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Pan X, Pei Y, Zhang M, Zhong W, Hu J, Wang Z, Xu D, Lou M, Chen H, Chen Z. Association of Atrial Fibrillation with Remote Intracerebral Hemorrhage After Intravenous Thrombolysis: Results from a Multicenter Study in China. Neurol Ther 2024; 13:127-139. [PMID: 38032536 PMCID: PMC10787712 DOI: 10.1007/s40120-023-00563-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION This study aimed to investigate the association between atrial fibrillation (AF), particularly newly diagnosed AF, and remote intracerebral hemorrhage (rICH) in patients with ischemic stroke who were treated with intravenous thrombolysis (IVT). METHODS This observational study was conducted on patients with ischemic stroke who received IVT with recombinant tissue-type plasminogen activator. The data were taken from a multicenter prospective registry of a Chinese population. rICH was defined as any extraischemic hemorrhage detected on computerized tomography (CT) 24 h after intravenous thrombolysis. We collected and compared the demographic data and clinical characteristics of all the patients with rICH to those of patients without any type of hemorrhagic transformation. The association between AF and rICH was analyzed using univariate analysis and binary logistic regression. RESULTS A total of 20,697 patients were included in the study, with 1566 (7.6%) experiencing intracerebral hemorrhage (ICH), 586 (2.8%) experiencing rICH, and 19,131 (92.4%) not experiencing any form of hemorrhagic transformation. Univariate analysis revealed significant differences in age, pre-thrombolysis systolic blood pressure, baseline National Institute of Health Stroke Scale score, previously known AF, newly diagnosed AF, coronary heart disease, congestive heart failure, hyperhomocysteinemia, and history of thrombolysis between the rICH and control groups (P < 0.05). Further multivariate logistic regression analysis indicated that total AF (OR 1.821, 95% CI 1.082-3.065, P < 0.05), previously known AF (OR 1.470, 95% CI 1.170-1.847), and newly diagnosed AF (OR 1.920, 95% CI 1.304-2.825) were independently associated with rICH. CONCLUSIONS This study suggests that AF, regardless of whether it is newly diagnosed or previously known, may be associated with the occurrence of rICH following intravenous thrombolysis. Interestingly, our findings suggest that newly diagnosed AF may have a stronger impact on rICH than previously known AF, although confirmation from more studies is needed.
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Affiliation(s)
- Xiaoling Pan
- Department of Neurology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, No. 365 Renmin East Road, Jinhua, 321000, Zhejiang Province, China
| | - Yingjian Pei
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, 310009, Zhejiang Province, China
| | - Meixia Zhang
- Department of Neurology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, No. 365 Renmin East Road, Jinhua, 321000, Zhejiang Province, China
| | - Wansi Zhong
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, 310009, Zhejiang Province, China
| | - Jin Hu
- Department of Neurology, The First Hospital of Jiaxing, Jiaxing, 314000, Zhejiang Province, China
| | - Zhimin Wang
- Department of Neurology, Taizhou First People's Hospital, Taizhou, 318020, Zhejiang Province, China
| | - Dongjuan Xu
- Department of Neurology, Dongyang People's Hospital, Dongyang, 322100, Zhejiang Province, China
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, 310009, Zhejiang Province, China
| | - Hongfang Chen
- Department of Neurology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, No. 365 Renmin East Road, Jinhua, 321000, Zhejiang Province, China.
| | - Zhicai Chen
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, 310009, Zhejiang Province, China.
