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Hellwig S, Krause T, Scheitz JF, Herm J, Grittner U, Jauert N, Fiebach JB, Kasner M, Doehner W, Endres M, Wachter R, Elgeti T, Nolte CH, Haeusler KG. Enhanced diagnostic workup increases pathological findings in patients with acute ischaemic stroke: results of the prospective HEBRAS study. Stroke Vasc Neurol 2024; 9:145-152. [PMID: 37353342 DOI: 10.1136/svn-2022-002179] [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: 11/17/2022] [Accepted: 06/05/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Stroke aetiology remains cryptogenic in a relevant proportion of patients with acute ischaemic stroke (AIS). We assessed whether enhanced diagnostic workup after AIS yields a higher rate of prespecified pathological findings compared with routine diagnostic care in-hospital. METHODS Hospitalised patients with AIS were prospectively enrolled in the investigator-initiated observational HEart and BRain Interfaces in Acute Ischaemic Stroke (HEBRAS) study at the Charité, Berlin, Germany. Patients with AIS without known atrial fibrillation (AF) underwent cardiovascular MR imaging (CMR), MR-angiography of the aortic arch and prolonged Holter-ECG monitoring on top of routine diagnostic care. RESULTS Among 356 patients with AIS (mean age 66 years, 37.6% female), enhanced workup yielded a higher rate of prespecified pathological findings compared with routine care (17.7% vs 5.3%; p<0.001). Consequently, fewer patients were classified as cryptogenic after enhanced diagnostic workup (38.5% vs 45.5%, p<0.001). Routine care included echocardiography in 228 (64.0%) patients. CMR was successfully performed in 292 (82.0%) patients and revealed more often a prespecified pathological finding compared with routine echocardiography (16.1% vs 5.3%). Furthermore, study-related ECG monitoring (median duration 162 hours (IQR 98-210)) detected AF in 16 (4.5%) patients, while routine monitoring (median duration 51 hours (IQR 34-74)) detected AF in seven (2.0%) patients. CONCLUSIONS Enhanced diagnostic workup revealed a higher rate of prespecified pathological findings in patients with AIS compared with routine diagnostic care and significantly reduced the proportion of patients with cryptogenic stroke. TRIAL REGISTRATION NUMBER NCT02142413.
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Affiliation(s)
- Simon Hellwig
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charité -Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
| | - Thomas Krause
- Department of Neurology, Jüdisches Krankenhaus Berlin, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charité -Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Berlin, Germany
| | - Juliane Herm
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nadja Jauert
- Center for Stroke Research Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Berlin, Germany
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité -Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Mario Kasner
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfram Doehner
- Center for Stroke Research Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Berlin, Germany
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité -Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charité -Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Thomas Elgeti
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charité -Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
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2
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Schuermann H, von Rennenberg R, Riegler C, Rangus I, Litmeier S, Scheitz JF, Doehner W, Audebert H, Braemswig TB, Nolte CH. Characteristics associated with occurrence of stroke in patients with infective endocarditis - a retrospective cohort study. Neurol Res Pract 2024; 6:22. [PMID: 38600573 PMCID: PMC11007977 DOI: 10.1186/s42466-024-00317-4] [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: 01/24/2024] [Accepted: 03/07/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Stroke is a severe complication of infective endocarditis (IE), associated with high rates of mortality. Data on how IE patients with and without stroke differ may help to improve understanding contributing mechanisms. METHODS All patients treated for IE between 2019 and 2021 with and without associated stroke were identified from the medical records of three academic tertiary care hospitals in Germany, all part of Charité - Universitätsmedizin Berlin, Germany. Multivariable logistic regression analyses were performed to identify variables associated with the occurrence of stroke. RESULTS The study population consisted of 353 patients diagnosed with IE. Concomitant stroke occurred in 96/353 (27.2%) patients. Acute stroke was independently associated with co-occurring extracerebral arterial embolism [adjusted Odds ratio (aOR = 2.52; 95% confidence interval (CI) 1.35-4.71)], acute liver failure (aOR = 2.62; 95% CI 1.06-6.50), dental focus of infection (aOR = 3.14; 95% CI 1.21-8.12) and left-sided IE (aOR = 28.26; 95% CI 3.59-222.19). Stroke was found less often in IE patients with congenital heart disease (aOR = 0.20; 95% CI 0.04-0.99) and atypical pathogens isolated from blood culture (aOR = 0.31; 95% CI 0.14-0.72). CONCLUSIONS Stroke is more likely to occur in individuals with systemic complications affecting other organs, too. Special attention should be addressed to dental status. The low incidence of stroke in patients with congenital heart disease may reflect awareness and prophylactic measures.
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Affiliation(s)
- H Schuermann
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.
- Paracelsus Medical University Salzburg, Salzburg, Austria.
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - R von Rennenberg
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - C Riegler
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - I Rangus
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - S Litmeier
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - J F Scheitz
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin, Berlin, Germany
- DZHK German Centre for Cardiovascular Research (DZHK), Partner-Site Berlin, Berlin, Germany
| | - W Doehner
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- DZHK German Centre for Cardiovascular Research (DZHK), Partner-Site Berlin, Berlin, Germany
- German Heart Center of the Charite, Campus Virchow, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health-Center or Regenerative Therapies, Universitätsmedizin Berlin, Berlin, Germany
| | - H Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - T B Braemswig
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin, Berlin, Germany
- DZHK German Centre for Cardiovascular Research (DZHK), Partner-Site Berlin, Berlin, Germany
| | - C H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin, Berlin, Germany
- DZHK German Centre for Cardiovascular Research (DZHK), Partner-Site Berlin, Berlin, Germany
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3
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von Rennenberg R, Nolte CH, Liman TG, Hellwig S, Riegler C, Scheitz JF, Georgakis MK, Fang R, Bode FJ, Petzold GC, Hermann P, Zerr I, Goertler M, Bernkopf K, Wunderlich S, Dichgans M, Endres M. High-Sensitivity Cardiac Troponin T and Cognitive Function Over 12 Months After Stroke-Results of the DEMDAS Study. J Am Heart Assoc 2024; 13:e033439. [PMID: 38456438 PMCID: PMC11010029 DOI: 10.1161/jaha.123.033439] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/24/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Subclinical myocardial injury in form of hs-cTn (high-sensitivity cardiac troponin) levels has been associated with cognitive impairment and imaging markers of cerebral small vessel disease (SVD) in population-based and cardiovascular cohorts. Whether hs-cTn is associated with domain-specific cognitive decline and SVD burden in patients with stroke remains unknown. METHODS AND RESULTS We analyzed patients with acute stroke without premorbid dementia from the prospective multicenter DEMDAS (DZNE [German Center for Neurodegenerative Disease]-Mechanisms of Dementia after Stroke) study. Patients underwent neuropsychological testing 6 and 12 months after the index event. Test results were classified into 5 cognitive domains (language, memory, executive function, attention, and visuospatial function). SVD markers (lacunes, cerebral microbleeds, white matter hyperintensities, and enlarged perivascular spaces) were assessed on cranial magnetic resonance imaging to constitute a global SVD score. We examined the association between hs-cTnT (hs-cTn T levels) and cognitive domains as well as the global SVD score and individual SVD markers, respectively. Measurement of cognitive and SVD-marker analyses were performed in 385 and 466 patients with available hs-cTnT levels, respectively. In analyses adjusted for demographic characteristics, cardiovascular risk factors, and cognitive status at baseline, higher hs-cTnT was negatively associated with the cognitive domains "attention" up to 12 months of follow-up (beta-coefficient, -0.273 [95% CI, -0.436 to -0.109]) and "executive function" after 12 months. Higher hs-cTnT was associated with the global SVD score (adjusted odds ratio, 1.95 [95% CI, 1.27-3.00]) and the white matter hyperintensities and lacune subscores. CONCLUSIONS In patients with stroke, hs-cTnT is associated with a higher burden of SVD markers and cognitive function in domains linked to vascular cognitive impairment. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01334749.
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Affiliation(s)
- Regina von Rennenberg
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BerlinBerlinGermany
| | - Christian H. Nolte
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BerlinBerlinGermany
- German Center for Cardiovascular Research (Deutsches Zentrum für Herz‐Kreislaufforschung), partner site Berlin, Charité‐Universitätsmedizin BerlinBerlinGermany
- Berlin Institute of Health at Charité –Universitätsmedizin Berlin, BIH Biomedical Innovation AcademyBerlinGermany
| | - Thomas G. Liman
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BerlinBerlinGermany
- Department of Neurology, School of Medicine and Health SciencesCarl von Ossietzky University of OldenburgOldenburgGermany
| | - Simon Hellwig
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
- Berlin Institute of Health at Charité –Universitätsmedizin Berlin, BIH Biomedical Innovation AcademyBerlinGermany
| | - Christoph Riegler
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
| | - Jan F. Scheitz
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
- German Center for Cardiovascular Research (Deutsches Zentrum für Herz‐Kreislaufforschung), partner site Berlin, Charité‐Universitätsmedizin BerlinBerlinGermany
- Berlin Institute of Health at Charité –Universitätsmedizin Berlin, BIH Biomedical Innovation AcademyBerlinGermany
| | - Marios K. Georgakis
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU MunichMunichGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site MunichMunichGermany
| | - Rong Fang
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU MunichMunichGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site MunichMunichGermany
| | - Felix J. Bode
- Division of Vascular Neurology, Department of NeurologyUniversity Hospital BonnBonnGermany
| | - Gabor C. Petzold
- Division of Vascular Neurology, Department of NeurologyUniversity Hospital BonnBonnGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BonnBonnGermany
| | - Peter Hermann
- German Center for Neurodegenerative Diseases (DZNE) GöttingenGöttingenGermany
- Clinical Dementia Center, Department of NeurologyUniversity Medical CenterGöttingenGermany
| | - Inga Zerr
- German Center for Neurodegenerative Diseases (DZNE) GöttingenGöttingenGermany
- Clinical Dementia Center, Department of NeurologyUniversity Medical CenterGöttingenGermany
| | - Michael Goertler
- Department of NeurologyMagdeburg University Vascular and Stroke CentreMagdeburgGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site MagdeburgMagdeburgGermany
| | - Kathleen Bernkopf
- Department of Neurology, School of MedicineKlinikum rechts der Isar, Technical University of MunichMunichGermany
| | - Silke Wunderlich
- Department of Neurology, School of MedicineKlinikum rechts der Isar, Technical University of MunichMunichGermany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU MunichMunichGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site MunichMunichGermany
| | - Matthias Endres
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BerlinBerlinGermany
- German Center for Cardiovascular Research (Deutsches Zentrum für Herz‐Kreislaufforschung), partner site Berlin, Charité‐Universitätsmedizin BerlinBerlinGermany
- Berlin Institute of Health at Charité –Universitätsmedizin Berlin, BIH Biomedical Innovation AcademyBerlinGermany
- German Center for Mental Health (DZPG), partner site BerlinBerlinGermany
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4
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Rosso M, Stengl H, Ganeshan R, Hellwig S, Klammer MG, von Rennenberg R, Böhme S, Nolte CH, Audebert HJ, Endres M, Kasner SE, Scheitz JF. Sex Differences in Outcomes of Acute Myocardial Injury After Stroke. J Am Heart Assoc 2024; 13:e032755. [PMID: 38410952 PMCID: PMC10944046 DOI: 10.1161/jaha.123.032755] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/11/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Sex differences in presentation, treatment, and prognosis of cardiovascular disorders are well recognized. Although an association between acute myocardial injury and mortality after ischemic stroke has been demonstrated, it is unclear whether prevalence and outcome of poststroke acute myocardial injury differ between women and men. METHODS AND RESULTS We prospectively screened consecutive patients with acute ischemic stroke and serial high-sensitivity cardiac troponin T measurements admitted to our center. Acute myocardial injury was defined as at least 1 high-sensitivity cardiac troponin T value above the upper reference limit (14 ng/L) with a rise/fall of >20%. Rates of acute myocardial injury were also calculated using sex-specific high-sensitivity cardiac troponin T cutoffs (women upper reference limit, 9 ng/L; men upper reference limit, 16 ng/L). Logistic regression analyses were performed to evaluate the association between acute myocardial injury and outcomes. Of 1067 patients included, 494 were women (46%). Women were older, had a higher rate of known atrial fibrillation, were more likely to be functionally dependent before admission, had higher stroke severity, and more often had cardioembolic strokes (all P values <0.05). The crude prevalence of acute myocardial injury differed by sex (29% women versus 23% men, P=0.024). Statistically significant associations between acute myocardial injury and outcomes were observed in women (7-day in-hospital mortality: adjusted odds ratio [aOR], 3.2 [95% CI, 1.07-9.3]; in-hospital mortality: aOR, 3.3 [95% CI, 1.4-7.6]; modified Rankin Scale score at discharge: aOR, 1.6 [95% CI, 1.1-2.4]) but not in men. The implementation of sex-specific cutoffs did not increase the prognostic value of acute myocardial injury for unfavorable outcomes. CONCLUSIONS The prevalence of acute myocardial injury after ischemic stroke and its association with mortality and greater disability might be sex-dependent. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03892226.
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Affiliation(s)
- Michela Rosso
- Department of Neurology University of Pennsylvania Philadelphia PA USA
| | - Helena Stengl
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin Berlin Germany
| | - Ramanan Ganeshan
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
| | - Simon Hellwig
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin Berlin Germany
| | - Markus G Klammer
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
| | - Regina von Rennenberg
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin Germany
| | - Sophie Böhme
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
| | - Christian H Nolte
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin Berlin Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin Germany
| | - Heinrich J Audebert
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
| | - Matthias Endres
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin Berlin Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin Germany
- German Center for Mental Health (DZPG) Partner Site Berlin Germany
| | - Scott E Kasner
- Department of Neurology University of Pennsylvania Philadelphia PA USA
| | - Jan F Scheitz
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin Berlin Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin Germany
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5
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Stengl H, Ganeshan R, von Rennenberg R, Hellwig S, Herm J, Krause T, Bauer A, Endres M, Georg Haeusler K, Scheitz JF, Nolte CH. Heart rate turbulence in acute ischemic stroke. Eur Stroke J 2024; 9:226-234. [PMID: 37932964 PMCID: PMC10916809 DOI: 10.1177/23969873231211166] [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: 08/01/2023] [Accepted: 10/13/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Heart rate turbulence (HRT), an ECG-based marker of autonomic cardiac regulation, has shown high prognostic value in patients with established cardiovascular diseases, while data in patients with acute ischemic stroke are scarce. PATIENTS AND METHODS The HRT parameters turbulence onset and turbulence slope were analyzed using Holter-ECG recordings from patients with acute ischemic stroke, consecutively enrolled in the prospective observational HEBRAS study. HRT was categorized as normal (category 0; both parameters normal), abnormal (category 1; one parameter abnormal), or severely abnormal (category 2; both parameters abnormal). Outcomes of interest were functional outcome according to modified Rankin Scale (mRS) score at 3 months, mortality at 1 year, newly detected atrial fibrillation (AF), and evidence of focal myocardial fibrosis on cardiovascular MRI. RESULTS HRT was assessed in 335 patients in sinus rhythm (median age 69 years, 37% female, median NIHSS score 2 on admission), including 262 (78%) with normal HRT, 47 (14%) with abnormal and 26 (8%) with severely abnormal HRT. Compared with normal HRT, severely abnormal HRT was associated with increased disability [higher mRS] at 3 months (adjusted odds ratio [aOR]: 2.9, 95% confidence interval [CI]: 1.3-6.6), new AF (aOR: 3.5, 95% CI: 1.1-10.6), MRI-detected myocardial fibrosis (aOR: 5.8, 95% CI: 1.3-25.9), but not with mortality at 1 year after stroke (aOR: 3.0, 95% CI: 0.7-13.9). Abnormal HRT was not associated with the analyzed outcomes. CONCLUSIONS Severely abnormal HRT was associated with increased disability and previously unknown cardiac comorbidities. The potential role of HRT in selecting patients for extended AF monitoring and cardiac imaging should be further investigated.
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Affiliation(s)
- Helena Stengl
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Ramanan Ganeshan
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Regina von Rennenberg
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
| | - Simon Hellwig
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Juliane Herm
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Krause
- Department of Neurology, Jüdisches Krankenhaus Berlin, Berlin, Germany
| | - Axel Bauer
- Working Group on Biosignal Analysis, Department of Cardiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Matthias Endres
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site, Berlin, Germany
- German Center for Mental Health (DZPG), Partner Site, Berlin, Germany
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | - Jan F Scheitz
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
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6
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Nelde A, Krumm L, Arafat S, Hotter B, Nolte CH, Scheitz JF, Klammer MG, Krämer M, Scheib F, Endres M, Meisel A, Meisel C. Machine learning using multimodal and autonomic nervous system parameters predicts clinically apparent stroke-associated pneumonia in a development and testing study. J Neurol 2024; 271:899-908. [PMID: 37851190 PMCID: PMC10827826 DOI: 10.1007/s00415-023-12031-3] [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: 04/24/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Stroke-associated pneumonia (SAP) is a preventable determinant for poor outcome after stroke. Machine learning (ML) using large-scale clinical data warehouses may be able to predict SAP and identify patients for targeted interventions. The aim of this study was to develop a prediction model for identifying clinically apparent SAP using automated ML. METHODS The ML model used clinical and laboratory parameters along with heart rate (HR), heart rate variability (HRV), and blood pressure (BP) values obtained during the first 48 h after stroke unit admission. A logistic regression classifier was developed and internally validated with a nested-cross-validation (nCV) approach. For every shuffle, the model was first trained and validated with a fixed threshold for 0.9 sensitivity, then finally tested on the out-of-sample data and benchmarked against a widely validated clinical score (A2DS2). RESULTS We identified 2390 eligible patients admitted to two-stroke units at Charité between October 2020 and June 2023, of whom 1755 had all parameters available. SAP was diagnosed in 96/1755 (5.5%). Circadian profiles in HR, HRV, and BP metrics during the first 48 h after admission exhibited distinct differences between patients with SAP diagnosis vs. those without. CRP, mRS at admission, leukocyte count, high-frequency power in HRV, stroke severity at admission, sex, and diastolic BP were identified as the most informative ML features. We obtained an AUC of 0.91 (CI 0.88-0.95) for the ML model on the out-of-sample data in comparison to an AUC of 0.84 (CI 0.76-0.91) for the previously established A2DS2 score (p < 0.001). The ML model provided a sensitivity of 0.87 (CI 0.75-0.97) with a corresponding specificity of 0.82 (CI 0.78-0.85) which outperformed the A2DS2 score for multiple cutoffs. CONCLUSIONS Automated, data warehouse-based prediction of clinically apparent SAP in the stroke unit setting is feasible, benefits from the inclusion of vital signs, and could be useful for identifying high-risk patients or prophylactic pneumonia management in clinical routine.
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Affiliation(s)
- Alexander Nelde
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | - Laura Krumm
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Bernstein Center for Computational Neuroscience, Berlin, Germany
- Einstein Center for Neurosciences, Berlin, Germany
| | - Subhi Arafat
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | - Benjamin Hotter
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
| | - Markus G Klammer
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | | | - Franziska Scheib
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- NeuroCure Clinical Research Center, Berlin, Germany
| | - Christian Meisel
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany.
- Center for Stroke Research Berlin, Berlin, Germany.
- Berlin Institute of Health, Berlin, Germany.
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany.
- Bernstein Center for Computational Neuroscience, Berlin, Germany.
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7
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Baumgartner P, Kook L, Altersberger VL, Gensicke H, Ardila-Jurado E, Kägi G, Salerno A, Michel P, Gopisingh KM, Nederkoorn PJ, Scheitz JF, Nolte CH, Heldner MR, Arnold M, Cordonnier C, Della Schiava L, Hametner C, Ringleb PA, Leker RR, Jubran H, Luft AR, Engelter ST, Wegener S. Safety and effectiveness of IV Thrombolysis in retinal artery occlusion: A multicenter retrospective cohort study. Eur Stroke J 2023; 8:966-973. [PMID: 37421135 PMCID: PMC10683723 DOI: 10.1177/23969873231185895] [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: 04/02/2023] [Accepted: 06/13/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Retinal artery occlusion (RAO) may lead to irreversible blindness. For acute RAO, intravenous thrombolysis (IVT) can be considered as treatment. However, due to the rarity of RAO, data about IVT safety and effectiveness is limited. METHODS From the multicenter database ThRombolysis for Ischemic Stroke Patients (TRISP), we retrospectively analyzed visual acuity (VA) at baseline and within 3 months in IVT and non-IVT treated RAO patients. Primary outcome was difference of VA between baseline and follow up (∆VA). Secondary outcomes were rates of visual recovery (defined as improvement of VA ⩾ 0.3 logMAR), and safety (symptomatic intracranial hemorrhage (sICH) according to ECASS II criteria, asymptomatic intracranial hemorrhage (ICH) and major extracranial bleeding). Statistical analysis was performed using parametric tests and a linear regression model adjusted for age, sex and baseline VA. RESULTS We screened 200 patients with acute RAO and included 47 IVT and 34 non-IVT patients with complete information about recovery of vision. Visual Acuity at follow up significantly improved compared to baseline in IVT patients (∆VA 0.5 ± 0.8, p < 0.001) and non-IVT patients (∆VA 0.40 ± 1.1, p < 0.05). No significant differences in ∆VA and visual recovery rate were found between groups at follow up. Two asymptomatic ICH (4%) and one (2%) major extracranial bleeding (intraocular bleeding) occurred in the IVT group, while no bleeding events were reported in the non-IVT group. CONCLUSION Our study provides real-life data from the largest cohort of IVT treated RAO patients published so far. While there is no evidence for superiority of IVT compared to conservative treatment, bleeding rates were low. A randomized controlled trial and standardized outcome assessments in RAO patients are justified to assess the net benefit of IVT in RAO.
