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Lim A, Ma H, Johnston SC, Singhal S, Muthusamy S, Wang Y, Pan Y, Coutts SB, Hill MD, Ois A, Kapral MK, Knoflach M, Woodhouse LJ, Bath PM, Phan TG. Ninety-Day Stroke Recurrence in Minor Stroke: Systematic Review and Meta-Analysis of Trials and Observational Studies. J Am Heart Assoc 2024:e032471. [PMID: 38641856 DOI: 10.1161/jaha.123.032471] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 03/18/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Risk of recurrence after minor ischemic stroke is usually reported with transient ischemic attack. No previous meta-analysis has focused on minor ischemic stroke alone. The objective was to evaluate the pooled proportion of 90-day stroke recurrence for minor ischemic stroke, defined as a National Institutes of Health Stroke Scale severity score of ≤5. METHODS AND RESULTS Published papers found on PubMed from 2000 to January 12, 2021, reference lists of relevant articles, and experts in the field were involved in identifying relevant studies. Randomized controlled trials and observational studies describing minor stroke cohort with reported 90-day stroke recurrence were selected by 2 independent reviewers. Altogether 14 of 432 (3.2%) studies met inclusion criteria. Multilevel random-effects meta-analysis was performed. A total of 6 randomized controlled trials and 8 observational studies totaling 45 462 patients were included. The pooled 90-day stroke recurrence was 8.6% (95% CI, 6.5-10.7), reducing by 0.60% (95% CI, 0.09-1.1; P=0.02) with each subsequent year of publication. Recurrence was lowest in dual antiplatelet trial arms (6.3%, 95% CI, 4.5-8.0) when compared with non-dual antiplatelet trial arms (7.2%, 95% CI, 4.7-9.6) and observational studies 10.6% (95% CI, 7.0-14.2). Age, hypertension, diabetes, ischemic heart disease, or known atrial fibrillation had no significant association with outcome. Defining minor stroke with a lower National Institutes of Health Stroke Scale threshold made no difference - score ≤3: 8.6% (95% CI, 6.0-11.1), score ≤4: 8.4% (95% CI, 6.1-10.6), as did excluding studies with n<500%-7.3% (95% CI, 5.5-9.0). CONCLUSIONS The risk of recurrence after minor ischemic stroke is declining over time but remains important.
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Affiliation(s)
- Andy Lim
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Emergency Medicine Monash Health Melbourne Victoria Australia
| | - Henry Ma
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Neurology Monash Health Melbourne Victoria Australia
| | | | - Shaloo Singhal
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Neurology Monash Health Melbourne Victoria Australia
| | - Subramanian Muthusamy
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Neurology Monash Health Melbourne Victoria Australia
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Centre for Neurological Diseases Beijing China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Centre for Neurological Diseases Beijing China
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology and Community Health Sciences Hotchkiss Brain Institute, University of Calgary Alberta Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Radiology and Community Health Sciences Hotchkiss Brain Institute, University of Calgary Alberta Canada
| | - Angel Ois
- Servicio de Neurologı'a, Hospital del Mar Barcelona Spain
| | - Moira K Kapral
- Department of Medicine University of Toronto Ontario Canada
| | - Michael Knoflach
- Department of Neurology Innsbruck Medical University Innsbruck Austria
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neuroscience University of Nottingham, Queen's Medical Centre Nottingham United Kingdom
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience University of Nottingham, Queen's Medical Centre Nottingham United Kingdom
| | - Thanh G Phan
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Neurology Monash Health Melbourne Victoria Australia
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Nadareishvili Z, Bath PM, England TJ. Remote Ischemic Conditioning for Secondary Stroke Prevention: Time for a Clinical Trial? Neurology 2024; 102:e208072. [PMID: 38457765 DOI: 10.1212/wnl.0000000000208072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/09/2023] [Indexed: 03/10/2024] Open
Affiliation(s)
- Zurab Nadareishvili
- From the Department of Neurology and Rehabilitation (Z.N.), The George Washington University School of Medicine and Health Sciences, Washington, DC; Comprehensive Stroke Center (Z.N.), VHC Health, Arlington, VA; and Stroke Trials Unit (P.M.B., T.J.E.), Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom
| | - Philip M Bath
- From the Department of Neurology and Rehabilitation (Z.N.), The George Washington University School of Medicine and Health Sciences, Washington, DC; Comprehensive Stroke Center (Z.N.), VHC Health, Arlington, VA; and Stroke Trials Unit (P.M.B., T.J.E.), Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom
| | - Timothy J England
- From the Department of Neurology and Rehabilitation (Z.N.), The George Washington University School of Medicine and Health Sciences, Washington, DC; Comprehensive Stroke Center (Z.N.), VHC Health, Arlington, VA; and Stroke Trials Unit (P.M.B., T.J.E.), Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom
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Blair G, Appleton JP, Mhlanga I, Woodhouse LJ, Doubal F, Bath PM, Wardlaw JM. Design of trials in lacunar stroke and cerebral small vessel disease: review and experience with the LACunar Intervention Trial 2 (LACI-2). Stroke Vasc Neurol 2024:svn-2023-003022. [PMID: 38569894 DOI: 10.1136/svn-2023-003022] [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: 12/05/2023] [Accepted: 03/02/2024] [Indexed: 04/05/2024] Open
Abstract
Cerebral small vessel disease (cSVD) causes lacunar stroke (25% of ischaemic strokes), haemorrhage, dementia, physical frailty, or is 'covert', but has no specific treatment. Uncertainties about the design of clinical trials in cSVD, which patients to include or outcomes to assess, may have delayed progress. Based on experience in recent cSVD trials, we reviewed ways to facilitate future trials in patients with cSVD.We assessed the literature and the LACunar Intervention Trial 2 (LACI-2) for data to inform choice of Participant, Intervention, Comparator, Outcome, including clinical versus intermediary endpoints, potential interventions, effect of outcome on missing data, methods to aid retention and reduce data loss. We modelled risk of missing outcomes by baseline prognostic variables in LACI-2 using binary logistic regression.Imaging versus clinical outcomes led to larger proportions of missing data. We present reasons for and against broad versus narrow entry criteria. We identified numerous repurposable drugs with relevant modes of action to test in various cSVD subtypes. Cognitive impairment is the most common clinical outcome after lacunar ischaemic stroke but was missing more frequently than dependency, quality of life or vascular events in LACI-2. Assessing cognitive status using Diagnostic and Statistical Manual for Mental Disorders Fifth Edition can use cognitive data from multiple sources and may help reduce data losses.Trials in patients with all cSVD subtypes are urgently needed and should use broad entry criteria and clinical outcomes and focus on ways to maximise collection of cognitive outcomes to avoid missing data.
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Affiliation(s)
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iris Mhlanga
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Labeit B, Michou E, Trapl-Grundschober M, Suntrup-Krueger S, Muhle P, Bath PM, Dziewas R. Dysphagia after stroke: research advances in treatment interventions. Lancet Neurol 2024; 23:418-428. [PMID: 38508837 DOI: 10.1016/s1474-4422(24)00053-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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 03/22/2024]
Abstract
After a stroke, most patients have dysphagia, which can lead to aspiration pneumonia, malnutrition, and adverse functional outcomes. Protective interventions aimed at reducing these complications remain the cornerstone of treatment. Dietary adjustments and oral hygiene help mitigate the risk of aspiration pneumonia, and nutritional supplementation, including tube feeding, might be needed to prevent malnutrition. Rehabilitative interventions aim to enhance swallowing function, with different behavioural strategies showing promise in small studies. Investigations have explored the use of pharmaceutical agents such as capsaicin and other Transient-Receptor-Potential-Vanilloid-1 (TRPV-1) sensory receptor agonists, which alter sensory perception in the pharynx. Neurostimulation techniques, such as transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and pharyngeal electrical stimulation, might promote neuroplasticity within the sensorimotor swallowing network. Further advancements in the understanding of central and peripheral sensorimotor mechanisms in patients with dysphagia after a stroke, and during their recovery, will contribute to optimising treatment protocols.
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Affiliation(s)
- Bendix Labeit
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, North Rhine-Westphalia, Germany.
| | - Emilia Michou
- Department of Speech and Language Therapy, School of Health Rehabilitation Sciences, University of Patras, Patras, Achaia, Greece; Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester and the Manchester Academic Health Sciences Centre (MAHSC), Manchester, Greater Manchester, UK
| | - Michaela Trapl-Grundschober
- Karl Landsteiner University of Health Sciences, Krems, Lower Austria, Austria; Division of Neurology, University Hospital Tulln, Tulln, Lower Austria, Austria
| | - Sonja Suntrup-Krueger
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, North Rhine-Westphalia, Germany
| | - Paul Muhle
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, North Rhine-Westphalia, Germany
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Rainer Dziewas
- Department of Neurology and Neurorehabilitation, Klinikum Osnabrueck - Academic teaching hospital of the University of Muenster, Osnabrueck, Lower Saxony, Germany
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5
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Macdonald AS, McConnachie A, Dickie DA, Bath PM, Forbes K, Quinn T, Broomfield NM, Dani K, Doney A, Muir KW, Struthers A, Walters M, Barber M, Bhalla A, Cameron A, Guyler P, Hassan A, Kearney M, Keegan B, Lakshmanan S, Macleod MJ, Randall M, Shaw L, Subramanian G, Werring D, Dawson J. Allopurinol and blood pressure variability following ischemic stroke and transient ischemic attack: a secondary analysis of XILO-FIST. J Hum Hypertens 2024; 38:307-313. [PMID: 38438602 PMCID: PMC11001576 DOI: 10.1038/s41371-024-00906-5] [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: 10/01/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/06/2024]
Abstract
Blood Pressure Variability (BPV) is associated with cardiovascular risk and serum uric acid level. We investigated whether BPV was lowered by allopurinol and whether it was related to neuroimaging markers of cerebral small vessel disease (CSVD) and cognition. We used data from a randomised, double-blind, placebo-controlled trial of two years allopurinol treatment after recent ischemic stroke or transient ischemic attack. Visit-to-visit BPV was assessed using brachial blood pressure (BP) recordings. Short-term BPV was assessed using ambulatory BP monitoring (ABPM) performed at 4 weeks and 2 years. Brain MRI was performed at baseline and 2 years. BPV measures were compared between the allopurinol and placebo groups, and with CSVD and cognition. 409 participants (205 allopurinol; 204 placebo) were included in the visit-to-visit BPV analyses. There were no significant differences found between placebo and allopurinol groups for any measure of visit-to-visit BPV. 196 participants were included in analyses of short-term BPV at week 4. Two measures were reduced by allopurinol: the standard deviation (SD) of systolic BP (by 1.30 mmHg (95% confidence interval (CI) 0.18-2.42, p = 0.023)); and the average real variability (ARV) of systolic BP (by 1.31 mmHg (95% CI 0.31-2.32, p = 0.011)). There were no differences in other measures at week 4 or in any measure at 2 years, and BPV was not associated with CSVD or cognition. Allopurinol treatment did not affect visit-to-visit BPV in people with recent ischemic stroke or TIA. Two BPV measures were reduced at week 4 by allopurinol but not at 2 years.
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Affiliation(s)
- Alexander S Macdonald
- School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, School of Health and Wellbeing, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, G12 8QQ, UK
| | - David Alexander Dickie
- DD Analytics Cubed Ltd, 73 Union Street, Greenock, Scotland, PA16 8BG, UK
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary & Life Sciences, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Kirsten Forbes
- Department of Neuroradiology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - Terence Quinn
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Niall M Broomfield
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Krishna Dani
- Department of Neurology, Institute of Neurological Sciences Glasgow, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - Alex Doney
- Medicine Monitoring Unit (MEMO), School of Medicine, University of Dundee. Ninewells Hospital, Dundee, DD1 9SY, UK
- Division of Imaging and Science Technology, School of Medicine, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Keith W Muir
- School of Psychology & Neuroscience, College of Medical, Veterinary & Life Sciences, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK
| | - Allan Struthers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Matthew Walters
- School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Mark Barber
- University Department of Stroke Care, University Hospital Monklands, Airdrie, ML6 OJS, UK
| | - Ajay Bhalla
- Department of Stroke, Ageing and Health, Guy's and St Thomas NHS Foundation Trust, St Thomas' Hospital, Lambeth Palace Rd, London, SE1 7EH, UK
| | - Alan Cameron
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary & Life Sciences, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK
| | - Paul Guyler
- Department of Stroke Medicine, Mid and South Essex University Hospitals Group, Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea, Essex, SS0 0RY, UK
| | - Ahamad Hassan
- Department of Neurology, Leeds General Infirmary, Leeds, UK
| | | | - Breffni Keegan
- Department of Medicine, Southwest Acute Hospital, Enniskillen, BT74 6DN, UK
| | - Sekaran Lakshmanan
- Department of Stroke Medicine, The Luton and Dunstable University Hospital, Bedfordshire, NHSFT, Lewsey Road, Luton, LU4 0DZ, UK
| | | | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Louise Shaw
- Department of Stroke Medicine, Royal United Hospital, Combe Park, Bath, BA1 3NG, UK
| | - Ganesh Subramanian
- Department of Stroke Medicine, Nottingham University Hospitals, Nottingham, NG5 1PB, UK
| | - David Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, Queen Square, University College Hospitals NHS Foundation Trust, London, UK
| | - Jesse Dawson
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary & Life Sciences, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK.
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6
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Wang X, Yang J, Moullaali TJ, Sandset EC, Woodhouse LJ, Law ZK, Arima H, Butcher KS, Delcourt C, Edwards L, Gupta S, Jiang W, Koch S, Potter J, Qureshi AI, Robinson TG, Al-Shahi Salman R, Saver JL, Sprigg N, Wardlaw J, Anderson CS, Sakamoto Y, Bath PM, Chalmers J. Influence of Time to Achieve Target Systolic Blood Pressure on Outcome After Intracerebral Hemorrhage: The Blood Pressure in Acute Stroke Collaboration. Stroke 2024. [PMID: 38410986 DOI: 10.1161/strokeaha.123.044358] [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: 07/12/2023] [Accepted: 01/17/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE To investigate whether an earlier time to achieving and maintaining systolic blood pressure (SBP) at 120 to 140 mm Hg is associated with favorable outcomes in a cohort of patients with acute intracerebral hemorrhage. METHODS We pooled individual patient data from randomized controlled trials registered in the Blood Pressure in Acute Stroke Collaboration. Time was defined as time form symptom onset plus the time (hour) to first achieve and subsequently maintain SBP at 120 to 140 mm Hg over 24 hours. The primary outcome was functional status measured by the modified Rankin Scale at 90 to 180 days. A generalized linear mixed models was used, with adjustment for covariables and trial as a random effect. RESULTS A total of 5761 patients (mean age, 64.0 [SD, 13.0], 2120 [36.8%] females) were included in analyses. Earlier SBP control was associated with better functional outcomes (modified Rankin Scale score, 3-6; odds ratio, 0.98 [95% CI, 0.97-0.99]) and a significant lower risk of hematoma expansion (0.98, 0.96-1.00). This association was stronger in patients with bigger baseline hematoma volume (>10 mL) compared with those with baseline hematoma volume ≤10 mL (0.006 for interaction). Earlier SBP control was not associated with cardiac or renal adverse events. CONCLUSIONS Our study confirms a clear time relation between early versus later SBP control (120-140 mm Hg) and outcomes in the one-third of patients with intracerebral hemorrhage who attained sustained SBP levels within this range. These data provide further support for the value of early recognition, rapid transport, and prompt initiation of treatment of patients with intracerebral hemorrhage.
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Affiliation(s)
- Xia Wang
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Australia. (X.W., T.J.M., C.D., C.S.A., J.C.)
| | - Jie Yang
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu (J.Y.)
| | - Tom J Moullaali
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Australia. (X.W., T.J.M., C.D., C.S.A., J.C.)
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (T.J.M., R.A.-S.S., J.W.)
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Norway (E.C.S.)
- Research and Development Department, The Norwegian Air Ambulance Foundation, Oslo, Norway (E.C.S.)
| | - Lisa J Woodhouse
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, United Kingdom (L.J.W., Z.K.L., N.S., P.M.B.)
| | - Zhe Kang Law
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, United Kingdom (L.J.W., Z.K.L., N.S., P.M.B.)
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (Z.K.L., N.S., P.M.B.)
- Neurology Unit, Department of Medicine, National University of Malaysia, Kuala Lumpur (Z.K.L.)
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Fukuoka University, Japan (H.A.)
| | - Kenneth S Butcher
- School of Clinical Medicine, University of New South Wales, Australia. (K.S.B.)
- Division of Neurology, University of Alberta, Edmonton, Canada (K.S.B.)
| | - Candice Delcourt
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Australia. (X.W., T.J.M., C.D., C.S.A., J.C.)
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia (C.D., C.S.A.)
| | - Leon Edwards
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, Australia (L.E.)
| | - Salil Gupta
- Department of Neurology, Army Hospital Research and Referral, New Delhi, India (S.G.)
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China (W.J.)
- The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China (W.J.)
| | - Sebastian Koch
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, United States (S.K.)
| | - John Potter
- Stroke Research Group, Norfolk and Norwich University Hospital, United Kingdom (J.P.)
