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Gwak DS, Ryu WS, Schellingerhout D, Chung J, Kim HR, Jeong SW, Kim BJ, Kim JT, Hong KS, Park JM, Park MS, Choi KH, Park TH, Lee K, Park SS, Kang K, Cho YJ, Park HK, Lee BC, Yu KH, Oh MS, Lee SJ, Kim JG, Cha JK, Kim DH, Lee J, Han MK, Lee JS, Bae HJ, Kim DE. Effects of white matter hyperintensity burden on functional outcome after mild versus moderate-to-severe ischemic stroke. Sci Rep 2024; 14:22567. [PMID: 39343768 DOI: 10.1038/s41598-024-71936-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/02/2024] [Indexed: 10/01/2024] Open
Abstract
It is uncertain whether the prognostic power of white matter hyperintensity (WMH) on post-stroke outcomes is modulated as a function of initial neurological severity, a critical determinant of outcome after stroke. This multi-center MRI study tested if higher WMH quintiles were associated with 3-month poor functional outcome (modified Rankin Scale ≥ 3) for mild versus moderate-to-severe ischemic stroke. Mild and moderate-to-severe stroke were defined as admission National Institute of Health Stroke Scale scores of 1-4 and ≥ 5, respectively. Mean age of the enrolled patients (n = 8918) was 67.2 ± 12.6 years and 60.1% male. The association between WMH quintiles and poor functional outcome was modified by stroke severity (p-for-interaction = 0.008). In mild stroke (n = 4994), WMH quintiles associated with the 3-month outcome in a dose-dependent manner for the 2nd to 5th quintile versus the 1st quintile, with adjusted-odds-ratios (aOR [95% confidence interval]) being 1.29 [0.96-1.73], 1.37 [1.02-1.82], 1.60 [1.19-2.13], and 1.89 [1.41-2.53], respectively. In moderate-to-severe stroke (n = 3924), however, there seemed to be a threshold effect: only the highest versus the lowest WMH quintile was significantly associated with poor functional outcome (aOR 1.69 [1.29-2.21]). WMH burden aggravates 3-month functional outcome after mild stroke, but has a lesser modulatory effect for moderate-to-severe stroke, likely due to saturation effects.
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Affiliation(s)
- Dong-Seok Gwak
- Department of Neurology, Dongguk University Ilsan Hospital, 52-6 Dongguk-Ro, Ilsandong-Gu, Goyang-si, Gyeonggi-do, 10326, Republic of Korea
- National Priority Research Center for Stroke, Goyang, Republic of Korea
| | - Wi-Sun Ryu
- Artificial Intelligence Research Center, JLK Inc., Seoul, Republic of Korea
| | - Dawid Schellingerhout
- Departments of Neuroradiology and Imaging Physics (D.S.), University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jinyong Chung
- National Priority Research Center for Stroke, Goyang, Republic of Korea
| | - Hang-Rai Kim
- Department of Neurology, Dongguk University Ilsan Hospital, 52-6 Dongguk-Ro, Ilsandong-Gu, Goyang-si, Gyeonggi-do, 10326, Republic of Korea
- National Priority Research Center for Stroke, Goyang, Republic of Korea
| | - Sang-Wuk Jeong
- Department of Neurology, Dongguk University Ilsan Hospital, 52-6 Dongguk-Ro, Ilsandong-Gu, Goyang-si, Gyeonggi-do, 10326, Republic of Korea
- National Priority Research Center for Stroke, Goyang, Republic of Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Uijeongbu, Republic of Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea
| | - Kyungbok Lee
- Department of Neurology, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Seoul, Republic of Korea
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, Republic of Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Daejeon, Republic of Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, Republic of Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Republic of Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji Sung Lee
- Department of Biostatistics, Asan Medical Center, Seoul, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, 52-6 Dongguk-Ro, Ilsandong-Gu, Goyang-si, Gyeonggi-do, 10326, Republic of Korea.
- National Priority Research Center for Stroke, Goyang, Republic of Korea.