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Tsivgoulis G, Palaiodimou L, Stefanou MI, Theodorou A, Kõrv J, Nunes AP, Candelaresi P, Dall'Ora E, Sariaslani P, Provinciali L, Conforto AB, Cidrao AADL, Karapanayiotides T, Ahmed N. Predictors of functional outcome after symptomatic intracranial hemorrhage complicating intravenous thrombolysis: results from the SITS-ISTR. Eur J Neurol 2023; 30:3161-3171. [PMID: 37410547 DOI: 10.1111/ene.15968] [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: 05/20/2023] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND AND PURPOSE Several risk factors of symptomatic intracerebral hemorrhage (SICH) following intravenous thrombolysis for acute ischaemic stroke have been established. However, potential predictors of good functional outcome post-SICH have been less studied. METHODS Patient data registered in the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) from 2005 to 2021 were used. Acute ischaemic stroke patients who developed post intravenous thrombolysis SICH according to the SITS Monitoring Study definition were analyzed to identify predictors of functional outcomes. RESULTS A total of 1679 patients with reported SICH were included, out of which only 2.8% achieved good functional outcome (modified Rankin Scale scores of 0-2), whilst 80.9% died at 3 months. Higher baseline National Institutes of Health Stroke Scale (NIHSS) score and 24-h ΔNIHSS score were independently associated with a lower likelihood of achieving both good and excellent functional outcomes at 3 months. Baseline NIHSS and hematoma location (presence of both SICHs, defined as remote and local SICH concurrently; n = 478) were predictors of early mortality within 24 h. Independent predictors of 3-month mortality were age, baseline NIHSS, 24-h ΔNIHSS, admission serum glucose values and hematoma location (both SICHs). Age, baseline NIHSS score, 24-h ΔNIHSS, hyperlipidemia, prior stroke/transient ischaemic attack, antiplatelet treatment, diastolic blood pressure at admission, glucose values on admission and SICH location (both SICHs) were associated with reduced disability at 3 months (≥1-point reduction across all modified Rankin Scale scores). Patients with remote SICH (n = 219) and local SICH (n = 964) had comparable clinical outcomes, both before and after propensity score matching. CONCLUSIONS Symptomatic intracerebral hemorrhage presents an alarmingly high prevalence of adverse clinical outcomes, with no difference in clinical outcomes between remote and local SICH.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Ioanna Stefanou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Aikaterini Theodorou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Ana Paiva Nunes
- Stroke Unit, Hospital São José, Lisbon Central University Hospital Center, Lisbon, Portugal
| | | | - Elisa Dall'Ora
- Stroke Unit, Department of Neurology, Bolzano Central Hospital, Bolzano, Italy
| | - Payam Sariaslani
- Department of Neurology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Leandro Provinciali
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Adriana B Conforto
- Divisão de Neurologia Clínica, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | | | - Theodore Karapanayiotides
- Second Department of Neurology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Chen J, Lin Y, Li J, Zhang P, Wang Y, Chen Y, Zhang C, Li C. Efficacy and safety of short-term high dosage dual antiplatelet therapy after 0.6 mg/kg rt-PA intravenous thrombolysis for acute ischemic stroke. Medicine (Baltimore) 2023; 102:e35099. [PMID: 37682162 PMCID: PMC10489488 DOI: 10.1097/md.0000000000035099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/16/2023] [Indexed: 09/09/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of short-term high-dose of dual antiplatelet therapy after 0.6 mg/kg rt-PA intravenous thrombolysis for acute ischemic stroke (AIS). METHODS All 208 patients with AIS were randomized into group 1 (103 cases, after 0.6 mg/kg rt-PA, 300 mg of oral aspirin(ASP) q.d. and 225 mg of oral clopidogrel (CLO) q.d. for for 5 days, then 100 mg of oral ASP q.d. for the next 85 days and 75 mg of oral CLO q.d. for the next 16 days) and group 2 (105 cases, after 0.9 mg/kg rt-PA, 100 mg of oral ASP q.d. for 90 days and 75 mg of oral CLO q.d. for 21 days).The efficacy index was the mRS score, NIHSS score and recurrence risk of stroke, while the safety index was the incidence of bleeding events and mortality. All parameters were evaluated at 30 and 90 days after thrombolysis. Patients whose characteristics may provide the best treatment benefit were further analyzed using the logistic regression model in group 1. RESULTS The proportion of mRS scores between 0 and 1 in group 1 was higher than that in group 2 at both 30 days (44.7% vs 32.4%, P < .05) and 90 days (50.5% vs 35.2%, P < .05). Compared to group 2, the proportion of NIHSS scores less than 4 was significantly higher in group 1 at both 30 days (37.9% vs 25.7%, P < .05) and 90 days (46.6% vs 30.5%, P < .05). At 90 days, Group 1 had a lower stroke recurrence risk than Group 2 (3.9% vs 10.5%, P < .05). The incidence of SICH was significantly different between the 2 groups at both 30 days (2.9% vs 9.5%, P < .05) and 90 days (2.9% vs 10.5%, P < .05). However, other bleeding events and mortality rates were not significantly different between the 2 groups. The lower the baseline NIHSS score and the shorter the OTT, the more favorable the outcomes obtained at 90 days. CONCLUSIONS Compared to standard doses, short term high-dose dual antiplatelet therapy after 0.6 mg/kg rt-PA intravenous thrombolysis may be a good choice for AIS patients.