- Norwich Medical School, University of East Anglia, UK (J.P.)
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia (A.I.Q.)
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, United Kingdom (T.G.R.)
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (T.J.M., R.A.-S.S., J.W.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, UCLA, Los Angeles (J.L.S.)
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, United Kingdom (L.J.W., Z.K.L., N.S., P.M.B.)
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (Z.K.L., N.S., P.M.B.)
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (T.J.M., R.A.-S.S., J.W.)
| | - Craig S Anderson
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Australia. (X.W., T.J.M., C.D., C.S.A., J.C.)
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia (C.D., C.S.A.)
- The George Institute China, Beijing (C.S.A.)
| | - Yuki Sakamoto
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan (Y.S.)
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, United Kingdom (L.J.W., Z.K.L., N.S., P.M.B.)
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (Z.K.L., N.S., P.M.B.)
| | - John Chalmers
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Australia. (X.W., T.J.M., C.D., C.S.A., J.C.)
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7
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Appleton JP, Woodhouse LJ, Anderson CS, Ankolekar S, Cala L, Dixon M, England TJ, Krishnan K, Mair G, Muir KW, Potter J, Price CI, Randall M, Robinson TG, Roffe C, Sandset EC, Saver JL, Shone A, Siriwardena AN, Wardlaw JM, Sprigg N, Bath PM. Prehospital transdermal glyceryl trinitrate for ultra-acute ischaemic stroke: data from the RIGHT-2 randomised sham-controlled ambulance trial. Stroke Vasc Neurol 2024; 9:38-49. [PMID: 37290930 PMCID: PMC10956104 DOI: 10.1136/svn-2022-001634] [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: 04/14/2022] [Accepted: 08/12/2022] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND The effect of transdermal glyceryl trinitrate (GTN, a nitrovasodilator) on clinical outcome when administered before hospital admission in suspected stroke patients is unclear. Here, we assess the safety and efficacy of GTN in the prespecified subgroup of patients who had an ischaemic stroke within the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2). METHODS RIGHT-2 was an ambulance-based multicentre sham-controlled blinded-endpoint study with patients randomised within 4 hours of onset. The primary outcome was a shift in scores on the modified Rankin scale (mRS) at day 90. Secondary outcomes included death; a global analysis (Wei-Lachin test) containing Barthel Index, EuroQol-5D, mRS, telephone interview for cognitive status-modified and Zung depression scale; and neuroimaging-determined 'brain frailty' markers. Data were reported as n (%), mean (SD), median [IQR], adjusted common OR (acOR), mean difference or Mann-Whitney difference (MWD) with 95% CI. RESULTS 597 of 1149 (52%) patients had a final diagnosis of ischaemic stroke; age 75 (12) years, premorbid mRS>2 107 (18%), Glasgow Coma Scale 14 (2) and time from onset to randomisation 67 [45, 108] min. Neuroimaging 'brain frailty' was common: median score 2 [2, 3] (range 0-3). At day 90, GTN did not influence the primary outcome (acOR for increased disability 1.15, 95% CI 0.85 to 1.54), death or global analysis (MWD 0.00, 95% CI -0.10 to 0.09). In subgroup analyses, there were non-significant interactions suggesting GTN may be associated with more death and dependency in participants randomised within 1 hour of symptom onset and in those with more severe stroke. CONCLUSIONS In patients who had an ischaemic stroke, ultra-acute administration of transdermal GTN in the ambulance did not improve clinical outcomes in a population with more clinical and radiological frailty than seen in previous in-hospital trials.
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Affiliation(s)
- Jason Philip Appleton
- Stroke, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Craig S Anderson
- Faculty of Medicine, The George Institute for Global Health, Sydney, New South Wales, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
- Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, New South Wales, Australia
| | - Sandeep Ankolekar
- Department of Neurology, King's College Hospital NHS Foundation Trust, London, UK
| | - Lesley Cala
- Faculty of Health and Medical Sciences, University of Western Australia, Crawley, Western Australia, Australia
| | - Mark Dixon
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Kailash Krishnan
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Grant Mair
- Centre for Clinical Brain Sciences, Dementia Research Institute, Univeristy of Edinburgh, Edinburgh, UK
| | - Keith W Muir
- Institute of Neurology and Psychology, University of Glasgow, Glasgow, UK
| | - John Potter
- Bob Champion Research and Education Building, University of East Anglia, Norwich, UK
| | | | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Christine Roffe
- Stroke Research in Stoke, Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent, UK
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Angela Shone
- Research and Graduate Services, University of Nottingham, Nottingham, UK
| | - Aloysius Niroshan Siriwardena
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
- Community and Health Research Unit, University of Lincoln, Lincoln, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, Dementia Research Institute, Univeristy of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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8
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Meng X, Wang A, Tian X, Johnston C, Li H, Bath PM, Xu Q, Zhang Y, Xie X, Jing J, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Wang Y. One-Year Outcomes of Early Therapy With Ticagrelor vs Clopidogrel in CYP2C19 Loss-of-Function Carriers With Stroke or TIA Trial. Neurology 2024; 102:e207809. [PMID: 38181311 DOI: 10.1212/wnl.0000000000207809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 11/07/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The Ticagrelor or Clopidogrel with Aspirin in High-Risk Patients with Acute Nondisabling Cerebrovascular Events II (CHANCE-2) trial showed that among Chinese patients with minor ischemic stroke or transient ischemic attack (TIA) who were carriers of CYP2C19 loss-of-function alleles, dual-antiplatelet therapy with ticagrelor-aspirin reduced the 90-day risk of stroke without increased severe or moderate bleeding compared with clopidogrel-aspirin. However, whether dual-antiplatelet therapy with ticagrelor was superior to clopidogrel beyond the 90 days of follow-up remained unclear. In this study, we reported 1-year follow-up outcomes of the CHANCE-2 trial. METHODS The CHANCE-2 trial is a randomized, double-blind, placebo-controlled trial at 202 centers in China. Patients with a minor stroke or TIA who carried CYP2C19 loss-of-function alleles were randomized within 24 hours after symptom onset, in a 1:1 ratio, to receive ticagrelor and placebo clopidogrel or to receive clopidogrel and placebo ticagrelor for 90 days; both groups received aspirin for the first 21 days. After day 90, treatment was as per the choice of the clinician and the patient. RESULTS Among 6,412 patients, the proportion of patients on ticagrelor plus aspirin, clopidogrel plus aspirin, ticagrelor alone, clopidogrel alone, aspirin alone, other antiplatelet, and no antiplatelet beyond month 3 to 1 year was 0.09%, 1.56%, 0.13%, 2.66%, 73.65%, 0.78%, and 21.13% in the ticagrelor-aspirin group and 0.03%, 1.63%, 0.19%, 2.60%, 72.83%, 0.66%, and 22.06% in the clopidogrel-aspirin group, respectively. The primary outcome of new stroke occurred in 252 patients (7.91%) in the ticagrelor-aspirin group and 310 patients (9.73%) in the clopidogrel-aspirin group by 1 year of follow-up (hazard ratio 0.80; 95% CI 0.68-0.95; p = 0.007); new stroke beyond 3 months to 1 year occurred in 61 patients (2.07%) and 67 patients (2.32%) (p = 0.48), respectively. Primary safety outcome of severe or moderate bleeding occurred in 17 patients (0.53%) in the ticagrelor-aspirin group and 20 patients (0.63%) in the clopidogrel-aspirin group (p = 0.61). DISCUSSION For CYP2C19 loss-of-function allele carriers, early dual-antiplatelet therapy with ticagrelor is superior to clopidogrel at 1 year in reducing recurrent stroke. TRIAL REGISTRATION INFORMATION URL: clinicaltrials.gov. Unique identifier: NCT04078737. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for patients with minor stroke or TIA with TIACYP2C19 loss-of-function, ticagrelor plus aspirin for 21 days is superior to clopidogrel plus aspirin in reducing the 1-year risk of recurrent stroke.
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Affiliation(s)
- Xia Meng
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Anxin Wang
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Xue Tian
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Claiborne Johnston
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Hao Li
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Philip M Bath
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Qin Xu
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Yijun Zhang
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Xuewei Xie
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Jing Jing
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Jinxi Lin
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Yilong Wang
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Xingquan Zhao
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Zixiao Li
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Yong Jiang
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Liping Liu
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Yongjun Wang
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
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9
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Wang A, Tian X, Xie X, Li H, Bath PM, Jing J, Lin J, Wang Y, Zhao X, Li Z, Liu L, Wang Y, Meng X. Differential effect of ticagrelor versus clopidogrel by homocysteine levels on risk of recurrent stroke: a post hoc analysis of the CHANCE-2 trial. CMAJ 2024; 196:E149-E156. [PMID: 38346785 PMCID: PMC10861269 DOI: 10.1503/cmaj.231262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Elevated homocysteine levels are associated with increased blood coagulation and platelet activity and may modulate the response to antiplatelet therapies. We aimed to investigate the effects of homocysteine levels on the efficacy and safety of ticagrelor-acetylsalicylic acid (ASA) versus clopidogrel-ASA among patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles. METHODS We conducted a post hoc analysis of the CHANCE-2 (The Clopidogrel in High-risk Patients with Acute Nondisabling Cerebrovascular Events-II) trial. Participants were randomly assigned to treatment with ticagrelor-ASA or clopidogrel-ASA. We categorized participants into groups with elevated and non-elevated homocysteine levels, based on the median level. The primary efficacy outcome was recurrent stroke within 90-day follow-up. The primary safety outcome was severe or moderate bleeding within 90 days. RESULTS A total of 2740 participants were randomly assigned to receive ticagrelor-ASA and 2700 to receive clopidogrel-ASA. Use of ticagrelor-ASA was associated with a reduced risk of recurrent stroke among participants with elevated homocysteine levels (74 [5.3%] v. 119 [8.5%]; hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.45-0.81), but not among those with non-elevated levels (86 [6.4%] v. 87 [6.7%]; HR 0.97, 95% CI 0.71-1.32; p = 0.04 for interaction). When analyzed as a continuous variable, the benefits of ticagrelor-ASA with regard to recurrent stroke increased as homocysteine levels increased (p = 0.04 for interaction). No significant interaction between homocysteine levels and treatment with regard to severe or moderate bleeding was observed (p = 0.7 for interaction). We found a significant interaction between homocysteine levels and therapy with regard to recurrent stroke in females (p = 0.04 for interaction) but not males. INTERPRETATION In comparison with clopidogrel-ASA, ticagrelor-ASA conferred more benefit to patients with elevated homocysteine levels, particularly to female patients, in this secondary analysis of a randomized controlled trial involving patients with minor ischemic stroke or TIA. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT04078737.
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Affiliation(s)
- Anxin Wang
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xue Tian
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuewei Xie
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Philip M Bath
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jinxi Lin
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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10
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Zhang X, Jing J, Wang A, Xie X, Johnston SC, Li H, Bath PM, Xu Q, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Chen W, Gong X, Li J, Han X, Meng X, Wang Y. Efficacy and safety of dual antiplatelet therapy in the elderly for stroke prevention: a subgroup analysis of the CHANCE-2 trial. Stroke Vasc Neurol 2024:svn-2023-002450. [PMID: 38286485 DOI: 10.1136/svn-2023-002450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 12/16/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVES Evidence of the optimal antiplatelet therapy for elderly patients who had a stroke is limited, especially those elder than 80 years. This study aimed to explore the efficacy and safety of dual antiplatelet therapy (DAPT) in old-old patients compared with younger patients in the ticagrelor or Clopidogrel with aspirin in High-risk patients with Acute Non-disabling Cerebrovascular Events-II (CHANCE-2) trial. METHODS CHANCE-2 was a randomised, double-blind, placebo-controlled trial in China involving patients with high-risk transient ischaemic attack or minor stroke with CYP2C19 loss-of-function alleles. In our substudy, all enrolled patients were stratified by age: old-old (≥80 years), young-old (65-80 years) and younger (<65 years). The primary outcomes were stroke recurrence and moderate to severe bleeding within 90 days, respectively. RESULTS Of all the 6412 patients, 406 (6.3%) were old-old, 2755 (43.0%) were young-old and 3251 (50.7%) were younger. Old-old patients were associated with higher composite vascular events (HR 1.41, 95% CI 1.00 to 1.98, p=0.048), disabling stroke (OR 2.43, 95% CI 1.52 to 3.88, p=0.0002), severe or moderate bleeding (HR 8.40, 95% CI 1.95 to 36.21, p=0.004) and mortality (HR 7.56, 95% CI 2.23 to 25.70, p=0.001) within 90 days. Ticagrelor-aspirin group was associated with lower risks of stroke recurrence within 90 days in younger patients (HR 0.68, 95% CI 0.51 to 0.91, p=0.008), which was no differences in old-old patients. CONCLUSION Elderly patients aged over 80 in CHANCE-2 trial had higher risks of composite vascular events, disabling stroke, severe or moderate bleeding and mortality within 90 days. Genotype-guided DAPT might not be as effective in old-old patients as in younger ones. TRIAL REGISTRATION NUMBER NCT04078737.
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Affiliation(s)
- Xinmiao Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Qin Xu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinxi Lin
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Weifeng Chen
- Department of Neurology, Xingyang People's Hospital, Henan, China
| | - Xuhai Gong
- Daqing Oilfield General Hospital, Daqing, Heilongjiang, China
| | - Jianhua Li
- The First Hospital of Fangshan District, Beijing, China
| | | | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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11
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Vacek A, Mair G, White P, Bath PM, Muir KW, Al-Shahi Salman R, Martin C, Dye D, Chappell FM, von Kummer R, Macleod M, Sprigg N, Wardlaw JM. Evaluating artificial intelligence software for delineating hemorrhage extent on CT brain imaging in stroke: AI delineation of ICH on CT. J Stroke Cerebrovasc Dis 2024; 33:107512. [PMID: 38007987 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/25/2023] [Accepted: 11/21/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND The extent and distribution of intracranial hemorrhage (ICH) directly affects clinical management. Artificial intelligence (AI) software can detect and may delineate ICH extent on brain CT. We evaluated e-ASPECTS software (Brainomix Ltd.) performance for ICH delineation. METHODS We qualitatively assessed software delineation of ICH on CT using patients from six stroke trials. We assessed hemorrhage delineation in five compartments: lobar, deep, posterior fossa, intraventricular, extra-axial. We categorized delineation as excellent, good, moderate, or poor. We assessed quality of software delineation with number of affected compartments in univariate analysis (Kruskall-Wallis test) and ICH location using logistic regression (dependent variable: dichotomous delineation categories 'excellent-good' versus 'moderate-poor'), and report odds ratios (OR) and 95 % confidence intervals (95 %CI). RESULTS From 651 patients with ICH (median age 75 years, 53 % male), we included 628 with assessable CTs. Software delineation of ICH extent was 'excellent' in 189/628 (30 %), 'good' in 255/628 (41 %), 'moderate' in 127/628 (20 %), and 'poor' in 57/628 cases (9 %). The quality of software delineation of ICH was better when fewer compartments were affected (Z = 3.61-6.27; p = 0.0063). Software delineation of ICH extent was more likely to be 'excellent-good' quality when lobar alone (OR = 1.56, 95 %CI = 0.97-2.53) but 'moderate-poor' with any intraventricular (OR = 0.56, 95 %CI = 0.39-0.81, p = 0.002) or any extra-axial (OR = 0.41, 95 %CI = 0.27-0.62, p<0.001) extension. CONCLUSIONS Delineation of ICH extent on stroke CT scans by AI software was excellent or good in 71 % of cases but was more likely to over- or under-estimate extent when ICH was either more extensive, intraventricular, or extra-axial.
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Affiliation(s)
- Adam Vacek
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
| | - Grant Mair
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK.
