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Piqueras-Sanchez C, Esteve-Pastor MA, Moreno-Fernandez J, Soler-Espejo E, Rivera-Caravaca JM, Roldán V, Marín F. Advances in the medical treatment and diagnosis of intracranial hemorrhage associated with oral anticoagulation. Expert Rev Neurother 2024; 24:913-928. [PMID: 39039686 DOI: 10.1080/14737175.2024.2379413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 07/09/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION With the increasing prevalence of atrial fibrillation (AF), it entails expanding oral anticoagulants (OACs) use, carrying a higher risk of associated hemorrhagic events, including intracranial hemorrhage (ICH). Despite advances in OACs development with a better safety profile and reversal agent for these anticoagulants, there is still no consensus on the optimal management of patients with OACs-associated ICH. AREAS COVERED In this review, the authors have carried out an exhaustive search on the advances in recent years. The authors provide an update on the management of ICH in anticoagulated patients, as well as an update on the latest evidence on anticoagulation resumption, recent therapeutic strategies, and investigational drugs that could play a role in the future. EXPERT OPINION Following an ICH event in an anticoagulated patient, a comprehensive clinical evaluation is imperative. Anticoagulation should be promptly withdrawn and reversed. Once the patient is stabilized, a reintroduction of anticoagulation should be considered, typically within a timeframe of 4-8 weeks, if feasible. If re-anticoagulation is not possible, alternative options such as Left Atrial Appendage Occlusion are available.
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Affiliation(s)
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- CIBERCV, Murcia, Spain
| | - Jorge Moreno-Fernandez
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Eva Soler-Espejo
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- Department of Hematology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | | | - Vanessa Roldán
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- Department of Hematology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- CIBERCV, Murcia, Spain
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Abramovitz Fouks A, Yaghi S, Gokcal E, Das AS, Rotschild O, Silverman SB, Singhal AB, Romero J, Kapur S, Greenberg SM, Gurol ME. Left atrial appendage closure for patients with atrial fibrillation at high intracranial haemorrhagic risk. Stroke Vasc Neurol 2024:svn-2024-003142. [PMID: 38821554 DOI: 10.1136/svn-2024-003142] [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: 01/23/2024] [Accepted: 04/14/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Although left atrial appendage closure (LAAC) is performed in patients with non-valvular atrial fibrillation (NVAF) at increased risk of intracranial haemorrhage (ICH), outcome data are scarce. We assessed the detailed neurological indications for LAAC and outcomes after LAAC in high ICH risk patients. METHODS Study population included consecutive patients with NVAF who underwent LAAC in a single hospital network between January 2015 and October 2021 because of prior ICH or the presence of high ICH risk imaging markers on brain MRI (cerebral microbleeds (CMBs)). Primary safety and efficacy outcome measures were the occurrence of ICH and thromboembolic events, respectively, after LAAC. RESULTS Among 146 patients with NVAF who underwent LAAC for high ICH risk, 122 had a history of ICH, while 24 presented with high ICH risk imaging markers only. Mean age was 75.7±7.61, 42 (28.8%) were women. Mean CHA2DS2-VASc score was 5.23±1.52. Of 122 patients with ICH history, 58 (47.5%) had intraparenchymal haemorrhage (IPH), 40 (32.8%) had traumatic ICH (T-ICH) and 18 (14.7%) had non-traumatic subdural haemorrhage. Of 85 patients with brain MRIs including necessary sequences, 43 (50.6%) were related to cerebral amyloid angiopathy and 37 (43.5%) to hypertensive microangiopathy. While 70% of patients were discharged on oral anticoagulants (OAC), 92% were not taking OAC at 1 year. Over 2.12 years mean follow-up, one patient had recurrent non-traumatic IPH (incidence rate (IR) 0.32 per 100 patient-years), five had T-ICH (IR 1.61 per 100 patient-years) and six had an ischaemic stroke (IR 1.94 per 100 patient-years). CONCLUSIONS Among patients with NVAF at high ICH risk, LAAC demonstrated a low risk of recurrent ICH or ischaemic stroke compared with previously published data. LAAC in high ICH risk populations should be considered in clinical practice per FDA approval and recent guidelines.
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Affiliation(s)
| | - Shadi Yaghi
- Neurology, Brown University, Warren Alpert Medical School, Providence, RI, USA
| | - Elif Gokcal
- Neurology, Massachussets General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alvin S Das
- Neurology, Massachussets General Hospital, Harvard Medical School, Boston, MA, USA
- Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ofer Rotschild
- Neurology, Massachussets General Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott B Silverman
- Neurology, Massachussets General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aneesh B Singhal
- Neurology, Massachussets General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jorge Romero
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sunil Kapur
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven M Greenberg
- Neurology, Massachussets General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mahmut Edip Gurol
- Neurology, Massachussets General Hospital, Harvard Medical School, Boston, MA, USA
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Jia S, Liu X, Qu H, Jia X. Observation of the Therapeutic Effect of Dual Antiplatelet Therapy with Aspirin and Clopidogrel on the Incidence, Characteristics, and Outcome in Acute Ischemic Stroke Patients with Cerebral Microbleeds at a Teaching Hospital, China. Int J Gen Med 2024; 17:2327-2336. [PMID: 38803551 PMCID: PMC11128718 DOI: 10.2147/ijgm.s459323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 04/30/2024] [Indexed: 05/29/2024] Open
Abstract
Background Cerebral microbleeds (CMBs) are an important risk factor for stroke recurrence and prognosis. However, there is no consensus on the safety of antiplatelet therapy in patients with ischemic stroke and CMBs. Objective This study aimed to observe the effects of dual antiplatelet therapy with aspirin and clopidogrel on bleeding conversion in patients with different degrees of CMBs. Materials and Methods An observational retrospective study was conducted on 160 patients with acute mild ischemic stroke admitted to the Stroke Center, Affiliated Hospital of Beihua University between March 2021 and December 2022. Patients were divided into the CMBs and non-CMB groups. The CMB group was then divided into the low, medium and high-risk groups. In two groups, all patients were administered dual antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg orally once a day for 21 days according to the Chinese Stroke Guidelines of 2018), and no other anticoagulant or antiplatelet drugs were administered during the treatment period. Head CT, National Institutes of Health Stroke Scale(NIHSS) and modified Rankin Scale (mRS) score were re-checked, and the number of bleeding conversions was calculated at 21 days. Results Five patients in the CMB group had intracranial hemorrhage (5/116, 4.3%), while no intracranial hemorrhage was observed in the non-CMB group. There were no differences in the conversion rate of cerebral hemorrhage, NIHSS score, or mRS score between two groups after dual antiplatelet therapy (p>0.05). The conversion rate of cerebral hemorrhage in the high-risk group was higher than that in the non-CMB group (p<0.05), but the NIHSS and mRS score showed no difference between the high-risk and non-CMB groups (p>0.05). Conclusion Dual antiplatelet therapy with aspirin and clopidogrel does not significantly increase the risk of bleeding transformation; however, it improves neurological recovery or long-term prognosis in patients with acute ischemic cerebral stroke complicated by low-risk and middle-risk CMBs.
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Affiliation(s)
- Shaojie Jia
- Stroke Center, Affiliated Hospital, Beihua University, Jilin, 132011, People’s Republic of China
- Department of Orthopedics, Affiliated Hospital, Beihua University, Jilin, 132011, People’s Republic of China
| | - Xin Liu
- Department of Neurology II, Affiliated Hospital, Beihua University, Jilin, 132011, People’s Republic of China
| | - Hongyan Qu
- Department of Neurology II, Affiliated Hospital, Beihua University, Jilin, 132011, People’s Republic of China
| | - Xiaojing Jia
- Stroke Center, Affiliated Hospital, Beihua University, Jilin, 132011, People’s Republic of China
- Department of Neurology II, Affiliated Hospital, Beihua University, Jilin, 132011, People’s Republic of China
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4
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Zhao B, Yuan Y, Li Z, Chen Y, Gao Y, Yang B, Wu J, Jia W. Risk of intracranial hemorrhage in patients using anticoagulant therapy for atrial fibrillation after cerebral microbleeds combined with acute ischemic stroke: a meta-analysis. Front Neurol 2024; 15:1372231. [PMID: 38560733 PMCID: PMC10978779 DOI: 10.3389/fneur.2024.1372231] [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: 01/17/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Objective To evaluate intracerebral hemorrhage (ICH) risk in patients with ischemic stroke (IS) and cerebral microbleeds (CMBs) undergoing anticoagulation therapy for non-valvular atrial fibrillation (AF). Methods We conducted a comprehensive search across multiple databases, including Embase, PubMed, Cochrane, UpToDate, Scopus, WOS, and SinoMed. The search covered observational literature published from each database inception until February 1, 2023. We analyzed the prevalence of CMBs during the follow-up period, compared future ICH risk between patients with and without baseline CMBs (CMBs presence/absence, ≧5 CMBs), and examined factors influencing ICH occurrence in patients with CMBs. Also studied recurrent stroke during anticoagulation therapy, the risk of future ICH when white matter hyperintensity (WMH) and CMBs coexist, and the effects of anticoagulants vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) on future ICH. Results We included 7 articles involving 5,134 participants. The incidence of CMBs was 24%; baseline CMBs were associated with an increased ICH risk compared to patients without CMBs. ICH-risk was more significant in patients with baseline ≥5 CMBs. After anticoagulant therapy, ICH risk was higher than that of recurrent IS. The risk of future ICH was significantly increased with anticoagulant VKAs compared with NOAC. Conclusion Anticoagulant therapy for ischemic stroke patients with non-valvular AF and CMBs increases future ICH risk. Discontinuing anticoagulation due to ICH risk should be avoided. NOACs are safe and effective for patients with CMBs and IS.
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Affiliation(s)
- Bingqing Zhao
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Ye Yuan
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Zheng Li
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Ying Chen
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Yali Gao
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Baoling Yang
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Jingyi Wu
- University of Glasgow, Glasgow, United Kingdom
| | - Weihua Jia
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
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5
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Grainger BT, McFadyen JD, Tran H. Between a rock and a hard place: resumption of oral anticoagulant therapy after intracranial hemorrhage. J Thromb Haemost 2024; 22:594-603. [PMID: 37913910 DOI: 10.1016/j.jtha.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023]
Abstract
Intracranial hemorrhage (ICH) is the most feared and lethal complication of oral anticoagulant (OAC) therapy. Resumption of OAC after ICH has long posed a challenge for clinicians, complicated by the expanding range of anticoagulant agents available in modern clinical practice, including direct OACs and, more recently, factor XI and XII inhibitors. A review of the current literature found support for resuming OAC in the majority of patients after ICH based on pooled retrospective data showing that resumption is associated with a lower risk of mortality and thromboembolism without a significantly increased risk of recurrent hemorrhage. The optimal time to resume OAC is less clear; however, the available evidence suggests that the composite risk of both recurrent hemorrhage and thromboembolism is likely minimized, somewhere between 4 and 6 weeks, after ICH in most patients. Specific considerations to guide the optimal resumption time in the individual patient include ICH location, mechanism, and anticoagulant class. Patients with mechanical heart valves and intracerebral malignancy represent high-risk groups who require more nuanced decision making. Here, we appraise the literature with the aim of providing a practical guide for clinicians while also discussing priorities for future investigation.
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Affiliation(s)
- Brian T Grainger
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia.
| | - James D McFadyen
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia; Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Huyen Tran
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia; Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Moutzouri E, Glutz M, Abolhassani N, Feller M, Adam L, Gencer B, Del Giovane C, Bétrisey S, Paladini RE, Hennings E, Aeschbacher S, Beer JH, Moschovitis G, Seiffge D, De Marchis GM, Coslovsky M, Reichlin T, Conte G, Sinnecker T, Schwenkglenks M, Bonati LH, Kastner P, Aujesky D, Kühne M, Osswald S, Fischer U, Conen D, Rodondi N. Association of statin use and lipid levels with cerebral microbleeds and intracranial hemorrhage in patients with atrial fibrillation: A prospective cohort study. Int J Stroke 2023; 18:1219-1227. [PMID: 37243540 PMCID: PMC10676039 DOI: 10.1177/17474930231181010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/02/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND An increased risk of intracranial hemorrhage (ICH) associated with statins has been reported, but data on the relationship between statin use and cerebral microbleeds (CMBs) in patients with atrial fibrillation (AF), a population at high bleeding and cardiovascular risk, are lacking. AIMS To explore the association between statin use and blood lipid levels with the prevalence and progression of CMBs in patients with AF with a particular focus on anticoagulated patients. METHODS Data of Swiss-AF, a prospective cohort of patients with established AF, were analyzed. Statin use was assessed during baseline and throughout follow-up. Lipid values were measured at baseline. CMBs were assessed using magnetic resonance imagining (MRI) at baseline and at 2 years follow-up. Imaging data were centrally assessed by blinded investigators. Associations of statin use and low-density lipoprotein (LDL) levels with CMB prevalence at baseline or CMB progression (at least one additional or new CMB on follow-up MRI at 2 years compared with baseline) were assessed using logistic regression models; the association with ICH was assessed using flexible parametric survival models. Models were adjusted for hypertension, smoking, body mass index, diabetes, stroke/transient ischemic attack, coronary heart disease, antiplatelet use, anticoagulant use, and education. RESULTS Of the 1693 patients with CMB data at baseline MRI (mean ± SD age 72.5 ± 8.4 years, 27.6% women, 90.1% on oral anticoagulants), 802 patients (47.4%) were statin users. The multivariable adjusted odds ratio (adjOR) for CMBs prevalence at baseline for statin users was 1.10 (95% CI = 0.83-1.45). AdjOR for 1 unit increase in LDL levels was 0.95 (95% CI = 0.82-1.10). At 2 years, 1188 patients had follow-up MRI. CMBs progression was observed in 44 (8.0%) statin users and 47 (7.4%) non-statin users. Of these patients, 64 (70.3%) developed a single new CMB, 14 (15.4%) developed 2 CMBs, and 13 developed more than 3 CMBs. The multivariable adjOR for statin users was 1.09 (95% CI = 0.66-1.80). There was no association between LDL levels and CMB progression (adjOR 1.02, 95% CI = 0.79-1.32). At follow-up 14 (1.2%) statin users had ICH versus 16 (1.3%) non-users. The age and sex adjusted hazard ratio (adjHR) was 0.75 (95% CI = 0.36-1.55). The results remained robust in sensitivity analyses excluding participants without anticoagulants. CONCLUSIONS In this prospective cohort of patients with AF, a population at increased hemorrhagic risk due to anticoagulation, the use of statins was not associated with an increased risk of CMBs.