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Kwan J, Hafdi M, Chiang LLW, Myint PK, Wong LS, Quinn TJ. Antithrombotic therapy to prevent cognitive decline in people with small vessel disease on neuroimaging but without dementia. Cochrane Database Syst Rev 2022; 7:CD012269. [PMID: 35833913 PMCID: PMC9281623 DOI: 10.1002/14651858.cd012269.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cerebral small vessel disease is a progressive disease of the brain's deep perforating blood vessels. It is usually diagnosed based on lesions seen on brain imaging. Cerebral small vessel disease is a common cause of stroke but can also cause a progressive cognitive decline. As antithrombotic therapy is an established treatment for stroke prevention, we sought to determine whether antithrombotic therapy might also be effective in preventing cognitive decline in people with small vessel disease. OBJECTIVES To assess the effects of antithrombotic therapy for prevention of cognitive decline in people with small vessel disease on neuroimaging but without dementia. SEARCH METHODS We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Review Group's Specialised Register, and the Cochrane Stroke Group's Specialised Register; the most recent search was on 21 July 2021. We also searched MEDLINE, Embase, four other databases and two trials registries. We searched the reference lists of the articles retrieved from these searches. As trials with a stroke focus may include relevant subgroup data, we complemented these searches with a focussed search of all antithrombotic titles in the Cochrane Stroke Group database. SELECTION CRITERIA: We included randomised controlled trials (RCT) of people with neuroimaging evidence of at least mild cerebral small vessel disease (defined here as white matter hyperintensities, lacunes of presumed vascular origin and subcortical infarcts) but with no evidence of dementia. The trials had to compare antithrombotic therapy of minimum 24 weeks' duration to no antithrombotic therapy (either placebo or treatment as usual), or compare different antithrombotic treatment regimens. Antithrombotic therapy could include antiplatelet agents (as monotherapy or combination therapy), anticoagulants or a combination. DATA COLLECTION AND ANALYSIS Two review authors independently screened all the titles identified by the searches. We assessed full texts for eligibility for inclusion according to our prespecified selection criteria, extracted data to a proforma and assessed risk of bias using the Cochrane tool for RCTs. We evaluated the certainty of evidence using GRADE. Due to heterogeneity across included participants, interventions and outcomes of eligible trials, it was not possible to perform meta-analyses. MAIN RESULTS We included three RCTs (3384 participants). One study investigated the effect of antithrombotic therapy in participants not yet on antithrombotic therapy; two studies investigated the effect of additional antithrombotic therapy, one in a population already taking a single antithrombotic agent and one in a mixed population (participants on an antithrombotic drug and antithrombotic-naive participants). Intervention and follow-up durations varied from 24 weeks to four years. Jia 2016 was a placebo-controlled trial assessing 24 weeks of treatment with DL-3-n-butylphthalide (a compound with multimodal actions, including a putative antiplatelet effect) in 280 Chinese participants with vascular cognitive impairment caused by subcortical ischaemic small vessel disease, but without dementia. There was very low-certainty evidence for a small difference in cognitive test scores favouring treatment with DL-3-n-butylphthalide, as measured by the 12-item Alzheimer's Disease Assessment Scale-Cognitive subscale (adjusted mean difference -1.07, 95% confidence interval (CI) -2.02 to -0.12), but this difference may not be clinically relevant. There was also very low-certainty evidence for greater proportional improvement measured with the Clinician Interview-Based Impression of Change-Plus Caregiver Input (57% with DL-3-n-butylphthalide versus 42% with placebo; P = 0.01), but there was no difference in other measures of cognition (Mini-Mental State Examination and Clinical Dementia Rating) or function. There was no evidence of a difference in adverse events between treatment groups. The SILENCE RCT compared antithrombotic therapy (aspirin) and placebo during four years of treatment in 83 participants with 'silent brain infarcts' who were on no prior antithrombotic therapy. There was very low-certainty evidence for no difference between groups across various measures of cognition and function, rates of stroke or adverse events. The Secondary Prevention of Subcortical Stroke Study (SPS3) compared dual antiplatelet therapy (clopidogrel plus aspirin) to aspirin alone in 3020 participants with recent lacunar stroke. There was low-certainty evidence of no effect on cognitive outcomes as measured by the Cognitive Abilities Screening Instruments (CASI) assessed annually over five years. There was also low-certainty evidence of no difference in the annual incidence of mild cognitive decline between the two treatment groups (9.7% with dual antiplatelet therapy versus 9.9% with aspirin), or the annual stroke recurrence rate (2.5% with dual antiplatelet therapy versus 2.7% with aspirin). Bleeding risk may be higher with dual antiplatelet therapy (hazard ratio (HR) 2.15, 95% CI 1.49 to 3.11; low certainty evidence), but there may be no significant increase in intracerebral bleeding risk (HR 1.52, 95% CI 0.79 to 2.93; low-certainty evidence). None of the included trials assessed the incidence of new dementia. AUTHORS' CONCLUSIONS We found no convincing evidence to suggest any clinically relevant cognitive benefit of using antithrombotic therapy in addition to standard treatment in people with cerebral small vessel disease but without dementia, but there may be an increased bleeding risk with this approach. There was marked heterogeneity across the trials and the certainty of the evidence was generally poor.