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Keith W Muir
- School of Psychology & Neuroscience, University of Glasgow, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
| | - Chloe Martin
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
| | - David Dye
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
| | - Francesca M Chappell
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
| | - Rüdiger von Kummer
- Department of Neuroradiology, University Hospital, Technische Universität Dresden, Germany
| | - Malcolm Macleod
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
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12
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Gao Y, Chen W, Pan Y, Jing J, Wang C, Johnston SC, Amarenco P, Bath PM, Jiang L, Yang Y, Wang T, Han S, Meng X, Lin J, Zhao X, Liu L, Zhao J, Li Y, Zang Y, Zhang S, Yang H, Yang J, Wang Y, Li D, Wang Y, Liu D, Kang G, Wang Y, Wang Y. Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke. N Engl J Med 2023; 389:2413-2424. [PMID: 38157499 DOI: 10.1056/nejmoa2309137] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Dual antiplatelet treatment has been shown to lower the risk of recurrent stroke as compared with aspirin alone when treatment is initiated early (≤24 hours) after an acute mild stroke. The effect of clopidogrel plus aspirin as compared with aspirin alone administered within 72 hours after the onset of acute cerebral ischemia from atherosclerosis has not been well studied. METHODS In 222 hospitals in China, we conducted a double-blind, randomized, placebo-controlled, two-by-two factorial trial involving patients with mild ischemic stroke or high-risk transient ischemic attack (TIA) of presumed atherosclerotic cause who had not undergone thrombolysis or thrombectomy. Patients were randomly assigned, in a 1:1 ratio, within 72 hours after symptom onset to receive clopidogrel (300 mg on day 1 and 75 mg daily on days 2 to 90) plus aspirin (100 to 300 mg on day 1 and 100 mg daily on days 2 to 21) or matching clopidogrel placebo plus aspirin (100 to 300 mg on day 1 and 100 mg daily on days 2 to 90). There was no interaction between this component of the factorial trial design and a second part that compared immediate with delayed statin treatment (not reported here). The primary efficacy outcome was new stroke, and the primary safety outcome was moderate-to-severe bleeding - both assessed within 90 days. RESULTS A total of 6100 patients were enrolled, with 3050 assigned to each trial group. TIA was the qualifying event for enrollment in 13.1% of the patients. A total of 12.8% of the patients were assigned to a treatment group no more than 24 hours after stroke onset, and 87.2% were assigned after 24 hours and no more than 72 hours after stroke onset. A new stroke occurred in 222 patients (7.3%) in the clopidogrel-aspirin group and in 279 (9.2%) in the aspirin group (hazard ratio, 0.79; 95% confidence interval [CI], 0.66 to 0.94; P = 0.008). Moderate-to-severe bleeding occurred in 27 patients (0.9%) in the clopidogrel-aspirin group and in 13 (0.4%) in the aspirin group (hazard ratio, 2.08; 95% CI, 1.07 to 4.04; P = 0.03). CONCLUSIONS Among patients with mild ischemic stroke or high-risk TIA of presumed atherosclerotic cause, combined clopidogrel-aspirin therapy initiated within 72 hours after stroke onset led to a lower risk of new stroke at 90 days than aspirin therapy alone but was associated with a low but higher risk of moderate-to-severe bleeding. (Funded by the National Natural Science Foundation of China and others; INSPIRES ClinicalTrials.gov number, NCT03635749.).
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Affiliation(s)
- Ying Gao
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Weiqi Chen
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yuesong Pan
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jing Jing
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Chunjuan Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - S Claiborne Johnston
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Pierre Amarenco
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Philip M Bath
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Lingling Jiang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yingying Yang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Tingting Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Shangrong Han
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xia Meng
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jinxi Lin
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xingquan Zhao
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Liping Liu
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jinguo Zhao
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Ying Li
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yingzhuo Zang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Shuo Zhang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Hongqin Yang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jianbo Yang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yuanwei Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Dali Li
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yanxia Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Dongqi Liu
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Guangming Kang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yongjun Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yilong Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
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Chen C, Lin Y, Liu F, Chen X, Billot L, Li Q, Guo Y, Liu H, Si L, Ouyang M, Zhang C, Arima H, Bath PM, Ford GA, Robinson T, Sandset EC, Saver JL, Sprigg N, van der Worp HB, Liu G, Song L, Yang J, Li G, Anderson CS. Update on the INTEnsive ambulance-delivered blood pressure Reduction in hyper-ACute stroke Trial (INTERACT4): progress and baseline features in 2053 participants. Trials 2023; 24:817. [PMID: 38124205 PMCID: PMC10731692 DOI: 10.1186/s13063-023-07861-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND AND AIMS Uncertainty persists over the effects of blood pressure (BP) lowering in acute stroke. The INTEnsive ambulance-delivered blood pressure Reduction in hyper-Acute stroke Trial (INTERACT4) aims to determine efficacy and safety of hyperacute intensive BP lowering in patients with suspected acute stroke. Given concerns over the safety of this treatment in the pre-hospital setting, particularly in relation to patients with intracerebral hemorrhage, we provide an update on progress of the study and profile of participants to date. METHODS INTERACT4 is an ongoing multicentre, ambulance-delivered, randomized, open-label, blinded endpoint trial of pre-hospital BP lowering in patients with suspected acute stroke and elevated BP in China. Patients are randomized via a mobile phone digital system to intensive (target systolic BP [SBP] <140mmHg within 30 min) or guideline-recommended BP management. Primary outcome is an ordinal analysis of the full range of scores on the modified Rankin scale scores at 90 days. RESULTS Between March 2020 and April 2023, 2053 patients (mean age 70 years, female 39%) were recruited with a mean BP 178/98 mmHg in whom 45% have a diagnosis of primary intracerebral hemorrhage upon arrival at hospital. At the time of presentation to hospital, the mean SBP was 160 and 170mmHg in the intensive and control groups (Δ10 mmHg), respectively. The independent data and safety monitoring board has not identified any safety concerns and recommended continuation of the trial. The sample size was reduced from 3116 to 2320 after meetings in August 2022 as the stroke mimic rate was persistently lower than initially estimated (6% vs 30%). The study is expected to be completed in late 2023 and the results announced in May 2024. CONCLUSIONS INTERACT4 is on track to provide reliable evidence of the effectiveness of ambulance-delivered intensive BP lowering in patients with suspected acute stroke. TRIAL REGISTRATION ClinicalTrials.gov NCT03790800 ; registered on 2 January 2019. Chinese Trial Registry ChCTR1900020534 , registered on 7 January 2019.
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Affiliation(s)
- Chen Chen
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, 1800, Yuntai Road, Shanghai, 200120, China
- The George Institute for Global Health, Faculty of Medicine, UNSW, PO Box M201, Missenden Rd., Sydney, NSW, 2050, Australia
- The George Institute for Global Health, Room 011, Unit 2, Tayuan Diplomatic Office Building, No. 14 Liangmahe Nan Lu, Chaoyang District, Beijing, 100600, China
| | - Yapeng Lin
- Department of Neurology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
- International Clinical Research Centre, Chengdu Medical College, Chengdu, China
| | - Feifeng Liu
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, 1800, Yuntai Road, Shanghai, 200120, China
| | - Xiaoying Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, PO Box M201, Missenden Rd., Sydney, NSW, 2050, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, UNSW, PO Box M201, Missenden Rd., Sydney, NSW, 2050, Australia
| | - Qiang Li
- The George Institute for Global Health, Faculty of Medicine, UNSW, PO Box M201, Missenden Rd., Sydney, NSW, 2050, Australia
| | - Yiija Guo
- Beijing Municipal Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China
- Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Hueiming Liu
- The George Institute for Global Health, Faculty of Medicine, UNSW, PO Box M201, Missenden Rd., Sydney, NSW, 2050, Australia
| | - Lei Si
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
- Translational Health Research Institute, Western Sydney University, Penrith, Australia
| | - Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, UNSW, PO Box M201, Missenden Rd., Sydney, NSW, 2050, Australia
| | - Chunfang Zhang
- Shanghai Pudong New Area Medical Emergency Centre, Shanghai, China
| | - Hisatomi Arima
- The George Institute for Global Health, Faculty of Medicine, UNSW, PO Box M201, Missenden Rd., Sydney, NSW, 2050, Australia
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, UK
| | - Thompson Robinson
- College of Life Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Norwegian Air Ambulance Foundation, Oslo, Norway
| | | | - Nikola Sprigg
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Gang Liu
- Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Lili Song
- The George Institute for Global Health, Faculty of Medicine, UNSW, PO Box M201, Missenden Rd., Sydney, NSW, 2050, Australia
- The George Institute for Global Health, Room 011, Unit 2, Tayuan Diplomatic Office Building, No. 14 Liangmahe Nan Lu, Chaoyang District, Beijing, 100600, China
| | - Jie Yang
- Department of Neurology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# W. Sec 2, 1st Ring Road, Chengdu, China
- Sichuan Provincial Key Laboratory for Human Disease Gene Study, Chengdu, China
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, 1800, Yuntai Road, Shanghai, 200120, China.
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, UNSW, PO Box M201, Missenden Rd., Sydney, NSW, 2050, Australia.
- The George Institute for Global Health, Room 011, Unit 2, Tayuan Diplomatic Office Building, No. 14 Liangmahe Nan Lu, Chaoyang District, Beijing, 100600, China.
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14
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Kadir RRA, Rakkar K, Othman OA, Sprigg N, Bath PM, Bayraktutan U. Analysis of endothelial progenitor cell subtypes as clinical biomarkers for elderly patients with ischaemic stroke. Sci Rep 2023; 13:21843. [PMID: 38071215 PMCID: PMC10710409 DOI: 10.1038/s41598-023-48907-7] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/01/2023] [Indexed: 12/18/2023] Open
Abstract
Endothelial progenitor cells (EPCs), expressing markers for stemness (CD34), immaturity (CD133) and endothelial maturity (KDR), may determine the extent of post-stroke vascular repair. Given the prevalence of stroke in elderly, this study explored whether variations in plasmatic availability of certain EPC subtypes could predict the severity and outcome of disease in older patients. Blood samples were collected from eighty-one consented patients (≥ 65 years) at admission and days 7, 30 and 90 post-stroke. EPCs were counted with flow cytometry. Stroke severity and outcome were assessed using the National Institutes of Health Stroke Scale, Barthel Index and modified Rankin Scale. The levels of key elements known to affect EPC characteristics were measured by ELISA. Diminished total antioxidant capacity and CD34 + KDR + and CD133 + KDR + counts in early phases of stroke were associated with disease severity and worse functional outcome at day 90 post-stroke. Baseline levels of angiogenic agent PDGF-BB, but not VEGF, positively correlated with CD34 + KDR + numbers at day 90. Baseline LDL-cholesterol levels were inversely correlated with CD34 + KDR+, CD133 + KDR + and CD34 + CD133 + KDR + numbers at day 90. Close correlation between baseline CD34 + KDR + and CD133 + KDR + counts and the outcome of stroke proposes these particular EPC subtypes as potential prognostic markers for ischaemic stroke.
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Affiliation(s)
- Rais Reskiawan A Kadir
- Academic Unit of Mental Health and Clinical Neuroscience, The University of Nottingham, Nottingham, UK
| | - Kamini Rakkar
- Academic Unit of Mental Health and Clinical Neuroscience, The University of Nottingham, Nottingham, UK
| | - Othman A Othman
- Academic Unit of Mental Health and Clinical Neuroscience, The University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Academic Unit of Mental Health and Clinical Neuroscience, The University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Academic Unit of Mental Health and Clinical Neuroscience, The University of Nottingham, Nottingham, UK
| | - Ulvi Bayraktutan
- Academic Unit of Mental Health and Clinical Neuroscience, The University of Nottingham, Nottingham, UK.
- Academic Unit of Mental Health and Clinical Neuroscience, Queens Medical Centre, School of Medicine, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
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15
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Dixon M, Appleton JP, Siriwardena AN, Williams J, Bath PM. A systematic review of ambulance service-based randomised controlled trials in stroke. Neurol Sci 2023; 44:4363-4378. [PMID: 37405524 PMCID: PMC10641071 DOI: 10.1007/s10072-023-06910-w] [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: 01/02/2023] [Accepted: 06/12/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Treatment for stroke is time-dependent, and ambulance services play a vital role in the early recognition, assessment and transportation of stroke patients. Innovations which begin in ambulance services to expedite delivery of treatments for stroke are developing. However, research delivery in ambulance services is novel, developing and not fully understood. AIMS To synthesise literature encompassing ambulance service-based randomised controlled interventions for acute stroke with consideration to the characteristics of the type of intervention, consent modality, time intervals and issues unique to research delivery in ambulance services. Online searches of MEDLINE, EMBASE, Web of Science, CENTRAL and WHO IRCTP databases and hand searches identified 15 eligible studies from 538. Articles were heterogeneous in nature and meta-analysis was partially available as 13 studies reported key time intervals, but terminology varied. Randomised interventions were evident across all points of contact with ambulance services: identification of stroke during the call for help, higher dispatch priority assigned to stroke, on-scene assessment and clinical interventions, direct referral to comprehensive stroke centres and definitive care delivery at scene. Consent methods ranged between informed patient, waiver and proxy modalities with country-specific variation. Challenges unique to the prehospital setting comprise the geographical distribution of ambulance resources, low recruitment rates, prolonged recruitment phases, management of investigational medicinal product and incomplete datasets. CONCLUSION Research opportunities exist across all points of contact between stroke patients and ambulance services, but randomisation and consent remain novel. Early collaboration and engagement between trialists and ambulance services will alleviate some of the complexities reported. REGISTRATION NUMBER PROSPERO 2018CRD42018075803.
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Affiliation(s)
- Mark Dixon
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Julia Williams
- Department of Paramedic Science, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK.
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.
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16
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Dixon M, Williams J, Bath PM. Challenges and Experiences in Multicenter Prehospital Stroke Research: Narrative Data from the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial-2 (RIGHT-2). PREHOSP EMERG CARE 2023:1-9. [PMID: 38019218 DOI: 10.1080/10903127.2023.2287171] [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: 07/10/2023] [Accepted: 11/20/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Ambulance services are increasingly research active and the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) is the largest United Kingdom (UK) ambulance-based randomized controlled trial in stroke. We explore the complexities and challenges encountered during RIGHT-2. METHODS Five hundred and sixteen of 1487 paramedics from eight UK ambulance services serving 54 comprehensive or primary stroke care centers screened and consented 1149 patients presenting within 4 h of FAST-positive stroke and with systolic blood pressure >120 mmHg; participants were randomized to treatment with transdermal glyceryl trinitrate versus sham patch in the ambulance. KEY FINDINGS Working with multiple ambulance services demanded flexibility in the trial protocol to overcome variation in operating procedures to ensure deliverability. Many paramedics are novice researchers, and research concepts and practices are emerging including consent strategies in emergency stroke care. Regional variation in hospital participation and hours/days of operation presented paramedics with additional considerations prior to patient recruitment. The working hours of hospital research staff often do not reflect the 24/7 nature of ambulance work, which challenged deliverability until trial processes became fully embedded. Management of investigational medicinal product between ambulance stations, in-transit when on ambulance vehicles and on handover at hospital, necessitated an in-depth review to maintain accountability. CONCLUSION RIGHT-2 demonstrated that although there are significant practical challenges to conducting multicenter ambulance-based research in a time-dependent environment, careful planning and management facilitated delivery. Lessons learned here will help inform the design and conduct of future ambulance-based trials.
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Affiliation(s)
- Mark Dixon
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre, Nottingham, UK
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Julia Williams
- Department of Paramedic Science, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre, Nottingham, UK
- Stroke, Acute Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
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17
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Wang C, Jia W, Jing J, Meng X, Wang A, Xu Q, Zhang X, Pan Y, Xie X, Johnston SC, Bath PM, Lin J, Jiang Y, Li H, Wang Y, Zhao X, Liu L, Li Z, Wang Y. Ticagrelor Versus Clopidogrel in Minor Stroke or Transient Ischemic Attack With Intracranial Artery Stenosis: A Post Hoc Analysis of CHANCE-2. J Am Heart Assoc 2023; 12:e031611. [PMID: 37889172 PMCID: PMC10727397 DOI: 10.1161/jaha.123.031611] [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: 08/01/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023]
Abstract
Background This study aimed to investigate the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in Chinese patients by the presence and clinical presentation of intracranial artery stenosis (ICAS) using randomized trial data from the CHANCE-2 (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events-II) trial. Methods and Results A total of 6412 patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles were randomized to either the ticagrelor-aspirin or clopidogrel-aspirin group. Patients without imaging of the intracranial artery were excluded from the nonprespecified subgroup analysis of CHANCE-2. All patients included were classified into the following groups: without ICAS, symptomatic ICAS, or asymptomatic ICAS. The primary efficacy outcome was new strokes within 90 days. There were 5893 patients (median age, 64.8 years; 33.9% women) included, and 172 (4.9%), 171 (10.5%), and 57 (7.7%) cases of new strokes occurred within 90 days in the without ICAS, with symptomatic ICAS, and with asymptomatic ICAS groups, respectively. Ticagrelor-aspirin was associated with reduced risk of new stroke in patients without ICAS (62 [3.5%] versus 110 [6.3%]; hazard ratio [HR], 0.57 [95% CI, 0.41-0.78]) but not in those with symptomatic ICAS (HR, 0.77 [95% CI, 0.56-1.05]) or in those with asymptomatic ICAS (HR, 0.77 [95% CI, 0.43-1.38]) compared with clopidogrel-aspirin (P for interaction=0.14). There were no significant differences in the proportion of severe or moderate bleeding events among different ICAS groups. Conclusions Patients without ICAS received a significantly greater benefit from ticagrelor-aspirin than clopidogrel-aspirin after minor ischemic stroke or transient ischemic attack, and there was no statistically significant difference between treatments in patients with symptomatic ICAS or asymptomatic ICAS. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04078737.