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Affiliation(s)
- Philipp Baumgartner
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Lucas Kook
- Epidemiology, Biostatistics & Prevention Institute, University of Zurich, Zurich, Switzerland
- Institute for Data Analysis and Process Design, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Valerian L Altersberger
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | | | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Kiran M Gopisingh
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan F Scheitz
- Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - Lucie Della Schiava
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | | | - Peter A. Ringleb
- Department of Neurology, University Hospital Heidelberg, Germany
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hamza Jubran
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Andreas R Luft
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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8
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Andina ME, Nelde A, Nolte CH, Scheitz JF, Olma MC, Krämer M, Meisel E, Bingel A, Meisel A, Scheibe F, Endres M, Schlemm L, Meisel C. Datawarehouse-enabled quality control of atrial fibrillation detection in the stroke unit setting. Heliyon 2023; 9:e18432. [PMID: 37534004 PMCID: PMC10391946 DOI: 10.1016/j.heliyon.2023.e18432] [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: 04/26/2023] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 08/04/2023] Open
Abstract
Objective (1) To assess the accuracy of a standard operating procedure (SOP) regarding the utilization of atrial fibrillation (AF) alarms in everyday clinical practice, and (2) to evaluate the performance of automated continuous surveillance for atrial fibrillation (AF) in hospitalized acute stroke patients. Design Retrospective cohort study. Setting Two stroke units from two tertiary care hospitals in Berlin, Germany. Participants We identified 635 patients with ischemic stroke diagnosis for the time period between 01. January and 30. September 2021 of which 176 patients had recorded AF alarms during monitoring. Of those, 115 patients were randomly selected for evaluation. After excluding 6 patients with hemorrhagic stroke in their records, 109 patients (mean age: 79.1 years, median NIHSS at admission: 6, 57% female) remained for analysis. Intervention Using a clinical data warehouse for comprehensive data storage we retrospectively downloaded and visualized ECG data segments of 65 s duration around the automated AF alarms. We restricted the maximum number of ECG segments to ten per patient. Each ECG segment plot was uploaded into a REDCap database and categorized as either AF, non-AF or artifact by manual review. Atrial flutter was subsumed as AF. These classifications were then matched with 1) medical history and known diseases before stroke, 2) discharge diagnosis, and 3) recommended treatment plan in the medical history using electronic health records. Main outcome measures The primary outcome was the proportion of previously unknown AF diagnoses correctly identified by the monitoring system but missed by the clinical team during hospitalization. Secondary outcomes included the proportion of patients in whom a diagnosis of AF would likely have led to anticoagulant therapy. We also evaluated the accuracy of the automated detection system in terms of its positive predictive value (PPV). Results We evaluated a total of 717 ECG alarm segments from 109 patients. In 4 patients (3.7, 95% confidence interval [CI] 1.18-9.68%) physicians had missed AF despite at least one true positive alarm. All four patients did not receive long-term secondary prevention in form of anticoagulant therapy. 427 out of 717 alarms were rated true positives, resulting in a positive predictive value of 0.6 (CI 0.56-0.63) in this cohort. Conclusion By connecting a data warehouse, electronic health records and a REDCap survey tool, we introduce a path to assess the monitoring quality of AF in acute stroke patients. We find that implemented standards of procedure to detect AF during stroke unit care are effective but leave room for improvement. Such data warehouse-based concepts may help to adjust internal processes or identify targets of further investigations.
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Affiliation(s)
- Mario E. Andina
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Nelde
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H. Nolte
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Cite Berlin, Germany
| | - Jan F. Scheitz
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
| | | | | | | | - Anne Bingel
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- NeuroCure Clinical Research Center, Berlin, Germany
| | - Franziska Scheibe
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Cite Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Germany
| | - Ludwig Schlemm
- Center for Stroke Research Berlin, Berlin, Germany
- Institute of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Radiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Meisel
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Bernstein Center for Computational Neuroscience, Berlin, Germany
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9
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Thevathasan T, Degbeon S, Paul J, Wendelburg DK, Füreder L, Gaul AL, Scheitz JF, Stadler G, Rroku A, Lech S, Buspavanich P, Huemer M, Attanasio P, Nagel P, Reinthaler M, Landmesser U, Skurk C. Safety and Healthcare Resource Utilization in Patients Undergoing Left Atrial Appendage Closure-A Nationwide Analysis. J Clin Med 2023; 12:4573. [PMID: 37510689 PMCID: PMC10380523 DOI: 10.3390/jcm12144573] [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: 05/28/2023] [Revised: 06/26/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Percutaneous left atrial appendage closure (LAAC) has emerged as a non-pharmacological alternative for stroke prevention in patients with atrial fibrillation (AF) not suitable for anticoagulation therapy. Real-world data on peri-procedural outcomes are limited. The aim of this study was to analyze outcomes of peri-procedural safety and healthcare resource utilization in 11,240 adult patients undergoing LAAC in the United States between 2016 and 2019. Primary outcomes (safety) were in-hospital ischemic stroke or systemic embolism (SE), pericardial effusion (PE), major bleeding, device embolization and mortality. Secondary outcomes (resource utilization) were adverse discharge disposition, hospital length of stay (LOS) and costs. Logistic and Poisson regression models were used to analyze outcomes by adjusting for 10 confounders. SE decreased by 97% between 2016 and 2019 [95% Confidence Interval (CI) 0-0.24] (p = 0.003), while a trend to lower numbers of other peri-procedural complications was determined. In-hospital mortality (0.14%) remained stable. Hospital LOS decreased by 17% (0.78-0.87, p < 0.001) and adverse discharge rate by 41% (95% CI 0.41-0.86, p = 0.005) between 2016 and 2019, while hospital costs did not significantly change (p = 0.2). Female patients had a higher risk of PE (OR 2.86 [95% CI 2.41-6.39]) and SE (OR 5.0 [95% CI 1.28-43.6]) while multi-morbid patients had higher risks of major bleeding (p < 0.001) and mortality (p = 0.031), longer hospital LOS (p < 0.001) and increased treatment costs (p = 0.073). Significant differences in all outcomes were observed between male and female patients across US regions. In conclusion, LAAC has become a safer and more efficient procedure. Significant sex differences existed across US regions. Careful considerations should be taken when performing LAAC in female and comorbid patients.
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Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Sêhnou Degbeon
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Julia Paul
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Darius-Konstantin Wendelburg
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Lisa Füreder
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Anna Leonie Gaul
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Jan F Scheitz
- Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
- Department of Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Gertraud Stadler
- Research Unit Gender in Medicine, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Andi Rroku
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
| | - Sonia Lech
- Institute for Medical Sociology and Rehabilitation Science, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
- Department of Psychiatry and Neurosciences, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Pichit Buspavanich
- Research Unit Gender in Medicine, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
- Institute for Sexology and Sexual Medicine, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Martin Huemer
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Philipp Attanasio
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Patrick Nagel
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Markus Reinthaler
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
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10
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Blaszczyk E, Hellwig S, Saad H, Ganeshan R, Stengl H, Nolte CH, Fiebach JB, Endres M, Kuhnt J, Gröschel J, Schulz-Menger J, Scheitz JF. Myocardial injury in patients with acute ischemic stroke detected by cardiovascular magnetic resonance imaging. Eur J Radiol 2023; 165:110908. [PMID: 37315403 DOI: 10.1016/j.ejrad.2023.110908] [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: 02/22/2023] [Revised: 04/29/2023] [Accepted: 05/30/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Patients with acute ischemic stroke (AIS) are at high risk of adverse cardiovascular events. Until now, the burden of myocardial injury derived from cardiovascular magnetic resonance imaging (CMR) has not been established in this population. METHODS Patients with AIS underwent CMR at 3 Tesla within 120 h after the index stroke as part of a prospective, single-center study. Patients with persistent atrial fibrillation were excluded. Morphology and function of both cardiac chambers and atria were assessed applying SSFP cine. Myocardial tissue differentiation was based on native and contrast-enhanced imaging including late gadolinium enhancement (LGE) after 0.15 mmol/kg gadobutrol for focal fibrosis and parametric T2- and T1-mapping for diffuse findings. To detect myocardial deformation global longitudinal (GLS), circumferential (GCS) and radial (GRS) strain was measured applying feature tracking. Cardiac troponin was measured using a high-sensitivity assay (99th percentile upper reference limit 14 ng/L). T2 mapping values were compared with 20 healthy volunteers. RESULTS CMR with contrast media was successfully performed in 92 of 115 patients (mean age 74 years, 40% female, known myocardial infarction 6%). Focal myocardial fibrosis (LGE) was detected in 31 of 92 patients (34%) of whom 23/31 (74%) showed an ischemic pattern. Patients with LGE were more likely to have diabetes, prior myocardial infarction, prior ischemic stroke, and to have elevated troponin levels compared to those without. Presence of LGE was accompanied by diffuse fibrosis (increased T1 native values) even in remote cardiac areas as well as reduced global radial, circumferential and longitudinal strain values. In 14/31 (45%) of all patients with LGE increased T2-mapping values were detectable. CONCLUSIONS More than one-third of patients with AIS have evidence of focal myocardial fibrosis on CMR. Nearly half of these changes may have acute or subacute onset. These findings are accompanied by diffuse myocardial changes and reduced myocardial deformation. Further studies, ideally with serial CMR measurements during follow-up, are required to establish the impact of these findings on long-term prognosis after AIS.
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Affiliation(s)
- E Blaszczyk
- Charité Universitätsmedizin Berlin, Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine , HELIOS Klinikum Berlin Buch, Cardiology, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - S Hellwig
- Klinik für Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin und Centrum für Schlaganfallforschung, Berlin, Germany
| | - H Saad
- Charité Universitätsmedizin Berlin, Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine , HELIOS Klinikum Berlin Buch, Cardiology, Berlin, Germany
| | - R Ganeshan
- Klinik für Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin und Centrum für Schlaganfallforschung, Berlin, Germany
| | - H Stengl
- Klinik für Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin und Centrum für Schlaganfallforschung, Berlin, Germany
| | - C H Nolte
- Klinik für Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin und Centrum für Schlaganfallforschung, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany; Berlin Institute of Health (BIH), Germany
| | - J B Fiebach
- Klinik für Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin und Centrum für Schlaganfallforschung, Berlin, Germany
| | - M Endres
- Klinik für Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin und Centrum für Schlaganfallforschung, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany; ExcellenceCluster NeuroCure, Germany; German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Germany; Berlin Institute of Health (BIH), Germany
| | - J Kuhnt
- Charité Universitätsmedizin Berlin, Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine , HELIOS Klinikum Berlin Buch, Cardiology, Berlin, Germany
| | - J Gröschel
- Charité Universitätsmedizin Berlin, Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine , HELIOS Klinikum Berlin Buch, Cardiology, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - J Schulz-Menger
- Charité Universitätsmedizin Berlin, Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine , HELIOS Klinikum Berlin Buch, Cardiology, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - J F Scheitz
- Klinik für Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin und Centrum für Schlaganfallforschung, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany.
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Sposato LA, Martins S, Scheitz JF, Aspberg S, Gurol ME, Abdalla M, Arauz A, Cano-Nigenda V, Fiorilli P, Israel C, Kusano K, Mansour O, Messé SR, Pille A, Secchi T, Polanczyk CA, Biolo A, Ramadan I, Sallam A, Schäbitz W, Toyoda K, Valencia S, Wang S, Xiong Y, Zaki A, Saposnik G, Fisher M, Bahit MC. World Stroke Organization Brain & hEart globAl iniTiative Program. Cerebrovasc Dis 2023; 53:115-124. [PMID: 37276846 DOI: 10.1159/000530471] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 01/25/2023] [Accepted: 03/03/2023] [Indexed: 06/07/2023] Open
Abstract
INTRODUCTION The World Stroke Organization (WSO) Brain & Heart Task Force developed the Brain & hEart globAl iniTiative (BEAT), a pilot feasibility implementation program to establish clinical collaborations between cardiologists and stroke physicians who work at large healthcare facilities. METHODS The WSO BEAT pilot project focused on atrial fibrillation (AF) and patent foramen ovale (PFO) detection and management, and poststroke cardiovascular complications known as the stroke-heart syndrome. The program included 10 sites from 8 countries: Brazil, China, Egypt, Germany, Japan, Mexico, Romania, and the USA The primary composite feasibility outcome was the achievement of the following 3 implementation metrics (1) developing site-specific clinical pathways for the diagnosis and management of AF, PFO, and the stroke-heart syndrome; (2) establishing regular Neurocardiology rounds (e.g., monthly); and (3) incorporating a cardiologist to the stroke team. The secondary objectives were (1) to identify implementation challenges to guide a larger program and (2) to describe qualitative improvements. RESULTS The WSO BEAT pilot feasibility program achieved the prespecified primary composite outcome in 9 of 10 (90%) sites. The most common challenges were the limited access to specific medications (e.g., direct oral anticoagulants) and diagnostic (e.g., prolonged cardiac monitoring) or therapeutic (e.g., PFO closure devices) technologies. The most relevant qualitative improvement was the achievement of a more homogeneous diagnostic and therapeutic approach. CONCLUSION The WSO BEAT pilot program suggests that developing neurocardiology collaborations is feasible. The long-term sustainability of the WSO BEAT program and its impact on quality of stroke care and clinical outcomes needs to be tested in a larger and longer duration program.
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Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Heart and Brain Laboratory, Western University, London, Ontario, Canada
- Robarts Research Institute, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | - Sheila Martins
- Hospital Moinhos de Vento, Neurology Service and Postgraduate in Stroke Neurology, Porto Alegre, Brazil
- Brazilian Stroke Network, Porto Alegre, Brazil
| | - Jan F Scheitz
- Klinik für Neurologie mit Experimenteller Neurologie and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Sara Aspberg
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed Abdalla
- Neurology Department, Armed Forces Medical Institute in Alexandria, Alexandria, Egypt
| | - Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Vanessa Cano-Nigenda
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Paul Fiorilli
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carsten Israel
- Department of Cardiology, Evangelisches Klinikum Bethel, University Hospital OWL, University Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Ossama Mansour
- Stroke and Neurointerventional Center, Alexandria University School of Medicine, Alexandria, Egypt
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania., Philadelphia, Pennsylvania, USA
| | - Arthur Pille
- Brazilian Stroke Network, Porto Alegre, Brazil
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Thaís Secchi
- Hospital Moinhos de Vento, Neurology Service and Postgraduate in Stroke Neurology, Porto Alegre, Brazil
- Brazilian Stroke Network, Porto Alegre, Brazil
| | | | - Andreia Biolo
- Hospital Moinhos de Vento, Neurology Service and Postgraduate in Stroke Neurology, Porto Alegre, Brazil
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ismail Ramadan
- Neurology Department, Alexandria University School of Medicine, Alexandria, Egypt
| | - Ashraf Sallam
- Cardiology and Angiology Department, Armed Forces Medical Institute, Alexandria, Egypt
| | - Wolf Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL, University Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sharon Valencia
- Cardiology and Echocardiography Department, Instituto Nacional de Neurología y Neurocirugia Manuel Velasco Suárez, Mexico City, Mexico
| | - Shang Wang
- Department of Neurocardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Amr Zaki
- Cardiology Department, Alexandria University School of Medicine, Alexandria, Egypt
| | - Gustavo Saposnik
- Department of Medicine (Neurology), Stroke Outcomes & Decision Neuroscience Research Unit, University of Toronto, Toronto, Canada
| | - Marc Fisher
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - M Cecilia Bahit
- Department of Cardiology, INECO Neurociencias Rosario, Rosario, Argentina
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12
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Altersberger VL, Sibolt G, Enz LS, Hametner C, Scheitz JF, Henon H, Bigliardi G, Strambo D, Martinez-Majander N, Stolze LJ, Heldner MR, Grisendi I, Jovanovic DR, Bejot Y, Pezzini A, Leker RR, Kägi G, Wegener S, Cereda CW, Ntaios G, De Marchis GM, Bonati LH, Psychogios M, Lyrer P, Räty S, Tiainen M, Wouters A, Caparros F, Heyse M, Erdur H, Padjen V, Zedde M, Arnold M, Nederkoorn PJ, Michel P, Zini A, Cordonnier C, Nolte CH, Ringleb PA, Curtze S, Engelter ST, Gensicke H. Intravenous Thrombolysis 4.5-9 Hours After Stroke Onset - a Cohort Study from the TRISP Collaboration. Ann Neurol 2023. [PMID: 37114466 DOI: 10.1002/ana.26669] [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] [Revised: 03/27/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE To investigate the safety and effectiveness of intravenous thrombolysis (IVT) >4.5-9 hours after stroke onset and the relevance of advanced neuroimaging for patient selection. METHODS Prospective multicenter cohort study from the ThRombolysis in Ischemic Stroke Patients (TRISP) collaboration. Outcomes were symptomatic intracranial hemorrhage (sICH), poor 3-month functional outcome (mRS 3-6) and mortality. We compared (i) IVT >4.5-9 hours versus 0-4.5 hours after stroke onset and (ii) within the >4.5-9 hours-group baseline advanced neuroimaging (CT perfusion, MR perfusion or MR DWI/FLAIR) versus non-advanced neuroimaging. RESULTS Of 15'827 patients, 663 (4.2%) received IVT >4.5-9 hours and 15'164 (95.8%) within 4.5 hours after stroke onset. The main baseline characteristics were evenly distributed between both groups. Time of stroke onset was known in 74.9% of patients treated between >4.5-9 hours. Using propensity score weighted binary logistic regression analysis (OTT >4.5-9 hours vs. OTT 0-4.5 hours), the probability of sICH (ORadjusted 0.80[0.53-1.17]), poor functional outcome (ORadjusted 1.01[0.83-1.22]) and mortality (ORadjusted 0.80[0.61-1.04]) did not differ significantly between both groups. In patients treated between >4.5-9 hours, the use of advanced neuroimaging was associated with a 50% lower mortality compared to non-advanced imaging only (9.9% vs 19.7%; ORadjusted 0.51[0.33-0.79]). INTERPRETATION This study showed no evidence in difference of sICH, poor outcome and mortality in selected stroke patients treated with IVT between >4.5-9 hours after stroke onset compared to those treated within 4.5 hours. Advanced neuroimaging for patient selection was associated with lower mortality. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Valerian L Altersberger
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| | - Gerli Sibolt
- Neurology, University of Helsinki and Helsinki University Hospital, Finland
| | - Lukas S Enz
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| | | | - Jan F Scheitz
- Klinik Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Germany
| | - Hilde Henon
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000, Lille, France
| | - Guido Bigliardi
- Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital, Modena, Italy
| | - Davide Strambo
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Lotte J Stolze
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Ilaria Grisendi
- Neurology Unit-Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Dejana R Jovanovic
- Neurology Clinic, University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Yannick Bejot
- Department of Neurology, University Hospital Dijon, France
| | - Alessandro Pezzini
- Neurology Clinic, Department of Clinical and Experimental Sciences, University of Brescia, Italy
- Department of Neurological Sciences and Vision, ASST Spedali Civili, Brescia, Italy
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, Switzerland
| | - Carlo W Cereda
- Stroke Center and department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Georges Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Gian Marco De Marchis
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| | - Leo H Bonati
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel and University of Basel, Switzerland
| | - Philippe Lyrer
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| | - Silja Räty
- Neurology, University of Helsinki and Helsinki University Hospital, Finland
| | - Marjaana Tiainen
- Neurology, University of Helsinki and Helsinki University Hospital, Finland
| | - Anke Wouters
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - François Caparros
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000, Lille, France
| | - Miriam Heyse
- Department of Neurology, University Hospital Heidelberg, Germany
| | - Hebun Erdur
- Klinik Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Germany
| | - Visnja Padjen
- Neurology Clinic, University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marialuisa Zedde
- Neurology Unit-Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Patrik Michel
- Stroke Center, Neurology Service, 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
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000, Lille, France
| | - Christian H Nolte
- Klinik Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Germany
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Finland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
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Nelde A, Klammer MG, Nolte CH, Stengl H, Krämer M, von Rennenberg R, Meisel A, Scheibe F, Endres M, Scheitz JF, Meisel C. Data lake-driven analytics identify nocturnal non-dipping of heart rate as predictor of unfavorable stroke outcome at discharge. J Neurol 2023:10.1007/s00415-023-11718-x. [PMID: 37079032 DOI: 10.1007/s00415-023-11718-x] [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] [Received: 02/06/2023] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Post-stroke heart rate (HR) and heart rate variability (HRV) changes have been proposed as outcome predictors after stroke. We used data lake-enabled continuous electrocardiograms to assess post-stroke HR and HRV, and to determine the utility of HR and HRV to improve machine learning-based predictions of stroke outcome. METHODS In this observational cohort study, we included stroke patients admitted to two stroke units in Berlin, Germany, between October 2020 and December 2021 with final diagnosis of acute ischemic stroke or acute intracranial hemorrhage and collected continuous ECG data through data warehousing. We created circadian profiles of several continuously recorded ECG parameters including HR and HRV parameters. The pre-defined primary outcome was short-term unfavorable functional outcome after stroke indicated through modified Rankin Scale (mRS) score of > 2. RESULTS We included 625 stroke patients, 287 stroke patients remained after matching for age and National Institute of Health Stroke Scale (NIHSS; mean age 74.5 years, 45.6% female, 88.9% ischemic, median NIHSS 5). Both higher HR and nocturnal non-dipping of HR were associated with unfavorable functional outcome (p < 0.01). The examined HRV parameters were not associated with the outcome of interest. Nocturnal non-dipping of HR ranked highly in feature importance of various machine learning models. CONCLUSIONS Our data suggest that a lack of circadian HR modulation, specifically nocturnal non-dipping, is associated with short-term unfavorable functional outcome after stroke, and that including HR into machine learning-based prediction models may lead to improved stroke outcome prediction.
