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Zheng C, Li R, Shen C, Hu Z, Qiu Z, Yang Q, Guo F. Leukoaraiosis in patients with tirofiban before endovascular thrombectomy: A post hoc analysis of a multicentre randomized clinical trial. J Formos Med Assoc 2024:S0929-6646(24)00391-7. [PMID: 39174395 DOI: 10.1016/j.jfma.2024.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 08/14/2024] [Accepted: 08/18/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND AND PURPOSE To evaluate the effectiveness and safety of intravenous tirofiban before endovascular thrombectomy in subgroups of acute ischemic stroke patients with different degrees of leukoaraiosis (LA). METHODS Patients of the RESCUE BT trial whose LA grade could be assessed were included. Eligible patients were dichotomized into two strata according to the van Swieten scale (VSS) score, absent-to-moderate LA (VSS score <3) and severe LA (VSS score ≥3). Furthermore, patients were divided into tirofiban and placebo groups in each stratum. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Safety outcome was radiological intracranial hemorrhage within 48 h. RESULTS 861 patients were included, 439 patients with absent-to-moderate LA and 422 patients with severe LA. There were no significant differences in 90-day mRS score between the tirofiban and placebo groups in either stratum (absent-to-moderate LA: adjusted OR 0.92 (95%CI, 0.66-1.28), P = 0.62; severe LA: adjusted OR 0.99 (95% CI, 0.69-1.42), P = 0.96). In the severe LA stratum, the occurrence of radiologic intracranial hemorrhage was greater in the tirofiban group compared to the placebo group. (35.7% vs 26.4%; adjusted OR, 1.72 (95% CI, 1.12-2.66); P = 0.014). However, no difference was observed in the absent-to-moderate LA stratum (33.2% vs 29.3%; adjusted OR, 1.15 (95% CI, 0.76-1.75); P = 0.51). CONCLUSION There was no significant difference in disability severity at 90 days when treating AIS patients using intravenous tirofiban before endovascular therapy, in either absent-to-moderate or severe LA strata. It should be noted that intravenous tirofiban before endovascular therapy increases the incidence of radiologic intracranial hemorrhage in patients with severe LA.
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Affiliation(s)
- Chong Zheng
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, No. 105, Jiuyi North Road, Longyan 364000, China.
| | - Rongtong Li
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, No. 105, Jiuyi North Road, Longyan 364000, China
| | - Chaoxiong Shen
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, No. 105, Jiuyi North Road, Longyan 364000, China
| | - Zhizhou Hu
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, No. 105, Jiuyi North Road, Longyan 364000, China
| | - Zhongming Qiu
- Neurology Department, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University) 183 Xinqiao Main Street, Shapingba District, Chongqing 400037, China
| | - Qingwu Yang
- Neurology Department, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University) 183 Xinqiao Main Street, Shapingba District, Chongqing 400037, China
| | - Fang Guo
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, No. 105, Jiuyi North Road, Longyan 364000, China
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Shen Y, Xiong Y, Cao Q, Li Y, Xiang W, Wang L, Nie Q, Tang B, Yang Y, Hong D. Construction and validation of a nomogram model to predict symptomatic intracranial hemorrhage after intravenous thrombolysis in severe white matter lesions. J Thromb Thrombolysis 2023:10.1007/s11239-023-02828-4. [PMID: 37193832 DOI: 10.1007/s11239-023-02828-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 05/18/2023]
Abstract
Cerebral white matter lesions (WMLs) increase the risk of bleeding after intravenous thrombolysis (IVT) but are also considered to require IVT. Its risk factors and predictive models are still poorly studied. The aim of this study is to develop a clinically applicable model for post-IVT haemorrhage. It offers the possibility to prevent symptomatic intracranial hemorrhage (sICH) in patients with IVT in severe WMLs. A large single-center observational study conducted a retrospective analysis of IVT in patients with severe WMLs from January 2018 to December 2022. Univariate and multi-factor logistic regression results were used to construct nomogram model, and a series of validations were performed on the model. More than 2,000 patients with IVT were screened for inclusion in this study after cranial magnetic resonance imaging evaluation of 180 patients with severe WMLs, 28 of whom developed sICH. In univariate analysis, history of hypertension (OR 3.505 CI 2.257-4.752, p = 0.049), hyperlipidemia (OR 4.622 CI 3.761- 5.483, p < 0.001), the NIHSS score before IVT (OR 41.250 CI 39.212-43.288, p < 0.001), low-density lipoprotein levels (OR 1.995 CI 1.448-2.543, p = 0.013), cholesterol levels (OR 1.668 CI 1.246-2.090, p = 0.017), platelet count (OR 0.992 CI 0.985-0.999, p = 0.028), systolic blood pressure (OR 1.044 CI 1.022-1.066, p < 0.001), diastolic blood pressure (OR 1.047 CI 1.024-1.070, p < 0.001) were significantly associated with sICH. In a multifactorial analysis, the NIHSS score before IVT (OR 94.743 CI 92.311-97.175, p < 0.001), and diastolic blood pressure (OR 1.051 CI 1.005-1.097, p = 0.033) were considered to be significantly associated with sICH after IVT as risk factors for the occurrence of sICH. The four most significant factors from logistic regression are subsequently fitted to create a predictive model. The accuracy was verified using ROC curves, calibration curves, decision curves, and clinical impact curves, and the model was considered to have high accuracy (AUC 0.932, 95% 0.888-0.976). The NHISS score before IVT and diastolic blood pressure are independent risk factors for sICH after IVT in patients with severe WMLs. The models based on hyperlipidemia, the NIHSS score before IVT, low-density lipoprotein and diastolic blood pressure are highly accurate and can be applied clinically to provide a reliable predictive basis for IVT in patients with severe WMLs.
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Affiliation(s)
- Yu Shen
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Yong Wai Zheng Street 17#, Nanchang, 330006, People's Republic of China
| | - Ying Xiong
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Yong Wai Zheng Street 17#, Nanchang, 330006, People's Republic of China
| | - Qian Cao
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - YanPing Li
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - WenWen Xiang
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - LuLu Wang
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Yong Wai Zheng Street 17#, Nanchang, 330006, People's Republic of China
| | - Quirui Nie
- Department of Gerontology, Nanchang First Hospital, Nanchang, China
| | - BoJi Tang
- Department of Neurology, Xiamen Fifth People's Hospital, Xiamen, China
| | - YiRong Yang
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Yong Wai Zheng Street 17#, Nanchang, 330006, People's Republic of China
| | - Daojun Hong
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Yong Wai Zheng Street 17#, Nanchang, 330006, People's Republic of China.