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Affiliation(s)
- Elisavet Moutzouri
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Glutz
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Nazanin Abolhassani
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health, (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Martin Feller
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Luise Adam
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Baris Gencer
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of Cardiology, HUG, University Hospital Geneva, Geneva, Switzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Sylvain Bétrisey
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Rebecca E Paladini
- Cardiovascular Research Institute Basel, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Elisa Hennings
- Cardiovascular Research Institute Basel, Basel University Hospital, University of Basel, Basel, Switzerland
- Cardiology Division, Department of Medicine, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Stefanie Aeschbacher
- Cardiovascular Research Institute Basel, Basel University Hospital, University of Basel, Basel, Switzerland
- Cardiology Division, Department of Medicine, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Jürg H Beer
- Department of Medicine, Cantonal Hospital of Baden and Center for Molecular Cardiology, University Hospital of Zurich, Zurich, Switzerland
| | - Giorgio Moschovitis
- Cardiology Division, Regional Hospital of Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Michael Coslovsky
- Cardiovascular Research Institute Basel, Basel University Hospital, University of Basel, Basel, Switzerland
- Department Clinical Research, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Tobias Reichlin
- Division of Cardiology, Department of Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Giulio Conte
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Tim Sinnecker
- Department of Neurology and Stroke Center, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Matthias Schwenkglenks
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, Basel University Hospital, University of Basel, Basel, Switzerland
| | | | - Drahomir Aujesky
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Kühne
- Cardiovascular Research Institute Basel, Basel University Hospital, University of Basel, Basel, Switzerland
- Cardiology Division, Department of Medicine, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Stefan Osswald
- Cardiovascular Research Institute Basel, Basel University Hospital, University of Basel, Basel, Switzerland
- Cardiology Division, Department of Medicine, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology and Stroke Center, Basel University Hospital, University of Basel, Basel, Switzerland
| | - David Conen
- Division of Cardiology, Department of Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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7
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Mitchell A, Elmasry Y, van Poelgeest E, Welsh TJ. Anticoagulant use in older persons at risk for falls: therapeutic dilemmas-a clinical review. Eur Geriatr Med 2023; 14:683-696. [PMID: 37392359 PMCID: PMC10447288 DOI: 10.1007/s41999-023-00811-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/02/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE The aim of this clinical narrative review was to summarise the existing knowledge on the use of anticoagulants and potential adverse events in older people at risk of falls with a history of atrial fibrillation or venous thromboembolism. The review also offers practical steps prescribers can take when (de-)prescribing anticoagulants to maximise safety. METHODS Literature searches were conducted using PubMed, Embase and Scopus. Additional articles were identified by searching reference lists. RESULTS Anticoagulants are often underused in older people due to concerns about the risk of falls and intracranial haemorrhage. However, evidence suggests that the absolute risk is low and outweighed by the reduction in stroke risk. DOACs are now recommended first line for most patients due to their favourable safety profile. Off-label dose reduction of DOACs is not recommended due to reduced efficacy with limited reduction in bleeding risk. Medication review and falls prevention strategies should be implemented before prescribing anticoagulation. Deprescribing should be considered in severe frailty, limited life expectancy and increased bleeding risk (e.g., cerebral microbleeds). CONCLUSION When considering whether to (de-)prescribe anticoagulants, it is important to consider the risks associated with stopping therapy in addition to potential adverse events. Shared decision-making with the patient and their carers is crucial as patient and prescriber views often differ.
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Affiliation(s)
- Anneka Mitchell
- Research Institute for the Care of Older People (RICE), Bath, UK.
- Pharmacy Department, University Hospitals Plymouth NHS Trust, Plymouth, UK.
- Life Sciences Department, University of Bath, Bath, UK.
| | - Yasmin Elmasry
- Pharmacy Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Tomas J Welsh
- Research Institute for the Care of Older People (RICE), Bath, UK
- Bristol Medical School, University of Bristol, Bristol, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
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8
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Role of cerebral microbleeds in acute ischemic stroke and atrial fibrillation. J Thromb Thrombolysis 2022; 55:553-565. [PMID: 36571659 DOI: 10.1007/s11239-022-02761-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2022] [Indexed: 12/27/2022]
Abstract
Cerebral microbleeds (CMBs) are commonly detected in the brains of patients with acute ischemic stroke (AIS). With the development of neuroimaging, clinicians are paying more attention to the presence of CMBs. CMBs were found to significantly increase the risk of intracranial hemorrhagic transformation and hemorrhage in patients with AIS, especially in patients with concurrent atrial fibrillation (AF). Additionally, the presence of CMBs is thought to be a symbol of a high risk of recurrent ischemic stroke (IS). A few researchers have found that the presence of CMBs has no significant effect on the prognosis of patients with AIS. Therefore, the current views on the role of CMBs in the prognoses of patients with IS are controversial. The use of anticoagulants and other drugs has also become a dilemma due to the special influence of CMBs on the prognosis of these patients. Due to the large number of patients with AF and CMBs, many studies have been conducted on the effects of CMBs on these patients and subsequent pharmacological treatments. However, at present, there are no relevant guidelines to guide the secondary preventive treatment of patients with stroke, CMBs, and AF. In this paper, we summarized the role of CMBs in AIS combined with AF and relevant preventive measures against the recurrence of stroke and the occurrence of intracerebral hemorrhage to help clarify the specifics of drug therapies for this group of patients.
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9
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Austin TR, Jensen PN, Nasrallah IM, Habes M, Rashid T, Ware JB, Chen LY, Greenland P, Hughes TM, Post WS, Shea SJ, Watson KE, Sitlani CM, Floyd JS, Kronmal RA, Longstreth WT, Bertoni AG, Shah SJ, Bryan RN, Heckbert SR. Left Atrial Function and Arrhythmias in Relation to Small Vessel Disease on Brain MRI: The Multi-Ethnic Study of Atherosclerosis. J Am Heart Assoc 2022; 11:e026460. [PMID: 36250665 PMCID: PMC9673671 DOI: 10.1161/jaha.122.026460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Atrial fibrillation (AF) is associated with increased stroke risk and accelerated cognitive decline, but the association of early manifestations of left atrial (LA) impairment with subclinical changes in brain structure is unclear. We investigated whether abnormal LA structure and function, greater supraventricular ectopy, and intermittent AF are associated with small vessel disease on magnetic resonance imaging of the brain. Methods and Results In the Multi‐Ethnic Study of Atherosclerosis, 967 participants completed 14‐day ambulatory electrocardiographic monitoring, speckle tracking echocardiography and, a median 17 months later, magnetic resonance imaging of the brain. We assessed associations of LA volume index and reservoir strain, supraventricular ectopy, and prevalent AF with brain magnetic resonance imaging measures of small vessel disease and atrophy. The mean age of participants was 72 years; 53% were women. In multivariable models, LA enlargement was associated with lower white matter fractional anisotropy and greater prevalence of microbleeds; reduced LA strain, indicating worse LA function, was associated with more microbleeds. More premature atrial contractions were associated with lower total gray matter volume. Compared with no AF, intermittent AF (prevalent AF with <100% AF during electrocardiographic monitoring) was associated with lower white matter fractional anisotropy (−0.25 SDs [95% CI, −0.44 to −0.07]) and greater prevalence of microbleeds (prevalence ratio: 1.42 [95% CI, 1.12–1.79]). Conclusions In individuals without a history of stroke or transient ischemic attack, alterations of LA structure and function, including enlargement, reduced strain, frequent premature atrial contractions, and intermittent AF, were associated with increased markers of small vessel disease. Detailed assessment of LA structure and function and extended ECG monitoring may enable early identification of individuals at greater risk of small vessel disease.
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Affiliation(s)
- Thomas R Austin
- Department of Epidemiology University of Washington Seattle WA
| | - Paul N Jensen
- Department of Medicine University of Washington Seattle WA
| | - Ilya M Nasrallah
- Center for Biomedical Image Computing and Analytics, Department of Radiology University of Pennsylvania Philadelphia PA
| | - Mohamad Habes
- Neuroimage Analytics Laboratory and the Biggs Institute Neuroimaging Core Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases, University of Texas Health Science Center, San Antonio TX
| | - Tanweer Rashid
- Neuroimage Analytics Laboratory and the Biggs Institute Neuroimaging Core Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases, University of Texas Health Science Center, San Antonio TX
| | - Jeffrey B Ware
- Department of Radiology University of Pennsylvania Philadelphia PA
| | - Lin Yee Chen
- Cardiovascular Division, Department of Medicine University of Minnesota Medical School Minneapolis MN
| | - Philip Greenland
- Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Division of Cardiology, Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Timothy M Hughes
- Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Wendy S Post
- Division of Cardiology, Department of Medicine Johns Hopkins University Baltimore MD
| | - Steven J Shea
- Departments of Medicine and Epidemiology Columbia University New York NY
| | - Karol E Watson
- Department of Medicine, David Geffen School of Medicine University of California Los Angeles CA
| | | | - James S Floyd
- Department of Epidemiology University of Washington Seattle WA.,Department of Medicine University of Washington Seattle WA
| | | | - W T Longstreth
- Department of Epidemiology University of Washington Seattle WA.,Department of Neurology University of Washington Seattle WA
| | - Alain G Bertoni
- Department of Epidemiology and Prevention Wake Forest School of Medicine Winston-Salem NC
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - R Nick Bryan
- Department of Radiology University of Pennsylvania Philadelphia PA
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10
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Wagner B, Hert L, Polymeris AA, Schaedelin S, Lieb JM, Seiffge DJ, Traenka C, Thilemann S, Fladt J, Altersberger VL, Zietz A, Dittrich TD, Fisch U, Gensicke H, De Marchis GM, Bonati LH, Lyrer PA, Engelter ST, Peters N. Impact of type of oral anticoagulants in patients with cerebral microbleeds after atrial fibrillation-related ischemic stroke or TIA: Results of the NOACISP-LONGTERM registry. Front Neurol 2022; 13:964723. [PMID: 36203998 PMCID: PMC9531011 DOI: 10.3389/fneur.2022.964723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCerebral microbleeds (CMBs) may have a differential impact on clinical outcome in stroke patients with atrial fibrillation (AF) treated with different types of oral anticoagulation (OAC).MethodsObservational single-center study on AF-stroke-patients treated with OAC. Magnetic-resonance-imaging was performed to assess CMBs. Outcome measures consisted of recurrent ischemic stroke (IS), intracranial hemorrhage (ICH), death, and their combined analysis. Functional disability was assessed by mRS. Using adjusted logistic regression and Cox proportional-hazards models, we assessed the association of the presence of CMBs and OAC type (vitamin K antagonists [VKAs] vs. direct oral anticoagulants [DOACs]) with clinical outcome.ResultsOf 310 AF-stroke patients treated with OAC [DOACs: n = 234 (75%); VKAs: n = 76 (25%)], CMBs were present in 86 (28%) patients; of these, 66 (77%) received DOACs. In both groups, CMBs were associated with an increased risk for the composite outcome: VKAs: HR 3.654 [1.614; 8.277]; p = 0.002; DOACs: HR 2.230 [1.233; 4.034]; p = 0.008. Patients with CMBs had ~50% higher absolute rates of the composite outcome compared to the overall cohort, with a comparable ratio between treatment groups [VKAs 13/20(65%) vs. DOACs 19/66(29%); p < 0.01]. The VKA-group had a 2-fold higher IS [VKAs:4 (20%) vs. DOACs:6 (9%); p = 0.35] and a 10-fold higher ICH rate [VKAs: 3 (15%) vs. DOACs: 1 (1.5%); p = 0.038]. No significant interaction was observed between type of OAC and presence of CMBs. DOAC-patients showed a significantly better functional outcome (OR 0.40 [0.17; 0.94]; p = 0.04).ConclusionsIn AF-stroke patients treated with OAC, the presence of CMBs was associated with an unfavorable composite outcome for both VKAs and DOACs, with a higher risk for recurrent IS than for ICH. Strokes were numerically higher under VKAs and increased in the presence of CMBs.Clinical trial registrationhttp://www.clinicaltrials.gov, Unique identifier: NCT03826927.
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Affiliation(s)
- Benjamin Wagner
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lisa Hert
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Intensive Care Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alexandros A. Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sabine Schaedelin
- Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Johanna M. Lieb
- Department of Diagnostic and Interventional Neuroradiology, Clinic for Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David J. Seiffge
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter and Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Joachim Fladt
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Valerian L. Altersberger
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tolga D. Dittrich
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Urs Fisch
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter and Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H. Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Philippe A. Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Stefan T. Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter and Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter and Department of Clinical Research, University of Basel, Basel, Switzerland
- Stroke Center, Klinik Hirslanden Zurich, Zurich, Switzerland
- *Correspondence: Nils Peters
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11
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Zhao DX, Gootee E, Johansen MC. Atrial cardiopathy is associated with cerebral microbleeds in ischemic stroke patients. Front Neurol 2022; 13:982926. [PMID: 36119677 PMCID: PMC9475192 DOI: 10.3389/fneur.2022.982926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveCerebral microbleeds (CMB) are small accumulations of hemosiderin associated with cerebrovascular risk factors, but whether they are associated with atrial cardiopathy is not known. The goal of this study is to determine, among ischemic stroke patients, the association between study-defined atrial cardiopathy and CMB presence, location, and number.MethodsIschemic stroke patients admitted to Johns Hopkins (2015–2019) with transthoracic echocardiography and electrocardiography were included. Cerebral microbleeds were defined as small, round hypo-intensities on T2* susceptibility weighted imaging or gradient recalled echo magnetic resonance imaging sequences. Atrial cardiopathy was defined as the presence of ≥1: left atrium diameter >4.0 cm (males) or >3.8 cm (females), PR interval >200 ms, or N-terminal pro-B-type natriuretic peptide >250 pg/ml. Binary/Ordinal logistic regression models were used to determine the association between atrial cardiopathy, and cerebral microbleed presence, location (lobar/deep), or number, each, adjusted for potential confounders.ResultsPatients (N = 120) were mean age 60 years (range 22–98), 46% female, 62% black, and 39% were on anti-thrombotic medication at time of admission. 39 (32%) participants had ≥1 cerebral microbleeds. Forty-six (38%) patients had atrial cardiopathy. Atrial cardiopathy was associated with higher odds of having cerebral microbleeds (OR 2.50, 95% CI 1.02–6.15). Atrial cardiopathy was associated with lobar cerebral microbleeds (OR 2.33, 95% CI 1.01–5.37) in univariate analysis but not with deep cerebral microbleeds (OR 0.45, 95% CI 0.13–1.54), with neither association significant after adjustment. There was no difference in risk of having 1 vs. no cerebral microbleeds (RRR 2.51, 95% CI 0.75–8.37) and >1 cerebral microbleed vs none (RRR 2.57, 95% CI 0.87–7.60) among those with atrial cardiopathy.ConclusionsAtrial cardiopathy is associated with the presence, but not burden, of cerebral microbleeds in ischemic stroke patients. We cautiously suggest that atrial cardiopathy, either directly or through shared vascular risk, may contribute to the presence of CMB.