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Affiliation(s)
- Alexander Nelde
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | - Markus G Klammer
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Helena Stengl
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | | | - Regina von Rennenberg
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- NeuroCure Clinical Research Center, Berlin, Germany
| | - Franziska Scheibe
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
| | - Christian Meisel
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany.
- Center for Stroke Research Berlin, Berlin, Germany.
- Berlin Institute of Health, Berlin, Germany.
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany.
- Bernstein Center for Computational Neuroscience, Berlin, Germany.
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14
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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.
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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
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15
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von Rennenberg R, Liman T, Nolte CH, Nave AH, Scheitz JF, Düzel S, Regitz-Zagrosek V, Gerstorf D, Steinhagen-Thiessen E, Demuth I, Endres M. High-Sensitivity Cardiac Troponin T and Cognitive Decline in Older Adults: Results of the Berlin Aging Study II. Gerontology 2023; 69:140-148. [PMID: 35512662 DOI: 10.1159/000523845] [Citation(s) in RCA: 1] [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: 11/10/2021] [Accepted: 02/15/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION There is evidence of an association between markers of cardiac injury and cognition in patients with cardiovascular disease. We hypothesized that levels of high-sensitivity cardiac troponin T (hs-cTnT) are associated with cognitive performance and cognitive decline in a population of predominantly healthy older adults. METHODS We included 1,226 predominantly healthy adults ≥60 years from the Berlin Aging Study II. Participants were recruited from the general population of the Berlin metropolitan area from 2009 to 2014. At baseline, participants underwent measurement of hs-cTnT and cognitive testing using the extended Consortium to Establish a Registry for Alzheimer's Disease (CERAD-Plus) battery. In addition, the Digit Symbol Substitution Test (DSST) was performed at baseline and at follow-up (7.3 ± 1.4 years after the baseline visit). The CERAD test results were summarized into four cognitive domains (processing speed, executive function, visuo-construction, and memory). After summing-up the respective raw scores, we calculated standardized z scores. We performed unadjusted and adjusted linear regression models to assess links between hs-cTnT and cognitive domains. We used linear mixed models to analyze associations between hs-cTnT and cognitive decline according to changes in DSST scores over time. RESULTS The mean age of study participants at baseline was 68.5 (±3.6) years, 49% were female, and median hs-cTnT levels were 6 ng/L (IQR 4-8 ng/L). We detected no significant association between hs-cTnT and different cognitive domains at baseline after adjustment for age, sex, education, and cardiovascular risk factors. Hs-cTnT was associated with cognitive decline, which remained statistically significant after full adjustment (adjusted beta-coefficient -0.82 (-1.28 to -0.36), p = 0.001). After stratification for sex, the association with hs-cTnT remained statistically significant in men but not in women. CONCLUSION Higher hs-cTnT levels in older men are associated with cognitive decline measured with the DSST.
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Affiliation(s)
- Regina von Rennenberg
- Department of Neurology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), Berlin, Germany
| | - Thomas Liman
- Department of Neurology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander H Nave
- Department of Neurology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sandra Düzel
- Max Planck Institute for Human Development, Berlin, Germany
| | - Vera Regitz-Zagrosek
- German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Gender in Medicine (Institut für Geschlechterforschung in der Medizin, GiM), Charite-Universitätsmedizin, Berlin, Germany
| | - Denis Gerstorf
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Elisabeth Steinhagen-Thiessen
- Biology of Aging working group, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ilja Demuth
- Biology of Aging working group, Department of Endocrinology and Metabolic Diseases (including Division of Lipid Metabolism), Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
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16
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Braemswig TB, Kusserow M, Bellmann B, Beckhoff F, Reinthaler M, von Rennenberg R, Erdur H, Scheitz JF, Galinovic I, Villringer K, Leistner DM, Audebert HJ, Endres M, Landmesser U, Haeusler KG, Fiebach JB, Lauten A, Rillig A, Nolte CH. New Cerebral Microbleeds After Catheter-Based Structural Heart Interventions: An Exploratory Analysis. J Am Heart Assoc 2023; 12:e8189. [PMID: 36734351 PMCID: PMC9973666 DOI: 10.1161/jaha.122.027284] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Cerebral microbleeds (CMBs) are increasingly recognized as "covert" brain lesions indicating increased risk of future neurological events. However, data on CMBs in patients undergoing catheter-based structural heart interventions are scarce. Therefore, we assessed occurrence and predictors of new CMBs in patients undergoing catheter-based left atrial appendage closure and percutaneous mitral valve repair using the MitraClip System. Methods and Results We conducted an exploratory analysis using data derived from 2 prospective, observational studies. Eligible patients underwent cerebral magnetic resonance imaging (3 Tesla) examinations and cognitive tests (using the Montreal Cognitive Assessment) before and after catheter-based left atrial appendage closure and percutaneous mitral valve repair. Forty-seven patients (53% men; median age, 77 years) were included. New CMBs occurred in 17 of 47 patients (36%) following catheter-based structural heart interventions. Occurrences of new CMBs did not differ significantly between patients undergoing catheter-based left atrial appendage closure and percutaneous mitral valve repair (7/25 versus 10/22; P=0.348). In univariable analysis, longer procedure time was significantly associated with new CMBs. Adjustment for heparin attenuated this association (adjusted odds ratio [per 30 minutes]: 1.77 [95% CI, 0.92-3.83]; P=0.090). Conclusions New CMBs occur in approximately one-third of patients after catheter-based left atrial appendage closure and percutaneous mitral valve repair using the MitraClip System. Our data suggest that longer duration of the procedure may be a risk factor for new CMBs. Future studies in larger populations are needed to further investigate their clinical relevance. Clinical Trial Registration German Clinical Trials Register: DRKS00010300 (https://drks.de/search/en/trial/DRKS00010300); ClinicalTrials.gov : NCT03104556 (https://clinicaltrials.gov/ct2/show/NCT03104556?term=NCT03104556&draw=2&rank=1).
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Affiliation(s)
- Tim Bastian Braemswig
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
| | - Madeleine Kusserow
- Klinik für Innere MedizinBundeswehrkrankenhaus BerlinBerlinGermany
- Charité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Barbara Bellmann
- MEDIAN Klinik AGZ DüsseldorfDüsseldorfGermany
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Frederik Beckhoff
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Markus Reinthaler
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Institute of Active Polymers and Berlin‐Brandenburg Center for Regenerative TherapiesHelmholtz‐Zentrum HereonTeltowGermany
- Deutsches Herzzentrum der Charité, Klinik für KardiologieAngiologie und IntensivmedizinBerlinGermany
| | - Regina von Rennenberg
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (DZNE), partner site BerlinBerlinGermany
| | - Hebun Erdur
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Jan F. Scheitz
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
| | - Ivana Galinovic
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Kersten Villringer
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - David M. Leistner
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin BerlinBerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Department of Medicine III, CardiologyGoethe UniversityFrankfurt am MainGermany
- German Centre for Cardiovascular Research (DZHK), partner site Rhine‐MainFrankfurtGermany
| | - Heinrich J. Audebert
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Matthias Endres
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (DZNE), partner site BerlinBerlinGermany
- ExcellenceCluster NeuroCureBerlinGermany
| | - Ulf Landmesser
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin BerlinBerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Deutsches Herzzentrum der Charité, Klinik für KardiologieAngiologie und IntensivmedizinBerlinGermany
| | | | - Jochen B. Fiebach
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Alexander Lauten
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Department of General and Interventional CardiologyHelios Klinikum ErfurtErfurtGermany
| | - Andreas Rillig
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Universitäres Herz‐ und Gefässzentrum Hamburg‐EppendorfHamburgGermany
| | - Christian H. Nolte
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (DZNE), partner site BerlinBerlinGermany
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17
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von Rennenberg R, Herm J, Krause T, Hellwig S, Stengl H, Scheitz JF, Elgeti T, Nagel SN, Endres M, Haeusler KG, Nolte CH. Elevation of cardiac biomarkers in stroke is associated with pathological findings on cardiac MRI-results of the HEart and BRain interfaces in Acute Stroke study. Int J Stroke 2023; 18:180-186. [PMID: 35403503 DOI: 10.1177/17474930221095698] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 02/01/2023]
Abstract
INTRODUCTION Cardiac biomarkers, such as high-sensitivity cardiac troponin T (hs-cTnT), are frequently elevated in ischemic stroke patients but the mechanisms underlying this elevation are insufficiently understood. We determined the presence of cardiac damage, assessed using cardiac magnetic resonance imaging (CMR), in stroke patients with elevated hs-cTnT and brain natriuretic peptide (BNP). METHODS This is a post hoc analysis of the prospective, investigator-initiated, cross-sectional HEart and BRain interfaces in Acute Stroke (HEBRAS) study. All patients underwent the measurement of hs-cTnT and BNP as well as gadolinium-enhanced CMR in the acute phase of ischemic stroke. We performed unadjusted and adjusted logistic regression models to assess the association between hs-cTnT and BNP elevation and the presence of pathological CMR findings. RESULTS Two hundred and thirty-three stroke patients (median age 67 years, 33% female) were included, of whom 43 (21%) had elevated hs-cTnT and 109 (47%) had elevated BNP. Hundred of the 233 (43%) patients had pathological findings on CMR had focal fibrosis as detected by late-gadolinium enhancement (LGE) in 51 (23%), left-ventricular hypertrophy (LVH) in 38 (16%), reduced LVEF in 32 (14%), and left-atrial dilatation in 34 (15%). After adjustment for potential confounders, both hs-cTnT (adjOR 5.0 (95%CI 2.1-11.7), p < 0.001) and BNP (adjOR 4.1 (95%CI 2.3-7.3), p < 0.001) were significantly associated with pathological findings on CMR. Hs-cTnT was associated with LGE, LVEF, and LVH, whereas BNP was associated with left-atrial dilatation and LVEF, LVH. CONCLUSION Elevated cardiac biomarkers in acute stroke including CMR are strongly associated with pathological findings on CMR. In acute stroke patients, the elevation of cardiac biomarkers may identify patients who require a more thorough cardiology work-up.
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Affiliation(s)
- Regina von Rennenberg
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - Juliane Herm
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research, Berlin, Germany
| | - Thomas Krause
- Department of Neurology, Jüdisches Krankenhaus Berlin, Berlin, Germany
| | - Simon Hellwig
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research, Berlin, Germany
| | - Helena Stengl
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research, Berlin, Germany
| | - Jan F Scheitz
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site, Berlin, Germany
| | - Thomas Elgeti
- Departments of Radiology Pediatric Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian N Nagel
- Departments of Radiology Pediatric Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site, Berlin, Germany.,ExcellenceCluster NeuroCure, Berlin, Germany
| | | | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site, Berlin, Germany
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18
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Stengl H, Ganeshan R, Hellwig S, Klammer MG, von Rennenberg R, Böhme S, Audebert HJ, Nolte CH, Endres M, Scheitz JF. Frequency, associated variables, and outcomes of acute myocardial injury according to the fourth Universal Definition of Myocardial Infarction in patients with acute ischemic stroke. Eur Stroke J 2022; 7:413-420. [PMID: 36478763 PMCID: PMC9720848 DOI: 10.1177/23969873221120159] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/30/2022] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Myocardial injury as indicated by elevation of cardiac troponin levels is common after acute ischemic stroke (AIS) and linked to poor outcomes. Previous studies rarely reported on serial hs-cTn measurements to distinguish whether myocardial injury is acute or chronic. Thus, little is known about frequency, associated variables, and outcome of acute myocardial injury in AIS. METHODS AND PATIENTS In this single-centered observational cohort study, from 01/2019 to 12/2020, consecutive patients with neuroimaging-confirmed AIS <48 h after symptom onset, and serial troponin measurements within the first 2 days after admission (Roche Elecsys®, hs-cardiac troponin T) were prospectively registered. Acute myocardial injury was defined according to the fourth Universal Definition of Myocardial Infarction (troponin above the upper reference limit and rise/fall>20%). Outcomes of interest were in-hospital mortality and unfavorable functional status at discharge (modified Rankin Scale >1). RESULTS Out of 1067 analyzed patients, 25.3% had acute myocardial injury, 40.4% had chronic myocardial injury and 34.3% had no myocardial injury. Older age, higher stroke severity, thrombolytic treatment, and impaired kidney function were independently associated with acute myocardial injury. In-hospital mortality was higher in patients with acute myocardial injury than in those without (13% vs 3%, adjusted OR, 2.9% [95% CI, 1.6-5.5]). Compared with no myocardial injury, both acute and chronic myocardial injury were associated with unfavorable functional status at discharge (adjusted OR, 1.6 [95% CI, 1.1-2.5] and OR, 1.7 [95% CI, 1.2-2.4], respectively). CONCLUSIONS A quarter of patients with AIS have evidence of acute myocardial injury according to the fourth Universal Definition of Myocardial Infarction. The strong association with in-hospital mortality highlights the need for clinical awareness and future studies on underlying mechanisms.
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Affiliation(s)
- Helena Stengl
- Department of Neurology, Charité –
Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin
(CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at
Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Ramanan Ganeshan
- Department of Neurology, Charité –
Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin
(CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at
Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Hellwig
- Department of Neurology, Charité –
Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin
(CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at
Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Markus G Klammer
- Department of Neurology, Charité –
Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin
(CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Excellence Cluster NeuroCure, Charité –
Universitätsmedizin Berlin, Berlin, Germany
| | - Regina von Rennenberg
- Department of Neurology, 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, Germany
| | - Sophie Böhme
- Department of Neurology, Charité –
Universitätsmedizin Berlin, Berlin, Germany
| | - Heinrich J Audebert
- Department of Neurology, Charité –
Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin
(CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité –
Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin
(CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular
Research (DZHK), Partner Site, Berlin, Germany
- Berlin Institute of Health (BIH) at
Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité –
Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin
(CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular
Research (DZHK), Partner Site, Berlin, Germany
- Berlin Institute of Health (BIH) at
Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative
Diseases (DZNE), Partner Site, Berlin, Germany
- Excellence Cluster NeuroCure, Charité –
Universitätsmedizin Berlin, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology, Charité –
Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin
(CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular
Research (DZHK), Partner Site, Berlin, Germany
- Berlin Institute of Health (BIH) at
Charité – Universitätsmedizin Berlin, Berlin, Germany
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19
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Altersberger VL, Rusche N, Martinez-Majander N, Hametner C, Scheitz JF, Henon H, Dell’Acqua ML, Strambo D, Stolp J, Heldner MR, Grisendi I, Jovanovic DR, Bejot Y, Pezzini A, Leker RR, Kägi G, Wegener S, Cereda CW, Lindgren E, Ntaios G, Piot I, Polymeris AA, Lyrer PA, Räty S, Sibolt G, Tiainen M, Heyse M, Erdur H, Kaaouana O, Padjen V, Zedde M, Arnold M, Nederkoorn PJ, Michel P, Bigliardi G, Zini A, Cordonnier C, Nolte CH, Ringleb PA, Curtze S, Engelter ST, Gensicke H. Intravenous Thrombolysis in Patients With Ischemic Stroke Aged ≥90 Years: A Cohort Study From the TRISP Collaboration. Stroke 2022; 53:3557-3563. [DOI: 10.1161/strokeaha.122.039426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The probability to receive intravenous thrombolysis (IVT) for treatment of acute ischemic stroke declines with increasing age and is consequently the lowest in very elderly patients. Safety concerns likely influence individual IVT treatment decisions. Using data from a large IVT registry, we aimed to provide more evidence on safety of IVT in the very elderly.
Methods:
In this prospective multicenter study from the TRISP (Thrombolysis in Ischemic Stroke Patients) registry, we compared patients ≥90 years with those <90 years using symptomatic intracranial hemorrhage (ECASS [European Cooperative Acute Stroke Study]-II criteria), death, and poor functional outcome in survivors (modified Rankin Scale score 3–5 for patients with prestroke modified Rankin Scale score ≤2 and modified Rankin Scale score 4–5 for patients prestroke modified Rankin Scale ≥3) at 3 months as outcomes. We calculated adjusted odds ratio with 95% CI using logistic regression models.
Results:
Of 16 974 eligible patients, 976 (5.7%) were ≥90 years. Patients ≥90 years had higher median National Institutes of Health Stroke Scale on admission (12 versus 8) and were more often dependent prior to the index stroke (prestroke modified Rankin Scale score of ≥3; 45.2% versus 7.4%). Occurrence of symptomatic intracranial hemorrhage (5.7% versus 4.4%, odds ratio
adjusted
1.14 [0.83–1.57]) did not differ significantly between both groups. However, the probability of death (odds ratio
adjusted
3.77 [3.14–4.53]) and poor functional outcome (odds ratio
adjusted
2.63 [2.13–3.25]) was higher in patients aged ≥90 years. Results for the sample of centenarians (n=21) were similar.
Conclusions:
The probability of symptomatic intracranial hemorrhage after IVT in very elderly patients with stroke did not exceed that of their younger counterparts. The higher probability of death and poor functional outcome during follow-up in the very elderly seems not to be related to IVT treatment. Very high age itself should not be a reason to withhold IVT.
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Affiliation(s)
- Valerian L. Altersberger
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
| | - Norman Rusche
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland (N.R., S.T.E., H.G.)
| | - Nicolas Martinez-Majander
- Neurology, University of Helsinki and Helsinki University Hospital, Finland (N.M.-M., S.R., G.S., M.T., S.C.)
| | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Germany C.H., M.H., P.A.R.)
| | - Jan F. Scheitz
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Germany (J.F.S., H.E., C.H.N.)
| | - Hilde Henon
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France (H.H., O.K., C.C.)
| | - Maria Luisa Dell’Acqua
- Neurology - Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital, Italy (M.L.D.A., G.B.)
| | - Davide Strambo
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland (D.S., P.M.)
| | - Jeffrey Stolp
- Amsterdam UMC location University of Amsterdam, Department of Neurology, the Netherlands (J.S., P.J.N.)
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland (M.R.H., G.K., M.A.)
| | - Ilaria Grisendi
- Neurology Unit-Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Italy (I.G., M.Z.)
| | - Dejana R. Jovanovic
- University of Belgrade, Faculty of Medicine, Neurology Clinic, University Clinical Centre of Serbia (D.R.J., V.P.)
| | - Yannick Bejot
- Department of Neurology, University Hospital Dijon, France (Y.B.)
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Italy (A.P.)
| | - Ronen R. Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel (R.R.L.)
| | - Georg Kägi
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland (M.R.H., G.K., M.A.)
- Department of Neurology, Kantonsspital St. Gallen, Switzerland (G.K.)