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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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Benzakoun J, Deslys MA, Legrand L, Hmeydia G, Turc G, Hassen WB, Charron S, Debacker C, Naggara O, Baron JC, Thirion B, Oppenheim C. Synthetic FLAIR as a Substitute for FLAIR Sequence in Acute Ischemic Stroke. Radiology 2022; 303:153-159. [PMID: 35014901 DOI: 10.1148/radiol.211394] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background In acute ischemic stroke (AIS), fluid-attenuated inversion recovery (FLAIR) is used for treatment decisions when onset time is unknown. Synthetic FLAIR could be generated with deep learning from information embedded in diffusion-weighted imaging (DWI) and could replace acquired FLAIR sequence (real FLAIR) and shorten MRI duration. Purpose To compare performance of synthetic and real FLAIR for DWI-FLAIR mismatch estimation and identification of patients presenting within 4.5 hours from symptom onset. Materials and Methods In this retrospective study, all pretreatment and early follow-up (<48 hours after symptom onset) MRI data sets including DWI (b = 0-1000 sec/mm2) and FLAIR sequences obtained in consecutive patients with AIS referred for reperfusion therapies between January 2002 and May 2019 were included. On the training set (80%), a generative adversarial network was trained to produce synthetic FLAIR with DWI as input. On the test set (20%), synthetic FLAIR was computed without real FLAIR knowledge. The DWI-FLAIR mismatch was evaluated on both FLAIR data sets by four independent readers. Interobserver reproducibility and DWI-FLAIR mismatch concordance between synthetic and real FLAIR were evaluated with κ statistics. Sensitivity and specificity for identification of AIS within 4.5 hours were compared in patients with known onset time by using McNemar test. Results The study included 1416 MRI scans (861 patients; median age, 71 years [interquartile range, 57-81 years]; 375 men), yielding 1134 and 282 scans for training and test sets, respectively. Regarding DWI-FLAIR mismatch, interobserver reproducibility was substantial for real and synthetic FLAIR (κ = 0.80 [95% CI: 0.74, 0.87] and 0.80 [95% CI: 0.74, 0.87], respectively). After consensus, concordance between real and synthetic FLAIR was almost perfect (κ = 0.88; 95% CI: 0.82, 0.93). Diagnostic value for identifying AIS within 4.5 hours did not differ between real and synthetic FLAIR (sensitivity: 107 of 131 [82%] vs 111 of 131 [85%], P = .2; specificity: 96 of 104 [92%] vs 96 of 104 [92%], respectively, P > .99). Conclusion Synthetic fluid-attenuated inversion recovery (FLAIR) had diagnostic performances similar to real FLAIR in depicting diffusion-weighted imaging-FLAIR mismatch and in helping to identify early acute ischemic stroke, and it may accelerate MRI protocols. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Carroll and Hurley in this issue.
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Affiliation(s)
- Joseph Benzakoun
- From the Departments of Neuroradiology (J.B., L.L., G.H., W.B.H., O.N., C.O.) and Neurology (G.T., J.C.B.), GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; INSERM U1266, Paris, France (J.B., M.A.D., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); Université de Paris, FHU Neurovasc, Paris, France (J.B., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); and PARIETAL Team, INRIA, Saclay, France (B.T.)
| | - Marc-Antoine Deslys
- From the Departments of Neuroradiology (J.B., L.L., G.H., W.B.H., O.N., C.O.) and Neurology (G.T., J.C.B.), GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; INSERM U1266, Paris, France (J.B., M.A.D., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); Université de Paris, FHU Neurovasc, Paris, France (J.B., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); and PARIETAL Team, INRIA, Saclay, France (B.T.)
| | - Laurence Legrand
- From the Departments of Neuroradiology (J.B., L.L., G.H., W.B.H., O.N., C.O.) and Neurology (G.T., J.C.B.), GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; INSERM U1266, Paris, France (J.B., M.A.D., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); Université de Paris, FHU Neurovasc, Paris, France (J.B., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); and PARIETAL Team, INRIA, Saclay, France (B.T.)
| | - Ghazi Hmeydia
- From the Departments of Neuroradiology (J.B., L.L., G.H., W.B.H., O.N., C.O.) and Neurology (G.T., J.C.B.), GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; INSERM U1266, Paris, France (J.B., M.A.D., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); Université de Paris, FHU Neurovasc, Paris, France (J.B., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); and PARIETAL Team, INRIA, Saclay, France (B.T.)
| | - Guillaume Turc
- From the Departments of Neuroradiology (J.B., L.L., G.H., W.B.H., O.N., C.O.) and Neurology (G.T., J.C.B.), GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; INSERM U1266, Paris, France (J.B., M.A.D., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); Université de Paris, FHU Neurovasc, Paris, France (J.B., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); and PARIETAL Team, INRIA, Saclay, France (B.T.)
| | - Wagih Ben Hassen
- From the Departments of Neuroradiology (J.B., L.L., G.H., W.B.H., O.N., C.O.) and Neurology (G.T., J.C.B.), GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; INSERM U1266, Paris, France (J.B., M.A.D., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); Université de Paris, FHU Neurovasc, Paris, France (J.B., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); and PARIETAL Team, INRIA, Saclay, France (B.T.)
| | - Sylvain Charron
- From the Departments of Neuroradiology (J.B., L.L., G.H., W.B.H., O.N., C.O.) and Neurology (G.T., J.C.B.), GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; INSERM U1266, Paris, France (J.B., M.A.D., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); Université de Paris, FHU Neurovasc, Paris, France (J.B., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); and PARIETAL Team, INRIA, Saclay, France (B.T.)
| | - Clément Debacker
- From the Departments of Neuroradiology (J.B., L.L., G.H., W.B.H., O.N., C.O.) and Neurology (G.T., J.C.B.), GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; INSERM U1266, Paris, France (J.B., M.A.D., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); Université de Paris, FHU Neurovasc, Paris, France (J.B., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); and PARIETAL Team, INRIA, Saclay, France (B.T.)
