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Al-Shahi Salman R, Keerie C, Stephen J, Lewis S, Norrie J, Dennis MS, Newby DE, Wardlaw JM, Lip GY, Parry-Jones A, White PM, Baigent C, Lasserson D, Oliver C, O'Mahony F, Amoils S, Bamford J, Armitage J, Emberson J, Rinkel GJ, Lowe G, Innes K, Adamczuk K, Dinsmore L, Drever J, Milne G, Walker A, Hutchison A, Williams C, Fraser R, Anderson R, Covil K, Stewart K, Rees J, Hall P, Bullen A, Stoddart A, Moullaali TJ, Palmer J, Sakka E, Perthen J, Lyttle N, Samarasekera N, MacRaild A, Burgess S, Teasdale J, Coakley M, Taylor P, Blair G, Whiteley W, Shenkin S, Clancy U, Macleod M, Sutherland R, Moullaali T, Barugh A, Lerpiniere C, Moreton F, Fethers N, Anjum T, Krishnan M, Slade P, Storton S, Williams M, Davies C, Connor L, Gainard G, Murphy C, Barber M, Esson D, Choulerton J, Shaw L, Lucas S, Hierons S, Avis J, Stone A, Gbadamoshi L, Costa T, Pearce L, Harkness K, Richards E, Howe J, Kamara C, Lindert R, Ali A, Rehan J, Chapman S, Edwards M, Bathula R, Cohen D, Devine J, Mpelembue M, Yesupatham P, Chhabra S, Adewetan G, Ballantine R, Brooks D, Smith G, Rogers G, Marsden S, Clark S, Wilkinson A, Brown E, Stephenson L, Nyo K, Abraham A, Pai Y, Shim G, Baliga V, Nair A, Robinson M, Hawksworth C, Greig J, Alam I, Nortcliffe T, Ramiz R, Shaw R, Parry-Jones A, Lee S, Marsden T, Perez J, Birleson E, Yadava R, Sangombe M, Stafford S, Hughes T, Knibbs L, Morse B, Schwarz S, Jelley B, White S, Richard B, Lawson H, Moseley S, Tayler M, Edwards M, Triscott C, Wallace R, Hall A, Dell A, Rashed K, Board S, Buckley C, Tanate A, Pitt-Kerby T, Beesley K, Perry J, Hellyer C, Guyler P, Menon N, Tysoe S, Prabakaran R, Cooper M, Rajapakse A, Wynter I, Smith S, Weir N, Boxall C, Yates H, Smith S, Crawford P, Marigold J, Smith F, Harvey J, Evans S, Baldwin L, Hammond S, Mudd P, Bowring A, Keenan S, Thorpe K, Haque M, Taaffe J, Temple N, Peachey T, Wells K, Haines F, Butterworth-Cowin N, Horne Z, Licenik R, Boughton H, England T, Hedstrom A, Menezes B, Davies R, Johnson V, Whittingham-Jones S, Werring D, Obarey S, Watchurst C, Ashton A, Feerick S, Francia N, Banaras A, Epstein D, Marinescu M, Williams A, Robinson A, Humphries F, Anwar I, Annamalai A, Crawford S, Collins V, Shepherd L, Siddle E, Penge J, Epstein D, Qureshi S, Krishnamurthy V, Papavasileiou V, Waugh D, Veraque E, Douglas N, Khan N, Ramachandran S, Sommerville P, Rudd A, Kullane S, Bhalla A, Birns J, Ahmed R, Gibbons M, Klamerus E, Cendreda B, Muir K, Day N, Welch A, Smith W, Elliot J, Eltawil S, Mahmood A, Hatherley K, Mitchell S, Bains H, Quinn L, Teal R, Gbinigie I, Harston G, Mathieson P, Ford G, Schulz U, Kennedy J, Nagaratnam K, Bangalore K, Bhupathiraju N, Wharton C, Fotherby K, Nasar A, Stevens A, Willberry A, Evans R, Rai B, Blake C, Thavanesan K, Hann G, Changuion T, Nix S, Whiting A, Dharmasiri M, Mallon L, Keltos M, Smyth N, Eglinton C, Duffy J, Tone E, Sykes L, Porter E, Fitton C, Kirkineziadis N, Cluckie G, Kennedy K, Trippier S, Williams R, Hayter E, Rackie J, Patel B, Rita G, Blight A, Jones V, Zhang L, Choy L, Pereira A, Clarke B, Al-Hussayni S, Dixon L, Young A, Bergin A, Broughton D, Raghunathan S, Jackson B, Appleton J, Wilkes G, Buck A, Richardson C, Clarke J, Fleming L, Squires G, Law Z, Hutchinson C, Cvoro V, Couser M, McGregor A, McAuley S, Pound S, Cochrane P, Holmes C, Murphy P, Devitt N, Osborn M, Steele A, Guthrie LB, Smith E, Hewitt J, Chaston N, Myint M, Smith A, Fairlie L, Davis M, Atkinson B, Woodward S, Hogg V, Fawcett M, Finlay L, Dixit A, Cameron