1
|
Palsson F, Forkert ND, Meyer L, Broocks G, Flottmann F, Maros ME, Bechstein M, Winkelmeier L, Schlemm E, Fiehler J, Gellißen S, Kniep HC. Prediction of tissue outcome in acute ischemic stroke based on single-phase CT angiography at admission. Front Neurol 2024; 15:1330497. [PMID: 38566856 PMCID: PMC10985353 DOI: 10.3389/fneur.2024.1330497] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction In acute ischemic stroke, prediction of the tissue outcome after reperfusion can be used to identify patients that might benefit from mechanical thrombectomy (MT). The aim of this work was to develop a deep learning model that can predict the follow-up infarct location and extent exclusively based on acute single-phase computed tomography angiography (CTA) datasets. In comparison to CT perfusion (CTP), CTA imaging is more widely available, less prone to artifacts, and the established standard of care in acute stroke imaging protocols. Furthermore, recent RCTs have shown that also patients with large established infarctions benefit from MT, which might not have been selected for MT based on CTP core/penumbra mismatch analysis. Methods All patients with acute large vessel occlusion of the anterior circulation treated at our institution between 12/2015 and 12/2020 were screened (N = 404) and 238 patients undergoing MT with successful reperfusion were included for final analysis. Ground truth infarct lesions were segmented on 24 h follow-up CT scans. Pre-processed CTA images were used as input for a U-Net-based convolutional neural network trained for lesion prediction, enhanced with a spatial and channel-wise squeeze-and-excitation block. Post-processing was applied to remove small predicted lesion components. The model was evaluated using a 5-fold cross-validation and a separate test set with Dice similarity coefficient (DSC) as the primary metric and average volume error as the secondary metric. Results The mean ± standard deviation test set DSC over all folds after post-processing was 0.35 ± 0.2 and the mean test set average volume error was 11.5 mL. The performance was relatively uniform across models with the best model according to the DSC achieved a score of 0.37 ± 0.2 after post-processing and the best model in terms of average volume error yielded 3.9 mL. Conclusion 24 h follow-up infarct prediction using acute CTA imaging exclusively is feasible with DSC measures comparable to results of CTP-based algorithms reported in other studies. The proposed method might pave the way to a wider acceptance, feasibility, and applicability of follow-up infarct prediction based on artificial intelligence.
Collapse
Affiliation(s)
- Frosti Palsson
- deCODE Genetics Inc., Reykjavik, Iceland
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils D. Forkert
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Máté E. Maros
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge C. Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
2
|
Poli S, Mbroh J, Baron JC, Singhal AB, Strbian D, Molina C, Lemmens R, Turc G, Mikulik R, Michel P, Tatlisumak T, Audebert HJ, Dichgans M, Veltkamp R, Hüsing J, Graessner H, Fiehler J, Montaner J, Adeyemi AK, Althaus K, Arenillas JF, Bender B, Benedikt F, Broocks G, Burghaus I, Cardona P, Deb-Chatterji M, Cviková M, Defreyne L, De Herdt V, Detante O, Ernemann U, Flottmann F, García Guillamón L, Glauch M, Gomez-Exposito A, Gory B, Sylvie Grand S, Haršány M, Hauser TK, Heck O, Hemelsoet D, Hennersdorf F, Hoppe J, Kalmbach P, Kellert L, Köhrmann M, Kowarik M, Lara-Rodríguez B, Legris L, Lindig T, Luntz S, Lusk J, Mac Grory B, Manger A, Martinez-Majander N, Mengel A, Meyne J, Müller S, Mundiyanapurath S, Naggara O, Nedeltchev K, Nguyen TN, Nilsson MA, Obadia M, Poli K, Purrucker JC, Räty S, Richard S, Richter H, Schilte C, Schlemm E, Stöhr L, Stolte B, Sykora M, Thomalla G, Tomppo L, van Horn N, Zeller J, Ziemann U, Zuern CS, Härtig F, Tuennerhoff J. Penumbral Rescue by normobaric O = O administration in patients with ischemic stroke and target mismatch proFile (PROOF): Study protocol of a phase IIb trial. Int J Stroke 2024; 19:120-126. [PMID: 37515459 PMCID: PMC10759237 DOI: 10.1177/17474930231185275] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/12/2023] [Indexed: 07/30/2023]
Abstract
RATIONALE Oxygen is essential for cellular energy metabolism. Neurons are particularly vulnerable to hypoxia. Increasing oxygen supply shortly after stroke onset could preserve the ischemic penumbra until revascularization occurs. AIMS PROOF investigates the use of normobaric oxygen (NBO) therapy within 6 h of symptom onset/notice for brain-protective bridging until endovascular revascularization of acute intracranial anterior-circulation occlusion. METHODS AND DESIGN Randomized (1:1), standard treatment-controlled, open-label, blinded endpoint, multicenter adaptive phase IIb trial. STUDY OUTCOMES Primary outcome is ischemic core growth (mL) from baseline to 24 h (intention-to-treat analysis). Secondary efficacy outcomes include change in NIHSS from baseline to 24 h, mRS at 90 days, cognitive and emotional function, and quality of life. Safety outcomes include mortality, intracranial hemorrhage, and respiratory failure. Exploratory analyses of imaging and blood biomarkers will be conducted. SAMPLE SIZE Using an adaptive design with interim analysis at 80 patients per arm, up to 456 participants (228 per arm) would be needed for 80% power (one-sided alpha 0.05) to detect a mean reduction of ischemic core growth by 6.68 mL, assuming 21.4 mL standard deviation. DISCUSSION By enrolling endovascular thrombectomy candidates in an early time window, the trial replicates insights from preclinical studies in which NBO showed beneficial effects, namely early initiation of near 100% inspired oxygen during short temporary ischemia. Primary outcome assessment at 24 h on follow-up imaging reduces variability due to withdrawal of care and early clinical confounders such as delayed extubation and aspiration pneumonia. TRIAL REGISTRATIONS ClinicalTrials.gov: NCT03500939; EudraCT: 2017-001355-31.
Collapse
Affiliation(s)
- Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | - Joshua Mbroh
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Jean-Claude Baron
- Department of Neurology, Hopital Sainte-Anne, Universite de Paris, Paris, France
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Carlos Molina
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven, University of Leuven, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Guillaume Turc
- Department of Neurology, Hopital Sainte-Anne, Universite de Paris, Paris, France
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences INSERM U1266 Universite Paris Cite FHU NeuroVasc, Paris, France
| | - Robert Mikulik
- Department of Neurology, St. Anne’s University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Patrik Michel
- Neurosciences Cliniques, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Heinrich J Audebert
- Department of Neurology and Center for Stroke Research Berlin, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE, Munich), Munich, Germany
- German Centre for Cardiovascular Research (DZHK, Munich), Munich, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, UK
| | - Johannes Hüsing
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
- Landeskrebsregister Nordrhein-Westfalen, Bochum, Germany
| | - Holm Graessner
- Center for Rare Diseases, Eberhard-Karls University, Tubingen, Germany
| | - Jens Fiehler
- Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Eppdata GmbH, Hamburg, Germany
| | - Joan Montaner
- Vall d’Hebron Institut de Recerca, Neurovascular Research Lab, Barcelona, Spain
| | | | | | | | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Frank Benedikt
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ina Burghaus
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
| | - Pere Cardona
- Department of Neurology, Hospital University de Bellvitge, Barcelona, Spain
| | - Milani Deb-Chatterji
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Cviková
- Department of Neurology, St. Anne’s University Hospital in Brno, Faculty of Medicine Masaryk University, Brno, Czech Republic
| | - Luc Defreyne
- Department of Vascular and Interventional Radiology, Ghent University Hospital, Ghent, Belgium
| | - Veerle De Herdt
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Olivier Detante
- Neurology, CHU Grenoble Alpes, Grenoble, France
- Inserm, U1216, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Ulrike Ernemann
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Monika Glauch
- Center for Rare Diseases, Eberhard-Karls University, Tubingen, Germany
| | - Alexandra Gomez-Exposito
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospital Regional Universitaire de Nancy, Universite de Lorraine, INSERM U1254, Nancy, France
| | - Sylvie Sylvie Grand
- Inserm, U1216, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
- Neuroradiology / MRI Department, CHU Grenoble Alpes, Grenoble, France
| | - Michal Haršány
- Department of Neurology, St. Anne’s University Hospital in Brno, Faculty of Medicine Masaryk University, Brno, Czech Republic
- International Clinical Research Centre, St. Anne’s University Hospital in Brno, Brno, Czech Republic
| | - Till Karsten Hauser
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Olivier Heck
- Neuroradiology / MRI Department, CHU Grenoble Alpes, Grenoble, France
| | | | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Julia Hoppe
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pia Kalmbach
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University (LMU), Munich, Germany
| | - Martin Köhrmann
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Markus Kowarik
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | | | - Loic Legris
- Neurology, CHU Grenoble Alpes, Grenoble, France
- Inserm, U1216, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Tobias Lindig
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Steffen Luntz
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
| | - Jay Lusk
- Duke University School of Medicine, Durham, NC, USA
| | - Brian Mac Grory
- Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Andreas Manger
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tubingen, Germany
| | | | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Johannes Meyne
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Susanne Müller
- Department of Neurology, University Hospital of Ulm, Ulm, Germany
| | | | - Olivier Naggara
- Department of Neuroradiology, GHU Paris Psychiatrie et Neurosciences INSERM U1266 Universite Paris Cite FHU NeuroVasc, Paris, France
| | - Krassen Nedeltchev
- Department of Neurology, KSA Kantonsspital Aarau and University of Bern, Bern, Switzerland
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Maike A Nilsson
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
| | - Michael Obadia
- Department of Neurology and Stroke Center, Hopital fondation Adolphe de Rothschild, Paris, France
| | - Khouloud Poli
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Hardy Richter
- Department of Infectiology, Eberhard-Karls-University, Tuebingen, Germany
| | - Clotilde Schilte
- Department of Anaesthesia and Critical Care, CHU Grenoble Alpes, Grenoble, France
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Stöhr
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
| | - Benjamin Stolte
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Marek Sykora
- Department of Neurology, St. John’s Hospital, Vienna, Austria
| | - Götz Thomalla
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Liisa Tomppo
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Noel van Horn
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Zeller
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | - Christine S Zuern
- Department of Cardiology, Universitatsspital Basel, Basel, Switzerland
| | - Florian Härtig
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tubingen, Germany
| | - Johannes Tuennerhoff
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| |
Collapse
|
3
|
Bendszus M, Fiehler J, Subtil F, Bonekamp S, Aamodt AH, Fuentes B, Gizewski ER, Hill MD, Krajina A, Pierot L, Simonsen CZ, Zeleňák K, Blauenfeldt RA, Cheng B, Denis A, Deutschmann H, Dorn F, Flottmann F, Gellißen S, Gerber JC, Goyal M, Haring J, Herweh C, Hopf-Jensen S, Hua VT, Jensen M, Kastrup A, Keil CF, Klepanec A, Kurča E, Mikkelsen R, Möhlenbruch M, Müller-Hülsbeck S, Münnich N, Pagano P, Papanagiotou P, Petzold GC, Pham M, Puetz V, Raupach J, Reimann G, Ringleb PA, Schell M, Schlemm E, Schönenberger S, Tennøe B, Ulfert C, Vališ K, Vítková E, Vollherbst DF, Wick W, Thomalla G. Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial. Lancet 2023; 402:1753-1763. [PMID: 37837989 DOI: 10.1016/s0140-6736(23)02032-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Recent evidence suggests a beneficial effect of endovascular thrombectomy in acute ischaemic stroke with large infarct; however, previous trials have relied on multimodal brain imaging, whereas non-contrast CT is mostly used in clinical practice. METHODS In a prospective multicentre, open-label, randomised trial, patients with acute ischaemic stroke due to large vessel occlusion in the anterior circulation and a large established infarct indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) of 3-5 were randomly assigned using a central, web-based system (using a 1:1 ratio) to receive either endovascular thrombectomy with medical treatment or medical treatment (ie, standard of care) alone up to 12 h from stroke onset. The study was conducted in 40 hospitals in Europe and one site in Canada. The primary outcome was functional outcome across the entire range of the modified Rankin Scale at 90 days, assessed by investigators masked to treatment assignment. The primary analysis was done in the intention-to-treat population. Safety endpoints included mortality and rates of symptomatic intracranial haemorrhage and were analysed in the safety population, which included all patients based on the treatment they received. This trial is registered with ClinicalTrials.gov, NCT03094715. FINDINGS From July 17, 2018, to Feb 21, 2023, 253 patients were randomly assigned, with 125 patients assigned to endovascular thrombectomy and 128 to medical treatment alone. The trial was stopped early for efficacy after the first pre-planned interim analysis. At 90 days, endovascular thrombectomy was associated with a shift in the distribution of scores on the modified Rankin Scale towards better outcome (adjusted common OR 2·58 [95% CI 1·60-4·15]; p=0·0001) and with lower mortality (hazard ratio 0·67 [95% CI 0·46-0·98]; p=0·038). Symptomatic intracranial haemorrhage occurred in seven (6%) patients with thrombectomy and in six (5%) with medical treatment alone. INTERPRETATION Endovascular thrombectomy was associated with improved functional outcome and lower mortality in patients with acute ischaemic stroke from large vessel occlusion with established large infarct in a setting using non-contrast CT as the predominant imaging modality for patient selection. FUNDING EU Horizon 2020.
