LVO.
Collapse
Affiliation(s)
| | | | | | | | | | - Yannick Béjot
- Dijon Stroke Registry, Department of Neurology, University Hospital of Dijon, EA7460, Pathophysiology and Epidemiology of Cardio-cerebrovascular Disease (PEC2), University of Burgundy, Dijon, France
| |
Collapse
|
44
|
Korsholm K, Damgaard D, Valentin JB, Packer EJS, Odenstedt J, Sinisalo J, Putaala J, Næss H, Al-Jazi MA, Karlsson JE, Pontoppidan J, Modrau B, Hjort J, Matzen KL, Johnsen SP, Nielsen-Kudsk JE. Left atrial appendage occlusion vs novel oral anticoagulation for stroke prevention in atrial fibrillation: rationale and design of the multicenter randomized occlusion-AF trial. Am Heart J 2022; 243:28-38. [PMID: 34537184 DOI: 10.1016/j.ahj.2021.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/28/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prevalence of atrial fibrillation (AF) is increasing globally, which is a major clinical and public health concern due to the 5-fold increased risk of stroke. Oral anticoagulation with novel oral anticoagulants (NOACs) is the current primary option for stroke prevention in patients with AF, although it increases the risk of major bleeding. Patients with prior ischemic cerebrovascular events are at particularly high risk of both recurrent ischemic events and major bleeding. Left atrial appendage occlusion (LAAO) provides an alternative option for stroke prevention in high-risk patients, however, with currently limited evidence. Thus, randomized trials comparing LAAO to NOACs are needed. OBJECTIVE The Occlusion-AF trial is designed to assess whether LAAO is non-inferior to NOAC therapy for reduction of the combined endpoint of stroke, systemic embolism, major bleeding (Bleeding Academic Research Consortium ≥ 3) and all-cause mortality in patients with AF and a recent ischemic stroke or transient ischemic attack (TIA). METHODS AND ANALYSIS Investigator-initiated multicenter, multinational, randomized open-label non-inferiority trial with blinded outcome evaluation (PROBE design). Patients with documented AF, and an ischemic stroke or TIA within 6 months will be eligible for enrollment. Major exclusion criteria are modified Rankin Scale > 3 at enrollment, glomerular filtration rate < 15 ml/min, and life-expectancy less than 2 years. A total of 750 patients will be randomized 1:1 to receive either a NOAC or LAAO using the Amplatzer Amulet (Abbott, MN, USA) or Watchman FLX (Boston Scientific, MN, USA) with subsequent life-long aspirin 75 mg daily. Follow-up will be based on in-office and telephone follow-up in combination with long-term follow-up (10 years) through national hospital discharge registries in the individual Nordic countries. The primary outcome will be a composite endpoint of stroke, systemic embolism, major bleeding (BARC ≥ 3) and all-cause mortality at 2-year follow-up. CONCLUSIONS The Occlusion-AF trial is designed to compare LAAO to NOAC therapy for secondary stroke prevention in AF patients with a high risk of recurrent thromboembolic events, i.e. with previous ischemic stroke or TIA, and otherwise eligible for anticoagulation. The results are expected to contribute significantly to the understanding of the effects of LAAO compared to the standard contemporary pharmacological treatment in these patients.
