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Lambert AT, Sætre DO, Ratajczak-Tretel B, Gleditsch J, Høie G, Al-Ani R, Pesonen M, Atar D, Aamodt AH. Imaging features for the identification of atrial fibrillation in cryptogenic stroke patients. J Neurol 2024; 271:5343-5356. [PMID: 38904781 PMCID: PMC11319500 DOI: 10.1007/s00415-024-12397-y] [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: 03/16/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Whether specific imaging aspects can be used to identify cryptogenic stroke (CS) patients with high risk of underlying atrial fibrillation (AF) remains unclear. The purpose of this study was to evaluate brain-imaging features in CS patients and their utility as AF predictors. METHODS The Nordic Atrial Fibrillation and Stroke study was a prospective observational study of CS and transient ischemic attack patients undergoing 12-month cardiac-rhythm monitoring, biomarker and clinical assessments. In this imaging sub-study, brain magnetic resonance imaging and computed tomography scans from 106 patients were assessed for acute and chronic ischemic lesions in relation to AF occurrence and included in a score to predict AF. Receiver operating characteristics (ROC) curve was used to evaluate the discriminative ability of the score and for its dichotomization for predictive model. RESULTS Age, periventricular white-matter hyperintensities (PVWMH), acute lesion size, and vessel occlusion were significantly associated with AF. Acute and chronic cortical infarcts as well as chronic cerebellar infarcts were numerically more frequent in the AF group than the non-AF group. A score consisting of six features (0-6 points) was proposed (age ≥ 65 years, chronic cortical or cerebellar lesions, acute cortical lesions, PVWMH ≥ 2 in Fazekas scale, vessel occlusion, and acute lesion size ≥ 10 mm). Area under ROC curve was 0.735 and a score of ≥ 3 points was a predictor of AF. CONCLUSIONS The suggested score was shown to identify CS patients with an increased risk of underlying AF.
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Affiliation(s)
- Anna Tancin Lambert
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Dag Ottar Sætre
- Dapartment of Radiology, Østfold Hospital Trust, Grålum, Norway
| | - Barbara Ratajczak-Tretel
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jostein Gleditsch
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Dapartment of Radiology, Østfold Hospital Trust, Grålum, Norway
| | - Gudrun Høie
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - Riadh Al-Ani
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - Maiju Pesonen
- Center for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Dan Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Anne Hege Aamodt
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway.
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Kalinin MN, Khasanova DR. Heterogeneous treatment effects of Cerebrolysin as an early add-on to reperfusion therapy: post hoc analysis of the CEREHETIS trial. Front Pharmacol 2024; 14:1288718. [PMID: 38249342 PMCID: PMC10796496 DOI: 10.3389/fphar.2023.1288718] [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: 09/11/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Background: There has been intensive research into enhancing the effects of reperfusion therapy to mitigate hemorrhagic transformation (HT) in stroke patients. Using neuroprotective agents alongside intravenous thrombolysis (IVT) appears a promising approach. Cerebrolysin is one of the candidates since it consists of neuropeptides mimicking the action of neurotrophic factors on brain protection and repair. Objectives: We looked at treatment effects of Cerebrolysin as an early add-on to IVT in stroke patients with varying HT risk. Methods: It was post hoc analysis of the CEREHETIS trial (ISRCTN87656744). Patients with middle cerebral artery infarction (n = 238) were selected from the intention-to-treat population. To stratify participants according to their HT risk, the DRAGON, SEDAN and HTI scores were computed for each eligible subject using on-admission data. The study endpoints were any and symptomatic HT, and functional outcome measured with the modified Rankin Scale (mRS) on day 90. Favorable functional outcome (FFO) was defined as an mRS ≤2. The performance of each stratification tool was estimated with regression approaches. Heterogeneous treatment effect analysis was conducted using techniques of meta-analysis and the matching-smoothing method. Results: The HTI score outperformed other tools in terms of HT risk stratification. Heterogeneity of Cerebrolysin treatment effects was moderate (I2, 35.8%-56.7%; H2, 1.56-2.31) and mild (I2, 10.9%; H2, 1.12) for symptomatic and any HT, respectively. A significant positive impact of Cerebrolysin on HT and functional outcome was observed in the moderate (HTI = 1) and high (HTI ≥2) HT risk patients, but it was neutral in those with the low (HTI = 0) risk. In particular, there was a steady decline in the rate of symptomatic (HTI = 0 vs. HTI = 4: by 4.3%, p = 0.077 vs. 21.1%, p < 0.001) and any HT (HTI = 0 vs. HTI = 4: by 1.2%, p = 0.737 vs. 32.7%, p < 0.001). Likewise, an mRS score reduction (HTI = 0 vs. HTI = 4: by 1.8%, p = 0.903 vs. 126%, p < 0.001) with a reciprocal increase of the fraction of FFO patients (HTI = 0 vs. HTI = 4: by 1.2% p = 0.757 vs. 35.5%, p < 0.001) was found. Conclusion: Clinically meaningful heterogeneity of Cerebrolysin treatment effects on HT and functional outcome was established in stroke patients. The beneficial effects were significant in those whose estimated on-admission HT risk was either moderate or high.
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Affiliation(s)
- Mikhail N. Kalinin
- Department of Neurology, Kazan State Medical University, Kazan, Russia
- Department of Neurology, Interregional Clinical Diagnostic Center, Kazan, Russia
| | - Dina R. Khasanova
- Department of Neurology, Kazan State Medical University, Kazan, Russia
- Department of Neurology, Interregional Clinical Diagnostic Center, Kazan, Russia
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Kalinin MN, Khasanova DR. [Cerebrolysin as an early add-on to reperfusion therapy: heterogeneous treatment effect analysis in ischemic stroke patients with varying risk of hemorrhagic transformation]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:55-66. [PMID: 38512096 DOI: 10.17116/jnevro202412403255] [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] [Indexed: 03/22/2024]
Abstract
OBJECTIVE The study goal was the assessment of heterogeneous treatment effects of Cerebrolysin as an early add-on to reperfusion therapy in stroke patients with varying risk of hemorrhagic transformation (HT). MATERIAL AND METHODS It was post hoc analysis of the CEREHETIS trial (ISRCTN87656744). Patients with middle cerebral artery infarction (n=238) were stratified by HT risk with the HTI score. The study outcomes were symptomatic and any HT, and functional outcome measured with the modified Rankin Scale (mRS) on day 90. Favorable outcome was defined as an mRS score of ≤2. Heterogeneous treatment effect analysis was performed using techniques of meta-analysis and the matching-smoothing method. RESULTS Heterogeneity of Cerebrolysin treatment effects was moderate (I2=36.98-69.3%, H2=1.59-3.26) and mild (I2=18.33-32.39%, H2=1.22-1.48) for symptomatic and any HT, respectively. A positive impact of the Cerebrolysin treatment on HT and functional outcome was observed in patients with moderate (HTI=1) and high (HTI≥2) HT risk. However, the effect was neutral in those with low risk (HTI=0). In high HT risk patients, there was a steady decline in the rate of symptomatic (HTI=0 vs. HTI≥2: by 3.8%, p=0.120 vs. 14.3%, p<0.001) and any HT (HTI=0 vs. HTI≥2: by 0.6%, p=0.864 vs. 19.5%, p<0.001). Likewise, Cerebrolysin treatment resulted in an overall decrease in the mRS scores (HTI=0 vs. HTI≥2: by 2.1%, p=0.893 vs. 63%, p<0.001) with a reciprocal increase of the fraction with favorable outcome (HTI=0 vs. HTI≥2: by 2% p=0.634 vs. 19.2%, p<0.001). CONCLUSION Clinically meaningful heterogeneity of Cerebrolysin treatment effects on HT and functional outcome was established in stroke patients. The Cerebrolysin positive impact was significant in those whose estimated on-admission HT risk was either moderate or high.
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Affiliation(s)
- M N Kalinin
- Kazan State Medical University, Kazan, Russia
- Interregional Clinical Diagnostic Center, Kazan, Russia
| | - D R Khasanova
- Kazan State Medical University, Kazan, Russia
- Interregional Clinical Diagnostic Center, Kazan, Russia
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Grifoni E, Bini C, Signorini I, Cosentino E, Micheletti I, Dei A, Pinto G, Madonia EM, Sivieri I, Mannini M, Baldini M, Bertini E, Giannoni S, Bartolozzi ML, Guidi L, Bartalucci P, Vanni S, Segneri A, Pratesi A, Giordano A, Dainelli F, Maggi F, Romagnoli M, Cioni E, Cioffi E, Pelagalli G, Mattaliano C, Schipani E, Murgida GS, Di Martino S, Sisti E, Cozzi A, Francolini V, Masotti L. Predictive Factors for Hemorrhagic Transformation in Acute Ischemic Stroke in the REAL-World Clinical Practice. Neurologist 2023; 28:150-156. [PMID: 36044909 DOI: 10.1097/nrl.0000000000000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few data exists on predictive factors of hemorrhagic transformation (HT) in real-world acute ischemic stroke patients. The aims of this study were: (i) to identify predictive variables of HT (ii) to develop a score for predicting HT. METHODS We retrospectively analyzed the clinical, radiographic, and laboratory data of patients with acute ischemic stroke consecutively admitted to our Stroke Unit along two years. Patients with HT were compared with those without HT. A multivariate logistic regression analysis was performed to identify independent predictors of HT on CT scan at 24 hours to develop a practical score. RESULTS The study population consisted of 564 patients with mean age 77.5±11.8 years. Fifty-two patients (9.2%) showed HT on brain CT at 24 hours (4.9% symptomatic). NIHSS score ≥8 at Stroke Unit admission (3 points), cardioembolic etiology (2 points), acute revascularization by systemic thrombolysis and/or mechanical thrombectomy (1 point), history of previous TIA/stroke (1 point), and major vessel occlusion (1 point) were found independent risk factors of HT and were included in the score (Hemorrhagic Transformation Empoli score (HTE)). The predictive power of HTE score was good with an AUC of 0.785 (95% CI: 0.749-0.818). Compared with 5 HT predictive scores proposed in the literature (THRIVE, SPAN-100, MSS, GRASPS, SITS-SIC), the HTE score significantly better predicted HT. CONCLUSIONS NIHSS score ≥8 at Stroke Unit admission, cardioembolism, urgent revascularization, previous TIA/stroke, and major vessel occlusion were independent predictors of HT. The HTE score has a good predictive power for HT. Prospective studies are warranted.
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Bhatia K, Ladd LM, Carr KH, Di Napoli M, Saver JL, McCullough LD, Hosseini Farahabadi M, Alsbrook DL, Hinduja A, Ortiz Garcia JG, Sabbagh SY, Jafarli A, Divani AA. Contemporary Antiplatelet and Anticoagulant Therapies for Secondary Stroke Prevention: A Narrative Review of Current Literature and Guidelines. Curr Neurol Neurosci Rep 2023; 23:235-262. [PMID: 37037980 DOI: 10.1007/s11910-023-01266-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE OF REVIEW Stroke is a leading cause of death and disability worldwide. The annual incidence of new or recurrent stroke is approximately 795,000 cases per year in the United States, of which 87% are ischemic in nature. In addition to the management of modifiable high-risk factors to reduce the risk of recurrent stroke, antithrombotic agents (antiplatelets and anticoagulants) play an important role in secondary stroke prevention. This review will discuss the published literature on the use of antiplatelets and anticoagulants in secondary prevention of acute ischemic stroke and transient ischemic attack (TIA), including their pharmacology, efficacy, and adverse effects. We will also highlight the role of dual antiplatelet therapy (DAPT) in secondary stroke prevention, along with supporting literature. RECENT FINDINGS Single antiplatelet therapy (SAPT) with aspirin or clopidogrel reduces the risk of recurrent ischemic stroke in patients with non-cardioembolic ischemic stroke or TIA. However, as shown in recent trials, short-term DAPT with aspirin and clopidogrel or ticagrelor for 21-30 days is more effective than SAPT in patients with minor acute non-cardioembolic stroke or high-risk TIA. Although short-term DAPT is highly effective in preventing recurrent stroke, a more prolonged course can increase bleeding risks without additional benefit. DAPT for 90 days, followed by aspirin monotherapy for patients with large vessel intracranial atherosclerotic disease, is suitable for secondary stroke prevention. However, patients need to be monitored for both minor (e.g., bruising) and major (e.g., intracranial) bleeding complications. Conversely, oral warfarin and newer direct oral anticoagulant (DOACs) such as dabigatran, rivaroxaban, apixaban, and edoxaban are the agents of choice for secondary stroke prevention in patients with non-valvular cardioembolic strokes. DOACs may be preferred over warfarin due to decreased bleeding risks, including ICH, lack of need for international normalized ratio monitoring, no dietary restrictions, and limited drug-drug interactions. The choice between different antiplatelets and anticoagulants for prevention of ischemic stroke depends on the underlying stroke mechanism, cytochrome P450 2C19 polymorphisms, bleeding risk profile, compliance, drug tolerance, and drug resistance. Physicians must carefully weigh each patient's relative benefits and bleeding risks before initiating an antiplatelet/anticoagulant treatment regimen. Further studies are warranted to study the optimal duration of DAPT in symptomatic intracranial atherosclerosis since the benefit is most pronounced in the short term while the bleeding risk remains high during the extended duration of therapy.