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, Switzerland (S.W.)
| | - Carlo W. Cereda
- Stroke Center EOC, Neurology, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland (C.W.C.)
| | - Erik Lindgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.L.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N.)
| | - Ines Piot
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
| | - Alexandros A. Polymeris
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
| | - Philippe A. Lyrer
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
| | - Silja Räty
- Neurology, University of Helsinki and Helsinki University Hospital, Finland (N.M.-M., S.R., G.S., M.T., S.C.)
| | - Gerli Sibolt
- Neurology, University of Helsinki and Helsinki University Hospital, Finland (N.M.-M., S.R., G.S., M.T., S.C.)
| | - Marjaana Tiainen
- Neurology, University of Helsinki and Helsinki University Hospital, Finland (N.M.-M., S.R., G.S., M.T., S.C.)
| | - Miriam Heyse
- Department of Neurology, University Hospital Heidelberg, Germany C.H., M.H., P.A.R.)
| | - Hebun Erdur
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Germany (J.F.S., H.E., C.H.N.)
| | - Olfa Kaaouana
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France (H.H., O.K., C.C.)
| | - Visnja Padjen
- University of Belgrade, Faculty of Medicine, Neurology Clinic, University Clinical Centre of Serbia (D.R.J., V.P.)
| | - Marialuisa Zedde
- Neurology Unit-Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Italy (I.G., M.Z.)
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland (M.R.H., G.K., M.A.)
| | - Paul J. Nederkoorn
- Amsterdam UMC location University of Amsterdam, Department of Neurology, the Netherlands (J.S., P.J.N.)
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland (D.S., P.M.)
| | - Guido Bigliardi
- Neurology - Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital, Italy (M.L.D.A., G.B.)
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy (A.Z.)
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France (H.H., O.K., C.C.)
| | - Christian H. Nolte
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Germany (J.F.S., H.E., C.H.N.)
| | - Peter A. Ringleb
- Department of Neurology, University Hospital Heidelberg, Germany C.H., M.H., P.A.R.)
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Finland (N.M.-M., S.R., G.S., M.T., S.C.)
| | - Stefan T. Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland (N.R., S.T.E., H.G.)
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland (N.R., S.T.E., H.G.)
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20
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Abstract
After ischemic stroke, there is a significant burden of cardiovascular complications, both in the acute and chronic phase. Severe adverse cardiac events occur in 10% to 20% of patients within the first few days after stroke and comprise a continuum of cardiac changes ranging from acute myocardial injury and coronary syndromes to heart failure or arrhythmia. Recently, the term stroke–heart syndrome was introduced to provide an integrated conceptual framework that summarizes neurocardiogenic mechanisms that lead to these cardiac events after stroke. New findings from experimental and clinical studies have further refined our understanding of the clinical manifestations, pathophysiology, and potential long‐term consequences of the stroke–heart syndrome. Local cerebral and systemic mediators, which mainly involve autonomic dysfunction and increased inflammation, may lead to altered cardiomyocyte metabolism, dysregulation of (tissue‐resident) leukocyte populations, and (micro‐) vascular changes. However, at the individual patient level, it remains challenging to differentiate between comorbid cardiovascular conditions and stroke‐induced heart injury. Therefore, further research activities led by joint teams of basic and clinical researchers with backgrounds in both cardiology and neurology are needed to identify the most relevant therapeutic targets that can be tested in clinical trials.
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Affiliation(s)
- Jan F Scheitz
- Department of Neurology With Experimental Neurology Charité-Universitätsmedizin Berlin Berlin Germany.,Center for Stroke Research Berlin Charité-Universitätsmedizin Berlin Berlin Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin Berlin Germany.,Berlin Institute of Health (BIH) Berlin Germany.,World Stroke Organization Brain & Heart Task Force
| | - Luciano A Sposato
- World Stroke Organization Brain & Heart Task Force.,Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry Western University London Ontario Canada.,Heart & Brain Laboratory Western University London Ontario Canada
| | - Jeanette Schulz-Menger
- Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center, a Joint Cooperation Between the Charité-Universitätsmedizin Berlin, Department of Internal Medicine and Cardiology and the Max-Delbrueck Center for Molecular Medicine DZHK (German Centre for Cardiovascular Research), Partner Site Berlin Berlin Germany.,Department of Cardiology and Nephrology HELIOS Klinikum Berlin Buch Berlin Germany
| | - Christian H Nolte
- Department of Neurology With Experimental Neurology Charité-Universitätsmedizin Berlin Berlin Germany.,Center for Stroke Research Berlin Charité-Universitätsmedizin Berlin Berlin Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin Berlin Germany.,Berlin Institute of Health (BIH) Berlin Germany
| | - Johannes Backs
- Institute of Experimental Cardiology Heidelberg University Heidelberg Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim Heidelberg Germany
| | - Matthias Endres
- Department of Neurology With Experimental Neurology Charité-Universitätsmedizin Berlin Berlin Germany.,Center for Stroke Research Berlin Charité-Universitätsmedizin Berlin Berlin Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin Berlin Germany.,Berlin Institute of Health (BIH) Berlin Germany.,DZNE (German Center for Neurodegenerative Disease), Partner Site Berlin Berlin Germany.,ExcellenceCluster NeuroCure Berlin Germany
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21
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Nolte CH, Scheitz JF, Erdur H, Audebert HJ. Regarding the new ESO guideline on pharmacological interventions for long-term secondary prevention after ischemic stroke or transient ischemic attack: Current evidence does not allow simplified recommendations. Eur Stroke J 2022; 7:339-340. [PMID: 36082265 PMCID: PMC9446321 DOI: 10.1177/23969873221108745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Christian H Nolte
- Klinik für Neurologie mit Experimenteller Neurologie, 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, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
- German Centre for Cardiovascular Research, Partner Site Berlin, Germany
| | - Jan F Scheitz
- Klinik für Neurologie mit Experimenteller Neurologie, 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, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Hebun Erdur
- Klinik für Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin and Berlin Institute of Health (BIH), Berlin, Germany
| | - Heinrich J Audebert
- Klinik für Neurologie mit Experimenteller Neurologie, 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, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
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22
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Polymeris AA, Meinel TR, Oehler H, Hölscher K, Zietz A, Scheitz JF, Nolte CH, Stretz C, Yaghi S, Stoll S, Wang R, Häusler KG, Hellwig S, Klammer MG, Litmeier S, Leon Guerrero CR, Moeini-Naghani I, Michel P, Strambo D, Salerno A, Bianco G, Cereda C, Uphaus T, Gröschel K, Katan M, Wegener S, Peters N, Engelter ST, Lyrer PA, Bonati LH, Grunder L, Ringleb PA, Fischer U, Kallmünzer B, Purrucker JC, Seiffge DJ. Aetiology, secondary prevention strategies and outcomes of ischaemic stroke despite oral anticoagulant therapy in patients with atrial fibrillation. J Neurol Neurosurg Psychiatry 2022; 93:588-598. [PMID: 35396339 PMCID: PMC9148984 DOI: 10.1136/jnnp-2021-328391] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/05/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate the aetiology, subsequent preventive strategies and outcomes of stroke despite anticoagulation in patients with atrial fibrillation (AF). METHODS We analysed consecutive patients with AF with an index imaging-proven ischaemic stroke despite vitamin K-antagonist (VKA) or direct oral anticoagulant (DOAC) treatment across 11 stroke centres. We classified stroke aetiology as: (i) competing stroke mechanism other than AF-related cardioembolism; (ii) insufficient anticoagulation (non-adherence or low anticoagulant activity measured with drug-specific assays); or, (iii) AF-related cardioembolism despite sufficient anticoagulation. We investigated subsequent preventive strategies with regard to the primary (composite of recurrent ischaemic stroke, intracranial haemorrhage, death) and secondary endpoint (recurrent ischaemic stroke) within 3 months after index stroke. RESULTS Among 2946 patients (median age 81 years; 48% women; 43% VKA, 57% DOAC), stroke aetiology was competing mechanism in 713 patients (24%), insufficient anticoagulation in 934 (32%) and cardioembolism despite sufficient anticoagulation in 1299 (44%). We found high rates of the primary (27% of patients; completeness 91.6%) and secondary endpoint (4.6%; completeness 88.5%). Only DOAC (vs VKA) treatment after index stroke showed lower odds for both endpoints (primary: adjusted OR (aOR) (95% CI) 0.49 (0.32 to 0.73); secondary: 0.44 (0.24 to 0.80)), but not switching between different DOAC types. Adding antiplatelets showed higher odds for both endpoints (primary: aOR (95% CI) 1.99 (1.25 to 3.15); secondary: 2.66 (1.40 to 5.04)). Only few patients (1%) received left atrial appendage occlusion as additional preventive strategy. CONCLUSIONS Stroke despite anticoagulation comprises heterogeneous aetiologies and cardioembolism despite sufficient anticoagulation is most common. While DOAC were associated with better outcomes than VKA, adding antiplatelets was linked to worse outcomes in these high-risk patients. Our findings indicate that individualised and novel preventive strategies beyond the currently available anticoagulants are needed. TRIAL REGISTRATION NUMBER ISRCTN48292829.
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Affiliation(s)
- Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Hannah Oehler
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kyra Hölscher
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Jan F Scheitz
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Stretz
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Svenja Stoll
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Karl Georg Häusler
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Simon Hellwig
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus G Klammer
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Litmeier
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Iman Moeini-Naghani
- Department of Neurology, The George Washington University, Washington, DC, USA
| | - Patrik Michel
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alexander Salerno
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurology Department, Neurocenter of Southern Switzerland EOC, Lugano, Ticino, Switzerland
| | - Carlo Cereda
- Stroke Center, Neurology Department, Neurocenter of Southern Switzerland EOC, Lugano, Ticino, Switzerland
| | - Timo Uphaus
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Klaus Gröschel
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Center, Klinik Hirslanden Zurich, Zurich, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lorenz Grunder
- Department of Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | | | - Urs Fischer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
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23
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Doehner W, Scherbakov N, Schellenberg T, Jankowska EA, Scheitz JF, von Haehling S, Joebges M. Iron deficiency is related to low functional outcome in patients at early rehabilitation after acute stroke. J Cachexia Sarcopenia Muscle 2022; 13:1036-1044. [PMID: 35166066 PMCID: PMC8977949 DOI: 10.1002/jcsm.12927] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Iron deficiency (ID) is a common co-morbidity in patients with cardiovascular disease and contributes to impaired functional capacity. The relevance of ID in patients in recovery after acute stroke is not known. We assessed the prevalence of ID and anaemia in relation to functional capacity and to recovery during early rehabilitation after stroke. METHODS This observational study enrolled consecutively 746 patients with ischaemic or haemorrhagic stroke at in-patient early rehabilitation (age 68 ± 13 years, female 47%, ischaemic stroke 87%). Functional capacity was assessed before and after rehabilitation using Barthel index (reha-BI), motricity index (MI), trunk control test (TCT), and functional ambulatory category (FAC). ID was defined as ferritin <100 μg/L or as transferrin saturation (TSAT) < 20% if ferritin was 100- < 300 μg/L or if CrP > 5 mg/L. Anaemia was defined as Hb < 12 g/dL (women) and <13 g/dL (men). RESULTS The prevalence of ID and anaemia before rehabilitation were 45% and 46%, respectively, and remained high at discharge (after 27 ± 17 days) at 40% and 48%, respectively. Patients with ID had lower functional capacity compared with patients without ID (reha-BI 20 [±86] vs. 40 [±80], MI 64 [±66] vs. 77 [±41], TCT 61 [±76] vs. 100 [±39], FAC 1 [±4] vs. 4 [±4]; median [IQR], all P < 0.001). ID was related to inflammation (OR 2.68 [95% CI 1.98-3.63], P < 0.001), female sex (OR 2.13 [95% CI 1.59-2.85], P < 0.001), haemorrhagic stroke (OR 1.70 [95% CI 1.11-2.61], P = 0.015), initial treatment on stroke unit (OR 3.59 [95% CI 1.08-11.89], P < 0.001), and anaemia (OR 2.94 [95% CI 2.18-3.96], P < 0.001), while age, BMI, and renal function were not related to ID. In adjusted analysis, ID was associated with low functional capacity in all functional scores: reha-BI (OR 1.66 [95% CI 1.08-2.54], P = 0.02), motricity index (OR 1.94 [95% CI 1.36-2.76], P < 0.001), trunk control test (OR 2.34 [95% CI] 1.64-3.32, P < 0.001) and functional ambulatory category (OR 1.77 [95% CI 1.2-2.63], P < 0.02). Functional capacity improved during rehabilitation regardless of presence of ID, but functional outcome remained significantly lower in patients with ID at the end of rehabilitation (rehab BI and MI, both P < 0.001). CONCLUSIONS Iron deficiency and anaemia are common and persistent findings in patients after acute stroke. ID and anaemia are independently related to lower functional capacity after acute stroke and to poor functional outcome after rehabilitation. Regular assessment of iron status may identify patients at risk of low functional recovery.
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Affiliation(s)
- Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiology (Virchow Klinikum), Charité Universitätsmedizin Berlin, and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Nadja Scherbakov
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tim Schellenberg
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Jan F Scheitz
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center (UMG), Göttingen, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Michael Joebges
- Department of Neurology, Brandenburg Klinik, Bernau, Germany
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24
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Filioglo A, Simaan N, Honig A, Heldner MR, von Rennenberg R, Pezzini A, Padjen V, Rentzos A, Altersberger VL, Baumgartner P, Zini A, Grisendi I, Aladdin S, Gomori JM, Pilgram-Pastor SM, Scheitz JF, Magoni M, Berisavac I, Nordanstig A, Psychogios M, Luft A, Gentile M, Assenza F, Arnold M, Nolte CH, Gamba M, Ercegovac M, Jood K, Engelter ST, Wegener S, Forlivesi S, Zedde M, Gensicke H, Tatlisumak T, Cohen JE, Leker RR. Outcomes after reperfusion therapies in patients with ACA stroke: A multicenter cohort study from the EVATRISP collaboration. J Neurol Sci 2022; 432:120081. [PMID: 34920158 DOI: 10.1016/j.jns.2021.120081] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/28/2021] [Accepted: 12/01/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with stroke secondary to occlusions of the anterior cerebral artery (ACA) often have poor outcomes. The optimal acute therapeutic intervention for these patients remains unknown. METHODS Patients with isolated ACA-stroke were identified from 10 centers participating in the EndoVascular treatment And ThRombolysis in Ischemic Stroke Patients (EVATRISP) prospective registry. Patients treated with endovascular thrombectomy (EVT) were compared to those treated with intravenous thrombolysis (IVT). Odds ratios with 95% confidence intervals (OR; 95%CI) were calculated using multivariate regression analysis. RESULTS Included were 92 patients with ACA-stroke. Of the 92 ACA patients, 55 (60%) were treated with IVT only and 37 (40%) with EVT (±bridging IVT). ACA patients treated with EVT had more often wake-up stroke (24% vs. 6%, p = 0.044) and proximal ACA occlusions (43% vs. 24%, p = 0.047) and tended to have higher stroke severity on admission [NIHSS: 10.0 vs 7.0, p = 0.054). However, odds for favorable outcome, mortality or symptomatic intracranial hemorrhage did not differ significantly between both groups. Exploration of the effect of clot location inside the ACA showed that in patients with A1 or A2/A3 ACA occlusions the chances of favorable outcome were not influenced by treatment allocation to IVT or EVT. DISCUSSION Treatment with either IVT or EVT could be safe with similar effect in patients with ACA-strokes and these effects may be independent of clot location within the occluded ACA.
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Affiliation(s)
- A Filioglo
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - N Simaan
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - A Honig
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - M R Heldner
- Department of Neurology, University Hospital Bern, Switzerland
| | - R von Rennenberg
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - A Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Italy
| | - V Padjen
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - A Rentzos
- Department of Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital and Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - V L Altersberger
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| | - P Baumgartner
- University Hospital Zurich and University of Zurich, Switzerland
| | - A Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - I Grisendi
- Neurology Unit, Stroke Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - S Aladdin
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J M Gomori
- Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - S M Pilgram-Pastor
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - J F Scheitz
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - M Magoni
- U.O Vascular Neurology, Stroke Unit, ASST Spedali Civili, Brescia, Italy
| | - I Berisavac
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - A Nordanstig
- Department of Clinical Neurosciences, Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Switzerland
| | - A Luft
- University Hospital Zurich and University of Zurich, Switzerland
| | - M Gentile
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - F Assenza
- Neurology Unit, Stroke Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - M Arnold
- Department of Neurology, University Hospital Bern, Switzerland
| | - C H Nolte
- Department of Neurology, Charité-Universitätsmedizin Berlin, Center for Stroke Research, Berlin, Berlin Institute of Health, Berlin, Germany
| | - M Gamba
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - M Ercegovac
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - K Jood
- Department of Clinical Neurosciences, Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - S T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland; Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland
| | - S Wegener
- University Hospital Zurich and University of Zurich, Switzerland
| | - S Forlivesi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - M Zedde
- Neurology Unit, Stroke Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - H Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland; Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland
| | - T Tatlisumak
- Department of Clinical Neurosciences, Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - J E Cohen
- Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - R R Leker
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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25
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von Rennenberg R, Krause T, Herm J, Hellwig S, Scheitz JF, Endres M, Haeusler KG, Nolte CH. Heart Rate Variability and Recurrent Stroke and Myocardial Infarction in Patients With Acute Mild to Moderate Stroke. Front Neurol 2022; 12:772674. [PMID: 35002927 PMCID: PMC8733333 DOI: 10.3389/fneur.2021.772674] [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: 09/08/2021] [Accepted: 12/08/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: In patients with acute ischemic stroke, reduced heart rate variability (HRV) may indicate poor outcome. We tested whether HRV in the acute phase of stroke is associated with higher rates of mortality, recurrent stroke, myocardial infarction (MI) or functional outcome. Materials and Methods: Patients with acute mild to moderate ischemic stroke without known atrial fibrillation were prospectively enrolled to the investigator-initiated Heart and Brain interfaces in Acute Ischemic Stroke (HEBRAS) study (NCT 02142413). HRV parameters were assessed during the in-hospital stay using a 10-min section of each patient's ECG recording at day- and nighttime, calculating time and frequency domain HRV parameters. Frequency of a combined endpoint of recurrent stroke, MI or death of any cause and the respective individual events were assessed 12 months after the index stroke. Patients' functional outcome was measured by the modified Rankin Scale (mRS) at 12 months. Results: We included 308 patients (37% female, median NIHSS = 2 on admission, median age 69 years). Complete follow-up was achieved in 286/308 (93%) patients. At 12 months, 32 (9.5%), 5 (1.7%) and 13 (3.7%) patients had suffered a recurrent stroke, MI or death, respectively. After adjustment for age, sex, stroke severity and vascular risk factors, there was no significant association between HRV and recurrent stroke, MI, death or the combined endpoint. We did not find a significant impact of HRV on a mRS ≥ 2 12 months after the index stroke. Conclusion: HRV did not predict recurrent vascular events in patients with acute mild to moderate ischemic stroke.
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Affiliation(s)
- Regina von Rennenberg
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), Berlin, Germany
| | - Thomas Krause
- Department of Neurology, Jüdisches Krankenhaus Berlin, Berlin, Germany
| | - Juliane Herm
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Hellwig
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan F Scheitz
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), Berlin, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), Berlin, Germany
| | | | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), Berlin, Germany
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26
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Cammann VL, Scheitz JF, von Rennenberg R, Jäncke L, Nolte CH, Szawan KA, Stengl H, Würdinger M, Endres M, Templin C, Ghadri JR. Clinical correlates and prognostic impact of neurologic disorders in Takotsubo syndrome. Sci Rep 2021; 11:23555. [PMID: 34876622 PMCID: PMC8651780 DOI: 10.1038/s41598-021-01496-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 08/16/2021] [Accepted: 10/29/2021] [Indexed: 01/21/2023] Open
Abstract
Cardiac alterations are frequently observed after acute neurological disorders. Takotsubo syndrome (TTS) represents an acute heart failure syndrome and is increasingly recognized as part of the spectrum of cardiac complications observed after neurological disorders. A systematic investigation of TTS patients with neurological disorders has not been conducted yet. The aim of the study was to expand insights regarding neurological disease entities triggering TTS and to investigate the clinical profile and outcomes of TTS patients after primary neurological disorders. The International Takotsubo Registry is an observational multicenter collaborative effort of 45 centers in 14 countries (ClinicalTrials.gov, identifier NCT01947621). All patients in the registry fulfilled International Takotsubo Diagnostic Criteria. For the present study, patients were included if complete information on acute neurological disorders were available. 2402 patients in whom complete information on acute neurological status were available were analyzed. In 161 patients (6.7%) an acute neurological disorder was identified as the preceding triggering factor. The most common neurological disorders were seizures, intracranial hemorrhage, and ischemic stroke. Time from neurological symptoms to TTS diagnosis was ≤ 2 days in 87.3% of cases. TTS patients with neurological disorders were younger, had a lower female predominance, fewer cardiac symptoms, lower left ventricular ejection fraction, and higher levels of cardiac biomarkers. TTS patients with neurological disorders had a 3.2-fold increased odds of in-hospital mortality compared to TTS patients without neurological disorders. In this large-scale study, 1 out of 15 TTS patients had an acute neurological condition as the underlying triggering factor. Our data emphasize that a wide spectrum of neurological diseases ranging from benign to life-threatening encompass TTS. The high rates of adverse events highlight the need for clinical awareness.
