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Morotti A, Shoamanesh A, Oliveira-Filho J, Schlunk F, Romero JM, Jessel M, Ayres A, Vashkevich A, Schwab K, Cassarly C, Martin RH, Greenberg SM, Qureshi AI, Rosand J, Goldstein JN. White Matter Hyperintensities and Blood Pressure Lowering in Acute Intracerebral Hemorrhage: A Secondary Analysis of the ATACH-2 Trial. Neurocrit Care 2020; 32:180-186. [PMID: 31218636 DOI: 10.1007/s12028-019-00761-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND It is not clear whether subsets of patients with intracerebral hemorrhage (ICH) benefit from intensive blood pressure (BP) lowering. We evaluated whether white matter hyperintensities (WMH) burden influences response to this therapy. METHODS Retrospective secondary analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 trial. Patients were randomized to intensive (systolic BP target: 110-139 mmHg) versus standard (systolic BP target: 140-179 mmHg) BP treatment with intravenous nicardipine within 4.5 h from onset between May 2011 and September 2015. WMH were rated on magnetic resonance images (fluid-attenuated inversion recovery sequences), defining moderate-severe WMH as total Fazekas scale score ≥ 3 (range 0-6). The main outcome was death or major disability at 90 days (modified Rankin scale ≥ 3). The secondary outcome was ICH expansion, defined as hematoma growth > 33% from baseline to follow-up CT scan. Predictors of the outcomes of interest were explored with multivariable logistic regression. RESULTS A total of 195/1000 patients had MRI images available for analysis, of whom 161 (82.6%) had moderate-severe WMH. When compared to patients with none-mild WMH, those with moderate-severe WMH did not have an increased risk of death or major disability (adjusted relative risk: 1.83, 95% CI 0.71-4.69) or ICH expansion (adjusted relative risk: 1.14, 95% CI 0.38-3.37). WMH burden did not modify the effect of intensive BP treatment on outcome (all p for interaction ≥ 0.2). CONCLUSION The majority of acute ICH patients have moderate-severe WMH, but advanced small vessel disease burden marked by WMH does not influence ICH-related outcomes or response to intensive BP reduction.
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Affiliation(s)
- Andrea Morotti
- Department of Neurology and Neurorehabilitation, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy.
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Jamary Oliveira-Filho
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Frieder Schlunk
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Javier M Romero
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Michael Jessel
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Alison Ayres
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Anastasia Vashkevich
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Kristin Schwab
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Christy Cassarly
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, USA
| | - Renee' Hebert Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, USA
| | - Steven M Greenberg
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, USA
| | - Jonathan Rosand
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Henry and Allison Center for Brain Health, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Joshua N Goldstein
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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2
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Lauer A, Ay H, Bianchi M, Charidimou A, Boulouis G, Ayres A, Vashkevich A, Schwab KM, Singhal AB, Viswanathan A, Rost NS, Goldstein JN, Rosand J, Schwamm LH, Greenberg SM, Gurol ME. Cerebral Small Vessel Diseases and Sleep Related Strokes. J Stroke Cerebrovasc Dis 2020; 29:104606. [PMID: 31937490 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/13/2019] [Accepted: 12/15/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Sleep related Stroke (SRS) is common and has been associated with cerebral small vessel diseases (SVD) in ischemic strokes (ISs). We tested the hypothesis that SRS is associated with SVD in both ischemic and hemorrhagic stroke. METHODS Prospectively collected data from patients consecutively enrolled after intracerebral hemorrhage (ICH) related to SVD or after IS were analyzed. Symptom onset was recorded as SRS versus awake. Each ICH was grouped according to lobar and deep locations. The IS cohort was etiologically characterized based on the Causative Classification of Stroke system. Frequencies of SRS within and between ICH and IS cohorts as well as its associations (etiology, risk factors) were analyzed. RESULTS We analyzed 1812 IS (mean age 67.9 years ± 15.9 years, 46.4% female) and 1038 ICH patients (mean age 72.5 years ± 13.0 years, 45.4% female). SRS was significantly more common among SVD-related ICH patients (n = 276, 26.6%) when compared to all IS (n = 363, 20.0%, P < .001) and in both, small artery occlusion (SAO) related IS and lobar ICH within the respective IS and ICH cohorts (16.3% SRS versus 9.1% awake for SAO within all IS, P < .001; and 57.1% SRS versus 47.7% awake for lobar bleeds within all ICH, P = .008). These associations remained significant after controlling for age, sex and risk factors. CONCLUSIONS SRS was associated with SVD. The SAO etiology and cerebral amyloid angiopathy related lobar ICH suggest that the presence of SVD can interact with sleep or arousal related hemodynamic changes to cause ischemic and hemorrhagic stroke.
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Affiliation(s)
- Arne Lauer
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Hakan Ay
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Matt Bianchi
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Andreas Charidimou
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Gregoire Boulouis
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Alison Ayres
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Anastasia Vashkevich
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Kristin M Schwab
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Aneesh B Singhal
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Anand Viswanathan
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Natalia S Rost
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan Rosand
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Lee H Schwamm
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Steven M Greenberg
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts
| | - Mahmut Edip Gurol
- Stroke Service, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, Massachusetts.
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3
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Charidimou A, Boulouis G, Xiong L, Pasi M, Roongpiboonsopit D, Ayres A, Schwab KM, Rosand J, Gurol ME, Viswanathan A, Greenberg SM. Cortical Superficial Siderosis Evolution. Stroke 2020; 50:954-962. [PMID: 30869563 DOI: 10.1161/strokeaha.118.023368] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- We investigated cortical superficial siderosis (cSS) progression and its clinical relevance for incident lobar intracerebral hemorrhage (ICH) risk, in probable cerebral amyloid angiopathy presenting with neurological symptoms and without ICH at baseline. Methods- Consecutive patients meeting modified Boston criteria for probable cerebral amyloid angiopathy from a single-center cohort who underwent magnetic resonance imaging (MRI) at baseline and during follow-up were analyzed. cSS progression was assessed by comparison of the baseline and follow-up images. Patients were followed prospectively for incident symptomatic ICH. cSS progression and first-ever ICH risk were investigated in Cox proportional hazard models adjusting for confounders. Results- The cohort included 118 probable cerebral amyloid angiopathy patients: 72 (61%) presented with transient focal neurological episodes and 46 (39%) with cognitive complaints prompting the baseline MRI investigation. Fifty-two patients (44.1%) had cSS at baseline. During a median scan interval of 2.2 years (interquartile range, 1.2-4.4 years) between the baseline (ie, first) MRI and the latest MRI, cSS progression was detected in 33 (28%) patients. In multivariable logistic regression, baseline cSS presence (odds ratio, 4.04; 95% CI, 1.53-10.70; P=0.005), especially disseminated cSS (odds ratio, 9.12; 95% CI, 2.85-29.18; P<0.0001) and appearance of new lobar microbleeds (odds ratio, 4.24; 95% CI, 1.29-13.9; P=0.017) were independent predictors of cSS progression. For patients without an ICH during the interscan interval (n=105) and subsequent follow-up (median postfinal MRI time, 1.34; interquartile range, 0.3-3 years), cSS progression independently predicted increased symptomatic ICH risk (hazard ratio, 3.76; 95% CI, 1.37-10.35; P=0.010). Conclusions- Our results suggest that cSS evolution may be a useful biomarker for assessing disease progression and ICH risk in cerebral amyloid angiopathy patients and a candidate biomarker for clinical studies and trials.
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Affiliation(s)
- Andreas Charidimou
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (A.C., G.B., L.X., M.P., D.R., A.A., K.M.S., J.R., M.E.G., A.V., S.M.G.)
| | - Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (A.C., G.B., L.X., M.P., D.R., A.A., K.M.S., J.R., M.E.G., A.V., S.M.G.)
| | - Li Xiong
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (A.C., G.B., L.X., M.P., D.R., A.A., K.M.S., J.R., M.E.G., A.V., S.M.G.)
| | - Marco Pasi
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (A.C., G.B., L.X., M.P., D.R., A.A., K.M.S., J.R., M.E.G., A.V., S.M.G.)
| | - Duangnapa Roongpiboonsopit
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (A.C., G.B., L.X., M.P., D.R., A.A., K.M.S., J.R., M.E.G., A.V., S.M.G.).,Division of Neurology, Faculty of Medicine, Department of Medicine, Naresuan University, Phitsanulok, Thailand (D.R.)
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (A.C., G.B., L.X., M.P., D.R., A.A., K.M.S., J.R., M.E.G., A.V., S.M.G.)
| | - Kristin M Schwab
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (A.C., G.B., L.X., M.P., D.R., A.A., K.M.S., J.R., M.E.G., A.V., S.M.G.)
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (A.C., G.B., L.X., M.P., D.R., A.A., K.M.S., J.R., M.E.G., A.V., S.M.G.).,MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core, Harvard Medical School, Boston (J.R.).,Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R.)
| | - M Edip Gurol
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (A.C., G.B., L.X., M.P., D.R., A.A., K.M.S., J.R., M.E.G., A.V., S.M.G.)
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (A.C., G.B., L.X., M.P., D.R., A.A., K.M.S., J.R., M.E.G., A.V., S.M.G.)
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (A.C., G.B., L.X., M.P., D.R., A.A., K.M.S., J.R., M.E.G., A.V., S.M.G.)
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4
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Pasi M, Charidimou A, Boulouis G, Fotiadis P, Morotti A, Xiong L, Marini S, Ayres A, Frosch MP, Goldstein JN, Rosand J, Gurol ME, Greenberg SM, Viswanathan A. Cerebral small vessel disease in patients with spontaneous cerebellar hemorrhage. J Neurol 2019; 266:625-630. [PMID: 30617995 DOI: 10.1007/s00415-018-09177-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/11/2018] [Accepted: 12/27/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Spontaneous cerebellar-intracerebral hemorrhage (ICH) can be associated with both cerebral amyloid angiopathy (CAA) and hypertensive small vessel disease (HTN-SVD, i.e. arteriolosclerosis). To better understand the underlying microangiopathy of cerebellar-ICH, we aimed to evaluate the spatial distribution of supratentorial cerebral microbleeds (CMBs) and neuropathologic profiles in these patients. METHODS We enrolled consecutive cerebellar-ICH patients. Clinical variables and MRI markers specific for CAA and HTN-SVD were assessed. Patients were classified into categories according to the topography (strictly-lobar, strictly-deep, and mixed) of supratentorial CMBs and comparisons were performed. Available neuropathological material was reviewed to evaluate the presence and severity of arteriolosclerosis and CAA. RESULTS Ninety-eight cerebellar-ICH patients were enrolled. Fifty patients (51%) had at least one supratentorial CMB. Twelve patients (12%) had strictly lobar-CMBs, 12 patients (12%) showed strictly deep-CMBs and mixed-CMBs (lobar and deep CMBs) were present in 26 cerebellar-ICH patients (27%). In multivariable analysis, cerebellar-ICH patients with mixed-CMBs were associated with higher prevalence of hypertension (OR 4.9, 95% confidence interval [CI] 1.2-20, p = 0.017) but with lower prevalence of severe centrum-semiovale enlarged perivascular spaces (OR 0.2, CI 0.05-0.8, p = 0.024) when compared to cerebellar-ICH patients with strictly lobar-CMBs. Vascular risk factors and neuroimaging characteristics were similar between strictly deep-CMBs and mixed-CMBs. Six patients had available neuropathological material for analyses and they all showed some degree of arteriolosclerosis. CONCLUSIONS Cerebellar-ICH patients frequently show supratentorial CMBs. The mixed-CMBs pattern appears to be the most common. Our radiological and pathological results suggest that the majority of cerebellar-ICH patients harbor HTN-SVD as dominant microangiopathy.
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Affiliation(s)
- Marco Pasi
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, 175 Cambridge Street, #300, Boston, MA, 02114, USA.
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, 175 Cambridge Street, #300, Boston, MA, 02114, USA
| | - Gregoire Boulouis
- Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Université Paris-Descartes, INSERM UMR 894, Paris, France
| | - Panagiotis Fotiadis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, 175 Cambridge Street, #300, Boston, MA, 02114, USA
| | - Andrea Morotti
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, 175 Cambridge Street, #300, Boston, MA, 02114, USA
| | - Li Xiong
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, 175 Cambridge Street, #300, Boston, MA, 02114, USA
| | - Sandro Marini
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, 175 Cambridge Street, #300, Boston, MA, 02114, USA
| | - Alison Ayres
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, 175 Cambridge Street, #300, Boston, MA, 02114, USA
| | - Matthew P Frosch
- C.S. Kubik Laboratory for Neuropathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Rosand
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - M Edip Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, 175 Cambridge Street, #300, Boston, MA, 02114, USA
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, 175 Cambridge Street, #300, Boston, MA, 02114, USA
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, 175 Cambridge Street, #300, Boston, MA, 02114, USA
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5
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Xiong L, Boulouis G, Charidimou A, Roongpiboonsopit D, Jessel MJ, Pasi M, Reijmer YD, Fotiadis P, Ayres A, Merrill E, Schwab K, Blacker D, Gurol ME, Greenberg SM, Viswanathan A. Dementia incidence and predictors in cerebral amyloid angiopathy patients without intracerebral hemorrhage. J Cereb Blood Flow Metab 2018; 38:241-249. [PMID: 28318355 PMCID: PMC5951014 DOI: 10.1177/0271678x17700435] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cerebral amyloid angiopathy (CAA) is a common cause of cognitive impairment in older individuals. This study aimed to investigate predictors of dementia in CAA patients without intracerebral hemorrhage (ICH). A total of 158 non-demented patients from the Stroke Service or the Memory Clinic who met the modified Boston Criteria for probable CAA were included. At baseline, neuroimaging markers, including lobar microbleeds (cerebral microbleeds (CMBs)), white matter hyperintensities (WMH), cortical superficial siderosis (cSS), magnetic resonance imaging (MRI)-visible centrum semiovale perivascular spaces (CSO-PVS), lacunes, and medial temporal atrophy (MTA) were assessed. The overall burden of small vessel disease (SVD) for CAA was calculated by a cumulative score based on CMB number, WMH severity, cSS presence and extent and CSO-PVS severity. The estimated cumulative dementia incidence at 1 year was 14% (95% confidence interval (CI): 5%-23%), and 5 years 73% (95% CI: 55%, 84%). Age (hazard ratio (HR) 1.05 per year, 95% CI: 1.01-1.08, p = 0.007), presence of MCI status (HR 3.40, 95% CI: 1.97-6.92, p < 0.001), MTA (HR 1.71 per point, 95% CI: 1.26-2.32, p = 0.001), and SVD score (HR 1.23 per point, 95% CI: 1.20-1.48, p = 0.030) at baseline were independent predictors for dementia conversion in these patients. Cognitive deterioration of CAA patients appears attributable to cumulative changes, from both vasculopathic and neurodegenerative lesions.
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Affiliation(s)
- Li Xiong
- 1 Department of Neurology, Harvard Medical School, Boston, USA
| | | | | | - Duangnapa Roongpiboonsopit
- 1 Department of Neurology, Harvard Medical School, Boston, USA.,2 Department of Medicine, Naresuan University, Phitsanulok, Thailand
| | | | - Marco Pasi
- 1 Department of Neurology, Harvard Medical School, Boston, USA
| | - Yael D Reijmer
- 1 Department of Neurology, Harvard Medical School, Boston, USA
| | | | - Alison Ayres
- 1 Department of Neurology, Harvard Medical School, Boston, USA
| | - Emily Merrill
- 3 MIND Informatics, Harvard Medical School, Boston, USA
| | - Kristin Schwab
- 1 Department of Neurology, Harvard Medical School, Boston, USA
| | - Deborah Blacker
- 4 Department of Psychiatry, Harvard Medical School, Boston, USA
| | - M Edip Gurol
- 1 Department of Neurology, Harvard Medical School, Boston, USA
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Pasi M, Marini S, Morotti A, Boulouis G, Xiong L, Charidimou A, Ayres A, Lee MJ, Biffi A, Goldstein JN, Rosand J, Gurol ME, Greenberg SM, Viswanathan A. Abstract 133: Cerebellar Hematoma Location: Implications for the Underlying Microangiopathy. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Previous pathologic reports have suggested that the underlying vasculopathy in cerebellar intracerebral hemorrhage (ICH) patients may be related to the location of the bleed whithin the cerebellum. We sought to determine whether the location of hematoma in the cerebellum (deep and superficial regions) was suggestive of a particular hemorrhage-prone small vessel disease pathology (hypertensive vasculopathy or cerebral amyloid angiopathy, CAA).
Methods:
Consecutive cerebellar-ICH patients were recruited from January 1998 to January 2016. Based on data from pathologic reports, patients were divided according to the location of the primary cerebellar hematoma (superficial,
Figure, panel A-B, blu circles in panel E
vs deep,
Figure, panel C-D, orange circles in panel E
). Location of cerebral microbleeds (CMB; strictly-lobar, strictly-deep and mixed-CMB) was evaluated on MRI.
Results:
One-hundred and eight patients (84%) had a deep cerebellar hematoma and 20 (16%) a superficial cerebellar hematoma. Hypertension was more prevalent in deep than in superficial cerebellar-ICH patients (89% vs 65%, respectively; p<0.05). Among the 80 patients who underwent MRI, those with superficial cerebellar-ICH had higher prevalence of strictly lobar-CMB (46%) and lower prevalence of strictly deep or mixed-CMB (0%) compared to those with deep superficial cerebellar-ICH (6% and 54%, respectively). Presence of lacunes was significantly higher in deep cerebellar-ICH than superficial cerebellar-ICH (53 vs 21%, respectively; p<0.05). In a multivariable model, presence of strictly lobar-CMB was associated with superficial cerebellar-ICH (OR: 3.8; 95% confidence interval: 1.5-8.5; p=0.004).
Conclusions:
Our study showed that superficial cerebellar-ICH is related to the presence of strictly lobar-CMB, a pathologically proven marker of CAA. Cerebellar hematoma location may thus help to identify those patients likely to have CAA pathology.