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Affiliation(s)
- Chunjuan Wang
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical SciencesBeijingChina
- National Center for Healthcare Quality Management in Neurological DiseasesBeijingChina
| | - Weili Jia
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Jing Jing
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xia Meng
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Anxin Wang
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Qin Xu
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xinmiao Zhang
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Yuesong Pan
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xuewei Xie
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | | | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical NeuroscienceUniversity of NottinghamNottinghamUnited Kingdom
| | - Jinxi Lin
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Yong Jiang
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Hao Li
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Yilong Wang
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xingquan Zhao
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Liping Liu
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Zixiao Li
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical SciencesBeijingChina
- National Center for Healthcare Quality Management in Neurological DiseasesBeijingChina
- Chinese Institute for Brain ResearchBeijingChina
| | - Yongjun Wang
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- Advanced Innovation Center for Human Brain ProtectionCapital Medical UniversityBeijingChina
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical SciencesBeijingChina
- Chinese Institute for Brain ResearchBeijingChina
- Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of SciencesShanghaiChina
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18
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Eilertsen H, Menon CS, Law ZK, Chen C, Bath PM, Steiner T, Desborough MJ, Sandset EC, Sprigg N, Al-Shahi Salman R. Haemostatic therapies for stroke due to acute, spontaneous intracerebral haemorrhage. Cochrane Database Syst Rev 2023; 10:CD005951. [PMID: 37870112 PMCID: PMC10591281 DOI: 10.1002/14651858.cd005951.pub5] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Outcome after acute spontaneous (non-traumatic) intracerebral haemorrhage (ICH) is influenced by haematoma volume. ICH expansion occurs in about 20% of people with acute ICH. Early haemostatic therapy might improve outcome by limiting ICH expansion. This is an update of a Cochrane Review first published in 2006, and last updated in 2018. OBJECTIVES To examine 1. the effects of individual classes of haemostatic therapies, compared with placebo or open control, in adults with acute spontaneous ICH, and 2. the effects of each class of haemostatic therapy according to the use and type of antithrombotic drug before ICH onset. SEARCH METHODS We searched the Cochrane Stroke Trials Register, CENTRAL (2022, Issue 8), MEDLINE Ovid, and Embase Ovid on 12 September 2022. To identify further published, ongoing, and unpublished randomised controlled trials (RCTs), we scanned bibliographies of relevant articles and searched international registers of RCTs in September 2022. SELECTION CRITERIA We included RCTs of any haemostatic intervention (i.e. procoagulant treatments such as clotting factor concentrates, antifibrinolytic drugs, platelet transfusion, or agents to reverse the action of antithrombotic drugs) for acute spontaneous ICH, compared with placebo, open control, or an active comparator. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was death/dependence (modified Rankin Scale (mRS) 4 to 6) by day 90. Secondary outcomes were ICH expansion on brain imaging after 24 hours, all serious adverse events, thromboembolic adverse events, death from any cause, quality of life, mood, cognitive function, Barthel Index score, and death or dependence measured on the Extended Glasgow Outcome Scale by day 90. MAIN RESULTS We included 20 RCTs involving 4652 participants: nine RCTs of recombinant activated factor VII (rFVIIa) versus placebo/open control (1549 participants), eight RCTs of antifibrinolytic drugs versus placebo/open control (2866 participants), one RCT of platelet transfusion versus open control (190 participants), and two RCTs of prothrombin complex concentrates (PCC) versus fresh frozen plasma (FFP) (47 participants). Four (20%) RCTs were at low risk of bias in all criteria. For rFVIIa versus placebo/open control for spontaneous ICH with or without surgery there was little to no difference in death/dependence by day 90 (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.05; 7 RCTs, 1454 participants; low-certainty evidence). We found little to no difference in ICH expansion between groups (RR 0.81, 95% CI 0.56 to 1.16; 4 RCTs, 220 participants; low-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 0.81, 95% CI 0.30 to 2.22; 2 RCTs, 87 participants; very low-certainty evidence; death from any cause: RR 0.78, 95% CI 0.56 to 1.08; 8 RCTs, 1544 participants; moderate-certainty evidence). For antifibrinolytic drugs versus placebo/open control for spontaneous ICH, there was no difference in death/dependence by day 90 (RR 1.00, 95% CI 0.93 to 1.07; 5 RCTs, 2683 participants; high-certainty evidence). We found a slight reduction in ICH expansion with antifibrinolytic drugs for spontaneous ICH compared to placebo/open control (RR 0.86, 95% CI 0.76 to 0.96; 8 RCTs, 2866 participants; high-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 1.02, 95% CI 0.75 to 1.39; 4 RCTs, 2599 participants; high-certainty evidence; death from any cause: RR 1.02, 95% CI 0.89 to 1.18; 8 RCTs, 2866 participants; high-certainty evidence). There was little to no difference in quality of life, mood, or cognitive function (quality of life: mean difference (MD) 0, 95% CI -0.03 to 0.03; 2 RCTs, 2349 participants; mood: MD 0.30, 95% CI -1.98 to 2.57; 2 RCTs, 2349 participants; cognitive function: MD -0.37, 95% CI -1.40 to 0.66; 1 RCTs, 2325 participants; all high-certainty evidence). Platelet transfusion likely increases death/dependence by day 90 compared to open control for antiplatelet-associated ICH (RR 1.29, 95% CI 1.04 to 1.61; 1 RCT, 190 participants; moderate-certainty evidence). We found little to no difference in ICH expansion between groups (RR 1.32, 95% CI 0.91 to 1.92; 1 RCT, 153 participants; moderate-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 1.46, 95% CI 0.98 to 2.16; 1 RCT, 190 participants; death from any cause: RR 1.42, 95% CI 0.88 to 2.28; 1 RCT, 190 participants; both moderate-certainty evidence). For PCC versus FFP for anticoagulant-associated ICH, the evidence was very uncertain about the effect on death/dependence by day 90, ICH expansion, all serious adverse events, and death from any cause between groups (death/dependence by day 90: RR 1.21, 95% CI 0.76 to 1.90; 1 RCT, 37 participants; ICH expansion: RR 0.54, 95% CI 0.23 to 1.22; 1 RCT, 36 participants; all serious adverse events: RR 0.27, 95% CI 0.02 to 3.74; 1 RCT, 5 participants; death from any cause: RR 0.49, 95% CI 0.16 to 1.56; 2 RCTs, 42 participants; all very low-certainty evidence). AUTHORS' CONCLUSIONS In this updated Cochrane Review including 20 RCTs involving 4652 participants, rFVIIa likely results in little to no difference in reducing death or dependence after spontaneous ICH with or without surgery; antifibrinolytic drugs result in little to no difference in reducing death or dependence after spontaneous ICH, but result in a slight reduction in ICH expansion within 24 hours; platelet transfusion likely increases death or dependence after antiplatelet-associated ICH; and the evidence is very uncertain about the effect of PCC compared to FFP on death or dependence after anticoagulant-associated ICH. Thirteen RCTs are ongoing and are likely to increase the certainty of the estimates of treatment effect.
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Affiliation(s)
- Helle Eilertsen
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Zhe Kang Law
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Chen Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, Australia
- The George Institute for Global Health, Beijing, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Philip M Bath
- Stroke Medicine, University of Nottingham, Nottingham, UK
| | - Thorsten Steiner
- Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Jr Desborough
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital Ullevål, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Nikola Sprigg
- Stroke Medicine, University of Nottingham, Nottingham, UK
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Woodhouse LJ, Montgomery AA, Pocock S, James M, Ranta A, Bath PM. Optimising the analysis of vascular prevention trials: Re-Assessment of the TARDIS trial, the first prevention trial to adopt an ordinal primary outcome measure. Contemp Clin Trials Commun 2023; 35:101186. [PMID: 37745289 PMCID: PMC10517366 DOI: 10.1016/j.conctc.2023.101186] [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: 11/23/2021] [Revised: 05/19/2023] [Accepted: 07/03/2023] [Indexed: 09/26/2023] Open
Abstract
Background Ordinalised vascular outcomes incorporating event severity are more informative than binary outcomes that just include event numbers. The TARDIS trial was the first vascular prevention study to use an ordinalised vascular outcome as its primary efficacy and safety measures and collected severity information for other vascular events. Methods TARDIS was an international prospective randomised open-label blinded-endpoint trial assessing one month of intensive versus guideline antiplatelet therapy in patients with acute non-cardioembolic stroke or TIA. Vascular events and their severity were recorded up to final follow-up at 90 days post randomisation. For each outcome, statistical techniques compared ordinal/continuous (10 models) and dichotomous (5 models) analyses; results were then ranked with the smallest p-value being given the smallest rank. Outcomes were also assessed within the pre-defined subgroup of participants with mild stroke (NIHSS≤3), or TIA recruited within 24 h. Results Ordinal versions of vascular event outcomes were created in 3096 participants for stroke, myocardial infarction, major cardiac events, bleeding events, serious adverse events and venous thromboembolism (VTE), with 32 outcomes being created overall (29 in the subgroup population due to the absence of VTE events). Overall, the tests run on ordinal outcomes tended to rank higher than tests performed on binary outcomes. 764 (24.7%) participants were recruited within 24 h of a mild stroke/TIA; again, tests run on ordinal outcomes ranked higher. Conclusions In TARDIS, tests performed on ordinal vascular outcomes tended to attain a higher rank than those performed on binary outcomes. Trial registration ISRCTN47823388.
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Affiliation(s)
- Lisa J. Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, D Floor South Block, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Stuart Pocock
- London School of Hygiene & Tropical Medicine, Keppel St., London, WC1E 7HT, UK
| | - Marilyn James
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Anna Ranta
- Department of Medicine, University of Otago Wellington, Wellington, 6242, New Zealand
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, D Floor South Block, Queen's Medical Centre, Nottingham, NG7 2UH, UK
- Stroke, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - for the TARDIS Investigators
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, D Floor South Block, Queen's Medical Centre, Nottingham, NG7 2UH, UK
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
- London School of Hygiene & Tropical Medicine, Keppel St., London, WC1E 7HT, UK
- Department of Medicine, University of Otago Wellington, Wellington, 6242, New Zealand
- Stroke, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
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Labeit B, Michou E, Hamdy S, Trapl-Grundschober M, Suntrup-Krueger S, Muhle P, Bath PM, Dziewas R. The assessment of dysphagia after stroke: state of the art and future directions. Lancet Neurol 2023; 22:858-870. [PMID: 37596008 DOI: 10.1016/s1474-4422(23)00153-9] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 03/10/2023] [Accepted: 04/14/2023] [Indexed: 08/20/2023]
Abstract
Dysphagia is a major complication following an acute stroke that affects the majority of patients. Clinically, dysphagia after stroke is associated with increased risk of aspiration pneumonia, malnutrition, mortality, and other adverse functional outcomes. Pathophysiologically, dysphagia after stroke is caused by disruption of an extensive cortical and subcortical swallowing network. The screening of patients for dysphagia after stroke should be provided as soon as possible, starting with simple water-swallowing tests at the bedside or more elaborate multi-consistency protocols. Subsequently, a more detailed examination, ideally with instrumental diagnostics such as flexible endoscopic evaluation of swallowing or video fluoroscopy is indicated in some patients. Emerging diagnostic procedures, technical innovations in assessment tools, and digitalisation will improve diagnostic accuracy in the future. Advances in the diagnosis of dysphagia after stroke will enable management based on individual patterns of dysfunction and predisposing risk factors for complications. Progess in dysphagia rehabilitation are essential to reduce mortality and improve patients' quality of life after a stroke.
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Affiliation(s)
- Bendix Labeit
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, Germany; Institute for Biomagnetism and Biosignal Analysis, University Hospital Muenster, Muenster, Germany.
| | - Emilia Michou
- Department of Speech Language Therapy, School of Health Rehabilitation Sciences, University of Patras, Patras, Achaia, Greece; Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Shaheen Hamdy
- Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | | | - Sonja Suntrup-Krueger
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, Germany
| | - Paul Muhle
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Muenster, Germany; Institute for Biomagnetism and Biosignal Analysis, University Hospital Muenster, Muenster, Germany
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Rainer Dziewas
- Department of Neurology and Neurorehabilitation, Klinikum Osnabrueck-Academic Teaching Hospital of the WWU Muenster, Osnabrueck, Germany
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21
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Xie X, Jing J, Meng X, Claiborne Johnston S, Bath PM, Li Z, Zhao X, Liu L, Wang Y, Xu Q, Wang A, Jiang Y, Li H, Wang Y. Dual Antiplatelet Therapies and Causes in Minor Stroke or Transient Ischemic Attack: A Prespecified Analysis in the CHANCE-2 Trial. Stroke 2023; 54:2241-2250. [PMID: 37548009 DOI: 10.1161/strokeaha.122.042233] [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: 12/05/2022] [Accepted: 04/25/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND It is unclear whether patients with different stroke/transient ischemic attack etiologies benefit differently from gene-directed dual antiplatelet therapy. This study explored the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in transient ischemic attack or minor stroke with different causes in the CHANCE-2 trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events-II). METHODS This was a prespecified analysis of the CHANCE-2 trial, which enrolled 6412 patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles. Patients with centralized evaluation of TOAST (Trial of ORG 10172 in Acute Stroke Treatment) classification of large-artery atherosclerosis, small-vessel occlusion, and stroke of undetermined cause were included. The primary efficacy outcome was new stroke, and the primary safety outcome was severe or moderate bleeding, both within 90 days. Cox proportional hazards models were used to assess the interaction of TOAST classification with the effects of dual antiplatelet therapy with ticagrelor-aspirin versus clopidogrel-aspirin. RESULTS A total of 6336 patients were included in this study. In patients administered ticagrelor-aspirin and clopidogrel-aspirin, respectively, stroke recurred in 85 (9.8%) and 88 (10.7%) patients with large-artery atherosclerosis (hazard ratio, 0.86 [95% CI, 0.63-1.18]; P=0.34); 32 (3.6%) and 61 (7.0%) patients with small-vessel occlusion (hazard ratio, 0.51 [95% CI, 0.33-0.79]; P=0.002); and 68 (4.8%) and 87 (5.9%) patients with stroke of undetermined cause (hazard ratio, 0.80 [95% CI, 0.58-1.10]; P=0.17), with P=0.08 for the treatment×cause subtype interaction effect. There were no significant differences in severe or moderate bleeding events in patients with different cause and different treatment. CONCLUSIONS In this prespecified analysis of the CHANCE-2 trial, the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in preventing new stroke were consistent in patients with different causes. The influence of stroke cause on benefit of gene-guided antiplatelet therapy should be explored by further trials. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04078737.
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Affiliation(s)
- Xuewei Xie
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Jing Jing
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Tiantan Neuroimaging Center of Excellence, Beijing, China (J.J.)
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | | | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.)
| | - Zixiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Xingquan Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Liping Liu
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Qin Xu
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
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22
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Woodhouse LJ, Appleton JP, Christensen H, Dineen RA, England TJ, James M, Krishnan K, Montgomery AA, Ranta A, Robinson TG, Sprigg N, Bath PM. Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia. Sci Rep 2023; 13:11717. [PMID: 37474599 PMCID: PMC10359249 DOI: 10.1038/s41598-023-38474-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 07/09/2023] [Indexed: 07/22/2023] Open
Abstract
Intensive antiplatelet therapy did not reduce recurrent stroke/transient ischaemic attack (TIA) events as compared with guideline treatment in the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial, but did increase the frequency and severity of bleeding. In this pre-specified analysis, we investigated predictors of bleeding and the association of bleeding with outcome. TARDIS was an international prospective randomised open-label blinded-endpoint trial in participants with ischaemic stroke or TIA within 48 h of onset. Participants were randomised to 30 days of intensive antiplatelet therapy (aspirin, clopidogrel, dipyridamole) or guideline-based therapy (either clopidogrel alone or combined aspirin and dipyridamole). Bleeding was defined using the International Society on Thrombosis and Haemostasis five-level ordered categorical scale: fatal, major, moderate, minor, none. Of 3,096 participants, bleeding severity was: fatal 0.4%, major 1.5%, moderate 1.2%, minor 11.4%, none 85.5%. Major/fatal bleeding was increased with intensive as compared with guideline therapy: 39 vs. 17 participants, adjusted hazard ratio 2.21, 95% CI 1.24-3.93, p = 0.007. Bleeding events diverged between treatment groups in the 8-35 day period but not in the 0-7 or 36-90 day epochs. In multivariate analysis more, and more severe, bleeding events were seen with increasing age, female sex, pre-morbid dependency, increased time to randomisation, prior major bleed, prior antiplatelet therapy and in those randomised to triple vs guideline antiplatelet therapy. More severe bleeding was associated with worse clinical outcomes across multiple physical, emotional and quality of life domains.Trial registration ISRCTN47823388 .