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Affiliation(s)
- Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lindsey M Ladd
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kelsey H Carr
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L'Aquila, Italy
| | - Jeffrey L Saver
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Louise D McCullough
- Department of Neurology, McGovern Medical School, University of Texas Health Sciences Center, Houston, TX, USA
| | | | - Diana L Alsbrook
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jorge G Ortiz Garcia
- Department of Neurology, the University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sara Y Sabbagh
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Alibay Jafarli
- Department of Neurology, Tufts Medical Center, Boston, MA, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA.
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Elsaid N, Bigliardi G, Dell'Acqua ML, Vandelli L, Ciolli L, Picchetto L, Borzì G, Ricceri R, Pentore R, Vallone S, Meletti S, Saied A. Proposal of multimodal computed tomography-based scoring system in prediction of hemorrhagic transformation in acute ischemic stroke. Acta Neurol Belg 2023:10.1007/s13760-023-02239-5. [PMID: 37029844 DOI: 10.1007/s13760-023-02239-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/10/2023] [Indexed: 04/09/2023]
Abstract
INTRODUCTION The routinely used computed tomography (CT)-based workup in the setting of acute ischemic stroke (AIS) includes non-contrast brain CT, CT angiography (CTA), and CT perfusion. Several CT, CTA, CTP-based radiological biomarkers of hemorrhagic transformation (HT) were reported. AIM OF THE STUDY To assess the predictive value of the combined multimodal CT parameters for HT after AIS and proposal of predictive scoring scale. METHODS The source images of the NCCT, CTA and CTP of 282 AIS patients involving the anterior circulation (HT = 91, non-HT = 191) were retrospectively reviewed and the following biomarkers were recorded and analyzed: Early subtle ischemic signs, hyperdense middle cerebral artery sign (HMCAS) and Alberta Stroke Program Early CT Score (ASPECTS) < 7 in NCCT, large-vessel occlusion (LVO), clot burden score (CBS) < 6, large-vessel occlusion, poor collateral score (CS) and Tmax > 6 s ≥ 56.5 ml. A scoring system to predict HT based on these biomarkers was developed. Each biomarker counts for a single point with the total score ranging from 0 to 7. RESULTS All the aforementioned multimodal CT biomarkers and the selected cut offs were significantly associated with higher HT risk. The calculated scores were statistically significant different between the HT and the non-HT groups with AUC 0.761 (95% CI 0.703-0.819, P < 0.0000001). Rates of HT were approximately five times higher in patients with score ≥ 3. CONCLUSION Multimodal CT-based scoring system may provide highly reliable predictive model of hemorrhagic transformation in acute ischemic stroke.
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Affiliation(s)
- Nada Elsaid
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy.
- Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - Guido Bigliardi
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Maria Luisa Dell'Acqua
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Laura Vandelli
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Ludovico Ciolli
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Livio Picchetto
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Giuseppe Borzì
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Riccardo Ricceri
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Roberta Pentore
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Stefano Vallone
- Neuroradiology, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Stefano Meletti
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - Ahmed Saied
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
- Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Ren H, Song H, Wang J, Xiong H, Long B, Gong M, Liu J, He Z, Liu L, Jiang X, Li L, Li H, Cui S, Li Y. A clinical-radiomics model based on noncontrast computed tomography to predict hemorrhagic transformation after stroke by machine learning: a multicenter study. Insights Imaging 2023; 14:52. [PMID: 36977913 PMCID: PMC10050271 DOI: 10.1186/s13244-023-01399-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/08/2023] [Indexed: 03/30/2023] Open
Abstract
OBJECTIVE To build a clinical-radiomics model based on noncontrast computed tomography images to identify the risk of hemorrhagic transformation (HT) in patients with acute ischemic stroke (AIS) following intravenous thrombolysis (IVT). MATERIALS AND METHODS A total of 517 consecutive patients with AIS were screened for inclusion. Datasets from six hospitals were randomly divided into a training cohort and an internal cohort with an 8:2 ratio. The dataset of the seventh hospital was used for an independent external verification. The best dimensionality reduction method to choose features and the best machine learning (ML) algorithm to develop a model were selected. Then, the clinical, radiomics and clinical-radiomics models were developed. Finally, the performance of the models was measured using the area under the receiver operating characteristic curve (AUC). RESULTS Of 517 from seven hospitals, 249 (48%) had HT. The best method for choosing features was recursive feature elimination, and the best ML algorithm to build models was extreme gradient boosting. In distinguishing patients with HT, the AUC of the clinical model was 0.898 (95% CI 0.873-0.921) in the internal validation cohort, and 0.911 (95% CI 0.891-0.928) in the external validation cohort; the AUC of radiomics model was 0.922 (95% CI 0.896-0.941) and 0.883 (95% CI 0.851-0.902), while the AUC of clinical-radiomics model was 0.950 (95% CI 0.925-0.967) and 0.942 (95% CI 0.927-0.958) respectively. CONCLUSION The proposed clinical-radiomics model is a dependable approach that could provide risk assessment of HT for patients who receive IVT after stroke.
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Affiliation(s)
- Huanhuan Ren
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Haojie Song
- College of Computer and Information Science, Chongqing Normal University, No. 37, Middle University Town Road, Shapingba District, Chongqing, 400016, China
| | - Jingjie Wang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Hua Xiong
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Bangyuan Long
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Meilin Gong
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Jiayang Liu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Zhanping He
- Department of Radiology, Haikou Affiliated Hospital of Central South University Xiangya School of Medicine, Haikou, China
| | - Li Liu
- Department of Radiology, People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Xili Jiang
- Department of Radiology, The Second People's Hospital of Hunan Province/Brain Hospital of Hunan Province, Changsha, China
| | - Lifeng Li
- Department of Radiology, Changsha Central Hospital (The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China), Changsha, China
| | - Hanjian Li
- Department of Radiology, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Shaoguo Cui
- College of Computer and Information Science, Chongqing Normal University, No. 37, Middle University Town Road, Shapingba District, Chongqing, 400016, China.
| | - Yongmei Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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Khasanova DR, Kalinin MN. Cerebrolysin as an Early Add-on to Reperfusion Therapy: Risk of Hemorrhagic Transformation after Ischemic Stroke (CEREHETIS), a prospective, randomized, multicenter pilot study. BMC Neurol 2023; 23:121. [PMID: 36973684 PMCID: PMC10041692 DOI: 10.1186/s12883-023-03159-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 03/13/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Cerebrolysin could mitigate reperfusion injury and hemorrhagic transformation (HT) in animal models of acute ischemic stroke. METHODS This was a prospective, randomized, open-label, parallel-group with active control, multicenter pilot study. Cerebrolysin (30 mL/day over 14 days) was administered concurrently with alteplase (0.9 mg/kg) in 126 patients, whereas 215 control patients received alteplase alone. The primary outcomes were the rate of any and symptomatic HT assessed from day 0 to 14. The secondary endpoints were drug safety and functional outcome measured with the National Institutes of Health Stroke Scale (NIHSS) on day 1 and 14, and the modified Rankin scale (mRS) on day 90. Advanced brain imaging analysis was applied on day 1 and 14 as a marker for in vivo pharmacology of Cerebrolysin. RESULTS Cerebrolysin treatment resulted in a substantial decrease of the symptomatic HT rate with an odds ratio (OR) of 0.248 (95% CI: 0.072-0.851; p = 0.019). No serious adverse events attributed to Cerebrolysin occurred. On day 14, the Cerebrolysin arm showed a significant decrease in the NIHSS score (p = 0.045). However, no difference in the mRS score was observed on day 90. A substantial improvement in the advanced brain imaging parameters of the infarcted area was evident in the Cerebrolysin group on day 14. CONCLUSIONS Early add-on of Cerebrolysin to reperfusion therapy was safe and significantly decreased the rate of symptomatic HT as well as early neurological deficit. No effect on day 90 functional outcome was detected. Improvements in the imaging metrics support the neuroprotective and blood-brain barrier stabilizing activity of Cerebrolysin. TRIAL REGISTRATION Name of Registry: ISRCTN. TRIAL REGISTRATION NUMBER ISRCTN87656744 . Trial Registration Date: 16/02/2021.
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Affiliation(s)
- Dina R Khasanova
- Department of Neurology and Neurosurgery for Postgraduate Training, Kazan State Medical University, Kazan, Russia
- Department of Neurology, Interregional Clinical Diagnostic Center, 12A Karbyshev St, Kazan, 420101, Russia
| | - Mikhail N Kalinin
- Department of Neurology and Neurosurgery for Postgraduate Training, Kazan State Medical University, Kazan, Russia.
- Department of Neurology, Interregional Clinical Diagnostic Center, 12A Karbyshev St, Kazan, 420101, Russia.
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van der Ende NA, Kremers FC, van der Steen W, Venema E, Kappelhof M, Majoie CB, Postma AA, Boiten J, van den Wijngaard IR, van der Lugt A, Dippel DW, Roozenbeek B. Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: External Validation of Prediction Models. Stroke 2023; 54:476-487. [PMID: 36689584 PMCID: PMC9855739 DOI: 10.1161/strokeaha.122.040065] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 12/09/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Symptomatic intracranial hemorrhage (sICH) is a severe complication of reperfusion therapy for ischemic stroke. Multiple models have been developed to predict sICH or intracranial hemorrhage (ICH) after reperfusion therapy. We provide an overview of published models and validate their ability to predict sICH in patients treated with endovascular treatment in daily clinical practice. METHODS We conducted a systematic search to identify models either developed or validated to predict sICH or ICH after reperfusion therapy (intravenous thrombolysis and/or endovascular treatment) for ischemic stroke. Models were externally validated in the MR CLEAN Registry (n=3180; Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands). The primary outcome was sICH according to the Heidelberg Bleeding Classification. Model performance was evaluated with discrimination (c-statistic, ideally 1; a c-statistic below 0.7 is considered poor in discrimination) and calibration (slope, ideally 1, and intercept, ideally 0). RESULTS We included 39 studies describing 40 models. The most frequently used predictors were baseline National Institutes of Health Stroke Scale (NIHSS; n=35), age (n=22), and glucose level (n=22). In the MR CLEAN Registry, sICH occurred in 188/3180 (5.9%) patients. Discrimination ranged from 0.51 (SPAN-100 [Stroke Prognostication Using Age and National Institutes of Health Stroke Scale]) to 0.61 (SITS-SICH [Safe Implementation of Treatments in Stroke Symptomatic Intracerebral Hemorrhage] and STARTING-SICH [STARTING Symptomatic Intracerebral Hemorrhage]). Best calibrated models were IST-3 (intercept, -0.15 [95% CI, -0.01 to -0.31]; slope, 0.80 [95% CI, 0.50-1.09]), SITS-SICH (intercept, 0.15 [95% CI, -0.01 to 0.30]; slope, 0.62 [95% CI, 0.38-0.87]), and STARTING-SICH (intercept, -0.03 [95% CI, -0.19 to 0.12]; slope, 0.56 [95% CI, 0.35-0.76]). CONCLUSIONS The investigated models to predict sICH or ICH discriminate poorly between patients with a low and high risk of sICH after endovascular treatment in daily clinical practice and are, therefore, not clinically useful for this patient population.