Collapse
Affiliation(s)
- Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark; Department of Cardiology, Regional Hospital, West Jutland, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Jan Brink Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | | | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Juha Sinisalo
- Heart and Lung Center, Helsinki University Central Hospital, and Helsinki University Helsinki, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Jan-Erik Karlsson
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jacob Pontoppidan
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Boris Modrau
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Jakob Hjort
- Clinical Trial Unit, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | | |
Collapse
|
45
|
Boytsov S, Samorodskaya I. Cardiovascular disease and cognitive impairment. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:7-13. [DOI: 10.17116/jnevro20221220717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
46
|
Farinha P, Coelho JMP, Reis CP, Gaspar MM. A Comprehensive Updated Review on Magnetic Nanoparticles in Diagnostics. NANOMATERIALS (BASEL, SWITZERLAND) 2021; 11:3432. [PMID: 34947781 PMCID: PMC8706278 DOI: 10.3390/nano11123432] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 02/07/2023]
Abstract
Magnetic nanoparticles (MNPs) have been studied for diagnostic purposes for decades. Their high surface-to-volume ratio, dispersibility, ability to interact with various molecules and superparamagnetic properties are at the core of what makes MNPs so promising. They have been applied in a multitude of areas in medicine, particularly Magnetic Resonance Imaging (MRI). Iron oxide nanoparticles (IONPs) are the most well-accepted based on their excellent superparamagnetic properties and low toxicity. Nevertheless, IONPs are facing many challenges that make their entry into the market difficult. To overcome these challenges, research has focused on developing MNPs with better safety profiles and enhanced magnetic properties. One particularly important strategy includes doping MNPs (particularly IONPs) with other metallic elements, such as cobalt (Co) and manganese (Mn), to reduce the iron (Fe) content released into the body resulting in the creation of multimodal nanoparticles with unique properties. Another approach includes the development of MNPs using other metals besides Fe, that possess great magnetic or other imaging properties. The future of this field seems to be the production of MNPs which can be used as multipurpose platforms that can combine different uses of MRI or different imaging techniques to design more effective and complete diagnostic tests.
Collapse
Affiliation(s)
- Pedro Farinha
- Research Institute for Medicines, iMed.ULisboa, Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal;
| | - João M. P. Coelho
- Instituto de Biofísica e Engenharia Biomédica (IBEB), Faculdade de Ciências, Universidade de Lisboa, Campo Grande, 1749-016 Lisboa, Portugal
| | - Catarina Pinto Reis
- Research Institute for Medicines, iMed.ULisboa, Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal;
- Instituto de Biofísica e Engenharia Biomédica (IBEB), Faculdade de Ciências, Universidade de Lisboa, Campo Grande, 1749-016 Lisboa, Portugal
| | - Maria Manuela Gaspar
- Research Institute for Medicines, iMed.ULisboa, Faculty of Pharmacy, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal;
| |
Collapse
|
47
|
Sanchez-Caro JM, de Lorenzo Martínez de Ubago I, de Celis Ruiz E, Arribas AB, Calviere L, Raposo N, Blancart RG, Fuentes B, Diez-Tejedor E, Rodriguez-Pardo J. Transient Focal Neurological Events in Cerebral Amyloid Angiopathy and the Long-term Risk of Intracerebral Hemorrhage and Death: A Systematic Review and Meta-analysis. JAMA Neurol 2021; 79:38-47. [PMID: 34779831 DOI: 10.1001/jamaneurol.2021.3989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Transient focal neurological episodes (TFNEs) are a frequently overlooked presentation of cerebral amyloid angiopathy (CAA), a condition with prognostic implications that are still not well described. Objective To perform a systematic review and meta-analysis to examine the factors associated with incident lobar intracerebral hemorrhage (ICH) and death in patients with CAA presenting with TFNEs. Data Sources A systematic review and individual participant meta-analysis including (1) a hospital-based cohort and (2) the results obtained from a systematic search performed in MEDLINE and Embase completed in December 2019. Study Selection Included studies were observational reports of TFNEs. Patient-level clinical, imaging, and prognostic data were required for inclusion. For aggregate data studies, patient-level data were requested. Disagreements were resolved by consensus. Data Extraction and Synthesis Data were extracted following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines by 4 independent reviewers. The quality of reports was determined based on the modified Pearson Case Report Quality Scale. Main Outcomes and Measures The clinical characteristics of TFNEs, neuroimaging features, and use of antithrombotics during follow-up were considered exposures. The predefined main outcomes were lobar ICH and risk of death during follow-up. Results Forty-two studies and 222 CAA-associated TFNE cases were included from the initial 1612 records produced by the systematic search; 26 additional patients (11 men [42.3%]; mean [SD] age, 77 [8] years) were provided by the hospital-based cohort. A total of 108 TFNEs (43.5%) consisted of motor symptoms. Convexity subarachnoid hemorrhage and cortical superficial siderosis were detected in 193 individuals (77.8%) and 156 individuals (62.9%) in the systematic search and hospital-based cohort, respectively. Follow-up duration could be obtained in 185 patients (median duration, 1 year [IQR, 0.8-2.5 years]). During follow-up, symptomatic lobar ICH occurred in 76 patients (39.4%). Motor symptoms (odds ratio, 2.08 [95% CI, 1.16-3.70]) at baseline and antithrombotic use during follow-up (odds ratio, 3.61 [95% CI, 1.67-7.84]) were associated with an increase in risk of lobar ICH. A total of 31 patients (16.5%) died during follow-up; lobar ICH during follow-up and cortical superficial siderosis were the main risk factors for death (odds ratio, 3.01 [95% CI, 1.36-6.69]; odds ratio, 3.20 [95% CI, 1.16-8.91], respectively). Conclusions and Relevance Patients presenting with CAA-associated TFNEs are at high risk of lobar ICH and death. Motor TFNEs and use of antithrombotics after a TFNE, in many cases because of misdiagnosis, are risk factors for ICH, and therefore accurate diagnosis and distinguishing this condition from transient ischemic attacks is critical.