E, Keegan B, Kelly J, Concannon D, Dutta D, Ward D, Glass J, O'Connell S, Ngeh J, O'Kelly A, Williams E, Ragab S, Jenkinson D, Dube J, Gleave L, Leggett J, Kissoon N, Southern L, Naghotra U, Bokhari M, McClelland B, Adie K, Mate A, Harrington F, James A, Swanson E, Chant T, Naccache M, Coutts A, Courtauld G, Whurr S, Webber S, Shead E, Luder R, Bhargava M, Murali E, Cuenoud L, Pasco K, Speirs O, Chapman L, Inskip L, Kavanagh L, Srinivasan M, Motherwell N, Mukherjee I, Tonks L, Donaldson D, Button H, Wilcox R, Hurford F, Logan R, Taylor A, Arden T, Carpenter M, Datta P, Zahoor T, Jackson L, Needle A, Stanners A, Ghouri I, Exley D, Akhtar S, Brooke H, Beadle S, O'Brien E, Francis J, McGee J, Amis E, Mitchell J, Finlay S, Sinha D, Manoczki C, King S, Tarka J, Choudhary S, Premaruban J, Sutton D, Kumar P, Culmsee C, Winckley C, Davies H, Thatcher H, Vasileiadis E, Aweid B, Holden M, Mason C, Hlaing T, Madzamba G, Ingram T, Linforth M, Cullen C, Thomas N, France J, Saulat A, Bhaskaran B, Fitzell P, Horan K, Manyoni C, Garfield-Smith J, Griffin H, Atkins S, Redome J, Muddegowda G, Maguire H, Barry A, Abano N, Varquez R, Hiden J, Lyjko S, Remegoso A, Finney K, Butler A, Strecker M, MaCleod MJ, Irvine J, Nelson S, Guzmangutierrez G, Furnace J, Taylor V, Ramadan H, Storton K, Hassan S, Abdus Sami E, Bellfield R, Stewart K, Quinn O, Patterson C, Emsley H, Gregary B, Ahmed S, Patel S, Raj S, Sultan S, Wright F, Langhorne P, Graham R, Quinn T, McArthur K. Effects of oral anticoagulation for atrial fibrillation after spontaneous intracranial haemorrhage in the UK: a randomised, open-label, assessor-masked, pilot-phase, non-inferiority trial. Lancet Neurol 2021; 20:842-853. [PMID: 34487722 DOI: 10.1016/s1474-4422(21)00264-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Oral anticoagulation reduces the rate of systemic embolism for patients with atrial fibrillation by two-thirds, but its benefits for patients with previous intracranial haemorrhage are uncertain. In the Start or STop Anticoagulants Randomised Trial (SoSTART), we aimed to establish whether starting is non-inferior to avoiding oral anticoagulation for survivors of intracranial haemorrhage who have atrial fibrillation. METHODS SoSTART was a prospective, randomised, open-label, assessor-masked, parallel-group, pilot phase trial done at 67 hospitals in the UK. We recruited adults (aged ≥18 years) who had survived at least 24 h after symptomatic spontaneous intracranial haemorrhage, had atrial fibrillation, and had a CHA2DS2-VASc score of at least 2. Web-based computerised randomisation incorporating a minimisation algorithm allocated participants (1:1) to start or avoid long-term (≥1 year) full treatment dose open-label oral anticoagulation. The participants assigned to start oral anticoagulation received either a direct oral anticoagulant or vitamin K antagonist, and the group assigned to avoid oral anticoagulation received standard clinical practice (antiplatelet agent or no antithrombotic agent). The primary outcome was recurrent symptomatic spontaneous intracranial haemorrhage, and was adjudicated by an individual masked to treatment allocation. All outcomes were ascertained for at least 1 year after randomisation and assessed in the intention-to-treat population of all randomly assigned participants, using Cox proportional hazards regression adjusted for minimisation covariates. We planned a sample size of 190 participants (one-sided p=0·025, power 90%, allowing for non-adherence) based on a non-inferiority margin of 12% (or adjusted hazard ratio [HR] of 3·2). This trial is registered with ClinicalTrials.gov (NCT03153150) and is complete. FINDINGS Between March 29, 2018, and Feb 27, 2020, consent was obtained at 61 sites for 218 participants, of whom 203 were randomly assigned at a median of 115 days (IQR 49-265) after intracranial haemorrhage onset. 