Collapse
Affiliation(s)
- Martin Bendszus
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Jens Fiehler
- Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany; eppdata GmbH, Hamburg, Germany
| | - Fabien Subtil
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Laboratoire de Biométrie et Biologie Évolutive, Université de Lyon, Villeurbanne, France
| | - Susanne Bonekamp
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | - Blanca Fuentes
- Department of Neurology and Stroke Center, Hospital La Paz Institute for Health Research-La Paz University Hospital-Universidad Autonoma de Madrid, Madrid, Spain
| | - Elke R Gizewski
- Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Health Science Centre, University of Calgary & Foothills Medical Centre, Calgary, AB, Canada
| | - Antonin Krajina
- Department of Radiology, Faculty of Medicine in Hradec Kralove, Charles University, Czech Republic
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | | | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Angélique Denis
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Laboratoire de Biométrie et Biologie Évolutive, Université de Lyon, Villeurbanne, France
| | - Hannes Deutschmann
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University Graz, Graz, Austria
| | - Franziska Dorn
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Fabian Flottmann
- Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes C Gerber
- Institute of Neuroradiology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany; Dresden Neurovascular Center, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Mayank Goyal
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Health Science Centre, University of Calgary & Foothills Medical Centre, Calgary, AB, Canada
| | - Jozef Haring
- Department of Neurology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Christian Herweh
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Silke Hopf-Jensen
- Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, DIAKO Krankenhaus gGmbH, Flensburg, Germany
| | - Vi Tuan Hua
- Department of Neurology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Kastrup
- Klinik für Neurologie, Klinikum Bremen Mitte, Bremen, Germany
| | - Christiane Fee Keil
- Institut für Neuroradiologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Andrej Klepanec
- Department of Radiology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Egon Kurča
- Clinic of Neurology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | - Ronni Mikkelsen
- Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Stefan Müller-Hülsbeck
- Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, DIAKO Krankenhaus gGmbH, Flensburg, Germany
| | - Nico Münnich
- Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Dortmund, Germany
| | - Paolo Pagano
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Panagiotis Papanagiotou
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Klinikum Bremen Mitte, Bremen, Germany; Department of Radiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gabor C Petzold
- Vascular Neurology Research Group, German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany; Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Mirko Pham
- Institut für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Volker Puetz
- Department of Neurology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany; Dresden Neurovascular Center, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Jan Raupach
- Department of Radiology, Faculty of Medicine in Hradec Kralove, Charles University, Czech Republic
| | - Gernot Reimann
- Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Dortmund, Germany
| | | | - Maximilian Schell
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Bjørn Tennøe
- Department of Neuroradiology, Oslo University Hospital, Oslo, Norway
| | - Christian Ulfert
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Kateřina Vališ
- St Anne's University Hospital Brno, Brno, Czech Republic
| | - Eva Vítková
- Department of Neurology, Faculty of Medicine in Hradec Kralove, Charles University, Czech Republic
| | | | - Wolfgang Wick
- Neurologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
| |
Collapse
|
4
|
Schlemm E, Cheng B, Thomalla G, Kessner SS. Functional Lesion Network Mapping of Sensory Deficits After Ischemic Stroke. Stroke 2023; 54:2918-2922. [PMID: 37795591 DOI: 10.1161/strokeaha.123.044470] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/05/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Sensory deficits are common after stroke, leading to disability and poor quality of life. Although lesion locations and patterns of structural brain network disruption have been associated with sensory disturbances, the relation with functional lesion connectivity has not yet been established. METHODS Retrospective analysis of a prospective cohort study of patients with acute ischemic stroke. Indirect functional lesion network mapping to identify brain regions remote from the primary lesion associated with deficits on the Rivermead Assessment of Somatosensory Performance test. Associations between Rivermead Assessment of Somatosensory Performance scores and functional connectivity of the lesion site with prespecified components of the somatosensory system. RESULTS One hundred one patients (mean age, 62 years; 32% women) from the TOPOS study (Topological and Clinical Prospective Study About Somatosensation in Stroke). Lesion network mapping identified a bilateral fronto-parietal network associated with sensory deficits in the acute phase after stroke. There were graded associations between deficits and functional lesion connectivity to sensory cortices, but not the thalamus. CONCLUSIONS Infarcts in brain regions remote from, but functionally connected, to the somatosensory network are associated with somatosensory deficits measured by the Rivermead Assessment of Somatosensory Performance test, reflecting the hierarchical functional anatomy of sensory processing. Further research is needed to translate these findings into improved prognosis and personalized rehabilitation strategies.
Collapse
Affiliation(s)
- Eckhard Schlemm
- Department of Neurology (E.S., B.C., G.T., S.S.K.), University Medical Center Hamburg-Eppendorf, Germany
| | - Bastian Cheng
- Department of Neurology (E.S., B.C., G.T., S.S.K.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- Department of Neurology (E.S., B.C., G.T., S.S.K.), University Medical Center Hamburg-Eppendorf, Germany
| | - Simon S Kessner
- Department of Neurology (E.S., B.C., G.T., S.S.K.), University Medical Center Hamburg-Eppendorf, Germany
- Department of Psychosomatic Medicine and Psychotherapy (S.S.K.), University Medical Center Hamburg-Eppendorf, Germany
| |
Collapse
|
5
|
Broocks G, Meyer L, Bechstein M, Hanning U, Kniep HC, Schlemm E, Kyselyova AA, Winkelmeier L, Schön G, Fiehler J, Kemmling A. Investigating Neurologic Improvement After IV Thrombolysis: The Effect of Time From Stroke Onset vs Imaging-Based Tissue Clock. Neurology 2023; 101:e1678-e1686. [PMID: 37657940 PMCID: PMC10624495 DOI: 10.1212/wnl.0000000000207714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/12/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Time from stroke onset is associated with clinical response to intravenous thrombolysis (IVT) with alteplase and is therefore used to select patients for treatment. Alternatively, neuroimaging may be used for treatment in the uncertain or extended time window. We hypothesized that the patient-specific imaging indicator of ischemic lesion progression ("tissue clock") using CT perfusion (CTP) or quantitative net water uptake (NWU) is a predictor of early neurologic improvement (ENI) independent of time. METHODS Observational study of anterior circulation ischemic stroke patients with proximal vessel occlusion and known time from symptom onset triaged by multimodal CT undergoing endovascular treatment. Quantitative NWU using an established threshold (11.5%) or CTP lesion core mismatch (EXTEND criteria) was used to estimate ischemic lesion progression. The treatment effect of IVT depending on lesion progression defined by tissue clock vs time clock was assessed by inverse probability weighting (IPW). End points were binarized ENI and functional independence at day 90. RESULTS Four hundred nine patients were included, of which 223 (54.5%) received IVT. The proportion of patients within an early time window (<4.5 hours), low NWU, and CTP mismatch were 45.0%, 86.5%, and 80.3%. In IPW, IVT was associated with higher rates of ENI (%-difference: 7.3%, p = 0.02). For patients with CTP mismatch or low NWU, IVT was associated with a 9.6% or 7.2% higher rate of ENI, which was different than the effect of IVT in patients without CTP mismatch or high NWU (-9.3%/-7.3%; p = 0.004/p = 0.03), whereas early treatment window did not modify the effect of IVT. DISCUSSION CT-based measures of the "tissue clock" might identify patients who benefit from IVT more accurately than conventional time windows. Considering the high number of patients with early "tissue clock" (low NWU/CTP mismatch) within an extended time window, considerable benefit from IVT using imaging indicators of the "tissue clock" may be achieved.
Collapse
Affiliation(s)
- Gabriel Broocks
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany.
| | - Lukas Meyer
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Matthias Bechstein
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Uta Hanning
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Helge C Kniep
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Eckhard Schlemm
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Anna A Kyselyova
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Laurens Winkelmeier
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Gerhard Schön
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Jens Fiehler
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Andre Kemmling
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| |
Collapse
|
6
|
Ingwersen T, Olma MC, Schlemm E, Mayer C, Cheng B, Tütüncü S, Kirchhof P, Veltkamp R, Röther J, Laufs U, Nabavi DG, Ntaios G, Endres M, Haeusler KG, Thomalla G. Independent external validation of a stroke recurrence score in patients with embolic stroke of undetermined source. Neurol Res Pract 2023; 5:51. [PMID: 37794453 PMCID: PMC10552210 DOI: 10.1186/s42466-023-00279-z] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/24/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Embolic stroke of undetermined source (ESUS) accounts for a substantial proportion of ischaemic strokes. A stroke recurrence score has been shown to predict the risk of recurrent stroke in patients with ESUS based on a combination of clinical and imaging features. This study aimed to externally validate the performance of the ESUS recurrence score using data from a randomized controlled trial. METHODS The validation dataset consisted of eligible stroke patients with available magnetic resonance imaging (MRI) data enrolled in the PreDAFIS sub-study of the MonDAFIS study. The score was calculated using three variables: age (1 point per decade after 35 years), presence of white matter hyperintensities (2 points), and multiterritorial ischaemic stroke (3 points). Patients were assigned to risk groups as described in the original publication. The model was evaluated using standard discrimination and calibration methods. RESULTS Of the 1054 patients, 241 (22.9%) were classified as ESUS. Owing to insufficient MRI quality, three patients were excluded, leaving 238 patients (median age 65.5 years [IQR 20.75], 39% female) for analysis. Of these, 30 (13%) patients experienced recurrent ischaemic stroke or transient ischemic attack (TIA) during a follow-up period of 383 patient-years, corresponding to an incidence rate of 7.8 per 100 patient-years (95% CI 5.3-11.2). Patients with an ESUS recurrence score value of ≥ 7 had a 2.46 (hazard ratio (HR), 95% CI 1.02-5.93) times higher risk of stroke recurrence than patients with a score of 0-4. The cumulative probability of stroke recurrence in the low-(0-4), intermediate-(5-6), and high-risk group (≥ 7) was 9%, 13%, and 23%, respectively (log-rank test, χ2 = 4.2, p = 0.1). CONCLUSIONS This external validation of a published scoring system supports a threshold of ≥ 7 for identifying ESUS patients at high-risk of stroke recurrence. However, further adjustments may be required to improve the model's performance in independent cohorts. The use of risk scores may be helpful in guiding extended diagnostics and further trials on secondary prevention in patients with ESUS. TRIAL REGISTRATION Clinical Trials, NCT02204267. Registered 30 July 2014, https://clinicaltrials.gov/ct2/show/NCT02204267 .
Collapse
Affiliation(s)
- Thies Ingwersen
- Department of Neurology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany.
| | - Manuel C Olma
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, BIH, Berlin, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Carola Mayer
- Department of Neurology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Serdar Tütüncü
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Partner Site Hamburg/Kiel/Lübeck, German Centre for Cardiovascular Research, Hamburg, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, UK
| | - Joachim Röther
- Department of Neurology, Asklepios Hospital Altona, Hamburg, Germany
| | - Ulrich Laufs
- Department of Cardiology, University Hospital Leipzig, Hamburg, Germany
| | - Darius G Nabavi
- Department of Neurology, Vivantes Hospital Neukölln, Berlin, Germany
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, BIH, Berlin, Germany
- Partner Site Hamburg/Kiel/Lübeck, German Centre for Cardiovascular Research, Hamburg, Germany
- Partner Site Berlin, German Centre for Neurodegenerative Diseases (DZNE), Berlin, Germany
- Excellence Cluster NeuroCure, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
| |
Collapse
|
7
|
Schlemm E, Piepke M, Kessner SS, Meyer L, Cheng B, Gerloff C, Thomalla G. Clinical Judgment vs Triage Scales for Detecting Large Vessel Occlusions in Suspected Acute Stroke. JAMA Netw Open 2023; 6:e2332894. [PMID: 37698866 PMCID: PMC10498329 DOI: 10.1001/jamanetworkopen.2023.32894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/25/2023] [Indexed: 09/13/2023] Open
Abstract
This cohort study examines clinical judgment of large vessel occlusions compared with triage scales in a sample of patients admitted to the emergency department with suspicion of acute stroke.
Collapse
Affiliation(s)
- Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marius Piepke
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon S. Kessner
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Psychosomatic Medicine und Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
8
|
Schlemm L, Siebert E, Kleine JF, Riegler C, Bode FJ, Petersens M, Schlemm E, Keil F, Tiedt S, Bohner G, Nolte CH. Decline of thrombolysis rates before endovascular therapy in patients with acute anterior circulation large vessel occlusion ischemic stroke: A multicenter analysis from the German Stroke Registry. Eur Stroke J 2023; 8:610-617. [PMID: 37243508 PMCID: PMC10472953 DOI: 10.1177/23969873231177774] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/07/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION In recent years, the role of intravenous thrombolysis (IVT) before endovascular stroke treatment (EVT) has been discussed intensively. Whether the discussion was accompanied by changing rates of bridging IVT is unknown. METHODS Data were extracted from the prospectively maintained German Stroke Registry, including patients treated with EVT at one of 28 stroke centers in Germany between 2016 and 2021. Primary outcome parameters were the rate of bridging IVT (a) in the entire registry cohort and (b) in patients without formal contraindications to IVT (i.e. recent oral anticoagulants, time window ⩾4.5 h, extensive early ischemic changes) adjusted for demographic and clinical confounders. RESULTS 10,162 patients (52.8% women, median age 77 years, median National Institutes of Health Stroke Scale score 14) were analyzed. In the entire cohort, the rate of bridging IVT decreased from 63.8% in 2016 to 43.6% in 2021 (average absolute annual decrease 3.1%, 95% CI 2.4%-3.8%), while the proportion of patients with at least one formal contraindication increased by only 1.2% annually (95% CI 0.6%-1.9%). Among 5460 patients without record of formal contraindications, the rate of bridging IVT decreased from 75.5% in 2016 to 63.2% in 2021 and was significantly associated with admission date in a multivariable model (average absolute annual decrease 1.4%, 95% CI 0.6%-2.2%). Clinical factors associated with lower odds of bridging IVT included diabetes mellitus, carotid-T-occlusion, dual antiplatelet therapy, and direct admission to a thrombectomy center. CONCLUSION We observed a substantial decline in bridging IVT rates independent of demographic confounders and not explained by an increase in contraindications. This observation deserves further exploration in independent populations.
Collapse
Affiliation(s)
- Ludwig Schlemm
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Radiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Justus F Kleine
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Fee Keil
- Institute for Neuroradiology, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Georg Bohner
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| |
Collapse
|
9
|
Frey BM, Shenas F, Boutitie F, Cheng B, Cho TH, Ebinger M, Endres M, Fiebach JB, Fiehler J, Galinovic I, Barow E, Königsberg A, Schlemm E, Pedraza S, Lemmens R, Thijs V, Muir KW, Nighoghossian N, Simonsen CZ, Gerloff C, Thomalla G. Intravenous Thrombolysis in Patients With White Matter Hyperintensities in the WAKE-UP Trial. Stroke 2023. [PMID: 37226772 DOI: 10.1161/strokeaha.122.040247] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND White matter hyperintensities of presumed vascular origin (WMH) are the most prominent imaging feature of cerebral small vessel disease (cSVD). Previous studies suggest a link between cSVD burden and intracerebral hemorrhage and worse functional outcome after thrombolysis in acute ischemic stroke. We aimed to determine the impact of WMH burden on efficacy and safety of thrombolysis in the MRI-based randomized controlled WAKE-UP trial of intravenous alteplase in unknown onset stroke. METHODS The design of this post hoc study was an observational cohort design of a secondary analysis of a randomized trial. WMH volume was quantified on baseline fluid-attenuated inversion recovery images of patients randomized to either alteplase or placebo in the WAKE-UP trial. Excellent outcome was defined as score of 0-1 on the modified Rankin Scale after 90 days. Hemorrhagic transformation was assessed on follow-up imaging 24-36 hours after randomization. Treatment effect and safety were analyzed by fitting multivariable logistic regression models. RESULTS Quality of scans was sufficient in 441 of 503 randomized patients to delineate WMH. Median age was 68 years, 151 patients were female, and 222 patients were assigned to receive alteplase. Median WMH volume was 11.4 mL. Independent from treatment, WMH burden was statistically significantly associated with worse functional outcome (odds ratio, 0.72 [95% CI, 0.57-0.92]), but not with higher chances of any hemorrhagic transformation (odds ratio, 0.78 [95% CI, 0.60-1.01]). There was no interaction of WMH burden and treatment group for the likelihood of excellent outcome (P=0.443) or any hemorrhagic transformation (P=0.151). In a subgroup of 166 patients with severe WMH, intravenous thrombolysis was associated with higher odds of excellent outcome (odds ratio, 2.40 [95% CI, 1.19-4.84]) with no significant increase in the rate of hemorrhagic transformation (odds ratio, 1.96 [95% CI, 0.80-4.81]). CONCLUSIONS Although WMH burden is associated with worse functional outcome, there is no association with treatment effect or safety of intravenous thrombolysis in patients with ischemic stroke of unknown onset. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01525290.