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Affiliation(s)
- Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Hanne Christensen
- Bispebjerg and Frederiksberg Hospital, Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - Rob A Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, School of Medicine, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Derby Stroke Centre, University Hospitals of Derby and Burton, Derby, DE22 3NE, UK
| | - Marilyn James
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
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23
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Mair G, White P, Bath PM, Muir K, Martin C, Dye D, Chappell F, von Kummer R, Macleod M, Sprigg N, Wardlaw JM. Accuracy of artificial intelligence software for CT angiography in stroke. Ann Clin Transl Neurol 2023; 10:1072-1082. [PMID: 37208850 PMCID: PMC10351662 DOI: 10.1002/acn3.51790] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/01/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE Software developed using artificial intelligence may automatically identify arterial occlusion and provide collateral vessel scoring on CT angiography (CTA) performed acutely for ischemic stroke. We aimed to assess the diagnostic accuracy of e-CTA by Brainomix™ Ltd by large-scale independent testing using expert reading as the reference standard. METHODS We identified a large clinically representative sample of baseline CTA from 6 studies that recruited patients with acute stroke symptoms involving any arterial territory. We compared e-CTA results with masked expert interpretation of the same scans for the presence and location of laterality-matched arterial occlusion and/or abnormal collateral score combined into a single measure of arterial abnormality. We tested the diagnostic accuracy of e-CTA for identifying any arterial abnormality (and in a sensitivity analysis compliant with the manufacturer's guidance that software only be used to assess the anterior circulation). RESULTS We include CTA from 668 patients (50% female; median: age 71 years, NIHSS 9, 2.3 h from stroke onset). Experts identified arterial occlusion in 365 patients (55%); most (343, 94%) involved the anterior circulation. Software successfully processed 545/668 (82%) CTAs. The sensitivity, specificity and diagnostic accuracy of e-CTA for detecting arterial abnormality were each 72% (95% CI = 66-77%). Diagnostic accuracy was non-significantly improved in a sensitivity analysis excluding occlusions from outside the anterior circulation (76%, 95% CI = 72-80%). INTERPRETATION Compared to experts, the diagnostic accuracy of e-CTA for identifying acute arterial abnormality was 72-76%. Users of e-CTA should be competent in CTA interpretation to ensure all potential thrombectomy candidates are identified.
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Affiliation(s)
- Grant Mair
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne Hospitals NHS TrustNewcastle upon TyneUK
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical NeuroscienceUniversity of NottinghamNottinghamUK
| | - Keith Muir
- Institute of Neuroscience & Psychology, University of GlasgowGlasgowUK
| | - Chloe Martin
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - David Dye
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | | | - Rüdiger von Kummer
- Department of NeuroradiologyUniversity Hospital, Technische Universität DresdenDresdenGermany
| | - Malcolm Macleod
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Nikola Sprigg
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne Hospitals NHS TrustNewcastle upon TyneUK
| | - Joanna M. Wardlaw
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
- UK Dementia Research Institute Centre at the University of EdinburghEdinburghUK
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24
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Desborough MJR, Al-Shahi Salman R, Stanworth SJ, Havard D, Woodhouse LJ, Craig J, Krishnan K, Brennan PM, Dineen RA, Coats TJ, Hepburn T, Bath PM, Sprigg N. Desmopressin for patients with spontaneous intracerebral haemorrhage taking antiplatelet drugs (DASH): a UK-based, phase 2, randomised, placebo-controlled, multicentre feasibility trial. Lancet Neurol 2023; 22:557-567. [PMID: 37353276 PMCID: PMC10284719 DOI: 10.1016/s1474-4422(23)00157-6] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND The risk of death from spontaneous intracerebral haemorrhage is increased for people taking antiplatelet drugs. We aimed to assess the feasibility of randomising patients on antiplatelet drug therapy with spontaneous intracerebral haemorrhage to desmopressin or placebo to reduce the antiplatelet drug effect. METHODS DASH was a phase 2, randomised, placebo-controlled, multicentre feasibility trial. Patients were recruited from ten acute stroke centres in the UK and were eligible if they had an intracerebral haemorrhage with stroke symptom onset within 24 h of randomisation, were aged 18 years or older, and were taking an antiplatelet drug. Participants were randomly assigned (1:1) to a single dose of intravenous desmopressin 20 μg or matching placebo. Treatment allocation was concealed from all staff and patients involved in the trial. The primary outcome was feasibility, which was measured as the number of eligible patients randomised and the proportion of eligible patients approached, and analysis was by intention to treat. The trial was prospectively registered with ISRCTN (reference ISRCTN67038373), and it is closed to recruitment. FINDINGS Between April 1, 2019, and March 31, 2022, 1380 potential participants were screened for eligibility. 176 (13%) participants were potentially eligible, of whom 57 (32%) were approached, and 54 (31%) consented and were subsequently recruited and randomly assigned to receive desmopressin (n=27) or placebo (n=27). The main reason for eligible patients not being recruited was the patient arriving out of hours (74 [61%] of 122 participants). The recruitment rate increased after the enrolment period was extended from 12 h to 24 h, but it was then impaired due to the COVID-19 pandemic. Of the 54 participants included in the analysis (mean age 76·4 years [SD 11·3]), most were male (36 [67%]) and White (50 [93%]). 53 (98%) of 54 participants received all of their allocated treatment (one participant assigned desmopressin only received part of the infusion). No participants were lost to follow-up or withdrew from the trial. Death or dependency on others for daily activities at day 90 (modified Rankin Scale score >4) occurred in six (22%) of 27 participants in the desmopressin group and ten (37%) of 27 participants in the placebo group. Serious adverse events occurred in 12 (44%) participants in the desmopressin group and 13 (48%) participants in the placebo group. The most common adverse events were expansion of the haemorrhagic stroke (four [15%] of 27 participants in the desmopressin group and six [22%] of 27 participants in the placebo group) and pneumonia (one [4%] of 27 participants in the desmopressin group and six [22%] of 27 participants in the placebo group). INTERPRETATION Our results show it is feasible to randomise patients with spontaneous intracerebral haemorrhage who are taking antiplatelet drugs to desmopressin or placebo. Our findings support the need for a definitive trial to determine if desmopressin improves outcomes in patients with intracerebral haemorrhage on antiplatelet drug therapy. FUNDING National Institute for Health Research.
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Affiliation(s)
- Michael J R Desborough
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
| | | | - Simon J Stanworth
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Diane Havard
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Jennifer Craig
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Kailash Krishnan
- Stroke, Medicine Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paul M Brennan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Robert A Dineen
- Radiological Sciences, University of Nottingham, Nottingham, UK; NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Tim J Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Trish Hepburn
- Mental Health and Clinical Neurosciences, and Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, UK; Stroke, Medicine Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Nottingham, UK; Stroke, Medicine Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Woodhouse LJ, Appleton JP, Ankolekar S, England TJ, Mair G, Muir K, Price CI, Pocock S, Randall M, Robinson TG, Roffe C, Sandset EC, Saver JL, Siriwardena AN, Sprigg N, Wardlaw JM, Bath PM. Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): effects on outcomes at day 365 in a randomised, sham-controlled, blinded, phase III, superiority ambulance-based trial. BMJ Neurol Open 2023; 5:e000424. [PMID: 37564156 PMCID: PMC10410995 DOI: 10.1136/bmjno-2023-000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/11/2023] [Indexed: 08/12/2023] Open
Abstract
Background The Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial-2 (RIGHT-2) reported no overall treatment difference between glyceryl trinitrate (GTN) and sham at day 90. Here we assess participants' outcomes 1 year after randomisation. Methods RIGHT-2 was an ambulance-based prospective randomised controlled trial where patients with presumed stroke and systolic blood pressure (BP) of >120 mm Hg received either GTN (5 mg/day) or sham patch. Centralised blinded telephone follow-up was performed at days 90 (primary endpoint) and 365 (secondary endpoint). The lead outcome was dependency assessed with the modified Rankin Scale (mRS). Results 1149 patients were recruited to RIGHT-2 between October 2015 and May 2018, and 1097 (95.5%) had outcome data recorded at day 365. At baseline, the patients were; female (48%), had a mean age of 73 (15) years, BP of 162 (25)/92 (18) mm Hg, onset to randomisation of 70 (45-115) min, diagnosis of ischaemic stroke (52%), intracerebral haemorrhage (ICH) (13%), transient ischaemic attack (TIA) (9%) and mimics (26%). There was no effect of GTN on mRS score at day 365 in participants with confirmed stroke/TIA (adjusted common odds ratio (acOR) 1.10, 95% CI 0.86 to 1.42) or in all patients. In patients randomised to GTN, mRS at day 365 tended to be worse in those with ICH (acOR 1.65, 95% CI 0.84 to 3.25) and better in those with a mimic diagnosis (acOR 0.53, 95% CI 0.33 to 0.84). Conclusion At 1 year post randomisation, dependency did not differ between GTN and sham treatment in either the target population or overall. In prespecified subgroup analyses, GTN was associated with reduced dependency in participants with a final diagnosis of mimic and a non-significant worse outcome in participants with ICH. Trial registration number ISRCTN26986053.
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Affiliation(s)
- Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sandeep Ankolekar
- Department of Neurology, King's College Hospital NHS Trust, London, UK
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences and GEM, Royal Derby Hospital, Derby, UK
| | - Grant Mair
- UK Dementia Research Institute, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
| | - Keith Muir
- Neurology, University of Glasgow, Glasgow, UK
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, and NIHR Biomedical Research Unit for Cardiovascular Diseases, University of Leicester, Leicester, UK
| | - Christine Roffe
- Institute for Science and Technology in Medicine, Keele University, Keele, UK
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joanna M Wardlaw
- UK Dementia Research Institute, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Appleton JP, Law ZK, Woodhouse LJ, Al-Shahi Salman R, Beridze M, Christensen H, Dineen RA, Guerrero JJE, England TJ, Karlinski M, Krishnan K, Laska AC, Lyrer P, Ozturk S, Roffe C, Roberts I, Robinson TG, Scutt P, Werring DJ, Bath PM, Sprigg N. Effects of blood pressure and tranexamic acid in spontaneous intracerebral haemorrhage: a secondary analysis of a large randomised controlled trial. BMJ Neurol Open 2023; 5:e000423. [PMID: 37337529 PMCID: PMC10277112 DOI: 10.1136/bmjno-2023-000423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/06/2023] [Indexed: 06/21/2023] Open
Abstract
Background Tranexamic acid reduced haematoma expansion and early death, but did not improve functional outcome in the tranexamic acid for hyperacute spontaneous intracerebral haemorrhage-2 (TICH-2) trial. In a predefined subgroup, there was a statistically significant interaction between prerandomisation baseline systolic blood pressure (SBP) and the effect of tranexamic acid on functional outcome (p=0.019). Methods TICH-2 was an international prospective double-blind placebo-controlled randomised trial evaluating intravenous tranexamic acid in patients with acute spontaneous intracerebral haemorrhage (ICH). Prerandomisation baseline SBP was split into predefined ≤170 and >170 mm Hg groups. The primary outcome at day 90 was the modified Rankin Scale (mRS), a measure of dependency, analysed using ordinal logistic regression. Haematoma expansion was defined as an increase in haematoma volume of >33% or >6 mL from baseline to 24 hours. Data are OR or common OR (cOR) with 95% CIs, with significance at p<0.05. Results Of 2325 participants in TICH-2, 1152 had baseline SBP≤170 mm Hg and were older, had larger lobar haematomas and were randomised later than 1173 with baseline SBP>170 mm Hg. Tranexamic acid was associated with a favourable shift in mRS at day 90 in those with baseline SBP≤170 mm Hg (cOR 0.73, 95% CI 0.59 to 0.91, p=0.005), but not in those with baseline SBP>170 mm Hg (cOR 1.05, 95% CI 0.85 to 1.30, p=0.63). In those with baseline SBP≤170 mm Hg, tranexamic acid reduced haematoma expansion (OR 0.62, 95% CI 0.47 to 0.82, p=0.001), but not in those with baseline SBP>170 mm Hg (OR 1.02, 95% CI 0.77 to 1.35, p=0.90). Conclusions Tranexamic acid was associated with improved clinical and radiological outcomes in ICH patients with baseline SBP≤170 mm Hg. Further research is needed to establish whether certain subgroups may benefit from tranexamic acid in acute ICH. Trial registration number ISRCTN93732214.
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Affiliation(s)
- Jason Philip Appleton
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Zhe Kang Law
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Neurology Unit, Department of Medicine, National University of Malaysia Faculty of Medicine, Kuala Lumpur, Malaysia
| | - Lisa Jane Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | | | - Maia Beridze
- The First University Clinic, Tbilisi State Medical University, Tbilisi, Georgia
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Robert A Dineen
- Radiological Sciences, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Juan José Egea Guerrero
- Neurocritical Care Unit, Virgen del Rocio University Hospital, Sevilla, Spain
- IbiS, CSIC, University of Seville, Sevilla, Spain
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Michal Karlinski
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Philippe Lyrer
- Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Serefnur Ozturk
- Neurology, Faculty of Medicine, Selcuk Universitesi, Konya, Turkey
| | - Christine Roffe
- Stroke Research, School of Medicine, University of Keele, Stoke-on-Trent, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Polly Scutt
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Philip M Bath
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
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Xie X, Johnston SC, Wang A, Xu Q, Bath PM, Pan Y, Li H, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Xu A, Jing J, Meng X, Wang Y. Association of CYP2C19 Loss-of-Function Metabolizer Status With Stroke Risk Among Chinese Patients Treated With Ticagrelor-Aspirin vs Clopidogrel-Aspirin: A Prespecified Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2317037. [PMID: 37279000 DOI: 10.1001/jamanetworkopen.2023.17037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
Importance The Clopidogrel With Aspirin in High-Risk Patients With Acute Nondisabling Cerebrovascular Events II (CHANCE-2) trial showed that ticagrelor-aspirin combination therapy reduced the risk of stroke compared with a clopidogrel-aspirin combination among carriers of CYP2C19 loss-of-function (LOF) alleles after a transient ischemic attack (TIA) or minor ischemic stroke. However, the association between the degree of CYP2C19 LOF and ideal treatment allocation remains unknown. Objective To investigate whether the efficacy and safety of ticagrelor-aspirin vs clopidogrel-aspirin are consistent with the expected degree of CYP2C19 LOF after TIA or minor stroke. Design, Setting, and Participants CHANCE-2 was a multicenter, double-blind, double-dummy, placebo-controlled randomized clinical trial. Patients were enrolled at 202 centers in China from September 23, 2019, through March 22, 2021. Patients with at least two *2 or *3 alleles (*2/*2, *2/*3, or *3/*3) according to point-of-care genotyping were classified as "poor metabolizers," and those with one *2 or *3 allele (*1/*2 or *1/*3) were classified as "intermediate metabolizers." Interventions Patients were randomly assigned in a 1:1 ratio to receive ticagrelor (180-mg loading dose on day 1 followed by 90 mg twice daily for days 2-90) or clopidogrel (300-mg loading dose on day 1 followed by 75 mg/d for days 2-90). All patients received aspirin (75- to 300-mg loading dose followed by 75 mg/d for 21 days). Main Outcomes and Measures The primary efficacy outcome was a new ischemic or hemorrhagic stroke. The secondary efficacy outcome was a composite of new clinical vascular events and individual ischemic stroke events within 3 months. The primary safety outcome was severe or moderate bleeding. Analyses were performed according to the intention-to-treat principle. Results Of the 6412 patients enrolled, the median age was 64.8 years (IQR, 57.0-71.4 years), and 4242 patients (66.2%) were men. Of the 6412 patients, 5001 (78.0%) were intermediate metabolizers, and 1411 (22.0%) were poor metabolizers. The primary outcome occurred less often with ticagrelor-aspirin vs clopidogrel-aspirin, irrespective of metabolizer status (6.0% [150 of 2486] vs 7.6% [191 of 2515]; hazard ratio [HR], 0.78 [95% CI, 0.63-0.97] among intermediate metabolizers and 5.7% [41 of 719] vs 7.5% [52 of 692]; HR, 0.77 [95% CI, 0.50-1.18] among poor metabolizers; P = .88 for interaction). Patients taking ticagrelor-aspirin had a higher risk of any bleeding event compared with those taking clopidogrel-aspirin, irrespective of metabolizer status: 5.4% (134 of 2486) vs 2.6% (66 of 2512) (HR, 2.14 [95% CI, 1.59-2.89]) among intermediate metabolizers and 5.0% (36 of 719) vs 2.0% (14 of 692) (HR, 2.99 [95% CI, 1.51-5.93]) among poor metabolizers (P = .66 for interaction). Conclusions and Relevance This prespecified analysis of a randomized clinical trial found no difference in treatment effect between poor and intermediate CYP2C19 metabolizers. The relative clinical efficacy and safety of ticagrelor-aspirin vs clopidogrel-aspirin were consistent across CYP2C19 genotypes. Trial Registration ClinicalTrials.gov Identifier: NCT04078737.