101 were assigned to start and 102 to avoid oral anticoagulation. Participants were followed up for median of 1·2 years (IQR 0·97-1·95; completeness 97·2%). Starting oral anticoagulation was not non-inferior to avoiding oral anticoagulation: eight (8%) of 101 in the start group versus four (4%) of 102 in the avoid group had intracranial haemorrhage recurrences (adjusted HR 2·42 [95% CI 0·72-8·09]; p=0·152). Serious adverse events occurred in 17 (17%) participants in the start group and 15 (15%) in the avoid group. 22 (22%) patients in the start group and 11 (11%) patients in the avoid group died during the study. INTERPRETATION Whether starting oral anticoagulation was non-inferior to avoiding it for people with atrial fibrillation after intracranial haemorrhage was inconclusive, although rates of recurrent intracranial haemorrhage were lower than expected. In view of weak evidence from analyses of three composite secondary outcomes, the possibility that oral anticoagulation might be superior for preventing symptomatic major vascular events should be investigated in adequately powered randomised trials. FUNDING British Heart Foundation, Medical Research Council, Chest Heart & Stroke Scotland.
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Cheng B, Boutitie F, Nickel A, Wouters A, Cho TH, Ebinger M, 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, Golsari A, Alegiani A, Beck C, Choe CU, Voget D, Hoppe J, Schröder J, Rozanski M, Nave AH, Wollboldt C, van Sloten I, Göhler J, Herm J, Jungehülsing J, Lückl J, Kröber JM, Schurig J, Koehler L, Schlemm L, Knops M, Roennefarth M, Ipsen N, Harmel P, Bathe-Peters R, Fleischmann R, Ganeshan R, Geran R, Hellwig S, Schmidt S, Tütüncü S, Krause T, Gramse V, Röther J, Michels P, Michalski D, Pelz J, Schulz A, Hobohm C, Weise C, Weise G, Orthgieß J, Pomrehn K, Wegscheider M, Mueller AK, Hennerici M, Griebe M, Alonso A, Filipov A, Marzina A, Anders B, Bähr C, Hoyer C, Schwarzbach C, Weber C, Hornberger E, Pledl HW, Klockziem M, Stuermlinger M, Wittayer M, Wolf M, Meyer N, Eisele P, Steinert S, Sauer T, Held V, Ringleb P, Nagel S, Veltkamp R, Schwarting S, Schwarz A, Gumbinger C, Hametner C, Amiri H, Purrucker J, Ciatipis M, Menn O, Mundiyanapurath S, Schieber S, Kessler T, Reiff T, Panitz V, Singer O, Foerch C, Lauer A, Männer A, Seiler A, Guerzoglu D, Schäfer JH, Filipski K, Lorenz M, Kurka N, Zeiner P, Pfeilschifter W, Dziewas R, Minnerup J, Albiker C, Ritter M, Seidel M, Dittrich R, Kallmünzer B, Bobinger T, Madzar D, Stark D, Sembill J, Macha K, Winder K, Breuer L, Koehrmann M, Spruegel M, Gerner S, Kraft P, Mackenrodt D, Kleinschnitz C, Elhfnawy A, Heinen F, Gunreben I, Poli S, Ziemann U, Gaenslen A, Schlak D, Haertig F, Russo F, Richter H, Ebner M, Ribitsch M, Wolf M, Weimar C, Zegarac V, Chen HC, Althaus K, Neugebauer H, Jüttler E, Meier J, Stösser S, Puetz V, Bodechtel U, Ostergaard L, Møller A, Damgaard D, Dupont KH, Poulsen M, Hjort N, de Morales NR, von Weitzel P, Harbo T, Marstrand J, Hansen A, Christensen H, Aegidius K, Jeppesen L, Meden P, Rosenbaum S, Iversen H, Hansen J, Michelsen L, Truelsen T, Modrau B, Vestergaard K, Oppel L, Sygehus A, Aalborg S, Swinnen B, Smets I, Demeestere