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Affiliation(s)
| | | | - Andrea Morotti
- C. Mondino National Neurological Institute, Pavia, Italy
| | | | - Li Xiong
- Massachusetts General Hosp, Boston, MA
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7
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Pasi M, Charidimou A, Boulouis G, Auriel E, Ayres A, Schwab KM, Goldstein JN, Rosand J, Viswanathan A, Pantoni L, Greenberg SM, Gurol ME. Mixed-location cerebral hemorrhage/microbleeds: Underlying microangiopathy and recurrence risk. Neurology 2018; 90:e119-e126. [PMID: 29247070 PMCID: PMC5772153 DOI: 10.1212/wnl.0000000000004797] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 09/10/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the predominant type of cerebral small vessel disease (SVD) and recurrence risk in patients who present with a combination of lobar and deep intracerebral hemorrhage (ICH)/microbleed locations (mixed ICH). METHODS Of 391 consecutive patients with primary ICH enrolled in a prospective registry, 75 (19%) had mixed ICH. Their demographics, clinical/laboratory features, and SVD neuroimaging markers were compared to those of 191 patients with probable cerebral amyloid angiopathy (CAA-ICH) and 125 with hypertensive strictly deep microbleeds and ICH (HTN-ICH). ICH recurrence and case fatality were also analyzed. RESULTS Patients with mixed ICH showed a higher burden of vascular risk factors reflected by a higher rate of left ventricular hypertrophy, higher creatinine values, and more lacunes and severe basal ganglia (BG) enlarged perivascular spaces (EPVS) than patients with CAA-ICH (all p < 0.05). In multivariable models mixed ICH diagnosis was associated with higher creatinine levels (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.2-5.0, p = 0.010), more lacunes (OR 3.4, 95% CI 1.7-6.8), and more severe BG EPVS (OR 5.8, 95% CI 1.7-19.7) than patients with CAA-ICH. Conversely, when patients with mixed ICH were compared to patients with HTN-ICH, they were independently associated with older age (OR 1.03, 95% CI 1.02-1.1), more lacunes (OR 2.4, 95% CI 1.1-5.3), and higher microbleed count (OR 1.6, 95% CI 1.3-2.0). Among 90-day survivors, adjusted case fatality rates were similar for all 3 categories. Annual risk of ICH recurrence was 5.1% for mixed ICH, higher than for HTN-ICH but lower than for CAA-ICH (1.6% and 10.4%, respectively). CONCLUSIONS Mixed ICH, commonly seen on MRI obtained during etiologic workup, appears to be driven mostly by vascular risk factors similar to HTN-ICH but demonstrates more severe parenchymal damage and higher ICH recurrence risk.
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Affiliation(s)
- Marco Pasi
- From the Hemorrhagic Stroke Research Program (M.P., A.C., G.B., E.A., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Andreas Charidimou
- From the Hemorrhagic Stroke Research Program (M.P., A.C., G.B., E.A., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program (M.P., A.C., G.B., E.A., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eitan Auriel
- From the Hemorrhagic Stroke Research Program (M.P., A.C., G.B., E.A., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program (M.P., A.C., G.B., E.A., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kristin M Schwab
- From the Hemorrhagic Stroke Research Program (M.P., A.C., G.B., E.A., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Joshua N Goldstein
- From the Hemorrhagic Stroke Research Program (M.P., A.C., G.B., E.A., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Program (M.P., A.C., G.B., E.A., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program (M.P., A.C., G.B., E.A., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Leonardo Pantoni
- From the Hemorrhagic Stroke Research Program (M.P., A.C., G.B., E.A., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program (M.P., A.C., G.B., E.A., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - M Edip Gurol
- From the Hemorrhagic Stroke Research Program (M.P., A.C., G.B., E.A., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston.
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Charidimou A, Boulouis G, Roongpiboonsopit D, Auriel E, Pasi M, Haley K, van Etten ES, Martinez-Ramirez S, Ayres A, Vashkevich A, Schwab KM, Goldstein JN, Rosand J, Viswanathan A, Greenberg SM, Gurol ME. Cortical superficial siderosis multifocality in cerebral amyloid angiopathy: A prospective study. Neurology 2017; 89:2128-2135. [PMID: 29070669 PMCID: PMC5696643 DOI: 10.1212/wnl.0000000000004665] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 08/15/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE In order to explore the mechanisms of cortical superficial siderosis (cSS) multifocality and its clinical implications for recurrent intracerebral hemorrhage (ICH) risk in patients with cerebral amyloid angiopathy (CAA), we used a new rating method that we developed specifically to evaluate cSS extent at spatially separated foci. METHODS Consecutive patients with CAA-related ICH according to Boston criteria from a single-center prospective cohort were analyzed. The new score that assesses cSS multifocality (total range 0-4) showed excellent interrater reliability (k = 0.87). The association of cSS with markers of CAA and acute ICH was investigated. Patients were followed prospectively for recurrent symptomatic ICH. RESULTS The cohort included 313 patients with CAA. Multifocal cSS prevalence was 21.1%. APOE ε2 allele prevalence was higher in patients with multifocal cSS. In probable/definite CAA, cSS multifocality was independently associated with neuroimaging markers of CAA severity, including lobar microbleeds, but not with acute ICH features, which conversely, were determinants of cSS in possible CAA. During a median follow-up of 2.6 years (interquartile range 0.9-5.1 years), the annual ICH recurrence rates per cSS scores (0-4) were 5%, 6.5%, 13.5%, 16.2%, and 26.9%, respectively. cSS multifocality (presence and spread) was the only independent predictor of increased symptomatic ICH risk (hazard ratio 3.19; 95% confidence interval 1.77-5.75; p < 0.0001). CONCLUSIONS The multifocality of cSS correlates with disease severity in probable CAA; therefore cSS is likely to be caused by discrete hemorrhagic foci. The new cSS scoring system might be valuable for clinicians in determining annual risk of ICH recurrence.
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Affiliation(s)
- Andreas Charidimou
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Duangnapa Roongpiboonsopit
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Eitan Auriel
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Marco Pasi
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Kellen Haley
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Ellis S van Etten
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Sergi Martinez-Ramirez
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Anastasia Vashkevich
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Kristin M Schwab
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Joshua N Goldstein
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel
| | - M Edip Gurol
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Stroke Research Center (A.C., G.B., D.R., E.A., M.P., K.H., E.S.v.E., S.M.-R., A.A., A. Vashkevich, K.M.S., J.N.G., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurology (E.A.), Carmel Medical Center, Haifa, Israel.
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9
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van Veluw SJ, Lauer A, Charidimou A, Bounemia N, Xiong L, Boulouis G, Fotiadis P, Ayres A, Gurol ME, Viswanathan A, Greenberg SM, Vernooij MW. Evolution of DWI lesions in cerebral amyloid angiopathy: Evidence for ischemia. Neurology 2017; 89:2136-2142. [PMID: 29070668 PMCID: PMC5696638 DOI: 10.1212/wnl.0000000000004668] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/15/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To address the pathophysiologic nature of small diffusion-weighted imaging (DWI) lesions in patients with cerebral amyloid angiopathy (CAA) who underwent serial MRI. Specifically, we tested (1) whether DWI lesions occurred preferentially in individuals with prior DWI lesions, (2) the cross-sectional association with chronic cortical cerebral microinfarcts (CMIs), and (3) the evolution of DWI lesions over time. METHODS Patients with probable CAA (n = 79) who underwent at least 2 MRI sessions were included. DWI lesions were assessed at each available time point. Lesion appearance and characteristics were assessed on available structural follow-up images. Presence and burden of other neuroimaging markers of small vessel disease (white matter hyperintensities, cerebral microbleeds, cortical superficial siderosis, and chronic cortical CMIs) were assessed as well. RESULTS Among 221 DWI scans (79 patients with 2 DWI scans; 40 with ≥3), 60 DWI lesions were found in 28 patients. Patients with DWI lesions at baseline were not more likely to have additional DWI lesions on follow-up compared to patients without DWI lesions at baseline. DWI lesions were associated with chronic cortical CMIs and cortical superficial siderosis, but not with other markers. For 39/60 DWI lesions, >1 MRI sequence was available at follow-up to determine lesion evolution. Twenty-four (62%) were demarcated as chronic lesions on follow-up MRI. Five appeared as cavitations, 18 as noncavitated infarcts, and 1 underwent hemorrhagic transformation. CONCLUSIONS Based on their neuroimaging signature as well as their association with chronic cortical CMIs, DWI lesions appear to have an ischemic origin and represent one part of the CMI spectrum.
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Affiliation(s)
- Susanne J van Veluw
- From the Hemorrhagic Stroke Research Program, Department of Neurology (S.J.v.V., A.L., A.C., N.B., L.X., G.B., P.F., A.A., M.E.G., A.V., S.M.G., M.W.V.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology and Nuclear Medicine (M.W.V.) and Epidemiology (M.W.V.), Erasmus MC, Rotterdam, the Netherlands.
| | - Arne Lauer
- From the Hemorrhagic Stroke Research Program, Department of Neurology (S.J.v.V., A.L., A.C., N.B., L.X., G.B., P.F., A.A., M.E.G., A.V., S.M.G., M.W.V.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology and Nuclear Medicine (M.W.V.) and Epidemiology (M.W.V.), Erasmus MC, Rotterdam, the Netherlands
| | - Andreas Charidimou
- From the Hemorrhagic Stroke Research Program, Department of Neurology (S.J.v.V., A.L., A.C., N.B., L.X., G.B., P.F., A.A., M.E.G., A.V., S.M.G., M.W.V.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology and Nuclear Medicine (M.W.V.) and Epidemiology (M.W.V.), Erasmus MC, Rotterdam, the Netherlands
| | - Narimene Bounemia
- From the Hemorrhagic Stroke Research Program, Department of Neurology (S.J.v.V., A.L., A.C., N.B., L.X., G.B., P.F., A.A., M.E.G., A.V., S.M.G., M.W.V.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology and Nuclear Medicine (M.W.V.) and Epidemiology (M.W.V.), Erasmus MC, Rotterdam, the Netherlands
| | - Li Xiong
- From the Hemorrhagic Stroke Research Program, Department of Neurology (S.J.v.V., A.L., A.C., N.B., L.X., G.B., P.F., A.A., M.E.G., A.V., S.M.G., M.W.V.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology and Nuclear Medicine (M.W.V.) and Epidemiology (M.W.V.), Erasmus MC, Rotterdam, the Netherlands
| | - Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program, Department of Neurology (S.J.v.V., A.L., A.C., N.B., L.X., G.B., P.F., A.A., M.E.G., A.V., S.M.G., M.W.V.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology and Nuclear Medicine (M.W.V.) and Epidemiology (M.W.V.), Erasmus MC, Rotterdam, the Netherlands
| | - Panagiotis Fotiadis
- From the Hemorrhagic Stroke Research Program, Department of Neurology (S.J.v.V., A.L., A.C., N.B., L.X., G.B., P.F., A.A., M.E.G., A.V., S.M.G., M.W.V.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology and Nuclear Medicine (M.W.V.) and Epidemiology (M.W.V.), Erasmus MC, Rotterdam, the Netherlands
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program, Department of Neurology (S.J.v.V., A.L., A.C., N.B., L.X., G.B., P.F., A.A., M.E.G., A.V., S.M.G., M.W.V.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology and Nuclear Medicine (M.W.V.) and Epidemiology (M.W.V.), Erasmus MC, Rotterdam, the Netherlands
| | - M Edip Gurol
- From the Hemorrhagic Stroke Research Program, Department of Neurology (S.J.v.V., A.L., A.C., N.B., L.X., G.B., P.F., A.A., M.E.G., A.V., S.M.G., M.W.V.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology and Nuclear Medicine (M.W.V.) and Epidemiology (M.W.V.), Erasmus MC, Rotterdam, the Netherlands
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program, Department of Neurology (S.J.v.V., A.L., A.C., N.B., L.X., G.B., P.F., A.A., M.E.G., A.V., S.M.G., M.W.V.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology and Nuclear Medicine (M.W.V.) and Epidemiology (M.W.V.), Erasmus MC, Rotterdam, the Netherlands
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program, Department of Neurology (S.J.v.V., A.L., A.C., N.B., L.X., G.B., P.F., A.A., M.E.G., A.V., S.M.G., M.W.V.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology and Nuclear Medicine (M.W.V.) and Epidemiology (M.W.V.), Erasmus MC, Rotterdam, the Netherlands
| | - Meike W Vernooij
- From the Hemorrhagic Stroke Research Program, Department of Neurology (S.J.v.V., A.L., A.C., N.B., L.X., G.B., P.F., A.A., M.E.G., A.V., S.M.G., M.W.V.), Massachusetts General Hospital, Harvard Medical School, Boston; and Departments of Radiology and Nuclear Medicine (M.W.V.) and Epidemiology (M.W.V.), Erasmus MC, Rotterdam, the Netherlands
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Grunwald Z, Beslow LA, Urday S, Vashkevich A, Ayres A, Greenberg SM, Goldstein JN, Leasure A, Shi FD, Kahle KT, Battey TWK, Simard JM, Rosand J, Kimberly WT, Sheth KN. Perihematomal Edema Expansion Rates and Patient Outcomes in Deep and Lobar Intracerebral Hemorrhage. Neurocrit Care 2017; 26:205-212. [PMID: 27844466 DOI: 10.1007/s12028-016-0321-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Perihematomal edema (PHE) expansion rate may predict functional outcome following spontaneous intracerebral hemorrhage (ICH). We hypothesized that the effect of PHE expansion rate on outcome is greater for deep versus lobar ICH. METHODS Subjects (n = 115) were retrospectively identified from a prospective ICH cohort enrolled from 2000 to 2013. Inclusion criteria were age ≥ 18 years, spontaneous supratentorial ICH, and known onset time. Exclusion criteria were primary intraventricular hemorrhage (IVH), trauma, subsequent surgery, or warfarin-related ICH. ICH and PHE volumes were measured from CT scans and used to calculate expansion rates. Logistic regression assessed the association between PHE expansion rates and 90-day mortality or poor functional outcome (modified Rankin Scale > 2). Odds ratios are per 0.04 mL/h. RESULTS PHE expansion rate from baseline to 24 h (PHE24) was associated with mortality for deep (p = 0.03, OR 1.13[1.02-1.26]) and lobar ICH (p = 0.02, OR 1.03[1.00-1.06]) in unadjusted regression and in models adjusted for age (deep p = 0.02, OR 1.15[1.02-1.28]; lobar p = 0.03, OR 1.03[1.00-1.06]), Glasgow Coma Scale (deep p = 0.03, OR 1.13[1.01-1.27]; lobar p = 0.02, OR 1.03[1.01-1.06]), or time to baseline CT (deep p = 0.046, OR 1.12[1.00-1.25]; lobar p = 0.047, OR 1.03[1.00-1.06]). PHE expansion rate from baseline to 72 h (PHE72) was associated with mRS > 2 for deep ICH in models that were unadjusted (p = 0.02, OR 4.04[1.25-13.04]) or adjusted for ICH volume (p = 0.02, OR 4.3[1.25-14.98]), age (p = 0.03, OR 5.4[1.21-24.11]), GCS (p = 0.02, OR 4.19[1.2-14.55]), or time to first CT (p = 0.03, OR 4.02[1.19-13.56]). CONCLUSIONS PHE72 was associated with poor functional outcomes after deep ICH, whereas PHE24 was associated with mortality for deep and lobar ICH.
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Affiliation(s)
- Zachary Grunwald
- Department of Neurology, Yale School of Medicine, 15 York Street, Bldg. LLCI, 10th Floor, 1003C, New Haven, CT, 06510, USA.
| | - Lauren A Beslow
- Department of Neurology, Yale School of Medicine, 15 York Street, Bldg. LLCI, 10th Floor, 1003C, New Haven, CT, 06510, USA
| | - Sebastian Urday
- Department of Neurology, Yale School of Medicine, 15 York Street, Bldg. LLCI, 10th Floor, 1003C, New Haven, CT, 06510, USA
| | - Anastasia Vashkevich
- Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alison Ayres
- Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven M Greenberg
- Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua N Goldstein
- Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Audrey Leasure
- Department of Neurology, Yale School of Medicine, 15 York Street, Bldg. LLCI, 10th Floor, 1003C, New Haven, CT, 06510, USA
| | - Fu-Dong Shi
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Kristopher T Kahle
- Departments of Neurosurgery, Pediatrics, and Cellular and Molecular Physiology, Yale School of Medicine, New Haven, CT, USA
| | - Thomas W K Battey
- Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - J Marc Simard
- Departments of Neurosurgery, Pathology and Physiology, University of Maryland School of Medicine, Baltimore, MA, USA
| | - Jonathan Rosand
- Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - W Taylor Kimberly
- Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, 15 York Street, Bldg. LLCI, 10th Floor, 1003C, New Haven, CT, 06510, USA
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11
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Valenti R, Reijmer YD, Charidimou A, Boulouis G, Martinez SR, Xiong L, Fotiadis P, Jessel M, Ayres A, Riley G, Pantoni L, Edip Gurol M, Greenberg SM, Viswanathan A. Total small vessel disease burden and brain network efficiency in cerebral amyloid angiopathy. J Neurol Sci 2017; 382:10-12. [PMID: 29110998 DOI: 10.1016/j.jns.2017.09.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/24/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cerebral amyloid angiopathy (CAA) is associated with hemorrhagic and nonhemorrhagic markers small vessel disease (SVD). A composite score to quantify the total burden of SVD on MRI specifically for CAA patients was recently developed. Brain network alterations related to individual MRI markers of SVD in CAA were demonstrated. OBJECTIVES Considering diffusion based network measures sensitive to detect different relevant SVD-related brain injury, we investigated if increased overall SVD injury on MRI corresponds to worse global brain connectivity in CAA. METHODS Seventy-three patients (79.5% male, mean age 70.58±8.22years) with a diagnosis CAA were considered. SVD markers in total MRI SVD score included: lobar cerebral microbleeds, cortical superficial siderosis (cSS), white matter hyperintensities (WMH) and centrum semiovale-enlarged perivascular spaces. Diffusion imaging based network reconstruction was made. The associations between total MRI SVD score and global network efficiency (GNE) were analyzed. RESULTS A modest significant inverse correlation between total MRI SVD score and GNE existed (p=0.013; R2=0.07). GNE was related with the presence of cSS and moderate-severe WMHs. CONCLUSIONS An increased burden of SVD neuroimaging markers corresponds to more reductions in global brain connectivity, implying a possible cumulative effect of overall SVD markers on disrupted physiology. GNE was related with some components of the score, specifically cSS and moderate-severe WMHs.