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Affiliation(s)
- Jing Chen
- Department of Neurology, Characteristic Medical Centre of People’s Armed Police Force, Tianjin, P.R. China
- Tianjin Medical University, Tianjin, P.R. China
| | - Yanchen Lin
- Department of Rehabilitation, Characteristic Medical Centre of People’s Armed Police Force, Tianjin, P.R. China
- Army Medical University, Chongqing, P. R. China
| | - Jingjing Li
- Department of Pharmacy, Tianjin Fourth Central Hospital, Tianjin, P. R. China
| | - Peilan Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, P.R. China
| | - Yuxin Wang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, P.R. China
| | - Yan Chen
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, P.R. China
| | - Chenhao Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, P.R. China
| | - Chenhua Li
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, P.R. China
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Exploring the Impact of Cerebral Microbleeds on Stroke Management. Neurol Int 2023; 15:188-224. [PMID: 36810469 PMCID: PMC9944881 DOI: 10.3390/neurolint15010014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/17/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023] Open
Abstract
Stroke constitutes a major cause of functional disability and mortality, with increasing prevalence. Thus, the timely and accurate prognosis of stroke outcomes based on clinical or radiological markers is vital for both physicians and stroke survivors. Among radiological markers, cerebral microbleeds (CMBs) constitute markers of blood leakage from pathologically fragile small vessels. In the present review, we evaluated whether CMBs affect ischemic and hemorrhagic stroke outcomes and explored the fundamental question of whether CMBs may shift the risk-benefit balance away from reperfusion therapy or antithrombotic use in acute ischemic stroke patients. A literature review of two databases (MEDLINE and Scopus) was conducted to identify all the relevant studies published between 1 January 2012 and 9 November 2022. Only full-text articles published in the English language were included. Forty-one articles were traced and included in the present review. Our findings highlight the utility of CMB assessments, not only in the prognostication of hemorrhagic complications of reperfusion therapy, but also in forecasting hemorrhagic and ischemic stroke patients' functional outcomes, thus indicating that a biomarker-based approach may aid in the provision of counseling for patients and families, improve the selection of more appropriate medical therapies, and contribute to a more accurate choice of patients for reperfusion therapy.
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Wang Y, Bai X, Ye C, Yu Y, Wu B. The association between the severity and distribution of white matter lesions and hemorrhagic transformation after ischemic stroke: A systematic review and meta-analysis. Front Aging Neurosci 2022; 14:1053149. [PMID: 36506465 PMCID: PMC9732368 DOI: 10.3389/fnagi.2022.1053149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022] Open
Abstract
Background and purpose As a part of the natural course of ischemic stroke, hemorrhagic transformation (HT) is a serious complication after reperfusion treatment, which may affect the prognosis of patients with ischemic stroke. White matter lesions (WMLs) refer to focal lesions on neuroimaging and have been suggested to indicate a high risk of HT. This systematic review and meta-analysis aimed to summarize current evidence on the relation between WML and HT. Methods This systematic review was prepared with reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, Embase, Web of Science, and Cochrane Library databases for publications on WML and HT in patients with ischemic stroke. Odds ratios (ORs) and 95% confidence intervals (CIs) from eligible studies were combined to quantify the association between the severity of WML and the risk of HT. In addition, the descriptive analysis was adopted to evaluate the influence of different WML distributions on predicting HT. Results A total of 2,303 articles were identified after removing duplicates through database searching, and 41 studies were included in our final analysis. The meta-analysis showed that the presence of WML was associated with HT (OR = 1.62, 95%CI 1.08-2.43, p = 0.019) and symptomatic intracerebral hemorrhage (sICH) (OR = 1.64, 95%CI 1.17-2.30, p = 0.004), and moderate-to-severe WML indicated a high risk of HT (OR = 2.03, 95%CI 1.33-3.12, p = 0.001) and sICH (OR = 1.92, 95%CI 1.31-2.81, p < 0.001). The dose-response meta-analysis revealed risk effects of increasing the severity of WML on both HT and ICH. In addition, both periventricular WML (PWML) (five of seven articles) and deep WML (DWML) (five of six articles) were shown to be associated with HT. Conclusions White matter lesions are associated with overall HT and sICH in patients with ischemic stroke, and more severe WMLs indicate a high risk of HT and sICH. In addition, both PWML and DWMLs could be risk factors for HT. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier: PROSPERO CRD42022313467.