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Affiliation(s)
- Joseph Kwan
- Department of Brain Sciences, Imperial College London, London, UK
| | - Melanie Hafdi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Lorraine L W Chiang
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Phyo K Myint
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Li Siang Wong
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Wardlaw JM, Debette S, Jokinen H, De Leeuw FE, Pantoni L, Chabriat H, Staals J, Doubal F, Rudilosso S, Eppinger S, Schilling S, Ornello R, Enzinger C, Cordonnier C, Taylor-Rowan M, Lindgren AG. ESO Guideline on covert cerebral small vessel disease. Eur Stroke J 2021; 6:CXI-CLXII. [PMID: 34414301 PMCID: PMC8370079 DOI: 10.1177/23969873211012132] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/02/2021] [Indexed: 12/11/2022] Open
Abstract
'Covert' cerebral small vessel disease (ccSVD) is common on neuroimaging in persons without overt neurological manifestations, and increases the risk of future stroke, cognitive impairment, dependency, and death. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist with clinical decisions about management of ccSVD, specifically white matter hyperintensities and lacunes, to prevent adverse clinical outcomes. The guidelines were developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We prioritised the clinical outcomes of stroke, cognitive decline or dementia, dependency, death, mobility and mood disorders, and interventions of blood pressure lowering, antiplatelet drugs, lipid lowering, lifestyle modifications, glucose lowering and conventional treatments for dementia. We systematically reviewed the literature, assessed the evidence, formulated evidence-based recommendations where feasible, and expert consensus statements. We found little direct evidence, mostly of low quality. We recommend patients with ccSVD and hypertension to have their blood pressure well controlled; lower blood pressure targets may reduce ccSVD progression. We do not recommend antiplatelet drugs such as aspirin in ccSVD. We found little evidence on lipid lowering in ccSVD. Smoking cessation is a health priority. We recommend regular exercise which may benefit cognition, and a healthy diet, good sleep habits, avoiding obesity and stress for general health reasons. In ccSVD, we found no evidence for glucose control in the absence of diabetes or for conventional Alzheimer dementia treatments. Randomised controlled trials with clinical endpoints are a priority for ccSVD.
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Affiliation(s)
- Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Stephanie Debette
- Bordeaux Population Health Center, University of Bordeaux, INSERM, UM1219, Team VINTAGE
- Department of Neurology, Institute for Neurodegenerative Disease, Bordeaux University Hospital, Bordeaux, France
| | - Hanna Jokinen
- HUS Neurocenter, Division of Neuropsychology, Helsinki University Hospital, University of Helsinki and Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Finland
| | - Frank-Erik De Leeuw
- Radboud University Medical Center, Department of Neurology; Donders Center for Medical Neuroscience, Nijmegen, The Netherlands
| | - Leonardo Pantoni
- Stroke and Dementia Lab, 'Luigi Sacco' Department of Biomedical and Clinical Sciences, University of Milan, Milano, Italy
| | - Hugues Chabriat
- Department of Neurology, Hopital Lariboisiere, APHP, INSERM U 1161, FHU NeuroVasc, University of Paris, Paris, France
| | - Julie Staals
- Department of Neurology, School for Cardiovascular Diseases (CARIM), Maastricht UMC+, AZ Maastricht, the Netherlands
| | - Fergus Doubal
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
- Dept of Medicine for the Elderly, University of Edinburgh, Edinburgh, UK
| | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic, Barcelona, Spain
| | - Sebastian Eppinger
- University Clinic of Neurology, Medical University of Graz, Graz, Austria
| | - Sabrina Schilling
- Bordeaux Population Health Center, University of Bordeaux, INSERM, UM1219, Team VINTAGE
| | - Raffaele Ornello
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Christian Enzinger
- University Clinic of Neurology, Medical University of Graz, Graz, Austria
| | - Charlotte Cordonnier
- Univ. Lille, INSERM, CHU Lille, U1172, LilNCog – Lille Neuroscience & Cognition, Lille, France
| | - Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Arne G Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University; Section of Neurology, Skåne University Hospital, Lund, Sweden
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Chou PS, Sung PS, Liu CH, Sung YF, Tzeng RC, Yang CP, Lien CH, Po HL, Ho SC, Tsai YT, Chen TS, Wu SL, Hu HH, Chao AC. Prevalence and Effect of Cerebral Small Vessel Disease in Stroke Patients With Aspirin Treatment Failure-A Hospital-Based Stroke Secondary Prevention Registry. Front Neurol 2021; 12:645444. [PMID: 33927682 PMCID: PMC8076747 DOI: 10.3389/fneur.2021.645444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/18/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Breakthrough strokes during treatment with aspirin, termed clinical aspirin treatment failure (ATF), is common in clinical practice. The burden of cerebral small vessel disease (SVD) is associated with an increased recurrent ischemic stroke risk. However, the association between SVD and ATF remains unclear. This study investigated the prevalence and clinical characteristics of SVD in stroke patients with ATF. Methods: Data from a prospective, and multicenter stroke with ATF registry established in 2018 in Taiwan were used, and 300 patients who developed ischemic stroke concurrent with regular use of aspirin were enrolled. White matter lesions (WMLs) and cerebral microbleeds (CMBs) were identified using the Fazekas scale and Microbleed Anatomical Rating Scale, respectively. Demographic data, cardiovascular comorbidities, and index stroke characteristics of patients with different WML and CMB severities were compared. Logistic regression analyses were performed to explore the factors independently associated with outcomes after ATF. Results: The mean patient age was 69.5 ± 11.8 years, and 70.0% of patients were men. Among all patients, periventricular WML (PVWML), deep WML (DWML), and CMB prevalence was 93.3, 90.0, and 52.5%, respectively. Furthermore, 46.0% of the index strokes were small vessel occlusions. Severe PVWMLs and DWMLs were significantly associated with high CMB burdens. Patients with moderate-to-severe PVWMLs and DWMLs were significantly older and had higher cardiovascular comorbidity prevalence than did patients with no or mild WMLs. Moreover, patients with favorable outcomes exhibited significantly low prevalence of severe PVWMLs (p = 0.001) and DWMLs (p = 0.001). After logistic regression was applied, severe WMLs predicted less favorable outcomes independently, compared with those with no to moderate PVWMLs and DWMLs [odds ratio (OR), 0.47; 95% confidence interval (CI), 0.25–0.87 for severe PVWMLs; OR, 0.40; 95% CI, 0.21–0.79 for severe DWMLs]. Conclusions: SVD is common in stroke patients with ATF. PVWMLs and DWMLs are independently associated with functional outcomes in stroke patients with ATF. The burden of SVD should be considered in future antiplatelet strategies for stroke patients after ATF.
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Affiliation(s)
- Ping-Song Chou
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Hung Liu
- Department of Neurology, Stroke Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yueh-Feng Sung
- Department of Neurology, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Ray-Chang Tzeng
- Department of Neurology, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan
| | - Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan.,Department of Nutrition, Huang-Kuang University, Taichung, Taiwan
| | - Chi-Hsun Lien
- Department of Neurology, Tungs' Taichung Metro Harbor Hospital, Taichung, Taiwan
| | - Helen L Po
- Department of Neurology, Stroke Center, MacKay Memorial Hospital, Taipei, Taiwan
| | - Shang-Chang Ho
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan
| | - Yi-Te Tsai
- Department of Neurology, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
| | - Tsang-Shan Chen
- Department of Neurology, Sin-Lau Hospital, The Presbyterian Church of Taiwan, Tainan, Taiwan
| | - Shey-Lin Wu
- Department of Neurology of Changhua Christian Hospital, Changhua, Taiwan
| | - Han-Hwa Hu
- Department of Neurology, Taipei Medical University-Shaung Ho Hospital, Taipei, Taiwan.,Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - A-Ching Chao
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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