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Affiliation(s)
- Raffaella Valenti
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA; NEUROFARBA Department, Neuroscience Section, University of Florence, Florence, Italy
| | - Yael D Reijmer
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Gregoire Boulouis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA; Université Paris-Descartes, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France
| | - Sergi Ramirez Martinez
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Li Xiong
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Panagiotis Fotiadis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Michael Jessel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Alison Ayres
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Grace Riley
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Leonardo Pantoni
- NEUROFARBA Department, Neuroscience Section, University of Florence, Florence, Italy
| | - M Edip Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA.
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12
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Boulouis G, Charidimou A, Pasi M, Roongpiboonsopit D, Xiong L, Auriel E, van Etten ES, Martinez-Ramirez S, Ayres A, Vashkevich A, Schwab KM, Rosand J, Goldstein JN, Gurol ME, Greenberg SM, Viswanathan A. Hemorrhage recurrence risk factors in cerebral amyloid angiopathy: Comparative analysis of the overall small vessel disease severity score versus individual neuroimaging markers. J Neurol Sci 2017; 380:64-67. [PMID: 28870591 DOI: 10.1016/j.jns.2017.07.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 06/09/2017] [Accepted: 07/08/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION An MRI-based score of total small vessel disease burden (CAA-SVD-Score) in cerebral amyloid angiopathy (CAA) has been demonstrated to correlate with severity of pathologic changes. Evidence suggests that CAA-related intracerebral hemorrhage (ICH) recurrence risk is associated with specific disease imaging manifestations rather than overall severity. We compared the correlation between the CAA-SVD-Score with the risk of recurrent CAA-related lobar ICH versus the predictive role of each of its components. METHODS Consecutive patients with CAA-related ICH from a single-center prospective cohort were analyzed. Radiological markers of CAA related SVD damage were quantified and categorized according to the CAA-SVD-Score (0-6 points). Subjects were followed prospectively for recurrent symptomatic ICH. Adjusted Cox proportional hazards models were used to investigate associations between the CAA-SVD-Score as well as each of the individual MRI signatures of CAA and the risk of recurrent ICH. RESULTS In 229 CAA patients with ICH, a total of 56 recurrent ICH events occurred during a median follow-up of 2.8years [IQR 0.9-5.4years, 781 person-years). Higher CAA-SVD-Score (HR=1.26 per additional point, 95%CI [1.04-1.52], p=0.015) and older age were independently associated with higher ICH recurrence risk. Analysis of individual markers of CAA showed that CAA-SVD-Score findings were due to the independent effect of disseminated superficial siderosis (HR for disseminated cSS vs none: 2.89, 95%CI [1.47-5.5], p=0.002) and high degree of perivascular spaces enlargement (RR=3.50-95%CI [1.04-21], p=0.042). CONCLUSION In lobar CAA-ICH patients, higher CAA-SVD-Score does predict recurrent ICH. Amongst individual elements of the score, superficial siderosis and dilated perivascular spaces are the only markers independently associated with ICH recurrence, contributing to the evidence for distinct CAA phenotypes singled out by neuro-imaging manifestations.
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Affiliation(s)
- Gregoire Boulouis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA.
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Marco Pasi
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Duangnapa Roongpiboonsopit
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA; Department of Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Li Xiong
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Eitan Auriel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Ellis S van Etten
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA; Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sergi Martinez-Ramirez
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Alison Ayres
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Anastasia Vashkevich
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Kristin M Schwab
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA; Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua N Goldstein
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA; Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - M Edip Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
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13
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Boulouis G, Morotti A, Brouwers HB, Charidimou A, Jessel MJ, Auriel E, Pontes-Neto O, Ayres A, Vashkevich A, Schwab KM, Rosand J, Viswanathan A, Gurol ME, Greenberg SM, Goldstein JN. Association Between Hypodensities Detected by Computed Tomography and Hematoma Expansion in Patients With Intracerebral Hemorrhage. JAMA Neurol 2017; 73:961-8. [PMID: 27323314 DOI: 10.1001/jamaneurol.2016.1218] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Hematoma expansion is a potentially modifiable predictor of poor outcome following an acute intracerebral hemorrhage (ICH). The ability to identify patients with ICH who are likeliest to experience hematoma expansion and therefore likeliest to benefit from expansion-targeted treatments remains an unmet need. Hypodensities within an ICH detected by noncontrast computed tomography (NCCT) have been suggested as a predictor of hematoma expansion. OBJECTIVE To determine whether hypodense regions, irrespective of their specific patterns, are associated with hematoma expansion in patients with ICH. DESIGN, SETTING, AND PARTICIPANTS We analyzed a large cohort of 784 patients with ICH (the development cohort; 55.6% female), examined NCCT findings for any hypodensity, and replicated our findings on a different cohort of patients (the replication cohort; 52.7% female). Baseline and follow-up NCCT data from consecutive patients with ICH presenting to a tertiary care hospital between 1994 and 2015 were retrospectively analyzed. Data analyses were performed between December 2015 and January 2016. MAIN OUTCOMES AND MEASURES Hypodensities were analyzed by 2 independent blinded raters. The association between hypodensities and hematoma expansion (>6 cm3 or 33% of baseline volume) was determined by multivariable logistic regression after controlling for other variables associated with hematoma expansion in univariate analyses with P ≤ .10. RESULTS A total of 1029 patients were included in the analysis. In the development and replication cohorts, 222 of 784 patients (28.3%) and 99 of 245 patients (40.4%; 321 of 1029 patients [31.2%]), respectively, had NCCT scans that demonstrated hypodensities at baseline (κ = 0.87 for interrater reliability). In univariate analyses, hypodensities were associated with hematoma expansion (86 of 163 patients with hematoma expansion had hypodensities [52.8%], whereas 136 of 621 patients without hematoma expansion had hypodensities [21.9%]; P < .001). The association between hypodensities and hematoma expansion remained significant (odds ratio, 3.42 [95% CI, 2.21-5.31]; P < .001) in a multivariable model; other independent predictors of hematoma expansion were a CT angiography spot sign, a shorter time to CT, warfarin use, and older age. The independent predictive value of hypodensities was again demonstrated in the replication cohort (odds ratio, 4.37 [95% CI, 2.05-9.62]; P < .001). CONCLUSION AND RELEVANCE Hypodensities within an acute ICH detected on an NCCT scan may predict hematoma expansion, independent of other clinical and imaging predictors. This novel marker may help clarify the mechanism of hematoma expansion and serve as a useful addition to clinical algorithms for determining the risk of and treatment stratification for hematoma expansion.
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Affiliation(s)
- Gregoire Boulouis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Andrea Morotti
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - H Bart Brouwers
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston2Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht Universi
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Michael J Jessel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Eitan Auriel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Octávio Pontes-Neto
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Alison Ayres
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Kristin M Schwab
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston3Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical Sch
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Mahmut E Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Joshua N Goldstein
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston3Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical Sch
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14
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Pasi M, Boulouis G, Fotiadis P, Auriel E, Charidimou A, Haley K, Ayres A, Schwab KM, Goldstein JN, Rosand J, Viswanathan A, Pantoni L, Greenberg SM, Gurol ME. Distribution of lacunes in cerebral amyloid angiopathy and hypertensive small vessel disease. Neurology 2017; 88:2162-2168. [PMID: 28476760 DOI: 10.1212/wnl.0000000000004007] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 02/16/2017] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To evaluate whether the burden of deep and lobar lacunes differs between patients with intracerebral hemorrhage (ICH) with definite/probable cerebral amyloid angiopathy (CAA) per the Boston criteria and hypertensive small vessel disease (HTN-SVD; ICH in basal ganglia, thalami, brainstem). METHODS We defined lobar and deep lacunes similar to the topographic distribution used for ICH and cerebral microbleeds (CMBs). We then compared their distribution between patients with CAA-ICH and those with strictly deep CMB and ICH (HTN-ICH). The independent associations of lacune location with the diagnosis of CAA-ICH and HTN-ICH were evaluated with multivariable models. The relationship between lobar lacunes and white matter hyperintensity (WMH) volume was evaluated by means of partial correlation analyses adjusted for age and a validated visual scale. RESULTS In our final cohort of 316 patients with ICH, lacunes were frequent (24.7%), with similar rates in 191 patients with CAA and 125 with HTN-ICH (23% vs 27.2%, p = 0.4). Lobar lacunes were more commonly present in CAA (20.4% vs 5.7%, p < 0.001), while deep lacunes were more frequent in HTN-ICH (15.2% vs 2.1%, p < 0.001). After correction for demographics and clinical and neuroimaging markers of SVD, lobar lacunes were associated with CAA (p = 0.003) and deep lacunes with HTN-ICH (p < 0.001). Lobar lacunes in 80% of the cases were at least in contact with WMH, and after adjustment for age, they were highly correlated to WMH volume (r = 0.42, p < 0.001). CONCLUSIONS Lobar lacunes are associated with CAA, whereas deep lacunes are more frequent in HTN-SVD. Lobar lacunes seem to have a close relationship with WMH, suggesting a possible common origin.
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Affiliation(s)
- Marco Pasi
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Panagiotis Fotiadis
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eitan Auriel
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Andreas Charidimou
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kellen Haley
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kristin M Schwab
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Joshua N Goldstein
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Leonardo Pantoni
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - M Edip Gurol
- From the Hemorrhagic Stroke Research Program (M.P., G.B., P.F., E.A., A.C., K.H., A.A., K.M.S., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; NEUROFARBA Department (M.P., L.P.), Neuroscience Section, University of Florence, Italy; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston.
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Charidimou A, Boulouis G, Xiong L, Jessel MJ, Roongpiboonsopit D, Ayres A, Schwab KM, Rosand J, Gurol ME, Greenberg SM, Viswanathan A. Cortical superficial siderosis and first-ever cerebral hemorrhage in cerebral amyloid angiopathy. Neurology 2017; 88:1607-1614. [PMID: 28356458 DOI: 10.1212/wnl.0000000000003866] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 01/25/2017] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To investigate whether cortical superficial siderosis (cSS) is associated with increased risk of future first-ever symptomatic lobar intracerebral hemorrhage (ICH) in patients with cerebral amyloid angiopathy (CAA) presenting with neurologic symptoms and without ICH. METHODS Consecutive patients meeting modified Boston criteria for probable CAA in the absence of ICH from a single-center cohort were analyzed. cSS and other small vessel disease MRI markers were assessed according to recent consensus recommendations. Patients were followed prospectively for future incident symptomatic lobar ICH. Prespecified Cox proportional hazard models were used to investigate cSS and first-ever lobar ICH risk adjusting for potential confounders. RESULTS The cohort included 236 patients with probable CAA without lobar ICH at baseline. cSS prevalence was 34%. During a median follow-up of 3.26 years (interquartile range 1.42-5.50 years), 27 of 236 patients (11.4%) experienced a first-ever symptomatic lobar ICH. cSS was a predictor of time until first ICH (p = 0.0007, log-rank test). The risk of symptomatic ICH at 5 years of follow-up was 19% (95% confidence interval [CI] 11%-32%) for patients with cSS at baseline vs 6% (95% CI 3%-12%) for patients without cSS. In multivariable Cox regression models, cSS presence was the only independent predictor of increased symptomatic ICH risk during follow-up (HR 4.04; 95% CI 1.73-9.44, p = 0.001), after adjusting for age, lobar cerebral microbleeds burden, and white matter hyperintensities. CONCLUSIONS cSS is consistently associated with an increased risk of future lobar ICH in CAA with potentially important clinical implications for patient care decisions such as antithrombotic use.
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Affiliation(s)
- Andreas Charidimou
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., L.X., M.J.J., D.R., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; and the Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand.
| | - Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., L.X., M.J.J., D.R., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; and the Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Li Xiong
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., L.X., M.J.J., D.R., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; and the Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Michel J Jessel
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., L.X., M.J.J., D.R., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; and the Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Duangnapa Roongpiboonsopit
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., L.X., M.J.J., D.R., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; and the Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., L.X., M.J.J., D.R., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; and the Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Kristin M Schwab
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., L.X., M.J.J., D.R., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; and the Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., L.X., M.J.J., D.R., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; and the Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - M Edip Gurol
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., L.X., M.J.J., D.R., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; and the Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., L.X., M.J.J., D.R., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; and the Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., L.X., M.J.J., D.R., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; and the Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
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Charidimou A, Boulouis G, Pasi M, Auriel E, van Etten ES, Haley K, Ayres A, Schwab KM, Martinez-Ramirez S, Goldstein JN, Rosand J, Viswanathan A, Greenberg SM, Gurol ME. MRI-visible perivascular spaces in cerebral amyloid angiopathy and hypertensive arteriopathy. Neurology 2017; 88:1157-1164. [PMID: 28228568 DOI: 10.1212/wnl.0000000000003746] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 12/20/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess MRI-visible enlarged perivascular spaces (EPVS) burden and different topographical patterns (in the centrum semiovale [CSO] and basal ganglia [BG]) in 2 common microangiopathies: cerebral amyloid angiopathy (CAA) and hypertensive arteriopathy (HA). METHODS Consecutive patients with spontaneous intracerebral hemorrhage (ICH) from a prospective MRI cohort were included. Small vessel disease MRI markers, including cerebral microbleeds (CMBs), cortical superficial siderosis (cSS), and white matter hyperintensities (WMH), were rated. CSO-EPVS/BG-EPVS were assessed on a validated 4-point visual rating scale (0 = no EPVS, 1 = <10, 2 = 11-20, 3 = 21-40, and 4 = >40 EPVS). We tested associations of predefined high-degree (score >2) CSO-EPVS and BG-EPVS with other MRI markers in multivariable logistic regression. We subsequently evaluated associations with CSO-EPVS predominance (i.e., CSO-EPVS > BG-EPVS) and BG-EPVS predominance pattern (i.e., BG-EPVS > CSO-EPVS) in adjusted multinomial logistic regression (reference group, BG-EPVS = CSO-EPVS). RESULTS We included 315 patients with CAA-ICH and 137 with HA-ICH. High-degree CSO-EPVS prevalence was greater in CAA-related ICH vs HA-related ICH (43.8% vs 17.5%, p < 0.001). In multivariable logistic regression, high-degree CSO-EPVS was associated with lobar CMB (odds ratio [OR] 1.33, 95% confidence interval [CI] 1.10-1.61, p = 0.003) and cSS (OR 2.08, 95% CI 1.30-3.32, p = 0.002). Deep CMBs (OR 2.85, 95% CI 1.75-4.64, p < 0.0001) and higher WMH volume (OR 1.02, 95% CI 1.01-1.04, p = 0.010) were predictors of high-degree BG-EPVS. A CSO-EPVS-predominant pattern was more common in CAA-ICH than in HA-ICH (75.9% vs 39.4%, respectively, p < 0.0001). CSO-PVS predominance was associated with lobar CMB burden and cSS, while BG-EPVS predominance was associated with HA-ICH and WMH volumes. CONCLUSIONS Different patterns of MRI-visible EPVS provide insights into the dominant underlying microangiopathy type in patients with spontaneous ICH.
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Affiliation(s)
- Andreas Charidimou
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston.
| | - Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Marco Pasi
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eitan Auriel
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ellis S van Etten
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kellen Haley
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kristin M Schwab
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Sergi Martinez-Ramirez
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Joshua N Goldstein
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - M Edip Gurol
- From the Hemorrhagic Stroke Research Program (A.C., G.B., M.P., E.A., E.S.v.E., K.H., A.A., K.M.S., S.M.-R., A.V., S.M.G., M.E.G.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Université Paris-Descartes (G.B.), INSERM UMR 894, Department of Neuroradiology, Centre Hospitalier Sainte-Anne, Paris, France; and Division of Neurocritical Care and Emergency Neurology (J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
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Valenti R, Charidimou A, Xiong L, Boulouis G, Fotiadis P, Ayres A, Riley G, Kuijf HJ, Reijmer YD, Pantoni L, Gurol ME, Davidsdottir S, Greenberg SM, Viswanathan A. Visuospatial Functioning in Cerebral Amyloid Angiopathy: A Pilot Study. J Alzheimers Dis 2017; 56:1223-1227. [DOI: 10.3233/jad-160927] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Raffaella Valenti
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
- Department of NEUROFARBA, Neuroscience Section, University of Florence, Florence, Italy
| | - Andreas Charidimou
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Li Xiong
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Gregoire Boulouis
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Panagiotis Fotiadis
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Alison Ayres
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Grace Riley
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Hugo J. Kuijf
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yael D. Reijmer
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Leonardo Pantoni
- Department of NEUROFARBA, Neuroscience Section, University of Florence, Florence, Italy
| | - M. Edip Gurol
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Sigurros Davidsdottir
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven M. Greenberg
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Anand Viswanathan
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
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Borowsky LH, Regan S, Chang Y, Ayres A, Greenberg SM, Singer DE. First Diagnosis of Atrial Fibrillation at the Time of Stroke. Cerebrovasc Dis 2017; 43:192-199. [PMID: 28208140 DOI: 10.1159/000457809] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 01/19/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a major cause of ischemic stroke. Individuals with undiagnosed AF lack the stroke protection afforded by oral anticoagulants. We obtained a contemporary estimate of the percentage of AF patients newly diagnosed at the time of stroke. METHODS We identified patients admitted to the Massachusetts General Hospital (MGH) from January 1, 2010 to December 31, 2013 with acute ischemic stroke and either previously or newly diagnosed AF using hospital stroke registry data and stroke and AF ICD-9 code searches of hospital databases. Reviewers categorized AF as previously known or newly diagnosed, and collected comorbidity and outcome data. To confirm AF as newly diagnosed, we searched patients' pre-event electronic medical records (EMRs) for AF terms. RESULTS AF was considered newly diagnosed in 156/856 patients (18%; 95% CI 16-21). In 136/156 cases, AF was diagnosed using 12-lead EKG, telemetry, or rhythm strips. New AF strokes had a median NIH stroke scale of 12; 60% had mRankin ≥3 at discharge, including 15% deaths. Pre-stroke CHA2DS2-VASc score was ≥2 in 89%. About half (76/156) had prior records in the MGH EMR. Evidence of pre-stroke AF, often peri-procedural, was found in 8/76, but the AF diagnosis was not carried forward. CONCLUSIONS In this contemporary cohort, nearly one in 5 AF-related strokes occurred without a pre-stroke AF diagnosis. AF was readily diagnosed using standard rhythm monitoring. The vast majority of patients with newly diagnosed AF were at high enough pre-stroke risk to merit anticoagulation. In conclusion, our findings support screening for AF before stroke. Patients with past transient AF may merit more intensive screening.