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Affiliation(s)
- Xuewei Xie
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qin Xu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jinxi Lin
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anding Xu
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Jing Jing
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Krishnan K, Hollingworth M, Nguyen TN, Kumaria A, Kirkman MA, Basu S, Tolias C, Bath PM, Sprigg N. Surgery for Malignant Acute Ischemic Stroke: A Narrative Review of the Knowns and Unknowns. Semin Neurol 2023; 43:370-387. [PMID: 37595604 DOI: 10.1055/s-0043-1771208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Malignant acute ischemic stroke (AIS) is characterized by acute neurological deterioration caused by progressive space-occupying brain edema, often occurring in the first hours to days after symptom onset. Without any treatment, the result is often fatal. Despite advances in treatment for AIS, up to 80% of patients with a large hemispheric stroke or cerebellar stroke are at risk of poor outcome. Decompressive surgery can be life-saving in a subgroup of patients with malignant AIS, but uncertainties exist on patient selection, predictors of malignant infarction, perioperative management, and timing of intervention. Although survivors are left disabled, most agree with the original decision to undergo surgery and would make the same decision again. In this narrative review, we focus on the clinical and radiological predictors of malignant infarction in AIS and outline the technical aspects of decompressive surgery as well as duraplasty and cranioplasty. We discuss the current evidence and recommendations for surgery in AIS, highlighting gaps in knowledge, and suggest directions for future studies. KEY POINTS: · Acute ischemic stroke from occlusion of a proximal intracranial artery can progress quickly to malignant edema, which can be fatal in 80% of patients despite medical management.. · Decompression surgery is life-saving within 48 hours of stroke onset, but the benefits beyond this time and in the elderly are unknown.. · Decompressive surgery is associated with high morbidity, particularly in the elderly. The decision to operate must be made after considering the individual's preference and expectations of quality of life in the context of the clinical condition.. · Further studies are needed to refine surgical technique including value of duraplasty and understand the role monitoring intracranial pressure during and after decompressive surgery.. · More studies are needed on the pathophysiology of malignant cerebral edema, prediction models including imaging and biomarkers to identify which subgroup of patients will benefit from decompressive surgery.. · More research is needed on factors associated with morbidity and mortality after cranioplasty, safety and efficacy of implants, and comparisons between them.. · Further studies are needed to assess the long-term effects of physical disability and quality of life of survivors after surgery, particularly those with severe neurological deficits..
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Affiliation(s)
- Kailash Krishnan
- Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Milo Hollingworth
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Thanh N Nguyen
- Department of Neurology, Neurosurgery and Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Ashwin Kumaria
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Matthew A Kirkman
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Surajit Basu
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Christos Tolias
- Department of Neurosurgery, King's College Hospitals NHS Foundation Trust, London, United Kingdom
| | - Philip M Bath
- Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke Unit, Department of Acute Medicine Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
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Ma A, Detaram HD, Steinfort B, Harrington T, Nguyen TN, Abdalkader M, Siopis G, Bath PM, Dhillon PS, Podlasek A, Qureshi AI, Qiu Z, Krishnan K. Antiplatelet Therapy in Neurointervention. Semin Neurol 2023; 43:466-479. [PMID: 37562452 DOI: 10.1055/s-0043-1771383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.
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Affiliation(s)
- Alice Ma
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | | | - Brendan Steinfort
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Tim Harrington
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Centre, Boston, Massachusetts
| | | | - George Siopis
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Permesh Singh Dhillon
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom
| | - Anna Podlasek
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People's Republic of China
| | - Kailash Krishnan
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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30
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Gao Y, Pan Y, Han S, Chen W, Jing J, Wang C, Yang Y, Wang T, Meng X, Zhao X, Liu L, Li H, Johnston SC, Amarenco P, Bath PM, Wang Y, Wang Y. Rationale and design of a randomised double-blind 2×2 factorial trial comparing the effect of a 3-month intensive statin and antiplatelet therapy for patients with acute mild ischaemic stroke or high-risk TIA with intracranial or extracranial atherosclerosis (INSPIRES). Stroke Vasc Neurol 2023; 8:249-258. [PMID: 36707080 PMCID: PMC10359782 DOI: 10.1136/svn-2022-002084] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/08/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND It remains unclear if intensive antiplatelet and statin treatments begun within 24-72 hours of cerebral ischaemic events from intracranial or extracranial atherosclerosis is effective or safe. METHODS The Intensive Statin and Antiplatelet Therapy for High-risk Intracranial or Extracranial Atherosclerosis (INSPIRES) trial is a randomised, double-blind, placebo-controlled, multicentre and 2×2 factorial trial. 6100 individuals between the ages of 35 and 80 who have experienced a mild ischaemic stroke or high-risk transient ischaemic attack (TIA) within the previous 72 hours that is attributed to ≥50% atherosclerotic stenosis of a major intracranial or extracranial artery or multiple infarctions of atherosclerotic origin will be enrolled in the trial. Eligible subjects will be randomised 1:1:1:1 to one of four groups: (1) intensive antiplatelet therapy (combined clopidogrel and aspirin for days 1-21, then aspirin placebo and clopidogrel for days 22-90) plus immediate intensive statin therapy(atorvastatin at a dose of 80 mg daily for the first 21 days, then 40 mg daily for days 22-90); (2) intensive antiplatelet therapy plus delayed intensive statin therapy (atorvastatin placebo for days 1-3, followed by 40 mg per day of atorvastatin for days 4-90); (3) standard antiplatelet therapy (combination of clopidogrel placebo with aspirin for 90 days) plus immediate intensive statin therapy and (4) standard antiplatelet therapy plus delayed intensive statin therapy. The primary efficacy endpoint is any new stroke (ischaemic or haemorrhagic) within 90 days after randomisation. The primary safety endpoint is moderate to severe bleeding at 90 days. CONCLUSION The INSPIRES trial will assess the efficacy and safety of intensive antiplatelet therapy and immediate intensive statin therapy begun within 72 hours of onset in decreasing the recurrent stroke at 90 days in patients with acute mild ischaemic stroke or high-risk TIA of intracranial or extracranial atherosclerosis origin. TRIAL REGISTRATION NUMBER NCT03635749.
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Affiliation(s)
- Ying Gao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shangrong Han
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weiqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yingying Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - S Claiborne Johnston
- Dean's Office, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Pierre Amarenco
- Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris (APHP), Bichat Hospital, INSERM LVTS-U1148, University of Paris, Paris, France
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- National Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- National Center for Neurological Diseases, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
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Wardlaw JM, Woodhouse LJ, Mhlanga II, Oatey K, Heye AK, Bamford J, Cvoro V, Doubal FN, England T, Hassan A, Montgomery A, O'Brien JT, Roffe C, Sprigg N, Werring DJ, Bath PM. Isosorbide Mononitrate and Cilostazol Treatment in Patients With Symptomatic Cerebral Small Vessel Disease: The Lacunar Intervention Trial-2 (LACI-2) Randomized Clinical Trial. JAMA Neurol 2023:2805321. [PMID: 37222252 DOI: 10.1001/jamaneurol.2023.1526] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Importance Cerebral small vessel disease (cSVD) is a common cause of stroke (lacunar stroke), is the most common cause of vascular cognitive impairment, and impairs mobility and mood but has no specific treatment. Objective To test the feasibility, drug tolerability, safety, and effects of 1-year isosorbide mononitrate (ISMN) and cilostazol treatment on vascular, functional, and cognitive outcomes in patients with lacunar stroke. Design, Setting, and Participants The Lacunar Intervention Trial-2 (LACI-2) was an investigator-initiated, open-label, blinded end-point, randomized clinical trial with a 2 × 2 factorial design. The trial aimed to recruit 400 participants from 26 UK hospital stroke centers between February 5, 2018, and May 31, 2021, with 12-month follow-up. Included participants had clinical lacunar ischemic stroke, were independent, were aged older than 30 years, had compatible brain imaging findings, had capacity to consent, and had no contraindications to (or indications for) the study drugs. Data analysis was performed on August 12, 2022. Interventions All patients received guideline stroke prevention treatment and were randomized to ISMN (40-60 mg/d), cilostazol (200 mg/d), ISMN-cilostazol (40-60 and 200 mg/d, respectively), or no study drug. Main Outcomes The primary outcome was recruitment feasibility, including retention at 12 months. Secondary outcomes were safety (death), efficacy (composite of vascular events, dependence, cognition, and death), drug adherence, tolerability, recurrent stroke, dependence, cognitive impairment, quality of life (QOL), and hemorrhage. Results Of the 400 participants planned for this trial, 363 (90.8%) were recruited. Their median age was 64 (IQR, 56.0-72.0) years; 251 (69.1%) were men. The median time between stroke and randomization was 79 (IQR, 27.0-244.0) days. A total of 358 patients (98.6%) were retained in the study at 12 months, with 257 of 272 (94.5%) taking 50% or more of the allocated drug. Compared with those participants not receiving that particular drug, neither ISMN (adjusted hazard ratio [aHR], 0.80 [95% CI, 0.59 to 1.09]; P = .16) nor cilostazol (aHR, 0.77 [95% CI, 0.57 to 1.05]; P = .10) alone reduced the composite outcome in 297 patients. Isosorbide mononitrate reduced recurrent stroke in 353 patients (adjusted odds ratio [aOR], 0.23 [95% CI, 0.07 to 0.74]; P = .01) and cognitive impairment in 308 patients (aOR, 0.55 [95% CI, 0.36 to 0.86]; P = .008). Cilostazol reduced dependence in 320 patients (aHR, 0.31 [95% CI, 0.14 to 0.72]; P = .006). Combination ISMN-cilostazol reduced the composite (aHR, 0.58 [95% CI, 0.36 to 0.92]; P = .02), dependence (aOR, 0.14 [95% CI, 0.03 to 0.59]; P = .008), and any cognitive impairment (aOR, 0.44 [95% CI, 0.23 to 0.85]; P = .02) and improved QOL (adjusted mean difference, 0.10 [95% CI, 0.03 to 0.17]; P = .005) in 153 patients. There were no safety concerns. Conclusions and Relevance These results show that the LACI-2 trial was feasible and ISMN and cilostazol were well tolerated and safe. These agents may reduce recurrent stroke, dependence, and cognitive impairment after lacunar stroke, and they could prevent other adverse outcomes in cSVD. Therefore, both agents should be tested in large phase 3 trials. Trial Registration ClinicalTrials.gov Identifier: NCT03451591.
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Affiliation(s)
- Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Iris I Mhlanga
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Anna K Heye
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - John Bamford
- Department of Neurology, Leeds General Infirmary, Leeds, United Kingdom
| | - Vera Cvoro
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- Victoria Hospital, National Health Service Fife, Kirkcaldy, United Kingdom
| | - Fergus N Doubal
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Timothy England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Ahamad Hassan
- Department of Neurology, Leeds General Infirmary, Leeds, United Kingdom
| | - Alan Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - John T O'Brien
- Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Christine Roffe
- Stroke Research, Keele University, Stoke-on-Trent, United Kingdom
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - David J Werring
- Stroke Research Centre, University College London Queen Square Institute of Neurology, Russell Square House, London, United Kingdom
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
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Rakkar K, Othman OA, Sprigg N, Bath PM, Bayraktutan U. Evaluation of Endothelial Progenitor Cell Characteristics as Clinical Biomarkers for Elderly Patients with Ischaemic Stroke. Stem Cell Rev Rep 2023:10.1007/s12015-023-10544-y. [PMID: 37129729 PMCID: PMC10390388 DOI: 10.1007/s12015-023-10544-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 05/03/2023]
Abstract
Ageing impairs endothelial function and predisposes the person to ischaemic stroke (IS). Endothelial progenitor cells (EPCs) repair endothelial damage and induce post-ischaemic neovascularisation. Given the prevalence of IS in older population, this study explored whether changes in EPC number and function may reliably predict the type or outcome of stroke in patients ≥ 65 years of age. For this, blood samples were collected once from healthy volunteers (HVs, n = 40) and four times (admission and days 7, 30 and 90 post-stroke) from participants with lacunar (n = 38) or cortical (n = 43) stroke. EPCs were counted with flow cytometry and defined as non-haematopoietic cells (CD45-) expressing markers for stemness (CD34 +), immaturity (CD133 +) and endothelial maturity (KDR +). Clonogenesis, tubulogenesis, migration and proliferation assays were performed as measures of EPC functionality. Biochemical profile of plasma inflammatory and angiogenic agents were studied using specific ELISAs. Primary outcome was disability or dependence on day 90 post-stroke, assessed by the modified Rankin Scale (mRS). Compared to HVs, EPC numbers were higher in stroke patients at all time points studied, reaching significance at baseline and day 30. No differences in EPC counts and functionality were observed between lacunar and cortical stroke groups at any time. Plasma endostatin, PDGF-BB, TNF-α and VEGF levels were higher in stroke patients vs HVs. Patient outcome, evaluated by mRS on day 90 post-stroke, did not correlate with EPC count or functionality. Baseline EPC counts may serve as a diagnostic marker for stroke but fail to distinguish between different stroke subtypes and predict post-stroke outcome.
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Affiliation(s)
- Kamini Rakkar
- Academic Unit of Mental Health and Clinical Neuroscience, Clinical Sciences Building, School of Medicine, The University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Othman Ahmad Othman
- Academic Unit of Mental Health and Clinical Neuroscience, Clinical Sciences Building, School of Medicine, The University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Nikola Sprigg
- Academic Unit of Mental Health and Clinical Neuroscience, Clinical Sciences Building, School of Medicine, The University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Philip M Bath
- Academic Unit of Mental Health and Clinical Neuroscience, Clinical Sciences Building, School of Medicine, The University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Ulvi Bayraktutan
- Academic Unit of Mental Health and Clinical Neuroscience, Clinical Sciences Building, School of Medicine, The University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK.
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33
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Pan Y, Meng X, Yuan B, Johnston SC, Li H, Bath PM, Dong Q, Xu A, Jing J, Lin J, Jiang Y, Xie X, Jin A, Suo Y, Yang H, Feng Y, Zhou Y, Liu Q, Li X, Liu B, Zhu H, Zhao J, Huang X, Li H, Xiong Y, Li Z, Wang Y, Zhao X, Liu L, Wang Y. Indobufen versus aspirin in patients with acute ischaemic stroke in China (INSURE): a randomised, double-blind, double-dummy, active control, non-inferiority trial. Lancet Neurol 2023; 22:485-493. [PMID: 37121237 DOI: 10.1016/s1474-4422(23)00113-8] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 02/26/2023] [Accepted: 03/10/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Aspirin is recommended for secondary stroke prevention in patients with moderate-to-severe ischaemic stroke but can lead to gastrointestinal intolerance and bleeding. Indobufen is used as an alternative antiplatelet agent in some countries, despite an absence of large-scale clinical trials for this indication. We tested the hypothesis that indobufen is non-inferior to aspirin in reducing the risk of new stroke at 90 days in patients with moderate-to-severe ischaemic stroke. METHODS We conducted a randomised, double-blind, double-dummy, active control, non-inferiority trial at 163 tertiary and district general hospitals in China. Eligible participants were aged 18-80 years with acute moderate-to-severe ischaemic stroke (National Institutes of Health Stroke Scale score 4-18). We randomly assigned (1:1) participants within 72 h of the onset of symptoms to receive either indobufen (100 mg tablet twice per day) or aspirin (100 mg tablet once per day) for 90 days. The randomisation sequence was computer generated centrally and stratified by local participating centres. Masked local investigators assigned the random code to patients in ascending order and provided a treatment kit corresponding to the random code. The primary efficacy outcome was new stroke and the primary safety outcome was severe or moderate bleeding, both within 90 days. This primary efficacy outcome was assessed in all randomly assigned and consenting patients and in a per-protocol group (ie, all patients finishing the treatment without major violation of the trial protocol). Safety analyses were done in the safety-analysis population (ie, all patients who received at least one dose of the study drug and had a safety assessment available). We assessed the non-inferiority of indobufen versus aspirin using the one-sided upper limit of the 95% CI of the hazard ratio (HR) with a prespecified non-inferiority margin of 1·25. This trial is registered with ClinicalTrials.gov (NCT03871517). FINDINGS This trial took place between June 2, 2019, and Nov 28, 2021. Of 84 093 patients screened, 5438 patients were randomly assigned to receive either indobufen (n=2715) or aspirin (n=2723), all of whom were included in the primary analyses. Median age was 64·2 years (IQR 56·1-70·6); 1921 (35·3%) were women and 3517 (64·7%) were men. Stroke occurred within 90 days in 213 (7·9%) patients in the indobufen group versus 175 (6·4%) in the aspirin group (HR 1·23, 95% CI 1·01-1·50; pnon-inferiority=0·44). Moderate or severe bleeding occurred in 18 (0·7%) patients in the indobufen group and in 28 (1·0%) in the aspirin group (0·63, 95% CI 0·35 to 1·15; p=0·13). Adverse events within 90 days occurred in 666 (24·5%) patients in the indobufen group and 679 (24·9%) patients in the aspirin group (p=0·73). INTERPRETATION In patients with acute moderate-to-severe ischaemic stroke, indobufen was not non-inferior to aspirin because the upper limit of the 95% CI was greater than 1·25. Furthermore, indobufen seemed to be inferior to aspirin in reducing the risk of recurrent stroke at 90 days because the lower limit of the 95% CI was greater than 1·00. Although moderate or severe bleeding did not differ between groups, these findings do not support the use of indobufen for secondary stroke prevention in patients with moderate-to-severe ischaemic stroke. FUNDING Hangzhou Zhongmei Huadong Pharmaceutical and Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences. TRANSLATION For the Chinese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Baoshi Yuan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Anding Xu
- Department of Neurology and Stroke Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Aoming Jin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yue Suo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongqin Yang
- Department of Neurology, Jiyuan Hospital of Traditional Chinese Medicine, Jiyuan, China
| | - Yefang Feng
- Department of Neurology, The Second People's Hospital of Huludao, Huludao, China
| | - Yanhua Zhou
- Department of Neurology, Panjin Central Hospital, Panjin, China
| | - Qing Liu
- Department of Neurology, The Second People's Hospital of Guiyang, Guiyang, China
| | - Xueli Li
- Department of Neurology, Liaocheng Hospital, Shandong First Medical University, Liaocheng, China
| | - Bin Liu
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Hui Zhu
- Department of Neurology, Lequn Branch, The First Hospital of Jilin University, Changchun, China
| | - Jinguo Zhao
- Department of Neurology, Weihai Wendeng District People's Hospital, Weihai, China
| | - Xuerong Huang
- Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Haitao Li
- Department of Neurology, Qihe County People's Hospital, Dezhou, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China.