Collapse
Affiliation(s)
- Benedikt M Frey
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (B.M.F., F.S., B.C., E.B., A.K., E.S., C.G., G.T.)
| | - Farhad Shenas
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (B.M.F., F.S., B.C., E.B., A.K., E.S., C.G., G.T.)
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, F-69003 Lyon, France; Université Lyon 1, FranceCNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France (F.B.)
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (B.M.F., F.S., B.C., E.B., A.K., E.S., C.G., G.T.)
| | - Tae-Hee Cho
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon; Hospices Civils de Lyon, France (T.-H.C., N.N.)
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
- Neurologie der Rehaklinik Medical Park Humboldtmühle, Berlin, Germany (M. Ebinger)
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (M. Endres)
| | - Jochen B Fiebach
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (J.F.)
| | - Ivana Galinovic
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
| | - Ewgenia Barow
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (B.M.F., F.S., B.C., E.B., A.K., E.S., C.G., G.T.)
| | - Alina Königsberg
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (B.M.F., F.S., B.C., E.B., A.K., E.S., C.G., G.T.)
| | - Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (B.M.F., F.S., B.C., E.B., A.K., E.S., C.G., G.T.)
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt, Girona, Spain (S.P.)
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Belgium (R.L.)
- KU Leuven - University of Leuven, Department of Neurosciences, Experimental Neurology, Belgium (R.L.)
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Belgium (R.L.)
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia (V.T.)
- Austin Health, Department of Neurology, Heidelberg, VIC, Australia (V.T.)
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, University Avenue, Glasgow, United Kingdom (K.W.M.)
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon; Hospices Civils de Lyon, France (T.-H.C., N.N.)
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Denmark (C.Z.S.)
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (B.M.F., F.S., B.C., E.B., A.K., E.S., C.G., G.T.)
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (B.M.F., F.S., B.C., E.B., A.K., E.S., C.G., G.T.)
| |
Collapse
|
10
|
Meinel TR, Wilson D, Gensicke H, Scheitz JF, Ringleb P, Goganau I, Kaesmacher J, Bae HJ, Kim DY, Kermer P, Suzuki K, Kimura K, Macha K, Koga M, Wada S, Altersberger V, Salerno A, Palanikumar L, Zini A, Forlivesi S, Kellert L, Wischmann J, Kristoffersen ES, Beharry J, Barber PA, Hong JB, Cereda C, Schlemm E, Yakushiji Y, Poli S, Leker R, Romoli M, Zedde M, Curtze S, Ikenberg B, Uphaus T, Giannandrea D, Portela PC, Veltkamp R, Ranta A, Arnold M, Fischer U, Cha JK, Wu TY, Purrucker JC, Seiffge DJ. Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants. JAMA Neurol 2023; 80:233-243. [PMID: 36807495 PMCID: PMC9857462 DOI: 10.1001/jamaneurol.2022.4782] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/21/2022] [Indexed: 02/07/2023]
Abstract
Importance International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC). Objective To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion. Design, Setting, and Participants This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021. Exposures Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation. Main Outcomes and Measures The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses. Results Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion. Conclusions and Relevance In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.
Collapse
Affiliation(s)
- Thomas R. Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Henrik Gensicke
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Jan F. Scheitz
- Department of Neurology, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research Partner Site Berlin, Germany
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ioana Goganau
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Do Yeon Kim
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Pawel Kermer
- Department of Neurology, Friesland Kliniken, Sande, Germany
- Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kosmas Macha
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Wada
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Valerian Altersberger
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Andrea Zini
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Stefano Forlivesi
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Espen S. Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, Institute of Health and Society (HELSAM), University of Oslo, Oslo, Norway
| | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - P. Alan Barber
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Jae Beom Hong
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Carlo Cereda
- Stroke Center and Department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Yusuke Yakushiji
- Department of Neurology Kansai Medical University, Hirakata, Japan
| | - Sven Poli
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ronen Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Benno Ikenberg
- Department of Neurology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - David Giannandrea
- Division of Neurology and Stroke Unit, Department of Neurology, Gubbio and Città di Castello Hospital, Perugia, Italy
| | - Pere Cardona Portela
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Klinik für Neurologie, Alfried Krupp Krankenhaus, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Capital and Coast District Health Board, Wellington, New Zealand
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J. Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | |
Collapse
|
11
|
Jensen M, Sehner S, Cheng B, Schlemm E, Quandt F, Barow E, Wegscheider K, Boutitie F, Ebinger M, Endres M, Fiebach JB, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Thomalla G, Gerloff C. Patient-Reported Quality of Life After Intravenous Alteplase for Stroke in the WAKE-UP Trial. Neurology 2023; 100:e154-e162. [PMID: 36302662 DOI: 10.1212/wnl.0000000000201375] [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] [Received: 03/09/2022] [Accepted: 08/23/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intravenous alteplase improves functional outcome after acute ischemic stroke. However, little is known about the effects on self-reported health-related quality of life (HRQoL). METHODS WAKE-UP was a multicenter, randomized, placebo-controlled trial of MRI-guided intravenous alteplase in stroke with unknown onset time. HRQoL was assessed using the EuroQol five-dimensional questionnaire (EQ-5D) at 90 days, comprising the EQ-5D index and the EQ visual analogue scale (VAS). Functional outcome was assessed by the modified Rankin Scale (mRS). We calculated the effect of treatment on EQ-5D index and EQ VAS using multiple linear regression models. Mediation analysis was performed on stroke survivors to explore the extent to which the effect of alteplase on HRQoL was mediated by functional outcome. RESULTS Among 490 stroke survivors, the EQ-5D index was available for 452 (92.2%), of whom 226 (50%) were assigned to treatment with alteplase and 226 (50%) to placebo. At 90 days, mean EQ-5D index was higher, reflecting a better health state, in patients randomized to treatment with alteplase than with placebo (0.75 vs 0.67) with an adjusted mean difference of 0.07 (95% CI 0.02-0.12, p = 0.005). In addition, mean EQ VAS was higher with alteplase than with placebo (72.6 vs 64.9), with an adjusted mean difference of 7.6 (95% CI 3.9-11.8, p < 0.001). Eighty-five percent of the total treatment effect of alteplase on the EQ-5D index was mediated using the mRS score while there was no significant direct effect. By contrast, the treatment effect on the EQ VAS was mainly through the direct pathway (60%), whereas 40% was mediated by the mRS. DISCUSSION Assessment of patient-reported outcome measures reveals a potential benefit of intravenous alteplase for HRQoL beyond improvement of functional outcome. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov number, NCT01525290; EudraCT number, 2011-005906-32.
Collapse
Affiliation(s)
- Märit Jensen
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark.
| | - Susanne Sehner
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Bastian Cheng
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Eckhard Schlemm
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Fanny Quandt
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Ewgenia Barow
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Karl Wegscheider
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Florent Boutitie
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Martin Ebinger
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Matthias Endres
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Jochen B Fiebach
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Vincent Thijs
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Robin Lemmens
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Keith W Muir
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Norbert Nighoghossian
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Salvador Pedraza
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Claus Z Simonsen
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Götz Thomalla
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Christian Gerloff
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| |
Collapse
|
12
|
Rimmele DL, Petersen EL, Schlemm E, Kessner SS, Petersen M, Mayer C, Cheng B, Zeller T, Waldeyer C, Behrendt CA, Gerloff C, Thomalla G. Association of Carotid Plaque and Flow Velocity With White Matter Integrity in a Middle-aged to Elderly Population. Neurology 2022; 99:e2699-e2707. [PMID: 36123124 DOI: 10.1212/wnl.0000000000201297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/10/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES It is uncertain whether there is an association of carotid plaques (CPs) and flow velocities with peak width mean diffusivity (PSMD) and white matter hyperintensities (WMH) independent of shared risk factors. We aimed to study this association controlling for biomarkers of inflammation and cardiac dysfunction and typical cardiovascular risk factors and spatial distribution. METHODS We included participants from the population-based Hamburg City Health Study, recruiting citizens between 45 and 74 years of age. Medical history was obtained from structured interviews and extended laboratory tests, physical examinations, MRI of the head, echocardiography, and abdominal and carotid ultrasound were performed. We performed multivariable regression analysis with PSMD and periventricular, deep, and total volume of WMH (pWMH, dWMH, tWMH) as dependent variables. PSMD was calculated as the difference between the 95th and 5th percentiles of MD values on the white skeleton in standard space. Volumes of WMH were determined by the application of a manually trained k-nearest neighbor segmentation algorithm. WMH measured within a distance of 1 cm from the surface of the lateral ventricles were defined as pWMH and above 1 cm as dWMH. RESULTS Two thousand six hundred twenty-three participants were included. The median age was 65 years, and 56% were women. Their median tWMH was 946 mm3(IQR:419, 2,164), PSMD 2.24 mm2/s × 10-4 (IQR: 2.04, 2.47), peak systolic velocity (PSV) of internal carotid arteries 0.70m/second (IQR:0.60, 0.81), and 35% had CPs. Adjusted for age, sex, high-sensitive CRP, NT-proBNP, and commonly measured cardiovascular risk and systemic hemodynamic factors, both CPs (B = 0.15; CI: 0.04, 0.26; p = 0.006) and low PSV (B = -0.49; CI: -0.87, -0.11; p = 0.012) were significantly associated with a higher tWMH and PSMD. Low PSV (B = -0.48; CI: -0.87, -0.1; p = 0.013) was associated with pWMH and the presence of CP with pWMH (B = 0.15; CI: 0.04, 0.26; p = 0.008) and dWMH (B = 0.42; CI: 0.11, 0.74; p < 0.009). DISCUSSION Low PSV and CP are associated with WMH and PSMD independent of cardiovascular risk factors and biomarkers of inflammation and cardiac dysfunction. This points toward pathophysiologic pathways underlying both large and small vessel disease beyond the common cardiovascular risk profile. TRIAL REGISTRATION INFORMATION The trial was submitted at clinicaltrials.gov, under NCT03934957 on January 4, 2019. The first participant was enrolled in February 2016.
Collapse
Affiliation(s)
- David Leander Rimmele
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany.
| | - Elina Larissa Petersen
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Eckhard Schlemm
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Simon S Kessner
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Marvin Petersen
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Carola Mayer
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Bastian Cheng
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Tanja Zeller
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Christoph Waldeyer
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Christian-Alexander Behrendt
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Christian Gerloff
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Götz Thomalla
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| |
Collapse
|
13
|
Abstract
The accurate assessment of cerebrospinal fluid opening pressure during spinal puncture provides important medical information in diagnosis, prognosis and therapy of several neurological conditions. However, purpose-specific spinal needle choice is debated. While atraumatic needles are associated with lower incidence of post-puncture headache and re-hospitalisation, some clinicians believe that they lack in accuracy of CSF opening pressure assessment. Our primary objective was to investigate different needle types on correctly assessing CSF opening pressure. We compared typical clinically utilised traumatic (0.9 mm outer diameter) and atraumatic (0.7 mm; 0.45 mm) spinal needles with regards to the assessment of the opening pressure in an experimental spinal puncture model testing experimental and cerebrospinal fluids in predefined pressures. Our goal was to measure the time until indicated pressure levels were correctly shown. Atraumatic needles of at least 0.7 mm diameter had a similar accuracy as traumatic needles without significant differences in time-to-equilibrium. These results were independent of protein and glucose concentration and the presence of haemoglobin. This study demonstrates that atraumatic needles can be used to accurately measure CSF opening pressure. This knowledge might guide clinicians in their choice of needle and help to reduce post-puncture headaches and re-hospitalisation.
Collapse
Affiliation(s)
- Marcel S Woo
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Simon S Kessner
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany.
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany.
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| |
Collapse
|
14
|
Schlemm E, Frey BM, Mayer C, Petersen M, Fiehler J, Hanning U, Kühn S, Twerenbold R, Gallinat J, Gerloff C, Thomalla G, Cheng B. Equalization of Brain State Occupancy Accompanies Cognitive Impairment in Cerebral Small Vessel Disease. Biol Psychiatry 2022; 92:592-602. [PMID: 35691727 DOI: 10.1016/j.biopsych.2022.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Received: 12/14/2021] [Revised: 03/08/2022] [Accepted: 03/23/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Cognitive impairment is a hallmark of cerebral small vessel disease (cSVD). Functional magnetic resonance imaging has highlighted connections between patterns of brain activity and variability in behavior. We aimed to characterize the associations between imaging markers of cSVD, dynamic connectivity, and cognitive impairment. METHODS We obtained magnetic resonance imaging and clinical data from the population-based Hamburg City Health Study. cSVD was quantified by white matter hyperintensities and peak-width of skeletonized mean diffusivity (PSMD). Resting-state blood oxygen level-dependent signals were clustered into discrete brain states, for which fractional occupancies (%) and dwell times (seconds) were computed. Cognition in multiple domains was assessed using validated tests. Regression analysis was used to quantify associations between white matter damage, spatial coactivation patterns, and cognitive function. RESULTS Data were available for 979 participants (ages 45-74 years, median white matter hyperintensity volume 0.96 mL). Clustering identified five brain states with the most time spent in states characterized by activation (+) or suppression (-) of the default mode network (DMN) (fractional occupancy: DMN+ = 25.1 ± 7.2%, DMN- = 25.5 ± 7.2%). Every 4.7-fold increase in white matter hyperintensity volume was associated with a 0.95-times reduction of the odds of occupying DMN+ or DMN-. Time spent in DMN-related brain states was associated with executive function. CONCLUSIONS Associations between white matter damage, whole-brain spatial coactivation patterns, and cognition suggest equalization of time spent in different brain states as a marker for cSVD-associated cognitive decline. Reduced gradients between brain states in association with brain damage and cognitive impairment reflect the dedifferentiation hypothesis of neurocognitive aging in a network-theoretical context.