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Affiliation(s)
- Victoria L Cammann
- Department of Cardiology, University Heart Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Jan F Scheitz
- Center for Stroke Research Berlin and Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Regina von Rennenberg
- Center for Stroke Research Berlin and Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,DZNE (German Center for Neurodegenerative Disease), Partner Site Berlin, Berlin, Germany
| | - Lutz Jäncke
- Division Neuropsychology, Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Christian H Nolte
- Center for Stroke Research Berlin and Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Konrad A Szawan
- Department of Cardiology, University Heart Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Helena Stengl
- Center for Stroke Research Berlin and Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Michael Würdinger
- Department of Cardiology, University Heart Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Endres
- Center for Stroke Research Berlin and Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,DZNE (German Center for Neurodegenerative Disease), Partner Site Berlin, Berlin, Germany
| | - Christian Templin
- Department of Cardiology, University Heart Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Jelena R Ghadri
- Department of Cardiology, University Heart Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
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27
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Hellwig S, Ihl T, Ganeshan R, Laumeier I, Ahmadi M, Steinicke M, Weber JE, Endres M, Audebert HJ, Scheitz JF. Cardiac Troponin and Recurrent Major Vascular Events after Minor Stroke or Transient Ischemic Attack. Ann Neurol 2021; 90:901-912. [PMID: 34561890 DOI: 10.1002/ana.26225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study was undertaken to investigate whether high-sensitivity cardiac troponin T (hs-cTnT) is associated with major adverse cardiovascular events (MACE) in patients with minor stroke or transient ischemic attack (TIA), and whether this association differs after risk stratification based on the Age, Blood Pressure, Clinical Features, Duration of Symptoms, Diabetes (ABCD2 ) score. METHODS INSPiRE-TMS was a randomized controlled trial allocating patients with minor stroke or TIA to an intensified support program or conventional care. In this post hoc analysis, participants were categorized using hs-cTnT levels (5th generation; Roche Diagnostics, Manheim, Germany; 99th percentile upper reference limit [URL] = 14ng/l). Vascular risk was stratified using the ABCD2 score (lower risk = 0-5 vs higher risk = 6-7). Cox proportional hazard regression was performed using covariate adjustment and propensity score matching (PSM) for the association between hs-cTnT and MACE (stroke/nonfatal coronary event/vascular death). RESULTS Among 889 patients (mean age = 70 years, 37% female), MACE occurred in 153 patients (17.2%) during a mean follow-up of 3.2 years. hs-cTnT was associated with MACE (9.3%/yr, >URL vs 4.4%/yr, ≤URL, adjusted hazard ratio [HR] = 1.63 [95% confidence interval (CI) = 1.13-2.35], adjusted HR [Q4 vs Q1 ] = 2.57 [95% CI = 1.35-4.97], adjusted HR [log-transformed] = 2.31 [95% CI = 1.37-3.89]). This association remained after PSM (adjusted HR = 1.76 [95% CI = 1.14-2.72]). There was a significant interaction between hs-cTnT and ABCD2 category for MACE occurrence (pinteraction = 0.04). In the lower risk category, MACE rate was 9.5%/yr in patients with hs-cTnT > URL, which was higher than in those ≤URL (3.8%/yr) and similar to the overall rate in the higher risk category. INTERPRETATION hs-cTnT levels are associated with incident MACE within 3 years after minor stroke or TIA and may help to identify high-risk individuals otherwise deemed at lower risk based on the ABCD2 score. If confirmed in independent validation studies, this might warrant intensified secondary prevention measures and cardiac diagnostics in stroke patients with elevated hs-cTnT. ANN NEUROL 2021;90:901-912.
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Affiliation(s)
- Simon Hellwig
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Ihl
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ramanan Ganeshan
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Inga Laumeier
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Ahmadi
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Maureen Steinicke
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim E Weber
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,Excellence Cluster NeuroCure, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases, partner site Berlin, Berlin, Germany.,German Center for Cardiovascular Research, partner site Berlin, Berlin, Germany
| | - Heinrich J Audebert
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Center for Cardiovascular Research, partner site Berlin, Berlin, Germany
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28
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Nordanstig A, Curtze S, Gensicke H, Zinkstok SM, Erdur H, Karlsson C, Karlsson JE, Martinez-Majander N, Sibolt G, Lyrer P, Traenka C, Baharoglu MI, Scheitz JF, Bricout N, Hénon H, Leys D, Eskandari A, Michel P, Hametner C, Ringleb PA, Arnold M, Fischer U, Sarikaya H, Seiffge DJ, Pezzini A, Zini A, Padjen V, Jovanovic DR, Luft A, Wegener S, Kellert L, Feil K, Kägi G, Rentzos A, Lappalainen K, Leker RR, Cohen JE, Gomori J, Brehm A, Liman J, Psychogios M, Kastrup A, Papanagiotou P, Gralla J, Magoni M, Majoie CBLM, Bohner G, Vukasinovic I, Cvetic V, Weber J, Kulcsar Z, Bendszus M, Möhlenbruch M, Ntaios G, Kapsalaki E, Jood K, Nolte CH, Nederkoorn PJJ, Engelter S, Strbian D, Tatlisumak T. EndoVAscular treatment and ThRombolysis for Ischemic Stroke Patients (EVA-TRISP) registry: basis and methodology of a pan-European prospective ischaemic stroke revascularisation treatment registry. BMJ Open 2021; 11:e042211. [PMID: 34373287 PMCID: PMC8354282 DOI: 10.1136/bmjopen-2020-042211] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration was a concerted effort initiated in 2010 with the purpose to address relevant research questions about the effectiveness and safety of intravenous thrombolysis (IVT). The collaboration also aims to prospectively collect data on patients undergoing endovascular treatment (EVT) and hence the name of the collaboration was changed from TRISP to EVA-TRISP. The methodology of the former TRISP registry for patients treated with IVT has already been published. This paper focuses on describing the EVT part of the registry. PARTICIPANTS All centres committed to collecting predefined variables on consecutive patients prospectively. We aim for accuracy and completeness of the data and to adapt local databases to investigate novel research questions. Herein, we introduce the methodology of a recently constructed academic investigator-initiated open collaboration EVT registry built as an extension of an existing IVT registry in patients with acute ischaemic stroke (AIS). FINDINGS TO DATE Currently, the EVA-TRISP network includes 20 stroke centres with considerable expertise in EVT and maintenance of high-quality hospital-based registries. Following several successful randomised controlled trials (RCTs), many important clinical questions remain unanswered in the (EVT) field and some of them will unlikely be investigated in future RCTs. Prospective registries with high-quality data on EVT-treated patients may help answering some of these unanswered issues, especially on safety and efficacy of EVT in specific patient subgroups. FUTURE PLANS This collaborative effort aims at addressing clinically important questions on safety and efficacy of EVT in conditions not covered by RCTs. The TRISP registry generated substantial novel data supporting stroke physicians in their daily decision making considering IVT candidate patients. While providing observational data on EVT in daily clinical practice, our future findings may likewise be hypothesis generating for future research as well as for quality improvement (on EVT). The collaboration welcomes participation of further centres willing to fulfill the commitment and the outlined requirements.
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Affiliation(s)
- Annika Nordanstig
- Department of Clinical Neurosciences Sahlgrenska Academy at University of Gothenburg, Sahlgrenska Academy, Goteborg, Sweden,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sami Curtze
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Sanne M Zinkstok
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Hebun Erdur
- Department of Neurology and Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Camilla Karlsson
- Department of Clinical Neurosciences Sahlgrenska Academy at University of Gothenburg, Sahlgrenska Academy, Goteborg, Sweden
| | - Jan-Erik Karlsson
- Department of Clinical Neurosciences Sahlgrenska Academy at University of Gothenburg, Sahlgrenska Academy, Goteborg, Sweden,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Gerli Sibolt
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Merih I Baharoglu
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Jan F Scheitz
- Department of Neurology and Center for Stroke Research, Charite Universitatsmedizin Berlin Klinik fur Neurologie mit Experimenteller Neurologie, Berlin, Germany
| | | | - Hilde Hénon
- Department of Neurology, University of Lille, Lille, France
| | - Didier Leys
- Department of Neurology, University of Lille, Lille, France
| | - Ashraf Eskandari
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Patrik Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Marcel Arnold
- Department of Neurology, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hakan Sarikaya
- Department of Neurology, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, Maggiore Hospital, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Visnja Padjen
- Neurology Clinic, Clinical Centre of Serbia, Belgrade, Clinical Center of Serbia, Beograd, Serbia
| | - Dejana R Jovanovic
- Neurology Clinic, Clinical Centre of Serbia, Belgrade, Clinical Center of Serbia, Beograd, Serbia,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Andreas Luft
- Department of Neurology, University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University of Zurich, Zurich, Switzerland
| | - Lars Kellert
- Department of Neurology, Ludwig-Maximilians-Universitat Munchen, Munchen, Germany
| | - Katharina Feil
- Neurology and German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universitat Munchen, Munchen, Germany
| | - Georg Kägi
- Department of Neurology, Kantonsspital St Gallen, Sankt Gallen, Switzerland
| | - Alexandros Rentzos
- Department of Radiology, Institute of clinical sciences, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden,Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kimmo Lappalainen
- Department of Radiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Ronen R Leker
- Department of Neurology, Hebrew University Hadassah Medical School, Yerushalayim, Israel
| | - Jose E Cohen
- Department of Neurosurgery, Hebrew University Hadassah Medical School, Yerushalayim, Israel
| | - John Gomori
- Department of Radiology, Hebrew University Hadassah Medical School, Yerushalayim, Israel
| | - Alex Brehm
- Department of Neurology, Georg-August-Universitat Gottingen Universitatsmedizin, Gottingen, Germany
| | - Jan Liman
- Department of Neurology, Georg-August-Universitat Gottingen Universitatsmedizin, Gottingen, Germany
| | - Marios Psychogios
- Department of Neuroradiology, Georg-August-Universitat Gottingen Universitatsmedizin, Gottingen, Germany,Neuroradiology and Stroke Center Basel, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Andreas Kastrup
- Department of Neurology, University Hospitals Bremen-Mitte and Bremen-Ost, Bremen, Germany
| | - Panagiotis Papanagiotou
- Clinic for Diagnostic and Interventional Neuroradiology, University Hospitals Bremen-Mitte and Bremen-Ost, University of Bremen, Bremen, Germany,Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mauro Magoni
- USD Stroke Unit and Vascular Neurology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Charles B L M Majoie
- Department of Neuroradiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Georg Bohner
- Institute of Neuroradiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Ivan Vukasinovic
- Clinic of Neurosurgery, Clinical Center of Serbia, Beograd, Serbia
| | - Vladimir Cvetic
- Faculty of Medicine, University of Belgrade, Beograd, Serbia,Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia
| | - Johannes Weber
- Department of Radiology and Nuclear Medicine, Kantonsspital St Gallen, Sankt Gallen, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Martin Bendszus
- Department of Neuroradiology, UniversitatsKlinikum Heidelberg, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, UniversitatsKlinikum Heidelberg, Heidelberg, Germany
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Volos, Thessaly, Greece
| | - Eftychia Kapsalaki
- Department of Radiology, University Hospital of Larissa, School of Medicine, University of Thessaly, Volos, Thessaly, Greece
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden,Department for Clinical Neuroscience and Rehabilitation, Sahlgrenska Academy, Goteborg, Sweden
| | - Christian H Nolte
- Department of Neurology and Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Paul J J Nederkoorn
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Stefan Engelter
- Department of Neurology and Stroke Center, University of Basel, Basel, Switzerland,Deptartment of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athen, Greece
| | - Daniel Strbian
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Clinical Neurosciences, Sahlgrenska University Hospital, Goteborg, Sweden,Department of Neurology, University of Helsinki, Helsinki, Finland
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Meinel TR, Eggimann A, Brignoli K, Wustmann K, Buffle E, Meinel FG, Scheitz JF, Nolte CH, Gräni C, Fischer U, Kaesmacher J, Seiffge DJ, Seiler C, Jung S. Cardiovascular MRI Compared to Echocardiography to Identify Cardioaortic Sources of Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:699838. [PMID: 34393979 PMCID: PMC8362907 DOI: 10.3389/fneur.2021.699838] [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: 04/24/2021] [Accepted: 06/30/2021] [Indexed: 01/21/2023] Open
Abstract
Background: To compare the diagnostic yield of echocardiography and cardiovascular MRI (CMR) to detect structural sources of embolism, in patients with ischemic stroke with a secondary analysis of non-stroke populations. Methods and Results: We searched MEDLINE/Embase (from 01.01.2000 to 24.04.2021) for studies including CMR to assess prespecified sources of embolism. Comparison included transthoracic and/or transesophageal echocardiography. Two authors independently screened studies, extracted data and assessed bias using the QUADAS-2 tool. Estimates of diagnostic yield were reported and pooled. Twenty-seven studies with 2,525 patients were included in a study-level analysis. Most studies had moderate to high risk of bias. Persistent foramen ovale, complex aortic plaques, left ventricular and left atrial thrombus were the most common pathologies. There was no difference in the yield of left ventricular thrombus detection between both modalities for stroke populations (4 studies), but an increased yield of CMR in non-stroke populations (28.1 vs. 16.0%, P < 0.001, 10 studies). The diagnostic yield in stroke patients for detection of persistent foramen ovale was lower in CMR compared to transoesophageal echocardiography (29.3 vs. 53.7%, P < 0.001, 5 studies). For both echocardiography and CMR the clinical impact of the management consequences derived from many of the diagnostic findings remained undetermined in the identified studies. Conclusions: Echocardiography and CMR seem to have similar diagnostic yield for most cardioaortic sources of embolism except persistent foramen ovale and left ventricular thrombus. Randomized controlled diagnostic trials are necessary to understand the impact on the management and potential clinical benefits of the assessment of structural cardioaortic stroke sources. Registration: PROSPERO: CRD42020158787.
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Affiliation(s)
- Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Angela Eggimann
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Kristina Brignoli
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Kerstin Wustmann
- Department of Cardiology, Inselspital Bern, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Eric Buffle
- Department of Cardiology, Inselspital Bern, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Felix G Meinel
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Jan F Scheitz
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Neurologie, Berlin Institute of Health, Berlin, Germany.,German Centre for Cardiovascular Research, Deutsches Zentrum für Herz-Kreislauf-Forschung, Berlin, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Neurologie, Berlin Institute of Health, Berlin, Germany.,German Centre for Cardiovascular Research, Deutsches Zentrum für Herz-Kreislauf-Forschung, Berlin, Germany
| | - Christoph Gräni
- Department of Cardiology, Inselspital Bern, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christian Seiler
- Department of Cardiology, Inselspital Bern, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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30
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Nolte CH, Endres M, Scheitz JF. Myocardial injury in acute ischemic stroke. Clinical and Translational Neuroscience 2021. [DOI: 10.1177/2514183x211018543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Since antiquity, the interaction of brain and heart has inspired physicians and philosophers. Today, our knowledge has vastly improved, but the exact way of their interaction still holds many secrets to reveal. The interaction between brain and heart merits particular attention in the aftermath of a sudden injury to the brain-like acute ischemic stroke (AIS). This narrative review gives an overview of current knowledge on frequency, prognosis, and potential pathophysiological mechanisms of myocardial injury following AIS.
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Affiliation(s)
- Christian H Nolte
- Klinik für Neurologie mit Experimenteller Neurologie and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- German Center for Cardiovascular Research (Deutsches Zentrum Für Herz-Kreislaufforschung; DZHK), partner site Berlin, Berlin, Germany
| | - Matthias Endres
- Klinik für Neurologie mit Experimenteller Neurologie and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- German Center for Cardiovascular Research (Deutsches Zentrum Für Herz-Kreislaufforschung; DZHK), partner site Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen; DZNE), partner site Berlin, Berlin, Germany
| | - Jan F Scheitz
- Klinik für Neurologie mit Experimenteller Neurologie and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- German Center for Cardiovascular Research (Deutsches Zentrum Für Herz-Kreislaufforschung; DZHK), partner site Berlin, Berlin, Germany
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31
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Scheitz JF, Lim J, Broersen LHA, Ganeshan R, Huo S, Sperber PS, Piper SK, Heuschmann PU, Audebert HJ, Nolte CH, Siegerink B, Endres M, Liman TG. High-Sensitivity Cardiac Troponin T and Recurrent Vascular Events After First Ischemic Stroke. J Am Heart Assoc 2021; 10:e018326. [PMID: 33982599 PMCID: PMC8200699 DOI: 10.1161/jaha.120.018326] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 02/22/2021] [Indexed: 12/16/2022]
Abstract
Background Recent evidence suggests cardiac troponin levels to be a marker of increased vascular risk. We aimed to assess whether levels of high-sensitivity cardiac troponin T (hs-cTnT) are associated with recurrent vascular events and death in patients with first-ever, mild to moderate ischemic stroke. Methods and Results We used data from the PROSCIS-B (Prospective Cohort With Incident Stroke Berlin) study. We computed Cox proportional hazards regression analyses to assess the association between hs-cTnT levels upon study entry (Roche Elecsys, upper reference limit, 14 ng/L) and the primary outcome (composite of recurrent stroke, myocardial infarction, and all-cause death). A total of 562 patients were analyzed (mean age, 67 years [SD 13]; 38.6% women; median National Institutes of Health Stroke Scale=2; hs-cTnT above upper reference limit, 39.2%). During a mean follow-up of 3 years, the primary outcome occurred in 89 patients (15.8%), including 40 (7.1%) recurrent strokes, 4 (0.7%) myocardial infarctions, and 51 (9.1%) events of all-cause death. The primary outcome occurred more often in patients with hs-cTnT above the upper reference limit (27.3% versus 10.2%; adjusted hazard ratio, 2.0; 95% CI, 1.3-3.3), with a dose-response relationship when the highest and lowest hs-cTnT quartiles were compared (15.2 versus 1.8 events per 100 person-years; adjusted hazard ratio, 4.8; 95% CI, 1.9-11.8). This association remained consistent in sensitivity analyses, which included age matching and stratification for sex. Conclusions Hs-cTnT is dose-dependently associated with an increased risk of recurrent vascular events and death within 3 years after first-ever, mild to moderate ischemic stroke. These findings support further studies of the utility of hs-cTnT for individualized risk stratification after stroke. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01363856.