Collapse
Affiliation(s)
- Juan María Sanchez-Caro
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Iñigo de Lorenzo Martínez de Ubago
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Elena de Celis Ruiz
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | | | - Lionel Calviere
- Neurology Department, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Nicolas Raposo
- Neurology Department, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Rafael Galiano Blancart
- Department of Neurology, Doctor Peset University Hospital, University of Valencia, Valencia, Spain
| | - Blanca Fuentes
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Exuperio Diez-Tejedor
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Jorge Rodriguez-Pardo
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| |
Collapse
|
48
|
Eilenberg W, Bechstein M, Charbonneau P, Rohlffs F, Eleshra A, Panuccio G, Bhangu JS, Fiehler J, Greenhalgh RM, Haulon S, Kölbel T. Cerebral microbleeds following thoracic endovascular aortic repair. Br J Surg 2021; 109:46-52. [PMID: 34694374 DOI: 10.1093/bjs/znab341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/27/2021] [Accepted: 08/29/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Stroke and neurological injury are a complication of thoracic endovascular aortic repair (TEVAR). Cerebral microbleeds (CMBs) are common in patients with white matter damage to the brain secondary to chronic vasculopathy. The aim of this study was to examine the occurrence of CMBs after TEVAR, and to evaluate their association with patient and procedural factors. METHODS Patients who underwent TEVAR between September 2018 and January 2020 in two specialist European aortic centres were analysed. All patients underwent postoperative susceptibility-weighted MRI. The location and number of CMBs were identified, and analysed with regard to procedural aspects, clinical outcome, and Fazekas score as an indicator of pre-existing vascular leucoencephalopathy. RESULTS Some 91 patients were included in the study. A total of 1531 CMBs were detected in 58 of 91 patients (64 per cent). In the majority of affected patients, CMBs were found bilaterally (79 per cent). Unilateral CMBs in the right or left hemisphere occurred in 16 and 5 per cent of patients respectively (P < 0.001). More CMBs were found in the middle cerebral than in the vertebrobasilar/posterior and anterior cerebral artery territories (mean(s.d.) 3.35(5.56) versus 2.26(4.05) versus 0.97(2.87); P = 0.045). Multivariable analysis showed an increased probability of CMBs after placement of TEVAR stent-grafts with a proximal diameter of at least 40 mm (odds ratio (OR) 6.85, 95 per cent c.i. 1.65 to 41.59; P = 0.007) and in patients with a higher Fazekas score on postoperative T2-weighted MRI (OR 2.62, 1.06 to 7.92; P = 0.037). CONCLUSION CMBs on postoperative MRI are common after endovascular repair in the aortic arch. Their occurrence appears to be associated with key aspects of the procedure and pre-existing vascular leucoencephalopathy.