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12
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Timing of anticoagulation after acute ischemic stroke in patients with atrial fibrillation. Neurol Sci 2022:1-12. [PMID: 35762354 DOI: 10.1017/cjn.2022.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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13
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Meinel TR, Seiffge DJ. Reader Response: Cerebral Microbleeds and Treatment Effect of Intravenous Thrombolysis in Acute Stroke: An Analysis of the WAKE-UP Randomized Clinical Trial. Neurology 2022; 98:816-817. [PMID: 35534240 DOI: 10.1212/wnl.0000000000200611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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14
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Li Y, Gao H, Zhang D, Gao X, Lu L, Liu C, Li Q, Miao C, Ma H, Li Y. Clinical Prediction Model for Screening Acute Ischemic Stroke Patients With More Than 10 Cerebral Microbleeds. Front Neurol 2022; 13:833952. [PMID: 35463120 PMCID: PMC9021829 DOI: 10.3389/fneur.2022.833952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 03/08/2022] [Indexed: 11/30/2022] Open
Abstract
Background Hemorrhagic transformation is one of the most serious complications in intravenous thrombolysis. Studies show that the existence of more than 10 cerebral microbleeds is strongly associated with hemorrhagic transformation. The current study attempts to develop and validate a clinical prediction model of more than 10 cerebral microbleeds. Methods We reviewed the computed tomography markers of cerebral small vessel diseases and the basic clinical information of acute ischemic stroke patients who were investigated using susceptibility weighted imaging from 2018 to 2021. A clinical prediction model of more than 10 cerebral microbleeds was established. Discrimination, calibration, and the net benefit of the model were assessed. Finally, a validation was conducted to evaluate the accuracy and stability of the model. Results The multivariate logistic regression model showed hypertension, and some computed tomography markers (leukoaraiosis, lacunar infarctions, brain atrophy) were independent risk factors of more than 10 cerebral microbleeds. These risk factors were used for establishing the clinical prediction model. The area under the receiver operating characteristic curve (AUC) was 0.894 (95% CI: 0.870–0.919); Hosmer–Lemeshow chi-squared test yielded χ2 = 3.946 (P = 0.862). The clinical decision cure of the model was higher than the two extreme lines. The simplified score of the model ranged from 0 to 12. The model in the internal and external validation cohort also had good discrimination (AUC 0.902, 95% CI: 0.868–0.937; AUC 0.914, 95% CI: 0.882–0.945) and calibration (P = 0.157, 0.247), and patients gained a net benefit from the model. Conclusions We developed and validated a simple scoring tool for acute ischemic stroke patients with more than 10 cerebral microbleeds; this tool may be beneficial for paradigm decision regarding intravenous recombinant tissue plasminogen activator therapy of acute ischemic stroke.
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Affiliation(s)
- Yifan Li
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Haifeng Gao
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Dongsen Zhang
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Xuan Gao
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Lin Lu
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Chunqin Liu
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Qian Li
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Chunzhi Miao
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Hongying Ma
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
- *Correspondence: Hongying Ma
| | - Yongqiu Li
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
- Yongqiu Li
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15
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Diseases That Occur Prior to Spontaneous Intracerebral Hemorrhage: Identification of Predisposing and Risk Factors Using Lag Sequential Analysis. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:9733712. [PMID: 35368939 PMCID: PMC8975635 DOI: 10.1155/2022/9733712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 12/31/2021] [Accepted: 02/26/2022] [Indexed: 11/17/2022]
Abstract
Spontaneous intracerebral hemorrhage (sICH) has many predisposing/risk factors. Lag sequential analysis (LSA) is a method of analyzing sequential patterns and their associations within categorical data in different system states. The results of this study will assist in preventing sICH and improving the patient outcome after sICH. The correlations between a first sICH and previous clinic visits were examined using LSA with data obtained from the Taiwan National Health Insurance Research Database (NHIRD). In this study, LSA was employed to examine the data in the Taiwan NHIRD in order to identify predisposing and risk factors related to sICH, and the results increased our knowledge of the temporal relationships between diseases. This study employed LSA to identify predisposing/risk factors prior to the first occurrence of sICH using a healthcare administrative database in Taiwan. The data were managed using the clinical classification software (CCS). All cases of traumatic ICH were excluded. Ten disease groups were identified using CCS. Hypertension and dizziness/vertigo were identified as two important predisposing/risk factors for sICH, and early treatment of hypertension resulted in a greater survival rate. Five disease groups were found to have occurred prior to other diseases and affected mostly the elderly, resulting in subsequent sICH. The results of this study also showed that nutritional status and tooth health were highly associated with the occurrence of sICH owing to a poor state of the digestive system. In conclusion, there are many diseases that influence the risk of a subsequent sICH. This study demonstrated that LSA is a very useful tool for future study of healthcare administrative databases.
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16
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Corica B, Romiti GF, Raparelli V, Cangemi R, Basili S, Proietti M. Epidemiology of cerebral microbleeds and risk of adverse outcomes in atrial fibrillation: a systematic review and meta-analysis. Europace 2022; 24:1395-1403. [PMID: 35244694 DOI: 10.1093/europace/euac028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 02/18/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS The aim of this study is to perform a systematic review and meta-analysis on the epidemiology of cerebral microbleeds (CMBs) and the risk of intracranial haemorrhage (ICH) and ischaemic stroke (IS) in patients with atrial fibrillation (AF). METHODS AND RESULTS PubMed and EMBASE databases were systematically searched from inception to 6 March 2021. All studies reporting the prevalence of CMBs and incidence of ICH and IS in AF patients with and without CMBs were included. Meta-analysis was conducted using random-effect models; odds ratios (ORs), 95% confidence intervals (CIs), and prediction intervals (PIs) were calculated for each outcome. Subgroup analyses were performed according to the number and localization of CMBs. A total of 562 studies were retrieved, with 17 studies finally included in the meta-analysis. Prevalence of CMBs in AF population was estimated at 28.3% (95% CI: 23.8-33.4%). Individuals with CMBs showed a higher risk of ICH (OR: 3.04, 95% CI: 1.83-5.06, 95% PI 1.23-7.49) and IS (OR: 1.78, 95% CI: 1.26-2.49, 95% PI 1.10-2.87). Patients with ≥5 CMBs showed a higher risk of ICH. Metaregression showed how higher of prevalence of diabetes mellitus in AF cohort is associated with higher prevalence of CMBs. CONCLUSIONS Cerebral microbleeds are common in patients with AF, found in almost one out of four subjects. Cerebral microbleeds were associated with both haemorrhagic and thromboembolic events in AF patients. Moreover, the risk of ICH increased consistently with the burden of CMBs. Cerebral microbleeds may represent an important overlooked risk factor for both ICH and IS in adults with AF.
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Affiliation(s)
- Bernadette Corica
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Roberto Cangemi
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Via Camaldoli, 64, 20138 Milan, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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17
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Tanaka T, Gyanwali B, Villaraza SG, Saridin FN, Vrooman H, Ihara M, Reilhac A, Chen CLH, Hilal S. The Association Between Standard Electrocardiography and Cerebral Small Vessel Disease in a Memory Clinic Study. J Alzheimers Dis 2022; 86:1093-1105. [PMID: 35180121 DOI: 10.3233/jad-215413] [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: 11/15/2022]
Abstract
BACKGROUND P-wave terminal force in lead V1 (PTFV1) on electrocardiography has been associated with atrial fibrillation and ischemic stroke. OBJECTIVE To investigate whether PTFV1 is associated with cerebral small vessel disease (CSVD) markers and etiological subtypes of cognitive impairment and dementia. METHODS Participants were recruited from ongoing memory clinic study between August 2010 to January 2019. All participants underwent physical and medical evaluation along with an electrocardiography and 3 T brain magnetic resonance imaging. Participants were classified as no cognitive impairment, cognitive impairment no dementia, vascular cognitive impairment no dementia, and dementia subtypes (Alzheimer's disease and vascular dementia). Elevated PTFV1 was defined as > 4,000μV×ms and measured manually on ECG. RESULTS Of 408 participants, 78 (19.1%) had elevated PTFV1 (37 women [47%]; mean [SD] age, 73.8 [7.2] years). The participants with elevated PTFV1 had higher burden of lacunes, cerebral microbleeds (CMB), and cortical microinfarcts. As for the CMB location, persons with strictly deep CMB and mixed CMB had significantly higher PTFV1 than those with no CMB (p = 0.005, p = 0.007). Regardless of adjustment for cardiovascular risk factors and/or heart diseases, elevated PTFV1 was significantly associated with presence of CMB (odds ratio, 2.26; 95% CI,1.33-3.91). CONCLUSION Elevated PTFV1 was associated with CSVD, especially deep CMB. PTFV1 in vascular dementia was also higher compared to Alzheimer's disease. Thus, PTFV1 might be a potential surrogate marker of brain-heart connection and vascular brain damage.
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Affiliation(s)
- Tomotaka Tanaka
- Department of Pharmacology, National University of Singapore, Singapore.,Memory Aging & Cognition Centre, National University Health System, Singapore.,Clinical Imaging Research Centre, National University of Singapore, Singapore.,Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Bibek Gyanwali
- Memory Aging & Cognition Centre, National University Health System, Singapore.,Department of Biochemistry, National University of Singapore, Singapore
| | | | - Francis N Saridin
- Department of Pharmacology, National University of Singapore, Singapore.,Memory Aging & Cognition Centre, National University Health System, Singapore
| | - Henri Vrooman
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Anthonin Reilhac
- Clinical Imaging Research Centre, National University of Singapore, Singapore
| | - Christopher L H Chen
- Department of Pharmacology, National University of Singapore, Singapore.,Memory Aging & Cognition Centre, National University Health System, Singapore
| | - Saima Hilal
- Department of Pharmacology, National University of Singapore, Singapore.,Memory Aging & Cognition Centre, National University Health System, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
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18
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Lansberg MG, Wintermark M, Kidwell CS, Albers GW. Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00048-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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19
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Ward RC, Graff-Radford J, Ponamgi S, English S, Meskill A, Challa AB, Hodge DO, Slusser JP, Rabinstein AA, Asirvatham SJ, Holmes D, DeSimone CV. Time in therapeutic range of anticoagulation among patients with atrial fibrillation and cerebral amyloid angiopathy. Proc (Bayl Univ Med Cent) 2021; 35:162-167. [DOI: 10.1080/08998280.2021.2013393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Robert C. Ward
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Shiva Ponamgi
- Department of Cardiology, Creighton University, Omaha, Nebraska
| | | | - Alayna Meskill
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Apurva B. Challa
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - David O. Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida
| | - Joshua P. Slusser
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | | | | | - David Holmes
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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20
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Sun Y, Zheng H, Liu H, Jiang Z, Ren Y, Huang X, Wang L. Effect of Tirofiban on new cerebral microbleeds after mechanical thrombectomy in patients with acute ischemic stroke. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2021; 67:1564-1569. [PMID: 34909879 DOI: 10.1590/1806-9282.20210563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to analyze the effect of tirofiban on new cerebral microhemorrhage after mechanical thrombectomy in patients with acute ischemic stroke. METHODS In total, 203 patients with acute ischemic stroke treated by mechanical thrombectomy in our department of neurology were enrolled as the research objects. The patients were divided into two groups: the patients who used tirofiban within 24 h after surgery were assigned to the study group (78 subjects), while patients who did not use tirofiban were assigned to the conventional group (125 subjects). Magnetic resonance imaging was used to detect new-onset cerebral microbleeds in patients with stroke after surgery. The National Institute of Health Stroke Scale, modified ranking scale, and activity of daily living scale were used to assess the prognosis of patients, and the general data and the occurrence of adverse effects between two groups were compared to comprehensively evaluate the efficacy and safety of tirofiban. RESULTS The proportion of atrial fibrillation in the research group was significantly lower than that in the conventional group. The research group had a much lower rate of new-onset cerebral microbleeds than the conventional group (p<0.001). There was no significant difference in the proportion of adverse reactions between the two groups (p>0.05). CONCLUSION The application of tirofiban in mechanical thrombectomy of patients with acute ischemic stroke has high safety, effectively reduces the occurrence of new cerebral microhemorrhage, and provides a guarantee for patient safety.
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Affiliation(s)
- Yongdong Sun
- Jizhong Energy Fengfeng Group General Hospital, Department of Neurosurgery - Handan, China
| | - Hongjiang Zheng
- Jizhong Energy Fengfeng Group General Hospital, Department of Pathology - Handan, China
| | - Hui Liu
- Jizhong Energy Fengfeng Group General Hospital, Department of Neurosurgery - Handan, China
| | - Zhifeng Jiang
- Jizhong Energy Fengfeng Group General Hospital, Department of Neurosurgery - Handan, China
| | - Yongying Ren
- Jizhong Energy Fengfeng Group General Hospital, Department of Neurosurgery - Handan, China
| | - Xin Huang
- Jizhong Energy Fengfeng Group General Hospital, Department of Neurosurgery - Handan, China
| | - Lihua Wang
- Jizhong Energy Fengfeng Group General Hospital, Department of Neurosurgery - Handan, China
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Chen XT, Zhang Q, Zhou CQ, Han YF, Cao QQ. Anticoagulant treatment for pulmonary embolism in patient with cerebral hemorrhage secondary to mechanical thrombectomy: A case report. World J Clin Cases 2021; 9:10279-10285. [PMID: 34904100 PMCID: PMC8638063 DOI: 10.12998/wjcc.v9.i33.10279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/08/2021] [Accepted: 08/19/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cerebral hemorrhage secondary to cerebral embolism after mechanical thrombectomy is characterized by high morbidity, disability and mortality. If the patient also has severe pulmonary embolism (PE) at the same time, the treatment becomes more complex. This report describes the treatment strategy for a patient with PE and cerebral hemorrhage secondary to cerebral embolism after mechanical thrombectomy.
CASE SUMMARY A 70-year-old woman presented to our emergency department with right-sided hemiplegia and mixed aphasia of 2.5 h duration. She was diagnosed with left cerebral embolism, left internal carotid artery occlusion, PE and left calf intramuscular vein thrombosis. Following mechanical thrombectomy, brain magnetic resonance imaging showed cerebral infarction with basal ganglia hemorrhage. We observed changes in cerebral hemorrhage on serial monitoring of brain computed tomography and adjusted the dose of anticoagulant drugs. After 3 wk of treatment, the patient’s neurological and respiratory symptoms significantly improved, and a favorable prognosis was obtained.
CONCLUSION Anticoagulation could be a potential option for PE accompanied by hemorrhagic transformation of an ischemic infarct.