J, Dobbels L, Brouns R, De Smedt A, DeKeyser J, Yperzeele L, Van Hooff RJ, Peeters A, Dusart A, Etexberria A, Hanseeuw B, London F, Leempoel J, Hohenbichler K, Younan N, Maqueda V, Laloux P, De Coene B, De Maeseneire C, Turine G, Vandermeeren Y, De Klippel N, Willems C, de Hollander I, Soors P, Hermans S, Hemelsoet D, Desfontaines P, Vanacker P, Rutgers M, Druart C, Peeters D, Bruneel B, Vancaester E, Vanhee F, Meersman G, Bourgeois P, Vanderdonckt P, Benoit A, Derex L, Mechthouff L, Berhoune N, Ritzenthaler T, Amarenco P, Hobeanu C, Gancedo EM, Calvet D, Ladoux A, Machet A, Lamy C, Mellerio C, Oppenheim C, Rodriguez-Regent C, Bodiguel E, Turc G, Birchenall J, Legrand L, Morin L, Edjali-Goujon M, Naggara O, Raphaelle S, Godon-Hardy S, Domigo V, Guiraud V, Samson Y, Leger A, Rosso C, Baronnet-Chauvet F, Crozier S, Deltour S, Yger M, Sibon I, Renou P, Sagnier S, Zuber M, Tamazyan R, Rodier G, Morel N, Felix S, Vadot W, Wolff V, Aniculaesei A, Yalo B, Bindila D, Quenardelle V, Blanc-Lasserre K, Landrault E, Breynaert L, Cakmak S, Peysson S, Viguier A, Lebely C, Raposo N, Vallet AE, Vallet P, Brugirard S, Cheripelli B, Kalladka D, Moreton F, Dani K, Tawil SE, Ramachandran S, Huang X, Warburton E, Evans N, Perry R, Patel B, Cloud G, Pereira A, Moynihan B, Lovelock C, Choy L, Khan U, Roffe C, Tyrell P, Smith C, Dixit A, Louw S, Broughton D, Shetty A, Appleton J, Sprigg N, Acosta BR, van Eendenburg C, Leal JS, Mar Castellanos Rodrigo MD, Izaga MT, Guillamon OB, Arenillas J, Calleja A, Cortijo E, Mulero P, de la Ossa NP, Garrido A, Martinez A, Esperón CG, Guerrero C, Carrera D, Vilas D, Lopez-cancio E, Palomeras E, Lucente G, Gomis M, Isern I, Becerra JL, Vicente JH, Sánchez J, Dorado L, Grau L, Ispierto L, Prats L, Almendrote M, Hernández M, Jimenez M, Sánchez ML, Torne MM, Presas S, Ustrell X, Pellisé A, Navalpotro I, Luna A, Schonewille W, Nederkoorn P, Majoie C, van den Berg L, van den Berg S, Zonneveld T, Remmers M, Fazekas F, Pichler A, Fandler S, Gattringer T, Mutzenbach J, Weber J, Höfner E, Kohlfürst H, Weinstich K, Kellert L, Bayer-Karpinska A, Opherk C, Wollenweber F, Klein M, Neumann- Haefelin T, Pierskalla A, Harloff A, Bardutzky J, Buggle F, von Schrader J, Kollmar R, Schill J, Löbbe AM, Moulin T, Bouamra B, Bonnet L, Touzé E, Bonnet AL, Touze E, Cogez J, Li L, Guettier S, Kar A, Sivagnanaratham A, Geraghty O, Bojaryn U, Nallasivan A, Gonzales MB, Rodríguez-Yáñez M, Tembl J, Gorriz D, Oberndorfer S, Prohaska E. Quantitative Signal Intensity in Fluid-Attenuated Inversion Recovery and Treatment Effect in the WAKE-UP Trial. Stroke 2020; 51:209-215. [DOI: 10.1161/strokeaha.119.027390] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Relative signal intensity of acute ischemic stroke lesions in fluid-attenuated inversion recovery (fluid-attenuated inversion recovery relative signal intensity [FLAIR-rSI]) magnetic resonance imaging is associated with time elapsed since stroke onset with higher intensities signifying longer time intervals. In the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke Trial), intravenous alteplase was effective in patients with unknown onset stroke selected by visual assessment of diffusion weighted imaging fluid-attenuated inversion recovery mismatch, that is, in those with no marked fluid-attenuated inversion recovery hyperintensity in the region of the acute diffusion weighted imaging lesion. In this post hoc analysis, we investigated whether quantitatively measured FLAIR-rSI modifies treatment effect of intravenous alteplase.