Collapse
Affiliation(s)
- Wolf Eilenberg
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, Vienna, Austria
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Philippe Charbonneau
- Centre de l'Aorte, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
| | - Fiona Rohlffs
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ahmed Eleshra
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jagdeep Singh Bhangu
- Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, Vienna, Austria
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Stephan Haulon
- Centre de l'Aorte, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
| | - Tilo Kölbel
- German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
49
|
Mazzucco S, Li L, McGurgan IJ, Tuna MA, Brunelli N, Binney LE, Rothwell PM. Age-specific cerebral haemodynamic effects of early blood pressure lowering after transient ischaemic attack and non-disabling stroke. Eur Stroke J 2021; 6:245-253. [PMID: 34746420 PMCID: PMC8564162 DOI: 10.1177/23969873211039716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/15/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION There is limited knowledge of the effects of blood pressure (BP) lowering on cerebral haemodynamics after transient ischaemic attack (TIA) and non-disabling stroke, particularly at older ages. We aimed to evaluate changes in transcranial Doppler (TCD) haemodynamic indices in patients undergoing early blood pressure lowering after TIA/non-disabling stroke, irrespective of age. PATIENTS AND METHODS Among consecutive eligible patients attending a rapid-access clinic with suspected TIA/non-disabling stroke and no evidence of extra/intracranial stenosis, hypertensive ones underwent intensive BP-lowering guided by daily home telemetric blood pressure monitoring (HBPM). Clinic-based BP, HBPM, End-tidal CO2 and bilateral middle cerebral artery (MCA) velocity on TCD were compared in the acute setting versus one-month follow-up; changes were stratified by baseline hypertension (clinic-BP≥140/90) and by age (<65, 65-79 and ≥80). RESULTS In 697 patients with repeated TCD measures, mean/SD baseline systolic-BP (145.0/21.3 mmHg) was reduced by an average of 11.3/19.9 mmHg (p < 0.0001) at one-month (133.7/17.4 mmHg), driven by patients hypertensive at baseline (systolic-BP change = -19.0/19.2 mmHg, p < 0.001; vs -0.5/15.4, p = 0.62 in normotensives). Compared with baseline, a significant change was observed at one-month only in mean/SD MCA end diastolic velocity (EDV) (0.77/7.26 cm/s, p = 0.005) and in resistance index (RI) (-0.005/0.051, p = 0.016), driven by hypertensive patients (mean/SD EDV change: 1.145/6.96 cm/s p = 0.001, RI change -0.007/0.06, p = 0.014). Findings were similar at all ages (EDV change - ptrend=0.357; RI change - ptrend=0.225), including 117 patients aged ≥80. EDV and RI changes were largest in 100 patients with clinic systolic-BP decrease ≥30 mmHg (mean/SD EDV change = 2.49/7.47 cm/s, p = 0.001; RI change -0.024/0.063, p < 0.0001). CONCLUSION There was no evidence of worsening of TCD haemodynamic indices associated with BP-lowering soon after TIA/non-disabling stroke, irrespective of age and degree of BP reduction. In fact, EDV increase and RI decrease observed after treatment of hypertensive patients suggest a decrease in distal vascular resistance.
Collapse
Affiliation(s)
- Sara Mazzucco
- Nuffield Department of Clinical
Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford
| | - Linxin Li
- Nuffield Department of Clinical
Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford
| | - Iain J McGurgan
- Nuffield Department of Clinical
Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford
| | - Maria A Tuna
- Nuffield Department of Clinical
Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford
| | - Nicoletta Brunelli
- institution-id-type="Ringgold" />Campus Bio-Medico University of
Rome, Rome, Italy
| | - Lucy E Binney
- Nuffield Department of Clinical
Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford
| | - Peter M Rothwell
- Nuffield Department of Clinical
Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford
| | | |
Collapse
|
50
|
Duloquin G, Graber M, Baptiste L, Mohr S, Garnier L, Ndiaye M, Blanc-Labarre C, Hervieu-Bègue M, Osseby GV, Giroud M, Béjot Y. [Management of ischemic stroke in the acute phase]. Rev Med Interne 2021; 43:286-292. [PMID: 34481684 DOI: 10.1016/j.revmed.2021.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/01/2021] [Indexed: 12/24/2022]
Abstract
Ischemic stroke accounts for 80% of overall stroke, and is one of the leading causes of death, disability and dementia in worldwide. Management of patients with acute ischemic stroke dramatically improved over time with the implementation of intensive care stroke units, the development of acute recanalization strategies, the optimization of the management of post-stroke complications, and the prevention of early stroke recurrence. The objective of this article is to provide a general overview of the current management of patients with acute ischemic stroke aiming at improving post-stroke outcome.
Collapse
Affiliation(s)
- G Duloquin
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Graber
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - L Baptiste
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - S Mohr
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - L Garnier
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Ndiaye
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - C Blanc-Labarre
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Hervieu-Bègue
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - G-V Osseby
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Giroud
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - Y Béjot
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France.
| |
Collapse
|