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Affiliation(s)
- Xiang-Ting Chen
- Department of Neurology, Bishan Hospital, First Affiliated Hospital of Chongqing Medical University, Chongqing 402760, China
| | - Qian Zhang
- Department of Neurology, Bishan Hospital, First Affiliated Hospital of Chongqing Medical University, Chongqing 402760, China
| | - Chang-Qing Zhou
- Department of Neurology, Bishan Hospital, First Affiliated Hospital of Chongqing Medical University, Chongqing 402760, China
| | - Yu-Fu Han
- Department of Neurology, Bishan Hospital, First Affiliated Hospital of Chongqing Medical University, Chongqing 402760, China
| | - Qing-Qing Cao
- Department of Neurology, Bishan Hospital, First Affiliated Hospital of Chongqing Medical University, Chongqing 402760, China
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22
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Wagner A, Maderer J, Wilfling S, Kaiser J, Kilic M, Linker RA, Schebesch KM, Schlachetzki F. Cerebrovascular Risk Factors in Possible or Probable Cerebral Amyloid Angiopathy, Modifier or Bystander? Front Neurol 2021; 12:676931. [PMID: 34354659 PMCID: PMC8335403 DOI: 10.3389/fneur.2021.676931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 06/07/2021] [Indexed: 11/13/2022] Open
Abstract
Goal: Cerebral amyloid angiopathy (CAA) is a frequent cause of atypical intracerebral hemorrhage (ICH) in the elderly. Stroke risk factors such as arterial hypertension (AHT), atrial fibrillation (AFib), diabetes mellitus (DM), and renal dysfunction (RD) are increasingly apparent in these patients. In this retrospective study, we analyzed the presence of these stroke risk factors in different initial CAA presentations comprising cerebral microbleeds (CMB), acute ischemic stroke (AIS), cortical superficial hemosiderosis (cSS), or lobar ICH (LICH) and evaluated their influence on the initial clinical presentation of patients with CAA. Material and Methods: We identified patients with at least possible CAA defined by the modified Boston criteria admitted to the Department of Neurology or Neurosurgery from 2002 to 2018. Findings: In the overall cohort of 209 patients, we analyzed the correlation between the number of stroke risk factors and the initial clinical presentation of patients with CAA and could show the high multimorbidity of the collective. There are large differences between the subgroups with different initial clinical presentations, e.g., patients with CMB as initial CAA presentation have the highest number of cerebrovascular risk factors and recurrent AIS, whereas AFib is more frequent in the Neurosurgery Department. Conclusion: There is a distinct overlap between the subgroups of CAA manifestations and stroke risk factors that need to be verified in larger patient collectives. Since these comorbidities are likely to influence the clinical course of CAA, they represent possible targets for secondary prevention until specific treatment for CAA becomes available.
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Affiliation(s)
- Andrea Wagner
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - Jonas Maderer
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - Sibylle Wilfling
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - Johanna Kaiser
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - Mustafa Kilic
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - Ralf A Linker
- Department of Neurology, University of Regensburg, Regensburg, Germany
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23
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Nagaraja N, Farooqui A, Bin Zahid A, Kaur S. Factors associated with the presence of cerebral microbleeds and its influence on outcomes of stroke not treated with alteplase. Clin Neurol Neurosurg 2021; 207:106798. [PMID: 34252690 DOI: 10.1016/j.clineuro.2021.106798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/02/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Cerebral microbleeds (CMB) are associated with increased risk of hemorrhagic transformation (HT) of ischemic stroke with alteplase. Whether the presence of CMB influences the risk of HT and discharge outcomes of stroke patients not receiving alteplase is unclear. We evaluated the factors associated with the presence of CMB, and if the rates of HT and discharge outcomes were modified by the presence of CMB among stroke patients not treated with alteplase. METHODS Ischemic stroke patients who had MRI and did not receive alteplase were included in the study. CMB, HT and white matter hyperintensity (WMH) were evaluated using Microbleed Anatomical Rating Scale, Heidelberg bleeding classification, and Fazekas scales, respectively. Multivariate regression analysis was performed to evaluate factors associated with the presence of CMB. RESULTS Among 196 patients in the study, 58 (30%) patients had CMB. Nine patients had ≥ 10 CMBs. Median National Institutes of Health stroke scale score was 4. In multivariate analysis, age (OR=1.07;95%CI=1.01-1.12), history of stroke (OR=3.10;95%CI=1.08-8.92), congestive heart failure (OR=7.26;95%CI=1.58-33.42), admission diastolic blood pressure (OR=1.03;95%CI=1.003-1.06) and severe WMH defined as Fazekas score 4-6 (OR=4.69;95%CI=1.80-12.23) were significantly associated with the presence of CMB. There was no difference in HT (10% vs 12%, p = 0.80) or discharge outcomes (modified Rankin Scale 0-2: 53% vs 57%, p = 0.62) of patients with CMB compared to those without CMB. CONCLUSION CMB are associated with severe WMH and higher diastolic blood pressure. CMB are not associated with the HT occurrence or discharge outcome of mild ischemic stroke in the absence of alteplase.
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Affiliation(s)
- Nandakumar Nagaraja
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.
| | - Amreen Farooqui
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Abdullah Bin Zahid
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Supreet Kaur
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
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24
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Graff-Radford J, Lesnick T, Rabinstein AA, Gunter JL, Przybelski SA, Noseworthy PA, Preboske GM, Mielke MM, Lowe VJ, Knopman DS, Petersen RC, Kremers WK, Jack CR, Vemuri P, Kantarci K. Cerebral Microbleeds: Relationship to Antithrombotic Medications. Stroke 2021; 52:2347-2355. [PMID: 33966498 DOI: 10.1161/strokeaha.120.031515] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Jonathan Graff-Radford
- Department of Neurology (J.G.-R., A.A.R., M.M.M., D.S.K., R.C.P.S), Mayo Clinic, Rochester, MN
| | - Timothy Lesnick
- Department of Health Sciences Research (T.L., S.A.P., M.M.M., W.K.K.), Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- Department of Neurology (J.G.-R., A.A.R., M.M.M., D.S.K., R.C.P.S), Mayo Clinic, Rochester, MN
| | - Jeffrey L Gunter
- Department of Radiology (J.L.G., G.M.P., V.J.L., C.R.J., P.V., K.K.), Mayo Clinic, Rochester, MN
| | - Scott A Przybelski
- Department of Health Sciences Research (T.L., S.A.P., M.M.M., W.K.K.), Mayo Clinic, Rochester, MN
| | | | - Gregory M Preboske
- Department of Radiology (J.L.G., G.M.P., V.J.L., C.R.J., P.V., K.K.), Mayo Clinic, Rochester, MN
| | - Michelle M Mielke
- Department of Neurology (J.G.-R., A.A.R., M.M.M., D.S.K., R.C.P.S), Mayo Clinic, Rochester, MN.,Department of Health Sciences Research (T.L., S.A.P., M.M.M., W.K.K.), Mayo Clinic, Rochester, MN
| | - Val J Lowe
- Department of Radiology (J.L.G., G.M.P., V.J.L., C.R.J., P.V., K.K.), Mayo Clinic, Rochester, MN
| | - David S Knopman
- Department of Neurology (J.G.-R., A.A.R., M.M.M., D.S.K., R.C.P.S), Mayo Clinic, Rochester, MN
| | - Ronald C Petersen
- Department of Neurology (J.G.-R., A.A.R., M.M.M., D.S.K., R.C.P.S), Mayo Clinic, Rochester, MN
| | - Walter K Kremers
- Department of Health Sciences Research (T.L., S.A.P., M.M.M., W.K.K.), Mayo Clinic, Rochester, MN
| | - Clifford R Jack
- Department of Radiology (J.L.G., G.M.P., V.J.L., C.R.J., P.V., K.K.), Mayo Clinic, Rochester, MN
| | - Prashanthi Vemuri
- Department of Radiology (J.L.G., G.M.P., V.J.L., C.R.J., P.V., K.K.), Mayo Clinic, Rochester, MN
| | - Kejal Kantarci
- Department of Radiology (J.L.G., G.M.P., V.J.L., C.R.J., P.V., K.K.), Mayo Clinic, Rochester, MN
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25
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Jiang Q, Stone CR, Elkin K, Geng X, Ding Y. Immunosuppression and Neuroinflammation in Stroke Pathobiology. Exp Neurobiol 2021; 30:101-112. [PMID: 33972464 PMCID: PMC8118752 DOI: 10.5607/en20033] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/03/2021] [Accepted: 02/23/2021] [Indexed: 02/07/2023] Open
Abstract
Over the preceding decades, there have been substantial advances in our knowledge of the pathophysiology of stroke. One such advance has been an increased understanding of the multifarious crosstalk in which the nervous and immune systems engage in order to maintain homeostasis. By interrupting the immune-nervous nexus, it is thought that stroke induces change in both systems. Additionally, it has been found that both innate and adaptive immunosuppression play protective roles against the effects of stroke. The release of danger-/damage-associated molecular patterns (DAMPs) activates Toll-like receptors (TLRs), contributing to the harmful inflammatory effects of ischemia/reperfusion injury after stroke; the Tyro3, Axl, and MerTK (TAM)/Gas6 system, however, has been shown to suppress inflammation via downstream signaling molecules that inhibit TLR signaling. Anti-inflammatory cytokines have also been found to promote neuroprotection following stroke. Additionally, adaptive immunosuppression merits further consideration as a potential endogenous protective mechanism. In this review, we highlight recent studies regarding the effects and mechanism of immunosuppression on the pathophysiology of stroke, with the hope that a better understanding of the function of both of innate and adaptive immunity in this setting will facilitate the development of effective therapies for post-stroke inflammation.
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Affiliation(s)
- Qian Jiang
- China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China.,Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
| | - Christopher R Stone
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit 48201, MI, USA
| | - Kenneth Elkin
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit 48201, MI, USA
| | - Xiaokun Geng
- China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China.,Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit 48201, MI, USA
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit 48201, MI, USA.,Department of Research & Development Center, John D. Dingell VA Medical Center, Detroit 48201, MI, USA
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26
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Daugherty AM. Hypertension-related risk for dementia: A summary review with future directions. Semin Cell Dev Biol 2021; 116:82-89. [PMID: 33722505 DOI: 10.1016/j.semcdb.2021.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/01/2021] [Accepted: 03/06/2021] [Indexed: 02/07/2023]
Abstract
Chronic hypertension, or high blood pressure, is the most prevalent vascular risk factor that accelerates cognitive aging and increases risk for Alzheimer's disease and related dementia. Decades of observational and clinical trials have demonstrated that midlife hypertension is associated with greater gray matter atrophy, white matter damage commiserate with demyelination, and functional deficits as compared to normotension over the adult lifespan. Critically, hypertension is a modifiable dementia risk factor: successful blood pressure control with antihypertensive treatment improves outcomes as compared to uncontrolled hypertension, but does not completely negate the risk for dementia. This suggests that hypertension-related risk for neural and cognitive decline in aging cannot be due to elevations in blood pressure alone. This summary review describes three putative pathways for hypertension-related dementia risk: oxidative damage and metabolic dysfunction; systemic inflammation; and autonomic control of heart rate variability. The same processes contribute to pre-clinical hypertension, and therefore hypertension may be an early symptom of an aging nervous system that then exacerbates cumulative and progressive neurodegeneration. Current evidence is reviewed and future directions for research are outlined, including blood biomarkers and novel neuroimaging methods that may be sensitive to test the specific hypotheses.
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Affiliation(s)
- Ana M Daugherty
- Department of Psychology, Department of Psychiatry and Behavioral Neurosciences, Institute of Gerontology, Wayne State University, 5057 Woodward Ave., Detroit, MI, USA.
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27
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Bergeret S, Queneau M, Rodallec M, Curis E, Dumurgier J, Hugon J, Paquet C, Farid K, Baron JC. [ 18 F]FDG PET may differentiate cerebral amyloid angiopathy from Alzheimer's disease. Eur J Neurol 2021; 28:1511-1519. [PMID: 33460498 DOI: 10.1111/ene.14743] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/07/2021] [Accepted: 01/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cerebral amyloid angiopathy (CAA) is a frequent cause of both intracerebral hemorrhage (ICH) and cognitive impairment in the elderly. Diagnosis relies on the Boston criteria, which use magnetic resonance imaging markers including ≥2 exclusively lobar cerebral microbleeds (lCMBs). Although amyloid positron emission tomography (PET) may provide molecular diagnosis, its specificity relative to Alzheimer's disease (AD) is limited due to the prevalence of positive amyloid PET in cognitively normal elderly. Using early-phase 11 C-Pittsburgh compound B as surrogate for tissue perfusion, a significantly lower occipital/posterior cingulate (O/PC) tracer uptake ratio in probable CAA relative to AD was recently reported, consistent with histopathological lesion distribution. We tested whether this finding could be reproduced using [18 F]fluorodeoxyglucose (FDG)-PET, a widely available modality that correlates well with early-phase amyloid PET in both healthy subjects and AD. METHODS From a large memory clinic database, we retrospectively included 14 patients with probable CAA (Boston criteria) and 21 patients with no lCMB fulfilling AD criteria including cerebrospinal fluid biomarkers. In all, [18 F]FDG-PET/computed tomography (CT) was available as part of routine care. No subject had a clinical history of ICH. Regional standardized [18 F]FDG uptake values normalized to the pons (standard uptake value ratio [SUVr]) were obtained, and the O/PC ratio was calculated. RESULTS The SUVr O/PC ratio was significantly lower in CAA versus AD (1.02 ± 0.14 vs. 1.19 ± 0.18, respectively; p = 0.024). CONCLUSIONS Despite the small sample, our findings are consistent with the previous early-phase amyloid PET study. Thus, [18 F]FDG-PET may help differentiate CAA from AD, particularly in cases of amyloid PET positivity. Larger prospective studies, including in CAA-related ICH, are however warranted.
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Affiliation(s)
- Sébastien Bergeret
- Department of Nuclear Medicine, CHU French West Indies, Fort-de-France, France
| | - Mathieu Queneau
- Department of Nuclear Medicine, Centre Cardiologique du Nord, Saint-Denis, France
| | - Mathieu Rodallec
- Department of Radiology, Centre Cardiologique du Nord, Saint-Denis, France
| | - Emmanuel Curis
- Laboratoire de Biomathématiques, EA 7537 "BioSTM", Faculté de Pharmacie, Université de Paris, Paris, France.,Service de Biostatistiques et d'Information Médicale, Hôpital Saint-Louis, APHP, Paris, France
| | - Julien Dumurgier
- INSERM UMR-S 1144: Therapeutic Optimization in Neuropsychopharmacology, Université de Paris, Paris, France
| | - Jacques Hugon
- INSERM UMR-S 1144: Therapeutic Optimization in Neuropsychopharmacology, Université de Paris, Paris, France.,Cognitive Neurology Center, APHP, Saint-Louis Lariboisière Fernand-Widal Hospital Group, Paris, France
| | - Claire Paquet
- INSERM UMR-S 1144: Therapeutic Optimization in Neuropsychopharmacology, Université de Paris, Paris, France.,Cognitive Neurology Center, APHP, Saint-Louis Lariboisière Fernand-Widal Hospital Group, Paris, France
| | - Karim Farid
- Department of Nuclear Medicine, CHU French West Indies, Fort-de-France, France.,INSERM UMR-S 1144: Therapeutic Optimization in Neuropsychopharmacology, Université de Paris, Paris, France
| | - Jean-Claude Baron
- Department of Neurology, Sainte-Anne Hospital, Université de Paris, Paris, France.,INSERM U1266: Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France
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28
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Choi KH, Kim JH, Lee C, Kim JM, Kang KW, Kim JT, Choi SM, Park MS, Cho KH. Microbleeds and Outcome in Patients With Acute Ischemic Stroke and Atrial Fibrillation Taking Anticoagulants. Stroke 2020; 51:3514-3522. [DOI: 10.1161/strokeaha.120.030300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background and Purpose:
We investigated the impact of the presence, burden, and location of cerebral microbleeds (CMBs) on the risk of major adverse cerebrovascular and cardiovascular events (MACCE) in patients with acute ischemic stroke and atrial fibrillation treated with oral anticoagulants (OACs). We also examined whether the clinical effect of CMBs differs according to the type of OACs.