Methods—
FLAIR-rSI of stroke lesions was measured relative to signal intensity in a mirrored region in the contralesional hemisphere. The relationship between FLAIR-rSI and treatment effect on functional outcome assessed by the modified Rankin Scale (mRS) after 90 days was analyzed by binary logistic regression using different end points, that is, favorable outcome defined as mRS score of 0 to 1, independent outcome defined as mRS score of 0 to 2, ordinal analysis of mRS scores (shift analysis). All models were adjusted for National Institutes of Health Stroke Scale at symptom onset and stroke lesion volume.
Results—
FLAIR-rSI was successfully quantified in stroke lesions in 433 patients (86% of 503 patients included in WAKE-UP). Mean FLAIR-rSI was 1.06 (SD, 0.09). Interaction of FLAIR-rSI and treatment effect was not significant for mRS score of 0 to 1 (
P
=0.169) and shift analysis (
P
=0.086) but reached significance for mRS score of 0 to 2 (
P
=0.004). We observed a smooth continuing trend of decreasing treatment effects in relation to clinical end points with increasing FLAIR-rSI.
Conclusions—
In patients in whom no marked parenchymal fluid-attenuated inversion recovery hyperintensity was detected by visual judgement in the WAKE-UP trial, higher FLAIR-rSI of diffusion weighted imaging lesions was associated with decreased treatment effects of intravenous thrombolysis. This parallels the known association of treatment effect and elapsing time of stroke onset.
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Affiliation(s)
- Bastian Cheng
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Florent Boutitie
- Service de Biostatistique, Hospices Civils de Lyon, France (F.B.)
- Université Lyon 1, Villeurbanne, France (F.B.)
- CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France (F.B.)
| | - Alina Nickel
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Anke Wouters
- Department of Neurology, University Hospitals Leuven, Belgium (A.W., R.L.)
- Department of Neurosciences, Experimental Neurology, KU Leuven–University of Leuven, Belgium (A.W., R.L.)
- VIB, Center for Brain and Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Leuven, Belgium (A.W., R.L.)
| | - Tae-Hee Cho
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon, France (T.-H.C., N.N.)
- Hospices Civils de Lyon, France (T.-H.C., N.N.)
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, 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, Charité–Universitätsmedizin Berlin, Campus Mitte, 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, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Ivana Galinovic
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
| | - Josep Puig
- Department of Radiology, Institut de Diagnostic per la Image, Hospital Dr Josep Trueta, Institut d’Investigació Biomèdica de Girona, Parc Hospitalari Martí i Julià de Salt, Girona, Spain (J.P., S.P.)
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia (V.T.)
- Austin Health, Department of Neurology, VIC, Australia (V.T.)
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Belgium (A.W., R.L.)
- Department of Neurosciences, Experimental Neurology, KU Leuven–University of Leuven, Belgium (A.W., R.L.)
- VIB, Center for Brain and Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Leuven, Belgium (A.W., R.L.)
| | - Keith W. Muir
- Institute of Neuroscience and Psychology, University of 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, France (T.-H.C., N.N.)
- Hospices Civils de Lyon, France (T.-H.C., N.N.)