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Affiliation(s)
- Nadinda A.M. van der Ende
- Departments of Neurology (N.A.M.v.d.E, F.C.C.K., W.v.d.S, E.V., D.W.J.D., B.R.), Erasmus MC University Medical Center, the Netherlands
- Radiology and Nuclear Medicine (N.A.M.v.d.Ee, W.v.d.S., B.R.), Erasmus MC University Medical Center, the Netherlands
| | - Femke C.C. Kremers
- Departments of Neurology (N.A.M.v.d.E, F.C.C.K., W.v.d.S, E.V., D.W.J.D., B.R.), Erasmus MC University Medical Center, the Netherlands
| | - Wouter van der Steen
- Departments of Neurology (N.A.M.v.d.E, F.C.C.K., W.v.d.S, E.V., D.W.J.D., B.R.), Erasmus MC University Medical Center, the Netherlands
- Radiology and Nuclear Medicine (N.A.M.v.d.Ee, W.v.d.S., B.R.), Erasmus MC University Medical Center, the Netherlands
| | - Esmee Venema
- Departments of Neurology (N.A.M.v.d.E, F.C.C.K., W.v.d.S, E.V., D.W.J.D., B.R.), Erasmus MC University Medical Center, the Netherlands
- Emergency Medicine (E.V.), Erasmus MC University Medical Center, the Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine (M.K.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Charles B.L.M. Majoie
- Departments of Neurology (N.A.M.v.d.E, F.C.C.K., W.v.d.S, E.V., D.W.J.D., B.R.), Erasmus MC University Medical Center, the Netherlands
- Radiology and Nuclear Medicine (N.A.M.v.d.Ee, W.v.d.S., B.R.), Erasmus MC University Medical Center, the Netherlands
- Emergency Medicine (E.V.), Erasmus MC University Medical Center, the Netherlands
- Department of Radiology and Nuclear Medicine (M.K.), Amsterdam UMC, University of Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, School for Mental Health and Sciences, Maastricht University Medical Center, the Netherlands (A.A.P.)
- Departments of Neurology (J.B., I.R.v.d.W.), Haaglanden Medical Center, the Netherlands
- Radiology and Nuclear Medicine (I.R.v.d.W.), Haaglanden Medical Center, the Netherlands
| | - Alida A. Postma
- Department of Radiology and Nuclear Medicine, School for Mental Health and Sciences, Maastricht University Medical Center, the Netherlands (A.A.P.)
| | - Jelis Boiten
- Departments of Neurology (J.B., I.R.v.d.W.), Haaglanden Medical Center, the Netherlands
| | - Ido R. van den Wijngaard
- Departments of Neurology (J.B., I.R.v.d.W.), Haaglanden Medical Center, the Netherlands
- Radiology and Nuclear Medicine (I.R.v.d.W.), Haaglanden Medical Center, the Netherlands
| | - Aad van der Lugt
- Departments of Neurology (N.A.M.v.d.E, F.C.C.K., W.v.d.S, E.V., D.W.J.D., B.R.), Erasmus MC University Medical Center, the Netherlands
- Radiology and Nuclear Medicine (N.A.M.v.d.Ee, W.v.d.S., B.R.), Erasmus MC University Medical Center, the Netherlands
- Emergency Medicine (E.V.), Erasmus MC University Medical Center, the Netherlands
- Department of Radiology and Nuclear Medicine (M.K.), Amsterdam UMC, University of Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, School for Mental Health and Sciences, Maastricht University Medical Center, the Netherlands (A.A.P.)
- Departments of Neurology (J.B., I.R.v.d.W.), Haaglanden Medical Center, the Netherlands
- Radiology and Nuclear Medicine (I.R.v.d.W.), Haaglanden Medical Center, the Netherlands
| | - Diederik W.J. Dippel
- Departments of Neurology (N.A.M.v.d.E, F.C.C.K., W.v.d.S, E.V., D.W.J.D., B.R.), Erasmus MC University Medical Center, the Netherlands
| | - Bob Roozenbeek
- Departments of Neurology (N.A.M.v.d.E, F.C.C.K., W.v.d.S, E.V., D.W.J.D., B.R.), Erasmus MC University Medical Center, the Netherlands
- Radiology and Nuclear Medicine (N.A.M.v.d.Ee, W.v.d.S., B.R.), Erasmus MC University Medical Center, the Netherlands
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10
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Predictive Value of CT Perfusion in Hemorrhagic Transformation after Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Brain Sci 2023; 13:brainsci13010156. [PMID: 36672136 PMCID: PMC9856940 DOI: 10.3390/brainsci13010156] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/02/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Background: Existing studies indicate that some computed tomography perfusion (CTP) parameters may predict hemorrhagic transformation (HT) after acute ischemic stroke (AIS), but there is an inconsistency in the conclusions alongside a lack of comprehensive comparison. Objective: To comprehensively evaluate the predictive value of CTP parameters in HT after AIS. Data sources: A systematical literature review of existing studies was conducted up to 1st October 2022 in six mainstream databases that included original data on the CTP parameters of HT and non-HT groups or on the diagnostic performance of relative cerebral blood flow (rCBF), relative permeability-surface area product (rPS), or relative cerebral blood volume (rCBV) in patients with AIS that completed CTP within 24 h of onset. Data Synthesis: Eighteen observational studies were included. HT and non-HT groups had statistically significant differences in CBF, CBV, PS, rCBF, rCBV, and rPS (p < 0.05 for all). The hierarchical summary receiver operating characteristic (HSROC) revealed that rCBF (area under the curve (AUC) = 0.9), rPS (AUC = 0.89), and rCBV (AUC = 0.85) had moderate diagnostic performances in predicting HT. The pooled sensitivity and specificity of rCBF were 0.85 (95% CI, 0.75−0.91) and 0.83 (95% CI, 0.63−0.94), respectively. Conclusions: rCBF, rPS, and rCBV had moderate diagnostic performances in predicting HT, and rCBF had the best pooled sensitivity and specificity.
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11
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Khasanova DR, Kalinin MN. [Effects of simultaneous use of Cerebrolysin and alteplase on hemorrhagic transformation of brain infarction and functional outcome in stroke patients: CEREHETIS, a randomized, multicenter pilot trial]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:60-69. [PMID: 37682097 DOI: 10.17116/jnevro202312308260] [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] [Indexed: 09/09/2023]
Abstract
OBJECTIVE The study aimed to assess effects of the simultaneous use of Cerebrolysin and intravenous thrombolysis (Alteplase) on hemorrhagic transformation (HT) and functional outcome as well as to analyze the treatment safety in acute stroke patients. MATERIAL AND METHODS It was a prospective, randomized, open-label, multicenter, parallel-group, active-controlled pilot study (Trial Registration Number: ISRCTN87656744, https://doi.org/10.1186/ISRCTN87656744, Trial registration date: 16/02/2021). The intervention group (n=126) was treated with Cerebrolysin infusion (30 mL) started simultaneously with Alteplase (0.9 mg/kg) via a separate IV line. The Cerebrolysin treatment continued for 14 consecutive days with the baseline therapy along. The control group (n=215) received only Alteplase and the baseline therapy. The primary endpoints were the rate of any and symptomatic hemorrhagic transformation (HT) from admission to day 14. Secondary endpoints were treatment safety and functional outcome measured with the National Institutes of Health stroke scale (NIHSS) in 24 h and on day 14, and with the modified Rankin scale (mRS) on day 90. RESULTS Treatment with Cerebrolysin resulted in a significant reduction of the symptomatic HT rate with an odds ratio of 0.248 (95% CI: 0.072-0.851; p=0.019). No serious adverse events related to Cerebrolysin were observed. On day 14, the intervention group showed a significant reduction in the NIHSS score (p=0.045). However, no difference in the mRS score was observed on day 90, but there was a trend towards its improvement. CONCLUSION The combination of Cerebrolysin and Alteplase was safe and significantly reduced the rate of symptomatic HT and improved early neurological deficit. However, no difference in functional outcome was found on day 90, but there was a trend towards favorable functional outcome.
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Affiliation(s)
- D R Khasanova
- Kazan State Medical University, Kazan, Russia
- Interregional Clinical Diagnostic Center, Kazan, Russia
| | - M N Kalinin
- Kazan State Medical University, Kazan, Russia
- Interregional Clinical Diagnostic Center, Kazan, Russia
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12
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Elsaid AF, Fahmi RM, Shehta N, Ramadan BM. Machine learning approach for hemorrhagic transformation prediction: Capturing predictors' interaction. Front Neurol 2022; 13:951401. [PMID: 36504664 PMCID: PMC9731336 DOI: 10.3389/fneur.2022.951401] [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: 05/24/2022] [Accepted: 10/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background and purpose Patients with ischemic stroke frequently develop hemorrhagic transformation (HT), which could potentially worsen the prognosis. The objectives of the current study were to determine the incidence and predictors of HT, to evaluate predictor interaction, and to identify the optimal predicting models. Methods A prospective study included 360 patients with ischemic stroke, of whom 354 successfully continued the study. Patients were subjected to thorough general and neurological examination and T2 diffusion-weighted MRI, at admission and 1 week later to determine the incidence of HT. HT predictors were selected by a filter-based minimum redundancy maximum relevance (mRMR) algorithm independent of model performance. Several machine learning algorithms including multivariable logistic regression classifier (LRC), support vector classifier (SVC), random forest classifier (RFC), gradient boosting classifier (GBC), and multilayer perceptron classifier (MLPC) were optimized for HT prediction in a randomly selected half of the sample (training set) and tested in the other half of the sample (testing set). The model predictive performance was evaluated using receiver operator characteristic (ROC) and visualized by observing case distribution relative to the models' predicted three-dimensional (3D) hypothesis spaces within the testing dataset true feature space. The interaction between predictors was investigated using generalized additive modeling (GAM). Results The incidence of HT in patients with ischemic stroke was 19.8%. Infarction size, cerebral microbleeds (CMB), and the National Institute of Health stroke scale (NIHSS) were identified as the best HT predictors. RFC (AUC: 0.91, 95% CI: 0.85-0.95) and GBC (AUC: 0.91, 95% CI: 0.86-0.95) demonstrated significantly superior performance compared to LRC (AUC: 0.85, 95% CI: 0.79-0.91) and MLPC (AUC: 0.85, 95% CI: 0.78-0.92). SVC (AUC: 0.90, 95% CI: 0.85-0.94) outperformed LRC and MLPC but did not reach statistical significance. LRC and MLPC did not show significant differences. The best models' 3D hypothesis spaces demonstrated non-linear decision boundaries suggesting an interaction between predictor variables. GAM analysis demonstrated a linear and non-linear significant interaction between NIHSS and CMB and between NIHSS and infarction size, respectively. Conclusion Cerebral microbleeds, NIHSS, and infarction size were identified as HT predictors. The best predicting models were RFC and GBC capable of capturing nonlinear interaction between predictors. Predictor interaction suggests a dynamic, rather than, fixed cutoff risk value for any of these predictors.