Collapse
Affiliation(s)
- Eckhard Schlemm
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
| | - Benedikt M Frey
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Carola Mayer
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Marvin Petersen
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Simone Kühn
- Department of Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Raphael Twerenbold
- Department of Cardiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jürgen Gallinat
- Department of Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
15
|
Schlemm E, Jensen M, Kuceyeski A, Jamison K, Ingwersen T, Mayer C, Königsberg A, Boutitie F, Ebinger M, Endres M, Fiebach JB, Fiehler J, Galinovic I, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Puig J, Simonsen CZ, Thijs V, Wouters A, Gerloff C, Thomalla G, Cheng B. Early effect of thrombolysis on structural brain network organisation after anterior‐circulation stroke in the randomized
WAKE‐UP
trial. Hum Brain Mapp 2022; 43:5053-5065. [PMID: 36102287 PMCID: PMC9582379 DOI: 10.1002/hbm.26073] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/11/2022] [Accepted: 08/22/2022] [Indexed: 11/08/2022] Open
Abstract
The symptoms of acute ischemic stroke can be attributed to disruption of the brain network architecture. Systemic thrombolysis is an effective treatment that preserves structural connectivity in the first days after the event. Its effect on the evolution of global network organisation is, however, not well understood. We present a secondary analysis of 269 patients from the randomized WAKE‐UP trial, comparing 127 imaging‐selected patients treated with alteplase with 142 controls who received placebo. We used indirect network mapping to quantify the impact of ischemic lesions on structural brain network organisation in terms of both global parameters of segregation and integration, and local disruption of individual connections. Network damage was estimated before randomization and again 22 to 36 h after administration of either alteplase or placebo. Evolution of structural network organisation was characterised by a loss in integration and gain in segregation, and this trajectory was attenuated by the administration of alteplase. Preserved brain network organization was associated with excellent functional outcome. Furthermore, the protective effect of alteplase was spatio‐topologically nonuniform, concentrating on a subnetwork of high centrality supported in the salvageable white matter surrounding the ischemic cores. This interplay between the location of the lesion, the pathophysiology of the ischemic penumbra, and the spatial embedding of the brain network explains the observed potential of thrombolysis to attenuate topological network damage early after stroke. Our findings might, in the future, lead to new brain network‐informed imaging biomarkers and improved prognostication in ischemic stroke.
Collapse
Affiliation(s)
- Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Kopf‐ und Neurozentrum University Medical Centre Hamburg‐Eppendorf Hamburg Germany
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf‐ und Neurozentrum University Medical Centre Hamburg‐Eppendorf Hamburg Germany
| | - Amy Kuceyeski
- Department of Radiology Weill Cornell Medicine New York New York USA
| | - Keith Jamison
- Department of Radiology Weill Cornell Medicine New York New York USA
| | - Thies Ingwersen
- Klinik und Poliklinik für Neurologie, Kopf‐ und Neurozentrum University Medical Centre Hamburg‐Eppendorf Hamburg Germany
| | - Carola Mayer
- Klinik und Poliklinik für Neurologie, Kopf‐ und Neurozentrum University Medical Centre Hamburg‐Eppendorf Hamburg Germany
| | - Alina Königsberg
- Klinik und Poliklinik für Neurologie, Kopf‐ und Neurozentrum University Medical Centre Hamburg‐Eppendorf Hamburg Germany
| | - Florent Boutitie
- Department of Radiology Weill Cornell Medicine New York New York USA
- Hospices Civils de Lyon, Service de Biostatistique Lyon France
- Université Lyon 1 Villeurbanne France
- CNRS, UMR 5558 Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique‐Santé Villeurbanne France
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin (CSB) Charité ‐ Universitätsmedizin Berlin Berlin Germany
- Klinik für Neurologie Medical Park Berlin Humboldtmühle Berlin Germany
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin (CSB) Charité ‐ Universitätsmedizin Berlin Berlin Germany
- Klinik und Hochschulambulanz für Neurologie Charité‐Universitätsmedizin Berlin Berlin Germany
- German Centre for Neurodegenerative Diseases (DZNE) Berlin Germany
- German Centre for Cardiovascular Research (DZHK) Berlin Germany
- ExcellenceCluster NeuroCure Berlin Germany
| | - Jochen B. Fiebach
- Centrum für Schlaganfallforschung Berlin (CSB) Charité ‐ Universitätsmedizin Berlin Berlin Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology University Medical Centre Hamburg‐Eppendorf Hamburg Germany
| | - Ivana Galinovic
- Centrum für Schlaganfallforschung Berlin (CSB) Charité ‐ Universitätsmedizin Berlin Berlin Germany
| | - Robin Lemmens
- Department of Neurology University Hospitals Leuven Leuven Belgium
- Department of Neurosciences Division of Experimental Neurology KU Leuven—University of Leuven Leuven Belgium
- VIB, Centre for Brain & Disease Research Laboratory of Neurobiology Leuven Belgium
| | - Keith W. Muir
- Institute of Neuroscience & Psychology University of Glasgow Glasgow UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1 CREATIS CNRS UMR 5220‐INSERM U1206, INSA‐Lyon Lyon France
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI) Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI) Girona Spain
| | - Josep Puig
- Department of Radiology, Institut de Diagnostic per la Image (IDI) Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI) Girona Spain
| | | | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health University of Melbourne Heidelberg Victoria Australia
- Department of Neurology Austin Health Heidelberg Victoria Australia
| | - Anke Wouters
- Department of Neurology University Hospitals Leuven Leuven Belgium
- Department of Neurosciences Division of Experimental Neurology KU Leuven—University of Leuven Leuven Belgium
- VIB, Centre for Brain & Disease Research Laboratory of Neurobiology Leuven Belgium
- Department of Neurology Amsterdam UMC University of Amsterdam Amsterdam Netherlands
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf‐ und Neurozentrum University Medical Centre Hamburg‐Eppendorf Hamburg Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf‐ und Neurozentrum University Medical Centre Hamburg‐Eppendorf Hamburg Germany
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf‐ und Neurozentrum University Medical Centre Hamburg‐Eppendorf Hamburg Germany
| |
Collapse
|
16
|
Pimentel BC, Ingwersen T, Haeusler KG, Schlemm E, Forkert ND, Rajashekar D, Mouches P, Königsberg A, Kirchhof P, Kunze C, Tütüncü S, Olma MC, Krämer M, Michalski D, Kraft A, Rizos T, Helberg T, Ehrlich S, Nabavi DG, Röther J, Laufs U, Veltkamp R, Heuschmann PU, Cheng B, Endres M, Thomalla G. Association of stroke lesion shape with newly detected atrial fibrillation – Results from the MonDAFIS study. Eur Stroke J 2022; 7:230-237. [PMID: 36082264 PMCID: PMC9446317 DOI: 10.1177/23969873221100895] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 04/26/2022] [Indexed: 11/16/2022] Open
Abstract
Paroxysmal Atrial fibrillation (AF) is often clinically silent and may be missed
by the usual diagnostic workup after ischemic stroke. We aimed to determine
whether shape characteristics of ischemic stroke lesions can be used to predict
AF in stroke patients without known AF at baseline. Lesion shape quantification
on brain MRI was performed in selected patients from the intervention arm of the
Impact of standardized MONitoring for Detection of Atrial
Fibrillation in Ischemic Stroke (MonDAFIS) study, which included
patients with ischemic stroke or TIA without prior AF. Multiple morphologic
parameters were calculated based on lesion segmentation in acute brain MRI data.
Multivariate logistic models were used to test the association of lesion
morphology, clinical parameters, and AF. A stepwise elimination regression was
conducted to identify the most important variables. A total of 755 patients were
included. Patients with AF detected within 2 years after stroke
(n = 86) had a larger overall oriented bounding box (OBB)
volume (p = 0.003) and a higher number of brain lesion
components (p = 0.008) than patients without AF. In the
multivariate model, OBB volume (OR 1.72, 95%CI 1.29–2.35,
p < 0.001), age (OR 2.13, 95%CI 1.52–3.06,
p < 0.001), and female sex (OR 2.45, 95%CI 1.41–4.31,
p = 0.002) were independently associated with detected AF.
Ischemic lesions in patients with detected AF after stroke presented with a more
dispersed infarct pattern and a higher number of lesion components. Together
with clinical characteristics, these lesion shape characteristics may help in
guiding prolonged cardiac monitoring after stroke.
Collapse
Affiliation(s)
- Bernardo Crespo Pimentel
- Department of Neurology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Thies Ingwersen
- Department of Neurology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Wurzburg, Germany
- German Atrial Fibrillation Network (AFNET), Münster, Germany
| | - Eckhard Schlemm
- Department of Neurology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils D Forkert
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | | | - Pauline Mouches
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Alina Königsberg
- Department of Neurology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paulus Kirchhof
- German Atrial Fibrillation Network (AFNET), Münster, Germany
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, UK
- Departments of Cardiology, UHB and SWBH NHS Trusts, Birmingham, UK
- University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Claudia Kunze
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Serdar Tütüncü
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Manuel C Olma
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Krämer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Dominik Michalski
- Department of Neurology, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Andrea Kraft
- Department of Neurology, Martha Maria Hospital, Halle Dölau, Germany
| | - Timolaos Rizos
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Torsten Helberg
- Department of Neurology, Clinical Center of Hubertusburg, Wermsdorf, Germany
| | - Sven Ehrlich
- Clinical Center of Hubertusburg, Wermsdorf, Germany
| | - Darius G Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Ulrich Laufs
- Department of Cardiology, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Krankenhaus, Essen, Germany
- Department of Brain Sciences, Imperial College London, UK
| | - Peter U Heuschmann
- Comprehensive Heart Failure Center & Clinical Trial Centre Würzburg, University Hospital Würzburg, Germany
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Wurzburg, Germany
| | - Bastian Cheng
- Department of Neurology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Endres
- University Heart and Vascular Center Hamburg, Hamburg, Germany
- Klinik und Hochschulambulanz für Neurologie mit Abteilung für Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases, Partner Site Berlin, Germany
- German Center for Cardiovascular Diseases, Partner Site Berlin, Germany
- ExcellenceCluster NeuroCure, Berlin, Germany
| | - Götz Thomalla
- Department of Neurology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
17
|
Fischer F, Malherbe C, Schlemm E, Schröder J, Heinze M, Cheng B, Schulz M, Fiehler J, Larena-Avellaneda A, Gerloff C, Thomalla G. Intrinsic functional brain connectivity is resilient to chronic hypoperfusion caused by unilateral carotid artery stenosis. Neuroimage Clin 2022; 34:103014. [PMID: 35483135 PMCID: PMC9125779 DOI: 10.1016/j.nicl.2022.103014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 12/01/2022]
Abstract
Unilateral internal carotid artery stenosis leads to chronic cerebral hypoperfusion. rsfMRI functional connectivity is well-compensated in asymptomatic ICA stenosis. Functional network properties remain stable before and after revascularization.
Introduction Chronic cerebral hypoperfusion caused by asymptomatic high-grade stenosis of the internal carotid artery (ICA) has been associated with impaired cognitive function. Only few studies exist on underlying changes of functional connectivity (FC). Methods 20 patients with unilateral high-grade ICA stenosis without MRI lesions and 25 aged-match controls underwent resting-state functional MRI (rsfMRI) and neuropsychological assessment. Patients were examined within ten days before and 6–10 weeks after surgical or interventional revascularization of carotid stenosis. We examined mean resting-state FC ipsi- and contralateral to stenosis and network topology using graph-theoretical measures. Results At baseline, intrahemispheric FC was similar for patients and healthy controls. After revascularization mean FC increased moderately without an effect on network topology. Patients performed worse in TMT B and Stroop test, while performance in global screening tests for dementia (Mini Mental Status Examination, DemTect) were comparable. Test results did not improve after revascularization. Conclusion In our study population, we find no effect of chronic hypoperfusion on FC and global cognitive function, although we observe minor impairments in processing speed and mental flexibility. The subtle increase of FC after revascularization could indicate excessive upregulation after restoration of perfusion. However, it might as well be a coincidental finding due to the limited sample size.
Collapse
Affiliation(s)
- Felix Fischer
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Caroline Malherbe
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Institute of Computational Neuroscience, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Schröder
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Heinze
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schulz
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
18
|
Schulz M, Mayer C, Schlemm E, Frey BM, Malherbe C, Petersen M, Gallinat J, Kühn S, Fiehler J, Hanning U, Twerenbold R, Gerloff C, Cheng B, Thomalla G. Association of Age and Structural Brain Changes With Functional Connectivity and Executive Function in a Middle-Aged to Older Population-Based Cohort. Front Aging Neurosci 2022; 14:782738. [PMID: 35283749 PMCID: PMC8916110 DOI: 10.3389/fnagi.2022.782738] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 01/06/2022] [Indexed: 01/02/2023] Open
Abstract
Aging is accompanied by structural brain changes that are thought to underlie cognitive decline and dementia. Yet little is known regarding the association between increasing age, structural brain damage, and alterations of functional brain connectivity. The aim of this study was to evaluate whether cortical thickness and white matter damage as markers of age-related structural brain changes are associated with alterations in functional connectivity in non-demented healthy middle-aged to older adults. Therefore, we reconstructed functional connectomes from resting-state functional magnetic resonance imaging (MRI) (rsfMRI) data of 976 subjects from the Hamburg City Health Study, a prospective population-based study including participants aged 45-74 years from the metropolitan region Hamburg, Germany. We performed multiple linear regressions to examine the association of age, cortical thickness, and white matter damage quantified by the peak width of skeletonized mean diffusivity (PSMD) from diffusion tensor imaging on whole-brain network connectivity and four predefined resting state networks (default mode, dorsal, salience, and control network). In a second step, we extracted subnetworks with age-related decreased functional connectivity from these networks and conducted a mediation analysis to test whether the effect of age on these networks is mediated by decreased cortical thickness or PSMD. We observed an independent association of higher age with decreased functional connectivity, while there was no significant association of functional connectivity with cortical thickness or PSMD. Mediation analysis identified cortical thickness as a partial mediator between age and default subnetwork connectivity and functional connectivity within the default subnetwork as a partial mediator between age and executive cognitive function. These results indicate that, on a global scale, functional connectivity is not determined by structural damage in healthy middle-aged to older adults. There is a weak association of higher age with decreased functional connectivity which, for specific subnetworks, appears to be mediated by cortical thickness.
Collapse
Affiliation(s)
- Maximilian Schulz
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carola Mayer
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt M. Frey
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caroline Malherbe
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute of Computational Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marvin Petersen
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jürgen Gallinat
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simone Kühn
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raphael Twerenbold
- Department of Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
19
|
König C, Grensemann J, Czorlich P, Schlemm E, Kluge S, Wicha SG. A dosing nomograph for cerebrospinal fluid penetration of meropenem applied by continuous infusion in patients with nosocomial ventriculitis. Clin Microbiol Infect 2022; 28:1022.e9-1022.e16. [PMID: 35182756 DOI: 10.1016/j.cmi.2022.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 10/25/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In difficult to treat infections such as nosocomial ventriculitis, meropenem exposure in the infected compartment is often uncertain but crucial for antibacterial effects. The aim of this study was to investigate the cerebrospinal fluid (CSF) penetration of meropenem in patients with nosocomial ventriculitis and to derive a nomograph to predict effective meropenem doses as a function of clinical parameters. METHODS Retrospective patient data including meropenem serum and CSF levels, as well as CSF inflammation markers were analysed using NONMEM® to assess the general pharmacokinetics and CSF penetration. Monte Carlo simulations (MCS) were used to evaluate different meropenem dosing regimens. Probability of target attainment (PTA) in CSF was assessed and a nomograph to achieve a target concentration of 4 mg/L was developed. RESULTS A one-compartment model with meropenem clearance dependent on the estimated glomerular filtration rate (CKD-EPI eGFR, p< 5 e-10) best described meropenem serum pharmacokinetics of 51 critically ill patients. CSF penetration ratio was correlated with the amount of protein in CSF (p< 1 e-8), with higher CSF protein levels accounting for higher penetration ratios. Preserved renal function (CKD-EPI GFR> 50 ml/min/1.73 m2) as well as low CSF protein levels (<500 mg/L) resulted in 80 % PTA (100 %fT>2xMIC) for a meropenem dose of 6 g/24 h. CONCLUSIONS High interindividual variability in meropenem CSF concentration was observed in patients with nosocomial ventriculitis. A nomograph to predict the daily meropenem dose required for target attainment for a given eGFR and CSF protein count was developed.