| | - Olivier Naggara
- From the Departments of Neuroradiology (J.B., L.L., G.H., W.B.H., O.N., C.O.) and Neurology (G.T., J.C.B.), GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; INSERM U1266, Paris, France (J.B., M.A.D., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); Université de Paris, FHU Neurovasc, Paris, France (J.B., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); and PARIETAL Team, INRIA, Saclay, France (B.T.)
| | - Jean-Claude Baron
- From the Departments of Neuroradiology (J.B., L.L., G.H., W.B.H., O.N., C.O.) and Neurology (G.T., J.C.B.), GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; INSERM U1266, Paris, France (J.B., M.A.D., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); Université de Paris, FHU Neurovasc, Paris, France (J.B., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); and PARIETAL Team, INRIA, Saclay, France (B.T.)
| | - Bertrand Thirion
- From the Departments of Neuroradiology (J.B., L.L., G.H., W.B.H., O.N., C.O.) and Neurology (G.T., J.C.B.), GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; INSERM U1266, Paris, France (J.B., M.A.D., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); Université de Paris, FHU Neurovasc, Paris, France (J.B., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); and PARIETAL Team, INRIA, Saclay, France (B.T.)
| | - Catherine Oppenheim
- From the Departments of Neuroradiology (J.B., L.L., G.H., W.B.H., O.N., C.O.) and Neurology (G.T., J.C.B.), GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; INSERM U1266, Paris, France (J.B., M.A.D., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); Université de Paris, FHU Neurovasc, Paris, France (J.B., L.L., G.T., W.B.H., S.C., C.D., O.N., J.C.B., C.O.); and PARIETAL Team, INRIA, Saclay, France (B.T.)
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Tang X, Jiang L, Luo Y, Fan H, Song L, Liu P, Chen Y. Leukoaraiosis and acute ischemic stroke. Eur J Neurosci 2021; 54:6202-6213. [PMID: 34331366 DOI: 10.1111/ejn.15406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022]
Abstract
Ischaemic stroke is characterized by high morbidity, high disability rate, high mortality and high recurrence rate, which can have a grave impact on the quality of life of the patients and consequently becomes an economic burden on their families and society. With the developments in imaging technology in recent years, patients with acute cerebral infarction are predominantly more likely to be diagnosed with leukoaraiosis (LA). LA is a common degenerative disease of the nervous system, which is related to cognitive decline, depression, abnormal gait, ischaemic stroke and atherosclerosis. The aetiology of LA is not clear and there is no gold standard for imaging assessment. Related studies have shown that LA has an adverse effect on the prognosis of cerebral infarction, but some experts have contrary beliefs. Hence, we undertook the present review of the literature on the mechanism and the effect of LA on the prognosis of patients with acute ischaemic stroke.
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Affiliation(s)
- Xiaojia Tang
- Department of Rehabilitation Medicine, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou City, China
| | - Li Jiang
- Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou City, China
| | - Yuhan Luo
- Health Management Center, People's Hospital of Deyang City, Deyang City, China
| | - Hongyang Fan
- Department of Neurology, Xuzhou Medical University Affiliated Hospital of Lianyungang, Lianyungang City, China
| | - Lilong Song
- Department of Neurology, Shanghai Fourth People's Hospital, Shanghai City, China
| | - Peipei Liu
- Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou City, China
| | - Yingzhu Chen
- Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou City, China
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Hooper D, Nisar T, McCane D, Lee J, Ling KC, Vahidy F, Wong K, Wong S, Chiu D, Gadhia R. Severe Cerebral Small Vessel Disease Burden Is Associated With Poor Outcomes After Endovascular Thrombectomy in Acute Ischemic Stroke With Large Vessel Occlusion. Cureus 2021; 13:e13122. [PMID: 33728139 PMCID: PMC7935286 DOI: 10.7759/cureus.13122] [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] [Indexed: 11/20/2022] Open
Abstract
Background Despite recent advancements in the treatment of acute ischemic stroke (AIS) with large vessel occlusion (LVO), infarct progression over time and functional outcomes remain variable. This variation in outcomes may be partially attributed to an underlying state of chronic cerebral hypoperfusion and ischemia affecting small cerebral perforating arterioles, venules, and capillaries of the brain; broadly termed cerebral small vessel disease (CSVD). We investigated the association between CSVD burden and the degree of disability following successful recanalization with endovascular thrombectomy (EVT) in patients with AIS presenting with LVO. Methodology We conducted a single center retrospective analysis of all patients presenting with AIS LVO between May 2016 and May 2019. Patients who were premorbidly independent and presented within six hours from the last known well (LKW) with a proximal anterior circulation occlusion confirmed on computed tomography (CT) angiography of the head or neck were treated with EVT. Patients presenting after six hours and up to 24 hours from LKW with a target ischemic core to perfusion mismatch profile on CT or magnetic resonance (MR) perfusion, or a clinical imaging mismatch on MR diffusion-weighted imaging, were also treated. Patients with successful revascularization, defined as a thrombolysis in cerebral infarction score 2b or 3, were included and evaluated for CSVD burden. The presence of CSVD was quantified using the Fazekas scale (0-3). All patients were further evaluated for disability at 90 days using the modified Rankin Scale (mRS, range 0-6). An mRS score of ≤2 was defined as a good functional outcome. Results Of the 190 patients evaluated, absent (Fazekas grade 0), mild (Fazekas grade 1), moderate (Fazekas grade 2), and severe (Fazekas grade 3) CSVD was present in 33 (17.4%), 84 (44.2%), 35 (18.4%), and 38 (20.0%) patients, respectively. Patients with severe CSVD (Fazekas grade 3) were found to be older, had a higher presenting National Institute of Health Stroke Scale (NIHSS), and had greater proportions of preexisting atrial fibrillation and dementia compared to patients with no CSVD (Fazekas grade 0). Using a multivariate ordinal logistic regression model to adjust for age, presenting NIHSS, thrombus location, LKW to groin puncture time, use of tissue plasminogen activator, ischemic infarct volume, development of a symptomatic intracerebral hemorrhage, and treatment with hemicraniectomy, patients with Fazekas grade 3 were significantly more likely to have poor 90-day functional outcomes compared to patients with Fazekas grade 0 (odds ratio 10.25, 95% confidence interval [3.3-31.84]). Conclusions Based on our analytical cohort of AIS LVO patients treated with EVT, we found that patients with severe CSVD burden had worse functional outcomes at 90 days and increased mortality. These results provide evidence that the burden of CSVD may be considered an independent risk factor of poor clinical outcome and a predictor of mortality in patients with AIS presenting with LVO, despite successful radiographic recanalization with EVT.