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Affiliation(s)
- Leila H Borowsky
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
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Boulouis G, Charidimou A, Jessel MJ, Xiong L, Roongpiboonsopit D, Fotiadis P, Pasi M, Ayres A, Merrill ME, Schwab KM, Rosand J, Gurol ME, Greenberg SM, Viswanathan A. Abstract TMP95: Small Vessel Disease Burden and Clinical Symptoms in Cerebral Amyloid Angiopathy Patients Presenting Without Symptomatic Hemorrhage. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.tmp95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Cerebral amyloid angiopathy (CAA) is a common age-related small vessel disease (SVD). Patients without ICH typically present with transient focal neurological episodes (TFNEs) or cognitive symptoms. We sought to determine if SVD lesion burden differed between CAA patients first presenting with TFNEs versus cognitive symptoms.
Methods:
A total of 647 patients presenting either to a stroke department (n=205) or an outpatient memory clinic (n=442), were screened for eligibility. Patients meeting modified Boston criteria for probable CAA were included and markers of SVD were quantified including cerebral microbleeds (CMBs), perivascular spaces, cortical superficial siderosis (cSS), and white matter hyperintensities (WMH). Patients were classified according to presentation symptoms (TFNEs vs cognitive). Total CAA-SVD burden was assessed using a validated summary score. Individual neuroimaging markers and total SVD burden were compared between groups using univariable and multivariable models.
Results:
There were 261 probable CAA patients included. After adjustment for confounders, patients first seen for TFNEs (n=97) demonstrated a higher prevalence of cSS (p<.0001), higher WMH volumes (p=0.03) and a trend towards higher CMBs counts (p=.09). The total SVD summary score was higher in patients seen for TFNEs (adjusted OR per additional score point=1.46, 95%CI [1.16 - 1.84], p=0.013).
Conclusion:
We present a large cohort of probable CAA patients without ICH and show that those first evaluated for TFNEs bear a higher burden of structural MRI SVD related damage compared to those first seen for cognitive symptoms. This study sheds light on CAA disease phenotypes, adds to the understanding of CAA clinical expression, and sets the basis for future works investigating CAA prognosis amongst phenotypes.
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Affiliation(s)
| | | | | | - Li Xiong
- Neurology Dept, Massachusetts General Hosp, Boston, MA
| | | | | | - Marco Pasi
- Neurology Dept, Massachusetts General Hosp, Boston, MA
| | - Alison Ayres
- Neurology Dept, Massachusetts General Hosp, Boston, MA
| | | | | | | | - M. Edip Gurol
- Neurology Dept, Massachusetts General Hosp, Boston, MA
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20
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Roongpiboonsopit D, Charidimou A, Boulouis G, Xiong L, Lauer A, Ayres A, Vashkevich A, Gurol ME, Rosand J, Greenberg SM, Viswanathan A. Abstract WP371: Cortical Superficial Siderosis and Mortality in Cerebral Amyloid Angiopathy. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
To investigate whether magnetic resonance imaging (MRI) markers of cerebral small vessel disease predict overall mortality in cerebral amyloid angiopathy (CAA) patients.
Methods:
Subjects were consecutive survivors (age≥55) of spontaneous symptomatic CAA-related-lobar ICH and CAA presenting without lobar ICH, diagnosed according to the Boston criteria drawn from an ongoing longitudinal cohort study and Memory Disorder Unit. All subjects had brain MRI at presentation. Baseline clinical, imaging, laboratory data and mortality information were collected. Neuroimaging markers including focal (≤3 sulci) or disseminated (>3 sulci) cortical superficial siderosis (cSS), cortical subarachnoid hemorrhage (cSAH), cerebral microbleeds (CMBs), enlarged perivascular spaces (EPVS) and white matter hyperintensities (WMH) were evaluated. Overall mortality risk was assessed using Cox proportional hazards models adjusting for potential confounders.
Results:
A total of 335 patients with probable CAA were enrolled, 196 presenting with lobar ICH and 139 without lobar ICH. During a median follow-up time of 3.44 years (interquartile range 1.61- 5.52 years), 181 of 335 patients (54.0%) died, 37.3% were patients with lobar ICH and 16.7% were those without. In univariable analysis, disseminated cSS, moderate to severe WMH, higher age and CAA related-lobar ICH group were predictors of overall mortality (p<0.05 for all comparisons). After adjusting for moderate to severe WMH and multiple CMBs (CMBs ≥5 foci), disseminated cSS remained as an independent neuroimaging predictor of overall mortality (HR 1.66; 95% CI 1.05-2.64, p = 0.030). Other predictors of mortality were older age (HR 1.08; 95% CI 1.06-1.11, p < 0.001) and presence of lobar ICH (HR 1.87; 95% CI 1.34-2.61, p < 0.001). The mortality risk was even greater in patients with both disseminated cSS and lobar ICH (HR 2.28; 95% CI 1.41-3.69, p = 0.001) and as well as in older patients (age>75 years) with disseminated cSS (HR 1.86; 95% CI 1.08-3.23, p = 0.026).
Conclusion:
Disseminated cSS is an independent neuroimaging biomarker of increased risk of overall mortality in probable CAA, particular in those patients with lobar ICH and older age. These findings may serve identify important markers of CAA severity.
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Affiliation(s)
| | | | | | - Li Xiong
- Neurology, Massachusetts General Hosp, Boston, MA
| | - Arne Lauer
- Neurology, Massachusetts General Hosp, Boston, MA
| | - Alison Ayres
- Neurology, Massachusetts General Hosp, Boston, MA
| | | | - M. E Gurol
- Neurology, Massachusetts General Hosp, Boston, MA
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21
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Charidimou A, Boulouis G, Moulin S, Roongpiboonsopit D, Raposo N, Hernandez-Guillamon M, Olivot JM, Ayres A, Schwab KM, Wollenweber FA, Rosand J, Linn J, Gurol ME, Cordonnier C, Greenberg SM, Viswanathan A. Abstract 212: Cortical Superficial Siderosis and Risk of Recurrent Intracerebral Haemorrhage in Cerebral Amyloid Angiopathy: A Meta-analysis. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Cerebral amyloid angiopathy (CAA) is a major cause of spontaneous lobar intracerebral hemorrhage (ICH) in the elderly. CAA-related ICH survivors are at substantial risk for recurrent ICH, accounting for the significant morbidity of the disease. Identifying predictors of recurrence is therefore crucial. Recent data have implicated cortical superficial siderosis (cSS) as a key hemorrhagic MRI signature of CAA, and a possible marker of increased risk for CAA-ICH recurrence. However, data remain limited. We obtained precise estimates on cSS as an independent predictor of ICH recurrence risk in CAA cohorts from a systematic review of published studies pooled with data from our centre.
Methods:
We included cohort studies of consecutive CAA-related ICH patients based on the original Boston criteria, with available blood-sensitive MRI sequences at baseline for cSS assessment, and adequate follow-up for recurrent symptomatic ICH. The strength of the association between cSS and recurrent ICH was quantified using random effects models. Covariate-adjusted hazard rations (adj-HR) as provided from pre-specified Cox proportional hazard models were used for a two-stage meta-analysis.
Results:
Three cohorts including 443 CAA-ICH patients were eligible for analysis. The pooled prevalence of cSS presence and disseminated cSS (>3 affected sulci) was 32% (95%CI: 32%-41%) and 21% (95%CI: 18%-25%) respectively. During a mean follow-up of 2.5 years (range: 2-3 years) 92 patients experienced recurrent ICH, a pooled risk ratio of 6.9% per year (I
2
: 63%, p=0.07). In adjusted pooled analysis, any cSS and disseminated cSS were both independently associated with increased lobar ICH recurrence risk (adj-HR: 2.4; 95%CI: 1.5-3.8; p<0.0001, I
2
: 0% and adj-HR: 4.1; 95%CI: 2.6-6.6; p<0.0001, I
2
: 47%), after adjusting for multiple strictly lobar microbleeds presence and increasing age.
Conclusions:
Our findings in a large population of CAA patients with ICH and a large number of recurrence events, indicate that cSS, particularly if disseminated, is the single most important prognostic risk factor on MRI for future recurrent lobar ICH. The provided estimates may help stratify future bleeding risk in CAA, with clinical implications for prognosis and treatment.
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Affiliation(s)
- Andreas Charidimou
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Harvard Med Sch, Boston, MA
| | - Gregoire Boulouis
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Harvard Med Sch, Boston, MA
| | - Solene Moulin
- Univ. Lille, Inserm, CHU Lille, U1171, Degenerative & vascular cognitive disorders, Lille, France
| | - Duangnapa Roongpiboonsopit
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Harvard Med Sch, Boston, MA
| | - Nicolas Raposo
- Dept of Vascular Neurology, Univ Hosp of Toulouse, Toulouse, France
| | - Mar Hernandez-Guillamon
- Neurovascular Rsch Laboratory, Vall d’Hebron Rsch Institute, Universitat Auto`noma de Barcelona, Barcelona, Spain
| | - Jean Marc Olivot
- Dept of Vascular Neurology, Univ Hosp of Toulouse, Toulouse, France
| | - Alison Ayres
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Harvard Med Sch, Boston, MA
| | - Kristin M Schwab
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Harvard Med Sch, Boston, MA
| | - Frank A Wollenweber
- Klinikum der Universität München, Ludwigs-Maximilians-Universität LMU, Munich, Germany
| | - Jonathan Rosand
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Harvard Med Sch, Boston, MA
| | - Jennifer Linn
- Dept of Neuroradiology, Univ Hosp Munich, Munich, Germany
| | - M. E Gurol
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Harvard Med Sch, Boston, MA
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1171, Degenerative & vascular cognitive disorders, Lille, France
| | - Steven M Greenberg
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Harvard Med Sch, Boston, MA
| | - Anand Viswanathan
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Harvard Med Sch, Boston, MA
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22
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van Veluw SJ, Lauer A, Ayres A, Viswanathan A, Greenberg S, Vernooij M. Abstract WMP101: The Evolution of Lesions on Diffusion-Weighted MR Imaging in Cerebral Amyloid Angiopathy. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wmp101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Small hyperintense diffusion-weighted imaging (DWI) lesions are frequent neuroimaging findings in patients with cerebral amyloid angiopathy (CAA). Despite their high occurrence, little is known about the clinical impact of these lesions as well as their evolution over time and potential underlying etiology. Although it is believed that DWI-bright lesions represent acute microinfarcts, it has also been suggested that they are precursors of microbleeds. In this study we assessed DWI lesions in a cohort of CAA patients that underwent multiple imaging sessions. Specifically, we addressed the pathophysiologic nature of DWI lesions by evaluating their appearance on follow-up MRI.
Methods:
Patients (n=79) with probable CAA, as assessed by the Boston criteria, who underwent at least two DWI scans >2 months apart (>2 weeks post-ICH), were included in the study. One experienced neuroradiologist assessed presence and number of DWI lesions at each available time-point. Lesions had to be hyperintense on DWI, hypointense on ADC, and isointense on GRE. Next, on available follow-up images (FLAIR, T1, and GRE scans), lesion visibility and imaging characteristics were assessed by two experienced raters. All ratings were performed on 1.5 T MRI scans.
Results:
A total number of 221 DWI scans were assessed for DWI lesions (39 patients had 2 DWI scans; 40 had ≥3). In total, 57 DWI lesions were found in this dataset (37 in white matter; 16 in grey matter; 4 in cerebellum). For 36/57 lesions >1 imaging sequence was available at follow-up to determine lesion appearance. Twenty-two/36 DWI lesions (61%) were visible on follow-up MRI. Five appeared as lacunar infarcts (of which 4 were located in white matter), 16 were visible as signal change on T1 or FLAIR sequences. Only a single DWI lesion showed evidence of hemosiderin deposition on follow-up, compatible with hemorrhagic transformation / microbleed.
Conclusions:
DWI lesions are common neuroimaging findings in patients with probable CAA. More than 60% of the observed DWI lesions evolve into chronic lesions, but the minority shows cavitation. Their neuroimaging signature strongly suggests that these lesions have an ischemic pathophysiologic nature. We found only one lesion that underwent hemorrhagic transformation.
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Affiliation(s)
| | - Arne Lauer
- Neurology, Massachusetts General Hosp, Boston, MA
| | - Alison Ayres
- Neurology, Massachusetts General Hosp, Boston, MA
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23
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Xiong L, Valenti R, Charidimou A, Boulouis G, Roongpiboonsopit D, Van Veluw SJ, Martinez-Ramirez S, Ayres A, Alessandro B, Gurol E, Greenberg S, Viswanathan A. Abstract TP432: Predictors for Dementia Conversion in Cerebral Amyloid Angiopathy From a Stroke Unit. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.tp432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
Cerebral amyloid angiopathy (CAA) is increasing recognized as a cause of cognitive impairment and dementia in older individuals. This study aimed to investigate predictors of dementia, including imaging markers, in CAA patients from a stroke unit.
Methods:
A total of 71 non-demented patients from a stroke unit were included according to modified Boston Criteria for probable CAA with available cognitive follow up. These CAA patients included both patients with and patients without previous intracerebral hemorrhage (ICH). At baseline, neuroimaging markers, including lobar microbleeds (CMBs), white matter hyperintensities (WMH), cortical superficial siderosis (cSS) and MRI-visible centrum semiovale perivascular spaces (CSO-PVS) were assessed. The small vessel disease (SVD) score for CAA was calculated by the scores of CMBs, WMH, cSS and CSO-PVS. The association between these neuroimaging markers and dementia conversion was analyzed.
Results:
The median follow up time is 1.91 years (quartiles 1.14-4.23 years). Fourteen (19.72%) CAA patients developed dementia during follow up period. Thirty-seven CAA patients (52.11%) had previous symptomatic ICH. Age, lobar CMBs≥20 and SVD score were selected from the univariate Cox-regression analysis with p value less than 0.1 (Table1). In a backward stepwise multivariabte analysis including age, previous ICH history and either SVD score or number of CMBs, age and SVD score independently predicted dementia conversion (Table 1). The individual neuroimaging markers for SVD related brain damage (CSO-PVS, cSS, lobar MBs and WMH) did not predict dementia conversion for probable CAA patients.
Conclusion:
Our results demonstrate that cognitive deterioration of CAA patients appears attributed to cumulative CAA related vasculopathic changes.
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Affiliation(s)
- Li Xiong
- The J. Philip Kistler Stroke Rsch Cntr, Massachusetts General Hosp, Cambridge, MA
| | | | - Andreas Charidimou
- The J. Philip Kistler Stroke Rsch Cntr, Massachusetts General Hosp, Boston, MA
| | - Gregoire Boulouis
- The J. Philip Kistler Stroke Rsch Cntr, Massachusetts General Hosp, Boston, MA
| | | | - Susanne J Van Veluw
- The J. Philip Kistler Stroke Rsch Cntr, Massachusetts General Hosp, Boston, MA
| | | | - Alison Ayres
- The J. Philip Kistler Stroke Rsch Cntr, Massachusetts General Hosp, Boston, MA
| | - Biffi Alessandro
- The J. Philip Kistler Stroke Rsch Cntr, Massachusetts General Hosp, Boston, MA
| | - Edip Gurol
- The J. Philip Kistler Stroke Rsch Cntr, Massachusetts General Hosp, Boston, MA
| | - Steven Greenberg
- The J. Philip Kistler Stroke Rsch Cntr, Massachusetts General Hosp, Boston, MA
| | - Anand Viswanathan
- The J. Philip Kistler Stroke Rsch Cntr, Massachusetts General Hosp, Boston, MA
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24
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Pasi M, Charidimou A, Boulouis G, Auriel E, Haley K, Ayres A, Schwab K, Goldstein J, Rosand J, Viswanathan A, Pantoni L, Greenberg S, Gurol E. Abstract TP324: Macrobleeds and Microbleeds: A Vascular Risk Factor Microangiopathy. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.tp324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The predominant type of cerebral small vessel disease (SVD) and clinical outcomes of patients who present with a combination of lobar and deep intracerebral hemorrhage (ICH)/microbleed (MB) locations (Mixed-ICH, see figure) is unknown.
Methods:
Out of 391 consecutive ICH, 75 (19%) had Mixed-ICH, and their demographics, clinical/laboratory features, and SVD neuroimaging markers were compared to 191 probable Cerebral Amyloid Angiopathy (CAA-ICH) and 125 strictly deep-MB and ICH (Deep-ICH) patients. ICH-recurrence on follow up was also analyzed.
Results:
Mixed-ICH patients had a higher prevalence of hypertension, diabetes, left ventricular hypertrophy rates, higher creatinine values, as well as more prevalent lacunes and basal ganglia (BG) enlarged perivascular spaces (EPVS) than CAA-ICH (all p<0.05). When compared to Deep-ICH, Mixed-ICH patients were older, had higher WMH volumes and MB count, and more prevalent lacunes and centrum semiovale EPVS (all p<0.05). In multivariable models, Mixed-ICH diagnosis was associated with higher creatinine, more lacunes and BG EPVS, than CAA-ICH (all p<0.05). When compared to Deep-ICH, Mixed-ICH patients were older and had more lacunes and MBs in multivariable models (all p<0.05). Annual risk of ICH-recurrence was 5.1% for Mixed-ICH, higher compared to Strictly Deep-ICH but lower than CAA-ICH (1.6% and 10.4%, respectively).
Conclusions:
Mixed-ICH, commonly seen when MRI obtained during etiologic workup, appears to be mostly driven by vascular risk factors similar to Strictly Deep-ICH, but demonstrates more severe parenchymal damage and higher ICH-recurrence risk.
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Affiliation(s)
- Marco Pasi
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Andreas Charidimou
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Gregoire Boulouis
- Université Paris-Descartes, INSERM UMR 894, Dept of Neuroradiology, Cntr Hospier Sainte-Anne, Paris, France
| | - Eitan Auriel
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Kellen Haley
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Alison Ayres
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Kristin Schwab
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Joshua Goldstein
- Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Jonathan Rosand
- Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Anand Viswanathan
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Leonardo Pantoni
- NEUROFARBA Dept, Neuroscience Section, Univ of Florence, Florence, Italy
| | - Steven Greenberg
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Edip Gurol
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
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25
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Pasi M, Boulouis G, Fotiadis P, Charidimou A, Auriel E, Aley K, Ayres A, Schwab KM, Goldstein J, Rosand J, Viswanathan A, Pantoni L, Greenberg SM, Gurol E. Abstract WMP100: Topographical Distribution of Lacunes in Cerebral Amyloid Angiopathy and Deep Hypertensive Intracerebral Hemorrhage. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wmp100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background/Aims:
To evaluate whether the burden of lacunes located at deep and lobar brain regions, would differ between intracerebral hemorrhage patients (ICH) with cerebral amyloid angiopathy (CAA) vs patients with strictly deep cerebral microbleeds (CMB) and ICH (Deep HTN-ICH).