Methods:
A total of 1742 patients with acute ischemic stroke and atrial fibrillation treated with OACs were enrolled in this cohort study. The primary composite outcome was the occurrence of MACCE (a composite of stroke, acute myocardial infarction, or vascular death) over a 2-year period according to CMB status.
Results:
CMB presence was significantly associated with the risk of future MACCE (hazard ratio, 1.89 [95% CI, 1.23–2.88];
P
=0.003) after adjustment for confounders in patients with acute ischemic stroke and atrial fibrillation taking OACs. Patients with exactly 1 CMB had a similar rate of MACCE compared with those without CMBs (
P
=0.461). However, patients with multiple CMBs (≥2), particularly high burden CMBs (≥5), had a significantly higher proportion of MACCE. Both CMB-positive groups with lobar and deep CMB had more frequent MACCE than the CMB-negative group, and the rate of MACCE was not different according to CMB location. In patients treated with warfarin, CMB was significantly associated with a risk of MACCE (
P
=0.002), but not in patients treated with direct OACs (
P
=0.517).
Conclusions:
The study results indicate that the risk of future MACCE increased with increasing CMB burden in patients with AIS and atrial fibrillation taking OACs, while the anatomic location of CMBs did not influence the risk of future MACCE. This risk seemed to be more apparent in patients taking warfarin.
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Affiliation(s)
- Kang-Ho Choi
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
- Department of Neurology, Chonnam National University Hwasun Hospital, Korea (K.-H. Choi, J.-M.K., K.-W.K.)
| | - Ja-Hae Kim
- Department of Nuclear Medicine, Molecular Imaging Center (J.-H.K.), Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Changho Lee
- Department of Nuclear Medicine, Chonnam National University Medical School and Hwasun Hospital, Korea (C.L.)
| | - Jae-Myung Kim
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
- Department of Neurology, Chonnam National University Hwasun Hospital, Korea (K.-H. Choi, J.-M.K., K.-W.K.)
| | - Kyung-Wook Kang
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
- Department of Neurology, Chonnam National University Hwasun Hospital, Korea (K.-H. Choi, J.-M.K., K.-W.K.)
| | - Joon-Tae Kim
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Seong-Min Choi
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Man-Seok Park
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Ki-Hyun Cho
- Department of Neurology (K.-H. Choi, J.-M.K., K.-W.K., J.-T.K., S.-M.C., M.-S.P., K.-H. Cho), Chonnam National University Medical School and Hospital, Gwangju, Korea
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29
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Umemura T, Mashita S, Kawamura T. Oral anticoagulant use and the development of new cerebral microbleeds in cardioembolic stroke patients with atrial fibrillation. PLoS One 2020; 15:e0238456. [PMID: 32941455 PMCID: PMC7498025 DOI: 10.1371/journal.pone.0238456] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 08/17/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Cerebral microbleeds (CMBs) are a magnetic resonance imaging (MRI) marker for cerebral small vessel disease. Existing CMBs and those that newly develop are associated with the risks of stroke incidence and recurrence. The purpose of the present study was to investigate the association of oral anticoagulant (OAC) use and the development of new CMBs in cardioembolic stroke patients with atrial fibrillation. SUBJECTS AND METHODS We prospectively followed cardioembolic stroke patients with atrial fibrillation who had been hospitalized in the stroke center of our hospital, had been prescribed anticoagulants at discharge, and underwent repeated brain MRI with an interval of at least one year from the baseline MRI. Assessing the presence, number and location of CMBs using T2*-weighted gradient-recalled echo MRI, we used logistic regression models to investigate the associations between OAC use and the incidence of new CMBs. We also examined associations of subsequent stroke with OACs and CMBs during the follow-up. RESULTS A total of 81 patients, consisting of 45 patients receiving direct oral anticoagulants (DOACs) and 36 patients receiving warfarin (WF), were analyzed in the present study. Baseline CMBs were observed in 19/81 patients (23.5%) and new CMBs in 18/81 patients (22.2%) on follow-up MRI (median interval, 34 months). Of the 31 new CMBs, 25 (80.6%) developed in the lobar location and 6 (19.4%) in the deep or infratentorial location. New CMBs occurred in 4 patients (10.0%) taking DOACs alone, in 10 patients (35.7%) taking WF alone, in 3 patients (37.5%) taking WF plus antiplatelet agents and in 1 patient (20.0%) taking DOAC plus antiplatelet agent. Regarding location, the new CMBs were the lobar type in 7 of the 10 patients taking WF alone, as well as in 3 of the 4 patients taking DOACs alone. In multivariate analysis, the presence of CMBs at baseline and WF use (vs. DOAC use) were associated with new CMBs (CMB presence at baseline: OR 4.16, 95% CI 1.19-14.44; WF use: OR 3.38, 95% CI 1.02-11.42). The presence of ≥ 2 CMBs at baseline was related to a higher risk of subsequent stroke (OR 7.25, 95% CI 1.01-52.35, P = 0.048). CONCLUSION Our findings suggest that DOAC compared with WF use at discharge is associated with a lower incidence of new CMBs in cardioembolic stroke patients with atrial fibrillation. Further prospective studies in the clinical setting are needed to confirm our exploratory data.
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Affiliation(s)
- Toshitaka Umemura
- Department of Neurology, Chubu Rosai Hospital, Japan Organization of Occupational Health and Safety, Nagoya, Japan
| | - Shinichi Mashita
- Department of Radiology, Chubu Rosai Hospital, Japan Organization of Occupational Health and Safety Nagoya, Japan
| | - Takahiko Kawamura
- Department of Diabetes and Endocrine Internal Medicine, Preventive Medical Center, Chubu Rosai Hospital, Japan Organization of Occupational Health and Safety Nagoya, Nagoya, Japan
- * E-mail:
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30
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Goel N, Jain D, Haddad DB, Shanbhogue D. Anticoagulation in Patients with End-Stage Renal Disease and Atrial Fibrillation: Confusion, Concerns and Consequences. J Stroke 2020; 22:306-316. [PMID: 33053946 PMCID: PMC7568986 DOI: 10.5853/jos.2020.01886] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 12/28/2022] Open
Abstract
End-stage renal disease (ESRD) patients have a higher prevalence of diabetes mellitus, hypertension, congestive heart failure and advanced age, along with an increased incidence of non-valvular atrial fibrillation (AF), thereby increasing the risk for cerebrovascular accidents. Systemic anticoagulation is therefore recommended in patients with ESRD with AF to reduce the risk and complications from thromboembolism. Paradoxically, these patients are at an increased risk of bleeding due to great degree of platelet dysfunction and impaired interaction between platelet and endothelium. Currently, CHA2DS2-VASc and Hypertension, Abnormal liver/kidney function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol (HAS-BLED) are the recommended models for stroke risk stratification and bleeding risk assessment in patients with AF. There is conflicting data regarding benefits and risks of medications such as antiplatelet agents, warfarin and direct oral anticoagulants in ESRD patients with AF. Moreover, there is no randomized controlled trial data to guide the clinical decision making. Hence, a multi-disciplinary approach with annual re-evaluation of treatment goals and risk-benefit assessment has been recommended. In this article, we review the current recommendations with risks and benefits of anticoagulation in patients with ESRD with AF.
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Affiliation(s)
- Narender Goel
- New Jersey Kidney Care, Jersey, NJ, USA
- Division of Nephrology, CarePoint Health Hospitals, Jersey, NJ, USA
- Division of Nephrology, Jersey City Medical Center, Jersey, NJ, USA
| | - Deepika Jain
- New Jersey Kidney Care, Jersey, NJ, USA
- Division of Nephrology, CarePoint Health Hospitals, Jersey, NJ, USA
- Division of Nephrology, Jersey City Medical Center, Jersey, NJ, USA
| | - Danny B. Haddad
- New Jersey Kidney Care, Jersey, NJ, USA
- Division of Nephrology, CarePoint Health Hospitals, Jersey, NJ, USA
- Division of Nephrology, Jersey City Medical Center, Jersey, NJ, USA
| | - Divya Shanbhogue
- Department of Medicine, Jersey City Medical Center, Jersey, NJ, USA
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31
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Casolla B, Cordonnier C. Intracerebral haemorrhage, microbleeds and antithrombotic drugs. Rev Neurol (Paris) 2020; 177:11-22. [PMID: 32747048 DOI: 10.1016/j.neurol.2020.05.008] [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: 03/23/2020] [Revised: 05/04/2020] [Accepted: 05/19/2020] [Indexed: 11/17/2022]
Abstract
Antithrombotic therapy is a cornerstone for secondary prevention of ischaemic events, cerebral and extra-cerebral. A number of clinical questions remain unanswered concerning the impact of antithrombotic drugs on the risk of first-ever and recurrent macro or micro cerebral haemorrhages, raising the clinical dilemma on the risk/benefit balance of giving antiplatelets and anticoagulants in patients with potential high risk of brain bleeds. High field magnetic resonance imaging (MRI) blood-weighted sequences, including susceptibility weighted imaging (SWI), have expanded the spectrum of these clinical questions, because of their increasing sensitivity in detecting radiological markers of small vessel disease. This review will summarise the literature, focusing on four main clinical questions: how do cerebral microbleeds impact the risk of cerebrovascular events in healthy patients, in patients with previous ischaemic stroke or transient ischaemic attack, and in patients with intracerebral haemorrhage? Is the risk/benefit balance of oral anticoagulants shifted by the presence of microbleeds in patients with atrial fibrillation after recent ischaemic stroke or transient ischaemic attack? Should we restart antiplatelet drugs after symptomatic intracerebral haemorrhage or not? Are oral anticoagulants allowed in patients with a history of atrial fibrillation and previous intracerebral haemorrhage?
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Affiliation(s)
- B Casolla
- University of Lille, Inserm, CHU of Lille, U1172-LilNCog-Lille Neuroscience & Cognition, 59000 Lille, France.
| | - C Cordonnier
- University of Lille, Inserm, CHU of Lille, U1172-LilNCog-Lille Neuroscience & Cognition, 59000 Lille, France
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Rivera-Caravaca JM, Esteve-Pastor MA, Camelo-Castillo A, Ramírez-Macías I, Lip GYH, Roldán V, Marín F. Treatment strategies for patients with atrial fibrillation and anticoagulant-associated intracranial hemorrhage: an overview of the pharmacotherapy. Expert Opin Pharmacother 2020; 21:1867-1881. [PMID: 32658596 DOI: 10.1080/14656566.2020.1789099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Oral anticoagulants (OAC) reduce stroke/systemic embolism and mortality risks in atrial fibrillation (AF). However, there is an inherent bleeding risk with OAC, where intracranial hemorrhage (ICH) is the most feared, disabling, and lethal complication of this therapy. Therefore, the optimal management of OAC-associated ICH is not well defined despite multiple suggested strategies. AREAS COVERED In this review, the authors describe the severity and risk factors for OAC-associated ICH and the associated implications for using DOACs in AF patients. We also provide an overview of the management of OAC-associated ICH and treatment reversal strategies, including specific and nonspecific reversal agents as well as a comprehensive summary of the evidence about the resumption of DOAC and the optimal timing. EXPERT OPINION In the setting of an ICH, supportive care/measures are needed, and reversal of anticoagulation with specific agents (including administration of vitamin K, prothrombin complex concentrates, idarucizumab and andexanet alfa) should be considered. Most patients will likely benefit from restarting anticoagulation after an ICH and permanently withdrawn of OAC is associated with worse clinical outcomes. Although the timing of OAC resumption is still under debate, reintroduction after 4-8 weeks of the bleeding event may be possible, after a multidisciplinary approach to decision-making.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
| | - Anny Camelo-Castillo
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
| | - Inmaculada Ramírez-Macías
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University , Aalborg, Denmark
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Universidad De Murcia, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca) , Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Instituto Murciano De Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia , Spain
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Anticoagulation decisions in elderly patients with stroke. Rev Neurol (Paris) 2020; 176:692-700. [PMID: 32631675 DOI: 10.1016/j.neurol.2020.04.015] [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: 01/06/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/22/2022]
Abstract
Primary and secondary prevention of stroke is often a challenge in elderly patients due to the increase in both thrombotic and hemorrhagic risks with age. In some cases, there is sufficient data in the elderly population to allow recommendations or anticoagulation decisions to be made, such as for the indication of anticoagulation to prevent stroke related to atrial fibrillation (AF) or the choice of oral anticoagulant therapy in this situation. In other situations, the less robust data leave some questions; this is the case for the delay to initiate an oral anticoagulant therapy after an AF-related ischemic stroke, for the management of antithrombotic treatment after a stroke of undetermined cause or after intracranial bleeding or in a high-risk bleeding situation associated with stroke in the elderly subject. These issues will be discussed in this paper.
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Abstract
With the elder proportion increasing and the antithrombotic agents widely using as well as the newly magnetic resonance imaging sequence emerging, the detection rate of cerebral microbleed (CMB) is gradually raising in recent years. As we all know that CMB mainly reflects the severity of deeply small vessel lesions, which predicts hemorrhagic transformation. Whereby, to some patients with both CMB and remarkable antithrombotic indication, treatment becomes a dilemma. We have to face the challenge of weighing the pros and cons of both drug indication and bleeding risk when making a proper decision for patients. This study summarized recent advance on CMB diagnosis and treatment, to provide a useful reference to physicians in their clinical practice.