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Affiliation(s)
| | - Tariq Nisar
- Statistics, Houston Methodist Neurological Institute, Houston, USA
| | - David McCane
- Neurology, Houston Methodist Hospital, Houston, USA
| | - Jason Lee
- Neurology, Houston Methodist Hospital, Houston, USA
| | | | - Farhaan Vahidy
- Statistics, Houston Methodist Neurological Institute, Houston, USA
| | - Kelvin Wong
- T.T. and W.F. Chao Center for BRAIN, Houston Methodist Neurological Institute, Houston, USA
| | - Stephen Wong
- T.T. and W.F. Chao Center for BRAIN, Houston Methodist Neurological Institute, Houston, USA
| | - David Chiu
- Neurology, Houston Methodist Hospital, Houston, USA
| | - Rajan Gadhia
- Neurology, Houston Methodist Hospital, Houston, USA
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Lakhter V, Zack CJ, Brailovsky Y, Azizi AH, Weinberg I, Rosenfield K, Schainfeld R, Kolluri R, Katz P, Zhao H, Bashir R. Predictors of intracranial hemorrhage in patients treated with catheter-directed thrombolysis for deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2020; 9:627-634.e2. [PMID: 32920166 DOI: 10.1016/j.jvsv.2020.08.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/02/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although acute intracranial hemorrhage (ICH) is a rare complication of catheter-directed thrombolysis (CDT), it remains a major concern associated with the use of CDT. The incidence and clinical predictors of developing ICH in the setting of CDT are not known. METHODS The National Inpatient Sample database was used to identify all patients with proximal lower extremity or caval deep vein thrombosis (DVT) from January 2005 to December 2013 in the United States. Multivariate logistic regression was performed to identify the clinical predictors of ICH between patients with DVT who had received anticoagulation therapy alone and those who had been treated with CDT plus anticoagulation therapy. RESULTS Of 138,049 patients with proximal lower extremity or caval DVT, 7119 (5.2%) had received anticoagulation therapy and CDT. Of the patients treated with anticoagulation alone, ICH had occurred in 0.2% compared with 0.7% for those treated with CDT (P < .01). The independent predictors of ICH in the CDT cohort were a history of stroke (odds ratio [OR], 19.4; 95% confidence interval [CI], 8.8-42.8; P < .01), chronic kidney disease (OR, 2.2; 95% CI, 1.1-4.7; P = .03), age >74 years (OR, 2.2; 95% CI, 1.2-4.3; P = .02), male sex (OR, 1.8; 95% CI, 1.01-3.3; P = .048). Of those patients treated with anticoagulation alone, the risk factors for the development of ICH were a history of stroke, hospital teaching status, and age >74 years. CONCLUSIONS The results from the present nationwide observational study showed that of patients with DVT treated with CDT, the independent predictors for developing ICH were a history of stroke, chronic kidney disease, male sex, and age >74 years.
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Affiliation(s)
- Vladimir Lakhter
- Division of Cardiology, Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, Pa
| | - Chad J Zack
- Division of Cardiology, Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pa
| | - Yevgeniy Brailovsky
- Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, NY
| | - Abdul Hussain Azizi
- Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, Pa
| | - Ido Weinberg
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Philadelphia, Pa
| | - Kenneth Rosenfield
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Philadelphia, Pa
| | - Robert Schainfeld
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Philadelphia, Pa
| | - Raghu Kolluri
- OhioHealth Vascular Institute, OhioHealth, Columbus, Ohio
| | - Paul Katz
- Department of Neurology, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, Pa
| | - Huaqing Zhao
- Department of Clinical Sciences, Temple University Hospital, Lewis Katz School of Medicinea, Philadelphia, Pa
| | - Riyaz Bashir
- Division of Cardiology, Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, Pa.
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8
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Modrego PJ. The Risk of Symptomatic Intracranial Hemorrhage after Thrombolysis for Acute Stroke: Current Concepts and Perspectives. Ann Indian Acad Neurol 2019; 22:336-340. [PMID: 31359953 PMCID: PMC6613400 DOI: 10.4103/aian.aian_323_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Thrombolysis is the standard of treatment for acute ischemic stroke, with a time window of up to 4½ h from stroke onset. Despite the long experience with the use of recombinant tissue plasminogen activator and the adherence to protocols symptomatic intracranial hemorrhage (SICH) may occur in around 6% of cases, with high-mortality rate and poor-functional outcomes. Many patients are excluded from thrombolysis on the basis of an evaluation of known risk factors, but there are other less known factors involved. Objective The purpose of this work is to analyze the less known risk factors for SICH after thrombolysis. A search of articles related with this field has been undertaken in PubMed with the keywords (brain hemorrhage, thrombolysis, and acute ischemic stroke). Some risk factors for SICH have emerged such as previous microbleeds on brain magnetic resonance imaging, leukoaraiosis, and previous antiplatelet drug use or statin use. Serum matrix metalloproteinases have emerged as a promising biomarker for better selection of patients, but further research is needed. Conclusions In addition to the already known risk factors considered in the standard protocols, an individualized evaluation of risks is needed to minimize the risk of brain hemorrhage after thrombolysis for ischemic stroke.