Collapse
Affiliation(s)
- Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Germany; Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Germany.
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University Hamburg, Germany
| |
Collapse
|
20
|
Schlemm E, Magnus T, Rimmele LD, Münsterberg J, Bester M, Kessner SS, Gelderblom M, Gerloff C. Recurrent amnesia caused by early seizures after hippocampal infarction: a case report. BMC Neurol 2022; 22:18. [PMID: 35012472 PMCID: PMC8744318 DOI: 10.1186/s12883-021-02543-8] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background We report the case of a patient with recurrent episodes of disturbed memory suggestive of transient epileptic amnesia, and a focal hippocampal lesion typically associated with transient global amnesia. We argue how careful consideration of clinical, electrophysiological and imaging findings can resolve this apparent contradiction and lead to a diagnosis of early symptomatic post-stroke seizures that links brain structure to function in a new, clinically relevant way. Case presentation A 70-year-old patient was identified in clinical practice in our tertiary care centre and was evaluated clinically as well as by repeated electroencephalography and magnetic resonance imaging. The presenting complaint were recurrent episodes of short-term memory disturbance which manifested as isolated anterograde amnesia on neurocognitive evaluation. EEG and MRI revealed predominantly right frontotemporal spikes and a punctate diffusion-restricted lesion in the left hippocampus, respectively. Both symptoms and EEG changes subsided under anticonvulsant treatment with levetiracetam. Conclusions Our report contributes to the current discussion of clinical challenges in the differential diagnosis of transient memory disturbance. It suggests that focal diffusion-restricted hippocampal lesions, as seen in TGA, might be ischemic and thus highlights the importance of considering post-stroke seizures as a possible cause of transient memory disturbance.
Collapse
Affiliation(s)
- Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Tim Magnus
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leander D Rimmele
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Justine Münsterberg
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxim Bester
- Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Zentrum für Radiologie und Endoskopie, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon S Kessner
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mathias Gelderblom
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
21
|
Ingwersen T, Wolf S, Birke G, Schlemm E, Bartling C, Bender G, Meyer A, Nolte A, Ottes K, Pade O, Peller M, Steinmetz J, Gerloff C, Thomalla G. Long-term recovery of upper limb motor function and self-reported health: results from a multicenter observational study 1 year after discharge from rehabilitation. Neurol Res Pract 2021; 3:66. [PMID: 34955097 PMCID: PMC8711154 DOI: 10.1186/s42466-021-00164-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background Impaired motor functions after stroke are common and negatively affect patients' activities of daily living and quality of life. In particular, hand motor function is essential for daily activities, but often returns slowly and incompletely after stroke. However, few data are available on the long-term dynamics of motor recovery and self-reported health status after stroke. The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE) project aims to address this knowledge gap by studying the clinical course of recovery after inpatient rehabilitation. Methods In this prospective observational longitudinal multicenter study, patients were included towards the end of inpatient rehabilitation after ischemic or hemorrhagic stroke. Follow-up examination was performed at three, six, and twelve months after enrollment. Motor function was assessed by the Upper Extremity Fugl-Meyer Assessment (FMA), grip and pinch strength, and the nine-hole peg test. In addition, Patient-Reported Outcomes Measurement Information System 10-Question Short Form (PROMIS-10) was included. Linear mixed effect models were fitted to analyze change over time. To study determinants of hand motor function, patients with impaired hand function at baseline were grouped into improvers and non-improvers according to hand motor function after twelve months. Results A total of 176 patients were included in the analysis. Improvement in all motor function scores and PROMIS-10 was shown up to 1 year after inpatient rehabilitation. FMA scores improved by an estimate of 5.0 (3.7–6.4) points per year. In addition, patient-reported outcome measures increased by 2.5 (1.4–3.6) and 2.4 (1.4–3.4) per year in the physical and mental domain of PROMIS-10. In the subgroup analysis non-improvers showed to be more often female (15% vs. 55%, p = 0.0155) and scored lower in the Montreal Cognitive Assessment (25 [23–27] vs. 22 [20.5–24], p = 0.0252). Conclusions Continuous improvement in motor function and self-reported health status is observed up to 1 year after inpatient stroke rehabilitation. Demographic and clinical parameters associated with these improvements need further investigation. These results may contribute to the further development of the post-inpatient phase of stroke rehabilitation. Trial registration: The trial is registered at ClinicalTrials.gov (NCT04119479).
Collapse
Affiliation(s)
- Thies Ingwersen
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Silke Wolf
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Gunnar Birke
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | | | - Gabriele Bender
- RehaCentrum Hamburg GmbH, Martinistraße 66, 20246, Hamburg, Germany
| | - Alfons Meyer
- MediClin Klinikum Soltau, Oeninger Weg 59, 29614, Soltau, Germany
| | - Achim Nolte
- VAMED Klinik Geesthacht, Johannes-Ritter-Straße 100, 21502, Geesthacht, Germany
| | - Katharina Ottes
- RehaCentrum Hamburg GmbH, Martinistraße 66, 20246, Hamburg, Germany
| | - Oliver Pade
- Klinikum Bad Bramstedt, Klinik Für Neurologische Rehabilitation, Oskar-Alexander-Straße 26, 24576, Bad Bramstedt, Germany
| | - Martin Peller
- VAMED Rehaklinik Damp, Seute-Deern-Ring 30, 24351, Damp, Germany
| | - Jochen Steinmetz
- Klinikum Bad Bramstedt, Klinik Für Neurologische Rehabilitation, Oskar-Alexander-Straße 26, 24576, Bad Bramstedt, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| |
Collapse
|
22
|
Cheng B, Pinnschmidt H, Königsberg A, Schlemm E, Boutitie F, Ebinger M, Endres M, Fiebach JB, Fiehler J, Galinovic I, Lemmens R, Muir KW, Pedraza S, Puig J, Simonsen CZ, Thijs V, Wouters A, Gerloff C, Thomalla G. Estimating nocturnal stroke onset times by magnetic resonance imaging in the WAKE-UP trial. Int J Stroke 2021; 17:323-330. [PMID: 34791943 DOI: 10.1177/17474930211059608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fluid-attenuated inversion recovery (FLAIR) sequences have gained a role to guide treatment of patients with unknown time of stroke symptom onset. Evolution of signal intensities in FLAIR is associated with time since stroke onset with continuous linear increases. AIMS Estimating symptom onset during night-sleep in patients from the WAKE-UP trial based on relative signal intensities FLAIR (FLAIR-rSI) from acute stroke lesions an independent dataset (PRE-FLAIR study). METHODS FLAIR-rSI was quantified in stroke lesions in PRE-FLAIR and WAKE-UP. The PRE-FLAIR study was a multicenter observational trial establishing FLAIR as a surrogate parameter for time since stroke onset. WAKE-UP was a randomized controlled trial that revealed a benefit for alteplase in patients selected based on a DWI-FLAIR mismatch. Stroke onset times were recorded in PRE-FLAIR and used to fit a linear regression model with FLAIR-rSI, adjusted for patient age and lesion volume. The model was applied to FLAIR-rSI of stroke lesions to estimate onset times in those patients enrolled in WAKE-UP who had symptom onset during night-sleep. RESULTS FLAIR-rSI was quantified in 399 patients from PRE-FLAIR. Linear regression indicated a significant association of age (p = 0.001), lesion volume (p = 0.005) and FLAIR-rSI (p < 0.001) with time since symptom onset (adjusted R2 = 0.179). In 813 patients from WAKE-UP, distribution of times of last seen well, symptom recognition and MRI examination were recorded. Median times of last seen well were 1 h before midnight (IQR 2.4 h) and symptom recognition 7 h after midnight (IRQ 2.2 h). Based on the FLAIR-rSI profiles, we estimated median stroke onset 6.1 h after midnight (IQR 2.7 h). CONCLUSION Nocturnal strokes during night-sleep may predominantly occur during the early morning hours. Our results are in line with evidence of characteristic diurnal patterns of cardiovascular events.
Collapse
Affiliation(s)
- Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans Pinnschmidt
- Institut für Medizinische Biometrie und Epidemiologie, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Königsberg
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin (CSB), Charité, Berlin, Germany.,Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin (CSB), Charité, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Campus Mitte, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - Jochen B Fiebach
- Centrum für Schlaganfallforschung Berlin (CSB), Charité, Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ivana Galinovic
- Centrum für Schlaganfallforschung Berlin (CSB), Charité, Berlin, Germany
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,Department of Neurosciences, University of Leuven, Leuven, Belgium.,Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, UK
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Girona, Spain
| | - Josep Puig
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Girona, Spain
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia.,Austin Health, Department of Neurology, Heidelberg, Australia
| | - Anke Wouters
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,Department of Neurosciences, University of Leuven, Leuven, Belgium.,Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
23
|
Lettow I, Jensen M, Schlemm E, Boutitie F, Quandt F, Cheng B, Ebinger M, Endres M, Fiebach JB, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Gerloff C, Thomalla G. Serious Adverse Events and Their Impact on Functional Outcome in Acute Ischemic Stroke in the WAKE-UP Trial. Stroke 2021; 52:3768-3776. [PMID: 34433305 DOI: 10.1161/strokeaha.120.033425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE During the first days and weeks after an acute ischemic stroke, patients are prone to complications that can influence further treatment, recovery, and functional outcome. In clinical trials, severe complications are recorded as serious adverse events (SAE). We analyzed the effect of SAE on functional outcome and predictors of SAE in the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke). METHODS We performed a post hoc analysis of WAKE-UP, a multicenter, randomized, placebo-controlled clinical trial of magnetic resonance imaging-guided intravenous thrombolysis with alteplase in patients with acute ischemic stroke and unknown time of onset. Functional outcome was assessed by the modified Rankin Scale 90 days after the stroke. SAE were reported to a central safety desk and recorded and categorized by organ system using Medical Dictionary for Regulatory Activities terminology. We used logistic regression analysis to determine the effect of SAE on functional outcome and linear multiple regression analysis to identify baseline predictors of SAE. RESULTS Among 503 patients randomized, 199 SAE were reported for n=110 (22%) patients. Of those patients who did suffer a SAE, 20 (10%) had a fatal outcome. Patients suffering from at least one SAE had a lower odds of reaching a favorable outcome (modified Rankin Scale score of 0-1) at 90 days (adjusted odds ratio, 0.36 [95% CI, 0.21-0.61], P<0.001). Higher age (P=0.04) and male sex (P=0.01) were predictors for the occurrence of SAE. CONCLUSIONS SAEs were observed in about one in 5 patients, were more frequent in elderly and male patients and were associated with worse functional outcome. These results may help to assess the risk of SAE in future stroke trials and create awareness for severe complications after stroke in clinical practice. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01525290 and https://eudract.ema.europa.eu; Unique identifier: 2011-005906-32.
Collapse
Affiliation(s)
- Iris Lettow
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | - Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, France (F.B.)
| | - Fanny Quandt
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | - Martin Ebinger
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Germany (M. Ebinger).,entrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Germany (M. Ebinger, M. Endres, J.B.F.)
| | - Matthias Endres
- entrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Germany (M. Ebinger, M. Endres, J.B.F.).,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (M. Endres)
| | - Jochen B Fiebach
- entrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Germany (M. Ebinger, M. Endres, J.B.F.)
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia (V.T.).,Austin Health, Department of Neurology, Australia (V.T.)
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Belgium (R.L.).,KU Leuven - University of Leuven, Department of Neurosciences, Experimental Neurology, Belgium (R.L.).,VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Belgium (R.L.)
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, University Avenue, Glasgow G12 8QQ, United Kingdom (K.W.M.)
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, France (N.N.)
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt - Edifici M2, Italysa (S.P.)
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Denmark (C.Z.S.)
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Germany (I.L., M.J., E.S., F.Q., B.C., C.G., G.T.)
| | | |
Collapse
|
24
|
Mayer C, Frey BM, Schlemm E, Petersen M, Engelke K, Hanning U, Jagodzinski A, Borof K, Fiehler J, Gerloff C, Thomalla G, Cheng B. Linking cortical atrophy to white matter hyperintensities of presumed vascular origin. J Cereb Blood Flow Metab 2021; 41:1682-1691. [PMID: 33259747 PMCID: PMC8221767 DOI: 10.1177/0271678x20974170] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 11/15/2022]
Abstract
We examined the relationship between white matter hyperintensities (WMH) and cortical neurodegeneration in cerebral small vessel disease (CSVD) by investigating whether cortical thickness is a remote effect of WMH through structural fiber tract connectivity in a population at increased risk of CSVD. We measured cortical thickness on T1-weighted images and segmented WMH on FLAIR images in 930 participants of a population-based cohort study at baseline. DWI-derived whole-brain probabilistic tractography was used to define WMH connectivity to cortical regions. Linear mixed-effects models were applied to analyze the relationship between cortical thickness and connectivity to WMH. Factors associated with cortical thickness (age, sex, hemisphere, region, individual differences in cortical thickness) were added as covariates. Median age was 64 [IQR 46-76] years. Visual inspection of surface maps revealed distinct connectivity patterns of cortical regions to WMH. WMH connectivity to the cortex was associated with reduced cortical thickness (p = 0.009) after controlling for covariates. This association was found for periventricular WMH (p = 0.001) only. Our results indicate an association between WMH and cortical thickness via connecting fiber tracts. The results imply a mechanism of secondary neurodegeneration in cortical regions distant, yet connected to subcortical vascular lesions, which appears to be driven by periventricular WMH.