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Affiliation(s)
- Youjie Wang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Xueling Bai
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Chen Ye
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yifan Yu
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Bo Wu
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He J, Fu F, Zhang W, Zhan Z, Cheng Z. Prognostic significance of the clinical and radiological haemorrhagic transformation subtypes in acute ischaemic stroke: A systematic review and meta-analysis. Eur J Neurol 2022; 29:3449-3459. [PMID: 35789517 DOI: 10.1111/ene.15482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE The aim was to investigate the associations of haemorrhagic transformation (HT) and its clinical and radiological subtypes with functional outcome, mortality, early neurological deterioration (END) and neurological complications in patients with acute ischaemic stroke (AIS). METHODS A systematic review and meta-analysis of observational studies on the associations of overall HT, clinical HT subtypes (asymptomatic intracerebral haemorrhage [aICH] and symptomatic intracerebral haemorrhage [sICH]) or radiological HT subtypes (haemorrhagic infarction [HI-1 or HI-2] and parenchymal haemorrhage [PH-1 or PH-2]) with prognosis in patients with AIS was performed. PubMed, Web of Science and Embase were systematically searched. Random effects models were used to calculate pooled estimates. RESULTS Fifty-one studies with 100,510 patients were pooled in the meta-analysis. Overall HT was associated with worse functional outcome (odds ratio [OR] 2.12, 95% confidence interval [CI] 1.55-2.90), increased mortality (OR 1.87, 95% CI 1.52-2.30), END (OR 2.35, 95% CI 1.46-3.77), early-onset seizures (OR 2.58, 95% CI 1.63-4.10) and post-stroke epilepsy (OR 2.23, 95% CI 1.11-4.49). For clinical subtypes, sICH remained significantly associated with the aforementioned poor prognoses except post-stroke epilepsy, and aICH was associated with worse functional outcome but was unrelated to mortality. For radiological subtypes, PH (especially PH-2) was strongly associated with poor prognosis. HI-2 was associated with worse functional outcome, and HI-1 was associated with a lower risk of mortality and END. CONCLUSIONS Regardless of whether AIS patients undergo thrombolysis or thrombectomy, overall HT, sICH and PH (especially PH-2) are associated with a substantially increased risk of worse functional outcome, mortality, END or neurological complications. The presence of aICH is related to worse functional outcome but is independent of increased mortality. HI-2 impairs functional independence, and HI-1 does not cause neurological impairment.
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Affiliation(s)
- Jinfeng He
- Department of Neurology, Taizhou Municipal Hospital, Taizhou, China
| | - Fangwang Fu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenyuan Zhang
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Neurology, Affiliated Yueqing Hospital, Wenzhou Medical University, Yueqing, China
| | - Zhenxiang Zhan
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zicheng Cheng
- Department of Neurology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
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Du H, Wu S, Lei H, Ambler G, Werring DJ, Li H, Chen Y, Chen D, Yuan Q, Fang S, Chen R, Zhang Y, Wei J, Chen G, Chen J, Liu N. Total Cerebral Small Vessel Disease Score and Cerebral Bleeding Risk in Patients With Acute Stroke Treated With Intravenous Thrombolysis. Front Aging Neurosci 2022; 14:790262. [PMID: 35478697 PMCID: PMC9037754 DOI: 10.3389/fnagi.2022.790262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe aim of this study was to investigate the association of total cerebral small vessel disease (cSVD) score with the risk of intracerebral hemorrhage (ICH) in patients with acute ischemic stroke who received intravenous thrombolysis (IVT) using recombinant tissue-plasminogen activator (rt-PA).MethodsWe retrospectively reviewed clinical data from two stroke registries of patients with acute ischemic stroke treated with IVT. We assessed the baseline magnetic resonance (MR) visible cSVD markers and total cSVD score (ranging from 0 to 4) between patients with and without ICH after IVT. Logistic regression analysis was used to determine the association of total cSVD score with the risk of ICH after IVT, adjusted for cofounders selected by least absolute shrinkage and selection operator (LASSO). We additionally performed an E-value analysis to fully explain away a specific exposure-outcome association. Receiver operating characteristic (ROC) curve analysis was used to quantify the predictive potential of the total cSVD score for any ICH after IVT.ResultsAmong 271 eligible patients, 55 (20.3%) patients experienced any ICH, 16 (5.9%) patients experienced a symptomatic ICH (sICH), and 5 (1.85%) patients had remote intracranial parenchymal hemorrhage (rPH). Logistic regression analysis showed that the risk of any ICH increased with increasing cSVD score [per unit increase, adjusted odds ratio (OR) 2.03, 95% CI 1.22–3.41, P = 0.007]. Sensitivity analyses using E-value revealed that it would need moderately robust unobserved confounding to render the exposure-outcome (cSVD-any ICH) association null. ROC analysis showed that compared with the National Institutes of Health Stroke Scale (NIHSS) score alone, a combination of cSVD and NIHSS score had a larger area under the curve for any ICH (0.811, 95% CI 0.756–0.866 vs. 0.784, 95% CI 0.723–0.846, P = 0.0004).ConclusionThe total cSVD score is associated with an increased risk of any ICH after IVT and improves prediction for any ICH compared with NIHSS alone.