Methods:
We defined lobar and deep lacunes similar to the topographic distribution used for ICH and microbleeds. We then compared their distribution between CAA and Deep HTN-ICH patients. The independent associations of lacune location (lobar vs deep) with diagnosis of CAA-ICH and Deep HTN-ICH were evaluated using multivariable models. The relationship between lobar and deep lacunes and WMH volume was evaluated using partial correlation analyses adjusting for age and by means of a validated visual scale.
Results:
In our cohort of 316 ICH patients, lobar lacunes were more commonly present in CAA (20.4% vs 5.7% in Deep HTN-ICH, p<0.001; see figure) while deep lacunes more frequent in Deep HTN-ICH patients (15.2% vs 2.1%, p<0.001; see figure). After correction for demographics, clinical and neuroimaging markers of SVD, lobar lacunes were associated with CAA diagnosis (p=0.023), while deep lacunes with Deep HTN-ICH (p<0.001). Lobar lacunes in 80% of the cases were at least in contact with WMH and after adjustment for age they were highly correlated to WMH volume (
r=0.52,
p<0.001).
Conclusions:
Lobar lacunes are associated with CAA whereas deep lacunes are more frequent in patients with Strictly deep CMBs and ICH, they can thus be clinically useful in the appropriate context. Lobar lacunes seem to have a close relationship with WMH suggesting a possible common origin.
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Affiliation(s)
- Marco Pasi
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Gregoire Boulouis
- Université Paris-Descartes, INSERM UMR 894, Dept of Neuroradiology, Cntr Hospier Sainte-Anne, Paris, France
| | - Panagiotis Fotiadis
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Andreas Charidimou
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Eitan Auriel
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Kellen Aley
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Alison Ayres
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Kristin M Schwab
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Joshua Goldstein
- Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Jonathan Rosand
- Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Anand Viswanathan
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Leonardo Pantoni
- NEUROFARBA Dept, Neuroscience Section, Univ of Florence, Florence, Italy
| | - Steven M Greenberg
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Edip Gurol
- Hemorrhagic Stroke Rsch Program, Dept of Neurology, Massachusetts General Hosp, Boston, MA
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26
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Boulouis G, Charidimou A, Jessel MJ, Xiong L, Roongpiboonsopit D, Fotiadis P, Pasi M, Ayres A, Merrill ME, Schwab KM, Rosand J, Gurol ME, Greenberg SM, Viswanathan A. Small vessel disease burden in cerebral amyloid angiopathy without symptomatic hemorrhage. Neurology 2017; 88:878-884. [PMID: 28130469 DOI: 10.1212/wnl.0000000000003655] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/12/2016] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE Cerebral amyloid angiopathy (CAA) is a common age-related small vessel disease (SVD). Patients without intracerebral hemorrhage (ICH) typically present with transient focal neurologic episodes (TFNEs) or cognitive symptoms. We sought to determine if SVD lesion burden differed between patients with CAA first presenting with TFNEs vs cognitive symptoms. METHODS A total of 647 patients presenting either to a stroke department (n = 205) or an outpatient memory clinic (n = 442) were screened for eligibility. Patients meeting modified Boston criteria for probable CAA were included and markers of SVD were quantified, including cerebral microbleeds (CMBs), perivascular spaces, cortical superficial siderosis (cSS), and white matter hyperintensities (WMHs). Patients were classified according to presentation symptoms (TFNEs vs cognitive). Total CAA-SVD burden was assessed using a validated summary score. Individual neuroimaging markers and total SVD burden were compared between groups using univariable and multivariable models. RESULTS There were 261 patients with probable CAA included. After adjustment for confounders, patients first seen for TFNEs (n = 97) demonstrated a higher prevalence of cSS (p < 0.0001), higher WMH volumes (p = 0.03), and a trend toward higher CMB counts (p = 0.09). The total SVD summary score was higher in patients seen for TFNEs (adjusted odds ratio per additional score point 1.46, 95% confidence interval 1.16-1.84, p = 0.013). CONCLUSIONS Patients with probable CAA without ICH first evaluated for TFNEs bear a higher burden of structural MRI SVD-related damage compared to those first seen for cognitive symptoms. This study sheds light on neuroimaging profile differences across clinical phenotypes of patients with CAA without ICH.
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Affiliation(s)
- Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand.
| | - Andreas Charidimou
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Michael J Jessel
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Li Xiong
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Duangnapa Roongpiboonsopit
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Panagiotis Fotiadis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Marco Pasi
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - M Emily Merrill
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Kristin M Schwab
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - M Edip Gurol
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
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Morotti A, Romero JM, Jessel MJ, Brouwers HB, Gupta R, Schwab K, Vashkevich A, Ayres A, Anderson CD, Gurol ME, Viswanathan A, Greenberg SM, Rosand J, Goldstein JN. Effect of CTA Tube Current on Spot Sign Detection and Accuracy for Prediction of Intracerebral Hemorrhage Expansion. AJNR Am J Neuroradiol 2016; 37:1781-1786. [PMID: 27197985 DOI: 10.3174/ajnr.a4810] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/17/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Reduction of CT tube current is an effective strategy to minimize radiation load. However, tube current is also a major determinant of image quality. We investigated the impact of CTA tube current on spot sign detection and diagnostic performance for intracerebral hemorrhage expansion. MATERIALS AND METHODS We retrospectively analyzed a prospectively collected cohort of consecutive patients with primary intracerebral hemorrhage from January 2001 to April 2015 who underwent CTA. The study population was divided into 2 groups according to the median CTA tube current level: low current (<350 mA) and high current (≥350 mA). CTA first-pass readings for spot sign presence were independently analyzed by 2 readers. Baseline and follow-up hematoma volumes were assessed by semiautomated computer-assisted volumetric analysis. Sensitivity, specificity, positive and negative predictive values, and accuracy of spot sign in predicting hematoma expansion were calculated. RESULTS This study included 709 patients (288 and 421 in the low- and high-current groups, respectively). A higher proportion of low-current scans identified at least 1 spot sign (20.8% versus 14.7%, P = .034), but hematoma expansion frequency was similar in the 2 groups (18.4% versus 16.2%, P = .434). Sensitivity and positive and negative predictive values were not significantly different between the 2 groups. Conversely, high-current scans showed superior specificity (91% versus 84%, P = .015) and overall accuracy (84% versus 77%, P = .038). CONCLUSIONS CTA obtained at high levels of tube current showed better diagnostic accuracy for prediction of hematoma expansion by using spot sign. These findings may have implications for future studies using the CTA spot sign to predict hematoma expansion for clinical trials.
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Affiliation(s)
- A Morotti
- From the Department of Clinical and Experimental Sciences (A.M.), Neurology Clinic, University of Brescia, Brescia, Italy
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - J M Romero
- Neuroradiology Service, Department of Radiology (J.M.R., R.G.)
| | - M J Jessel
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - H B Brouwers
- Department of Neurosurgery (H.B.B.), Brain Center Rudolf Magnus, University Medical Center, Utrecht, the Netherlands
| | - R Gupta
- Neuroradiology Service, Department of Radiology (J.M.R., R.G.)
| | - K Schwab
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - A Vashkevich
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - A Ayres
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - C D Anderson
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - M E Gurol
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - A Viswanathan
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - S M Greenberg
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - J Rosand
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
- Division of Neurocritical Care and Emergency Neurology (J.R., J.N.G.)
| | - J N Goldstein
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
- Division of Neurocritical Care and Emergency Neurology (J.R., J.N.G.)
- Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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28
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Roongpiboonsopit D, Charidimou A, William CM, Lauer A, Falcone GJ, Martinez-Ramirez S, Biffi A, Ayres A, Vashkevich A, Awosika OO, Rosand J, Gurol ME, Silverman SB, Greenberg SM, Viswanathan A. Cortical superficial siderosis predicts early recurrent lobar hemorrhage. Neurology 2016; 87:1863-1870. [PMID: 27694268 DOI: 10.1212/wnl.0000000000003281] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 06/30/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To identify predictors of early lobar intracerebral hemorrhage (ICH) recurrence, defined as a new ICH within 6 months of the index event, in patients with cerebral amyloid angiopathy (CAA). METHODS Participants were consecutive survivors (age ≥55 years) of spontaneous symptomatic probable or possible CAA-related lobar ICH according to the Boston criteria, drawn from an ongoing single-center cohort study. Neuroimaging markers ascertained in CT or MRI included focal (≤3 sulci) or disseminated (>3 sulci) cortical superficial siderosis (cSS), acute convexity subarachnoid hemorrhage (cSAH), cerebral microbleeds, white matter hyperintensities burden and location, and baseline ICH volume. Participants were followed prospectively for recurrent symptomatic ICH. Cox proportional hazards models were used to identify predictors of early recurrent ICH adjusting for potential confounders. RESULTS A total of 292 patients were enrolled. Twenty-one patients (7%) had early recurrent ICH. Of these, 24% had disseminated cSS on MRI and 19% had cSAH on CT scan. In univariable analysis, the presence of disseminated cSS, cSAH, and history of previous ICH were predictors of early recurrent ICH (p < 0.05 for all comparisons). After adjusting for age and history of previous ICH, disseminated cSS on MRI and cSAH on CT were independent predictors of early recurrent ICH (hazard ratio [HR] 3.92, 95% confidence interval [CI] 1.38-11.17, p = 0.011, and HR 3.48, 95% CI 1.13-10.73, p = 0.030, respectively). CONCLUSIONS Disseminated cSS on MRI and cSAH on CT are independent imaging markers of increased risk for early recurrent ICH. These markers may provide additional insights into the mechanisms of ICH recurrence in patients with CAA.
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Affiliation(s)
- Duangnapa Roongpiboonsopit
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD.
| | - Andreas Charidimou
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Christopher M William
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Arne Lauer
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Guido J Falcone
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Sergi Martinez-Ramirez
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Alessandro Biffi
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Alison Ayres
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Anastasia Vashkevich
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Oluwole O Awosika
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Jonathan Rosand
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - M Edip Gurol
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Scott B Silverman
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Steven M Greenberg
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
| | - Anand Viswanathan
- From The Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center (D.R., A.C., A.L., G.J.F., S.M.-R., A.A., A. Vashkevich, M.E.G., S.B.S., S.M.G., A. Viswanathan), and Division of Behavioral Neurology (A.B.), Department of Neurology, Division of Neuropsychiatry, Department of Psychiatry (A.B.), Neuropathology Service, Department of Pathology (C.M.W.), and The Center for Human Genetic Research (G.J.F., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and Human Cortical Physiology and Stroke Neurorehabilitation Section (O.O.A.), NINDS/NIH, Bethesda, MD
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Lauer A, van Veluw SJ, William CM, Charidimou A, Roongpiboonsopit D, Vashkevich A, Ayres A, Martinez-Ramirez S, Gurol EM, Biessels GJ, Frosch M, Greenberg SM, Viswanathan A. Microbleeds on MRI are associated with microinfarcts on autopsy in cerebral amyloid angiopathy. Neurology 2016; 87:1488-1492. [PMID: 27613583 DOI: 10.1212/wnl.0000000000003184] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/20/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To identify in vivo MRI markers that might correlate with cerebral microinfarcts (CMIs) on autopsy in patients with cerebral amyloid angiopathy (CAA). METHODS We included patients with neuropathologic evidence of CAA on autopsy and available antemortem brain MRI. Clinical characteristics and in vivo MRI markers of CAA-related small vessel disease were recorded, including white matter hyperintensities, cerebral microbleeds, cortical superficial siderosis, and centrum semiovale perivascular spaces. In addition, the presence of intracerebral hemorrhage on MRI was assessed. Evaluation of the presence and number of CMIs was performed in 9 standard histology sections. RESULTS Of 49 analyzed patients with CAA, CMIs were present in 36.7%. The presence of ≥1 CMIs on autopsy was associated with higher numbers of microbleeds on antemortem MRI (median 8 [interquartile range 2.5-33.0] vs 1 [interquartile range 0-3], p = 0.003) and with the presence of intracerebral hemorrhage (44.4% vs 16.1%, p = 0.03). No associations between CMIs and other in vivo MRI markers of CAA were found. In a multivariable model adjusted for severe CAA pathology, higher numbers of microbleeds were independent predictors of the presence of CMIs on pathology. CONCLUSIONS CMIs are a common finding at autopsy in patients with CAA. The strong association between MRI-observed microbleeds and CMIs at autopsy may suggest a shared underlying pathophysiologic mechanism between these lesions.
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Affiliation(s)
- Arne Lauer
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston.
| | - Susanne J van Veluw
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Christopher M William
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Andreas Charidimou
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Duangnapa Roongpiboonsopit
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Sergi Martinez-Ramirez
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Edip M Gurol
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Geert Jan Biessels
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Matthew Frosch
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program (A.L., S.J.v.V., A.C., D.R., A.V., A.A., S.M.-R., E.M.G., S.M.G., A.V.), Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston; Department of Neurology (S.J.v.V., G.J.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Pathology (C.M.W.), New York University Langone Medical Center, New York University School of Medicine; Department of Medicine (D.R.), Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; and C.S. Kubik Laboratory for Neuropathology (M.F.), Massachusetts General Hospital, Harvard Medical School, Boston
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Boulouis G, Morotti A, Brouwers HB, Charidimou A, Jessel MJ, Auriel E, Pontes-Neto O, Ayres A, Vashkevich A, Schwab KM, Rosand J, Viswanathan A, Gurol ME, Greenberg SM, Goldstein JN. Noncontrast Computed Tomography Hypodensities Predict Poor Outcome in Intracerebral Hemorrhage Patients. Stroke 2016; 47:2511-6. [PMID: 27601380 DOI: 10.1161/strokeaha.116.014425] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/02/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Noncontrast computed tomographic (CT) hypodensities have been shown to be associated with hematoma expansion in intracerebral hemorrhage (ICH), but their impact on functional outcome is yet to be determined. We evaluated whether baseline noncontrast CT hypodensities are associated with poor clinical outcome. METHODS We performed a retrospective review of a prospectively collected cohort of consecutive patients with primary ICH presenting to a single academic medical center between 1994 and 2016. The presence of CT hypodensities was assessed by 2 independent raters on the baseline CT. Unfavorable outcome was defined as a modified Rankin score >3 at 90 days. The associations between CT hypodensities and unfavorable outcome were investigated using uni- and multivariable logistic regression models. RESULTS During the study period, 1342 patients presented with ICH and 800 met restrictive inclusion criteria (baseline CT available for review, and 90-day outcome available). Three hundred and four (38%) patients showed hypodensities on CT, and 520 (65%) patients experienced unfavorable outcome. In univariate analysis, patients with unfavorable outcome were more likely to demonstrate hypodensities (48% versus 20%; P<0.0001). After adjustment for age, admission Glasgow coma scale, warfarin use, intraventricular hemorrhage, baseline ICH volume, and location, CT hypodensities were found to be independently associated with an increase in the odds of unfavorable outcome (odds ratio 1.70, 95% confidence interval [1.10-2.65]; P=0.018). CONCLUSIONS The presence of noncontract CT hypodensities at baseline independently predicts poor outcome and comes as a useful and widely available addition to our ability to predict ICH patients' clinical evolution.
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Affiliation(s)
- Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
| | - Andrea Morotti
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - H Bart Brouwers
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Andreas Charidimou
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Michael J Jessel
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Eitan Auriel
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Octavio Pontes-Neto
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Anastasia Vashkevich
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Kristin M Schwab
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Mahmut E Gurol
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Joshua N Goldstein
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
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Boulouis G, Charidimou A, Auriel E, Haley KE, van Etten ES, Fotiadis P, Reijmer Y, Ayres A, Schwab KM, Martinez-Ramirez S, Rosand J, Viswanathan A, Goldstein JN, Greenberg SM, Gurol ME. Intracranial atherosclerosis and cerebral small vessel disease in intracerebral hemorrhage patients. J Neurol Sci 2016; 369:324-329. [PMID: 27653918 DOI: 10.1016/j.jns.2016.08.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/11/2016] [Accepted: 08/23/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND The association between cerebral small vessel diseases (cSVD) and intracranial atherosclerosis is debated and conflicting results have been reported. We sought to investigate this association in patients with intracerebral hemorrhage (ICH), due to severe cSVD. METHODS Consecutive ICH patients were divided into those meeting criteria for cerebral amyloid angiopathy (CAA) and those with deep hypertensive ICH consistent with hypertensive cSVD (HTN-SVD). White matter hyperintensity volumes (WMH) and microbleed counts (MB) were measured on MRI. CTA was rated for severity of intracranial carotid calcifications and for presence of >50% intracranial stenosis (ICS). Associations of intracranial atherosclerosis severity with type of SVD (CAA vs HTN-cSVD) and with imaging and clinical markers of cSVD burden were analyzed. RESULTS The cohort included 253 CAA and 90 HTN-SVD patients. In multivariable models, the type of cSVD (CAA vs. HTN-cSVD) was not associated with calcification severity (OR=1.04, 95% CI [0.62-3.5], p=0.37) or presence of ICS (OR=0.84, 95% CI [0.21-2.74], p=0.78). We found no association between intracranial atherosclerosis (calcifications and stenoses) and parenchymal markers of cSVD severity (WMH and MB, adjusted p≥0.2 for all comparisons) and no association with presence of dementia before ICH (adjusted p≥0.2 for both comparisons). CONCLUSIONS We found no association between intracranial atherosclerosis and parenchymal or clinical consequences of cSVD, suggesting that cSVDs while sharing some risk factors are not influenced by upstream larger vessel pathologies.
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Affiliation(s)
- Gregoire Boulouis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Eitan Auriel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Kellen E Haley
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Ellis S van Etten
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Panagiotis Fotiadis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Yael Reijmer
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Alison Ayres
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Kristin M Schwab
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Sergi Martinez-Ramirez
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Jonathan Rosand
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Joshua N Goldstein
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA; Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - M Edip Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA.