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Affiliation(s)
- Pedro J Modrego
- Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain
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9
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Ren XM, Qiu SW, Liu RY, Wu WB, Xu Y, Zhou H. White Matter Lesions Predict Recurrent Vascular Events in Patients with Transient Ischemic Attacks. Chin Med J (Engl) 2018; 131:130-136. [PMID: 29336359 PMCID: PMC5776841 DOI: 10.4103/0366-6999.222341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background: White matter lesions (WMLs) are common findings in brain magnetic resonance imaging (MRI) and are strongly associated with stroke incidence, recurrence, and prognosis. However, the relationship between WMLs and transient ischemic attacks (TIAs) is not well established. This study aimed to determine the clinical significance of WMLs in patients with TIA. Methods: A total of 181 consecutive inpatients with first-ever TIA were enrolled. Brain MRIs within 2 days of symptom onset were used to measure WML volumes. Recurrent vascular events within 1 year of TIA onset were assessed. The relationship between WMLs and recurrent risk of vascular events was determined by a multivariate logistic regression. Results: WMLs were identified in 104 patients (57.5%). Age and ratio of hypertension were significantly different between patients with and without WMLs. The incidence of vascular events in patients with WMLs significantly increased in comparison to those without WMLs (21.15% vs. 5.19%, 95% confidence interval [CI]: 1.18–15.20, P = 0.027) after controlling for confounders. Furthermore, distributions of WML loads were found to be different between patients who developed vascular events and those who did not. WML volumes were demonstrated to be correlated with recurrent risks, and the fourth quartile of WML volumes led to an 8.5-fold elevation of recurrent risk of vascular events compared with the first quartile (95% CI: 1.52–47.65, P = 0.015) after adjusting for hyperlipidemia. Conclusion: WMLs occur frequently in patients with TIA and are associated with the high risk of recurrent vascular events, suggesting a predictive neuroimaging marker for TIA outcomes.
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Affiliation(s)
- Xiao-Mei Ren
- Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu 210008; Department of Neurology, Yizheng People's Hospital, Yangzhou, Jiangsu 211400, China
| | - Shu-Wei Qiu
- Jiangsu Key Laboratory for Molecular Medicine, Nanjing, Jiangsu 210008, China
| | - Ren-Yuan Liu
- Department of Radiology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Wen-Bo Wu
- Department of Radiology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Yun Xu
- Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University; Jiangsu Key Laboratory for Molecular Medicine; Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Hong Zhou
- Department of Immunology, Nanjing Medical University, Nanjing, Jiangsu 211166, China
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Tsivgoulis G, Kargiotis O, Alexandrov AV. Intravenous thrombolysis for acute ischemic stroke: a bridge between two centuries. Expert Rev Neurother 2018. [PMID: 28644924 DOI: 10.1080/14737175.2017.1347039] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intravenous tissue-plasminogen activator (tPA) remains the only approved systemic reperfusion therapy suitable for most patients presenting timely with acute ischemic stroke. Accumulating real-word experience for over 20 years regarding tPA safety and effectiveness led to re-appraisal of original contraindications for intravenous thrombolysis (IVT). Areas covered: This narrative review focuses on fast yet appropriate selection of patients for safe administration of tPA per recently expanded indications. Novel strategies for rapid patient assessment will be discussed. The potential for mobile stroke units (MSU) that shorten onset-to-needle time and increase tPA treatment rates is addressed. The use of IVT in the era of non-vitamin K antagonist oral anticoagulants (NOACs) is highlighted. The continuing role of IVT in large vessel occlusion (LVO) patients eligible for mechanical thrombectomy (MT) is discussed with regards to 'drip and ship' vs. 'mothership' treatment paradigms. Promising studies of penumbral imaging to extend IVT beyond the 4.5-hour window and in wake-up strokes are summarized. Expert commentary: This review provides an update on the role of IVT in specific conditions originally considered tPA contraindications. Novel practice challenges including NOAC's, MSU proliferation and bridging therapy (IVT&MT) for LVO patients, and the potential extension of IVT time-window using penumbral imaging are emerging as safe and potentially effective IVT applications.
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Affiliation(s)
- Georgios Tsivgoulis
- a Second Department of Neurology , National & Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital , Athens , Greece.,b Department of Neurology , University of Tennessee Health Science Center , Memphis , TN , USA
| | | | - Andrei V Alexandrov
- b Department of Neurology , University of Tennessee Health Science Center , Memphis , TN , USA
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Ye H, Wang Y, Qiu J, Wu Q, Xu M, Wang J. White matter hyperintensities and their subtypes in patients with carotid artery stenosis: a systematic review and meta-analysis. BMJ Open 2018; 8:e020830. [PMID: 29769255 PMCID: PMC5961568 DOI: 10.1136/bmjopen-2017-020830] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We aimed to perform a systematic review and meta-analysis to clarify the association between white matter hyperintensities (WMHs) and carotid artery (CA) stenosis. STUDY DESIGN Systematic review and meta-analysis. PARTICIPANTS CA stenosis was set at ≥50%, and WMHs were assessed by MRI and evaluated quantitatively or semiquantitatively. DATA SOURCES A comprehensive literature search was performed in PubMed, EMBASE and Cochrane Library for studies evaluating the association between WMHs and CA stenosis ≥50% from inception to 13 September 2017. MAIN OUTCOMES AND MEASURES Standardised mean difference (SMD) with 95% CI was used to evaluate the association between WMHs and CA stenosis. Results were presented in a forest plot with a fixed-effects model or random-effects model. We assessed the quality of included studies using the Newcastle-Ottawa Scale. Funnel plots and Egger's and Begg's tests were conducted to assess publication bias. Sensitivity analysis was performed to evaluate the influence of each individual study. RESULTS Eight studies enrolling 677 patients were included. There was a positive relationship between the total WMHs and CA stenosis, with a pooled fixed-effects SMD of 0.326 (95% CI 0.194 to 0.459, p=0.000). Heterogeneity and publication bias were low among these studies. Subgroup analysis of three studies enrolling 225 patients showed an association between periventricular WMHs and CA stenosis, with a pooled fixed-effects SMD of 0.412 (95% CI 0.202 to 0.622, p=0.000). CONCLUSION This meta-analysis showed that the total WMHs and periventricular WMHs were associated with CA stenosis. WMHs may be considered as an individual risk stratification score when choosing a proper plan for therapy of CA stenosis.