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image, Hospital Dr Josep Trueta, Institut d’Investigació Biomèdica de Girona, Parc Hospitalari Martí i Julià de Salt, Girona, Spain (J.P., S.P.)
| | - Claus Z. Simonsen
- Department of Neurology, Aarhus University Hospital, Denmark (C.Z.S.)
| | - Christian Gerloff
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
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Dennis M, Mead G, Forbes J, Graham C, Hackett M, Hankey GJ, House A, Lewis S, Lundström E, Sandercock P, Innes K, Williams C, Drever J, Mcgrath A, Deary A, Fraser R, Anderson R, Walker P, Perry D, Mcgill C, Buchanan D, Chun Y, Dinsmore L, Maschauer E, Barugh A, Mikhail S, Blair G, Hoeritzauer I, Scott M, Fraser G, Lawrence K, Shaw A, Williamson J, Burgess D, Macleod M, Morales D, Sullivan F, Brady M, French R, Van Wijck F, Watkins C, Proudfoot F, Skwarski J, Mcgowan D, Murphy R, Burgess S, Rutherford W, Mccormick K, Buchan R, Macraild A, Paulton R, Fazal A, Taylor P, Parakramawansha R, Hunter N, Perry J, Bamford J, Waugh D, Veraque E, Bedford C, Kambafwile M, Idrovo L, Makawa L, Smalley P, Randall M, Thirugnana-Chandran T, Hassan A, Vowden R, Jackson J, Bhalla A, Rudd A, Tam CK, Birns J, Gibbs C, Lee Carbon L, Cattermole E, Marks K, Cape A, Hurley L, Kullane S, Smyth N, Eglinton C, Wilson J, Giallombardo E, Frith A, Reidy P, Pitt M, Sykes L, Dellafera D, Croome V, Kerwood L, Hancevic 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Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial. Lancet 2019; 393:265-274. [PMID: 30528472 PMCID: PMC6336936 DOI: 10.1016/s0140-6736(18)32823-x] [Citation(s) in RCA: 174] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects. METHODS FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762. FINDINGS Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839-1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26-6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38-2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months. INTERPRETATION Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function. FUNDING UK Stroke Association and NIHR Health Technology Assessment Programme.
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Wollenweber FA, Hanecker P, Bayer-Karpinska A, Malik R, Bäzner H, Moreton F, Muir KW, Müller S, Giese A, Opherk C, Dichgans M, Haffner C, Duering M. Cysteine-Sparing CADASIL Mutations in
NOTCH3
Show Proaggregatory Properties In Vitro. Stroke 2015; 46:786-92. [DOI: 10.1161/strokeaha.114.007472] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Mutations in
NOTCH3
cause cerebral autosomal–dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), the most common monogenic cause of stroke and vascular dementia. Misfolding and aggregation of NOTCH3 proteins triggered by cysteine-affecting mutations are considered to be the key disease mechanisms. However, the significance of cysteine-sparing mutations is still debated.
Methods—
We studied a family with inherited small vessel disease by standardized medical history, clinical examination, MRI, ultrastructural analysis of skin biopsies, and Sanger sequencing of all
NOTCH3
exons. In addition, we performed in vitro characterization of
NOTCH3
variants using recombinant protein fragments and a single-particle aggregation assay.
Results—
We identified a novel cysteine-sparing
NOTCH3
mutation (D80G) in 4 family members, which was absent in a healthy sibling. All mutation carriers exhibited a CADASIL typical brain imaging and clinical phenotype, whereas skin biopsy showed inconsistent results. In vitro aggregation behavior of the D80G mutant was similar compared with cysteine-affecting mutations. This was reproduced with cysteine-sparing mutations from previously reported families having a phenotype consistent with CADASIL.
Conclusions—
Our findings support the view that cysteine-sparing mutations, such as D80G, might cause CADASIL with a phenotype largely indistinguishable from cysteine mutations. The in vitro aggregation analysis of atypical
NOTCH3
mutations offers novel insights into pathomechanisms and might represent a tool for estimating their clinical significance.
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Affiliation(s)
- Frank Arne Wollenweber
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
| | - Patrizia Hanecker
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
| | - Anna Bayer-Karpinska
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
| | - Rainer Malik
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
| | - Hansjörg Bäzner
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
| | - Fiona Moreton
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
| | - Keith W. Muir
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
| | - Susanna Müller
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
| | - Armin Giese
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
| | - Christian Opherk
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
| | - Martin Dichgans
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
| | - Christof Haffner
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
| | - Marco Duering
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München (F.A.W., P.H., A.B.-K., R.M., C.O., M.D., C.H., M.D.), Institute for Pathology (S.M.), and Center for Neuropathology and Prion Research (A.G.), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany (H.B.); Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom (F.M., K.W.M.); Department of Neurology, Klinikum am
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