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Affiliation(s)
- Jan F. Scheitz
- Center for Stroke Research Berlin (CSB)Charité Universitätsmedizin BerlinBerlinGermany
- Klinik für Neurologie mit Experimenteller NeurologieCharité–Universitätsmedizin BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BerlinGermany
| | - Jess Lim
- Klinik für Neurologie mit Experimenteller NeurologieCharité–Universitätsmedizin BerlinBerlinGermany
| | - Leonie H. A. Broersen
- Center for Stroke Research Berlin (CSB)Charité Universitätsmedizin BerlinBerlinGermany
- Klinik für Neurologie mit Experimenteller NeurologieCharité–Universitätsmedizin BerlinBerlinGermany
| | - Ramanan Ganeshan
- Center for Stroke Research Berlin (CSB)Charité Universitätsmedizin BerlinBerlinGermany
- Klinik für Neurologie mit Experimenteller NeurologieCharité–Universitätsmedizin BerlinBerlinGermany
| | - Shufan Huo
- Center for Stroke Research Berlin (CSB)Charité Universitätsmedizin BerlinBerlinGermany
- Klinik für Neurologie mit Experimenteller NeurologieCharité–Universitätsmedizin BerlinBerlinGermany
| | - Pia S. Sperber
- Center for Stroke Research Berlin (CSB)Charité Universitätsmedizin BerlinBerlinGermany
- German Center for Cardiovascular Research (Deutsches Zentrum für Herz‐Kreislaufforschung, DHZK), partner site BerlinGermany
| | - Sophie K. Piper
- Berlin Institute of Health (BIH)Germany
- Institute of Biometry and Clinical EpidemiologyCharité–Universitätsmedizin BerlinBerlinGermany
| | - Peter U. Heuschmann
- Institute of Clinical Epidemiology and BiometryUniversity of WürzburgGermany
- Clinical Trial CenterUniversity Hospital WürzburgGermany
| | - Heinrich J. Audebert
- Center for Stroke Research Berlin (CSB)Charité Universitätsmedizin BerlinBerlinGermany
- Klinik für Neurologie mit Experimenteller NeurologieCharité–Universitätsmedizin BerlinBerlinGermany
| | - Christian H. Nolte
- Center for Stroke Research Berlin (CSB)Charité Universitätsmedizin BerlinBerlinGermany
- Klinik für Neurologie mit Experimenteller NeurologieCharité–Universitätsmedizin BerlinBerlinGermany
- German Center for Cardiovascular Research (Deutsches Zentrum für Herz‐Kreislaufforschung, DHZK), partner site BerlinGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BerlinGermany
- Berlin Institute of Health (BIH)Germany
| | - Bob Siegerink
- Center for Stroke Research Berlin (CSB)Charité Universitätsmedizin BerlinBerlinGermany
| | - Matthias Endres
- Center for Stroke Research Berlin (CSB)Charité Universitätsmedizin BerlinBerlinGermany
- Klinik für Neurologie mit Experimenteller NeurologieCharité–Universitätsmedizin BerlinBerlinGermany
- German Center for Cardiovascular Research (Deutsches Zentrum für Herz‐Kreislaufforschung, DHZK), partner site BerlinGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BerlinGermany
- ExcellenceCluster NeuroCureBerlinGermany
- Berlin Institute of Health (BIH)Germany
| | - Thomas G. Liman
- Center for Stroke Research Berlin (CSB)Charité Universitätsmedizin BerlinBerlinGermany
- Klinik für Neurologie mit Experimenteller NeurologieCharité–Universitätsmedizin BerlinBerlinGermany
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Sposato LA, Aspberg S, Scheitz JF, Fisher M. The World Stroke Organization Brain & Heart Task Force: collaborations between stroke physicians and cardiologists. Eur Heart J 2021; 42:3594-3596. [PMID: 33855349 DOI: 10.1093/eurheartj/ehab198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Luciano A Sposato
- World Stroke Organization Brain & Heart Task Force, World Stroke Organization, Geneva, Switzerland.,Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Heart & Brain Laboratory, Western University, London, ON, Canada.,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Robarts Research Institute, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Sara Aspberg
- World Stroke Organization Brain & Heart Task Force, World Stroke Organization, Geneva, Switzerland.,Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jan F Scheitz
- World Stroke Organization Brain & Heart Task Force, World Stroke Organization, Geneva, Switzerland.,Klinik für Neurologie mit Experimenteller Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), partner site Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,The Berlin Institute of Health, Berlin, Germany
| | - Marc Fisher
- World Stroke Organization.,Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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33
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Altersberger VL, Stolze LJ, Heldner MR, Henon H, Martinez-Majander N, Hametner C, Nordanstig A, Zini A, Nannoni S, Gonçalves B, Nolte CH, Baumgartner P, Kastrup A, Papanagiotou P, Kägi G, Leker RR, Zedde M, Padovani A, Pezzini A, Padjen V, Cereda CW, Ntaios G, Bonati LH, Rinkel LA, Fischer U, Scheitz JF, Wegener S, Turc G, Michel P, Gentile M, Rentzos A, Ringleb PA, Curtze S, Cordonnier C, Arnold M, Nederkoorn PJ, Engelter ST, Gensicke H. Maintenance of Acute Stroke Care Service During the COVID-19 Pandemic Lockdown. Stroke 2021; 52:1693-1701. [PMID: 33793320 PMCID: PMC8078117 DOI: 10.1161/strokeaha.120.032176] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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] [Indexed: 01/28/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Timely reperfusion is an important goal in treatment of eligible patients with acute ischemic stroke. However, during the coronavirus disease 2019 (COVID-19) pandemic, prehospital and in-hospital emergency procedures faced unprecedented challenges, which might have caused a decline in the number of acute reperfusion therapy applied and led to a worsening of key quality measures for this treatment during lockdown. Methods: This prospective multicenter cohort study used data from the TRISP (Thrombolysis in Ischemic Stroke Patients) registry of patients with acute ischemic stroke treated with reperfusion therapies, that is, intravenous thrombolysis or endovascular therapy. We compared prehospital and in-hospital time-based performance measures (stroke-onset-to-admission, admission-to-treatment, admission-to-image, and image-to-treatment time) during the first 6 weeks after announcement of lockdown (lockdown period) with the same period in 2019 (reference period). Secondary outcomes included stroke severity (National Institutes of Health Stroke Scale) after 24 hours and occurrence of symptomatic intracranial hemorrhage (following the ECASS [European-Australasian Acute Stroke Study]-II criteria). Results: Across 20 stroke centers, 540 patients were treated with intravenous thrombolysis/endovascular therapy during lockdown period compared with 578 patients during reference period (−7% [95% CI, 5%–9%]). Performance measures did not change significantly during the lockdown period (2020/2019 minutes median: onset-to-admission 133/145; admission-to-treatment 51/48). Same was true for admission-to-image (20/19) and image-to-treatment (31/30) time in patients with available time of first image (n=871, 77.9%). Median National Institutes of Health Stroke Scale on admission (2020/2019: 11/11) and after 24 hours (2020/2019: 6/5) and percentage of symptomatic intracranial hemorrhage (2020/2019: 6.2/5.7) did not differ significantly between both periods. Conclusions: The COVID-19 pandemic lockdown resulted in a mild decline in the number of patients with stroke treated with acute reperfusion therapies. More importantly, the solid stability of key quality performance measures between the 2020 and 2019 period may indicate resilience of acute stroke care service during the lockdown, at least in well-established European stroke centers.
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Affiliation(s)
- Valerian L Altersberger
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., L.H.B., S.T.E.)
| | - Lotte J Stolze
- Department of Neurology, Amsterdam UMC, University of Amsterdam, the Netherlands (L.J.S., L.A.R., P.J.N.)
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland (M.R.H., U.F, M.A.)
| | - Hilde Henon
- University Lille, Inserm, CHU Lille, U1172- F-59000, France (H.H., C.C.)
| | | | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.A.R.)
| | - Annika Nordanstig
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg (A.N., A.R.).,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (A.N., A.R.)
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy (A.Z., M.G.)
| | - Stefania Nannoni
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland (S.N., P.M.)
| | - Bruno Gonçalves
- Department of Neurology, Sainte-Anne Hospital, Paris, France Université Paris Descartes, France (B.G., G.T.).,Niteroi D'Or Hospital, Niteroi, Brazil (B.G.)
| | - Christian H Nolte
- Klinik Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Germany (C.H.N., J.F.S.)
| | - Philipp Baumgartner
- Zurich Department of Neurology, University Hospital Zurich and University of Zurich, Switzerland (P.B., S.W.)
| | - Andreas Kastrup
- Departments of Neurology and Neuroradiology, Klinikum Bremen-Mitte, Germany (A.K., P.P.)
| | | | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, Switzerland (G.K.)
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel (R.R.L.)
| | - Marialuisa Zedde
- Neurology Unit, Neuromotor & Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy (M.Z.)
| | - Alessandro Padovani
- Neurology Section, Department of Clinical and Experimental Sciences, University of Brescia; Neurology Unit, ASST Spedali Civili, Italy (A. Padovani, A. Pezzini)
| | - Alessandro Pezzini
- Neurology Section, Department of Clinical and Experimental Sciences, University of Brescia; Neurology Unit, ASST Spedali Civili, Italy (A. Padovani, A. Pezzini)
| | - Visnja Padjen
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Serbia (V.P.)
| | - Carlo W Cereda
- University Lille, Inserm, CHU Lille, U1172- F-59000, France (H.H., C.C.).,Stroke Center and Department of Neurology, Neurocenter of Southern Switzerland, Lugano (C.W.C.)
| | - Georges Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N.)
| | - Leo H Bonati
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., L.H.B., S.T.E.)
| | - Leon A Rinkel
- Department of Neurology, Amsterdam UMC, University of Amsterdam, the Netherlands (L.J.S., L.A.R., P.J.N.)
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland (M.R.H., U.F, M.A.)
| | - Jan F Scheitz
- Klinik Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Germany (C.H.N., J.F.S.)
| | - Susanne Wegener
- Zurich Department of Neurology, University Hospital Zurich and University of Zurich, Switzerland (P.B., S.W.)
| | - Guillaume Turc
- Department of Neurology, Sainte-Anne Hospital, Paris, France Université Paris Descartes, France (B.G., G.T.)
| | - Patrik Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland (S.N., P.M.)
| | - Mauro Gentile
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy (A.Z., M.G.)
| | - Alexandros Rentzos
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg (A.N., A.R.).,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (A.N., A.R.)
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.A.R.).,Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital and Department of Radiology, Institute of clinical sciences, Sahlgrenska Academy, University of Gothenburg, Sweden (A.R.)
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Finland (N.M.-M., S.C.)
| | | | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland (M.R.H., U.F, M.A.)
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, the Netherlands (L.J.S., L.A.R., P.J.N.)
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., L.H.B., S.T.E.).,Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland (S.T.E., H.G.)
| | - Henrik Gensicke
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland (S.T.E., H.G.)
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Abstract
Cardiologists need a better understanding of stroke and of cardiac implications in modern stroke management. Stroke is a leading disease in terms of mortality and disability in our society. Up to half of ischaemic strokes are directly related to cardiac and large artery diseases and cardiovascular risk factors are involved in most other strokes. Moreover, in an acute stroke direct central brain signals and a consecutive autonomic/vegetative imbalance may account for severe and life-threatening cardiovascular complications. The strong cerebro-cardiac link in acute stroke has recently been addressed as the stroke-heart syndrome that requires careful cardiovascular monitoring and immediate therapeutic measures. The regular involvement of cardiologic expertise in daily work on a stroke unit is therefore of high importance and a cornerstone of up-to-date comprehensive stroke care concepts. The main targets of the cardiologists' contribution to acute stroke care can be categorized in three main areas (i) diagnostics workup of stroke aetiology, (ii) treatment and prevention of complications, and (iii) secondary prevention and sub-acute workup of cardiovascular comorbidity. All three aspects are by themselves highly relevant to support optimal acute management and to improve the short-term and long-term outcomes of patients. In this article, an overview is provided on these main targets of cardiologists' contribution to acute stroke management.
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Affiliation(s)
- Wolfram Doehner
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Germany.,Department of Cardiology (Virchow Hospital), Charité Universitätsmedizin Berlin and DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany, Germany.,Center for Stroke Research Berlin (CSB), Berlin, Germany
| | - David Manuel Leistner
- Department of Cardiology; Campus Benjamin Franklin (CBF), Charité Universitätsmedizin Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, 10117, Germany
| | - Heinrich J Audebert
- Center for Stroke Research Berlin (CSB), Berlin, Germany.,Department of Neurology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Germany
| | - Jan F Scheitz
- Center for Stroke Research Berlin (CSB), Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany.,Department of Neurology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Germany
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Sposato LA, Hilz MJ, Aspberg S, Murthy SB, Bahit MC, Hsieh CY, Sheppard MN, Scheitz JF. Post-Stroke Cardiovascular Complications and Neurogenic Cardiac Injury: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 76:2768-2785. [PMID: 33272372 DOI: 10.1016/j.jacc.2020.10.009] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [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] [Received: 08/27/2020] [Revised: 09/25/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
Over 1.5 million deaths worldwide are caused by neurocardiogenic syndromes. Furthermore, the consequences of deleterious brain-heart interactions are not limited to fatal complications. Cardiac arrhythmias, heart failure, and nonfatal coronary syndromes are also common. The brain-heart axis is implicated in post-stroke cardiovascular complications known as the stroke-heart syndrome, sudden cardiac death, and Takotsubo syndrome, among other neurocardiogenic syndromes. Multiple pathophysiological mechanisms with the potential to be targeted with novel therapies have been identified in the last decade. In the present state-of-the-art review, we describe recent advances in the understanding of anatomical and functional aspects of the brain-heart axis, cardiovascular complications after stroke, and a comprehensive pathophysiological model of stroke-induced cardiac injury.
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Affiliation(s)
- Luciano A Sposato
- Heart & Brain Laboratory, Western University, London, Ontario, Canada; Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada; Robarts Research Institute, London, Ontario, Canada.
| | - Max J Hilz
- University of Erlangen-Nuremberg, Erlangen, Germany; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sara Aspberg
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York. https://twitter.com/san_murthy
| | - M Cecilia Bahit
- INECO Neurociencias Oroño, Rosario, Santa Fe, Argentina. https://twitter.com/ceciliabahit
| | - Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan; School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan. https://twitter.com/chengyanghsieh
| | - Mary N Sheppard
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Jan F Scheitz
- Klinik für Neurologie mit Experimenteller Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), partner site Berlin, Charité-Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Berlin, Germany. https://twitter.com/Jan_FriSch
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36
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Scheitz JF, Stengl H, Nolte CH, Landmesser U, Endres M. Correction to: Neurological update: use of cardiac troponin in patients with stroke. J Neurol 2021; 268:2293. [PMID: 33634339 PMCID: PMC8179906 DOI: 10.1007/s00415-021-10434-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jan F Scheitz
- Klinik für Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.
- German Center for Cardiovascular Research (Deutsches Zentrum Für Herz-Kreislaufforschung; DZHK), partner site Berlin, Berlin, Germany.
- Berlin Institute of Health, Berlin, Germany.
| | - Helena Stengl
- Klinik für Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Christian H Nolte
- Klinik für Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (Deutsches Zentrum Für Herz-Kreislaufforschung; DZHK), partner site Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Ulf Landmesser
- German Center for Cardiovascular Research (Deutsches Zentrum Für Herz-Kreislaufforschung; DZHK), partner site Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, 12203, Berlin, Germany
| | - Matthias Endres
- Klinik für Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (Deutsches Zentrum Für Herz-Kreislaufforschung; DZHK), partner site Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum Für Neurodegenerative Erkrankungen; DZNE), partner site Berlin, Berlin, Germany
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Stengl H, Ganeshan R, Hellwig S, Blaszczyk E, Fiebach JB, Nolte CH, Bauer A, Schulz-Menger J, Endres M, Scheitz JF. Cardiomyocyte Injury Following Acute Ischemic Stroke: Protocol for a Prospective Observational Cohort Study. JMIR Res Protoc 2021; 10:e24186. [PMID: 33544087 PMCID: PMC7895641 DOI: 10.2196/24186] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/30/2020] [Accepted: 12/15/2020] [Indexed: 01/01/2023] Open
Abstract
Background Elevated cardiac troponin, which indicates cardiomyocyte injury, is common after acute ischemic stroke and is associated with poor functional outcome. Myocardial injury is part of a broad spectrum of cardiac complications that may occur after acute ischemic stroke. Previous studies have shown that in most patients, the underlying mechanism of stroke-associated myocardial injury may not be a concomitant acute coronary syndrome. Evidence from animal research and clinical and neuroimaging studies suggest that functional and structural alterations in the central autonomic network leading to stress-mediated neurocardiogenic injury may be a key underlying mechanism (ie, stroke-heart syndrome). However, the exact pathophysiological cascade remains unclear, and the diagnostic and therapeutic implications are unknown. Objective The aim of this CORONA-IS (Cardiomyocyte injury following Acute Ischemic Stroke) study is to quantify autonomic dysfunction and to decipher downstream cardiac mechanisms leading to myocardial injury after acute ischemic stroke. Methods In this prospective, observational, single-center cohort study, 300 patients with acute ischemic stroke, confirmed via cerebral magnetic resonance imaging (MRI) and presenting within 48 hours of symptom onset, will be recruited during in-hospital stay. On the basis of high-sensitivity cardiac troponin levels and corresponding to the fourth universal definition of myocardial infarction, 3 groups are defined (ie, no myocardial injury [no cardiac troponin elevation], chronic myocardial injury [stable elevation], and acute myocardial injury [dynamic rise/fall pattern]). Each group will include approximately 100 patients. Study patients will receive routine diagnostic care. In addition, they will receive 3 Tesla cardiovascular MRI and transthoracic echocardiography within 5 days of symptom onset to provide myocardial tissue characterization and assess cardiac function, 20-min high-resolution electrocardiogram for analysis of cardiac autonomic function, and extensive biobanking. A follow-up for cardiovascular events will be conducted 3 and 12 months after inclusion. Results After a 4-month pilot phase, recruitment began in April 2019. We estimate a recruitment period of approximately 3 years to include 300 patients with a complete cardiovascular MRI protocol. Conclusions Stroke-associated myocardial injury is a common and relevant complication. Our study has the potential to provide a better mechanistic understanding of heart and brain interactions in the setting of acute stroke. Thus, it is essential to develop algorithms for recognizing patients at risk and to refine diagnostic and therapeutic procedures. Trial Registration Clinicaltrials.gov NCT03892226; https://www.clinicaltrials.gov/ct2/show/NCT03892226. International Registered Report Identifier (IRRID) DERR1-10.2196/24186
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Affiliation(s)
- Helena Stengl
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Ramanan Ganeshan
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Hellwig
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Edyta Blaszczyk
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center, a Joint Cooperation Between the Charité - Universitätsmedizin Berlin, Department of Internal Medicine and Cardiology and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner site Berlin, Berlin, Germany
| | - Axel Bauer
- Working group on biosignal analysis, department of Cardiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jeanette Schulz-Menger
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center, a Joint Cooperation Between the Charité - Universitätsmedizin Berlin, Department of Internal Medicine and Cardiology and the Max-Delbrueck Center for Molecular Medicine, and HELIOS Klinikum Berlin Buch, Department of Cardiology and Nephrology, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner site Berlin, Berlin, Germany.,Excellence Cluster NeuroCure, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
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Ebinger M, Siegerink B, Kunz A, Wendt M, Weber JE, Schwabauer E, Geisler F, Freitag E, Lange J, Behrens J, Erdur H, Ganeshan R, Liman T, Scheitz JF, Schlemm L, Harmel P, Zieschang K, Lorenz-Meyer I, Napierkowski I, Waldschmidt C, Nolte CH, Grittner U, Wiener E, Bohner G, Nabavi DG, Schmehl I, Ekkernkamp A, Jungehulsing GJ, Mackert BM, Hartmann A, Rohmann JL, Endres M, Audebert HJ. Association Between Dispatch of Mobile Stroke Units and Functional Outcomes Among Patients With Acute Ischemic Stroke in Berlin. JAMA 2021; 325:454-466. [PMID: 33528537 PMCID: PMC7856548 DOI: 10.1001/jama.2020.26345] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [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] [Indexed: 01/27/2023]
Abstract
IMPORTANCE Effects of thrombolysis in acute ischemic stroke are time-dependent. Ambulances that can administer thrombolysis (mobile stroke units [MSUs]) before arriving at the hospital have been shown to reduce time to treatment. OBJECTIVE To determine whether dispatch of MSUs is associated with better clinical outcomes for patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This prospective, nonrandomized, controlled intervention study was conducted in Berlin, Germany, from February 1, 2017, to October 30, 2019. If an emergency call prompted suspicion of stroke, both a conventional ambulance and an MSU, when available, were dispatched. Functional outcomes of patients with final diagnosis of acute cerebral ischemia who were eligible for thrombolysis or thrombectomy were compared based on the initial dispatch (both MSU and conventional ambulance or conventional ambulance only). EXPOSURE Simultaneous dispatch of an MSU (computed tomographic scanning with or without angiography, point-of-care laboratory testing, and thrombolysis capabilities on board) and a conventional ambulance (n = 749) vs conventional ambulance alone (n = 794). MAIN OUTCOMES AND MEASURES The primary outcome was the distribution of modified Rankin Scale (mRS) scores (a disability score ranging from 0, no neurological deficits, to 6, death) at 3 months. The coprimary outcome was a 3-tier disability scale at 3 months (none to moderate disability; severe disability; death) with tier assignment based on mRS scores if available or place of residence if mRS scores were not available. Common odds ratios (ORs) were used to quantify the association between exposure and outcome; values less than 1.00 indicated a favorable shift in the mRS distribution and lower odds of higher levels of disability. RESULTS Of the 1543 patients (mean age, 74 years; 723 women [47%]) included in the adjusted primary analysis, 1337 (87%) had available mRS scores (primary outcome) and 1506 patients (98%) had available the 3-tier disability scale assessment (coprimary outcome). Patients with an MSU dispatched had lower median mRS scores at month 3 (1; interquartile range [IQR], 0-3) than did patients without an MSU dispatched (2; IQR, 0-3; common OR for worse mRS, 0.71; 95% CI, 0.58-0.86; P < .001). Similarly, patients with an MSU dispatched had lower 3-month coprimary disability scores: 586 patients (80.3%) had none to moderate disability; 92 (12.6%) had severe disability; and 52 (7.1%) had died vs patients without an MSU dispatched: 605 (78.0%) had none to moderate disability; 103 (13.3%) had severe disability; and 68 (8.8%) had died (common OR for worse functional outcome, 0.73, 95% CI, 0.54-0.99; P = .04). CONCLUSIONS AND RELEVANCE In this prospective, nonrandomized, controlled intervention study of patients with acute ischemic stroke in Berlin, Germany, the dispatch of mobile stroke units, compared with conventional ambulances alone, was significantly associated with lower global disability at 3 months. Clinical trials in other regions are warranted.