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Armistead B, Crawford K, Ayres A, Tamashiro P, Peron E, Dante S. Observing risk factors for diarrheal disease and malnutrition in rural
Peru. Ann Glob Health 2016. [DOI: 10.1016/j.aogh.2016.04.604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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33
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Charidimou A, Martinez-Ramirez S, Reijmer YD, Oliveira-Filho J, Lauer A, Roongpiboonsopit D, Frosch M, Vashkevich A, Ayres A, Rosand J, Gurol ME, Greenberg SM, Viswanathan A. Total Magnetic Resonance Imaging Burden of Small Vessel Disease in Cerebral Amyloid Angiopathy: An Imaging-Pathologic Study of Concept Validation. JAMA Neurol 2016; 73:994-1001. [PMID: 27366898 PMCID: PMC5283697 DOI: 10.1001/jamaneurol.2016.0832] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IMPORTANCE Cerebral amyloid angiopathy (CAA) is characteristically associated with magnetic resonance imaging (MRI) biomarkers of small vessel brain injury, including strictly lobar cerebral microbleeds, cortical superficial siderosis, centrum semiovale perivascular spaces, and white matter hyperintensities. Although these neuroimaging markers reflect distinct pathophysiologic aspects in CAA, no studies to date have combined these structural imaging features to gauge total brain small vessel disease burden in CAA. OBJECTIVES To investigate whether a composite score can be developed to capture the total brain MRI burden of small vessel disease in CAA and to explore whether this score contributes independent and complementary information about CAA severity, defined as intracerebral hemorrhage during life or bleeding-related neuropathologic changes. DESIGN, SETTING, AND PARTICIPANTS This retrospective, cross-sectional study examined a single-center neuropathologic CAA cohort of eligible patients from the Massachusetts General Hospital from January 1, 1997, through December 31, 2012. Data analysis was performed from January 2, 2015, to January 9, 2016. Patients with pathologic evidence of CAA (ie, any presence of CAA from routinely collected brain biopsy specimen, biopsy specimen at hematoma evacuation, or autopsy) and available brain MRI sequences of adequate quality, including T2-weighted, T2*-weighted gradient-recalled echo, and/or susceptibility-weighted imaging and fluid-attenuated inversion recovery sequences, were considered for the study. MAIN OUTCOMES AND MEASURES Brain MRIs were rated for lobar cerebral microbleeds, cortical superficial siderosis, centrum semiovale perivascular spaces, and white matter hyperintensities. All 4 MRI lesions were incorporated into a prespecified ordinal total small vessel disease score, ranging from 0 to 6 points. Associations with severity of CAA-associated vasculopathic changes (fibrinoid necrosis and concentric splitting of the wall), clinical presentation, number of intracerebral hemorrhages, and other imaging markers not included in the score were explored using logistic and ordinal regression. RESULTS In total, 105 patients with pathologically defined CAA were included: 52 with autopsies, 22 with brain biopsy specimens, and 31 with pathologic samples from hematoma evacuations. The mean (range) age of the patients was 73 (71-74) years, and 55 (52.4%) were women. In multivariable ordinal regression analysis, severity of CAA-associated vasculopathic changes (odds ratio, 2.40; 95% CI, 1.06-5.45; P = .04) and CAA presentation with symptomatic intracerebral hemorrhage (odds ratio, 2.23; 95% CI, 1.07-4.64; P = .03) were independently associated with the total MRI small vessel disease score. The score was associated with small, acute, diffusion-weighted imaging lesions and posterior white matter hyperintensities in adjusted analyses. CONCLUSIONS AND RELEVANCE This study provides evidence of concept validity of a total MRI small vessel disease score in CAA. After further validation, this approach can be potentially used in prospective clinical studies.
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Affiliation(s)
- Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Sergi Martinez-Ramirez
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Yael D. Reijmer
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Jamary Oliveira-Filho
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Arne Lauer
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Duangnapa Roongpiboonsopit
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Matthew Frosch
- C.S. Kubik Laboratory for Neuropathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anastasia Vashkevich
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Alison Ayres
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Center for Human Genetic Research, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mahmut Edip Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Steven M. Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
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Schlunk F, Chang Y, Ayres A, Battey T, Vashkevich A, Raffeld M, Rost N, Viswanathan A, Gurol ME, Schwab K, Greenberg SM, Rosand J, Goldstein JN. Blood pressure burden and outcome in warfarin-related intracerebral hemorrhage. Int J Stroke 2016; 11:898-909. [PMID: 27462095 DOI: 10.1177/1747493016658300] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and purpose Blood pressure reduction is a promising intervention for acute intracerebral hemorrhage, but clinical trials of this treatment often exclude those with anticoagulant-associated intracerebral hemorrhage, leaving it unclear whether this population might benefit. We examined whether persistently elevated blood pressure values (blood pressure burden) over the first 24 h are associated with hematoma expansion and mortality in anticoagulant-associated intracerebral hemorrhage. Methods We retrospectively identified consecutive patients with primary anticoagulant-associated intracerebral hemorrhage (warfarin anticoagulation) who presented within 6 h after symptom onset and a matched set of non-anticoagulant-associated intracerebral hemorrhage patients. Associations between 24 h blood pressure burden, hematoma expansion, and mortality were evaluated using univariable and multivariable logistic regression. Results Sixty-nine anticoagulant-associated intracerebral hemorrhage and 69 matched non-anticoagulant-associated intracerebral hemorrhage patients were included. Hematoma expansion occurred in 25 anticoagulant-associated intracerebral hemorrhage patients (36%) and 15 control patients (22 %; p = 0.091). Twenty-four-hour blood pressure burden was in fact lower in anticoagulant-associated intracerebral hemorrhage than in non-anticoagulant-associated intracerebral hemorrhage patients (p = 0.033). No association was found in anticoagulant-associated intracerebral hemorrhage and non-anticoagulant-associated intracerebral hemorrhage between BP burden, hematoma expansion, and 30-day mortality. Conclusion We found no evidence that higher 24 h blood pressure burden is associated with hematoma expansion or mortality in anticoagulant-associated intracerebral hemorrhage.
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Affiliation(s)
- Frieder Schlunk
- 1 Department of Neurology, Massachusetts General Hospital, Boston, USA
| | - Yuchiao Chang
- 2 Department of Medicine, Massachusetts General Hospital, Boston, USA
| | - Alison Ayres
- 1 Department of Neurology, Massachusetts General Hospital, Boston, USA
| | - Thomas Battey
- 1 Department of Neurology, Massachusetts General Hospital, Boston, USA
| | | | - Miriam Raffeld
- 1 Department of Neurology, Massachusetts General Hospital, Boston, USA
| | - Natalia Rost
- 1 Department of Neurology, Massachusetts General Hospital, Boston, USA
| | - Anand Viswanathan
- 1 Department of Neurology, Massachusetts General Hospital, Boston, USA
| | - M Edip Gurol
- 1 Department of Neurology, Massachusetts General Hospital, Boston, USA
| | - Kristin Schwab
- 1 Department of Neurology, Massachusetts General Hospital, Boston, USA
| | | | - Jonathan Rosand
- 1 Department of Neurology, Massachusetts General Hospital, Boston, USA
| | - Joshua N Goldstein
- 3 Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA
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Fotiadis P, van Rooden S, van der Grond J, Schultz A, Martinez-Ramirez S, Auriel E, Reijmer Y, van Opstal AM, Ayres A, Schwab KM, Hedden T, Rosand J, Viswanathan A, Wermer M, Terwindt G, Sperling RA, Polimeni JR, Johnson KA, van Buchem MA, Greenberg SM, Gurol ME. Cortical atrophy in patients with cerebral amyloid angiopathy: a case-control study. Lancet Neurol 2016; 15:811-819. [PMID: 27180034 PMCID: PMC5248657 DOI: 10.1016/s1474-4422(16)30030-8] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 03/23/2016] [Accepted: 03/23/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Loss of cortical grey matter is a diagnostic marker of many neurodegenerative diseases, and is a key mediator of cognitive impairment. We postulated that cerebral amyloid angiopathy (CAA), characterised by cortical vascular amyloid deposits, is associated with cortical tissue loss independent of parenchymal Alzheimer's disease pathology. We tested this hypothesis in patients with hereditary cerebral haemorrhage with amyloidosis-Dutch type (HCHWA-D), a monogenetic disease with minimal or no concomitant Alzheimer's disease pathology, as well as in patients with sporadic CAA and healthy and Alzheimer's disease controls. METHODS In this observational case-control study, we included six groups of participants: patients diagnosed with HCHWA-D using genetic testing; healthy controls age-matched to the HCHWA-D group; patients with probable sporadic CAA without dementia; two independent cohorts of healthy controls age-matched to the CAA group; and patients with Alzheimer's disease age-matched to the CAA group. De-identified (but unmasked) demographic, clinical, radiological, and genetic data were collected at Massachusetts General Hospital (Boston, MA, USA), at Leiden University (Leiden, Netherlands), and at sites contributing to Alzheimer's Disease Neuroimaging Initiative (ADNI). The primary outcome measure was cortical thickness. The correlations between cortical thickness and structural lesions, and blood-oxygen-level-dependent time-to-peak (BOLD-TTP; a physiological measure of vascular dysfunction) were analysed to understand the potential mechanistic link between vascular amyloid and cortical thickness. The radiological variables of interest were quantified using previously validated computer-assisted tools, and all results were visually reviewed to ensure their accuracy. RESULTS Between March 15, 2006, and Dec 1, 2014, we recruited 369 individuals (26 patients with HCHWA-D and 28 age-matched, healthy controls; 63 patients with sporadic CAA without dementia; two healthy control cohorts with 63 and 126 individuals; and 63 patients with Alzheimer's disease). The 26 patients with HCHWA-D had thinner cortices (2·31 mm [SD 0·18]) than the 28 healthy controls (mean difference -0·112 mm, 95% CI -0·190 to -0·034, p=0·006). The 63 patients with sporadic CAA without dementia had thinner cortices (2·17 mm [SD 0·11]) than the two healthy control cohorts (n=63, mean difference -0·14 mm, 95% CI -0·17 to -0·10, p<0·0001; and n=126, -0·10, -0·13 to -0·06, p<0·0001). All differences remained independent in multivariable analyses. The 63 patients with Alzheimer's disease displayed more severe atrophy than the patients with sporadic CAA (2·1 mm [SD 0·14], difference 0·07 mm, 95% CI 0·11 to 0·02, p=0·005). We found strong associations between cortical thickness and vascular dysfunction in the patients with HCHWA-D (ρ=-0·58, p=0·003) or sporadic CAA (r=-0·4, p=0·015), but not in controls. Vascular dysfunction was identified as a mediator of the effect of hereditary CAA on cortical atrophy, accounting for 63% of the total effect. INTERPRETATION The appearance of cortical thinning in patients with HCHWA-D indicates that vascular amyloid is an independent contributor to cortical atrophy. These results were reproduced in patients with the more common sporadic CAA. Our findings also suggest that CAA-related cortical atrophy is at least partly mediated by vascular dysfunction. Our results also support the view that small vessel diseases such as CAA can cause cortical atrophy even in the absence of Alzheimer's disease, a conclusion that can help radiologists, neurologists, and other clinicians who diagnose these common geriatric conditions. FUNDING National Institutes of Health.
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Affiliation(s)
- Panagiotis Fotiadis
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
| | - Sanneke van Rooden
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen van der Grond
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Aaron Schultz
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | | | - Eitan Auriel
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
| | - Yael Reijmer
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
| | - Anna M. van Opstal
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alison Ayres
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
| | - Kristin M. Schwab
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
| | | | - Trey Hedden
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Marieke Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gisela Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Reisa A. Sperling
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Jonathan R. Polimeni
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Keith A. Johnson
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Mark A. van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Steven M. Greenberg
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - M. Edip Gurol
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
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Roongpiboonsopit D, Charidimou A, William CM, Lauer A, Falcone GJ, Raminez SM, Biffi A, Ayres A, Vashkevich A, Awosika OO, Rosand J, Silverman SB, Gurol ME, Greenberg SM, Viswanathan A. Abstract 122: Cortical Superficial Siderosis is a Predictor of Early Recurrent Intracerebral Hemorrhage in Cerebral Amyloid Angiopathy. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Cerebral amyloid angiopathy (CAA) is a major cause of lobar intracerebral hemorrhage (ICH). A subgroup of patients with CAA experience multiple, recurrent ICHs over a short period of time. In this study, we investigated predictors of early lobar ICH recurrence (defined as ICH within six month after index event) in order to better understand the mechanisms for early recurrence in CAA-related ICH.
Methods:
Subjects were consecutive survivors (age≥55) of spontaneous symptomatic CAA-related lobar ICH according to the Boston criteria drawn from an ongoing longitudinal cohort study. All subjects had brain computed tomography (CT) scan and magnetic resonance imaging (MRI) at presentation. Baseline clinical, imaging and laboratory data were collected. Neuroimaging markers including focal (≤3 sulci) or disseminated (>3 sulci) cortical superficial siderosis (cSS), acute convexity subarachanoid hemorrhage (cSAH), cerebral microbleeds (CMBs), white matter hyperintensities and baseline ICH volume, on CT and/or MRI were evaluated. Subjects were followed prospectively for future recurrent symptomatic ICH. Cox proportional hazard models were used to identify predictors of early recurrent ICH adjusting for potential confounders.
Results:
A total of 296 patients with probable or possible CAA were enrolled. In univariable analysis, the presence of disseminated cSS, cSAH, and number of CMBs were predictors of early recurrent ICH (p<0.05 for all comparisons). After adjusting for age and previous symptomatic ICH history, disseminated cSS on MRI and cSAH on CT were independent predictors of early recurrent ICH (HR 3.79, 95% CI 1.46-9.84, p=0.006, HR 3.16, 95% CI 1.05-9.51, p=0.041, respectively).
Conclusions:
Disseminated cSS on MRI and cSAH on CT are independent imaging markers of increased risk for early recurrent ICH. These markers may provide additional insights into the mechanisms of ICH recurrence in patients with CAA.
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Affiliation(s)
| | | | | | - Arne Lauer
- Neurology, Massachusetts General Hosp, Boston, MA
| | | | | | | | - Alison Ayres
- Neurology, Massachusetts General Hosp, Boston, MA
| | | | - Oluwole O Awosika
- Human Cortical Physiology and Stroke Neurorehabilitation Section, NINDS/NIH, Bethesda, MD
| | | | | | - M. E Gurol
- Neurology, Massachusetts General Hosp, Boston, MA
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Grunwald Z, Urday S, Beslow LA, Vashkevich A, Ayres A, Greenberg SM, Goldstein JN, Battey TW, Simard JM, Rosand J, Kimberly WT, Sheth KN. Abstract WMP88: Perihematomal Edema Expansion Rate Predicts Functional Outcome in Deep Intracerebral Hemorrhage. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.wmp88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Perihematomal edema (PHE) expansion rate may be an independent predictor of poor functional outcome following spontaneous intracerebral hemorrhage (ICH). We examined whether this association varies by ICH location.
Hypothesis:
The effect size of PHE expansion rate on mortality and poor functional outcome will be greater for deep ICH compared to lobar ICH.
Methods:
Subjects (n=139) were retrospectively identified from a prospective ICH cohort enrolled from 2000-2013. Inclusion criteria: ≥18 years of age, spontaneous supratentorial ICH, and known time of onset. Exclusion criteria: infratentorial or primary intraventricular hemorrhage, subsequent surgery, trauma, or warfarin-related ICH. ICH, PHE, and intraventricular hemorrhage (IVH) volumes were measured from CT scans. PHE expansion rates were calculated from serial PHE volume measurements. Logistic regression assessed the association between PHE expansion rate and mortality or poor functional outcome (modified Rankin Scale >2) at 90 days. Odds ratios are per 0.04 mL/h.
Results:
PHE expansion rate from baseline to 24 hours (PHE24) predicts mortality for deep (p=0.03, OR 1.13[1.02-1.26]) and lobar ICH (p=0.02, OR 1.03[1.00-1.06]) in unadjusted regression, and in models adjusted for age (Deep: p=0.02; Lobar: p=0.03), blood pressure (Deep: p=0.02; Lobar: p=0.04), IVH volume (Deep: p=0.02; Lobar: p=0.05), Glasgow Coma Scale (Deep: p=0.03; Lobar: p=0.02), or time to baseline CT (Deep: p=0.05; Lobar: p=0.05). PHE24 also predicts mortality for lobar ICH adjusting for ICH volume (p=0.05, OR 1.03[1-1.06]). A significant interaction exists between ICH location and PHE expansion rate from baseline to 72 hours (PHE72) in models predicting mRS>2 (p=0.04). PHE72 predicts mRS>2 for deep but not lobar ICH (p-values not shown) in models that are unadjusted (p=0.02, OR 4.04[1.25-13.04]) or adjusted for ICH volume (p=0.02, OR 4.3[1.25-14.98]), age (p=0.03, OR 5.4[1.21-24.11]), blood pressure (p=0.05, OR 3.28[1.02-10.57]), IVH volume (p=0.02, OR 4.59[1.28-16.41]), GCS (p=0.02, OR 4.19[1.2-14.55]), or time to first CT (p=0.03, OR 4.02[1.19-13.56]).
Conclusion:
PHE72 predicts poor functional outcomes exclusively after deep ICH, whereas PHE24 predicts mortality for deep and lobar ICH.
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Affiliation(s)
| | | | | | - Anastasia Vashkevich
- Cntr for Human Genetic Rsch and Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Boston, MA
| | - Alison Ayres
- Cntr for Human Genetic Rsch and Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Boston, MA
| | - Steven M Greenberg
- Cntr for Human Genetic Rsch and Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Boston, MA
| | - Joshua N Goldstein
- Cntr for Human Genetic Rsch and Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Boston, MA
| | - Thomas W Battey
- Cntr for Human Genetic Rsch and Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Boston, MA
| | - J M Simard
- Neurosurgery, Pathology and Physiology, Univ of Maryland Sch of Medicine, Baltimore, MD
| | - Jonathan Rosand
- Cntr for Human Genetic Rsch and Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Boston, MA
| | - W T Kimberly
- Cntr for Human Genetic Rsch and Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Boston, MA
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Boulouis G, Charidimou A, Auriel E, Haley KE, van Etten ES, Fotiadis P, Reijmer YD, Riley GA, Vashkevich A, Gomes TM, Ayres A, Schwab KM, Martinez-Ramirez S, Goldstein JN, Viswanathan A, Greenberg SM, Gurol ME. Abstract TP458: Is There “Crosstalk” Between Intracranial Arterial Pathologies and Small Vessel Disease?? Stroke 2016. [DOI: 10.1161/str.47.suppl_1.tp458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Interactions between intracranial arterial pathologies (IAP) and cerebral small vessel disease (SVD) are an increasingly debated topic.