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Affiliation(s)
- Houwei Du
- Department of Neurology, Stroke Research Center, Fujian Medical University Union Hospital, Fuzhou, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, China
| | - Sangru Wu
- Department of Neurology, Stroke Research Center, Fujian Medical University Union Hospital, Fuzhou, China
- Department of Neurology, Fujian Provincial Governmental Hospital, Fuzhou, China
| | - Hanhan Lei
- Department of Neurology, Stroke Research Center, Fujian Medical University Union Hospital, Fuzhou, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, China
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, United Kingdom
| | - David J. Werring
- Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, United Kingdom
| | - Hangfeng Li
- Department of Neurology, Longyan First Hospital of Fujian Medical University, Longyan, China
| | - Yangui Chen
- Department of Neurology, Longyan First Hospital of Fujian Medical University, Longyan, China
| | - Dongping Chen
- Department of Neurology, Longyan First Hospital of Fujian Medical University, Longyan, China
| | - Qilin Yuan
- Department of Neurology, Stroke Research Center, Fujian Medical University Union Hospital, Fuzhou, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, China
| | - Shuangfang Fang
- Department of Neurology, Stroke Research Center, Fujian Medical University Union Hospital, Fuzhou, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, China
| | - Ronghua Chen
- Department of Neurology, Stroke Research Center, Fujian Medical University Union Hospital, Fuzhou, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou, China
| | - Yixian Zhang
- Department of Rehabilitation, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jin Wei
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Guangliang Chen
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jianhua Chen
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Nan Liu
- Department of Neurology, Stroke Research Center, Fujian Medical University Union Hospital, Fuzhou, China
- Department of Rehabilitation, Fujian Medical University Union Hospital, Fuzhou, China
- *Correspondence: Nan Liu,
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Miwa K, Koga M, Inoue M, Yoshimura S, Sasaki M, Yakushiji Y, Fukuda-Doi M, Okada Y, Nakase T, Ihara M, Nagakane Y, Takizawa S, Asakura K, Aoki J, Kimura K, Yamamoto H, Toyoda K. Cerebral microbleeds development after stroke thrombolysis: A secondary analysis of the THAWS randomized clinical trial. Int J Stroke 2021; 17:628-636. [PMID: 34282985 DOI: 10.1177/17474930211035023] [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: 11/17/2022]
Abstract
BACKGROUND AND AIM We determined to investigate the incidence and clinical impact of new cerebral microbleeds after intravenous thrombolysis in patients with acute stroke. METHODS The THAWS was a multicenter, randomized trial to study the efficacy and safety of intravenous thrombolysis with alteplase in patients with wake-up stroke or unknown onset stroke. Prescheduled T2*-weighted imaging assessed cerebral microbleeds at three time points: baseline, 22-36 h, and 7-14 days. Outcomes included new cerebral microbleeds development, modified Rankin Scale (mRS) ≥3 at 90 days, and change in the National Institutes of Health Stroke Scale (NIHSS) score from 24 h to 7 days. RESULTS Of all 131 patients randomized in the THAWS trial, 113 patients (mean 74.3 ± 12.6 years, 50 female, 62 allocated to intravenous thrombolysis) were available for analysis. Overall, 46 (41%) had baseline cerebral microbleeds (15 strictly lobar cerebral microbleeds, 14 mixed cerebral microbleeds, and 17 deep cerebral microbleeds). New cerebral microbleeds only emerged in the intravenous thrombolysis group (seven patients, 11%) within a median of 28.3 h, and did not additionally increase within a median of 7.35 days. In adjusted models, number of cerebral microbleeds (relative risk (RR) 1.30, 95% confidence interval (CI): 1.17-1.44), mixed distribution (RR 19.2, 95% CI: 3.94-93.7), and cerebral microbleeds burden ≥5 (RR 44.9, 95% CI: 5.78-349.8) were associated with new cerebral microbleeds. New cerebral microbleeds were associated with an increase in NIHSS score (p = 0.023). Treatment with alteplase in patients with baseline ≥5 cerebral microbleeds resulted in a numerical shift toward worse outcomes on ordinal mRS (median [IQR]; 4 [3-4] vs. 0 [0-3]), compared with those with <5 cerebral microbleeds (common odds ratio 17.1, 95% CI: 0.76-382.8). The association of baseline ≥5 cerebral microbleeds with ordinal mRS score differed according to the treatment group (p interaction = 0.042). CONCLUSION New cerebral microbleeds developed within 36 h in 11% of the patients after intravenous thrombolysis, and they were significantly associated with mixed-distribution and ≥5 cerebral microbleeds. New cerebral microbleeds development might impede neurological improvement. Furthermore, cerebral microbleeds burden might affect the effect of alteplase.
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Affiliation(s)
- Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan.,Department of Neurology, Kansai Medical University, Hirakata, Japan
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Taizen Nakase
- Department of Stroke Science, Research Institute for Brain and Blood Vessels, Akita, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Shunya Takizawa
- 0Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Koko Asakura
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junya Aoki
- 1Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Wang Y, Yan X, Zhan J, Zhang P, Zhang G, Ge S, Wen H, Wang L, Xu N, Lu L. Neuroimaging Markers of Cerebral Small Vessel Disease on Hemorrhagic Transformation and Functional Outcome After Intravenous Thrombolysis in Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Aging Neurosci 2021; 13:692942. [PMID: 34326767 PMCID: PMC8315270 DOI: 10.3389/fnagi.2021.692942] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/11/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The aim of this study was to perform a systematic review and meta-analysis to assess whether cerebral small vessel disease (CSVD) on neuroimaging of patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT) is associated with an increased risk of hemorrhagic transformation (HT), symptomatic intracranial hemorrhage (sICH), and poor functional outcome (PFO). Methods: A thorough search of several databases was carried out to identify relevant studies up to December 2020. We included studies of patients with AIS and neuroimaging markers of CSVD treated with IVT. The primary outcome was HT, and the secondary outcomes were sICH and 3-month PFO. The quality of the studies involved was evaluated using the Newcastle-Ottawa Scale (NOS). The meta-analysis with the fixed effects model was performed. Results: Twenty-four eligible studies (n = 9,419) were pooled in the meta-analysis. All included studies were regarded as high quality with the NOS scores of at least 6 points. The meta-analysis revealed associations between the presence of CSVD and HT, sICH, and the 3-month PFO after IVT. Compared with no CSVD, the presence of CSVD was associated with an increased risk of HT (OR: 1.81, 95% CI: 1.52-2.16), sICH (OR: 2.42, 95% CI: 1.76-3.33), and 3-month PFO (OR: 2.15, 95% CI: 1.89-2.44). For patients with AIS complicated with CSVD, compared with a CSVD score of 0-1, a CSVD score of 2-4 was associated with an increased risk of HT (OR: 3.10, 95% CI: 1.67-5.77), sICH (OR: 2.86, 95% CI: 1.26-6.49), and 3-month PFO (OR: 4.58, 95% CI: 2.97-7.06). Conclusion: Patients with AIS complicated with neuroimaging markers of CSVD are at increased risk of HT and 3-month PFO after IVT. However, it is still necessary to clarify the exact role of CSVD in the occurrence, development, and prognosis of AIS. Systematic Review Registration: www.ClinicalTrials.gov, identifier CRD4202123 3900.