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Elavarasi A, Mahadevan A, Vijayan Sobha V. CNS and PNS vasculitis: Looking beyond the obvious-A teaching exercise. Clin Neurol Neurosurg 2020; 195:105907. [PMID: 32442807 DOI: 10.1016/j.clineuro.2020.105907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 10/24/2022]
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Chen H, Pan Y, Zong L, Jing J, Meng X, Xu Y, Yan H, Zhao X, Liu L, Li H, Johnston SC, Wang Y, Wang Y. Cerebral small vessel disease or intracranial large vessel atherosclerosis may carry different risk for future strokes. Stroke Vasc Neurol 2020; 5:128-137. [PMID: 32606085 PMCID: PMC7337361 DOI: 10.1136/svn-2019-000305] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 11/26/2019] [Accepted: 12/01/2019] [Indexed: 11/26/2022] Open
Abstract
Background The effect of cerebral small vessel disease (CSVD) and intracranial arterial stenosis (ICAS) on stroke outcomes remains unclear. Methods Data of 1045 patients with minor stroke or transient ischaemic attack (TIA) were obtained from 45 sites of the Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial. We assessed the associations of burdens of CSVD and ICAS with new strokes and bleeding events using multivariate Cox regression models and those with modified Rankin Scale (mRS) scores using ordinal logistic regression models. Results Among the 1045 patients, CSVD was present in 830 cases (79.4%) and ICAS in 460 (44.0%). Patients with >1 ICAS segment showed the highest risk of new strokes (HR 2.03, 95% CI 1.15 to 3.56, p=0.01). No association between CSVD and the occurrence of new strokes was found. The presence of severe CSVD (common OR (cOR) 2.01, 95% CI 1.40 to 2.89, p<0.001) and >1 ICAS segment (cOR 2.15, 95% CI 1.57 to 2.93, p<0.001) was associated with higher mRS scores. Severe CSVD (HR 10.70, 95% CI 1.16 to 99.04, p=0.04), but not ICAS, was associated with a higher risk of bleeding events. Six-point modified CSVD score improved the predictive power for bleeding events and disability. Interpretation CSVD is associated with more disability and bleeding events, and ICAS is associated with an increased risk of stroke and disability in patients with minor stroke and TIA at 3 months. CSVD and ICAS may represent different vascular pathologies and play distinct roles in stroke outcomes. Trial registration number NCT00979589
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Affiliation(s)
- Huimin Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Projection, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Projection, Capital Medical University, Beijing, China
| | - Lixia Zong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Projection, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Projection, Capital Medical University, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Projection, Capital Medical University, Beijing, China
| | - Yuyuan Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Projection, Capital Medical University, Beijing, China
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Projection, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Projection, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Projection, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Projection, Capital Medical University, Beijing, China
| | | | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Projection, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Projection, Capital Medical University, Beijing, China
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Boursier-Bossy V, Zuber M, Emmerich J. Ischemic stroke and non-valvular atrial fibrillation: When to introduce anticoagulant therapy? JOURNAL DE MEDECINE VASCULAIRE 2020; 45:72-80. [PMID: 32265018 DOI: 10.1016/j.jdmv.2020.01.153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/19/2019] [Indexed: 06/11/2023]
Abstract
About 20 to 30% of ischemic strokes are related to non-valvular atrial fibrillation. This type of situation is particularly at risk for both recurrence of the ischemic event and the hemorrhagic transformation of this stroke. The timing of the introduction or going back to the anticoagulant therapy in these patients remains a difficult issue, with a complex benefit-risk balance that needs to be assessed. Randomized controlled studies are lacking and current recommendations do not allow for clear decision making. The administration of a curative anticoagulant within 72 hours after the event is not recommended in the absence of demonstrated efficacy in preventing recurrence at this stage and because of the risk of intracerebral hemorrhage. This attitude can nevertheless be qualified by a transient accident or ischemic accident of very small size, and in the absence of any other risk factor for intra- or extra-cerebral hemorrhage. From the 4th day, after an appropriate case by case evaluation, the introduction of anticoagulant would be possible within a time which will remain at the appreciation of the medical teams. If the patient's risk of an intracerebral hemorrhage or general bleeding is transiently increased, it will be preferable to wait at least 2 weeks after the stroke. If this risk persists in the long term, the decision of the administration or not of an anticoagulant will have to be made with a multidisciplinary consultation. Vitamin K antagonists or direct oral anticoagulants may be prescribed as first-line therapy for the prevention of recurrence of ischemic stroke in a non-valvular atrial fibrillation patient. The choice will be based on the clinical and biological data of each patient. Direct oral anticoagulants have not shown superiority in the prevention of ischemic recurrence but open up new prospects for earlier treatment if their lesser risk of bleeding is confirmed after further studies.
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Affiliation(s)
- V Boursier-Bossy
- Department of Neurology and Neurovascular, Paris Saint-Joseph Hospital Group, 185, rue Raymond-Losserand, 75014 Paris, France.
| | - M Zuber
- Department of Neurology and Neurovascular, Paris Saint-Joseph Hospital Group, 185, rue Raymond-Losserand, 75014 Paris, France; Paris Descartes University, Paris, France
| | - J Emmerich
- Department of Vascular Medicine, Paris Saint-Joseph Hospital Group, 185, rue Raymond-Losserand, 75014 Paris, France; Paris Descartes University, Paris, France
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Cerebral Microbleeds and Chronic Kidney Disease in Acute Ischemic Stroke Patients with Atrial Fibrillation. J Stroke Cerebrovasc Dis 2020; 29:104650. [PMID: 32024601 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/27/2019] [Accepted: 01/06/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cerebral microbleeds (CMBs) are associated with the risk of intracerebral hemorrhage in stroke patients with atrial fibrillation (AF). We investigated the association between CMBs and chronic kidney disease (CKD) in patients with acute ischemic stroke and AF. METHODS We retrospectively examined consecutive patients with acute ischemic stroke and AF who underwent brain gradient-echo T2*-weighted magnetic resonance imaging. The number and distribution (lobar, deep or infratentorial, and mixed) of CMBs were assessed. Kidney function was assessed according to the estimated glomerular filtration rate (eGFR), which was calculated using a modified version of the Modification of Diet in Renal Disease equation. RESULTS Of the 357 included patients, 105 (29.4%) had CMBs. CKD (eGFR < 60 mL/min/1.73 m2) was found in 131 (36.7%) patients. Patients with CKD showed a higher prevalence of any form of CMB (41.2% versus 22.6%, P < .001), deep or infratentorial CMBs (19.9% versus 9.3%, P < .01), and mixed CMBs (14.5% versus 5.3%, P < .01) than those without CKD. After adjusting for age and other confounding factors, CKD was found to be independently associated with the presence of any form of CMB (odds ratio 1.89, P = .02) and mixed CMBs (odds ratio 3.10, P < .01). Moreover, moderate to severe CKD (eGFR < 45 mL/min/1.73 m2) was independently associated with the presence of multiple CMBs (odds ratio 2.31, P = .04). CONCLUSIONS CMBs and CKD are common in acute ischemic stroke patients with AF, and CKD may be a risk factor for CMBs. Further longitudinal studies are needed to evaluate whether maintaining kidney function can prevent the development of CMBs.
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Claesson TB, Putaala J, Shams S, Salli E, Gordin D, Liebkind R, Forsblom C, Summanen PA, Tatlisumak T, Groop PH, Martola J, Thorn LM. Comparison of Manual Cross-Sectional Measurements and Automatic Volumetry of the Corpus Callosum, and Their Clinical Impact: A Study on Type 1 Diabetes and Healthy Controls. Front Neurol 2020; 11:27. [PMID: 32063882 PMCID: PMC7000520 DOI: 10.3389/fneur.2020.00027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/09/2020] [Indexed: 12/13/2022] Open
Abstract
Background and purpose: Degenerative change of the corpus callosum might serve as a clinically useful surrogate marker for net pathological cerebral impact of diabetes type 1. We compared manual and automatic measurements of the corpus callosum, as well as differences in callosal cross-sectional area between subjects with type 1 diabetes and healthy controls. Materials and methods: This is a cross-sectional study on 188 neurologically asymptomatic participants with type 1 diabetes and 30 healthy age- and sex-matched control subjects, recruited as part of the Finnish Diabetic Nephropathy Study. All participants underwent clinical work-up and brain MRI. Callosal area was manually measured and callosal volume quantified with FreeSurfer. The measures were normalized using manually measured mid-sagittal intracranial area and volumetric intracranial volume, respectively. Results: Manual and automatic measurements correlated well (callosal area vs. volume: ρ = 0.83, p < 0.001 and mid-sagittal area vs. intracranial volume: ρ = 0.82, p < 0.001). We found no significant differences in the callosal measures between cases and controls. In type 1 diabetes, the lowest quartile of normalized callosal area was associated with higher insulin doses (p = 0.029) and reduced insulin sensitivity (p = 0.033). In addition, participants with more than two cerebral microbleeds had smaller callosal area (p = 0.002). Conclusion: Manually measured callosal area and automatically segmented are interchangeable. The association seen between callosal size with cerebral microbleeds and insulin resistance is indicative of small vessel disease pathology in diabetes type 1.
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Affiliation(s)
- Tor-Björn Claesson
- Department of Radiology, Visby Regional Hospital, Visby, Sweden.,Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Radiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Sara Shams
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Radiology, Stanford University, Stanford, CA, United States
| | - Eero Salli
- HUS Helsinki Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Daniel Gordin
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Finland Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland.,Joslin Diabetes Center, Harvard Medical School, Boston, MA, United States
| | - Ron Liebkind
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Carol Forsblom
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Finland Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Paula A Summanen
- Department of Ophthalmology, Helsinki University Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.,Department of Clinical Neuroscience/Neurology, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Finland Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland.,Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Juha Martola
- Department of Radiology, Helsinki University Central Hospital, Helsinki, Finland.,Department of Radiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Radiology, Stanford University, Stanford, CA, United States
| | - Lena M Thorn
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Finland Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
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Debette S, Schilling S, Duperron MG, Larsson SC, Markus HS. Clinical Significance of Magnetic Resonance Imaging Markers of Vascular Brain Injury: A Systematic Review and Meta-analysis. JAMA Neurol 2019; 76:81-94. [PMID: 30422209 DOI: 10.1001/jamaneurol.2018.3122] [Citation(s) in RCA: 383] [Impact Index Per Article: 76.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Covert vascular brain injury (VBI) is highly prevalent in community-dwelling older persons, but its clinical and therapeutic implications are debated. Objective To better understand the clinical significance of VBI to optimize prevention strategies for the most common age-related neurological diseases, stroke and dementia. Data Source We searched for articles in PubMed between 1966 and December 22, 2017, studying the association of 4 magnetic resonance imaging (MRI) markers of covert VBI (white matter hyperintensities [WMHs] of presumed vascular origin, MRI-defined covert brain infarcts [BIs], cerebral microbleeds [CMBs], and perivascular spaces [PVSs]) with incident stroke, dementia, or death. Study Selection Data were taken from prospective, longitudinal cohort studies including 50 or more adults. Data Extraction and Synthesis We performed inverse variance-weighted meta-analyses with random effects and z score-based meta-analyses for WMH burden. The significance threshold was P < .003 (17 independent tests). We complied with the Meta-analyses of Observational Studies in Epidemiology guidelines. Main Outcomes and Measures Stroke (hemorrhagic and ischemic), dementia (all and Alzheimer disease), and death. Results Of 2846 articles identified, 94 studies were eligible, with up to 14 529 participants for WMH, 16 012 participants for BI, 15 693 participants for CMB, and 4587 participants for PVS. Extensive WMH burden was associated with higher risk of incident stroke (hazard ratio [HR], 2.45; 95% CI, 1.93-3.12; P < .001), ischemic stroke (HR, 2.39; 95% CI, 1.65-3.47; P < .001), intracerebral hemorrhage (HR, 3.17; 95% CI, 1.54-6.52; P = .002), dementia (HR, 1.84; 95% CI, 1.40-2.43; P < .001), Alzheimer disease (HR, 1.50; 95% CI, 1.22-1.84; P < .001), and death (HR, 2.00; 95% CI, 1.69-2.36; P < .001). Presence of MRI-defined BIs was associated with higher risk of incident stroke (HR, 2.38; 95% CI, 1.87-3.04; P < .001), ischemic stroke (HR, 2.18; 95% CI, 1.67-2.85; P < .001), intracerebral hemorrhage (HR, 3.81; 95% CI, 1.75-8.27; P < .001), and death (HR, 1.64; 95% CI, 1.40-1.91; P < .001). Presence of CMBs was associated with increased risk of stroke (HR, 1.98; 95% CI, 1.55-2.53; P < .001), ischemic stroke (HR, 1.92; 95% CI, 1.40-2.63; P < .001), intracerebral hemorrhage (HR, 3.82; 95% CI, 2.15-6.80; P < .001), and death (HR, 1.53; 95% CI, 1.31-1.80; P < .001). Data on PVS were limited and insufficient to conduct meta-analyses but suggested an association of high PVS burden with increased risk of stroke, dementia, and death; this requires confirmation. Conclusions and Relevance We report evidence that MRI markers of VBI have major clinical significance. This research prompts careful evaluation of the benefit-risk ratio for available prevention strategies in individuals with covert VBI.
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Affiliation(s)
- Stéphanie Debette
- University of Bordeaux, Inserm 1219, Bordeaux Population Health Research Center, Bordeaux, France.,Department of Neurology, Memory Clinic, Bordeaux University Hospital, Bordeaux, France
| | - Sabrina Schilling
- University of Bordeaux, Inserm 1219, Bordeaux Population Health Research Center, Bordeaux, France
| | - Marie-Gabrielle Duperron
- University of Bordeaux, Inserm 1219, Bordeaux Population Health Research Center, Bordeaux, France
| | - Susanna C Larsson
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom.,Unit of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
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Hert L, Polymeris AA, Schaedelin S, Lieb J, Seiffge DJ, Traenka C, Fladt J, Thilemann S, Gensicke H, De Marchis GM, Bonati L, Lyrer P, Engelter ST, Peters N. Small vessel disease is associated with an unfavourable outcome in stroke patients on oral anticoagulation. Eur Stroke J 2019; 5:63-72. [PMID: 32232171 DOI: 10.1177/2396987319888016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 10/13/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction Cerebral small vessel disease is an important cause for both ischaemic stroke and intracranial haemorrhage. To date, knowledge on the impact of small vessel disease on the clinical course in stroke patients treated with oral anticoagulation for atrial fibrillation is limited. Patients and Methods Registry-based prospective observational study of 320 patients (aged 78.2 ± 9.2 years) treated with anticoagulation following atrial fibrillation stroke. Patients underwent standardised magnetic-resonance-imaging assessing measures of small vessel disease, including cerebral microbleeds and white matter hyperintensities. Median follow-up was 754 (interquartile range = [708-828]) days. Using adjusted logistic and Cox regression, we assessed the association of imaging measures with clinical outcome including recurrent ischaemic stroke, intracranial haemorrhage and death and assessed disability (modified Rankin Scale). Results Overall, recurrent ischaemic stroke was more common than intracranial haemorrhage (22 versus 8, respectively). Cerebral microbleeds were related to an increased risk of the composite endpoint (ischaemic stroke, intracranial haemorrhage, death: odds ratio (OR) 2.05, 95% confidence interval (CI) 1.27-3.31; P = 0.003), as were white matter hyperintensities (OR 2.00, 95%CI 1.23-3.27, P = 0.005). This was also true in time-to-event analysis (cerebral microbleeds: HR 2.31, 95%CI 1.39-3.52; P < 0.001; white matter hyperintensities: HR 1.99, 95%CI 1.20-3.17; P = 0.007). Both measures were associated with an increased risk for recurrent ischaemic stroke (cerebral microbleeds: HR 4.42, 95%CI 1.07-18.20; P = 0.04; white matter hyperintensities: HR 5.27, 95%CI 1.08-25.79, P = 0.04) and intracranial haemorrhage (cerebral microbleeds: HR 2.43, 95%CI 1.04-5.69; P = 0.04; white matter hyperintensities: HR 2.57, 95%CI 1.11-5.98, P = 0.03). Furthermore, confluent white matter hyperintensities were associated with increased disability (OR 4.03; 95%CI 2.16-7.52; P < 0.001) and mortality (HR 1.81, 95%CI 1.04-3.14, P = 0.04). Discussion and conclusion In atrial fibrillation stroke patients treated with oral anticoagulation, small vessel disease is associated with an unfavourable outcome. The presence of microbleeds indicated a risk higher for recurrent ischaemic stroke than for intracranial haemorrhage.