Hypothesis:
We analyzed associations between the type/severity of SVD and two IAPs, the intracranial arterial calcifications (ICAC) and intracranial stenosis (ICS) in intracerebral hemorrhage (ICH) patients.
Methods:
Consecutive ICH patients from a prospective cohort were included. Patients were divided into those meeting Boston criteria for cerebral amyloid angiopathy (CAA) and those with strictly deep hypertensive ICH consistent with hypertensive SVD (HTN-SVD). White matter hyperintensity volume (WMH) and microbleed count (MB) were quantitatively measured on MRI as markers of SVD severity. Head CT angiography was rated for presence of ICAC and for presence of >50% intracranial arterial stenosis (ICS). Associations of IAPs with the type of SVD (CAA vs HTN) as well as imaging markers of SVD severity were analyzed in multivariate models. We also explored the association between IAPs and presence of pre-ICH dementia.
Results:
The cohort included 253 CAA patients and 90 HTN-SVD. CAA patients were older (73.5 vs 64.8, p<0.001), demonstrating higher WMH (25ml vs 16ml, p<0.001) but lower prevalence of hypertension than HTN-ICH. In univariate comparisons between CAA and HTN-SVD, the presence of ICACs (74% vs 72%, p=0.7) and ICS (7% vs 7.8%, p=0.8) were not different. ICS was not related to the type of SVD in multivariate models either. Using multivariate logistic regression, HTN-SVD was independently associated with presence of ICAC (adjusted OR = 2.56 [95% CI 1.1-6.2, p=0.002), as well as older age, male gender and hypercholesterolemia. We found no association between IAPs and parenchymal markers of SVD severity (WMH and MB) (all p>0.2) and no association with presence of dementia before ICH (p>0.2).
Conclusions:
HTN-SVD is associated with increased ICAC in multivariate models, suggesting either shared risk factors or direct interactions between SVD and IAP. There is no association of intracranial large artery pathologies (ICAC, ICS) with parenchymal (WMH, MB) or clinical (dementia) consequences of cerebral small vessel diseases.
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Affiliation(s)
| | | | - Eitan Auriel
- Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Boston, MA
| | - Kellen E Haley
- Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Boston, MA
| | | | | | - Yael D Reijmer
- Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Boston, MA
| | - Grace A Riley
- Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Boston, MA
| | | | - Thomas M Gomes
- Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Boston, MA
| | - Alison Ayres
- Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Boston, MA
| | - Kristin M Schwab
- Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Boston, MA
| | | | - Joshua N Goldstein
- Emergency and Critical Care, Massachusetts General Hosp Stroke Rsch Cntr, Boston, MA
| | | | | | - Mahmut E Gurol
- Neurology, Massachusetts General Hosp Stroke Rsch Cntr, Boston, MA
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Lauer A, Ay H, Charidimou A, Bianchi M, Ayres A, Schwab K, Viswanathan A, Rosand J, Greenberg S, Gurol EM. Abstract 85: Small Vessel Disease and Stroke During Sleep. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction/Hypothesis:
Stroke onset during sleep is common and sleep related pathologies have been associated with increased stroke risk. Based on available preliminary data, we tested the hypothesis that stroke during sleep is associated with small vessel disease (SVD).
Methods:
Prospectively collected data from patients consecutively enrolled after an intracerebral hemorrhage (ICH) related to SVD or after an ischemic stroke (IS) were analyzed. Symptom onset was recorded in relation to sleep vs. awake. Etiology of ICH was coded as cerebral amyloid angiopathy (CAA, per Boston criteria) and hypertensive deep ICH (HTN-ICH). The IS cohort was characterized based on the Causative Classification of Stroke system (5 subtype CCS). We compared frequencies of stroke onset during sleep between the SVD-related ICH and IS cohorts. Event rates, proportions of strokes during sleep and its associations (etiology, risk factors and stroke characteristics) were also analyzed within each cohort.
Results:
We analyzed 1,038 ICH (mean age: 72.5y +/- 13.0y, 45.4% female) and 1,812 IS patients (mean age: 67.9y +/- 15.9y, 46.4% female). Stroke while asleep was significantly more common among ICH patients (n=282, 26.6%) when compared to IS (n=363, 20.0%, p<0.001). This association between SVD-related ICH and stroke during sleep remained significant after controlling for age, gender and other risk factors (p<0.001). CAA-related ICH and small artery occlusion (SAA) related IS were etiologic subtypes more common among patients who had a stroke during sleep within their respective cohorts (asleep vs awake for CAA within ICH: 57.2% vs. 48.0%, p=0.008 and for SAA within IS: 19.3% vs. 9.1%, p<0.001). CAA and SAA etiologic types remained independent predictors of ICH and IS during sleep in respective multivariate models including other clinical features and risk factors (p=0.019 and p=0.011).
Conclusions:
Stroke during sleep was strongly associated with SVD-related ICH when compared to all IS. CAA within ICH group and SAA etiology within IS cohort were related to stroke during sleep in univariate and multivariate models. Presence of SVD can interact with sleep pathologies and/or sleep related hemodynamic changes to cause ischemic and hemorrhagic stroke.
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Affiliation(s)
- Arne Lauer
- Neurology, Massachusetts General Hosp, Boston, MA
| | - Hakan Ay
- Neurology, Massachusetts General Hosp, Boston, MA
| | | | - Matt Bianchi
- Neurology, Massachusetts General Hosp, Boston, MA
| | - Alison Ayres
- Neurology, Massachusetts General Hosp, Boston, MA
| | | | | | | | | | - Edip M Gurol
- Neurology, Massachusetts General Hosp, Boston, MA
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Zimmerman EE, Ayres A, Gurol ME, Greenberg SM. Abstract WP415: What Factors Determine Choice of Anticoagulant? Stroke 2016. [DOI: 10.1161/str.47.suppl_1.wp415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Non-vitamin K antagonist Oral Anticoagulation (NOAC) agents are approved for prevention of ischemic stroke in atrial fibrillation (Afib). NOACs offer both advantages (ease of use, reduced rate of intracranial hemorrhage) and disadvantages (cost, absence of reversal agent, less clinical experience) relative to warfarin. We tested the hypothesis that the decision to prescribe a NOAC might be influenced by non-medical factors such as prescriber subspecialty or patient demographics.
Methods:
We performed an IRB-approved search of the Research Patient Data Registry at our major tertiary referral hospital for all Afib patients prescribed warfarin, dabigatran, rivaroxaban or apixaban between January 2013 and June 2014. We encoded data related to prescriber clinic, patient demographics (including home ZIP code as a marker of family income), intracerebral hemorrhage (ICH) and medical comorbidities.
Results:
Of 4,261 individuals with Afib prescribed oral anticoagulants during the specified interval, 3450 (81%) received warfarin, 442 (10.4%) rivaroxaban, 304 (7.1%) dabigatran, and 65 (1.5%) apixaban per their last prescription during the period. In univariate analyses patients prescribed NOACs were younger (71.5 ± 11.4 vs. 76.6 ± 10.5 years, p < 0.001), more likely male (64.4% vs. 35.6%, p < 0.005), had lower CHADS2 scores (2.17 ± 1.43 vs. 2.68 ± 1.40, p<0.001) and resided in areas with higher median income ($86,384 ± 33,410 vs. $80,470 ± 30,390, p<0.001). Race and prior ICH did not differ. Among 2,013 prescriptions from a defined subset of cardiology, primary care and neurology clinics, NOACs were more commonly used by cardiologists (37.1%) than neurologists (18.9%) or primary care providers (17.1%, p<0.001). Multivariable analysis of this subset found that physician specialty, residential area income, age and CHADS2 score but not gender were independently associated with receiving a NOAC.
Conclusions:
Younger, more affluent individuals treated by a cardiologist were likeliest to receive NOACs for prevention of Afib-related stroke. The data suggest that factors other than medical characteristics might influence the decision to use NOACs.
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Affiliation(s)
| | - Alison Ayres
- Neurology, Massachusetts General Hosp, Boston, MA
| | - M. E Gurol
- Neurology, Massachusetts General Hosp, Boston, MA
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Fotiadis P, Schultz A, Hedden T, Martinez-Ramirez S, Reijmer Y, Ayres A, Schwab K, Viswanathan A, Sperling R, Johnson K, Greenberg SM, Gurol ME. Abstract 47: White Matter Atrophy in Cerebral Amyloid Angiopathy. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background/Purpose:
Cerebral Amyloid Angiopathy (CAA) leads to leukoaraiosis, lacunar infarcts and cortical tissue loss. We hypothesized that CAA is also associated with white matter atrophy (WMA).
Methods:
We have compared volumetric multimodal MRIs from 72 prospectively enrolled non-demented patients with probable CAA (per Boston criteria), to 3 other well-studied cohorts: 289 Healthy Controls (HC) from the Harvard Aging Brain (HAB) study, 231 HC and 198 patients with AD from the Alzheimer’s Disease Neuroimaging Initiative (ADNI). Validated FreeSurfer algorithms were used to calculate White Matter Volume (WMV), white matter hyperintensity volume (WMHv), and cortical thickness. Microbleeds (MBs) were counted on SWI-MRI. Measures were obtained from the contralateral hemisphere if intracerebral hemorrhage present. All volumes were corrected for total intracranial volume (ICV), so reported as percent of ICV.
Results:
The CAA patients were significantly younger (mean age: 70.1) compared to both HC cohorts (ADNI-HC: 76.0, p<0.001, HAB-HC: 73.8, p < 0.001), and to patients with AD (75.5, p < 0.001). Despite being younger, patients with CAA presented significantly lower global WMV (28% ± 2.6) than both ADNI-HC (29.2% ± 2.2, p < 0.001), HAB-HC (29.0% ± 2.5, p = 0.001), and patients with AD (28.7% ± 2.2, p = 0.02) [Figure]. The association persisted after correcting for age, gender and WMHv. Within the CAA cohort, there was a negative correlation between WMV and lobar MB counts (rho = -0.26, p = 0.03), it remained significant after correcting for age, gender, WMHv (p=0.016). There were no significant associations however between WMV and neither WMHv, nor cortical thickness (both p>0.2).
Conclusions:
Patients with CAA show WMA when compared to older HC and AD. WMA independently correlates with MBs, a marker of CAA severity. Consistent spatial patterns of atrophy especially in posterior regions when compared to both HC and AD [Figure] might represent the “WMA signature of CAA”.
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Affiliation(s)
| | | | - Trey Hedden
- Radiology, Massachusetts General Hosp, Boston, MA
| | | | - Yael Reijmer
- Neurology, Massachusetts General Hosp, Boston, MA
| | - Alison Ayres
- Neurology, Massachusetts General Hosp, Boston, MA
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Etherton M, Siddiqui KA, Ayres A, Schwamm LH. Abstract WP174: Prestroke Selective Serotonin Reuptake Inhibitor Use and Functional Outcomes in Ischemic Stroke. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.wp174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Selective serotonin reuptake inhibitors (SSRIs) have been implicated in contributing to recovery after acute ischemic stroke. In particular, post stroke initiation of an SSRI has been demonstrated to improve motor recovery. The role of prestroke SSRI use on functional outcomes and stroke recovery is less clear. We aimed to examine the effect of prestroke SSRI use on metrics of hospitalization and functional recovery.
Hypothesis:
Pre-event SSRI therapy improves functional outcome in acute ischemic stroke.
Methods:
We included 4968 consecutive patients from January 2006 to June 2015 in our local Get with the Guidelines-Stroke registry in whom the preadmission admission drug list could be extracted from an administrative research data registry. Univariate and multivariable analyses were performed to identify predictors of functional outcomes.
Results:
Among 4698 ischemic strokes (740 SSRI users and 3948 nonusers) univariate analysis of SSRI use before acute ischemic stroke did not impact admission NIHSS, length of stay or rate of symptomatic hemorrhage (Table 1). Patients using SSRIs prior to their stroke were more likely to present with weakness (57% vs 47.3%, p<0.001) and have hospitalizations complicated by pneumonia (7.6% vs 5.7%, p<0.001). Moreover, pre-stroke SSRI use was associated with a negative impact on ambulatory status at discharge and discharge to home. On multivariable regression analysis, SSRI use was associated with lower likelihood of discharge to home (aOR 0.79, 95%CI 0.62, 0.997; p<0.05).
Conclusions:
SSRI use preceding an acute ischemic stroke is associated with lower rates of discharge to home despite no significant increase in length of stay or NIHSS. Further studies evaluating potential confounding factors, the influence of prior SSRI use on infarct size, and longer term outcomes are warranted.
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Affiliation(s)
| | | | - Alison Ayres
- Neurology, J. Philip Kistler Stroke Rsch Cntr, Boston, MA
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Charidimou A, Ni J, Martinez-Ramirez S, Vashkevich A, Ayres A, Rosand J, Gurol EM, Greenberg SM, Viswanathan A. Cortical Superficial Siderosis in Memory Clinic Patients: Further Evidence for Underlying Cerebral Amyloid Angiopathy. Cerebrovasc Dis 2016; 41:156-62. [PMID: 26751369 DOI: 10.1159/000442299] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 10/30/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Cerebral amyloid angiopathy (CAA) is associated with many cases of spontaneous symptomatic lobar intracerebral haemorrhage in older individuals and is emerging as an important contributor to cognitive impairment. Cortical superficial siderosis (cSS) is an increasingly recognized haemorrhagic neuroimaging manifestation of CAA. We sought to investigate its prevalence and its association with underlying CAA among memory clinic patients. METHODS We included consecutive eligible patients who presented to the out-patient memory clinic at the Massachusetts General Hospital from 2007 to 2010 and had appropriate MRI, including blood-sensitive sequences. We analyzed the prevalence and topography of cSS according to demographic, clinical, APOE and MRI data. RESULTS Our cohort consisted of 339 memory clinic patients: Alzheimer's disease (n = 86); mild cognitive impairment (n = 162); vascular dementia/mixed dementia (n = 18); other dementia/undetermined (n = 42); and subjective cognitive complains (n = 31). cSS was detected in 10 patients (3%; 95% CI 1.4-5.4): in 7 cases cSS was focal and in 3 cases, it was disseminated. In multivariable logistic regression analysis, the presence of cSS was associated with lobar microbleeds (OR 1.08; 95% CI 1.03-1.13; p = 0.001, per each additional microbleed) and severe white matter hyperintensities (Fazekas score 5-6, OR 4.43; 95% CI 1.21-26.28; p = 0.028) after adjusting for age. These associations were not influenced by the clinical diagnosis. In patients with APOE data, the APOE ε4/ε4 genotype was overrepresented among subjects with vs. without cSS. In the subgroup of patients with probable CAA (n = 68; 9 with cSS) based on the presence of strictly lobar microbleeds, cSS was also associated with a higher prevalence of severe white matter hyperintensities (66.7 vs. 10.2%; p = 0.001), high centrum semiovale perivascular spaces burden (88.9 vs. 52.4%; p = 0.041) and higher counts of lobar microbleeds (median 13; IQR 10-36 vs. median 1; IQR 1-2; p < 0.00001), compared to patients without cSS. CONCLUSIONS Our data provide further evidence supporting the hypothesis that cSS is a manifestation of advanced CAA in memory clinic populations. Future longitudinal studies should explore any direct effect of cSS on cognition or haemorrhage risk and disease progression.
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Affiliation(s)
- Andreas Charidimou
- Hemorrhagic Stroke Research Program, Massachusetts General Hospital Stroke Research Center, Boston, Mass., USA
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Charidimou A, Boulouis G, Haley K, Auriel E, van Etten ES, Fotiadis P, Reijmer Y, Ayres A, Vashkevich A, Dipucchio ZY, Schwab KM, Martinez-Ramirez S, Rosand J, Viswanathan A, Greenberg SM, Gurol ME. White matter hyperintensity patterns in cerebral amyloid angiopathy and hypertensive arteriopathy. Neurology 2016; 86:505-11. [PMID: 26747886 DOI: 10.1212/wnl.0000000000002362] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/12/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To identify different white matter hyperintensity (WMH) patterns between 2 hemorrhage-prone cerebral small vessel diseases (SVD): cerebral amyloid angiopathy (CAA) and hypertensive arteriopathy (HA). METHODS Consecutive patients with SVD-related intracerebral hemorrhage (ICH) from a single-center prospective cohort were analyzed. Four predefined subcortical WMH patterns were compared between the CAA and HA groups. These WMH patterns were (1) multiple subcortical spots; (2) peri-basal ganglia (BG); (3) large posterior subcortical patches; and (4) anterior subcortical patches. Their associations with other imaging (cerebral microbleeds [CMBs], enlarged perivascular spaces [EPVS]) and clinical markers of SVD were investigated using multivariable logistic regression. RESULTS The cohort included 319 patients with CAA and 137 patients with HA. Multiple subcortical spots prevalence was higher in the CAA compared to the HA group (29.8% vs 16.8%; p = 0.004). Peri-BG WMH pattern was more common in the HA- vs the CAA-ICH group (19% vs 7.8%; p = 0.001). In multivariable logistic regression, presence of multiple subcortical spots was associated with lobar CMBs (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.01-1.50, p = 0.039) and high degree of centrum semiovale EPVS (OR 2.43; 95% CI 1.56-3.80, p < 0.0001). By contrast, age (OR 1.05; 95% CI 1.02-1.09, p = 0.002), deep CMBs (OR 2.46; 95% CI 1.44-4.20, p = 0.001), total WMH volume (OR 1.02; 95% CI 1.01-1.04, p = 0.002), and high BG EPVS degree (OR 8.81; 95% CI 3.37-23.02, p < 0.0001) were predictors of peri-BG WMH pattern. CONCLUSION Different patterns of subcortical leukoaraiosis visually identified on MRI might provide insights into the dominant underlying microangiopathy type as well as mechanisms of tissue injury in patients with ICH.
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Affiliation(s)
- Andreas Charidimou
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Kellen Haley
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Eitan Auriel
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Ellis S van Etten
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Panagiotis Fotiadis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Yael Reijmer
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Anastasia Vashkevich
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Zora Y Dipucchio
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Kristin M Schwab
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Sergi Martinez-Ramirez
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA
| | - M Edip Gurol
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (A.C., G.B., K.H., E.A., E.S.v.E., P.F., Y.R., A.A., A. Vashkevich, Z.Y.D., K.M.S., S.M.-R., J.R., A. Viswanathan, S.M.G., M.E.G.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA.