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Affiliation(s)
- Huirong Ye
- Department of Neurology, Cerebrovascular Disease Center, People’s Hospital, China Medical University, Shenyang, People’s Republic of China
| | - Yujie Wang
- Department of Neurology, Cerebrovascular Disease Center, People’s Hospital, China Medical University, Shenyang, People’s Republic of China
| | - Jianting Qiu
- Department of Neurology, Cerebrovascular Disease Center, People’s Hospital, China Medical University, Shenyang, People’s Republic of China
| | - Qing Wu
- Department of Neurology, Dalian Medical University, Dalian, People’s Republic of China
| | - Mengmeng Xu
- Department of Neurology, Dalian Medical University, Dalian, People’s Republic of China
| | - Jian Wang
- Department of Neurology, Cerebrovascular Disease Center, People’s Hospital, China Medical University, Shenyang, People’s Republic of China
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12
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Yang CM, Hung CL, Su HC, Lin HJ, Chen CH, Lin CC, Hu HH, Lin SH, Sung PS. Leukoaraiosis and risk of intracranial hemorrhage and outcome after stroke thrombolysis. PLoS One 2018; 13:e0196505. [PMID: 29715283 PMCID: PMC5929505 DOI: 10.1371/journal.pone.0196505] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 04/13/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The impact of leukoaraiosis on the risk of symptomatic intracerebral hemorrhage (SICH) after stroke thrombolysis is conflicting, and the data on Asian populations are lacking. Therefore, in this study, we assessed the association between leukoaraiosis and SICH, and the association between leukoaraiosis and the 90-day functional outcome in the Asian population. METHODS Data were collected from a two-center prospective registry of acute ischemic stroke patients given intravenous tissue plasminogen activator between 2006 and 2014. A total of 614 pretreatment brain CT and 455 posttreatment MRI were retrospectively assessed using two different rating scales for the presence of leukoaraiosis. Outcome measures were the occurrence of SICH with three definitions and any hemorrhage after thrombolysis and functional outcome at 3 months. RESULTS Of the 614 patients assessed, 30.3% showed severe leukoaraiosis on the baseline brain CT. The SICH rate was 4.6% - 7.2% based on different definitions, and overall, 24.9% of patients showed any post-tPA hemorrhage. No association was observed between the severity of leukoaraiosis and SICH, regardless of having used different leukoaraiosis rating scales or as assessment using different imaging modalities. However, severe leukoaraiosis was independently associated with poor functional outcome at 3 months (OR 1.96, 95% C1 1.24-3.11, P = 0.004) after adjustment for confounders. CONCLUSIONS Our results showed no association between leukoaraiosis and the risk of SICH. Although the presence of severe leukoaraiosis predicted a poor functional outcome after stroke, IV thrombolysis might not be withheld in acute ischemic stroke patients solely based on the presence of severe leukoaraiosis on pre-thrombolytic CT scans.
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Affiliation(s)
- Chun-Ming Yang
- Department of Neurology, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Ling Hung
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hui-Chen Su
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Huey-Juan Lin
- Department of Neurology, Chi Mei Medical Center, Tainan, Taiwan
| | - Chih-Hung Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chou-Ching Lin
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Han-Hwa Hu
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Sheng-Hsiang Lin
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pi-Shan Sung
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- * E-mail:
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13
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Nagaraja N, Tasneem N, Shaban A, Dandapat S, Ahmed U, Policeni B, Olalde H, Shim H, Samaniego EA, Pieper C, Ortega-Gutierrez S, Leira EC, Adams HP. Cerebral Microbleeds are an Independent Predictor of Hemorrhagic Transformation Following Intravenous Alteplase Administration in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2018; 27:1403-1411. [PMID: 29398533 DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.044] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 11/10/2017] [Accepted: 12/22/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Intravenous alteplase (rt-PA) increases the risk of hemorrhagic transformation of acute ischemic stroke. The objective of our study was to evaluate clinical, laboratory, and imaging predictors on forecasting the risk of hemorrhagic transformation following treatment with rt-PA. We also evaluated the factors associated with cerebral microbleeds that increase the risk of hemorrhagic transformation. METHODS Consecutive patients with acute ischemic stroke admitted between January 1, 2009 and December 31, 2013 were included in the study if they received IV rt-PA, had magnetic resonance imaging (MRI) of the brain on admission, and computed tomography or MRI of the brain at 24 (18-36) hours later to evaluate for the presence of hemorrhagic transformation. The clinical data, lipid levels, platelet count, MRI, and computed tomography images were retrospectively reviewed. RESULTS The study included 366 patients, with mean age 67 ± 15 years; 46% were women and 88% were white. The median National Institutes of Health Stroke Scale (NIHSS) score was 6 (interquartile range 3-15). Hemorrhagic transformation was observed in 87 (23.8%) patients and cerebral microbleeds were noted in 95 (25.9%). Patients with hemorrhagic transformation tended to be older, nonwhite, have atrial fibrillation, higher baseline NIHSS score, lower cholesterol and triglyceride levels, and cerebral microbleeds and nonlacunar infarcts. Patients with cerebral microbleeds were more likely to be older, have hypertension, hyperlipidemia, previous history of stroke, and prior use of antithrombotics. On multivariate analysis race, NIHSS score, nonlacunar infarct, and presence of cerebral microbleeds were independently associated with hemorrhagic transformation following treatment with rt-PA. CONCLUSIONS Presence of cerebral microbleeds is an independent predictor of hemorrhagic transformation of acute ischemic stroke following treatment with rt-PA.
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Affiliation(s)
- Nandakumar Nagaraja
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida; Department of Neurology, Carver College of Medicine, University of Iowa, Iowa.
| | - Nudrat Tasneem
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Amir Shaban
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Sudeepta Dandapat
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Uzair Ahmed
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Bruno Policeni
- Department of Radiology, Carver College of Medicine, University of Iowa, Iowa
| | - Heena Olalde
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Hyungsub Shim
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Edgar A Samaniego
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Connie Pieper
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | | | - Enrique C Leira
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
| | - Harold P Adams
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa
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14
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Liu Y, Zhang M, Chen Y, Gao P, Yun W, Zhou X. The degree of leukoaraiosis predicts clinical outcomes and prognosis in patients with middle cerebral artery occlusion after intravenous thrombolysis. Brain Res 2017; 1681:28-33. [PMID: 29288062 DOI: 10.1016/j.brainres.2017.12.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/19/2017] [Accepted: 12/21/2017] [Indexed: 10/18/2022]
Abstract
Leukoaraiosis (LA) is common in elderly patients with ischemic stroke on magnetic resonance imaging. In this study, we investigate whether the degree of LA is associated with clinical outcomes and prognosis of patients with middle cerebral artery occlusion following intravenous thrombolytic. Ninety-seven patients were recruited and divided into three groups based on the degree of LA (no, mild and moderate to severe LA) by the Fazekas scale. Clinical outcomes, recurrent stroke, Fugl-Meyer rating scale (FMS) and complications of intravenous thrombolysis were assessed. The association between the degree of LA and functional outcomes was analyzed by multivariable logistic regression model. Patients enrolled were divided into three groups: 26 patients with no LA, 43 patients with mild LA and 28 patients with moderate to severe LA. Impressively, the patients with mild LA were better in early neurological recovery and 90-day FMS score than patients in the other two groups. Multivariate logistic analysis revealed that moderate to severe LA was an independent predictor of poor functional outcome (OR: 10.482; 95% CI: 1.442-76.181; P = .020). Moreover, the patients with moderate to severe LA have a higher rate of hemorrhagic transformation and recurrent stroke as compared with two other groups during 90-day follow-up. Different degrees of LA differentially affect clinical outcome and prognosis in patients with middle cerebral artery occlusion following intravenous thrombolytic. Moderate to severe LA is a risk factor of poor prognosis. Mild LA is associated with early neurological recovery and good motor functional outcome.