Collapse
Affiliation(s)
- Carola Mayer
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt M Frey
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marvin Petersen
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristin Engelke
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annika Jagodzinski
- Epidemiological Study Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of General and Interventional Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Katrin Borof
- Epidemiological Study Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
25
|
Königsberg A, DeMarco AT, Mayer C, Wouters A, Schlemm E, Ebinger M, Cho TH, Endres M, Fiebach JB, Fiehler J, Galinovic I, Puig J, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Gerloff C, Thomalla G, Cheng B. Influence of stroke infarct location on quality of life assessed in a multivariate lesion-symptom mapping study. Sci Rep 2021; 11:13490. [PMID: 34188114 PMCID: PMC8241844 DOI: 10.1038/s41598-021-92865-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/15/2021] [Indexed: 11/20/2022] Open
Abstract
Stroke has a deleterious impact on quality of life. However, it is less well known if stroke lesions in different brain regions are associated with reduced quality of life (QoL). We therefore investigated this association by multivariate lesion-symptom mapping. We analyzed magnetic resonance imaging and clinical data from the WAKE-UP trial. European Quality of Life 5 Dimensions (EQ-5D) 3 level questionnaires were completed 90 days after stroke. Lesion symptom mapping was performed using a multivariate machine learning algorithm (support vector regression) based on stroke lesions 22-36 h after stroke. Brain regions with significant associations were explored in reference to white matter tracts. Of 503 randomized patients, 329 were included in the analysis (mean age 65.4 years, SD 11.5; median NIHSS = 6, IQR 4-9; median EQ-5D score 90 days after stroke 1, IQR 0-4, median lesion volume 3.3 ml, IQR 1.1-16.9 ml). After controlling for lesion volume, significant associations between lesions and EQ-5D score were detected for the right putamen, and internal capsules of both hemispheres. Multivariate lesion inference analysis revealed an association between injuries of the cortico-spinal tracts with worse self-reported quality of life 90 days after stroke in comparably small stroke lesions, extending previous reports of the association of striato-capsular lesions with worse functional outcome. Our findings are of value to identify patients at risk of impaired QoL after stroke.
Collapse
Affiliation(s)
- Alina Königsberg
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Andrew T DeMarco
- Department of Rehabilitation Medicine, Georgetown University, Washington, DC, USA
| | - Carola Mayer
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Anke Wouters
- Neurology, Amsterdam University Medical Centers, AMC, Amsterdam, The Netherlands
| | - Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany
- Neurologie der Rehaklinik Medical Park Humboldtmühle, An der Mühle 2-9, 13507, Berlin, Germany
| | - Tae-Hee Cho
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon, Hospices Civils de Lyon, Lyon, France
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany
| | - Jochen B Fiebach
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Ivana Galinovic
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117, Berlin, Germany
| | - Josep Puig
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt - Edifici M2, 17190, Salt, Girona, Spain
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, HeidelbergVictoria, VIC, 3084, Australia
- Department of Neurology, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Oude Markt 13, Bus 5005, 3000, Leuven, Belgium
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Herestraat 49, Bus 602, 3000, Leuven, Belgium
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon, Hospices Civils de Lyon, Lyon, France
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt - Edifici M2, 17190, Salt, Girona, Spain
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, 8200, Aarhus, Denmark
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| |
Collapse
|
26
|
Kessner SS, Schlemm E, Gerloff C, Thomalla G, Cheng B. Grey and white matter network disruption is associated with sensory deficits after stroke. Neuroimage Clin 2021; 31:102698. [PMID: 34023668 PMCID: PMC8163991 DOI: 10.1016/j.nicl.2021.102698] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 12/04/2022]
Abstract
Somatosensory deficits occur in about 60% of patients after ischaemic stroke. Clinical and imaging data of 101 ischaemic stroke patients were analysed. Stroke lesions may disrupt grey (GM) and/or white matter (WM) network. Lesion volume explains 23% of sensory deficit variance; GM / WM disruption adds 14% Subnetwork of postcentral, supramarginal, transverse temporal gyri involved.
Somatosensory deficits after ischaemic stroke are common and can occur in patients with lesions in the anterior parietal cortex and subcortical nuclei. It is less clear to what extent damage to white matter tracts within the somatosensory system may contribute to somatosensory deficits after stroke. We compared the roles of cortical damage and disruption of subcortical white matter tracts as correlates of somatosensory deficit after ischaemic stroke. Clinical and imaging data were assessed in incident stroke patients. Somatosensory deficits were measured using a standardized somatosensory test. Remote effects were quantified by projecting the MRI-based segmented stroke lesions onto a predefined atlas of white matter connectivity. Direct ischaemic damage to grey matter was computed by lesion overlap with grey matter areas. The association between lesion impact scores and sensory deficit was assessed statistically. In 101 patients, median sensory score was 188/193 (97.4%). Lesion volume was associated with somatosensory deficit, explaining 23.3% of variance. Beyond this, the stroke-induced grey and white matter disruption within a subnetwork of the postcentral, supramarginal, and transverse temporal gyri explained an additional 14% of the somatosensory outcome variability. On mutual comparison, white matter network disruption was a stronger predictor than grey matter damage. Ischaemic damage to both grey and white matter are structural correlates of acute somatosensory disturbance after ischaemic stroke. Our data suggest that white matter integrity of a somatosensory network of primary and secondary cortex is a prerequisite for normal processing of somatosensory inputs and might be considered as an additional parameter for stroke outcome prediction in the future.
Collapse
Affiliation(s)
- Simon S Kessner
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
27
|
Schlemm E, Ingwersen T, Königsberg A, Boutitie F, Ebinger M, Endres M, Fiebach JB, Fiehler J, Galinovic I, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Puig J, Simonsen CZ, Thijs V, Wouters A, Gerloff C, Thomalla G, Cheng B. Preserved structural connectivity mediates the clinical effect of thrombolysis in patients with anterior-circulation stroke. Nat Commun 2021; 12:2590. [PMID: 33972513 PMCID: PMC8110812 DOI: 10.1038/s41467-021-22786-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/29/2021] [Indexed: 12/12/2022] Open
Abstract
Thrombolysis with recombinant tissue plasminogen activator in acute ischemic stroke aims to restore compromised blood flow and prevent further neuronal damage. Despite the proven clinical efficacy of this treatment, little is known about the short-term effects of systemic thrombolysis on structural brain connectivity. In this secondary analysis of the WAKE-UP trial, we used MRI-derived measures of infarct size and estimated structural network disruption to establish that thrombolysis is associated not only with less infarct growth, but also with reduced loss of large-scale connectivity between grey-matter areas after stroke. In a causal mediation analysis, infarct growth mediated a non-significant 8.3% (CI95% [-8.0, 32.6]%) of the clinical effect of thrombolysis on functional outcome. The proportion mediated jointly through infarct growth and change of structural connectivity, especially in the border zone around the infarct core, however, was as high as 33.4% (CI95% [8.8, 77.4]%). Preservation of structural connectivity is thus an important determinant of treatment success and favourable functional outcome in addition to lesion volume. It might, in the future, serve as an imaging endpoint in clinical trials or as a target for therapeutic interventions.
Collapse
Affiliation(s)
- Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Thies Ingwersen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Königsberg
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France
- Université Lyon 1, Villeurbanne, France
- CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
- ExcellenceCluster NeuroCure, Berlin, Germany
| | - Jochen B Fiebach
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ivana Galinovic
- Centrum für Schlaganfallforschung Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- KU Leuven - University of Leuven, Department of Neurosciences, Experimental Neurology, Leuven, Belgium
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Leuven, Belgium
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon; Hospices Civils de Lyon, Lyon, France
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt - Edifici M2, Salt, Girona, Spain
| | - Josep Puig
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Parc Hospitalari Martí i Julià de Salt - Edifici M2, Salt, Girona, Spain
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
- Austin Health, Department of Neurology, Heidelberg, VIC, Australia
| | - Anke Wouters
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- KU Leuven - University of Leuven, Department of Neurosciences, Experimental Neurology, Leuven, Belgium
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Leuven, Belgium
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| |
Collapse
|
28
|
Schulz M, Malherbe C, Cheng B, Thomalla G, Schlemm E. Functional connectivity changes in cerebral small vessel disease - a systematic review of the resting-state MRI literature. BMC Med 2021; 19:103. [PMID: 33947394 PMCID: PMC8097883 DOI: 10.1186/s12916-021-01962-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/17/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cerebral small vessel disease (CSVD) is a common neurological disease present in the ageing population that is associated with an increased risk of dementia and stroke. Damage to white matter tracts compromises the substrate for interneuronal connectivity. Analysing resting-state functional magnetic resonance imaging (fMRI) can reveal dysfunctional patterns of brain connectivity and contribute to explaining the pathophysiology of clinical phenotypes in CSVD. MATERIALS AND METHODS This systematic review provides an overview of methods and results of recent resting-state functional MRI studies in patients with CSVD. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol, a systematic search of the literature was performed. RESULTS Of 493 studies that were screened, 44 reports were identified that investigated resting-state fMRI connectivity in the context of cerebral small vessel disease. The risk of bias and heterogeneity of results were moderate to high. Patterns associated with CSVD included disturbed connectivity within and between intrinsic brain networks, in particular the default mode, dorsal attention, frontoparietal control, and salience networks; decoupling of neuronal activity along an anterior-posterior axis; and increases in functional connectivity in the early stage of the disease. CONCLUSION The recent literature provides further evidence for a functional disconnection model of cognitive impairment in CSVD. We suggest that the salience network might play a hitherto underappreciated role in this model. Low quality of evidence and the lack of preregistered multi-centre studies remain challenges to be overcome in the future.
Collapse
Affiliation(s)
- Maximilian Schulz
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Caroline Malherbe
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- Department of Computational Neuroscience, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
| |
Collapse
|
29
|
Frey BM, Petersen M, Schlemm E, Mayer C, Hanning U, Engelke K, Fiehler J, Borof K, Jagodzinski A, Gerloff C, Thomalla G, Cheng B. White matter integrity and structural brain network topology in cerebral small vessel disease: The Hamburg city health study. Hum Brain Mapp 2021; 42:1406-1415. [PMID: 33289924 PMCID: PMC7927298 DOI: 10.1002/hbm.25301] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
Cerebral small vessel disease is a common finding in the elderly and associated with various clinical sequelae. Previous studies suggest disturbances in the integration capabilities of structural brain networks as a mediating link between imaging and clinical presentations. To what extent cerebral small vessel disease might interfere with other measures of global network topology is not well understood. Connectomes were reconstructed via diffusion weighted imaging in a sample of 930 participants from a population based epidemiologic study. Linear models were fitted testing for an association of graph-theoretical measures reflecting integration and segregation with both the Peak width of Skeletonized Mean Diffusivity (PSMD) and the load of white matter hyperintensities of presumed vascular origin (WMH). The latter were subdivided in periventricular and deep for an analysis of localisation-dependent correlations of cerebral small vessel disease. The median WMH volume was 0.6 mL (1.4) and the median PSMD 2.18 mm2 /s x 10-4 (0.5). The connectomes showed a median density of 0.880 (0.030), the median values for normalised global efficiency, normalised clustering coefficient, modularity Q and small-world propensity were 0.780 (0.045), 1.182 (0.034), 0.593 (0.026) and 0.876 (0.040) respectively. An increasing burden of cerebral small vessel disease was significantly associated with a decreased integration and increased segregation and thus decreased small-worldness of structural brain networks. Even in rather healthy subjects increased cerebral small vessel disease burden is accompanied by topological brain network disturbances. Segregation parameters and small-worldness might as well contribute to the understanding of the known clinical sequelae of cerebral small vessel disease.
Collapse
Affiliation(s)
- Benedikt M. Frey
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Marvin Petersen
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Eckhard Schlemm
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Carola Mayer
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Uta Hanning
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Kristin Engelke
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Jens Fiehler
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Katrin Borof
- Epidemiological study centerUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Annika Jagodzinski
- Epidemiological study centerUniversity Medical Center Hamburg‐EppendorfHamburgGermany
- Department of General and Interventional CardiologyUniversity Heart and Vascular CenterHamburgGermany
| | - Christian Gerloff
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Götz Thomalla
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Bastian Cheng
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| |
Collapse
|
30
|
Deb-Chatterji M, Schlemm E, Flottmann F, Meyer L, Alegiani A, Brekenfeld C, Fiehler J, Gerloff C, Thomalla G. Sex Differences in Outcome After Thrombectomy for Acute Ischemic Stroke are Explained by Confounding Factors. Clin Neuroradiol 2020; 31:1101-1109. [PMID: 33346850 PMCID: PMC8648700 DOI: 10.1007/s00062-020-00983-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/21/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of this study was to analyze sex differences in outcome after thrombectomy for acute ischemic stroke in clinical practice in a large prospective multicenter registry. METHODS Data of consecutive stroke patients treated with thrombectomy (June 2015-April 2018) derived from an industry-independent registry (German Stroke Registry-Endovascular Treatment) were prospectively analyzed. Multivariable binary logistic regression analyses were applied to determine whether sex is a predictor of functional independence outcome (defined as a modified Rankin scale [mRS] 0-2) 90 days after stroke. RESULTS In total, 2316 patients were included in the analysis, 1170 (50.5%) were female and 1146 (49.5%) were male. Women were older (median age 78 vs. 72 years; p < 0.001) and more frequently had a prestroke functional impairment defined by mRS >1 (24.8% vs. 14.1%; p < 0.001). In unadjusted analyses, independent outcome at 90 days was less frequent in women (33.2%) than men (40.6%; p < 0.001). Likewise, mortality was higher in women than in men (30.7% vs. 26.4%; p = 0.024). In adjusted regression analyses, however, sex was not associated with outcome. Lower age, a lower baseline National Institutes of Health Stroke Scale score, a higher Alberta Stroke Program Early CT score, prestroke functional independence, successful reperfusion, and concomitant intravenous thrombolysis therapy predicted independent outcome. CONCLUSION Women showed a worse functional outcome after thrombectomy for acute ischemic stroke in clinical practice; however, after adjustment for crucial confounders sex was not a predictor of outcome. The difference in outcome thus appears to result from differences in confounding factors such as age and prestroke functional status.