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Affiliation(s)
- Martin Ebinger
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
| | - Alexander Kunz
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Wendt
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Germany
| | - Joachim E. Weber
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
| | - Eugen Schwabauer
- Klinik für Neurologie mit Stroke Unit, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Frederik Geisler
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Erik Freitag
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Julia Lange
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Janina Behrens
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Hebun Erdur
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Ramanan Ganeshan
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Thomas Liman
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Jan F. Scheitz
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Ludwig Schlemm
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Peter Harmel
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Katja Zieschang
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Germany
| | - Irina Lorenz-Meyer
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Ira Napierkowski
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Carolin Waldschmidt
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
- Klinik für Neurologie–Stroke Unit–Zentrum für Epilepsie; Vivantes Humboldt-Klinikum, Berlin, Germany
| | - Christian H. Nolte
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
| | - Ulrike Grittner
- Berlin Institute of Health (BIH), Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Germany
| | - Edzard Wiener
- Institut für Neuroradiologie, Charité–Universitätsmedizin Berlin, Germany
| | - Georg Bohner
- Institut für Neuroradiologie, Charité–Universitätsmedizin Berlin, Germany
| | - Darius G. Nabavi
- Klinik für Neurologie mit Stroke Unit, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Ingo Schmehl
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Germany
| | - Axel Ekkernkamp
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Germany
| | | | - Bruno-Marcel Mackert
- Klinik für Neurologie mit Stroke Unit, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | | | - Jessica L. Rohmann
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Institute of Public Health, Charité–Universitätsmedizin Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
- NeuroCure Cluster of Excellence, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Germany
| | - Heinrich J. Audebert
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
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Sprügel MI, Kuramatsu JB, Volbers B, Saam JI, Sembill JA, Gerner ST, Balk S, Hamer HM, Lücking H, Hölter P, Nolte CH, Scheitz JF, Rocco A, Endres M, Huttner HB. Impact of Statins on Hematoma, Edema, Seizures, Vascular Events, and Functional Recovery After Intracerebral Hemorrhage. Stroke 2021; 52:975-984. [PMID: 33517701 DOI: 10.1161/strokeaha.120.029345] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE The impact of statins on hematoma characteristics, perihemorrhagic edema (PHE), cardiovascular events, seizures, and functional recovery in patients with intracerebral hemorrhage (ICH) is insufficiently studied. METHODS Patients with ICH of the prospective UKER-ICH (Universitätsklinikum Erlangen Cohort of Patients With Spontaneous Intracerebral Hemorrhage) study (URL: https://www.clinicaltrials.gov; Unique identifier: NCT03183167) were analyzed by multivariable regression modeling and propensity score matching, and PHE volumes were volumetrically assessed. Outcomes comprised hematoma characteristics, the impact of continuation, discontinuation, and initiation of statins on peak PHE extent, and the influence of statin treatment on the occurrence of seizures, cardiovascular adverse events, and functional recovery after ICH. RESULTS A total of 1275 patients with ICH with information on statin treatment were analyzed. Statin treatment on hospital admission (21.7%) was associated with higher rates of lobar versus nonlobar ICH (odds ratio, 1.57 [1.03-2.40]; P=0.038). Initiation of statins after ICH was associated with increased peak PHE (β=0.12, SE=0.06, P=0.008), whereas continuation versus discontinuation of prior statin treatment was not significantly associated with edema formation (P>0.10). There were no significant differences in the incidence of remote symptomatic seizures according to statin exposure during follow-up (statins: 11.5% versus no statins: 7.8%, subdistribution hazard ratio: 1.15 [0.80-1.66]; P=0.512). Patients on statins revealed less cardiovascular adverse events and more frequently functional recovery after 12 months (functional recovery: 57.7% versus 45.0%, odds ratio 1.67 [1.09-2.56]; P=0.019). CONCLUSIONS Among statin users, lobar ICH occurs more frequently as compared with nonstatin users. While continuation of prior statin treatment appears to be safe regarding PHE formation, the initiation of statins during the first days after ICH may increase PHE extent. However, statins should be initiated thereafter (eg, at hospital discharge) to prevent cardiovascular events and potentially improve functional recovery.
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Affiliation(s)
- Maximilian I Sprügel
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Joji B Kuramatsu
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Bastian Volbers
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Justina I Saam
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Jochen A Sembill
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Stefan T Gerner
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Stefanie Balk
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Hajo M Hamer
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Hannes Lücking
- Department of Neuroradiology (H.L., P.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Philip Hölter
- Department of Neuroradiology (H.L., P.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (C.H.N., J.F.S., A.R., M.E.)
| | - Jan F Scheitz
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (C.H.N., J.F.S., A.R., M.E.)
| | - Andrea Rocco
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (C.H.N., J.F.S., A.R., M.E.)
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (C.H.N., J.F.S., A.R., M.E.).,Center for Stroke Research Berlin (M.E.).,German Center for Neurodegenerative Diseases (DZNE) (M.E.), partner site Berlin.,German Centre for Cardiovascular Research (DZHK) (M.E.), partner site Berlin
| | - Hagen B Huttner
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
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40
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Erdur H, Siegerink B, Leithner C, Franke C, Lorenz-Meyer I, Theen S, Angermaier A, Kinze S, Weber JE, Rohmann JL, Scheitz JF, Nolte CH, Endres M, Audebert HJ. Stroke Admissions, Stroke Severity, and Treatment Rates in Urban and Rural Areas During the COVID-19 Pandemic. Front Neurol 2021; 11:607193. [PMID: 33488501 PMCID: PMC7815522 DOI: 10.3389/fneur.2020.607193] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/09/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Many regions worldwide reported a decline of stroke admissions during the early phase of the coronavirus disease 2019 (COVID-19) pandemic. It remains unclear whether urban and rural regions experienced similar declines and whether deviations from historical admission numbers were more pronounced among specific age, stroke severity or treatment groups. Methods: We used registry datasets from (a) nine acute stroke hospitals in Berlin, and (b) nine hospitals from a rural TeleNeurology network in Northeastern Germany for primary analysis of 3-week-rolling average of stroke/TIA admissions before and during the COVID-19 pandemic. We compared course of stroke admission numbers with regional cumulative severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2) infections. In secondary analyses, we used emergency department logs of the Berlin Charité University hospital to investigate changes in age, stroke severity, and thrombolysis/thrombectomy frequencies during the early regional Sars-CoV-2 spread (March and April 2020) and compared them with preceding years. Results: Compared to past years, stroke admissions decreased by 20% in urban and 20-25% in rural hospitals. Deviations from historical averages were observable starting in early March and peaked when numbers of regional Sars-CoV-2 infections were still low. At the same time, average admission stroke severity and proportions of moderate/severe strokes (NIHSS >5) were 20 and 20–40% higher, respectively. There were no relevant deviations observed in proportions of younger patients (<65 years), proportions of patients with thrombolysis, or number of thrombectomy procedures. Stroke admissions at Charité subsequently rebounded and reached near-normal levels after 4 weeks when the number of new Sars-CoV-2 infections started to decrease. Conclusions: During the early pandemic, deviations of stroke-related admissions from historical averages were observed in both urban and rural regions of Northeastern Germany and appear to have been mainly driven by avoidance of admissions of mildly affected stroke patients.
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Affiliation(s)
- Hebun Erdur
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Leithner
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christiana Franke
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sarah Theen
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anselm Angermaier
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Stephan Kinze
- Klinik für Neurologie, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Joachim E Weber
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Jessica L Rohmann
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan F Scheitz
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany.,DZNE (German Center for Neurodegenerative Diseases), partner site Berlin, Berlin, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany.,DZNE (German Center for Neurodegenerative Diseases), partner site Berlin, Berlin, Germany
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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41
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Nolte CH, von Rennenberg R, Litmeier S, Scheitz JF, Leistner DM, Blankenberg S, Dichgans M, Katus H, Petzold GC, Pieske B, Regitz-Zagrosek V, Wegscheider K, Zeiher AM, Landmesser U, Endres M. PRediction of acute coronary syndrome in acute ischemic StrokE (PRAISE) - protocol of a prospective, multicenter trial with central reading and predefined endpoints. BMC Neurol 2020; 20:318. [PMID: 32854663 PMCID: PMC7450553 DOI: 10.1186/s12883-020-01903-0] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/23/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Current guidelines recommend measurement of troponin in acute ischemic stroke (AIS) patients. In AIS patients, troponin elevation is associated with increased mortality and worse outcome. However, uncertainty remains regarding the underlying pathophysiology of troponin elevation after stroke, particularly regarding diagnostic and therapeutic consequences. Troponin elevation may be caused by coronary artery disease (CAD) and more precisely acute coronary syndrome (ACS). Both have a high prevalence in stroke patients and contribute to poor outcome. Therefore, better diagnostic algorithms are needed to identify those AIS patients likely to have ACS or other manifestations of CAD. METHODS/DESIGN The primary goal of the "PRediction of Acute coronary syndrome in acute Ischemic StrokE" (PRAISE) study is to develop a diagnostic algorithm for prediction of ACS in AIS patients. The primary hypothesis will test whether dynamic high-sensitivity troponin levels determined by repeat measurements (i.e., "rise or fall-pattern") indicate presence of ACS when compared to stable (chronic) troponin elevation. PRAISE is a prospective, multicenter, observational trial with central reading and predefined endpoints guided by a steering committee. Clinical symptoms, troponin levels as well as findings on electrocardiogram, echocardiogram, and coronary angiogram will be recorded and assessed by central academic core laboratories. Diagnosis of ACS will be made by an endpoint adjudication committee. Severe adverse events will be evaluated by a critical event committee. Safety will be judged by a data and safety monitoring board. Follow-up will be conducted at three and twelve months and will record new vascular events (i.e., stroke and myocardial infarction) as well as death, functional and cognitive status. According to sample size calculation, 251 patients have to be included. DISCUSSION PRAISE will prospectively determine the frequency of ACS and characterize cardiac and coronary pathologies in a large, multicenter cohort of AIS patients with troponin elevation. The findings will elucidate the origin of troponin elevation, shed light on its impact on necessary diagnostic procedures and provide data on the safety and diagnostic yield of coronary angiography early after stroke. Thereby, PRAISE will help to refine algorithms and develop guidelines for the cardiac workup in AIS. TRIAL REGISTRATION NCT03609385 registered 1st August 2018.
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Affiliation(s)
- Christian H Nolte
- Klinik für Neurologie mit Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany. .,Center for Stroke Research, Berlin, Germany. .,Berlin Institute of Health (BiH), Berlin, Germany. .,Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany. .,Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) - German Center for Neurodegenerative Diseases, 53127, Bonn, Germany.
| | - Regina von Rennenberg
- Klinik für Neurologie mit Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) - German Center for Neurodegenerative Diseases, 53127, Bonn, Germany
| | - Simon Litmeier
- Klinik für Neurologie mit Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) - German Center for Neurodegenerative Diseases, 53127, Bonn, Germany
| | - Jan F Scheitz
- Klinik für Neurologie mit Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,Berlin Institute of Health (BiH), Berlin, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany
| | - David M Leistner
- Berlin Institute of Health (BiH), Berlin, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Medizinische Klinik für Kardiologie, Campus Benjamin-Franklin, Charite-Universitätsmedizin, 12203, Berlin, Germany
| | - Stephan Blankenberg
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Klinik und Poliklinik für Kardiologe, Universitäres Herz- und Gefäßzentrum, Universitätsklinikum, 20246, Hamburg, Germany
| | - Martin Dichgans
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) - German Center for Neurodegenerative Diseases, 53127, Bonn, Germany.,Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, 81377, Munich, Germany.,German Center for Neurodegenerative Diseases (DZNE, Munich) Partnersite, 81377, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), 81377, Munich, Germany
| | - Hugo Katus
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Klinik für Kardiologie, Angiologie, Pneumologie, Universitätsklinikum Heidelberg, 69120, Heidelberg, Germany
| | - Gabor C Petzold
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) - German Center for Neurodegenerative Diseases, 53127, Bonn, Germany.,Sektion für Vaskuläre Neurologie, Klinik und Poliklinik für Neurologie, Universitätsklinikum Bonn, 53105, Bonn, Germany
| | - Burkert Pieske
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Medizinische Klinik mit Schwerpunkt Kardiologie, Campus Virchow-Klinikum, Charite-Universitätsmedizin, 13353, Berlin, Germany
| | - Vera Regitz-Zagrosek
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Institut für Geschlechterforschung in der Medizin (Gender in Medicine, GiM), Charite-Universitätsmedizin, 10115, Berlin, Germany
| | - Karl Wegscheider
- Institut für Medizinische Biometrie und Epidemiologie, Universitätsklinikum Hamburg-Eppendorf, 20251, Hamburg, Germany
| | - Andreas M Zeiher
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Klinik für Kardiologie, Angiologie, Nephrologie, Uniklinik Frankfurt, 60590, Frankfurt am Main, Germany
| | - Ulf Landmesser
- Berlin Institute of Health (BiH), Berlin, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Medizinische Klinik für Kardiologie, Campus Benjamin-Franklin, Charite-Universitätsmedizin, 12203, Berlin, Germany
| | - Matthias Endres
- Klinik für Neurologie mit Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,Berlin Institute of Health (BiH), Berlin, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK), 10785, Berlin, Germany.,Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) - German Center for Neurodegenerative Diseases, 53127, Bonn, Germany.,Medizinische Klinik für Kardiologie, Campus Benjamin-Franklin, Charite-Universitätsmedizin, 12203, Berlin, Germany.,Excellence Cluster NeuroCure, 10117, Berlin, Germany
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42
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Altersberger VL, Sturzenegger R, Räty S, Hametner C, Scheitz JF, Moulin S, Berg SA, Zini A, Nannoni S, Heldner MR, Jovanovic DR, Martinez‐Majander N, Tiainen M, Valkonen K, Berberich A, Erdur H, Cordonnier C, Peters N, Gopisingh KM, Bigliardi G, Strambo D, De Marchis GM, Ntaios G, Cereda CW, Wegener S, Kägi G, Pezzini A, Padjen V, Arnold M, Michel P, Vandelli L, Nederkoorn PJ, Leys D, Nolte CH, Ringleb PA, Curtze S, Engelter ST, Gensicke H. Prior Dual Antiplatelet Therapy and Thrombolysis in Acute Stroke. Ann Neurol 2020; 88:857-859. [DOI: 10.1002/ana.25850] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/22/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Valerian L. Altersberger
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
| | | | - Silja Räty
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Christian Hametner
- Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Jan F. Scheitz
- Department of Neurology and Center for Stroke Research Berlin Charité, Berlin Germany
| | - Solène Moulin
- Department of Neurology Centre Hospitalier Universitaire de Reims Reims France
| | - Sophie A. Berg
- Department of Neurology Amsterdam University Medical Center, University of Amsterdam Amsterdam The Netherlands
| | - Andrea Zini
- Department of Neurology and Stroke Center IRCCS Istituto di Scienze Neurologiche di Bologna, Maggiore Hospital Bologna Italy
| | - Stefania Nannoni
- Department of Neurology Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital Bern University Hospital and University of Bern Bern Switzerland
| | - Dejana R. Jovanovic
- Neurology Clinic, Clinical Centre of Serbia Belgrade Serbia
- Medical Faculty University of Belgrade Belgrade Serbia
| | | | - Marjaana Tiainen
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Kati Valkonen
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Anne Berberich
- Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Hebun Erdur
- Department of Neurology and Center for Stroke Research Berlin Charité, Berlin Germany
| | | | - Nils Peters
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
- Neurorehabilitation, University of Basel and University Department of Geriatric Medicine FELIX PLATTER University of Basel Basel Switzerland
| | - Kiran M. Gopisingh
- Department of Neurology Amsterdam University Medical Center, University of Amsterdam Amsterdam The Netherlands
| | - Guido Bigliardi
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile “S. Agostino‐Estense,” Modena University Hospital Modena Italy
| | - Davide Strambo
- Department of Neurology Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne Switzerland
| | - Gian M. De Marchis
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine School of Health Sciences, University of Thessaly Larissa Greece
| | - Carlo W. Cereda
- Stroke Center and Department of Neurology Neurocenter of Southern Switzerland Lugano Switzerland
| | - Susanne Wegener
- Department of Neurology University Hospital Zurich and University of Zurich Zurich Switzerland
| | - Georg Kägi
- Department of Neurology Kantonsspital St. Gallen St. Gallen Switzerland
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences Neurology Clinic, University of Brescia Brescia Italy
| | - Visnja Padjen
- Neurology Clinic, Clinical Centre of Serbia Belgrade Serbia
| | - Marcel Arnold
- Department of Neurology, Inselspital Bern University Hospital and University of Bern Bern Switzerland
| | - Patrik Michel
- Department of Neurology Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne Switzerland
| | - Laura Vandelli
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile “S. Agostino‐Estense,” Modena University Hospital Modena Italy
| | - Paul J. Nederkoorn
- Department of Neurology Amsterdam University Medical Center, University of Amsterdam Amsterdam The Netherlands
| | | | - Christian H. Nolte
- Department of Neurology and Center for Stroke Research Berlin Charité, Berlin Germany
| | - Peter A. Ringleb
- Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Sami Curtze
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Stefan T. Engelter
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
- Neurorehabilitation, University of Basel and University Department of Geriatric Medicine FELIX PLATTER University of Basel Basel Switzerland
| | - Henrik Gensicke
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
- Neurorehabilitation, University of Basel and University Department of Geriatric Medicine FELIX PLATTER University of Basel Basel Switzerland
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Scheitz JF, Pare G, Pearce LA, Mundl H, Peacock WF, Czlonkowska A, Sharma M, Nolte CH, Shoamanesh A, Berkowitz SD, Krahn T, Endres M. High-Sensitivity Cardiac Troponin T for Risk Stratification in Patients With Embolic Stroke of Undetermined Source. Stroke 2020; 51:2386-2394. [DOI: 10.1161/strokeaha.120.029628] [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:
Optimal secondary prevention for patients with embolic stroke of undetermined source (ESUS) remains unknown. We aimed to assess whether high-sensitivity cardiac troponin T (hs-cTnT) levels are associated with major vascular events and whether hs-cTnT may identify patients who benefit from anticoagulation following ESUS.
Methods:
Data were obtained from the biomarker substudy of the NAVIGATE ESUS trial, a randomized controlled trial testing the efficacy of rivaroxaban versus aspirin for secondary stroke prevention in ESUS. Patients were dichotomized at the hs-cTnT upper reference limit (14 ng/L, Gen V, Roche Diagnostics). Cox proportional hazard models were computed to explore the association between hs-cTnT, the combined cardiovascular end point (recurrent stroke, myocardial infarction, systemic embolism, cardiovascular death), and recurrent ischemic stroke.
Results:
Among 1337 patients enrolled at 111 participating centers in 18 countries (mean age 67±9 years, 61% male), hs-cTnT was detectable in 95% and at/above the upper reference limit in 21%. During a median follow-up of 11 months, the combined cardiovascular end point occurred in 68 patients (5.0%/y, rivaroxaban 28 events, aspirin 40 events; hazard ratio, 0.67 [95% CI, 0.41–1.1]), and recurrent ischemic stroke occurred in 50 patients (4.0%/y, rivaroxaban 16 events, aspirin 34 events, hazard ratio 0.45 [95% CI, 0.25–0.81]). Annualized combined cardiovascular end point rates were 8.2% (9.5% rivaroxaban, 7.0% aspirin) for those above hs-cTnT upper reference limit and 4.8% (3.1% rivaroxaban, 6.6% aspirin) below with a significant treatment modification (
P
=0.04). Annualized ischemic stroke rates were 4.7% above hs-cTnT upper reference limit and 3.9% below, with no suggestion of an interaction between hs-cTnT and treatment (
P
=0.3).
Conclusions:
In patients with ESUS, hs-cTnT was associated with increased cardiovascular event rates. While fewer recurrent strokes occurred in patients receiving rivaroxaban, outcomes were not stratified by hs-cTn results. Our findings support using hs-cTnT for cardiovascular risk stratification but not for decision-making regarding anticoagulation therapy in patients with ESUS.
Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT02313909.