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Affiliation(s)
- Ahmed F. Elsaid
- Department of Public Health and Community Medicine, Zagazig University, Zagazig, Egypt,*Correspondence: Ahmed F. Elsaid ;
| | - Rasha M. Fahmi
- Neurology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Nahed Shehta
- Neurology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Bothina M. Ramadan
- Neurology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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13
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de Andrade JBC, Mohr JP, Costa FFM, Malheiros JEF, Ikeda RK, Barros LCM, Lima FO, Pontes-Neto OM, Merida KLB, Franciscato L, Marques MS, Silva GS. Predicting hemorrhagic transformation in posterior circulation stroke patients not treated with reperfusion therapies. J Clin Neurosci 2022; 103:78-84. [PMID: 35843184 DOI: 10.1016/j.jocn.2022.07.008] [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: 05/09/2022] [Revised: 07/02/2022] [Accepted: 07/09/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Posterior Circulation (PC) stroke represents one-fifth of all ischemic strokes, with peculiar physiological characteristics. Hemorrhagic Transformation (HT) is a dreaded complication among stroke patients. Many predictive scores of this complication have been proposed, but none is designed specifically for PC stroke patients - therefore, patients who are not eligible for reperfusion therapies (RT) represent about 80% of hospitalized cases. We propose a scoring system to assess the HT risk in PC stroke patients not submitted to RT. METHODS We retrospectively evaluated data of patients diagnosed with PC stroke not treated with RT from 5 Comprehensive Stroke Centers (four in Brazil, 1 in the US) from 2015 to 2018. All patients underwent CT scan or MRI at admission and a follow-up neuroimaging within seven days. Independent variables identified in a logistic regression analysis were used to produce a predictive grading score. RESULTS We included 952 patients in the final analysis. The overall incidence of HT was 8.7%. Male gender (1 point), NIH Stroke Scale at admission ≥ 5 points (1), blood glucose at admission ≥ 160 mg/dL (1), and cardioembolism (2) were independently associated with HT. The AUC of the grading score (0 to 5 points) was 0.713 (95% CI 0.65-0.78). Subjects with a score ≥ 3 points had an OR of 4.8 (95% CI 2.9-7.9, p < 0.001) for HT. CONCLUSIONS Our score has good accuracy in identifying patients at higher risk of HT. This score may be useful for evaluating secondary prevention and stratifying patients in the context of even clinical trials.
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Affiliation(s)
- Joao Brainer Clares de Andrade
- Universidade Federal de São Paulo, Sao Paulo, Brazil; Columbia University, Doris and Stanley Tananbaum Stroke Center, USA; Centro Universitario São Camilo, São Paulo, Brazil.
| | - Jay P Mohr
- Columbia University, Doris and Stanley Tananbaum Stroke Center, USA
| | | | | | | | | | | | | | | | | | | | - Gisele Sampaio Silva
- Universidade Federal de São Paulo, Sao Paulo, Brazil; Hospital Israelita Brasileiro Albert Einstein, São Paulo, Brazil
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14
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Brainer Clares de Andrade J, Mohr JP, Oliveira Lima F, José de Freitas Carvalho J, Andre Castro de Oliveira R, Coelho Maia Barros L, Sampaio Silva G. Predictors of hemorrhagic transformation differences between patients treated or not with reperfusion therapy. J Clin Neurosci 2022; 101:9-15. [DOI: 10.1016/j.jocn.2022.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 02/08/2022] [Accepted: 04/23/2022] [Indexed: 11/25/2022]
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15
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Best JG, Cardus B, Klijn CJM, Lip G, Seiffge DJ, Smith EE, Werring DJ. Antithrombotic dilemmas in stroke medicine: new data, unsolved challenges. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2020-325249. [PMID: 35728935 DOI: 10.1136/jnnp-2020-325249] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 05/16/2022] [Indexed: 11/04/2022]
Abstract
Antithrombotic therapy is a key element of secondary prevention in patients who have had an ischaemic stroke or transient ischaemic attack. However, its use in clinical practice is not always straightforward. This review provides an update on certain difficult scenarios in antithrombotic management, with a focus on recent clinical trials and large observational studies. We discuss the approach to patients with an indication for antithrombotic treatment who also have clinical or radiological evidence of previous intracranial bleeding, patients with indications for both anticoagulant and antiplatelet treatment, and patients in whom antithrombotic treatment fails to prevent stroke. We also review the timing of anticoagulation initiation after cardioembolic stroke, and the use of antithrombotics in patients with asymptomatic cerebrovascular disease. Despite a wealth of new evidence, numerous uncertainties remain and we highlight ongoing trials addressing these.
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Affiliation(s)
- Jonathan G Best
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Beatrix Cardus
- Royal Surrey County Hospital, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Catharina J M Klijn
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Gregory Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital, Bern, Switzerland
| | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
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16
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Andrade JBCD, Mohr JP, Ahmad M, Lima FO, Barros LCM, Silva GS. Accuracy of predictive scores of hemorrhagic transformation in patients with acute ischemic stroke. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:455-461. [PMID: 35293556 DOI: 10.1590/0004-282x-anp-2021-0091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/07/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hemorrhagic transformation (HT) is a complication in ischemic strokes, regardless of use of reperfusion therapy (RT). There are many predictive scores for estimating the risk of HT. However, most of them include patients also treated with RT. Therefore, this may lead to a misinterpretation of the risk of HT in patients who did not undergo RT. OBJECTIVE We aimed to review published predictive scores and analyze their accuracy in our dataset. METHODS We analyzed the accuracy of seven scales. Our dataset was derived from a cohort of 1,565 consecutive patients from 2015 to 2017 who were admitted to a comprehensive stroke center. All patients were evaluated with follow-up neuroimaging within seven days. Comparison of area under the curve (AUC) was performed on each scale, to analyze differences between patients treated with recombinant tissue plasminogen activator (tPA) and those without this treatment. RESULTS Our dataset provided enough data to assess seven scales, among which six were used among patients with and without tPA treatment. HAT (AUC 0.76), HTI (0.73) and SEDAN (0.70) were the most accurate scores for patients not treated with tPA. SPAN-100 (0.55) had the worst accuracy in both groups. Three of these scores had different cutoffs between study groups. CONCLUSIONS The predictive scores had moderate to fair accuracy for predicting HT in patients treated with tPA. Three scales were more accurate for predicting HT in patients not treated with tPA. Through standardizing these characteristics and including more patients not treated with RT in a large multicenter series, accurate predictive scores may be created.
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Affiliation(s)
| | | | - Muhammad Ahmad
- CMH Lahore Medical College and Institute of Dentistry, Lahore, Pakistan
| | - Fabricio Oliveira Lima
- Hospital Geral de Fortaleza, Fortaleza CE, Brazil.,Universidade de Fortaleza, Fortaleza CE, Brazil
| | | | - Gisele Sampaio Silva
- Universidade Federal de São Paulo, São Paulo SP, Brazil.,Hospital Israelita Albert Einstein, São Paulo SP, Brazil
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Honig A, Percy J, Sepehry AA, Gomez AG, Field TS, Benavente OR. Hemorrhagic Transformation in Acute Ischemic Stroke: A Quantitative Systematic Review. J Clin Med 2022; 11:jcm11051162. [PMID: 35268253 PMCID: PMC8910828 DOI: 10.3390/jcm11051162] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
The prevalence and risk factors of hemorrhagic transformation (HT) after acute ischemic stroke HT have not been adequately delineated. We performed a systematic review and meta-analysis to identify English-language prospective observational MEDLINE and EMBASE-listed reports of acute ischemic stroke with HT published from 1985–2017. Studies that used the ECASS-2 definitions of hemorrhagic transformation subtypes, hemorrhagic infarction (HI), and parenchymal hematoma (PH) were included. Patients treated with intravenous thrombolysis with tissue plasminogen activator (IV-tPA) were compared with those who did not receive thrombolysis. A total of 65 studies with 17,259 patients met inclusion criteria. Overall, HT prevalence was 27%; 32% in patients receiving IV-tPA vs. 20% in those without. Overall PH prevalence was 9%; 12% in IV-tPA treated patients vs. 5% in those without. HT was associated with a history of atrial fibrillation (OR 2.94) and use of anticoagulants (OR 2.47). HT patients had higher NIHSS (Hedge’s-G 0.96) and larger infarct volume (diffusion-weighted MRI, Hedge’s-G 0.8). In IV-tPA treated patients, PH correlated with antiplatelet (OR 3) and statin treatment (OR 4). HT (OR 3) and PH (OR 8) were associated with a poor outcome at 90-day (mRS 5–6). Hemorrhagic transformation is a frequent complication of acute ischemic stroke and is associated with poor outcome. Recognition of risk factors for HT and PH may reduce their incidence and severity.
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Affiliation(s)
- Asaf Honig
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
- Correspondence:
| | - Jennifer Percy
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
| | - Amir A. Sepehry
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
- Clinical Psychology Program, Adler University, Vancouver, BC V6B 3J5, Canada
| | - Alejandra G. Gomez
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
| | - Thalia S. Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
| | - Oscar R. Benavente
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
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Baker AD, Schwamm LH, Sanborn DY, Furie K, Stretz C, Mac Grory B, Yaghi S, Kleindorfer D, Sucharew H, Mackey J, Walsh K, Flaherty M, Kissela B, Alwell K, Khoury J, Khatri P, Adeoye O, Ferioli S, Woo D, Martini S, De Los Rios La Rosa F, Demel SL, Madsen T, Star M, Coleman E, Slavin S, Jasne A, Mistry EA, Haverbusch M, Merkler AE, Kamel H, Schindler J, Sansing LH, Faridi KF, Sugeng L, Sheth KN, Sharma R. Acute Ischemic Stroke, Depressed Left Ventricular Ejection Fraction, and Sinus Rhythm: Prevalence and Practice Patterns. Stroke 2022; 53:1883-1891. [PMID: 35086361 DOI: 10.1161/strokeaha.121.036706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are limited data about the epidemiology and secondary stroke prevention strategies used for patients with depressed left ventricular ejection fraction (LVEF) and sinus rhythm following an acute ischemic stroke (AIS). We sought to describe the prevalence of LVEF ≤40% and sinus rhythm among patients with AIS and antithrombotic treatment practice in a multi-center cohort from 2002 to 2018. METHODS This was a multi-center, retrospective cohort study comprised of patients with AIS hospitalized in the Greater Cincinnati Northern Kentucky Stroke Study and 4 academic, hospital-based cohorts in the United States. A 1-stage meta-analysis of proportions was undertaken to calculate a pooled prevalence. Univariate analyses and an adjusted multivariable logistic regression model were performed to identify demographic, clinical, and echocardiographic characteristics associated with being prescribed an anticoagulant upon AIS hospitalization discharge. RESULTS Among 14 338 patients with AIS with documented LVEF during the stroke hospitalization, the weighted pooled prevalence of LVEF ≤40% and sinus rhythm was 5.0% (95% CI, 4.1-6.0%; I2, 84.4%). Of 524 patients with no cardiac thrombus and no prior indication for anticoagulant who survived postdischarge, 200 (38%) were discharged on anticoagulant, 289 (55%) were discharged on antiplatelet therapy only, and 35 (7%) on neither. There was heterogeneity by site in the proportion discharged with an anticoagulant (22% to 45%, P<0.0001). Cohort site and National Institutes of Health Stroke Severity scale >8 (odds ratio, 2.0 [95% CI, 1.1-3.8]) were significant, independent predictors of being discharged with an anticoagulant in an adjusted analysis. CONCLUSIONS Nearly 5% of patients with AIS have a depressed LVEF and are in sinus rhythm. There is significant variation in the clinical practice of antithrombotic therapy prescription by site and stroke severity. Given this clinical equipoise, further study is needed to define optimal antithrombotic treatment regimens for secondary stroke prevention in this patient population.