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Stock CJ, Carley N, Hickman B, Primrose J, Ayres A, McGrath C, Edwards CJ, Faust SN. Clinician engagement is critical to public engagement with clinical trials. BMJ 2015; 350:h3140. [PMID: 26071322 DOI: 10.1136/bmj.h3140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Christopher J Stock
- University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | | | | | - John Primrose
- University of Southampton Faculty of Medicine, Southampton SO16 6YD
| | - Alison Ayres
- University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Christine McGrath
- University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | | | - Saul N Faust
- Southampton NIHR Wellcome Trust Clinical Research Facility, Southampton SO16 6YD
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Ni J, Auriel E, Jindal J, Ayres A, Schwab KM, Martinez-Ramirez S, Gurol EM, Greenberg SM, Viswanathan A. The characteristics of superficial siderosis and convexity subarachnoid hemorrhage and clinical relevance in suspected cerebral amyloid angiopathy. Cerebrovasc Dis 2015; 39:278-86. [PMID: 25871492 DOI: 10.1159/000381223] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 02/18/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND AIMS Systematic studies of superficial siderosis (SS) and convexity subarachnoid hemorrhage (cSAH) in patients with suspected cerebral amyloid angiopathy (CAA) without lobar intracerebral hemorrhage (ICH) are lacking. We sought to determine the potential anatomic correlation between SS/cSAH and transient focal neurological episodes (TFNE) and whether SS/cSAH is predictor of future cerebral hemorrhagic events in these patients. METHODS We enrolled 90 consecutive patients with suspected CAA (due to the presence of strictly lobar microbleeds (CMBs) and/or SS/cSAH) but without the history of symptomatic lobar ICH who underwent brain MRI including T2*-weighted, diffusion-weighted imaging and fluid-attenuated inversion recovery sequences from an ongoing single center CAA cohort from 1998 to 2012. Evaluation of SS, cSAH and CMBs was performed. Medical records and follow-up information were obtained from prospective databases and medical charts. TFNE was defined according to published criteria and electroencephalogram reports were reviewed. RESULTS Forty-one patients (46%) presented with SS and/or cSAH. The prevalence of TFNE was significantly higher in those with SS/cSAH (61 vs. 10%; p < 0.001) and anatomically correlated with the location of cSAH, but not SS. The majority of TFNE in patients with SS/cSAH presented with spreading sensory symptoms. Intermittent focal slowing on electroencephalogram was present in the same area as SS/cSAH in 6 patients, but no epileptiform activity was found in any patients. Among those with available clinical follow-up (76/90 patients, 84%), ten patients with SS/cSAH (29%, median time from the scan for all patients with SS/cSAH: 21 months) had a symptomatic cerebral bleeding event on follow up (average time to events: 34 months) compared with only 1 event (2.4%, 25 months from the scan) in patients without SS/cSAH (time to event: 25 months) (p = 0.001). The location of hemorrhages on follow-up scan was not in the same location of previously noted SS/cSAH in 9 of 10 patients. Follow-up imaging was obtained in 9 of 17 patients with cSAH and showed evidence of SS in the same location as initial cSAH in all these 9 cases. CONCLUSIONS SS/cSAH is common in patients with suspected CAA without lobar intracerebral hemorrhage and may have a significantly higher risk of future cerebral bleeding events, regardless of the severity of the baseline CMB burden. The findings further highlight a precise anatomical correlation between TFNE and cSAH, but not SS. Distinct from transient ischemic attack or seizure, the majority of TFNE caused by SS/cSAH appear to present with spreading sensory symptoms.
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Affiliation(s)
- Jun Ni
- The Department of Neurology, Peking Union Medical College Hospital, Peking, China
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Charidimou A, Martinez-Ramirez S, Shoamanesh A, Oliveira-Filho J, Frosch M, Vashkevich A, Ayres A, Rosand J, Gurol ME, Greenberg SM, Viswanathan A. Cerebral amyloid angiopathy with and without hemorrhage: evidence for different disease phenotypes. Neurology 2015; 84:1206-12. [PMID: 25716356 DOI: 10.1212/wnl.0000000000001398] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To gain insight into different cerebral amyloid angiopathy (CAA) phenotypes and mechanisms, we investigated cortical superficial siderosis (CSS), a new imaging marker of the disease, and its relation with APOE genotype in patients with pathologically proven CAA, who presented with and without intracerebral hemorrhage (ICH). METHODS MRI scans of 105 patients with CAA pathologic confirmation and MRI were analyzed for CSS (focal, ≤3 sulci; disseminates, ≥4 sulci) and other imaging markers. We compared pathologic, imaging, and APOE genotype data between subjects with vs without ICH, and investigated associations between CSS and APOE genotype. RESULTS Our cohort consisted of 54 patients with CAA with symptomatic lobar ICH and 51 without ICH. APOE genotype was available in 53 patients. More than 90% of pathology samples in both groups had neuritic plaques, whereas neurofibrillary tangles were more commonly present in the patients without ICH (87% vs 42%, p < 0.0001). There was a trend for patients with CAA with ICH to more commonly have APOE ε2 (48.7% vs 21.4%, p = 0.075), whereas patients without ICH were more likely to be APOE ε4 carriers (85.7% vs 53.9%, p = 0.035). Disseminated CSS was considerably commoner in patients with ICH (33.3% vs 5.9%, p < 0.0001). In logistic regression, disseminated CSS was associated with APOE ε2 (but not APOE ε4) (odds ratio 5.83; 95% confidence interval 1.49-22.82, p = 0.011). CONCLUSIONS This neuropathologically defined CAA cohort suggests that CSS and APOE ε2 are related to the hemorrhagic expression of the disease; APOE ε4 is enriched in nonhemorrhagic CAA. Our study emphasizes the concept of different CAA phenotypes, suggesting divergent pathophysiologic mechanisms.
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Affiliation(s)
- Andreas Charidimou
- From the Department of Brain Repair and Rehabilitation (A.C.), UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK; and the Hemorrhagic Stroke Research Program, Stroke Research Center, Department of Neurology (A.C., S.M.-R., A.S., J.O.-F., A. Vashkevich, A.A., J.R., M.E.G., S.M.G., A. Viswanathan), C.S. Kubik Laboratory for Neuropathology (M.F.), Division of Neurocritical Care and Emergency Neurology (J.R.), and Center for Human Genetic Research (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston.
| | - Sergi Martinez-Ramirez
- From the Department of Brain Repair and Rehabilitation (A.C.), UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK; and the Hemorrhagic Stroke Research Program, Stroke Research Center, Department of Neurology (A.C., S.M.-R., A.S., J.O.-F., A. Vashkevich, A.A., J.R., M.E.G., S.M.G., A. Viswanathan), C.S. Kubik Laboratory for Neuropathology (M.F.), Division of Neurocritical Care and Emergency Neurology (J.R.), and Center for Human Genetic Research (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ashkan Shoamanesh
- From the Department of Brain Repair and Rehabilitation (A.C.), UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK; and the Hemorrhagic Stroke Research Program, Stroke Research Center, Department of Neurology (A.C., S.M.-R., A.S., J.O.-F., A. Vashkevich, A.A., J.R., M.E.G., S.M.G., A. Viswanathan), C.S. Kubik Laboratory for Neuropathology (M.F.), Division of Neurocritical Care and Emergency Neurology (J.R.), and Center for Human Genetic Research (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jamary Oliveira-Filho
- From the Department of Brain Repair and Rehabilitation (A.C.), UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK; and the Hemorrhagic Stroke Research Program, Stroke Research Center, Department of Neurology (A.C., S.M.-R., A.S., J.O.-F., A. Vashkevich, A.A., J.R., M.E.G., S.M.G., A. Viswanathan), C.S. Kubik Laboratory for Neuropathology (M.F.), Division of Neurocritical Care and Emergency Neurology (J.R.), and Center for Human Genetic Research (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Matthew Frosch
- From the Department of Brain Repair and Rehabilitation (A.C.), UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK; and the Hemorrhagic Stroke Research Program, Stroke Research Center, Department of Neurology (A.C., S.M.-R., A.S., J.O.-F., A. Vashkevich, A.A., J.R., M.E.G., S.M.G., A. Viswanathan), C.S. Kubik Laboratory for Neuropathology (M.F.), Division of Neurocritical Care and Emergency Neurology (J.R.), and Center for Human Genetic Research (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- From the Department of Brain Repair and Rehabilitation (A.C.), UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK; and the Hemorrhagic Stroke Research Program, Stroke Research Center, Department of Neurology (A.C., S.M.-R., A.S., J.O.-F., A. Vashkevich, A.A., J.R., M.E.G., S.M.G., A. Viswanathan), C.S. Kubik Laboratory for Neuropathology (M.F.), Division of Neurocritical Care and Emergency Neurology (J.R.), and Center for Human Genetic Research (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Alison Ayres
- From the Department of Brain Repair and Rehabilitation (A.C.), UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK; and the Hemorrhagic Stroke Research Program, Stroke Research Center, Department of Neurology (A.C., S.M.-R., A.S., J.O.-F., A. Vashkevich, A.A., J.R., M.E.G., S.M.G., A. Viswanathan), C.S. Kubik Laboratory for Neuropathology (M.F.), Division of Neurocritical Care and Emergency Neurology (J.R.), and Center for Human Genetic Research (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Rosand
- From the Department of Brain Repair and Rehabilitation (A.C.), UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK; and the Hemorrhagic Stroke Research Program, Stroke Research Center, Department of Neurology (A.C., S.M.-R., A.S., J.O.-F., A. Vashkevich, A.A., J.R., M.E.G., S.M.G., A. Viswanathan), C.S. Kubik Laboratory for Neuropathology (M.F.), Division of Neurocritical Care and Emergency Neurology (J.R.), and Center for Human Genetic Research (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Mahmut Edip Gurol
- From the Department of Brain Repair and Rehabilitation (A.C.), UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK; and the Hemorrhagic Stroke Research Program, Stroke Research Center, Department of Neurology (A.C., S.M.-R., A.S., J.O.-F., A. Vashkevich, A.A., J.R., M.E.G., S.M.G., A. Viswanathan), C.S. Kubik Laboratory for Neuropathology (M.F.), Division of Neurocritical Care and Emergency Neurology (J.R.), and Center for Human Genetic Research (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Steven M Greenberg
- From the Department of Brain Repair and Rehabilitation (A.C.), UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK; and the Hemorrhagic Stroke Research Program, Stroke Research Center, Department of Neurology (A.C., S.M.-R., A.S., J.O.-F., A. Vashkevich, A.A., J.R., M.E.G., S.M.G., A. Viswanathan), C.S. Kubik Laboratory for Neuropathology (M.F.), Division of Neurocritical Care and Emergency Neurology (J.R.), and Center for Human Genetic Research (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anand Viswanathan
- From the Department of Brain Repair and Rehabilitation (A.C.), UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK; and the Hemorrhagic Stroke Research Program, Stroke Research Center, Department of Neurology (A.C., S.M.-R., A.S., J.O.-F., A. Vashkevich, A.A., J.R., M.E.G., S.M.G., A. Viswanathan), C.S. Kubik Laboratory for Neuropathology (M.F.), Division of Neurocritical Care and Emergency Neurology (J.R.), and Center for Human Genetic Research (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
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Singhal AB, Schwamm LH, PN S, Khurana D, Kaul S, Padma MV, Arora D, Thankachan T, Ayres A, Mills B, Kaur P, Pandian JD. Abstract W P202: Comparison of Stroke in India versus USA: The Indo-US Stroke Project. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.wp202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
There is little knowledge about differences in ischemic stroke risk factors, mechanisms, and outcomes between geographically diverse countries such as India and USA.
METHODS:
The Indo-US Stroke Registry/Infrastructure Development Project, jointly funded by NINDS and Indian Dept of Biotechnology, has 5 Indian centers (AIIMS Delhi; PGI Chandigarh; CMC Ludhiana; Nizam’s Hyderabad; SCTMS Kerala) and one in Boston, USA. Trained MDs and research coordinators prospectively collect data on consecutive adult patients with imaging-confirmed ischemic stroke <2wks after onset. Data is entered into a central web-based electronic database. We compared stroke demographics, risk factors, mechanisms, and outcome between the 5 Indian centers (1944 patients, Nov-2012 to July-2014) and the US center (2167 patients, Jan-2007 to Mar-2011).
RESULTS:
As compared to patients in India, patients in Boston, USA were older (69±15y vs 58.5±15y, p<0.001); more women (47% vs. 33%, p<0.001), and had lower admission NIHSS scores (median, IQR: 4 (2-12) v. 10 (5-15); p<001). Risk factors and stroke mechanisms, showed impressive differences (Table). The Indian patients had higher in-hospital complications (pneumonia, 13% vs. 6%, p<0.001; UTI, 10% vs. 8.5%, p=0.1), and worse 90-day outcomes (mRS score 0-3, 50% vs. 57%, p=0.001).
CONCLUSION:
These data provide insights into the differences in stroke between India and USA. Our results have implications concerning the limited generalizability of the results of stroke prevention trials, and suggest opportunities to reduce stroke burden in both countries.
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Affiliation(s)
| | | | - Sylaja PN
- Sree Chitra Thirunal Institute, Kerala, India
| | - Dheeraj Khurana
- Postgraduate Institute of Med Education & Rsch, Chandigarh, India
| | - Subhash Kaul
- Nizam’s Institute of Med Sciences, Hyderabad, India
| | - MV Padma
- All-India Institute of Med Sciences, New Delhi, India
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Olm-Shipman C, Marquevich V, Rosand J, Patel A, Eskandar E, Cordier A, Ayres A, Schwamm LH, Singhal AB. Abstract W P299: Impact of an Institutional Guideline on Implementing Early Decompressive Hemicraniectomy (DHC) for Large Middle Cerebral Artery Stroke. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.wp299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Recent AHA Acute Stroke Guidelines endorse DHC (Class 1, Level B) based on clinical trials showing benefit of early DHC on outcome and mortality. In 2011, our multidisciplinary quality improvement team developed a process to translate DHC guideline recommendations into clinical practice.
Methods:
Our consensus guideline includes a tool (STATE Criteria, based on inclusion/exclusion criteria of DHC clinical trials) to rapidly identify and triage potential DHC candidates, and provide specific guidelines for pre- and post-surgical management, adjunctive therapy, and DHC after IV/IA thrombolysis. Patients meeting all STATE Criteria including age ≤ 60 years are sent for urgent DHC. Patients meeting all criteria except age ≤ 60 years receive DHC only if age < 75 years and Neurology and Neurosurgery teams reach consensus about benefit. Patients not meeting criteria are observed and referred for DHC if criteria are met within 48 hours of onset. The guideline was disseminated to all stakeholders via email, conferences, and intranet. In this study, we retrospectively analyzed process and outcome measures for DHC before and after guideline implementation in February 2011.
Results:
Of 1518 stroke patients age ≤ 60 years admitted between January 2007 and April 2014, 47 (3%) received DHC (22 pre- and 25 post-guideline implementation; 28% female, 13% Hispanic). Mean admission NIHSS was similar (17±7 vs 18±5; p=.82). Mean time from admission to DHC improved significantly from 45±30 hours to 29±18 hours (p=0.04). The percentage of patients undergoing DHC beyond 48 hours decreased from 27% to 16% (p=0 .35). The degree of midline shift evident on CT or MRI prior to DHC significantly decreased from 9±4 mm to 5±4 mm (p=.01). There was no significant difference in length of stay, frequency of tracheostomy, gastrostomy, pneumonia, or urinary tract infection, or percentage of patients who died within 30 days of DHC.
Conclusion:
Our institutional guideline has facilitated the rapid identification and triage of patients with large MCA stroke to DHC. Follow-up is ongoing to determine the impact of our guideline on functional outcome after stroke.
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Urday S, Beslow LA, Goldstein D, Dai F, Zhang F, Vashkevich A, Ayres A, Battey TW, Simard MJ, Rosand J, Kimberly TW, Sheth KN. Abstract T MP65: Rate of Peri-Hematomal Edema Expansion Predicts Outcome After Intracerebral Hemorrhage. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.tmp65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
There have been conflicting reports regarding the association between peri-hematomal edema (PHE) in spontaneous intracerebral hemorrhage (ICH) and outcome. We hypothesized that PHE expansion rate from baseline to 24 hours predicts mortality and poor functional outcome after ICH.
Methods:
ICH, PHE and intraventricular hemorrhage volumes were measured for 139 subjects who presented with primary ICH and received head computed tomography scans at baseline and 24-hours post-ICH. Subjects were retrospectively identified from a prospective cohort study of ICH. Inclusion criteria were age over 18 years with primary spontaneous supratentorial ICH. Exclusion criteria were infratentorial hemorrhage, primary intraventricular hemorrhage, or any suspected cause of secondary ICH. Logistic regression was performed to evaluate the relationship between PHE expansion rate and 90-day mortality and functional outcome. Poor functional outcome was defined as a modified Rankin Scale (mRS) score > 2.
Results:
There was a strong association between PHE expansion rate and mortality (OR 1.42, p = 0.0025) and a trend in the correlation between PHE expansion rate and poor outcome (OR 1.50, p = 0.07). In a multivariable model accounting for hematoma volume and time from symptom onset to 24 hour scan, PHE expansion rate was a significant predictor of mortality (OR 1.07, p = 0.032). In a multivariable model accounting for hematoma volume, age, Glasgow Coma Scale score, presence of intraventricular hemorrhage and time from symptom onset to 24 hour scan, PHE expansion rate predicted poor functional outcome (OR 2.58, p = 0.05).
Conclusions:
PHE expansion rate predicts outcome in ICH and may represent a novel therapeutic target.
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Affiliation(s)
| | | | | | - Feng Dai
- Neurology, Yale Sch of Medicine, New Haven, CT
| | - Fan Zhang
- Neurology, Yale Sch of Medicine, New Haven, CT
| | - Anastasia Vashkevich
- Cntr for Human Genetic Rsch and Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Alison Ayres
- Cntr for Human Genetic Rsch and Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Thomas W Battey
- Cntr for Human Genetic Rsch and Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Marc J Simard
- Depts of Neurosurgery, Pathology and Physiology, Univ of Maryland Sch of Medicine, Baltimore, MD
| | - Jonathan Rosand
- Cntr for Human Genetic Rsch and Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Taylor W Kimberly
- Cntr for Human Genetic Rsch and Div of Neurocritical Care and Emergency Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
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