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Affiliation(s)
- Jan F. Scheitz
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (J.F.S., C.H.N., M.E.)
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (J.F.S., C.H.N., M.E.)
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (J.F.S., C.H.N., M.E.)
- Berlin Institute of Health (BIH), Germany (J.F.S., C.H.N., M.E.)
| | - Guillaume Pare
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada (G.P.)
| | | | | | | | - Anna Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.C.)
| | - Mukul Sharma
- Department of Medicine (Neurology), Population Health Research Institute, McMaster University, Hamilton Health Sciences, Canada (M.S., A.S.)
| | - Christian H. Nolte
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (J.F.S., C.H.N., M.E.)
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (J.F.S., C.H.N., M.E.)
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (J.F.S., C.H.N., M.E.)
- Berlin Institute of Health (BIH), Germany (J.F.S., C.H.N., M.E.)
| | - Ashkan Shoamanesh
- Department of Medicine (Neurology), Population Health Research Institute, McMaster University, Hamilton Health Sciences, Canada (M.S., A.S.)
| | - Scott D. Berkowitz
- Research & Development, Pharmaceuticals, Bayer U.S., LLC, Whippany (S.D.B.)
| | - Thomas Krahn
- Bayer AG, Wuppertal, Germany (H.M., T.K.)
- Department of Pharmacology and Personalised Medicine, Maastricht University, the Netherlands (T.K.)
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (J.F.S., C.H.N., M.E.)
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (J.F.S., C.H.N., M.E.)
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany (J.F.S., C.H.N., M.E.)
- Berlin Institute of Health (BIH), Germany (J.F.S., C.H.N., M.E.)
- DZNE (German Center for Neurodegenerative Disease), partner site Berlin, Germany (M.E.)
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44
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Hellwig S, Grittner U, Elgeti M, Wyschkon S, Nagel SN, Fiebach JB, Krause T, Herm J, Scheitz JF, Endres M, Nolte CH, Haeusler KG, Elgeti T. Evaluation of left ventricular function in patients with acute ischaemic stroke using cine cardiovascular magnetic resonance imaging. ESC Heart Fail 2020; 7:2572-2580. [PMID: 32667736 PMCID: PMC7524103 DOI: 10.1002/ehf2.12833] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 02/24/2020] [Revised: 05/05/2020] [Accepted: 05/27/2020] [Indexed: 01/09/2023] Open
Abstract
Aims Heart failure (HF) is frequent in patients with acute ischaemic stroke (AIS) and associated with higher morbidity and mortality. Assessment of cardiac function in AIS patients using cardiovascular MRI (CMR) may help to detect HF. We report the rate of systolic and diastolic dysfunction in a cohort of patients with AIS using CMR and compare cine real‐time (CRT) sequences with the reference of segmented cine steady‐state free precession sequences. Methods and results Patients with AIS without known atrial fibrillation were prospectively enrolled in the HEart and BRain Interfaces in Acute Ischemic Stroke (HEBRAS) study (NCT 02142413) and underwent CMR at 3 Tesla within 7 days after AIS. Validity of CRT sequences was determined in 50 patients. A total of 229 patients were included in the analysis (mean age 66 years; 35% women; HF 2%). Evaluation of cardiac function was successful in 172 (75%) patients. Median time from stroke onset to CMR was 82 h (interquartile range 56–111) and 54 h (interquartile range 31–78) from cerebral MRI to CMR. Systolic dysfunction was observed in 43 (25%) and diastolic dysfunction in 102 (59%) patients. Diagnostic yield was similar using CRT or segmented cine imaging (no significant difference in left ventricular ejection fraction, myocardial mass, time to peak filling rate, and peak filling rate ratio E/A). Intraobserver and interobserver agreement was high (κ = 0.78–1.0 for all modalities). Conclusions Cardiovascular MRI at 3 Tesla is an appropriate method for the evaluation of cardiac function in a selected cohort of patients with AIS. Systolic and diastolic dysfunction is frequent in these patients. CRT imaging allows reliable assessment of systolic and diastolic function.
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Affiliation(s)
- Simon Hellwig
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Matthias Elgeti
- Jules Stein Eye Institute and Department for Chemistry and Biochemistry, University of California, Los Angeles, CA, USA
| | - Sebastian Wyschkon
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian N Nagel
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Krause
- Department of Neurology, Jüdisches Krankenhaus Berlin, Berlin, Germany
| | - Juliane Herm
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Centre for Cardiovascular Diseases (DZHK), partner site Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Centre for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany.,German Centre for Cardiovascular Diseases (DZHK), partner site Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Centre for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany.,German Centre for Cardiovascular Diseases (DZHK), partner site Berlin, Berlin, Germany
| | | | - Thomas Elgeti
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Westphal LP, Widmer R, Held U, Steigmiller K, Hametner C, Ringleb P, Curtze S, Martinez-Majander N, Tiainen M, Nolte CH, Scheitz JF, Erdur H, Polymeris AA, Traenka C, Eskandari A, Michel P, Heldner MR, Arnold M, Zini A, Vandelli L, Coutinho JM, Groot AE, Padjen V, Jovanovic DR, Bejot Y, Brenière C, Turc G, Seners P, Pezzini A, Magoni M, Leys D, Gilliot S, Scherrer MJ, Kägi G, Luft AR, Gensicke H, Nederkoorn P, Tatlisumak T, Engelter ST, Wegener S. Association of prestroke metformin use, stroke severity, and thrombolysis outcome. Neurology 2020; 95:e362-e373. [PMID: 32601121 DOI: 10.1212/wnl.0000000000009951] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 01/06/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate whether pretreatment with metformin (MET) is associated with less stroke severity and better outcome after IV thrombolysis (IVT), we analyzed a cohort of 1,919 patients with stroke with type 2 diabetes mellitus in a multicenter exploratory analysis. METHODS Data from patients with diabetes and ischemic stroke treated with IVT were collected within the European Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration. We applied propensity score matching (PSM) to obtain balanced baseline characteristics of patients treated with and without MET. RESULTS Of 1,919 patients with stroke with type 2 diabetes who underwent IVT, 757 (39%) had received MET before stroke (MET+), whereas 1,162 (61%) had not (MET-). MET+ patients were younger with a male preponderance. Hypercholesterolemia and pretreatment with statins, antiplatelets, or antihypertensives were more common in the MET+ group. After PSM, the 2 groups were well balanced with respect to demographic and clinical aspects. Stroke severity on admission (NIH Stroke Scale 10.0 ± 6.7 vs 11.3 ± 6.5), 3-month degree of independence on modified Rankin Scale (2 [interquartile range (IQR) 1.0-4.0] vs 3 [IQR 1.0-4.0]), as well as mortality (12.5% vs 18%) were significantly lower in the MET+ group. The frequency of symptomatic intracerebral hemorrhages did not differ between groups. HbA1c levels were well-balanced between the groups. CONCLUSIONS Patients with stroke and diabetes on treatment with MET receiving IVT had less severe strokes on admission and a better functional outcome at 3 months. This suggests a protective effect of MET resulting in less severe strokes as well as beneficial thrombolysis outcome.
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Affiliation(s)
- Laura P Westphal
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Roni Widmer
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Ulrike Held
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Klaus Steigmiller
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Christian Hametner
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Peter Ringleb
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Sami Curtze
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Nicolas Martinez-Majander
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Marjaana Tiainen
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Christian H Nolte
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Jan F Scheitz
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Hebun Erdur
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Alexandros A Polymeris
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Christopher Traenka
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Ashraf Eskandari
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Patrik Michel
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Mirjam R Heldner
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Marcel Arnold
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Andrea Zini
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Laura Vandelli
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Jonathan M Coutinho
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Adrien E Groot
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Visnja Padjen
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Dejana R Jovanovic
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Yannick Bejot
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Céline Brenière
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Guillaume Turc
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Pierre Seners
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Alessandro Pezzini
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Mauro Magoni
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Didier Leys
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Sixtine Gilliot
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Michael J Scherrer
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Georg Kägi
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Andreas R Luft
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Henrik Gensicke
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Paul Nederkoorn
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Turgut Tatlisumak
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Stefan T Engelter
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Susanne Wegener
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland.
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Siegerink B, Broersen LHA, Scheitz JF. Response by Siegerink et al to Letter Regarding Article, "Association Between High-Sensitivity Cardiac Troponin and Risk of Stroke in 96 702 Individuals: A Meta-Analysis". Stroke 2020; 51:e98. [PMID: 32295507 DOI: 10.1161/strokeaha.120.029610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bob Siegerink
- Center for Stroke Research Berlin (CSB) and Klinik für, Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin, Germany
| | - Leonie H A Broersen
- Center for Stroke Research Berlin (CSB) and Klinik für, Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin, Germany
| | - Jan F Scheitz
- Center for Stroke Research Berlin (CSB) and Klinik für, Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin, Germany
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Broersen LHA, Siegerink B, Sperber PS, von Rennenberg R, Piper SK, Nolte CH, Heuschmann PU, Endres M, Scheitz JF, Liman TG. High-Sensitivity Cardiac Troponin T and Cognitive Function in Patients With Ischemic Stroke. Stroke 2020; 51:1604-1607. [PMID: 32279621 DOI: 10.1161/strokeaha.119.028410] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background and Purpose- Our study aim was to assess whether high-sensitivity cardiac troponin T (hs-cTnT), a specific biomarker for myocardial injury, is associated with cognitive function in patients after mild-to-moderate first-ever ischemic stroke. Methods- We used data from PROSCIS-B (Prospective Cohort With Incident Stroke Berlin). Cognitive function was assessed by Mini-Mental-State-Examination at baseline, and Telephone Interview for Cognitive Status-modified after 1 to 3 years of follow-up. Patients were categorized according to hs-cTnT quartiles. We performed generalized linear regression to calculate risk ratios of cognitive impairment (Mini-Mental-State-Examination <27; Telephone Interview for Cognitive Status-modified <32). Association of hs-cTnT with cognitive function over time was estimated using a linear mixed model. Results- We included 555 patients (mean age, 67 years, 62% male, median National Institutes of Health Stroke Scale 2 [interquartile range, 1-5], hs-cTnT above upper reference limit 40%, baseline cognitive impairment 28%). Baseline Mini-Mental-State-Examination score and rate of cognitive impairment were lower in patients in the highest versus lowest hs-cTnT quartile (median Mini-Mental-State-Examination 27 versus 29, and 15.3% versus 43.0%, adjusted risk ratio, 1.76 [95% CI, 1.07-2.90], respectively). If anything, cognition seemed to improve in all groups, yet Telephone Interview for Cognitive Status-modified scores were consistently lower in patients within the highest versus lowest hs-cTnT quartile (adjusted β, -1.33 [95% CI, -2.65 to -0.02]), without difference in the rate of change over time. Conclusions- In patients with mild-to-moderate first-ever ischemic stroke without dementia, higher hs-cTnT was associated with higher prevalence of cognitive impairment at baseline and lower Telephone Interview for Cognitive Status-modified during 3-year follow-up. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT01363856.
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Affiliation(s)
- Leonie H A Broersen
- From the Center for Stroke Research Berlin (L.H.A.B., B.S., P.S.S., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany.,Klinik für Neurologie mit Experimenteller Neurologie (L.H.A.B., P.S.S., R.v.R., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany
| | - Bob Siegerink
- From the Center for Stroke Research Berlin (L.H.A.B., B.S., P.S.S., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany
| | - Pia S Sperber
- From the Center for Stroke Research Berlin (L.H.A.B., B.S., P.S.S., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany.,Klinik für Neurologie mit Experimenteller Neurologie (L.H.A.B., P.S.S., R.v.R., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin (P.S.S., C.H.N., M.E., J.F.S.)
| | - Regina von Rennenberg
- Klinik für Neurologie mit Experimenteller Neurologie (L.H.A.B., P.S.S., R.v.R., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany
| | - Sophie K Piper
- Berlin Institute of Health (S.K.P., C.H.N., M.E., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,Institute of Biometry and Clinical Epidemiology (S.K.P.), Charité-Universitätsmedizin Berlin, Germany
| | - Christian H Nolte
- From the Center for Stroke Research Berlin (L.H.A.B., B.S., P.S.S., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany.,Klinik für Neurologie mit Experimenteller Neurologie (L.H.A.B., P.S.S., R.v.R., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany.,Berlin Institute of Health (S.K.P., C.H.N., M.E., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin (P.S.S., C.H.N., M.E., J.F.S.).,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Germany (C.H.N., M.E.)
| | - Peter U Heuschmann
- Comprehensive Heart Failure (P.U.H.), University of Würzburg, Germany.,Institute of Clinical Epidemiology and Biometry (P.U.H.), University of Würzburg, Germany.,Center for Clinical Studies, University Hospital Würzburg, Germany (P.U.H.)
| | - Matthias Endres
- From the Center for Stroke Research Berlin (L.H.A.B., B.S., P.S.S., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany.,Klinik für Neurologie mit Experimenteller Neurologie (L.H.A.B., P.S.S., R.v.R., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany.,Berlin Institute of Health (S.K.P., C.H.N., M.E., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin (P.S.S., C.H.N., M.E., J.F.S.).,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Germany (C.H.N., M.E.)
| | - Jan F Scheitz
- From the Center for Stroke Research Berlin (L.H.A.B., B.S., P.S.S., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany.,Klinik für Neurologie mit Experimenteller Neurologie (L.H.A.B., P.S.S., R.v.R., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany.,Berlin Institute of Health (S.K.P., C.H.N., M.E., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin (P.S.S., C.H.N., M.E., J.F.S.)
| | - Thomas G Liman
- From the Center for Stroke Research Berlin (L.H.A.B., B.S., P.S.S., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany.,Klinik für Neurologie mit Experimenteller Neurologie (L.H.A.B., P.S.S., R.v.R., C.H.N., M.E., J.F.S., T.G.L.), Charité-Universitätsmedizin Berlin, Germany
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Broersen LHA, Stengl H, Nolte CH, Westermann D, Endres M, Siegerink B, Scheitz JF. Association Between High-Sensitivity Cardiac Troponin and Risk of Stroke in 96 702 Individuals: A Meta-Analysis. Stroke 2020; 51:1085-1093. [PMID: 32078461 DOI: 10.1161/strokeaha.119.028323] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background and Purpose- Our study aim was to estimate risk of incident stroke based on levels of hs-cTn (high-sensitivity cardiac troponin), a specific biomarker indicating myocardial injury, in the general population, patients with atrial fibrillation, and patients with previous stroke. Methods- Embase, PubMed, and Web of Science were searched until March 14, 2019 to identify relevant articles. Randomized controlled trials and cohort studies assessing the risk of incident stroke based on hs-cTn were eligible. Pooled adjusted hazard ratios including 95% CI were calculated using a random-effects model due to study heterogeneity per population, coding of hs-cTn (categorical/continuous data), per hs-cTn subunit (T or I), for low risk of bias, and for all-cause and ischemic stroke separately. Results- We included 17 articles with 96 702 participants. In studies conducted in the general population (n=12; 77 780 participants), the pooled adjusted hazard ratio for incident stroke was 1.25 (CI, 1.10-1.40) for high versus low hs-cTn (as defined by included studies) during an average follow-up of 1 to 20 years (median 10). When categorical data were used, this was increased to 1.58 (CI, 1.26-1.90). The results were robust when accounting for stroke classification (all-cause stroke/ischemic stroke), hs-cTn subunit, risk of bias, and coding of hs-cTn. In patients with atrial fibrillation (4 studies; 18 725 participants), the pooled adjusted hazard ratio for incident stroke was 1.95 (CI, 1.29-2.62) for high versus low hs-cTn. Due to lack of data (one study, 197 participants), no meta-analysis could be performed in patients with previous stroke. Conclusions- This meta-analysis suggests that hs-cTn can be regarded as a risk marker for incident stroke, with different effect size in different subgroups. More research about the association between hs-cTn and incident stroke in high-risk populations is needed, especially in patients with history of ischemic stroke.
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Affiliation(s)
- Leonie H A Broersen
- From the Klinik für Neurologie mit Experimenteller Neurologie (L.H.A.B., H.S., C.H.N., M.E., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin (CSB) (L.H.A.B., H.S., C.H.N., M.E., B.S., J.F.S.), Charité-Universitätsmedizin Berlin, Germany
| | - Helena Stengl
- From the Klinik für Neurologie mit Experimenteller Neurologie (L.H.A.B., H.S., C.H.N., M.E., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin (CSB) (L.H.A.B., H.S., C.H.N., M.E., B.S., J.F.S.), Charité-Universitätsmedizin Berlin, Germany
| | - Christian H Nolte
- From the Klinik für Neurologie mit Experimenteller Neurologie (L.H.A.B., H.S., C.H.N., M.E., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin (CSB) (L.H.A.B., H.S., C.H.N., M.E., B.S., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), partner site Berlin (C.H.N., M.E., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,Berlin Institute of Health (C.H.N., M.E., J.F.S.), partner site Berlin, Germany.,German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen) (C.H.N., M.E.), partner site Berlin, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Centre Hamburg, Germany (D.W.).,German Centre for Cardiovascular Research, partner site Hamburg/Kiel/Lübeck, Germany (D.W.)
| | - Matthias Endres
- From the Klinik für Neurologie mit Experimenteller Neurologie (L.H.A.B., H.S., C.H.N., M.E., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin (CSB) (L.H.A.B., H.S., C.H.N., M.E., B.S., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), partner site Berlin (C.H.N., M.E., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,Berlin Institute of Health (C.H.N., M.E., J.F.S.), partner site Berlin, Germany.,German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen) (C.H.N., M.E.), partner site Berlin, Germany
| | - Bob Siegerink
- Center for Stroke Research Berlin (CSB) (L.H.A.B., H.S., C.H.N., M.E., B.S., J.F.S.), Charité-Universitätsmedizin Berlin, Germany
| | - Jan F Scheitz
- From the Klinik für Neurologie mit Experimenteller Neurologie (L.H.A.B., H.S., C.H.N., M.E., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin (CSB) (L.H.A.B., H.S., C.H.N., M.E., B.S., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislaufforschung), partner site Berlin (C.H.N., M.E., J.F.S.), Charité-Universitätsmedizin Berlin, Germany.,Berlin Institute of Health (C.H.N., M.E., J.F.S.), partner site Berlin, Germany
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Affiliation(s)
- Jan F Scheitz
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jelena R Ghadri
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Christian Templin
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland.
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Doerrfuss JI, Abdul-Rahim AH, Siegerink B, Nolte CH, Lees KR, Endres M, Kasner SE, Scheitz JF. Early in-hospital exposure to statins and outcome after intracerebral haemorrhage - Results from the Virtual International Stroke Trials Archive. Eur Stroke J 2019; 5:85-93. [PMID: 32232174 DOI: 10.1177/2396987319889258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/21/2019] [Indexed: 01/16/2023] Open
Abstract
Introduction Recent data suggest that statin use after intracerebral haemorrhage might be beneficial. However, data on the effects of early in-hospital statin exposure are lacking. Therefore, we sought to assess whether (1) early statin exposure during the acute phase after intracerebral haemorrhage and (2) early continuation of prevalent statin use are associated with favourable functional outcome. Patients and methods Data were obtained from the Virtual International Stroke Trials Archive. Patients were categorised according to use patterns of statins during this early in-hospital phase (continuation, discontinuation or new initiation of statins). Univariate and multivariable analyses were conducted to explore the association between early statin exposure and functional outcome. Results A total of 919 patients were included in the analysis. Early in-hospital statin exposure (n = 89, 9.7%) was associated with better functional outcome (modified Rankin Scale ≤ 3) compared with 790 patients without statin exposure before or early after the event (66% versus 47%, adjusted OR 2.1, 95% confidence interval 1.3-3.6). Compared with patients without exposure to statins before and early after the event, early continuation of statin therapy (n = 57) was associated with favourable functional outcome (adjusted odds ratio 2.6, 95% confidence interval 1.3-5.2). The association between early continuation of statins and outcome remained robust in sensitivity analyses restricted to patients able to take oral medication within 72 h and one-week survivors. Discussion It is possible that part of the observed associations are not due to a protective effect of statins but are confounded by indication bias. Conclusion Statin exposure and continuation of prevalent statin therapy early after intracerebral haemorrhage are associated with favourable functional outcome after 90 days.
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Affiliation(s)
- Jakob I Doerrfuss
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, BIH, Berlin, Germany
| | - Azmil H Abdul-Rahim
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
| | - Bob Siegerink
- Berlin Institute of Health, BIH, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, BIH, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kennedy R Lees
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Matthias Endres
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, BIH, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, USA
| | - Jan F Scheitz
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, BIH, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Charité - Universitätsmedizin Berlin, Berlin, Germany
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