Collapse
Affiliation(s)
- Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Interventional Neuroradiology and Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Interventional Neuroradiology and Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Interventional Neuroradiology and Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Interventional Neuroradiology and Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
31
|
Jensen M, Schlemm E, Cheng B, Lettow I, Quandt F, Boutitie F, Ebinger M, Endres M, Fiebach JB, Fiehler J, Galinovic I, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Gerloff C, Thomalla G. Clinical Characteristics and Outcome of Patients With Hemorrhagic Transformation After Intravenous Thrombolysis in the WAKE-UP Trial. Front Neurol 2020; 11:957. [PMID: 32982951 PMCID: PMC7483750 DOI: 10.3389/fneur.2020.00957] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/23/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Hemorrhagic transformation (HT) is an important complication of intravenous thrombolysis with alteplase. HT can show a wide range from petechiae to parenchymal hematoma with mass effect with varying clinical impact. We studied clinical and imaging characteristics of patients with HT and evaluated whether different types of HT are associated with functional outcome. Methods: We performed a post-hoc analysis of WAKE-UP, a multicenter, randomized, placebo-controlled trial of MRI-guided intravenous alteplase in unknown onset stroke. HT was assessed on follow-up MRI or CT and diagnosed as hemorrhagic infarction type 1 and type 2 (HI1 and HI2, combined as HI), and parenchymal hemorrhage type 1 and type 2 (PH1 and PH2, combined as PH). Severity of stroke symptoms was assessed using the National Institutes of Health Stroke Scale (NIHSS) at baseline. Stroke lesion volume was measured on baseline diffusion weighted imaging (DWI). Primary endpoint was a favorable outcome defined as a modified Rankin Scale score 0–1 at 90 days. Results: Of 483 patients included in the analysis, 95 (19.7%) showed HI and 21 (4.4%) had PH. Multiple logistic regression analysis identified treatment with alteplase (OR, 2.08 [95% CI, 1.28–3.40]), baseline NIHSS score (OR, 1.11 [95% CI, 1.05–1.17]), DWI lesion volume (OR, 1.03 [95% CI, 1.01–1.05]), baseline glucose levels (OR, 1.01 [95% CI, 1.00–1.01]) and atrial fibrillation (OR, 3.02 [95% CI, 1.57–5.80]) as predictors of any HT. The same parameters predicted HI. Predictors of PH were baseline NIHSS score (OR, 1.11 [95% CI, 1.01–1.22]) and as a trend treatment with alteplase (OR, 2.40 [95% CI, 0.93–6.96]). PH was associated with lower odds of favorable outcome (OR 0.25, 95% [CI 0.05–0.86]), while HI was not. Conclusion: Our results indicate that HI is associated with stroke severity, cardiovascular risk factors and thrombolysis. PH is a rare complication, more frequent in severe stroke and with thrombolysis. In contrast to HI, PH is associated with worse functional outcome. The impact of HT after MRI-guided intravenous alteplase for unknown onset stroke on clinical outcome is similar as in the trials of stroke thrombolysis within a known early time-window.
Collapse
Affiliation(s)
- Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Iris Lettow
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fanny Quandt
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France.,Université Lyon 1, Villeurbanne, France.,CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Disease (DZNE), Partner Site Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Centrum für Schlaganfallforschung Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ivana Galinovic
- Centrum für Schlaganfallforschung Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia.,Austin Health, Department of Neurology, Heidelberg, VIC, Australia
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,Department of Neurosciences, Experimental Neurology, KU Leuven-University of Leuven, Leuven, Belgium.,VIB, Laboratory of Neurobiology, Center for Brain & Disease Research, Leuven, Belgium
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, Hospices Civils de Lyon, Lyon, France
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr. Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Girona, Spain
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
32
|
Ernst M, Psychogios MN, Schlemm E, Holodinsky JK, Kamal N, Rodt T, Henningsen H, Kraemer C, Thomalla G, Fiehler J, Brekenfeld C. Modeling the Optimal Transportation for Acute Stroke Treatment : Impact of Diurnal Variations in Traffic Rate. Clin Neuroradiol 2020; 31:729-736. [PMID: 32676698 PMCID: PMC8463378 DOI: 10.1007/s00062-020-00933-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/25/2020] [Indexed: 11/26/2022]
Abstract
Purpose Prolonged transfer times between the primary stroke center (PSC) and the comprehensive stroke center (CSC) are one of the major causes of treatment delay for endovascular stroke treatment. We aimed to analyze the effect of the diurnal variations in traffic rates at weekdays and weekends on the catchment area size of three transportation paradigms, i.e. mothership, drip-and-ship (DS) and drip-and-drive (DD). Methods A conditional probability model that predicts the probability of good outcome for patients with suspected large vessel occlusion was used to analyze the prehospital stroke triage in northwest Germany and produce catchment area maps. Transportation times were calculated during each hour of a weekday and a Sunday using Google Maps. For comparison, real DD transportation times from our CSC in Hamburg-Eppendorf (blinded for review) to a PSC in Lüneburg were prospectively recorded. Result On weekdays, the mothership catchment area was the largest (≥40,000 km2, 63%) except for a decrease during morning rush hours, when the DD catchment area was highest (30,879 km2, 48%). The DS catchment area was higher than the DD catchment area during the afternoon rush hours both during the week as well as on Sundays. Conclusion Our study showed a considerable impact of the diurnal variations in traffic rate and direction of travel on optimal stroke transportation. Stroke systems of care should take real time traffic information into account. Electronic supplementary material The online version of this article (10.1007/s00062-020-00933-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Haus Ost 22 (O 22), Martinistr. 52, 20246, Hamburg, Germany.
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jessalyn K Holodinsky
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada
| | - Thomas Rodt
- Department of Diagnostic and Interventional Radiology, Klinikum Lüneburg, Lüneburg, Germany
| | | | | | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Haus Ost 22 (O 22), Martinistr. 52, 20246, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Haus Ost 22 (O 22), Martinistr. 52, 20246, Hamburg, Germany
| |
Collapse
|
33
|
Petersen M, Frey BM, Schlemm E, Mayer C, Hanning U, Engelke K, Fiehler J, Borof K, Jagodzinski A, Gerloff C, Thomalla G, Cheng B. Network Localisation of White Matter Damage in Cerebral Small Vessel Disease. Sci Rep 2020; 10:9210. [PMID: 32514044 PMCID: PMC7280237 DOI: 10.1038/s41598-020-66013-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/11/2020] [Indexed: 11/25/2022] Open
Abstract
Cerebral small vessel disease (CSVD) is a widespread condition associated to stroke, dementia and depression. To shed light on its opaque pathophysiology, we conducted a neuroimaging study aiming to assess the location of CSVD-induced damage in the human brain network. Structural connectomes of 930 subjects of the Hamburg City Health Study were reconstructed from diffusion weighted imaging. The connectome edges were partitioned into groups according to specific schemes: (1) connection to grey matter regions, (2) course and length of underlying streamlines. Peak-width of skeletonised mean diffusivity (PSMD) - a surrogate marker for CSVD - was related to each edge group's connectivity in a linear regression analysis allowing localisation of CSVD-induced effects. PSMD was associated with statistically significant decreases in connectivity of most investigated edge groups except those involved in connecting limbic, insular, temporal or cerebellar regions. Connectivity of interhemispheric and long intrahemispheric edges as well as edges connecting subcortical and frontal brain regions decreased most severely with increasing PSMD. In conclusion, MRI findings of CSVD are associated with widespread impairment of structural brain network connectivity, which supports the understanding of CSVD as a global brain disease. The pattern of regional preference might provide a link to clinical phenotypes of CSVD.
Collapse
Affiliation(s)
- Marvin Petersen
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Benedikt M Frey
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carola Mayer
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristin Engelke
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katrin Borof
- Epidemiological study center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annika Jagodzinski
- Epidemiological study center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of General and Interventional Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
34
|
Schlemm E, Schulz R, Bönstrup M, Krawinkel L, Fiehler J, Gerloff C, Thomalla G, Cheng B. Structural brain networks and functional motor outcome after stroke-a prospective cohort study. Brain Commun 2020; 2:fcaa001. [PMID: 32954275 PMCID: PMC7425342 DOI: 10.1093/braincomms/fcaa001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 10/08/2019] [Accepted: 12/02/2019] [Indexed: 01/27/2023] Open
Abstract
The time course of topological reorganization that occurs in the structural connectome after an ischaemic stroke is currently not well understood. We aimed to determine the evolution of structural brain networks in stroke patients with motor deficits and relate changes in their global topology to residual symptom burden and functional impairment. In this prospective cohort study, ischaemic stroke patients with supratentorial infarcts and motor symptoms were assessed longitudinally by advanced diffusion MRI and detailed clinical testing of upper extremity motor function at four time points from the acute to the chronic stage. For each time point, structural connectomes were reconstructed, and whole-hemisphere global network topology was quantified in terms of integration and segregation parameters. Using non-linear joint mixed-effects regression modelling, network evolution was related to lesion volume and clinical outcome. Thirty patients were included for analysis. Graph-theoretical analysis demonstrated that, over time, brain networks became less integrated and more segregated with decreasing global efficiency and increasing modularity. Changes occurred in both stroke and intact hemispheres and, in the latter, were positively associated with lesion volume. Greater change in topology was associated with larger residual symptom burden and greater motor impairment 1, 3 and 12 months after stroke. After ischaemic stroke, brain networks underwent characteristic changes in both ipsi- and contralesional hemispheres. Topological network changes reflect the severity of damage to the structural network and are associated with functional outcome beyond the impact of lesion volume.
Collapse
Affiliation(s)
- Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg–Eppendorf, 20246 Hamburg, Germany
| | - Robert Schulz
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg–Eppendorf, 20246 Hamburg, Germany
| | - Marlene Bönstrup
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg–Eppendorf, 20246 Hamburg, Germany
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Lutz Krawinkel
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg–Eppendorf, 20246 Hamburg, Germany
| | - Jens Fiehler
- Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Hamburg–Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg–Eppendorf, 20246 Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg–Eppendorf, 20246 Hamburg, Germany
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg–Eppendorf, 20246 Hamburg, Germany
| |
Collapse
|
35
|
Abstract
Background and Purpose- About 50% to 80% of stroke survivors present with somatosensory deficits. Somatosensory deficits because of an ischemic stroke are determined by the infarct location. However, a detailed understanding of the long-term effect of lesions on somatosensory performance is lacking. Methods- This prospective observational study enrolled 101 ischemic stroke patients. For voxel-based lesion-symptom mapping, magnetic resonance imaging fluid-attenuated inversion recovery imaging infarct lesions were segmented within 5 days after stroke. Standardized tests such as the National Institutes of Health Stroke Scale and the Rivermead Assessment of Somatosensory Performance were performed during acute stage, after 3 and 12 months. This included bilateral testing for multiple tactile and proprioceptive somatosensory modalities (pressure, light touch, sharp-dull discrimination, temperature discrimination, sensory extinction, 2-point discrimination, and joint position and movement sense). We further study the association of acute somatosensory deficit with functional outcome 12 months after stroke assessed by the modified Rankin Scale using univariate and multiple linear regression analysis also including acute motor deficit assessed by the arm research action test. Results- Sixty patients (59.4%) showed impairment in at least one somatosensory modality. Light touch was most frequently affected (38.7%), whereas temperature was least frequently affected (21.8%). After 3 months, significant recovery was observed in all somatosensory modalities, with only minor additional improvements after 12 months. Voxel-based lesion-symptom mapping revealed significant associations of lesions in the primary and secondary somatosensory and insular cortex with somatosensory deficits. Acute somatosensory deficit was associated with functional outcome at 12 months. However, including the acute motor deficit, somatosensory deficit was no longer an independent predictor of functional outcome. Conclusions- Our study confirms that somatosensory deficits are frequent in acute ischemic stroke but largely recover over time. Infarct lesions in the primary and secondary somatosensory cortex and insula show a robust association with somatosensory impairment. Long-term disability is influenced by somatosensory deficits but driven by motor symptoms.
Collapse
Affiliation(s)
- Simon S Kessner
- From the Department of Neurology (S.S.K., E.S., B.C., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Eckhard Schlemm
- From the Department of Neurology (S.S.K., E.S., B.C., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Bastian Cheng
- From the Department of Neurology (S.S.K., E.S., B.C., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Ulrike Bingel
- Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Germany (U.B.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Christian Gerloff
- From the Department of Neurology (S.S.K., E.S., B.C., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- From the Department of Neurology (S.S.K., E.S., B.C., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| |
Collapse
|
36
|
Ernst M, Schlemm E, Holodinsky JK, Kamal N, Thomalla G, Fiehler J, Brekenfeld C. Modeling the Optimal Transportation for Acute Stroke Treatment: The Impact of the Drip-and-Drive Paradigm. Stroke 2019; 51:275-281. [PMID: 31735142 DOI: 10.1161/strokeaha.119.027493] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background and Purpose- Health systems are faced with the challenge of ensuring fast access to appropriate therapy for patients with acute stroke. The paradigms primarily discussed are mothership and drip and ship. Less attention has been focused on the drip-and-drive (DD) paradigm. Our aim was to analyze whether and under what conditions DD would predict the greatest probability of good outcome for patients with suspected ischemic stroke in Northwestern Germany. Methods- Conditional probability models based on the decay curves for endovascular therapy and intravenous thrombolysis were created to determine the best transport paradigm, and results were displayed using map visualizations. Our study area consisted of the federal states of Lower Saxony, Hamburg, and Schleswig-Holstein in Northwestern Germany covering an area of 64 065 km2 with a population of 12 703 561 in 2017 (198 persons per km2). In several scenarios, the catchment area, that is, the region that would result in the greatest probability of good outcomes, was calculated for each of the mothership, drip-and-ship, and the DD paradigms. Several different treatment time parameters were varied including onset-to-first-medical-response time, ambulance-on-scene time, door-to-needle time at primary stroke center, needle-to-door time, door-to-needle time at comprehensive stroke center, door-to-groin-puncture time, needle-to-interventionalist-leave time, and interventionalist-arrival-to-groin-puncture time. Results- The mothership paradigm had the largest catchment area; however, the DD catchment area was larger than the drip-and-ship catchment area so long as the needle-to-interventionalist-leave time and the interventionalist-arrival-to-groin-puncture time remain <40 minutes each. A slowed workflow in the DD paradigm resulted in a decrease of the DD catchment area to 1221 km2 (2%). Conclusions- Our study suggests the largest catchment area for the mothership paradigm and a larger catchment area of DD paradigm compared with the drip-and-ship paradigm in Northwestern Germany in most scenarios. The existence of different paradigms allows the spread of capacities, shares the cost and hospital income, and gives primary stroke centers the possibility to provide endovascular therapy services 24/7.
Collapse
Affiliation(s)
- Marielle Ernst
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Eckhard Schlemm
- Department of Neurology (E.S., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jessalyn K Holodinsky
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.K.H.)
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada (N.K.)
| | - Götz Thomalla
- Department of Neurology (E.S., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jens Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Caspar Brekenfeld
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| |
Collapse
|
37
|
Cheng B, Schlemm E, Schulz R, Boenstrup M, Messé A, Hilgetag C, Gerloff C, Thomalla G. Altered topology of large-scale structural brain networks in chronic stroke. Brain Commun 2019; 1:fcz020. [PMID: 32954263 PMCID: PMC7425306 DOI: 10.1093/braincomms/fcz020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/04/2019] [Accepted: 09/02/2019] [Indexed: 12/15/2022] Open
Abstract
Beyond disruption of neuronal pathways, focal stroke lesions induce structural disintegration of distant, yet connected brain regions via retrograde neuronal degeneration. Stroke lesions alter functional brain connectivity and topology in large-scale brain networks. These changes are associated with the degree of clinical impairment and recovery. In contrast, changes of large scale, structural brain networks after stroke are less well reported. We therefore aimed to analyse the impact of focal lesions on the structural connectome after stroke based on data from diffusion-weighted imaging and probabilistic fibre tracking. In total, 17 patients (mean age 64.5 ± 8.4 years) with upper limb motor deficits in the chronic stage after stroke and 21 healthy participants (mean age 64.9 ± 10.3 years) were included. Clinical deficits were evaluated by grip strength and the upper extremity Fugl-Meyer assessment. We calculated global and local graph theoretical measures to characterize topological changes in the structural connectome. Results from our analysis demonstrated significant alterations of network topology in both ipsi- and contralesional, primarily unaffected, hemispheres after stroke. Global efficiency was significantly lower in stroke connectomes as an indicator of overall reduced capacity for information transfer between distant brain areas. Furthermore, topology of structural connectomes was shifted toward a higher degree of segregation as indicated by significantly higher values of global clustering and modularity. On a level of local network parameters, these effects were most pronounced in a subnetwork of cortico-subcortical brain regions involved in motor control. Structural changes were not significantly associated with clinical measures. We propose that the observed network changes in our patients are best explained by the disruption of inter- and intrahemispheric, long white matter fibre tracts connecting distant brain regions. Our results add novel insights on topological changes of structural large-scale brain networks in the ipsi- and contralesional hemisphere after stroke.