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Affiliation(s)
- Yanyan Liu
- Department of Neurology, Laboratory of Neurological Diseases, Changzhou No.2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, Jiangsu Province, China
| | - Min Zhang
- Department of Neurology, Laboratory of Neurological Diseases, Changzhou No.2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, Jiangsu Province, China
| | - Yuan Chen
- Department of Neurology, Laboratory of Neurological Diseases, Changzhou No.2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, Jiangsu Province, China
| | - Ping Gao
- Department of Neurology, Laboratory of Neurological Diseases, Changzhou No.2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, Jiangsu Province, China
| | - Wenwei Yun
- Department of Neurology, Laboratory of Neurological Diseases, Changzhou No.2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, Jiangsu Province, China.
| | - Xianju Zhou
- Department of Neurology, Laboratory of Neurological Diseases, Changzhou No.2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, Jiangsu Province, China.
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15
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Liu M, Pan Y, Zhou L, Wang Y. Predictors of post-thrombolysis symptomatic intracranial hemorrhage in Chinese patients with acute ischemic stroke. PLoS One 2017; 12:e0184646. [PMID: 28922363 PMCID: PMC5602541 DOI: 10.1371/journal.pone.0184646] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 08/28/2017] [Indexed: 12/31/2022] Open
Abstract
Background and purpose Predictors of symptomatic intracranial hemorrhage (sICH) in Chinese patients with acute ischemic stroke treated with recombinant tissue plasminogen activator remain unclear. Methods Data from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) study were assessed to explore risk factors for symptomatic intracranial hemorrhage after intravenous thrombolysis. Three candidate sICH definitions were analyzed. Results Among 1128 patients with acute ischemic stroke treated with intravenous rtPA within 4.5 hours of symptom onset, 23 (2.0%), 44(3.9%) and 61 (5.4%) experienced modified mSITS-MOST, ECASS II, and NINDS defined sICH, respectively. Multivariate logistic regression revealed independent risk factors for sICH were age≧70 years-old(sICH per NINDS, adjusted OR = 1.73[95%CI1.02–2.95],p = 0.04),diabetes(sICH per SITS-MOST, adjusted OR = 3.50 [95%CI1.34–9.16], p = 0.01), serum glucose on admission >9.0mmol/L(sICH per ECASS II, adjusted OR = 2.84[95%CI1.48–5.46], p = 0.002),NIHSS on admission>20(sICH per SITS-MOST, adjusted OR = 5.06[95%CI1.68–15.20], p = 0.004 or sICH per NINDS, adjusted OR 2.81[95%CI1.42–5.57], p = 0.003) and cardioembolism(sICH per SITS-MOST, adjusted OR = 7.09[95%CI2.41–20.87], p<0.001 or sICH per ECASS II, adjusted OR = 4.99[95%CI2.53–9.84], p<0.001)or sICH per NINDS, adjusted OR = 2.47[95%CI1.39–4.39], p = 0.002). Conclusion Cardioembolism, NIHSS on admission higher than 20, serum glucose on admission higher than 9.0 mmol/L and age ≧70 years were independent risk factors for symptomatic intracranial hemorrhage in Chinese patients with acute ischemic stroke treated with recombinant tissue plasminogen activator.
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Affiliation(s)
- Mingyong Liu
- Center of Stroke, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China.,Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Lichun Zhou
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Center of Stroke, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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16
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Fierini F, Poggesi A, Pantoni L. Leukoaraiosis as an outcome predictor in the acute and subacute phases of stroke. Expert Rev Neurother 2017; 17:963-975. [PMID: 28829216 DOI: 10.1080/14737175.2017.1371013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Leukoaraiosis (LA) is one of the neuroimaging features of cerebral small vessel disease and is associated with poor long-term prognosis. Areas covered: This narrative review focuses on the predictive role of LA on the evolution of the ischemic brain damage and on the clinical outcome in the subacute phase of stroke and in the short-term period afterwards. Expert commentary: LA predicts poorer tissue outcome and clinical prognosis also in acute and subacute stroke. In acute stroke, LA is associated with a less favorable fate of brain infarct and is a marker of increased risk of thrombolysis-related hemorrhagic transformation. The impaired cerebral microcirculation in LA patients may sustain the progression of ischemic lesion and enhance the bleeding risk. The short-term worse clinical outcome in ischemic stroke and intracranial hemorrhage patients with LA might be attributable to a state of altered brain connectivity. Endothelial failure, reduced micro-vessels density, and deficient collateral flow together with reduced functional reserve are some of the involved mechanisms. Future studies should aim at bridging the gap between the knowledge about LA pathophysiology and the therapeutic improvement of brain tissue perfusion and at producing data on early rehabilitation of stroke patients with LA at high disability risk.