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Affiliation(s)
- Yiqiao Wang
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaoting Yan
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jie Zhan
- Postdoctoral Programme, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Peiming Zhang
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Guangming Zhang
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shuqi Ge
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hao Wen
- Department of Neurology, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lin Wang
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Nenggui Xu
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Liming Lu
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
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Tábuas-Pereira M, Galego O, Almeida MR, Tomás J, Félix-Morais R, Silva F, Rodrigues B, Cordeiro G, Sargento-Freitas J. Apolipoprotein E genotype does not influence the risk of symptomatic hemorrhage in acute ischemic stroke. J Clin Neurosci 2021; 88:34-38. [PMID: 33992200 DOI: 10.1016/j.jocn.2021.03.014] [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: 12/10/2020] [Revised: 02/11/2021] [Accepted: 03/11/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND APOE ε4 is independently associated with lobar intracranial hemorrhages (ICH). Although the ε4 allele enhances amyloid deposition in blood vessels, the ε2 allele predisposes to vasculopathic changes leading to rupture of amyloid laden vessels. Thus, ε4 and ε2 carriers might have increased susceptibility to ICH. We aimed to study the impact of the apolipoprotein E alleles in the development of symptomatic ICH (sICH). METHODS We included 384 consecutive ischemic anterior circulation stroke patients submitted to thrombolysis between January 2014 and March 2016. Admission CT-scans were reviewed to calculate the ASPECTS. Patients were followed for up to at least 6 months post-stroke or until death. Outcome was development of sICH, defined according to the ECASS III. RESULTS Considering APOE genotyping, three patients had ε2/ε2, four had ε2/ε4, 38 had ε2/ε3, 284 had ε3/ε3, 51 had ε3/ε4 and four had ε4/ε4. sICH was associated with sex and diabetes. In multivariate analysis, sICH was not associated with carrying one or more ε4 alleles (OR: 0.483, 95%CI = [0.059, 3.939], p = 0.497) nor with carrying one or more ε2 alleles (OR: 1.369, 95%CI = [0.278, 6.734], p = 0.699). CONCLUSION No association was found between APOE genotype and the development of symptomatic intracranial hemorrhage.
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Affiliation(s)
- Miguel Tábuas-Pereira
- Neurology Department - Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Orlando Galego
- Neurology Department - Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | | | - José Tomás
- Neurology Department - Hospital Amato Lusitano, Castelo Branco, Portugal
| | - Ricardo Félix-Morais
- Neurology Department - Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Fernando Silva
- Neurology Department - Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Bruno Rodrigues
- Neurology Department - Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Gustavo Cordeiro
- Neurology Department - Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - João Sargento-Freitas
- Neurology Department - Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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11
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Charbonnier G, Bonnet L, Biondi A, Moulin T. Intracranial Bleeding After Reperfusion Therapy in Acute Ischemic Stroke. Front Neurol 2021; 11:629920. [PMID: 33633661 PMCID: PMC7900408 DOI: 10.3389/fneur.2020.629920] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/29/2020] [Indexed: 12/16/2022] Open
Abstract
Intracranial hemorrhage is one of the most feared complications following brain infarct. Ischemic tissues have a natural tendency to bleed. Moreover, the first recanalization trials using intravenous thrombolysis have shown an increase in mild to severe intracranial hemorrhage. Symptomatic intracerebral hemorrhage is strongly associated with poor outcomes and is an important factor in recanalization decisions. Stroke physicians have to weigh the potential benefit of recanalization therapies, first, with different risks of intracranial hemorrhage described in randomized controlled trials, and second with numerous risk markers that have been found to be associated with intracranial hemorrhage in retrospective series. These decisions have become quite complex with different intravenous thrombolytics and mechanical thrombectomy. This review aims to outline some elements of the pathophysiological mechanisms and classifications, describe most of the risk factors identified for each reperfusion therapy, and finally suggest future research directions that could help physicians dealing with these complications.
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Affiliation(s)
- Guillaume Charbonnier
- Neurology Department, Besançon University Hospital, Besançon, France.,Interventional Neuroradiology Department, Besançon University Hospital, Besançon, France.,EA 481 Neurosciences laboratory, Franche-Comté University, Besançon, France
| | - Louise Bonnet
- Neurology Department, Besançon University Hospital, Besançon, France
| | - Alessandra Biondi
- Interventional Neuroradiology Department, Besançon University Hospital, Besançon, France.,CIC-1431 Inserm, Besançon, France
| | - Thierry Moulin
- Neurology Department, Besançon University Hospital, Besançon, France.,EA 481 Neurosciences laboratory, Franche-Comté University, Besançon, France.,CIC-1431 Inserm, Besançon, France
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