Collapse
Affiliation(s)
- Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, D20246 Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, D20246 Hamburg, Germany
| | - Robert Schulz
- Department of Neurology, University Medical Center Hamburg-Eppendorf, D20246 Hamburg, Germany
| | - Marlene Boenstrup
- Department of Neurology, University Medical Center Hamburg-Eppendorf, D20246 Hamburg, Germany.,Human Cortical Physiology and Neurorehabilitation Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA
| | - Arnaud Messé
- Institute of Computational Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg 20252, Germany
| | - Claus Hilgetag
- Institute of Computational Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg 20252, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, D20246 Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, D20246 Hamburg, Germany
| |
Collapse
|
38
|
Schlemm L, Endres M, Scheitz JF, Ernst M, Nolte CH, Schlemm E. Comparative Evaluation of 10 Prehospital Triage Strategy Paradigms for Patients With Suspected Acute Ischemic Stroke. J Am Heart Assoc 2019; 8:e012665. [PMID: 31189395 PMCID: PMC6645624 DOI: 10.1161/jaha.119.012665] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background The best strategy to identify patients with suspected acute ischemic stroke and unknown vessel status (large vessel occlusion) for direct transport to a comprehensive stroke center instead of a nearer primary stroke center is unknown. Methods and Results We used mathematical modeling to estimate the impact of 10 increasingly complex prehospital triage strategy paradigms on the reduction of population‐wide stroke‐related disability. The model was applied to suspected acute ischemic stroke patients in (1) abstract geographies, and (2) 3 real‐world urban and rural geographies in Germany. Transport times were estimated based on stroke center location and road infrastructure; spatial distribution of emergency medical services calls was derived from census data with high spatial granularity. Parameter uncertainty was quantified in sensitivity analyses. The mothership strategy was associated with a statistically significant population‐wide gain of 8 to 18 disability‐adjusted life years in the 3 real‐world geographies and in most simulated abstract geographies (net gain −4 to 66 disability‐adjusted life years). Of the more complex paradigms, transportation of patients with clinically suspected large vessel occlusion based on a dichotomous large vessel occlusion detection scale to the nearest comprehensive stroke center yielded an additional clinical benefit of up to 12 disability‐adjusted life years in some rural but not in urban geographies. Triage strategy paradigms based on probabilistic conditional modeling added an additional benefit of 0 to 4 disability‐adjusted life years over less complex strategies if based on variable cutoff scores. Conclusions Variable stroke severity cutoff scores were associated with the highest reduction in stroke‐related disability. The mothership strategy yielded better clinical outcome than the drip‐‘n'‐ship strategy in most geographies.
Collapse
Affiliation(s)
- Ludwig Schlemm
- Klinik und Hochschulambulanz für NeurologieCharité—Universitätsmedizin BerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinGermany
- Berlin Institute of Health (BIH)BerlinGermany
| | - Matthias Endres
- Klinik und Hochschulambulanz für NeurologieCharité—Universitätsmedizin BerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinGermany
- Berlin Institute of Health (BIH)BerlinGermany
- DZHK (German Center for Cardiovascular Research)BerlinGermany
- DZNE (German Center for Neurodegenerative Diseases)BerlinGermany
| | - Jan F. Scheitz
- Klinik und Hochschulambulanz für NeurologieCharité—Universitätsmedizin BerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinGermany
- Berlin Institute of Health (BIH)BerlinGermany
- DZHK (German Center for Cardiovascular Research)BerlinGermany
| | - Marielle Ernst
- Medizinische FakultätUniversität HamburgGermany
- Abteilung für diagnostische und interventionelle NeuroradiologieUniversitätsklinikum Hamburg‐EppendorfHamburgGermany
| | - Christian H. Nolte
- Klinik und Hochschulambulanz für NeurologieCharité—Universitätsmedizin BerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinGermany
- Berlin Institute of Health (BIH)BerlinGermany
- DZHK (German Center for Cardiovascular Research)BerlinGermany
- DZNE (German Center for Neurodegenerative Diseases)BerlinGermany
| | - Eckhard Schlemm
- Medizinische FakultätUniversität HamburgGermany
- Klinik und Poliklinik für Neurologie, Kopf‐ und NeurozentrumUniversitätsklinikum Hamburg‐EppendorfHamburgGermany
| |
Collapse
|
39
|
Schlemm L, Schlemm E, Nolte CH, Endres M. Pre-hospital Triage of Acute Ischemic Stroke Patients-Importance of Considering More Than Two Transport Options. Front Neurol 2019; 10:437. [PMID: 31114538 PMCID: PMC6503645 DOI: 10.3389/fneur.2019.00437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/10/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Patients with acute ischemic stroke (AIS) and large vessel occlusion benefit from rapid access to mechanical thrombectomy in addition to intravenous thrombolysis. Prehospital triage algorithms to determine the optimal transport destination for AIS patients with unknown vessel status have so far only considered two alternatives: the nearest comprehensive (CSC) and the nearest primary stroke center (PSC). Objective: This study explores the importance of considering a larger number of PSCs during pre-hospital triage of AIS patients. Methods: Analysis was performed in random two-dimensional abstract geographic stroke care infrastructure environments and two models based on real-world geographic scenarios. Transport times to CSCs and PSCs were calculated to define sub-regions with specific triage properties. Possible transport destinations included the nearest CSC, the nearest PSC, and any of the remaining PSCs that are not closest to the scene, but transport to which would imply a shorter total time-to-CSC-via-PSC. Results: In abstract geographic environments, the median relative size of the sub-region where a triage decision is required ranged from 34 to 92%. The median relative size of the sub-region where more than two triage options need to be considered ranged from 0 to 56%. The achievable reduction in time-to-thrombectomy ("benefit") exceeded the increase in time-to-thrombolysis ("harm") by a factor of 2 in 30.5-37.0% of the sub-region where more than two triage options need to be considered. Results were confirmed in geographic environments based on real-world urban and rural stroke care infrastructures. Conclusion: Pre-hospital triage algorithms for AIS patients that only take into account the nearest CSC and the nearest PSC as transport destinations may be unable to identify the optimal transport destination for a significant proportion of patients.
Collapse
Affiliation(s)
- Ludwig Schlemm
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Eckhard Schlemm
- Medizinische Fakultät, Universität Hamburg, Hamburg, Germany.,Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christian H Nolte
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Berlin, Germany.,DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Berlin, Germany.,DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin, Germany
| |
Collapse
|
40
|
Schlemm L, Schlemm E. Clinical benefit of improved Prehospital stroke scales to detect stroke patients with large vessel occlusions: results from a conditional probabilistic model. BMC Neurol 2018; 18:16. [PMID: 29427993 PMCID: PMC5807751 DOI: 10.1186/s12883-018-1021-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 02/02/2018] [Indexed: 11/18/2022] Open
Abstract
Background Clinical scales to detect large vessel occlusion (LVO) may help to determine the optimal transport destination for patients with suspected acute ischemic stroke (AIS). The clinical benefit associated with improved diagnostic accuracy of these scales has not been quantified. Methods We used a previously reported conditional model to estimate the probability of good outcome (modified Rankin scale sore ≤2) for patients with AIS and unknown vessel status occurring in regions with greater proximity to a primary than to a comprehensive stroke center. Optimal rapid arterial occlusion evaluation (RACE) scale cutoff scores were calculated based on time-dependent effect-size estimates from recent randomized controlled trials. Probabilities of good outcome were compared between a triage strategy based on these cutoffs and a strategy based on a hypothetical perfect LVO detection tool with 100% diagnostic accuracy. Results In our model, the additional benefit of a perfect LVO detection tool as compared to optimal transport-time dependent RACE cutoff scores ranges from 0 to 5%. It is largest for patients with medium stroke symptom severity (RACE score 5) and in geographic environments with longer transfer time between the primary and comprehensive stroke center. Conclusion Based on a probabilistic conditional model, the results of our simulation indicate that more accurate prehospital clinical LVO detections scales may be associated with only modest improvements in the expected probability of good outcome for patients with suspected acute ischemic stroke and unknown vessel status. Electronic supplementary material The online version of this article (10.1186/s12883-018-1021-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Ludwig Schlemm
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany. .,Berlin Institute of Health (BIH), Berlin, Germany. .,London School of Economics and Political Science, London, UK.
| | - Eckhard Schlemm
- Universität Hamburg, Medizinische Fakultät, Hamburg, Germany.,Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
41
|
Schlemm E, Ebinger M, Nolte CH, Endres M, Schlemm L. Optimal Transport Destination for Ischemic Stroke Patients With Unknown Vessel Status. Stroke 2017; 48:2184-2191. [PMID: 28655816 DOI: 10.1161/strokeaha.117.017281] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 05/28/2017] [Accepted: 06/02/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Eckhard Schlemm
- From the University of Glasgow, School of Life Sciences, United Kingdom (E.S.); Queen Elizabeth University Hospital Glasgow, NHS Greater Glasgow and Clyde, United Kingdom (E.S.); Universität Hamburg, Medizinische Fakultät, Germany (E.S.); Department of Neurology (M. Ebinger, C.H.N., M. Endres, L.S.) and Center for Stroke Research Berlin (CSB) (M. Ebinger, C.H.N., M. Endres, L.S.), Charité—Universitätsmedizin, Germany; Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger)
| | - Martin Ebinger
- From the University of Glasgow, School of Life Sciences, United Kingdom (E.S.); Queen Elizabeth University Hospital Glasgow, NHS Greater Glasgow and Clyde, United Kingdom (E.S.); Universität Hamburg, Medizinische Fakultät, Germany (E.S.); Department of Neurology (M. Ebinger, C.H.N., M. Endres, L.S.) and Center for Stroke Research Berlin (CSB) (M. Ebinger, C.H.N., M. Endres, L.S.), Charité—Universitätsmedizin, Germany; Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger)
| | - Christian H. Nolte
- From the University of Glasgow, School of Life Sciences, United Kingdom (E.S.); Queen Elizabeth University Hospital Glasgow, NHS Greater Glasgow and Clyde, United Kingdom (E.S.); Universität Hamburg, Medizinische Fakultät, Germany (E.S.); Department of Neurology (M. Ebinger, C.H.N., M. Endres, L.S.) and Center for Stroke Research Berlin (CSB) (M. Ebinger, C.H.N., M. Endres, L.S.), Charité—Universitätsmedizin, Germany; Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger)
| | - Matthias Endres
- From the University of Glasgow, School of Life Sciences, United Kingdom (E.S.); Queen Elizabeth University Hospital Glasgow, NHS Greater Glasgow and Clyde, United Kingdom (E.S.); Universität Hamburg, Medizinische Fakultät, Germany (E.S.); Department of Neurology (M. Ebinger, C.H.N., M. Endres, L.S.) and Center for Stroke Research Berlin (CSB) (M. Ebinger, C.H.N., M. Endres, L.S.), Charité—Universitätsmedizin, Germany; Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger)
| | - Ludwig Schlemm
- From the University of Glasgow, School of Life Sciences, United Kingdom (E.S.); Queen Elizabeth University Hospital Glasgow, NHS Greater Glasgow and Clyde, United Kingdom (E.S.); Universität Hamburg, Medizinische Fakultät, Germany (E.S.); Department of Neurology (M. Ebinger, C.H.N., M. Endres, L.S.) and Center for Stroke Research Berlin (CSB) (M. Ebinger, C.H.N., M. Endres, L.S.), Charité—Universitätsmedizin, Germany; Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger)
| |
Collapse
|
42
|
Abstract
We consider the first passage percolation problem on the random graph with vertex set N x {0, 1}, edges joining vertices at a Euclidean distance equal to unity, and independent exponential edge weights. We provide a central limit theorem for the first passage times ln between the vertices (0, 0) and (n, 0), thus extending earlier results about the almost-sure convergence of ln / n as n → ∞. We use generating function techniques to compute the n-step transition kernels of a closely related Markov chain which can be used to explicitly calculate the asymptotic variance in the central limit theorem.
Collapse
|
43
|
Schlemm E. A differential equation for the asymptotic fitness distribution in the Bak-Sneppen model with five species. Math Biosci 2015; 267:53-60. [PMID: 26144945 DOI: 10.1016/j.mbs.2015.06.011] [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: 03/09/2015] [Revised: 06/15/2015] [Accepted: 06/17/2015] [Indexed: 10/23/2022]
Abstract
The Bak-Sneppen model is an abstract representation of a biological system that evolves according to the Darwinian principles of random mutation and selection. The species in the system are characterized by a numerical fitness value between zero and one. We show that in the case of five species the steady-state fitness distribution can be obtained as a solution to a linear differential equation of order five with hypergeometric coefficients. Similar representations for the asymptotic fitness distribution in larger systems may help pave the way towards a resolution of the question of whether or not, in the limit of infinitely many species, the fitness is asymptotically uniformly distributed on the interval [fc, 1] with fc ≳ 2/3.
Collapse
Affiliation(s)
- Eckhard Schlemm
- University College London Medical School, Gower Street, London WC1E 6BT, United Kingdom.
| |
Collapse
|
44
|
Schlemm E. On the expected number of successes in a sequence of nested Bernoulli trials. Stat Probab Lett 2013. [DOI: 10.1016/j.spl.2013.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
45
|
Brockwell PJ, Schlemm E. Parametric estimation of the driving Lévy process of multivariate CARMA processes from discrete observations. J MULTIVARIATE ANAL 2013. [DOI: 10.1016/j.jmva.2012.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
46
|
Schlemm E, Stelzer R. Multivariate CARMA processes, continuous-time state space models and complete regularity of the innovations of the sampled processes. BERNOULLI 2012. [DOI: 10.3150/10-bej329] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
47
|
Schlemm E, Stelzer R. Quasi maximum likelihood estimation for strongly mixing state space models and multivariate Lévy-driven CARMA processes. Electron J Stat 2012. [DOI: 10.1214/12-ejs743] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
48
|
|