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Affiliation(s)
- Fabio Fierini
- a Neurofarba Department, Neuroscience Section , University of Florence , Florence , Italy
| | - Anna Poggesi
- a Neurofarba Department, Neuroscience Section , University of Florence , Florence , Italy
| | - Leonardo Pantoni
- a Neurofarba Department, Neuroscience Section , University of Florence , Florence , Italy
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Benzakoun J, Maïer B, Calvet D, Edjlali M, Turc G, Lion S, Legrand L, Ben Hassen W, Naggara O, Meder J, Mas J, Oppenheim C. Can a 15-sec FLAIR replace conventional FLAIR sequence in stroke MR protocols? J Neuroradiol 2017; 44:192-197. [DOI: 10.1016/j.neurad.2016.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 10/10/2016] [Accepted: 11/21/2016] [Indexed: 10/20/2022]
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Wei CC, Zhang ST, Wang YH, Liu JF, Li J, Yuan RZ, Tan G, Zhang SH, Liu M. Association between leukoaraiosis and hemorrhagic transformation after cardioembolic stroke due to atrial fibrillation and/or rheumatic heart disease. J Neurol Sci 2017; 378:94-99. [PMID: 28566189 DOI: 10.1016/j.jns.2017.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/19/2017] [Accepted: 05/01/2017] [Indexed: 02/05/2023]
Abstract
Cardioembolic stroke due to atrial fibrillation (AF) and/or rheumatic heart disease (RHD) often involves hemorrhagic transformation (HT), and we examined whether leukoaraiosis (LA) was associated with HT in these cases. We prospectively enrolled 251 patients who were admitted to two hospitals within one month of experiencing cardioembolic stroke due to AF/RHD. LA severity was assessed using three visual rating scales. HT was identified in 99 patients (39.4%) based on baseline computed tomography (CT) and post-admission magnetic resonance imaging or second CT. Univariate analysis identified risk of HT as higher in the presence of frontal LA based on the age-related white matter changes scale and in the presence of anterior LA based on the VSS scale. Multivariate analysis confirmed that moderate to severe LA was independently associated with higher HT risk. Of the various sites affected in LA, frontal LA correlated with highest risk of HT (OR 3.199, 95%CI 1.555-6.580). These results suggest that moderate to severe LA, especially at periventricular and anterior sites, is associated with HT after cardioembolic stroke due to AF/RHD. These findings suggest the need to take LA into account as a HT risk factor when considering the use of anticoagulation and thrombolysis in these patients.
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Affiliation(s)
- Chen-Chen Wei
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, PR China
| | - Shu-Ting Zhang
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, PR China
| | - Yun-Han Wang
- Department of Ultrasound, Chengdu First People's Hospital, 18 Wanxiang North Road, Chengdu 610041, Sichuan Province, PR China
| | - Jun-Feng Liu
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, PR China
| | - Jie Li
- Department of Neurology, People's Hospital of Deyang City, No. 174 North Section 1, Taishan Road, Deyang 618000, Sichuan Province, PR China
| | - Ruo-Zhen Yuan
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, PR China
| | - Ge Tan
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, PR China
| | - Shi-Hong Zhang
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, PR China.
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, PR China.
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He R, Gao L, Ma J, Peng Z, Zhou S, Yang L, Feng Z, Dang Y, Chen G. The essential role of MTDH in the progression of HCC: a study with immunohistochemistry, TCGA, meta-analysis and in vitro investigation. Am J Transl Res 2017; 9:1561-1579. [PMID: 28469766 PMCID: PMC5411909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 03/22/2017] [Indexed: 06/07/2023]
Abstract
Recent studies found that metadherin (MTDH) played an essential role in hepatocellular carcinoma (HCC). Nevertheless, the exact function of MTDH in the pathogenesis of HCC was unclarified. In the present study, we aimed to investigate the clinical significance of MTDH in HCC and its effect on HCC cells. Immunohistochemistry (IHC) was performed to detect MTDH expression in HCC tissues. Data from The Cancer Genome Atlas (TCGA) and ONCOMINE was obtained to examine MTDH expression in HCC and its clinical significance. Meta-analysis was conducted to assess the correlation between MTDH expression and both the prognosis (Overall Survival (OS) or Disease-free Survival (DFS)) and clinicopathological features of HCC via STATA 12.0. In vitro experiments were performed to investigate the role of MTDH in cell growth, caspase-3/7 activity and apoptosis in HCC cells. The MTDH staining was remarkably stronger in HCC tissues than in non-cancer tissues from IHC, TCGA and ONCOMINE data. Moreover, MTDH-positive expression was significantly correlated with pathological grade, distant metastasis and hepatitis B virus (HBV) infection by IHC. For meta-analysis, MTDH expression was indicative of poor OS without heterogeneity in HCC patients. Additionally, MTDH expression was correlated with high-grade histological differentiation, non-vascular invasion and metastasis in HCC. In vitro experiments revealed that MTDH could the inhibit cell growth and activate caspase-3/7 activity and apoptosis in the four HCC cell lines. In conclusion, MTDH expression may serve as a novel targeting strategy for HCC due to its clinical significance and oncogenic function in HCC cells.
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Affiliation(s)
- Rongquan He
- Department of Medical Oncology, First Affiliated Hospital of Guangxi Medical University6 Shuangyong Road, Nanning 530021, Guangxi Zhuang Autonomous Region, P. R. China
| | - Li Gao
- Department of Pathology, First Affiliated Hospital of Guangxi Medical University6 Shuangyong Road, Nanning 530021, Guangxi Zhuang Autonomous Region, P. R. China
| | - Jie Ma
- Department of Medical Oncology, First Affiliated Hospital of Guangxi Medical University6 Shuangyong Road, Nanning 530021, Guangxi Zhuang Autonomous Region, P. R. China
| | - Zhigang Peng
- Department of Medical Oncology, First Affiliated Hospital of Guangxi Medical University6 Shuangyong Road, Nanning 530021, Guangxi Zhuang Autonomous Region, P. R. China
| | - Shengsheng Zhou
- Department of Medical Oncology, First Affiliated Hospital of Guangxi Medical University6 Shuangyong Road, Nanning 530021, Guangxi Zhuang Autonomous Region, P. R. China
| | - Lihua Yang
- Department of Medical Oncology, First Affiliated Hospital of Guangxi Medical University6 Shuangyong Road, Nanning 530021, Guangxi Zhuang Autonomous Region, P. R. China
| | - Zhenbo Feng
- Department of Pathology, First Affiliated Hospital of Guangxi Medical University6 Shuangyong Road, Nanning 530021, Guangxi Zhuang Autonomous Region, P. R. China
| | - Yiwu Dang
- Department of Pathology, First Affiliated Hospital of Guangxi Medical University6 Shuangyong Road, Nanning 530021, Guangxi Zhuang Autonomous Region, P. R. China
| | - Gang Chen
- Department of Pathology, First Affiliated Hospital of Guangxi Medical University6 Shuangyong Road, Nanning 530021, Guangxi Zhuang Autonomous Region, P. R. China
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