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Affiliation(s)
- Anna D Baker
- Department of Neurology (A.D.B., A.J., J.S., L.H.S., K.N.S., R.S.), Yale School of Medicine, New Haven, CT
| | | | - Danita Y Sanborn
- Division of Cardiology (D.Y.S.), Massachusetts General Hospital and Harvard Medical School Boston
| | - Karen Furie
- Department of Neurology (K.F., C.S., S.Y.), Alpert Medical School of Brown University, Providence, RI
| | - Christoph Stretz
- Department of Neurology (K.F., C.S., S.Y.), Alpert Medical School of Brown University, Providence, RI
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine (B.M.G.)
| | - Shadi Yaghi
- Department of Neurology (K.F., C.S., S.Y.), Alpert Medical School of Brown University, Providence, RI
| | - Dawn Kleindorfer
- Department of Neurology, University of Michigan School of Medicine, Ann Arbor (D.K.).,Department of Neurology, University of Cincinnati, OH (D.K., K.A., F.D.L.R.L.R., M.H.)
| | - Heidi Sucharew
- Department of Pediatrics, Division of Biostatistics and Epidemiology (H.S.), Cincinnati Children's Hospital Medical Center, OH
| | - Jason Mackey
- Department of Neurology, Indiana University School of Medicine, Indianapolis (J.M.)
| | - Kyle Walsh
- Department of Emergency Medicine (K.W.), University of Cincinnati Gardner Neuroscience Institute, OH
| | - Matt Flaherty
- Department of Neurology & Rehabilitation Medicine and Comprehensive Stroke Center (M.F., B.K., P.K., S.F., D.W., S.L.D.), University of Cincinnati Gardner Neuroscience Institute, OH
| | - Brett Kissela
- Department of Neurology & Rehabilitation Medicine and Comprehensive Stroke Center (M.F., B.K., P.K., S.F., D.W., S.L.D.), University of Cincinnati Gardner Neuroscience Institute, OH
| | - Kathleen Alwell
- Department of Neurology, University of Cincinnati, OH (D.K., K.A., F.D.L.R.L.R., M.H.)
| | - Jane Khoury
- Division of Biostatistics and Epidemiology, Department of Pediatrics, University of Cincinnati Medical Center (J.K.), Cincinnati Children's Hospital Medical Center, OH
| | - Pooja Khatri
- Department of Neurology & Rehabilitation Medicine and Comprehensive Stroke Center (M.F., B.K., P.K., S.F., D.W., S.L.D.), University of Cincinnati Gardner Neuroscience Institute, OH
| | - Opeolu Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO (O.A.)
| | - Simona Ferioli
- Department of Neurology & Rehabilitation Medicine and Comprehensive Stroke Center (M.F., B.K., P.K., S.F., D.W., S.L.D.), University of Cincinnati Gardner Neuroscience Institute, OH
| | - Daniel Woo
- Department of Neurology & Rehabilitation Medicine and Comprehensive Stroke Center (M.F., B.K., P.K., S.F., D.W., S.L.D.), University of Cincinnati Gardner Neuroscience Institute, OH
| | - Sharyl Martini
- Department of Neurology, Baylor College of Medicine and VA National TeleStroke Program, Houston, TX (S.M.)
| | - Felipe De Los Rios La Rosa
- Department of Neurology, University of Cincinnati, OH (D.K., K.A., F.D.L.R.L.R., M.H.).,Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL (F.D.L.R.L.R.)
| | - Stacie L Demel
- Department of Neurology & Rehabilitation Medicine and Comprehensive Stroke Center (M.F., B.K., P.K., S.F., D.W., S.L.D.), University of Cincinnati Gardner Neuroscience Institute, OH
| | - Tracy Madsen
- Department of Emergency Medicine, Division of Sex and Gender (T.M.), Alpert Medical School of Brown University, Providence, RI
| | - Michael Star
- Department of Neurology, Soroka Medical Center, Beersheva, Israel (M.S.)
| | - Elisheva Coleman
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL (E.C.)
| | - Sabreena Slavin
- Department of Neurology, University of Kansas Medical Center (S.S.)
| | - Adam Jasne
- Department of Neurology (A.D.B., A.J., J.S., L.H.S., K.N.S., R.S.), Yale School of Medicine, New Haven, CT
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN (E.A.M.)
| | - Mary Haverbusch
- Department of Neurology, University of Cincinnati, OH (D.K., K.A., F.D.L.R.L.R., M.H.)
| | | | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, NY (A.E.M., H.K.)
| | - Joseph Schindler
- Department of Neurology (A.D.B., A.J., J.S., L.H.S., K.N.S., R.S.), Yale School of Medicine, New Haven, CT
| | - Lauren H Sansing
- Department of Neurology (A.D.B., A.J., J.S., L.H.S., K.N.S., R.S.), Yale School of Medicine, New Haven, CT.,Department of Neurology and Comprehensive Stroke Center (L.H.S.), Massachusetts General Hospital and Harvard Medical School Boston
| | - Kamil F Faridi
- Section of Cardiovascular Medicine, Department of Medicine (K.F.F., L.S.), Yale School of Medicine, New Haven, CT
| | - Lissa Sugeng
- Section of Cardiovascular Medicine, Department of Medicine (K.F.F., L.S.), Yale School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Department of Neurology (A.D.B., A.J., J.S., L.H.S., K.N.S., R.S.), Yale School of Medicine, New Haven, CT
| | - Richa Sharma
- Department of Neurology (A.D.B., A.J., J.S., L.H.S., K.N.S., R.S.), Yale School of Medicine, New Haven, CT
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19
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Hong L, Hsu TM, Zhang Y, Cheng X. Neuroimaging Prediction of Hemorrhagic Transformation for Acute Ischemic Stroke. Cerebrovasc Dis 2022; 51:542-552. [PMID: 35026765 DOI: 10.1159/000521150] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/20/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemorrhagic transformation (HT) is a common complication of acute ischemic stroke, often resulting from reperfusion therapy. Early prediction of HT can enable stroke neurologists to undertake measures to avoid clinical deterioration and make optimal treatment strategies. Moreover, the trend of extending the time window for reperfusion therapy (both for intravenous thrombolysis and endovascular treatment) further requires more precise detection of HT tendency. SUMMARY In this review, we summarized and discussed the neuroimaging markers of HT prediction of acute ischemic stroke patients, mainly focusing on neuroimaging markers of ischemic degree and neuroimaging markers of blood-brain barrier permeability. This review is aimed to provide a concise introduction of HT prediction and to elicit possibilities of future research combining advanced technology to improve the accessibility and accuracy of HT prediction under emergent clinical settings. Key Messages: Substantial studies have utilized neuroimaging, blood biomarkers, and clinical variables to predict HT occurrence. Although huge progress has been made, more individualized and precise HT prediction using simple and robust imaging predictors combining stroke onset time should be the future goal of development.
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Affiliation(s)
- Lan Hong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China,
| | - Tzu-Ming Hsu
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Yiran Zhang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
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20
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Wei C, Liu J, Guo W, Jin Y, Song Q, Wang Y, Ye C, Li J, Zhang S, Liu M. Development and Validation of a Predictive Model for Spontaneous Hemorrhagic Transformation After Ischemic Stroke. Front Neurol 2021; 12:747026. [PMID: 34867730 PMCID: PMC8634397 DOI: 10.3389/fneur.2021.747026] [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: 07/26/2021] [Accepted: 09/30/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Hemorrhagic transformation (HT) after reperfusion therapy for acute ischemic stroke (AIS) has been well studied; however, there is scarce research focusing on spontaneous HT (sHT). Spontaneous HT is no less important with a relatively high incidence and could be associated with neurological worsening. We aimed to develop and validate a simple and practical model to predict sHT after AIS (SHAIS) and compared the predictive value of the SHAIS score against the models of post-Reperfusion HT for sHT. Methods: Patients with AIS admitted within 24 h of onset were prospectively screened to develop and validate the SHAIS score. The primary outcome was sHT during hospitalization (within 30 days after onset), and the secondary outcomes were symptomatic sHT and parenchymal hematoma (PH). Clinical information, laboratory, and neuroimaging data were screened to construct the SHAIS score. We selected six commonly used scales for predicting HT after reperfusion therapy and compared their predictive ability for sHT with the SHAIS score using Delong's test. Results: The derivation cohort included 539 patients (mean age, 68.1 years; men, 61.4%), of whom 91 (16.9%) patients developed sHT with 25.3% (23/91) being symptomatic sHT and 62.6% (57/91) being PH. Five variables (atrial fibrillation, NIHSS score ≥ 10, hypodensity > 1/3 of middle cerebral artery territory, hyperdense artery sign, and anterior circulation infarction) composed the SHAIS score, which ranged from 0 to 11 points. The area under the receiver-operating characteristic curve (AUC) was 0.86 (95% CI 0.82–0.91, p < 0.001) for the overall sHT, 0.85 (95% CI 0.76–0.92, p < 0.001) for symptomatic sHT, and 0.89 (95% CI 0.85–0.94, p < 0.001) for PH. No evidence of miscalibration of the SHAIS score was found to predict the overall sHT (p = 0.19), symptomatic sHT (p = 0.44), and PH (p = 0.22). The internal (n = 245) and external validation cohorts (n = 200) depicted similar predictive performance compared to the derivation cohort. The SHAIS score had a higher AUC to predict sHT than any of the six pre-Existing models (p < 0.05). Conclusions: The SHAIS score provides an easy-to-use model to predict sHT, which could help providers with decision-making about treatments with high bleeding risk, and to counsel patients and families on the baseline risk of HT, aligning expectations with probable outcomes.
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Affiliation(s)
- Chenchen Wei
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.,Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Junfeng Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Wen Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuxi Jin
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Quhong Song
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yanan Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Chen Ye
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Li
- Department of Neurology, The First People's Hospital of Ziyang, Ziyang, China
| | - Shanshan Zhang
- Department of Neurology, Mianyang Central Hospital, Mianyang, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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21
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Hong JM, Kim DS, Kim M. Hemorrhagic Transformation After Ischemic Stroke: Mechanisms and Management. Front Neurol 2021; 12:703258. [PMID: 34917010 PMCID: PMC8669478 DOI: 10.3389/fneur.2021.703258] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/21/2021] [Indexed: 01/01/2023] Open
Abstract
Symptomatic hemorrhagic transformation (HT) is one of the complications most likely to lead to death in patients with acute ischemic stroke. HT after acute ischemic stroke is diagnosed when certain areas of cerebral infarction appear as cerebral hemorrhage on radiological images. Its mechanisms are usually explained by disruption of the blood-brain barrier and reperfusion injury that causes leakage of peripheral blood cells. In ischemic infarction, HT may be a natural progression of acute ischemic stroke and can be facilitated or enhanced by reperfusion therapy. Therefore, to balance risks and benefits, HT occurrence in acute stroke settings is an important factor to be considered by physicians to determine whether recanalization therapy should be performed. This review aims to illustrate the pathophysiological mechanisms of HT, outline most HT-related factors after reperfusion therapy, and describe prevention strategies for the occurrence and enlargement of HT, such as blood pressure control. Finally, we propose a promising therapeutic approach based on biological research studies that would help clinicians treat such catastrophic complications.
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Affiliation(s)
- Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Da Sol Kim
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Min Kim
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
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22
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Li C, Hao X, Lin L, Sun C, Yu H, Yao Z, Feng X, Yang Y. Prognostic Value of a New Integrated Parameter-Both Collateral Circulation and Permeability Surface-in Hemorrhagic Transformation of Middle Cerebral Artery Occlusion Acute Ischemic Stroke: Retrospective Cohort Study. Front Aging Neurosci 2021; 13:703734. [PMID: 34512306 PMCID: PMC8424095 DOI: 10.3389/fnagi.2021.703734] [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: 04/30/2021] [Accepted: 07/26/2021] [Indexed: 12/03/2022] Open
Abstract
Background Multimodal CT, including CT angiography (CTA) and CT perfusion (CTP), was increasingly used in stroke triage. This study was to determine the relationship between a new integrated parameter—both collateral circulation and relative permeability surface (PS)—and the hemorrhagic transformation (HT) in acute ischemic stroke (AIS) with middle cerebral artery occlusion (MCAO). Methods We retrospectively reviewed consecutive AIS patients with MCAO who underwent baseline CTA/CTP within 4 h of symptom onset and follow-up susceptibility-weighted imaging (SWI) within 3 weeks. Collateral circulation was assessed on the baseline CTA. Baseline CTP data were postprocessed to generate PS parameter. The patients with poor collateral circulation and at the same time with high relative PS were classified as the group of both poor collateral circulation and high relative PS. HT was defined according to European Cooperative Acute Stroke Study II criteria on follow-up SWI imaging. Multivariate logistic regression analysis was performed using HT as an outcome variable. Results The group of patients with both poor collateral circulation and high relative PS was thirteen and thirty-three (52%) developed HT of the final cohort sixty-three AIS patients with MCAO. Multivariate logistic analysis revealed the new integrated parameter—both collateral circulation and relative PS (odds ratio, 16.59; 95% confidence interval, 13.09–19.10; P < 0.001) was independent predictor of HT. The area under the curve was 0.85 (95% confidence interval, 0.81–0.89). The sensitivity was 57%, specificity 97% and positive predictive value 92%, negative predictive value 58%. Conclusions For AIS patients with MCAO, these with poor collateral circulation on CTA and at the same time with high relative PS on CTP were at high risk for HT.