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34
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Chen C, Ouyang M, Ong S, Zhang L, Zhang G, Delcourt C, Mair G, Liu L, Billot L, Li Q, Chen X, Parsons M, Broderick JP, Demchuk AM, Bath PM, Donnan GA, Levi C, Chalmers J, Lindley RI, Martins SO, Pontes-Neto OM, Venturelli PM, Olavarría V, Lavados P, Robinson TG, Wardlaw JM, Li G, Wang X, Song L, Anderson CS. Effects of intensive blood pressure lowering on cerebral ischaemia in thrombolysed patients: insights from the ENCHANTED trial. EClinicalMedicine 2023; 57:101849. [PMID: 36820100 PMCID: PMC9938155 DOI: 10.1016/j.eclinm.2023.101849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 02/17/2023] Open
Abstract
Background Intensive blood pressure lowering may adversely affect evolving cerebral ischaemia. We aimed to determine whether intensive blood pressure lowering altered the size of cerebral infarction in the 2196 patients who participated in the Enhanced Control of Hypertension and Thrombolysis Stroke Study, an international randomised controlled trial of intensive (systolic target 130-140 mm Hg within 1 h; maintained for 72 h) or guideline-recommended (systolic target <180 mm Hg) blood pressure management in patients with hypertension (systolic blood pressure >150 mm Hg) after thrombolysis treatment for acute ischaemic stroke between March 3, 2012 and April 30, 2018. Methods All available brain imaging were analysed centrally by expert readers. Log-linear regression was used to determine the effects of intensive blood pressure lowering on the size of cerebral infarction, with adjustment for potential confounders. The primary analysis pertained to follow-up computerised tomography (CT) scans done between 24 and 36 h. Sensitivity analysis were undertaken in patients with only a follow-up magnetic resonance imaging (MRI) and either MRI or CT at 24-36 h, and in patients with any brain imaging done at any time during follow-up. This trial is registered with ClinicalTrials.gov, number NCT01422616. Findings There were 1477 (67.3%) patients (mean age 67.7 [12.1] y; male 60%, Asian 65%) with available follow-up brain imaging for analysis, including 635 patients with a CT done at 24-36 h. Mean achieved systolic blood pressures over 1-24 h were 141 mm Hg and 149 mm Hg in the intensive group and guideline group, respectively. There was no effect of intensive blood pressure lowering on the median size (ml) of cerebral infarction on follow-up CT at 24-36 h (0.3 [IQR 0.0-16.6] in the intensive group and 0.9 [0.0-12.5] in the guideline group; log Δmean -0.17, 95% CI -0.78 to 0.43). The results were consistent in sensitivity and subgroup analyses. Interpretation Intensive blood pressure lowering treatment to a systolic target <140 mm Hg within several hours after the onset of symptoms may not increase the size of cerebral infarction in patients who receive thrombolysis treatment for acute ischaemic stroke of mild to moderate neurological severity. Funding National Health and Medical Research Council of Australia; UK Stroke Association; UK Dementia Research Institute; Ministry of Health and the National Council for Scientific and Technological Development of Brazil; Ministry for Health, Welfare, and Family Affairs of South Korea; Takeda.
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Affiliation(s)
- Chen Chen
- Neurology Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Menglu Ouyang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Sheila Ong
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Luyun Zhang
- The George Institute for Global Health China, Beijing, China
- Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, Shenyang, China
| | - Guobin Zhang
- The George Institute for Global Health China, Beijing, China
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Grant Mair
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences and Centre in the UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Leibo Liu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Xiaoying Chen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Mark Parsons
- Ingham Institute for Applied Medical Research, Liverpool Hospital, UNSW, Sydney, Australia
| | - Joseph P. Broderick
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH, USA
| | - Andrew M. Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Geoffrey A. Donnan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Christopher Levi
- Neurology Department, John Hunter Hospital, and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Richard I. Lindley
- University of Sydney, Sydney, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Sheila O. Martins
- Stroke Division of Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Octavio M. Pontes-Neto
- Stroke Service - Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of Sao Paulo, Ribeirão Preto, SP, Brazil
| | - Paula Muñoz Venturelli
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Centro de Estudios Clínicos, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Verónica Olavarría
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Santiago, Chile
| | - Pablo Lavados
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Santiago, Chile
| | - Thompson G. Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Joanna M. Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences and Centre in the UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Gang Li
- Neurology Department, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xia Wang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Lili Song
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
| | - Craig S. Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health China, Beijing, China
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
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35
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Benfield JK, Hedstrom A, Everton LF, Bath PM, England TJ. Randomized controlled feasibility trial of swallow strength and skill training with surface electromyographic biofeedback in acute stroke patients with dysphagia. J Oral Rehabil 2023; 50:440-451. [PMID: 36810785 DOI: 10.1111/joor.13437] [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: 08/08/2022] [Revised: 12/14/2022] [Accepted: 01/24/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND & OBJECTIVES Swallow strength and skill training with surface electromyography (sEMG) biofeedback may improve dysphagia but little is known about the feasibility and efficacy of this intervention in acute stroke. METHODS We conducted a randomized controlled feasibility study in acute stroke patients with dysphagia. Participants were randomized to either usual care or usual care plus swallow strength and skill training with sEMG biofeedback. Primary outcomes were feasibility and acceptability. Secondary measures included swallowing and clinical outcomes, safety and swallow physiology. RESULTS Twenty-seven patients (13 biofeedback, 14 control) with average age of 73.3 (SD 11.0) and National Institute of Health Stroke Scale (NIHSS) of 10.7 (5.1) were recruited 22.4 (9.5) days post stroke. About 84.6% of participants completed >80% of sessions; failed sessions were mainly due to participant availability, drowsiness or refusal. Sessions lasted for an average of 36.2 (7.4) min. Although 91.7% found the intervention comfortable with satisfactory administration time, frequency and time post stroke, 41.7% found it challenging. There were no treatment-related serious adverse events. The biofeedback group had a lower Dysphagia Severity Rating Scale (DSRS) score at 2 weeks compared to control (3.2 vs. 4.3), but the difference did not reach statistical significance. CONCLUSIONS Swallow strength and skill training with sEMG biofeedback appears feasible and acceptable to acute stroke patients with dysphagia. Preliminary data suggests it is safe and further research refining the intervention and investigating treatment dose and efficacy is warranted.
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Affiliation(s)
- Jacqueline K Benfield
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Derbyshire Community Health Services NHS Trust, Derby, UK
| | - Amanda Hedstrom
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lisa F Everton
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Speech and Language Therapy, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.,University Hospitals of Derby and Burton, NHS Trust, Derby, UK
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36
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Hubert N, Herdegen S, Maegerlein C, Kraus F, Wiestler H, Hohenbichler K, Witton-Davies T, Heinrich I, Jarsch I, Wehrle B, Bath PM, Haberl R, Audebert HJ, Hubert GJ. Abstract 97: Association Between Use Of A Flying Intervention Team Versus Patient Interhospital Transfer And Longterm Clinical Outcome Among Patients With Acute Ischemic Stroke And Large Vessel Occlusion In Non-urban Germany. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.97] [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: 02/05/2023]
Abstract
Background and Aims:
Use of a Flying Intervention Team has shown to significantly reduce time to endovascular thrombectomy compared to interhospital transfer. Aim of this study is to determine whether this new system of care is also associated with improved long-term outcome.
Methods:
This is a non-randomized controlled intervention study comparing two systems of care in alternating weeks. Thirteen telemedicine assisted primary stroke centers in a non-urban region in Germany participated. Acute ischemic stroke patients for whom the decision to pursue thrombectomy had been made, were either treated by a Flying Intervention Team (an interventionist and a nurse flown by a dedicated helicopter to the primary stroke center to perform thrombectomy on site), or were transferred to the closest referral center. Enrollment was between 2018-02-01 and 2019-10-24. In this secondary analysis, results of the modified Rankin Scale (mRS), Barthel Index, and mortality rate after 12 months were compared between groups.
Results:
Among 146 patients included, 70 received flying team care and 76 were transferred. Functional outcome (ordinal mRS) after 12 months was significantly improved in the FIT group (acOR, 1.96; 95% CI [1.05-3.69]; p = 0.036). No significant differences were found for Barthel Index in surviving patients and mortality rate.
Conclusion:
Deployment of a Flying Intervention Team was associated with significantly improved functional outcome at 12 months. FIT should be considered as a system of care for primary stroke centers with adequate infrastructure and sufficient experience in stroke management onsite.
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Affiliation(s)
- Nikolai Hubert
- Telestroke Cntr TEMPiS, Neurology, München Klinik, Munich, Germany
| | - Sophie Herdegen
- Telestroke Cntr TEMPiS, Neurology, München Klinik, Munich, Germany
| | - Christian Maegerlein
- Dept of Diagnostic and interventional neuroradiology, Technical Univ Munich, Munich, Germany
| | - Frank Kraus
- Telestroke Cntr TEMPiS, Neurology, München Klinik, Munich, Germany
| | - Hanni Wiestler
- Telestroke Cntr TEMPiS, Neurology, München Klinik, Munich, Germany
| | | | - Thomas Witton-Davies
- Dept of diagnostic and interventional radiology, München Klinik, Munich, Germany
| | - Isabel Heinrich
- Telestroke Cntr TEMPiS, Neurology, München Klinik, Munich, Germany
| | - Iris Jarsch
- Telestroke Cntr TEMPiS, Neurology, München Klinik, Munich, Germany
| | | | | | - Roman Haberl
- Dept of Neurology, Klinikum Harlaching, München Klinik, Munich, Germany
| | | | - Gordian J Hubert
- Telestroke Cntr TEMPiS, Neurology, München Klinik, Munich, Germany
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Abstract
BACKGROUND Central adjudication of outcomes is common in randomized clinical trials in stroke. The rationale for adjudication is clear; centrally adjudicated outcomes should have less random and systematic errors than outcomes assessed locally by site investigators. However, adjudication brings added complexities to a clinical trial and can be costly. AIM To assess the evidence for outcome adjudication in stroke trials. SUMMARY OF REVIEW We identified 12 studies evaluating central adjudication in stroke trials. The majority of these were secondary analyses of trials, and the results of all of these would have remained unchanged had central adjudication not taken place, even for trials without sufficient blinding. The largest differences between site-assessed and adjudicator-assessed outcomes were between the most subjective outcomes, such as causality of serious adverse events. We found that the cost of adjudication could be upward of £100,000 for medium to large prevention trials. These findings suggest that the cost of central adjudication may outweigh the advantages it brings in many cases. However, through simulation, we found that only a small amount of bias is required in site investigators' outcome assessments before adjudication becomes important. CONCLUSION Central adjudication may not be necessary in stroke trials with blinded outcome assessment. However, for open-label studies, central adjudication may be more important.
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Affiliation(s)
- Peter J Godolphin
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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McDermott JH, Woodhouse LJ, Sen D, Smith CJ, Newman WG, Bath PM. Abstract WP173: Interaction Between CYP2C19 Allele Status And Outcome Following Ischemic Stroke In Patients Treated With Clopidogrel: A TARDIS Trial Substudy. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp173] [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: 02/05/2023]
Abstract
Background:
Clopidogrel is routinely prescribed following ischaemic stroke (IS), or transient ischaemic attack (TIA), as secondary prevention. Conversion of clopidogrel to its active form involves several hepatic cytochrome P450 enzymes (CYP450), including P450-2C19 (CYP2C19). Previous evidence suggests that CYP2C19 loss of function (LoF) carriers prescribed clopidogrel are at increased risk of vascular events in comparison with non-carriers. We sought to test for interaction between CYP2C19 LoF status and treatment effects in the TARDIS trial.
Methods:
TARDIS was an international, randomised trial recruiting participants with acute IS/TIA. Participants were assigned to receive intensive antiplatelet therapy (aspirin, clopidogrel, and dipyridamole) or guideline therapy (clopidogrel alone or aspirin and dipyridamole). Blood samples for genotyping were taken from consented participants at a 70 of the 106 recruiting centres.
Results:
Of 3096 participants, 1361 (44%) had samples available for genotyping. Median age was 69.0 years and 65.1% were male. Of the 1361 with samples, 1071 (78.7%) were randomised to clopidogrel and 290 (21.3%) to aspirin plus dipyridamole. 387 (28.4%) participants were CYP2C19 LoF allele carriers. At 35 days, 64 participants (4.7%) had a further IS/TIA and the rate of major adverse cardiovascular events was 6.8%. In participants randomised to clopidogrel (monotherapy or intensive) the rates of further IS/TIA were 4.9% in LoF allele carriers and 4.2% in non-carriers. As for those taking clopidogrel monotherapy, the rates of further IS/TIA were 7.4% in LoF allele carriers compared to 3.8% in non-carriers, though this difference was non-significant (p=0.14). There were no significant differences, in outcome or bleeding risk, by treatment group and LoF carrier status.
Conclusions:
No significant interaction was found between CYP2C19 genotype and outcome following IS/TIA when prescribed clopidogrel, either as monotherapy or in combination with aspirin and dipyridamole. There was no observed interaction between LoF status, clinical outcome, and bleeding rates. A caveat is that this analysis was undertaken on a subgroup of TARDIS participants and so was underpowered to detect a difference in the monotherapy group.
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Affiliation(s)
- John H McDermott
- The Div of Evolution, Infection and Genomics, UNIVERSITY OF MANCHESTER, Manchester, United Kingdom
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Univ of Nottingham, Nottingham, United Kingdom
| | - Dwaipayan Sen
- Greater Manchester Comprehensive Stroke Cntr, Geoffrey Jefferson Brain Rsch Cntr, Salford, United Kingdom
| | | | - William G Newman
- The Div of Evolution, Infection and Genomics, UNIVERSITY OF MANCHESTER, Manchester, United Kingdom
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, UNIVERSITY OF NOTTINGHAM, Nottingham, United Kingdom
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Kadir RRA, Alwjwaj M, Rakkar K, Othman OA, Sprigg N, Bath PM, Bayraktutan U. Outgrowth Endothelial Cell Conditioned Medium Negates TNF-α-Evoked Cerebral Barrier Damage: A Reverse Translational Research to Explore Mechanisms. Stem Cell Rev Rep 2023; 19:503-515. [PMID: 36056287 PMCID: PMC9902316 DOI: 10.1007/s12015-022-10439-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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] [Accepted: 07/28/2022] [Indexed: 02/07/2023]
Abstract
Improved understanding of the key mechanisms underlying cerebral ischemic injury is essential for the discovery of efficacious novel therapeutics for stroke. Through detailed analysis of plasma samples obtained from a large number of healthy volunteers (n = 90) and ischemic stroke patients (n = 81), the current study found significant elevations in the levels of TNF-α at baseline (within the first 48 h of stroke) and on days 7, 30, 90 after ischaemic stroke. It then assessed the impact of this inflammatory cytokine on an in vitro model of human blood-brain barrier (BBB) and revealed dramatic impairments in both barrier integrity and function, the main cause of early death after an ischemic stroke. Co-treatment of BBB models in similar experiments with outgrowth endothelial cell-derived conditioned media (OEC-CM) negated the deleterious effects of TNF-α on BBB. Effective suppression of anti-angiogenic factor endostatin, stress fiber formation, oxidative stress, and apoptosis along with concomitant improvements in extracellular matrix adhesive and tubulogenic properties of brain microvascular endothelial cells and OECs played an important role in OEC-CM-mediated benefits. Significant increases in pro-angiogenic endothelin-1 and monocyte chemoattractant protein-1 in OEC-CM compared to the secretomes of OEC and HBMEC, detected by proteome profiling assay, accentuate the beneficial effects of OEC-CM. In conclusion, this reverse translational study identifies TNF-α as an important mediator of post-ischemic cerebral barrier damage and proposes OEC-CM as a potential vasculoprotective therapeutic strategy by demonstrating its ability to regulate a wide range of mechanisms associated with BBB function. Clinical trial registration NCT02980354.
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Affiliation(s)
- Rais Reskiawan A Kadir
- Academic Unit of Mental Health and Clinical Neuroscience, Clinical Sciences Building, School of Medicine, The University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Mansour Alwjwaj
- Academic Unit of Mental Health and Clinical Neuroscience, Clinical Sciences Building, School of Medicine, The University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Kamini Rakkar
- Academic Unit of Mental Health and Clinical Neuroscience, Clinical Sciences Building, School of Medicine, The University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Othman Ahmad Othman
- Academic Unit of Mental Health and Clinical Neuroscience, Clinical Sciences Building, School of Medicine, The University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Nikola Sprigg
- Academic Unit of Mental Health and Clinical Neuroscience, Clinical Sciences Building, School of Medicine, The University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Philip M Bath
- Academic Unit of Mental Health and Clinical Neuroscience, Clinical Sciences Building, School of Medicine, The University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Ulvi Bayraktutan
- Academic Unit of Mental Health and Clinical Neuroscience, Clinical Sciences Building, School of Medicine, The University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK.