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Affiliation(s)
- Lisa Hert
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Switzerland
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Switzerland
| | | | - Johanna Lieb
- Department of Neuroradiology, University Hospital and University of Basel, Switzerland
| | - David J Seiffge
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Switzerland
| | - Joachim Fladt
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Switzerland.,Neurology and Neurorehabilitation, University Department for Medicine of Aging, Felix Platter-Hospital and University of Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Switzerland
| | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Switzerland.,Neurology and Neurorehabilitation, University Department for Medicine of Aging, Felix Platter-Hospital and University of Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Switzerland.,Neurology and Neurorehabilitation, University Department for Medicine of Aging, Felix Platter-Hospital and University of Basel, Switzerland
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42
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Association of Ultrasonography and MRI Findings with Stroke Recurrence: Differences Between Patients with Past Histories of Atherothrombotic Versus Lacunar Infarctions. J Stroke Cerebrovasc Dis 2019; 28:104391. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/11/2019] [Accepted: 08/31/2019] [Indexed: 11/22/2022] Open
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43
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Cheng Y, Wang Y, Song Q, Qiu K, Liu M. Use of anticoagulant therapy and cerebral microbleeds: a systematic review and meta-analysis. J Neurol 2019; 268:1666-1679. [PMID: 31616992 DOI: 10.1007/s00415-019-09572-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Anticoagulant therapy increases the risk that cerebral microbleeds (CMBs) progress to intracerebral hemorrhage, but whether the therapy increases risk of CMB occurrence is unclear. We performed a systematic review and meta-analysis to investigate the potential association between anticoagulant use and CMB occurrence in stroke and stroke-free individuals. METHODS We searched observational studies in PubMed, Ovid EMBASE, and Cochrane Library from their inception until September 2019. We calculated the pooled odds ratio (OR) and 95% confidence interval (CI) for the prevalence and incidence of CMBs in anticoagulant users relative to non-anticoagulant users. RESULTS Forty-seven studies with 25,245 participants were included. The pooled analysis showed that anticoagulant use was associated with CMB prevalence (OR 1.54, 95% CI 1.26-1.88). The association was observed in subgroups stratified by type of participants: stroke-free, OR 1.86, 95% CI 1.25-2.77; ischemic stroke/transient ischemic attack, OR 1.33, 95% CI 1.06-1.67; and intracerebral hemorrhage, OR 2.26, 95% CI 1.06-4.83. Anticoagulant use was associated with increased prevalence of strictly lobar CMBs (OR 1.68, 95% CI 1.22-2.32) but not deep/infratentorial CMBs. Warfarin was associated with increased CMB prevalence (OR 1.64, 95% CI 1.23-2.18), but novel oral anticoagulants were not. Anticoagulant users showed higher incidence of CMBs during long-term follow-up (OR 1.72, 95% CI 1.22-2.44). CONCLUSION Anticoagulant use is associated with higher prevalence and incidence of CMBs. This association appears to depend on location of CMBs and type of anticoagulants. More longitudinal investigations with adjustment for confounders are required to establish the causality.
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Affiliation(s)
- Yajun Cheng
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yanan Wang
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Quhong Song
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Ke Qiu
- West China School of Medicine, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Ming Liu
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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44
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Poggesi A, Barbato C, Galmozzi F, Camilleri E, Cesari F, Chiti S, Diciotti S, Galora S, Giusti B, Gori AM, Marzi C, Melone A, Mistri D, Pescini F, Pracucci G, Rinnoci V, Sarti C, Fainardi E, Marcucci R, Salvadori E. Role of Biological Markers for Cerebral Bleeding Risk STRATification in Patients with Atrial Fibrillation on Oral Anticoagulants for Primary or Secondary Prevention of Ischemic Stroke (Strat-AF Study): Study Design and Methodology. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E626. [PMID: 31548494 PMCID: PMC6843419 DOI: 10.3390/medicina55100626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 09/09/2019] [Accepted: 09/19/2019] [Indexed: 01/31/2023]
Abstract
Background and Objectives: In anticoagulated atrial fibrillation (AF) patients, the validity of models recommended for the stratification of the risk ratio between benefits and hemorrhage risk is limited. Cerebral small vessel disease (SVD) represents the pathologic substrate for primary intracerebral hemorrhage and ischemic stroke. We hypothesize that biological markers-both circulating and imaging-based-and their possible interaction, might improve the prediction of bleeding risk in AF patients under treatment with any type of oral anticoagulant. Materials and Methods: The Strat-AF study is an observational, prospective, single-center hospital-based study enrolling patients with AF, aged 65 years or older, and with no contraindications to magnetic resonance imaging (MRI), referring to Center of Thrombosis outpatient clinic of our University Hospital for the management of oral anticoagulation therapy. Recruited patients are evaluated by means of a comprehensive protocol, with clinical, cerebral MRI, and circulating biomarkers assessment at baseline and after 18 months. The main outcome is SVD progression-particularly microbleeds-as a selective surrogate marker of hemorrhagic complication. Stroke occurrence (ischemic or hemorrhagic) and the progression of functional, cognitive, and motor status will be evaluated as secondary outcomes. Circulating biomarkers may further improve predictive potentials. Results: Starting from September 2017, 194 patients (mean age 78.1 ± 6.7, range 65-97; 61% males) were enrolled. The type of AF was paroxysmal in 93 patients (48%), and persistent or permanent in the remaining patients. Concerning the type of oral anticoagulant, 57 patients (29%) were on vitamin K antagonists, and 137 (71%) were on direct oral anticoagulants. Follow-up clinical evaluation and brain MRI are ongoing. Conclusions: The Strat-AF study may be an essential step towards the exploration of the role of a combined clinical biomarker or multiple biomarker models in predicting stroke risk in AF, and might sustain the incorporation of such new markers in the existing stroke prediction schemes by the demonstration of a greater incremental value in predicting stroke risk and improvement in clinical outcomes in a cost-effective fashion.
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Affiliation(s)
- Anna Poggesi
- Stroke Unit, Careggi University Hospital, 50134 Florence, Italy.
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
- IRCCS Don Carlo Gnocchi, 50143 Florence, Italy.
| | - Carmen Barbato
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
| | - Francesco Galmozzi
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
| | - Eleonora Camilleri
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy.
| | - Francesca Cesari
- Central Laboratory, Careggi University Hospital, 50134 Florence, Italy.
| | - Stefano Chiti
- Department Health Professions, U.O.c Research and Development, 50134 Careggi University Hospital, 50134 Florence, Italy.
| | - Stefano Diciotti
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, 40136 Bologna, Italy.
| | - Silvia Galora
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy.
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy.
| | - Anna Maria Gori
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy.
| | - Chiara Marzi
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, 40136 Bologna, Italy.
| | - Anna Melone
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
| | - Damiano Mistri
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
| | | | - Giovanni Pracucci
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
| | - Valentina Rinnoci
- Stroke Unit, Careggi University Hospital, 50134 Florence, Italy.
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
- IRCCS Don Carlo Gnocchi, 50143 Florence, Italy.
| | - Cristina Sarti
- Stroke Unit, Careggi University Hospital, 50134 Florence, Italy.
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Careggi University Hospital, 50134 Florence, Italy.
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy.
| | - Emilia Salvadori
- Stroke Unit, Careggi University Hospital, 50134 Florence, Italy.
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
- IRCCS Don Carlo Gnocchi, 50143 Florence, Italy.
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45
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Breiding PS, Duerrenmatt JT, Meinel FG, Carrel T, Schönhoff F, Zibold F, Kaesmacher J, Gralla J, Pilgrim T, Jung S, Fischer U, Arnold M, Meinel TR. Prevalence and Evolution of Susceptibility-Weighted Imaging Lesions in Patients With Artificial Heart Valves. J Am Heart Assoc 2019; 8:e012814. [PMID: 31379252 PMCID: PMC6761656 DOI: 10.1161/jaha.119.012814] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background In patients with mechanical heart valves, cerebral susceptibility‐weighted imaging (SWI) lesions on magnetic resonance imaging, postulated to be caused by degenerative metallic abrasion, are frequently referred to as valve abrasion. It remains unclear whether valve implantation not requiring cardiopulmonary bypass or biological heart valves also shows those lesions. Methods and Results Two blinded readers rated SWI lesions and cerebral amyloid angiopathy probability according to established criteria on brain magnetic resonance imaging pre‐ and postinterventionally. We assessed the association between valve type/cardiopulmonary bypass use and SWI lesion count on the first postinterventional scan using multivariable logistic regression. On postinterventional magnetic resonance imaging, 57/58 (98%) patients with mechanical heart valves had at least 1 and 46/58 (79%) 3 or more SWI lesions, while 92/97 (95%) patients with biological heart valves had at least 1 and 72/97 (74%) 3 or more SWI lesions. On multivariate analysis, duration of cardiopulmonary bypass during implantation significantly increased the odds of having SWI lesions on the first postinterventional magnetic resonance imaging (β per 10 minutes 0.498; 95% CI, 0.116–0.880; P=0.011), whereas valve type showed no significant association (P=0.338). Thirty‐seven of 155 (23.9%) patients fulfilled the criteria of possible/probable cerebral amyloid angiopathy. Conclusions SWI lesions in patients with artificial heart valves evolve around the time point of valve implantation and the majority of patients had multiple lesions. The missing association with the valve type weakens the hypothesis of degenerative metallic abrasion and highlights cardiopulmonary bypass as the main risk factor for SWI occurrence. SWI lesions associated with cardiac procedures can mimic cerebral amyloid angiopathy. Further research needs to clarify whether those lesions are associated with intracranial hemorrhage after intravenous thrombolysis or anticoagulation.
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Affiliation(s)
- Philipe S Breiding
- University Institute of Diagnostic and Interventional Neuroradiology University Hospital Bern Inselspital University of Bern Switzerland
| | - Jana T Duerrenmatt
- Department of Neurology University Hospital Bern Inselspital University of Bern Switzerland
| | - Felix G Meinel
- Institute of Diagnostic and Interventional Radiology Rostock University Medical Center Rostock Germany
| | - Thierry Carrel
- Department of Cardiothoracic Surgery University Hospital Bern Inselspital University of Bern Switzerland
| | - Florian Schönhoff
- Department of Cardiothoracic Surgery University Hospital Bern Inselspital University of Bern Switzerland
| | - Felix Zibold
- University Institute of Diagnostic and Interventional Neuroradiology University Hospital Bern Inselspital University of Bern Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology University Hospital Bern Inselspital University of Bern Switzerland.,Department of Neurology University Hospital Bern Inselspital University of Bern Switzerland.,Institute of Diagnostic, Interventional and Pediatric Radiology University Hospital Bern Inselspital University of Bern Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology University Hospital Bern Inselspital University of Bern Switzerland
| | - Thomas Pilgrim
- Department of Cardiology University Hospital Bern Inselspital University of Bern Switzerland
| | - Simon Jung
- Department of Neurology University Hospital Bern Inselspital University of Bern Switzerland
| | - Urs Fischer
- Department of Neurology University Hospital Bern Inselspital University of Bern Switzerland
| | - Marcel Arnold
- Department of Neurology University Hospital Bern Inselspital University of Bern Switzerland
| | - Thomas R Meinel
- Department of Neurology University Hospital Bern Inselspital University of Bern Switzerland
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46
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Das AS, Regenhardt RW, Feske SK, Gurol ME. Treatment Approaches to Lacunar Stroke. J Stroke Cerebrovasc Dis 2019; 28:2055-2078. [PMID: 31151838 PMCID: PMC7456600 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/15/2019] [Accepted: 05/02/2019] [Indexed: 12/12/2022] Open
Abstract
Lacunar strokes are appropriately named for their ability to cavitate and form ponds or "little lakes" (Latin: lacune -ae meaning pond or pit is a diminutive form of lacus meaning lake). They account for a substantial proportion of both symptomatic and asymptomatic ischemic strokes. In recent years, there have been several advances in the management of large vessel occlusions. New therapies such as non-vitamin K antagonist oral anticoagulants and left atrial appendage closure have recently been developed to improve stroke prevention in atrial fibrillation; however, the treatment of small vessel disease-related strokes lags frustratingly behind. Since Fisher characterized the lacunar syndromes and associated infarcts in the late 1960s, there have been no therapies specifically targeting lacunar stroke. Unfortunately, many therapeutic agents used for the treatment of ischemic stroke in general offer only a modest benefit in reducing recurrent stroke while adding to the risk of intracerebral hemorrhage and systemic bleeding. Escalation of antithrombotic treatments beyond standard single antiplatelet agents has not been effective in long-term lacunar stroke prevention efforts, unequivocally increasing intracerebral hemorrhage risk without providing a significant benefit. In this review, we critically review the available treatments for lacunar stroke based on evidence from clinical trials. For several of the major drugs, we summarize the adverse effects in the context of this unique patient population. We also discuss the role of neuroprotective therapies and neural repair strategies as they may relate to recovery from lacunar stroke.
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Affiliation(s)
- Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steven K Feske
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mahmut Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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47
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Lioutas VA, Goyal N, Katsanos AH, Krogias C, Zand R, Sharma VK, Varelas P, Malhotra K, Paciaroni M, Sharaf A, Chang J, Kargiotis O, Pandhi A, Schroeder C, Tsantes A, Boviatsis E, Mehta C, Mitsias PD, Selim MH, Alexandrov AV, Tsivgoulis G. Microbleed prevalence and burden in anticoagulant-associated intracerebral bleed. Ann Clin Transl Neurol 2019; 6:1546-1551. [PMID: 31402613 PMCID: PMC6689674 DOI: 10.1002/acn3.50834] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/21/2019] [Accepted: 06/06/2019] [Indexed: 11/06/2022] Open
Abstract
Prior studies suggest an association between Vitamin K antagonists (VKA) and cerebral microbleeds (CMBs); less is known about nonvitamin K oral anticoagulants (NOACs). In this observational study we describe CMB profiles in a multicenter cohort of 89 anticoagulation‐related intracerebral hemorrhage (ICH) patients. CMB prevalence was 51% (52% in VKA‐ICH, 48% in NOAC‐ICH). NOAC‐ICH patients had lower median CMB count [2(IQR:1–3) vs. 7(4–11); P < 0.001]; ≥5 CMBs were less prevalent in NOAC‐ICH (4% vs. 31%, P = 0.006). This inverse association between NOAC exposure and high CMB count persisted in multivariable logistic regression models adjusting for potential confounders (OR 0.10, 95%CI: 0.01–0.83; P = 0.034).