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Affiliation(s)
- Chanchan Li
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaozhu Hao
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Luyi Lin
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chengfeng Sun
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hai Yu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhenwei Yao
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoyuan Feng
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yanmei Yang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
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23
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Spronk E, Sykes G, Falcione S, Munsterman D, Joy T, Kamtchum-Tatuene J, Jickling GC. Hemorrhagic Transformation in Ischemic Stroke and the Role of Inflammation. Front Neurol 2021; 12:661955. [PMID: 34054705 PMCID: PMC8160112 DOI: 10.3389/fneur.2021.661955] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/29/2021] [Indexed: 01/01/2023] Open
Abstract
Hemorrhagic transformation (HT) is a common complication in patients with acute ischemic stroke. It occurs when peripheral blood extravasates across a disrupted blood brain barrier (BBB) into the brain following ischemic stroke. Preventing HT is important as it worsens stroke outcome and increases mortality. Factors associated with increased risk of HT include stroke severity, reperfusion therapy (thrombolysis and thrombectomy), hypertension, hyperglycemia, and age. Inflammation and the immune system are important contributors to BBB disruption and HT and are associated with many of the risk factors for HT. In this review, we present the relationship of inflammation and immune activation to HT in the context of reperfusion therapy, hypertension, hyperglycemia, and age. Differences in inflammatory pathways relating to HT are discussed. The role of inflammation to stratify the risk of HT and therapies targeting the immune system to reduce the risk of HT are presented.
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Affiliation(s)
- Elena Spronk
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Gina Sykes
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sarina Falcione
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Danielle Munsterman
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Twinkle Joy
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Joseph Kamtchum-Tatuene
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Glen C Jickling
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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24
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Liu C, Xie J, Sun S, Li H, Li T, Jiang C, Chen X, Wang J, Le A, Wang J, Li Z, Wang J, Wang W. Hemorrhagic Transformation After Tissue Plasminogen Activator Treatment in Acute Ischemic Stroke. Cell Mol Neurobiol 2020; 42:621-646. [PMID: 33125600 DOI: 10.1007/s10571-020-00985-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/22/2020] [Indexed: 12/17/2022]
Abstract
Hemorrhagic transformation (HT) is a common complication after thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) in ischemic stroke. In this article, recent research progress of HT in vivo and in vitro studies was reviewed. We have discussed new potential mechanisms and possible experimental models of HT development, as well as possible biomarkers and treatment methods. Meanwhile, we compared and analyzed rodent models, large animal models and in vitro BBB models of HT, and the limitations of these models were discussed. The molecular mechanism of HT was investigated in terms of BBB disruption, rt-PA neurotoxicity and the effect of neuroinflammation, matrix metalloproteinases, reactive oxygen species. The clinical features to predict HT were represented including blood biomarkers and clinical factors. Recent progress in neuroprotective strategies to improve HT after stroke treated with rt-PA is outlined. Further efforts need to be made to reduce the risk of HT after rt-PA therapy and improve the clinical prognosis of patients with ischemic stroke.
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Affiliation(s)
- Chengli Liu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Jie Xie
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Shanshan Sun
- Department of Ultrasound Imaging, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Hui Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Tianyu Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Chao Jiang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Xuemei Chen
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China
| | - Junmin Wang
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China
| | - Anh Le
- Washington University in St. Louis, Saint Louis, MO, 63130, USA
| | - Jiarui Wang
- The Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Zhanfei Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Jian Wang
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China.
| | - Wei Wang
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China.
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25
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Wang Y, Wei C, Song Q, Liu J, Cheng Y, Li Y, Wu B, Liu M. Reduction in the Ratio of Low-density Lipoprotein Cholesterol to Highdensity Lipoprotein Cholesterol is Associated with Increased Risks of Hemorrhagic Transformation in Patients with Acute Ischemic Stroke. Curr Neurovasc Res 2020; 16:266-272. [PMID: 31258087 DOI: 10.2174/1567202616666190619151914] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE Hemorrhagic transformation (HT) is a potentially serious complication in patients with acute ischemic stroke (AIS). Whether the ratio of low-density lipoprotein cholesterol to high-density lipoprotein cholesterol (LDL-C/HDL-C) is associated with HT remains unclear. METHODS Ischemic stroke patients within 7 days of stroke onset from January 2016 to November 2017 were included in this study. Lipid profiles were measured within 24h after admission. HT was determined by a second computed tomography or magnetic resonance imaging within 7 days after admission. Univariate and multivariate logistic regression analysis was used to assess the association between LDL-C/HDL-C and HT. RESULTS We enrolled 1239 patients with AIS (788 males; mean age, 64 ± 15 years), of whom 129 (10.4%) developed HT. LDL-C/HDL-C was significantly lower on admission in patients with HT than those without HT (2.00 ± 0.89 vs. 2.25 ± 1.02, P=0.009). The unadjusted odds ratio (OR) of low LDL-C/HDL-C for HT was 2.07 (95% confidence interval [CI] 1.42-3.01, P<0.001). After adjustment for possible confounders, lower LDL-C/HDL-C (≤1.52) was significantly associated with HT (OR 1.53, 95% CI: 1.02-2.31, P=0.046). Similar results were observed between lower LDL-C (≤ 4 mmol/L) and HT (OR 4.17, 95% CI: 1.25-13.90, P=0.02). However, no significant association was found between HT and high HDL-C, low triglycerides or low total cholesterol. CONCLUSION Lower LDL-C/HDL-C and LDL-C were significantly associated with increased risk of HT after AIS. Further investigations are warranted to confirm these findings and then optimize lipid management in stroke patients with lower LDL/HDL-C or LDL-C.
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Affiliation(s)
- Yanan Wang
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Chenchen Wei
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Quhong Song
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Junfeng Liu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Yajun Cheng
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Yisong Li
- Department of Laboratory Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Bo Wu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Ming Liu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
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26
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Renard D, Castelnovo G, Ion I, Guillamo JS, Thouvenot E. Single and simultaneous multiple intracerebral hemorrhages: a radiological review. Acta Neurol Belg 2020; 120:819-829. [PMID: 32449137 DOI: 10.1007/s13760-020-01385-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/14/2020] [Indexed: 01/11/2023]
Abstract
Simultaneous multiple intracerebral hemorrhage (SMICH) is defined as ICH in two or more discrete noncontiguous acute intraparenchymal locations on initial CT. About 5% of ICH patients present with SMICH. ICH/SMICH etiology is classically divided into disorders of primary or secondary origin. About half of primary SMICH cases are caused by cerebral amyloid angiopathy or hypertensive arteriopathy. In this review, we will discuss the radiological features associated with the different causes of primary and secondary ICH and SMICH. Due to its rarity and the associated high morbidity and mortality, we will focus in particular on SMICH.
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Affiliation(s)
- Dimitri Renard
- Department of Neurology, CHU Nîmes, Hôpital Caremeau, University of Montpellier, 4, Rue Du Pr Debré, 30029, Nîmes Cedex 4, France.
| | - Giovanni Castelnovo
- Department of Neurology, CHU Nîmes, Hôpital Caremeau, University of Montpellier, 4, Rue Du Pr Debré, 30029, Nîmes Cedex 4, France
| | - Ioana Ion
- Department of Neurology, CHU Nîmes, Hôpital Caremeau, University of Montpellier, 4, Rue Du Pr Debré, 30029, Nîmes Cedex 4, France
| | - Jean Sebastien Guillamo
- Department of Neurology, CHU Nîmes, Hôpital Caremeau, University of Montpellier, 4, Rue Du Pr Debré, 30029, Nîmes Cedex 4, France
| | - Eric Thouvenot
- Department of Neurology, CHU Nîmes, Hôpital Caremeau, University of Montpellier, 4, Rue Du Pr Debré, 30029, Nîmes Cedex 4, France
- Institut de Génomique Fonctionnelle, UMR 5203, INSERM 1191, Université Montpellier, Montpellier, France
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27
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de Andrade JBC, Mohr JP, Lima FO, Carvalho JJDF, de Farias VAE, Oliveira-Filho J, Pontes-Neto OM, Bazan R, Merida KLB, Franciscato L, Pires MM, Modolo GP, Marques MS, Miranda RCAN, Silva GS. Predicting hemorrhagic transformation in patients not submitted to reperfusion therapies. J Stroke Cerebrovasc Dis 2020; 29:104940. [PMID: 32689629 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104940] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/22/2020] [Accepted: 05/05/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Well studied in patients with ischemic stroke after reperfusion therapies (RT), hemorrhagic transformation (HT) is also common in patients not treated with RT and can lead to disability even in initially asymptomatic cases. The best predictors of HT in patients not treated with RT are not well established. Therefore, we aimed to identify predictors of HT in patients not submitted to RT and create a user-friendly predictive score (PROpHET). MATERIAL AND METHODS Patients admitted to a Comprehensive Stroke Center from 2015 to 2017 were prospectively evaluated and randomly selected to the derivation cohort. A multivariable logistic regression modeling was built to produce a predictive grading score for HT. The external validation was assessed using datasets from 7 Comprehensive Stroke Centers using the area under the receiver operating characteristic curve (AUROC). RESULTS In the derivation group, 448 patients were included in the final analysis. The validation group included 2,683 patients. The score derived from significant predictors of HT in the multivariate logistic regression analysis was male sex (1 point), ASPECTS ≤ 7 (2 points), presence of leukoaraiosis (1 point), hyperdense cerebral middle artery sign (1 point), glycemia at admission ≥180 mg/dL (1 point), cardioembolism (1 point) and lacunar syndrome (-3 points) as a protective factor. The grading score ranges from -3 to 7. A Score ≥3 had 78.2% sensitivity and 75% specificity, and AUROC of 0.82 for all cases of HT. In the validation cohort, our score had an AUROC of 0.83. CONCLUSIONS The PROpHET is a simple, quick, cost-free, and easy-to-perform tool that allows risk stratification of HT in patients not submitted to RT. A cost-free computerized version of our score is available online with a user-friendly interface.
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Affiliation(s)
- Joao Brainer Clares de Andrade
- Universidade Federal de São Paulo, Sao Paulo, SP, Brazil; Columbia University, Doris and Stanley Tananbaum Stroke Center, 710 W 168th St. Neurological Institute of New York. 6TH Floor. NI 614. ZIP 10032. New York City, NY, USA.
| | - Jay P Mohr
- Columbia University, Doris and Stanley Tananbaum Stroke Center, 710 W 168th St. Neurological Institute of New York. 6TH Floor. NI 614. ZIP 10032. New York City, NY, USA
| | - Fabricio Oliveira Lima
- Universidade de Fortaleza, Fortaleza, Ceará, Brazil; Hospital Geral de Fortaleza, Ceara, Brazil
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28
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Andrade JBC, Mohr JP, Lima FO, de Carvalho JJF, Barros LCM, Nepomuceno CR, Ferrer JVCC, Silva GS. The Role of Hemorrhagic Transformation in Acute Ischemic Stroke Upon Clinical Complications and Outcomes. J Stroke Cerebrovasc Dis 2020; 29:104898. [PMID: 32417239 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104898] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/04/2020] [Accepted: 04/19/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Hemorrhagic transformation (HT) is a common neurological complication after ischemic stroke. The influence of symptomatic HT upon clinical outcomes post-stroke is well established, however, the role of asymptomatic HT upon prognosis is still unclear. We aimed to analyze the relationship between HT, clinical complications and outcomes in patients not submitted to reperfusion therapies (RT). METHODS We included 448 randomly selected patients admitted with acute ischemic stroke to a tertiary hospital stroke unit from 2015 to 2017. Patients submitted to RT were excluded. All patients were evaluated with computed tomography (CT) at admission and within 7 days from the initial CT. Patients with HT were divided into two groups: symptomatic and asymptomatic cases based on the ECASS II definition. A good clinical outcome was defined as a modified Rankin Scale (mRS) 0-2 at discharge. RESULTS A total of 95 patients (21.2%) had HT (51 asymptomatic and 44 symptomatic). Age, NIHSS at admission and symptomatic HT were associated with a higher risk of developing pneumonia and seizures during hospitalization. Symptomatic HT was also associated with a prolonged length of hospitalization and death and inversely associated with good clinical outcomes at discharge (OR 0.96, 95% CI 0.94-0.98, p<0.001). In an adjusted analysis, even asymptomatic HT was independently associated with worse clinical outcomes at discharge (mRS 4-6) (OR 5.99, 95% CI 1.83-19.58, p = 0.003). CONCLUSIONS Symptomatic HT is associated with a higher risk of clinical complications, prolonged hospitalization, death and worse clinical outcome at discharge. Furthermore, even patients with asymptomatic HT had a higher chance of worse clinical outcomes at discharge.
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Affiliation(s)
- Joao Brainer Clares Andrade
- Department of Neurology, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Sao Paulo, SP 04039-001, Brazil; Columbia University, Doris and Stanley Tananbaum Stroke Center, USA.
| | - Jay P Mohr
- Columbia University, Doris and Stanley Tananbaum Stroke Center, USA.
| | | | | | | | | | | | - Gisele Sampaio Silva
- Department of Neurology, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Sao Paulo, SP 04039-001, Brazil.
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29
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Andrade JBCD, Mohr JP, Lima FO, Barros LCM, Nepomuceno CR, Portela LB, Silva GS. Predictors of hemorrhagic transformation after acute ischemic stroke based on the experts' opinion. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:390-396. [PMID: 32401833 DOI: 10.1590/0004-282x20200008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 01/10/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hemorrhagic transformation (HT) is a common complication after ischemic stroke. It may be associated to poor outcomes. Some predictors of HT have been previously identified, but there remain controversies. OBJECTIVE To describe the risk factors for HT more frequently reported by a panel of experts surveyed for this project. METHODS We sent a standard questionnaire by e-mail to specialists in Vascular Neurology from 2014 to 2018. Forty-five specialists were contacted and 20 of them responded to the invitation. Predictors cited by three or more specialists were included in a table and ranked by the frequency in which they appeared. A review of the literature looking for published predictive scores of HT was performed, comparing to the answers received. RESULTS The 20 responding specialists cited 23 different risk factors for HT. The most frequent factors in the order of citation were the volume of ischemia, previous use of antithrombotic medication, neurological severity, age, hyperglycemia at presentation, hypertension on admission, and cardioembolism. Most variables were also found in previously published predictive scores, but they were reported by the authors with divergences of frequency. CONCLUSION Although many studies have evaluated HT in patients with acute ischemic stroke, the published risk factors were neither uniform nor in agreement with those cited by the stroke specialists. These findings may be helpful to build a score that can be tested with the goal of improving the prediction of HT.
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Affiliation(s)
| | - Jay Preston Mohr
- Doris and Stanley Tananbaum Stroke Center, Columbia University, New York City, USA
| | | | | | | | | | - Gisele Sampaio Silva
- Vascular Neurology Department, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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30
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Muscari A, Faccioli L, Lega MV, Lorusso A, Masetti M, Pastore Trossello M, Puddu GM, Spinardi L, Zoli M. Predicting hemorrhagic transformation and its timing from maximum cerebral lesion diameter in nonlacunar ischemic strokes. Brain Behav 2020; 10:e01497. [PMID: 31846215 PMCID: PMC6955832 DOI: 10.1002/brb3.1497] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 10/29/2019] [Accepted: 11/22/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES We performed this retrospective cohort study to establish which factors are mostly indicative of the appearance of hemorrhagic transformation (HT) and of its time course in a sample of nonlacunar ischemic strokes. MATERIALS AND METHODS In 402 patients with nonlacunar ischemic stroke (75.0 ± 12.7 years, 192 male), clinical, laboratory, and neuroimaging variables obtained during the first 3 days of hospitalization were compared between patients with and without HT at computer tomography scan. RESULTS HT was documented in 129 patients (32.1%), including 36 with parenchymal hematoma (PH), after a median time of 6 days (range 1-27). Many variables were univariately associated with HT, but only 5 of them were confirmed in Cox regression (Hazard Ratio, 95% Confidence Interval): maximum cerebral lesion diameter (CLD) in cm (1.12, 1.06-1.18; p = .0001), hemoglobin in g/dl (1.16, 1.06-1.27; p = .002), blood glucose in mmol/L (1.10, 1.03-1.18; p = .007), prior anticoagulant therapy (1.82, 1.10-3.03; p = .02), and edema with mass effect (1.72, 1.08-2.75; p = .02). Thus, the most significant predictor was CLD. The overall risk of HT was minimum for CLD < 2 cm (1.5%), intermediate for CLD ≥ 2 and < 5 cm (22%), and maximum for CLD ≥ 5 cm (58%). The residual probability of having HT decreased progressively over time, and a simple formula is proposed to predict, from CLD in cm, when the probability of HT falls below 10%. CONCLUSIONS The main determinant of HT was CLD, a simple quantitative parameter that could prove useful, in particular, in deciding the timing of anticoagulation in cardioembolic stroke patients.
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Affiliation(s)
- Antonio Muscari
- Stroke Unit, Medical Department of Continuity of Care and Disability, S.Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Luca Faccioli
- Diagnostic and Interventional Neuroradiology Unit, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Maria Vittoria Lega
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Lorusso
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Marco Masetti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Marco Pastore Trossello
- Diagnostic and Interventional Neuroradiology Unit, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Giovanni M Puddu
- Stroke Unit, Medical Department of Continuity of Care and Disability, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Luca Spinardi
- Diagnostic and Interventional Neuroradiology Unit, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Marco Zoli
- Stroke Unit, Medical Department of Continuity of Care and Disability, S.Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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31
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Hassan AE, Kotta H, Shariff U, Preston L, Tekle W, Qureshi A. There Is No Association Between the Number of Stent Retriever Passes and the Incidence of Hemorrhagic Transformation for Patients Undergoing Mechanical Thrombectomy. Front Neurol 2019; 10:818. [PMID: 31440198 PMCID: PMC6694295 DOI: 10.3389/fneur.2019.00818] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/16/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Previous research has focused on the association between hemorrhagic transformation (HT) incidence and pre-procedural variables (i.e., baseline variables) rather than the association between HT incidence and endovascular treatment (EVT) procedural variables (e.g., stent retriever passes). Objective: To assess the association, if any, that exists between the number of stent retriever passes per procedure and the incidence of HT for patients undergoing mechanical thrombectomy. Methods: An endovascular database from a comprehensive stroke center was used to collect data on EVT patients treated with Trevo, Solitaire, or Penumbra stent retrievers from the years 2012 to 2017. Statistical analyses were conducted on the stent retriever passes, demographics, morbidities, medication usage, and outcomes and their association with HT. Results: Of the 329 total patients, 46 (14%) had HT. The HT group had an average [SD] of 1.65 [0.67] and range of [1–3] passes per procedure while the non-HT group had an average [SD] of 1.63 [0.86] and range of [1–5] passes per procedure. Admission NIHSS score (p = 0.0003) and the incidence of diabetes mellitus (DM) (p = 0.05) were significantly higher in the HT group. Subdividing HT into symptomatic and asymptomatic ICH groups failed to display significant differences in the distribution of the stent retriever passes (p = 0.969). The number of passes failed to show any association with HT (p = 0.804) while admission NIHSS score was found to have an OR of 1.07 (95%CI: 1.029–1.121, p = 0.001) with HT incidence. Conclusion: No significant association was found between HT incidence and the stent retriever passes. Further multicenter studies are warranted to corroborate our results.
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Affiliation(s)
- Ameer E Hassan
- Department of Neurology and Radiology, University of Texas Rio Grande Valley, Harlingen, TX, United States
| | - Hari Kotta
- Department of Neurology, University of Texas Medical Branch, Galveston, TX, United States
| | - Umar Shariff
- Department of Neurology and Radiology, University of Texas Rio Grande Valley, Harlingen, TX, United States
| | - Laurie Preston
- Department of Neurology and Radiology, University of Texas Rio Grande Valley, Harlingen, TX, United States
| | - Wondwossen Tekle
- Department of Neurology and Radiology, University of Texas Rio Grande Valley, Harlingen, TX, United States
| | - Adnan Qureshi
- Department of Neurology, University of Missouri, Columbia, MO, United States
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32
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Altavilla R, Caso V, Bandini F, Agnelli G, Tsivgoulis G, Yaghi S, Furie KL, Tadi P, Becattini C, Zedde M, Abdul-Rahim AH, Lees KR, Alberti A, Venti M, Acciarresi M, D'Amore C, Mosconi MG, Anna Cimini L, Fusaro J, Bovi P, Carletti M, Rigatelli A, Cappellari M, Putaala J, Tomppo L, Tatlisumak T, Marcheselli S, Pezzini A, Poli L, Padovani A, Masotti L, Vannucchi V, Sohn SI, Lorenzini G, Tassi R, Guideri F, Acampa M, Martini G, Ntaios G, Athanasakis G, Makaritsis K, Karagkiozi E, Vadikolias K, Liantinioti C, Chondrogianni M, Mumoli N, Consoli D, Galati F, Sacco S, Carolei A, Tiseo C, Corea F, Ageno W, Bellesini M, Silvestrelli G, Ciccone A, Lanari A, Scoditti U, Denti L, Mancuso M, Maccarrone M, Ulivi L, Orlandi G, Giannini N, Gialdini G, Tassinari T, De Lodovici ML, Bono G, Rueckert C, Baldi A, D'Anna S, Toni D, Letteri F, Giuntini M, Maria Lotti E, Flomin Y, Pieroni A, Kargiotis O, Karapanayiotides T, Monaco S, Maimone Baronello M, Csiba L, Szabó L, Chiti A, Giorli E, Del Sette M, Imberti D, Zabzuni D, Doronin B, Volodina V, Michel P, Vanacker P, Barlinn K, Pallesen LP, Barlinn J, Deleu D, Melikyan G, Ibrahim F, Akhtar N, Gourbali V, Paciaroni M. Anticoagulation After Stroke in Patients With Atrial Fibrillation. Stroke 2019; 50:2093-2100. [PMID: 31221054 DOI: 10.1161/strokeaha.118.022856] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Bridging therapy with low-molecular-weight heparin reportedly leads to a worse outcome for acute cardioembolic stroke patients because of a higher incidence of intracerebral bleeding. However, this practice is common in clinical settings. This observational study aimed to compare (1) the clinical profiles of patients receiving and not receiving bridging therapy, (2) overall group outcomes, and (3) outcomes according to the type of anticoagulant prescribed. Methods- We analyzed data of patients from the prospective RAF and RAF-NOACs studies. The primary outcome was defined as the composite of ischemic stroke, transient ischemic attack, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding observed at 90 days after the acute stroke. Results- Of 1810 patients who initiated oral anticoagulant therapy, 371 (20%) underwent bridging therapy with full-dose low-molecular-weight heparin. Older age and the presence of leukoaraiosis were inversely correlated with the use of bridging therapy. Forty-two bridged patients (11.3%) reached the combined outcome versus 72 (5.0%) of the nonbridged patients (P=0.0001). At multivariable analysis, bridging therapy was associated with the composite end point (odds ratio, 2.3; 95% CI, 1.4-3.7; P<0.0001), as well as ischemic (odds ratio, 2.2; 95% CI, 1.3-3.9; P=0.005) and hemorrhagic (odds ratio, 2.4; 95% CI, 1.2-4.9; P=0.01) end points separately. Conclusions- Our findings suggest that patients receiving low-molecular-weight heparin have a higher risk of early ischemic recurrence and hemorrhagic transformation compared with nonbridged patients.
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Affiliation(s)
- Riccardo Altavilla
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)
| | - Valeria Caso
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)
| | - Fabio Bandini
- Department of Neurology, Ospedale San Paolo, Savona, Italy (F.B.)
| | - Giancarlo Agnelli
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.).,Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (G.T., C.L., M. Chondrogianni)
| | - Shadi Yaghi
- Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy (M.Z.)
| | - Karen L Furie
- Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy (M.Z.)
| | - Prasanna Tadi
- Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy (M.Z.)
| | - Cecilia Becattini
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy (M.Z.)
| | - Azmil H Abdul-Rahim
- Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., K.R.L.)
| | - Kennedy R Lees
- Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., K.R.L.)
| | - Andrea Alberti
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)
| | - Michele Venti
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)
| | - Monica Acciarresi
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)
| | - Cataldo D'Amore
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)
| | - Maria Giulia Mosconi
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)
| | - Ludovica Anna Cimini
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)
| | - Jessica Fusaro
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)
| | - Paolo Bovi
- SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, A.R., M. Cappellari)
| | - Monica Carletti
- SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, A.R., M. Cappellari)
| | - Alberto Rigatelli
- SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, A.R., M. Cappellari)
| | - Manuel Cappellari
- SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, A.R., M. Cappellari)
| | - Jukka Putaala
- Department of Neurology, Helsinki University Central Hospital, Finland (J.P., L.T., T.T.)
| | - Liisa Tomppo
- Department of Neurology, Helsinki University Central Hospital, Finland (J.P., L.T., T.T.)