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Affiliation(s)
- Vasileios-Arsenios Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Aristeidis H Katsanos
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Ramin Zand
- Department of Neurology, Geisinger Medical Center, Danville, Pennsylvania
| | - Vijay K Sharma
- Division of Neurology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Konark Malhotra
- Department of Neurology, West Virginia University Charleston Division, Charleston, West Virginia
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Aboubakar Sharaf
- Department of Neurology, Essentia Health-Duluth Clinic, Duluth, Minnesota
| | - Jason Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC
| | | | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Christoph Schroeder
- Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Argyrios Tsantes
- Laboratory of Haematology and Blood Bank Unit (A.T.), "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Boviatsis
- Second Department of Neurosurgery, "Attikon University Hospital", School of Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Chandan Mehta
- Department of Neurology, West Virginia University Charleston Division, Charleston, West Virginia
| | - Panayiotis D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan.,Department of Neurology, School of Medicine, University of Crete, Crete, Greece
| | - Magdy H Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee.,Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece
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48
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Caso V, Masuhr F. A Narrative Review of Nonvitamin K Antagonist Oral Anticoagulant Use in Secondary Stroke Prevention. J Stroke Cerebrovasc Dis 2019; 28:2363-2375. [PMID: 31281110 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/17/2019] [Accepted: 05/18/2019] [Indexed: 01/28/2023] Open
Abstract
The prevalence of atrial fibrillation (AF), the most common cardiac arrhythmia, increases with age, predisposing elderly patients to an increased risk of embolic stroke. With an increasingly aged population the number of people who experience a stroke every year, overall global burden of stroke, and numbers of stroke survivors and related deaths continue to increase. Anticoagulation with vitamin K antagonists (VKAs) reduces the risk of ischemic stroke in patients with AF; however, increased bleeding risk is well documented, particularly in the elderly. Consequently, VKAs have been underused in the elderly. Alternative anticoagulants may offer a safer choice, particularly in patients who have experienced previous stroke. The aim of this narrative review is to examine available evidence for the effective treatment of patients with AF and previous cerebral vascular events with non-VKA oral anticoagulants, including the most appropriate time to start or reinitiate treatment after a stroke, systemic embolism, or clinically relevant bleed. For patients with AF treated with oral anticoagulants it is important to balance increased protection against future stroke/systemic embolism and reduced risk of major bleeding events. For patients with AF who have previously experienced a cerebrovascular event, the use of oral anticoagulants alone also appears more effective than low-molecular weight heparin (LMWH) alone or LMWH followed by oral anticoagulants. Available data suggest that significant reduction in stroke, symptomatic cerebral bleeding, and major extracranial bleeding within 90 days from acute stroke can be achieved if oral anticoagulation is initiated at 4-14 days from stroke onset.
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Affiliation(s)
- Valeria Caso
- Stroke Unit and Division of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy.
| | - Florian Masuhr
- Department of Neurology, German Army Hospital, Berlin, Germany
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49
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Wilson D, Ambler G, Lee KJ, Lim JS, Shiozawa M, Koga M, Li L, Lovelock C, Chabriat H, Hennerici M, Wong YK, Mak HKF, Prats-Sánchez L, Martínez-Domeño A, Inamura S, Yoshifuji K, Arsava EM, Horstmann S, Purrucker J, Lam BYK, Wong A, Kim YD, Song TJ, Schrooten M, Lemmens R, Eppinger S, Gattringer T, Uysal E, Tanriverdi Z, Bornstein NM, Assayag EB, Hallevi H, Tanaka J, Hara H, Coutts SB, Hert L, Polymeris A, Seiffge DJ, Lyrer P, Algra A, Kappelle J, Al-Shahi Salman R, Jäger HR, Lip GYH, Mattle HP, Panos LD, Mas JL, Legrand L, Karayiannis C, Phan T, Gunkel S, Christ N, Abrigo J, Leung T, Chu W, Chappell F, Makin S, Hayden D, Williams DJ, Kooi ME, van Dam-Nolen DHK, Barbato C, Browning S, Wiegertjes K, Tuladhar AM, Maaijwee N, Guevarra C, Yatawara C, Mendyk AM, Delmaire C, Köhler S, van Oostenbrugge R, Zhou Y, Xu C, Hilal S, Gyanwali B, Chen C, Lou M, Staals J, Bordet R, Kandiah N, de Leeuw FE, Simister R, van der Lugt A, Kelly PJ, Wardlaw JM, Soo Y, Fluri F, Srikanth V, Calvet D, Jung S, Kwa VIH, Engelter ST, Peters N, Smith EE, Yakushiji Y, Orken DN, Fazekas F, Thijs V, Heo JH, Mok V, Veltkamp R, Ay H, Imaizumi T, Gomez-Anson B, Lau KK, Jouvent E, Rothwell PM, Toyoda K, Bae HJ, Marti-Fabregas J, Werring DJ. Cerebral microbleeds and stroke risk after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies. Lancet Neurol 2019; 18:653-665. [PMID: 31130428 PMCID: PMC6562236 DOI: 10.1016/s1474-4422(19)30197-8] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 04/26/2019] [Accepted: 05/01/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Cerebral microbleeds are a neuroimaging biomarker of stroke risk. A crucial clinical question is whether cerebral microbleeds indicate patients with recent ischaemic stroke or transient ischaemic attack in whom the rate of future intracranial haemorrhage is likely to exceed that of recurrent ischaemic stroke when treated with antithrombotic drugs. We therefore aimed to establish whether a large burden of cerebral microbleeds or particular anatomical patterns of cerebral microbleeds can identify ischaemic stroke or transient ischaemic attack patients at higher absolute risk of intracranial haemorrhage than ischaemic stroke. METHODS We did a pooled analysis of individual patient data from cohort studies in adults with recent ischaemic stroke or transient ischaemic attack. Cohorts were eligible for inclusion if they prospectively recruited adult participants with ischaemic stroke or transient ischaemic attack; included at least 50 participants; collected data on stroke events over at least 3 months follow-up; used an appropriate MRI sequence that is sensitive to magnetic susceptibility; and documented the number and anatomical distribution of cerebral microbleeds reliably using consensus criteria and validated scales. Our prespecified primary outcomes were a composite of any symptomatic intracranial haemorrhage or ischaemic stroke, symptomatic intracranial haemorrhage, and symptomatic ischaemic stroke. We registered this study with the PROSPERO international prospective register of systematic reviews, number CRD42016036602. FINDINGS Between Jan 1, 1996, and Dec 1, 2018, we identified 344 studies. After exclusions for ineligibility or declined requests for inclusion, 20 322 patients from 38 cohorts (over 35 225 patient-years of follow-up; median 1·34 years [IQR 0·19-2·44]) were included in our analyses. The adjusted hazard ratio [aHR] comparing patients with cerebral microbleeds to those without was 1·35 (95% CI 1·20-1·50) for the composite outcome of intracranial haemorrhage and ischaemic stroke; 2·45 (1·82-3·29) for intracranial haemorrhage and 1·23 (1·08-1·40) for ischaemic stroke. The aHR increased with increasing cerebral microbleed burden for intracranial haemorrhage but this effect was less marked for ischaemic stroke (for five or more cerebral microbleeds, aHR 4·55 [95% CI 3·08-6·72] for intracranial haemorrhage vs 1·47 [1·19-1·80] for ischaemic stroke; for ten or more cerebral microbleeds, aHR 5·52 [3·36-9·05] vs 1·43 [1·07-1·91]; and for ≥20 cerebral microbleeds, aHR 8·61 [4·69-15·81] vs 1·86 [1·23-1·82]). However, irrespective of cerebral microbleed anatomical distribution or burden, the rate of ischaemic stroke exceeded that of intracranial haemorrhage (for ten or more cerebral microbleeds, 64 ischaemic strokes [95% CI 48-84] per 1000 patient-years vs 27 intracranial haemorrhages [17-41] per 1000 patient-years; and for ≥20 cerebral microbleeds, 73 ischaemic strokes [46-108] per 1000 patient-years vs 39 intracranial haemorrhages [21-67] per 1000 patient-years). INTERPRETATION In patients with recent ischaemic stroke or transient ischaemic attack, cerebral microbleeds are associated with a greater relative hazard (aHR) for subsequent intracranial haemorrhage than for ischaemic stroke, but the absolute risk of ischaemic stroke is higher than that of intracranial haemorrhage, regardless of cerebral microbleed presence, antomical distribution, or burden. FUNDING British Heart Foundation and UK Stroke Association.
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Affiliation(s)
- Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, London UK; New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Keon-Joo Lee
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University School of Medicine, Seongnam, South Korea
| | - Jae-Sung Lim
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Linxin Li
- Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Caroline Lovelock
- Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Hugues Chabriat
- Assistance Publique Hôpitaux de Paris, Lariboisière Hospital, Department of Neurology, Paris, France; Département Hospitalo-Universtaire NeuroVasc, University Paris Diderot, and INSERM U1141, Paris, France
| | - Michael Hennerici
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Yuen Kwun Wong
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong
| | - Henry Ka Fung Mak
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong
| | - Luis Prats-Sánchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Alejandro Martínez-Domeño
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - Shigeru Inamura
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Kazuhisa Yoshifuji
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Ethem Murat Arsava
- Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Solveig Horstmann
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bonnie Yin Ka Lam
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Adrian Wong
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae-Jin Song
- Department of Neurology, Ewha Womans University College of Medicine, Seoul, South Korea
| | | | - Robin Lemmens
- Experimental Neurology and Leuven Institute for Neuroscience and Disease, Katholieke Universiteit Leuven, University of Leuven, Laboratory of Neurobiology, Leuven, Belgium
| | | | | | - Ender Uysal
- Department of Neurology, Demiroglu Bilim University, Istanbul, Turkey
| | - Zeynep Tanriverdi
- Department of Neurology, Demiroglu Bilim University, Istanbul, Turkey
| | - Natan M Bornstein
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Einor Ben Assayag
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hen Hallevi
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jun Tanaka
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Nabeshima, Saga, Japan
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Nabeshima, Saga, Japan
| | - Shelagh B Coutts
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Lisa Hert
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alexandros Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David J Seiffge
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, London UK; Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology and Department of Neurology Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ale Algra
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands; Department of Neurology and Neurosurgery, Utrecht Stroke Centre, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Jaap Kappelle
- Department of Neurology and Neurosurgery, Utrecht Stroke Centre, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Hans R Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Heinrich P Mattle
- Department of Diagnostic and Interventional Neuroradiology and Department of Neurology Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Leonidas D Panos
- Department of Diagnostic and Interventional Neuroradiology and Department of Neurology Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jean-Louis Mas
- Department of Neurology, Sainte-Anne Hospital, Paris Descartes University, INSERM U1266, Paris, France
| | - Laurence Legrand
- Department of Neuroradiology, Sainte-Anne Hospital, Paris Descartes University, INSERM U1266, Paris, France
| | | | - Thanh Phan
- Stroke and Ageing Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Sarah Gunkel
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider Strasse 11, Würzburg, Germany
| | - Nicolas Christ
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider Strasse 11, Würzburg, Germany
| | - Jill Abrigo
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Thomas Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Winnie Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Francesca Chappell
- Edinburgh Imaging, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Institute at the University of Edinburgh, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Stephen Makin
- Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Derek Hayden
- The Neurovascular Research Unit and Health Research Board, Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - David J Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland; Beaumont Hospital Dublin, Ireland
| | - M Eline Kooi
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Dianne H K van Dam-Nolen
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, University Medical Centre, Rotterdam, Netherlands
| | - Carmen Barbato
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, London UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Simone Browning
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, London UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Kim Wiegertjes
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, Netherlands
| | - Anil M Tuladhar
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, Netherlands
| | - Noortje Maaijwee
- Lucerne State Hospital; Switzerland Center for Neurology and Neurorehabilitation, Luzern, Switzerland
| | - Christine Guevarra
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Chathuri Yatawara
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Anne-Marie Mendyk
- University of Lille, Inserm, CHU de Lille, Degenerative and vascular cognitive disorders U1171, Lille, France
| | - Christine Delmaire
- University of Lille, Inserm, CHU de Lille, Degenerative and vascular cognitive disorders U1171, Lille, France
| | - Sebastian Köhler
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ying Zhou
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Chao Xu
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Saima Hilal
- Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore
| | - Bibek Gyanwali
- Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore
| | - Christopher Chen
- Memory Aging and Cognition Centre, National University Health System, Singapore, Singapore
| | - Min Lou
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Julie Staals
- Department of Neurology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Régis Bordet
- University of Lille, Inserm, CHU de Lille, Degenerative and vascular cognitive disorders U1171, Lille, France
| | - Nagaendran Kandiah
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, Netherlands
| | - Robert Simister
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, London UK; Comprehensive Stroke Service, University College London Hospitals NHS Trust, London, UK
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, University Medical Centre, Rotterdam, Netherlands
| | - Peter J Kelly
- The Neurovascular Research Unit and Health Research Board, Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - Joanna M Wardlaw
- Edinburgh Imaging, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Institute at the University of Edinburgh, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Yannie Soo
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Felix Fluri
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider Strasse 11, Würzburg, Germany
| | - Velandai Srikanth
- Peninsula Clinical School, Peninsula Health, Monash University, Melbourne, VIC, Australia
| | - David Calvet
- Department of Neurology, Sainte-Anne Hospital, Paris Descartes University, INSERM U1266, Paris, France
| | - Simon Jung
- Department of Diagnostic and Interventional Neuroradiology and Department of Neurology Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Vincent I H Kwa
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Nabeshima, Saga, Japan
| | | | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Austin Health, Melbourne, VIC, Australia; Department of Neurosciences, University Hospitals Leuven, Belgium
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Vincent Mok
- Therese Pei Fong Chow Research Centre for Prevention of Dementia, Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Roland Veltkamp
- Department of Stroke Medicine, Imperial College London, London, UK; Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hakan Ay
- Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Toshio Imaizumi
- Department of Neurosurgery, Kushiro City General Hospital, Kushiro, Japan
| | - Beatriz Gomez-Anson
- Unit of Neuroradiology, Hospital Santa Creu i Sant Pau, Universitat Autonoma, Barcelona, Spain
| | - Kui Kai Lau
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong
| | - Eric Jouvent
- Assistance Publique Hôpitaux de Paris, Lariboisière Hospital, Department of Neurology, Paris, France; Département Hospitalo-Universtaire NeuroVasc, University Paris Diderot, and INSERM U1141, Paris, France
| | - Peter M Rothwell
- Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University School of Medicine, Seongnam, South Korea
| | - Joan Marti-Fabregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, Barcelona, Spain
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK.
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Tsivgoulis G, Katsanos AH. Can cerebral microbleeds predict stroke recurrence? Lancet Neurol 2019; 18:619-620. [DOI: 10.1016/s1474-4422(19)30194-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
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