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Finland (J.P., L.T., T.T.).,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden (T.T.).,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.)
| | - Simona Marcheselli
- Neurologia d'urgenza e Stroke Unit, Istituto Clinico Humanitas, Rozzano, Milano, Italy (S.M.)
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A. Pezzini, L.P., A. Padovani)
| | - Loris Poli
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A. Pezzini, L.P., A. Padovani)
| | - Alessandro Padovani
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A. Pezzini, L.P., A. Padovani)
| | - Luca Masotti
- Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy (L.M., V.V.)
| | - Vieri Vannucchi
- Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy (L.M., V.V.)
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea (S.I.S.)
| | - Gianni Lorenzini
- SC Medicina e Chirurgia d'Accettazione e d'Urgenza, Ospedale Lotti Pontedera, Azienda USL Toscana Nordovest, Pisa, Italy (G.L.)
| | - Rossana Tassi
- Stroke Unit, AOU Senese, Siena, Italy (R.T., F.G., M.A., G. Martini)
| | - Francesca Guideri
- Stroke Unit, AOU Senese, Siena, Italy (R.T., F.G., M.A., G. Martini)
| | - Maurizio Acampa
- Stroke Unit, AOU Senese, Siena, Italy (R.T., F.G., M.A., G. Martini)
| | - Giuseppe Martini
- Stroke Unit, AOU Senese, Siena, Italy (R.T., F.G., M.A., G. Martini)
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece (G.N., G.A., K.M., E.K.)
| | - George Athanasakis
- Department of Medicine, University of Thessaly, Larissa, Greece (G.N., G.A., K.M., E.K.)
| | | | - Efstathia Karagkiozi
- Department of Medicine, University of Thessaly, Larissa, Greece (G.N., G.A., K.M., E.K.)
| | - Konstantinos Vadikolias
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece (K.V.)
| | - Chrysoula Liantinioti
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (G.T., C.L., M. Chondrogianni)
| | - Maria Chondrogianni
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (G.T., C.L., M. Chondrogianni)
| | - Nicola Mumoli
- Department of Internal Medicine, Ospedale Civile di Livorno, Italy (N.M.)
| | - Domenico Consoli
- Stroke Unit, Jazzolino Hospital, Vibo Valentia, Italy (D.C., F.G.)
| | - Franco Galati
- Stroke Unit, Jazzolino Hospital, Vibo Valentia, Italy (D.C., F.G.)
| | - Simona Sacco
- Department of Neurology, University of L'Aquila, Avezzano Hospital, Italy (S.S., A. Carolei, C.T.)
| | - Antonio Carolei
- Department of Neurology, University of L'Aquila, Avezzano Hospital, Italy (S.S., A. Carolei, C.T.)
| | - Cindy Tiseo
- Department of Neurology, University of L'Aquila, Avezzano Hospital, Italy (S.S., A. Carolei, C.T.)
| | - Francesco Corea
- UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno, Italy (F.C.)
| | - Walter Ageno
- Department of Internal Medicine, Insubria University, Varese, Italy (W.A., M.B.)
| | - Marta Bellesini
- Department of Internal Medicine, Insubria University, Varese, Italy (W.A., M.B.)
| | - Giorgio Silvestrelli
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Italy (G.S., A. Ciccone, A.L.)
| | - Alfonso Ciccone
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Italy (G.S., A. Ciccone, A.L.)
| | - Alessia Lanari
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Italy (G.S., A. Ciccone, A.L.)
| | - Umberto Scoditti
- Stroke Unit, Neuroscience Department (U.S.), University of Parma, Italy
| | - Licia Denti
- Stroke Unit, Dipartimento Geriatrico Riabilitativo (L.D.), University of Parma, Italy
| | - Michelangelo Mancuso
- Clinica Neurologica, Azienda Ospedaliero Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., G.O., N.G., G.G., A.C.)
| | - Miriam Maccarrone
- Clinica Neurologica, Azienda Ospedaliero Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., G.O., N.G., G.G., A.C.)
| | - Leonardo Ulivi
- Clinica Neurologica, Azienda Ospedaliero Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., G.O., N.G., G.G., A.C.)
| | - Giovanni Orlandi
- Clinica Neurologica, Azienda Ospedaliero Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., G.O., N.G., G.G., A.C.).,Neurologia, Ospedale Apuano, Massa Carrara, Italy (G.O., M.G.)
| | - Nicola Giannini
- Clinica Neurologica, Azienda Ospedaliero Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., G.O., N.G., G.G., A.C.)
| | - Gino Gialdini
- Clinica Neurologica, Azienda Ospedaliero Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., G.O., N.G., G.G., A.C.)
| | - Tiziana Tassinari
- Stroke Unit, Department of Neurology, Santa Corona Hospital, Pietra Ligure (Savona), Italy (T.T.)
| | | | - Giorgio Bono
- Stroke Unit, Department of Neurology, Insubria University, Varese, Italy (M.L.D.L., G.B.)
| | - Christina Rueckert
- Abteilung für Neurologie, Oberschwabenklinik gGmbH, Ravensburg, Germany (C.R.)
| | - Antonio Baldi
- Stroke Unit, Ospedale di Portogruaro, Venice, Italy (A.B., S.D.)
| | | | - Danilo Toni
- Department of Neurology and Psychiatry, Sapienza University of Rome, Italy (D.T., F.L., A.P.)
| | - Federica Letteri
- Department of Neurology and Psychiatry, Sapienza University of Rome, Italy (D.T., F.L., A.P.)
| | | | - Enrico Maria Lotti
- U.O. Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Italy (E.M.L.)
| | - Yuriy Flomin
- Stroke and Neurorehabilitation Unit, MC Universal Clinic 'Oberig', Kyiv, Ukraine (Y.F.)
| | - Alessio Pieroni
- Department of Neurology and Psychiatry, Sapienza University of Rome, Italy (D.T., F.L., A.P.)
| | | | | | - Serena Monaco
- Stroke Unit, Ospedale Civico, Palermo, Italy (S.M., M.M.B.)
| | | | - Laszló Csiba
- Stroke Unit, University of Debrecen, Hungary (L.C., L.S.)
| | - Lilla Szabó
- Stroke Unit, University of Debrecen, Hungary (L.C., L.S.)
| | - Alberto Chiti
- Clinica Neurologica, Azienda Ospedaliero Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., G.O., N.G., G.G., A.C.).,Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy (A.C., E.G., M.D.S.)
| | - Elisa Giorli
- Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy (A.C., E.G., M.D.S.)
| | - Massimo Del Sette
- Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy (A.C., E.G., M.D.S.).,Divisione di Neurologia, Ospedale Galliera, Genoa, Italy (M.D.S.)
| | - Davide Imberti
- Department of Internal Medicine, Ospedale Civile di Piacenza, Italy (D.I., D.Z.)
| | - Dorjan Zabzuni
- Department of Internal Medicine, Ospedale Civile di Piacenza, Italy (D.I., D.Z.)
| | - Boris Doronin
- Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital No. 1, Novosibirsk State Medical University, Russia (B.D., V.V.)
| | - Vera Volodina
- Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital No. 1, Novosibirsk State Medical University, Russia (B.D., V.V.)
| | - Patrik Michel
- Département des Neurosciences Cliniques, Centre Cérébrovasculaire, Service de Neurologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M.)
| | - Peter Vanacker
- Department of Neurology, Born Bunge Institute, Antwerp University Hospital, Belgium (P.V.)
| | - Kristian Barlinn
- Department of Neurology, Dresden University Stroke Center, Germany (K.B., L.-P.P., J.B.)
| | - Lars-Peder Pallesen
- Department of Neurology, Dresden University Stroke Center, Germany (K.B., L.-P.P., J.B.)
| | - Jessica Barlinn
- Department of Neurology, Dresden University Stroke Center, Germany (K.B., L.-P.P., J.B.)
| | - Dirk Deleu
- Neurology, Hamad Medical Corporation, Doha, Qatar (D.D., G. Melikyan, F.I., N.A.)
| | - Gayane Melikyan
- Neurology, Hamad Medical Corporation, Doha, Qatar (D.D., G. Melikyan, F.I., N.A.)
| | - Faisal Ibrahim
- Neurology, Hamad Medical Corporation, Doha, Qatar (D.D., G. Melikyan, F.I., N.A.)
| | - Naveed Akhtar
- Neurology, Hamad Medical Corporation, Doha, Qatar (D.D., G. Melikyan, F.I., N.A.)
| | | | - Maurizio Paciaroni
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (R.A., V.C., G.A., C.B., A.A., M.V., M.A., C.D., M.G.M., L.A.C., J.F., M.P.)
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Kalinin MN, Khasanova DR, Ibatullin MM. A comprehensive assessment of brain perfusion data in patients with acute ischemic stroke for prediction of hemorrhagic transformation. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:24-36. [DOI: 10.17116/jnevro201911903224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Leiva-Salinas C, Jiang B, Wintermark M. Computed Tomography, Computed Tomography Angiography, and Perfusion Computed Tomography Evaluation of Acute Ischemic Stroke. Neuroimaging Clin N Am 2018; 28:565-572. [DOI: 10.1016/j.nic.2018.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Carlos Leiva-Salinas
- Division of Neuroradiology, Department of Radiology, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA
| | - Bin Jiang
- Division of Neuroradiology, Department of Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Max Wintermark
- Division of Neuroradiology, Department of Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA.
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Lee YB, Yoon W, Lee YY, Kim SK, Baek BH, Kim JT, Park MS. Predictors and impact of hemorrhagic transformations after endovascular thrombectomy in patients with acute large vessel occlusions. J Neurointerv Surg 2018; 11:469-473. [DOI: 10.1136/neurintsurg-2018-014080] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 08/29/2018] [Accepted: 09/07/2018] [Indexed: 01/23/2023]
Abstract
BackgroundPredictors and impact of hemorrhagic transformation (HT) after thrombectomy remain to be elucidated.ObjectiveTo investigate the independent predictors and impact of each hemorrhagic infarction (HI) and parenchymal hematoma (PH) after thrombectomy in patients with acute stroke due to intracranial large vessel occlusion (LVO).Materials and methodsWe retrospectively reviewed data from 400 patients with acute LVO who underwent thrombectomy. Logistic regression analyses were performed to determine independent predictors of HI and PH on post-treatment CT scans. Associations between HT and poor outcome (modified Rankin Scalescore ≥3) at 90 days were analyzed.ResultsHT was observed in 98 patients (62 HIs (15.5%) and 36 PHs (9%)). Independent predictors of HI were male sex, atrial fibrillation, and time from symptom onset to groin puncture. Hyperlipidemia (OR=0.221, 95% CI 0.064 to 0.767, P=0.017) and successful reperfusion (OR=0.246, 95% CI 0.093 to 0.651, P=0.005) were independently associated with a lower chance of PH, while hypertension (OR=2.260, 95% CI 1.014 to 5.035, P=0.046) and longer procedure duration (OR=1.046, 95% CI 1.016 to 1.077, P=0.003) were independently associated with a higher chance of PH. Only PH (OR=10.154, 95% CI 3.260 to 31.632, P<0.001) was an independent predictor of poor outcome.ConclusionsPH is independently associated with poor outcome, whereas HI does not predict outcome after thrombectomy in patients with acute LVO. Our findings suggest that rapid and successful reperfusion is essential to prevent PH in patients undergoing thrombectomy for acute LVO. In addition, our study suggests that hyperlipidemia is associated with a lower risk of PH in such patients.
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