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Wang A, Meng X, Tian X, Zuo Y, Bath PM, Li H, Xie X, Jing J, Lin J, Wang Y, Zhao X, Liu L, Li Z, Jiang Y, Xu J, Wang F, Chen W, Cao M, Li J, Wang Y. Ticagrelor Aspirin vs Clopidogrel Aspirin in CYP2C19 Loss-of-Function Carriers With Minor Stroke or TIA Stratified by Risk Profile. Neurology 2023; 100:e497-e504. [PMID: 36535779 PMCID: PMC9931078 DOI: 10.1212/wnl.0000000000201454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Genotype data of the Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack (CHANCE) trial showed that efficacy of clopidogrel aspirin depended on CYP2C19 genotype and risk profile. A stratification of patients who carried CYP2C19 loss-of-function (LOF) alleles according to the risk of recurrent stroke may be important for selecting optimal antiplatelet therapy. We aimed to compare the efficacy and safety of ticagrelor aspirin with clopidogrel aspirin in CYP2C19 LOF carriers with minor stroke or transient ischemic attack (TIA) stratified by risk profile. METHODS Data were obtained from Ticagrelor or Clopidogrel with Aspirin in High-Risk Patients with Acute Nondisabling Cerebrovascular Events II (CHANCE-2) trial. Low-risk and high-risk profiles were defined by Essen Stroke Risk Score (ESRS) (<3 [low risk] and ≥3 [high risk], respectively). RESULTS A total of 6,412 CYP2C19 LOF carriers were enrolled; ticagrelor aspirin was associated with a reduced risk of primary outcome (new stroke within 90-day follow-up) in patients at low risk (hazard ratio [HR], 0.65; 95% CI, 0.48-0.82), but not in those at high risk (HR, 0.97; 95% CI, 0.73-1.29), compared with clopidogrel aspirin (p = 0.02 for interaction). Secondary outcomes generally went in the same direction as the primary outcome. The primary safety outcome of severe or moderate bleeding did not differ based on risk profile (p = 0.24 for interaction), although the incidence of total bleeding was greater with ticagrelor aspirin than with clopidogrel aspirin among patients at low risk (p < 0.01 for interaction). Analysis in the per-protocol population yielded similar results. DISCUSSION This post hoc analysis of CHANCE-2 trial showed that CYP2C19 LOF carriers with minor stroke or TIA at low risk of recurrent stroke received a greater benefit from ticagrelor aspirin than from clopidogrel aspirin. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that CYP2C19 LOF carriers with minor stroke or TIA at low risk, but not at high risk, of recurrent stroke (by the ESRS) received a greater benefit from ticagrelor aspirin than from clopidogrel aspirin. TRIAL REGISTRATION INFORMATION URL: www. CLINICALTRIALS gov. Unique identifier: NCT04078737.
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Affiliation(s)
- Anxin Wang
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Xia Meng
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Xue Tian
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Yingting Zuo
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Philip M Bath
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Hao Li
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Xuewei Xie
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Jing Jing
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Jinxi Lin
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Yilong Wang
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Xingquan Zhao
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Liping Liu
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Zixiao Li
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Yong Jiang
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Jie Xu
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Feng Wang
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Weifeng Chen
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Minghua Cao
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Jianhua Li
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Yongjun Wang
- From the Department of Neurology (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China; China National Clinical Research Center for Neurological Diseases (A.W., X.M., X.T., Y.Z., H.L., X.X., J.J., J.L., Y.W., X.Z., L.L., Z.L., Y.J., J.X., Y.W.), Beijing, China; Department of Epidemiology and Health Statistics (X.T.), School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.), China; Stroke Trials Unit, Mental Health & Clinical Neuroscience (P.M.B.), University of Nottingham, United Kingdom; Departments of Neurology (F.W.), Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Neurology (W.C.), Xingyang People's Hospital, Henan, China; Department of Neurology (M.C.), Jingdezheng First People's Hospital, Jiangxi, China; Department of Neurology (J.L.), The First Hospital of Fangshan District, Beijing, China; Advanced Innovation Center for Human Brain Protection (A.W., X.M., Y.W.), Beijing Tiantan Hospital, Capital Medical University, China.
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Phan TG, Beare R, Bath PM, Ievlieva S, Ho S, Ly J, Thrift AG, Srikanth VK, Ma H. Effect of alteplase, benzodiazepines and beta-blocker on post-stroke pneumonia: Exploration of VISTA-Acute. PLoS One 2023; 18:e0281617. [PMID: 37126535 PMCID: PMC10150972 DOI: 10.1371/journal.pone.0281617] [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: 07/17/2022] [Accepted: 01/27/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Post-stroke pneumonia is a frequent complication of stroke and is associated with high mortality. Investigators have described its associations with beta-blocker. However, there has been no evaluation of the role of recombinant tissue plasminogen activator (RTPA). We postulate that RTPA may modify the effect of stroke on pneumonia by reducing stroke disability. We explore this using data from neuroprotection trials in Virtual International Stroke Trials Archive (VISTA)-Acute. METHOD We evaluated the impact of RTPA and other medications in random forest model. Random forest is a type of supervised ensemble tree-based machine learning method. We used the standard approach for performing random forest and partitioned the data into training (70%) and validation (30%) sets. This action enabled to the model developed on training data to be evaluated in the validation data. We borrowed idea from Coalition Game Theory on fair distribution of marginal profit (Shapley value) to determine proportional contribution of a covariate to the model. Consistent with other analysis using the VISTA-Acute data, the diagnosis of post-stroke pneumonia was based on reports of serious adverse events. RESULTS The overall frequency of pneumonia was 10.9% (614/5652). It was present in 11.5% of the RTPA (270/2358) and 10.4% (344/3295) of the no RTPA groups. There was significant (p<0.05) imbalance in covariates (age, baseline National Institutes of Health Stroke Scale (NIHSS), diabetes, and sex). The AUC for training data was 0.70 (95% CI 0.65-0.76), validation data was 0.67 (95% CI 0.62-0.73). The Shapley value shows that baseline NIHSS (≥10) and age (≥80) made the largest contribution to the model of pneumonia while absence of benzodiazepine may protect against pneumonia. RTPA and beta-blocker had very low effect on frequency of pneumonia. CONCLUSION In this cohort pneumonia was strongly associated with stroke severity and age whereas RTPA had a much lower effect. An intriguing finding is a possible association between benzodiazepine and pneumonia but this requires further evaluation.
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Affiliation(s)
- Thanh G Phan
- Department of Neurology, Monash Medical Centre, Clayton, Australia
- Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Richard Beare
- Department of Medicine, Peninsula Health and Central Clinical School, Monash University and National Centre for Healthy Ageing, Melbourne, Australia
- Murdoch Children Institute of Research, Melbourne, Australia
| | - Philip M Bath
- Division of Clinical Neuroscience, Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Svitlana Ievlieva
- Department of Neurology, Monash Medical Centre, Clayton, Australia
- Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Stella Ho
- Department of Pharmacy, Monash Health, Clayton, Australia
| | - John Ly
- Department of Neurology, Monash Medical Centre, Clayton, Australia
- Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Amanda G Thrift
- Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Velandai K Srikanth
- Department of Medicine, Peninsula Health and Central Clinical School, Monash University and National Centre for Healthy Ageing, Melbourne, Australia
| | - Henry Ma
- Department of Neurology, Monash Medical Centre, Clayton, Australia
- Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
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Jing J, Xie X, Johnston SC, Bath PM, Li Z, Zhao X, Liu L, Wang Y, Xu Q, Wang A, Jiang Y, Li H, Meng X, Wang Y. Genotype-Guided Dual Antiplatelet Use for Transient Ischemic Attack and Minor Stroke by Imaging Status: Subgroup Analysis of the CHANCE-2 Trial. Ann Neurol 2022; 93:783-792. [PMID: 36571569 DOI: 10.1002/ana.26589] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study was performed to investigate whether ticagrelor/aspirin versus clopidogrel/aspirin can further reduce the residual risk of stroke recurrence in patients with positive diffusion-weighted imaging (DWI) in the High-Risk Patients with Acute Nondisabling Cerebrovascular Events II (CHANCE-2) trial. METHODS Patients with DWI data in the CHANCE-2 trial were included and divided into those with and without acute infarction according to their DWI findings. The primary efficacy outcome and safety outcome were stroke recurrence and moderate to severe bleeding within 3 months of follow-up, respectively. RESULTS Of the 6,412 patients enrolled in the CHANCE-2 trial, 5,796 (90.4%) patients with DWI data were included in the subgroup analysis. A total of 4,369 patients (75.4%) had an acute infarction on DWI. Patients with positive DWI had higher risk of recurrent stroke (8.1%) than those without infarction (2.2%) within 3-month follow-up. Compared with clopidogrel/aspirin, ticagrelor/aspirin was associated with lower risk of stroke in patients with positive DWI (hazard ratio [HR] = 0.65, 95% confidence interval [CI] = 0.52-0.80, p < 0.001) than in those negative DWI (HR = 1.22, 95% CI = 0.55-2.72, p = 0.63), with a significant interaction association (p for interaction = 0.049). The risk of moderate to severe bleeding was similar between ticagrelor/aspirin and clopidogrel/aspirin treatment in the different groups. INTERPRETATION Our study demonstrates that imaging evaluation should be emphasized before targeting the best candidates for genotype-guided dual antiplatelet therapy in future clinical research and practice. ANN NEUROL 2023.
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Affiliation(s)
- Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Tiantan Neuroimaging Center of Excellence, Beijing, China
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qin Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Abstract
Background We hypothesized that stroke outcome is related to multiple baseline hydration-related factors including volume contracted state (VCS) and diuretic use. Methods and Results We analyzed a prospective cohort of subjects with ischemic stroke <24 hours of onset enrolled in acute treatment trials within VISTA (Virtual International Stroke Trials Archive). A VCS was defined based on blood urea nitrogen-to-creatinine ratio. The primary end point was modified Rankin Scale score at 90 days. Primary analysis used generalized ordinal logistic regression over the mRS range, adjusted for Totaled Health Risks in Vascular Events score, onset-to-enrollment time, and thrombolytic use. Of 5971 eligible patients with stroke, 42% were taking diuretics at the time of hospitalization, and 44% were in a VCS. Patients in a VCS were older, had more vascular risk factors, were more likely taking diuretics, and had more severe strokes. Diuretic use was associated with both reduced chance of achieving a good functional outcome (odds ratio [OR], 0.57 [95% CI, 0.52-0.63]) and increased mortality at 90 days (OR, 2.30 [95% CI, 2.04-2.61]). VCS was associated with greater mortality 90 days after stroke (OR, 1.53 [95% CI, 1.33-1.76]). There was no evidence of effect modification among the 3 exposures of VCS, diuretic use, or hypokalemia in relation to outcome. Conclusions A VCS at the time of hospitalization was associated with more severe stroke and odds of death but not associated with worse functional outcome when accounting for relevant characteristics. Diuretic use and low serum potassium at the time of stroke onset were associated with worse outcome and may be worthy of further investigation.
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Affiliation(s)
| | | | - Philip M. Bath
- Stroke Trials Unit, University of NottinghamNottinghamUnited Kingdom
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Seiffge DJ, Polymeris AA, Law ZK, Krishnan K, Zietz A, Thilemann S, Werring D, Al-Shahi Salman R, Dineen RA, Engelter ST, Bath PM, Sprigg N, Lyrer P, Peters N. Cerebral Amyloid Angiopathy and the Risk of Hematoma Expansion. Ann Neurol 2022; 92:921-930. [PMID: 36054211 PMCID: PMC9804369 DOI: 10.1002/ana.26481] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE We assessed whether hematoma expansion (HE) and favorable outcome differ according to type of intracerebral hemorrhage (ICH). METHODS Among participants with ICH enrolled in the TICH-2 (Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage) trial, we assessed baseline scans for hematoma location and presence of cerebral amyloid angiopathy (CAA) using computed tomography (CT, simplified Edinburgh criteria) and magnetic resonance imaging (MRI; Boston criteria) and categorized ICH as lobar CAA, lobar non-CAA, and nonlobar. The main outcomes were HE and favorable functional outcome. We constructed multivariate regression models and assessed treatment effects using interaction terms. RESULTS A total of 2,298 out of 2,325 participants were included with available CT (98.8%; median age = 71 years, interquartile range = 60-80 years; 1,014 female). Additional MRI was available in 219 patients (9.5%). Overall, 1,637 participants (71.2%) had nonlobar ICH; the remaining 661 participants (28.8%) had lobar ICH, of whom 202 patients had lobar CAA-ICH (8.8%, 173 participants according to Edinburgh and 29 participants according to Boston criteria) and 459 did not (lobar non-CAA, 20.0%). For HE, we found a significant interaction of lobar CAA ICH with time from onset to randomization (increasing risk with time, pinteraction < 0.001) and baseline ICH volume (constant risk regardless of volume, pinteraction < 0.001) but no association between type of ICH and risk of HE or favorable outcome. Tranexamic acid significantly reduced the risk of HE (adjusted odds ratio = 0.7, 95% confidence interval = 0.6-1.0, p = 0.020) without statistically significant interaction with type of ICH (pinteraction = 0.058). Tranexamic acid was not associated with favorable outcome. INTERPRETATION Risk of HE in patients with lobar CAA-ICH was not independently increased but seems to have different dynamics compared to other types of ICH. The time window for treatment of CAA-ICH to prevent HE may be longer. ANN NEUROL 2022;92:921-930.
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Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Zhe Kang Law
- Stroke Trials Unit, University of Nottingham, Nottingham, UK.,Department of Medicine, National University of Malaysia, Bangi, Malaysia
| | - Kailash Krishnan
- Stroke Trials Unit, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David Werring
- Stroke Research Centre, University College London Queen Square Institute of Neurology, London, UK
| | | | - Robert A Dineen
- Radiological Sciences, University of Nottingham, Nottingham, UK.,National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham, UK
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland.,Stroke Center, Hirslanden Clinic, Zürich, Switzerland
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Mair G, White P, Bath PM, Muir KW, Al‐Shahi Salman R, Martin C, Dye D, Chappell FM, Vacek A, von Kummer R, Macleod M, Sprigg N, Wardlaw JM. External Validation of e-ASPECTS Software for Interpreting Brain CT in Stroke. Ann Neurol 2022; 92:943-957. [PMID: 36053916 PMCID: PMC9826303 DOI: 10.1002/ana.26495] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 07/08/2022] [Accepted: 08/29/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The purpose of this study was to test e-ASPECTS software in patients with stroke. Marketed as a decision-support tool, e-ASPECTS may detect features of ischemia or hemorrhage on computed tomography (CT) imaging and quantify ischemic extent using Alberta Stroke Program Early CT Score (ASPECTS). METHODS Using CT from 9 stroke studies, we compared software with masked experts. As per indications for software use, we assessed e-ASPECTS results for patients with/without middle cerebral artery (MCA) ischemia but no other cause of stroke. In an analysis outside the intended use of the software, we enriched our dataset with non-MCA ischemia, hemorrhage, and mimics to simulate a representative "front door" hospital population. With final diagnosis as the reference standard, we tested the diagnostic accuracy of e-ASPECTS for identifying stroke features (ischemia, hyperattenuated arteries, and hemorrhage) in the representative population. RESULTS We included 4,100 patients (51% women, median age = 78 years, National Institutes of Health Stroke Scale [NIHSS] = 10, onset to scan = 2.5 hours). Final diagnosis was ischemia (78%), hemorrhage (14%), or mimic (8%). From 3,035 CTs with expert-rated ASPECTS, most (2084/3035, 69%) e-ASPECTS results were within one point of experts. In the representative population, the diagnostic accuracy of e-ASPECTS was 71% (95% confidence interval [CI] = 70-72%) for detecting ischemic features, 85% (83-86%) for hemorrhage. Software identified more false positive ischemia (12% vs 2%) and hemorrhage (14% vs <1%) than experts. INTERPRETATION On independent testing, e-ASPECTS provided moderate agreement with experts and overcalled stroke features. Therefore, future prospective trials testing impacts of artificial intelligence (AI) software on patient care and outcome are required before widespread implementation of stroke decision-support software. ANN NEUROL 2022;92:943-957.
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Affiliation(s)
- Grant Mair
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Philip White
- Translational and Clinical Research InstituteNewcastle University and Newcastle upon Tyne Hospitals NHS TrustNewcastle upon TyneUK
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical NeuroscienceUniversity of NottinghamNottinghamUK
| | - Keith W. Muir
- School of Psychology & NeuroscienceUniversity of GlasgowGlasgowUK
| | | | - Chloe Martin
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - David Dye
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | | | - Adam Vacek
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Rüdiger von Kummer
- Department of NeuroradiologyUniversity Hospital, Technische Universität DresdenDresdenGermany
| | - Malcolm Macleod
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Nikola Sprigg
- Translational and Clinical Research InstituteNewcastle University and Newcastle upon Tyne Hospitals NHS TrustNewcastle upon TyneUK
| | - Joanna M. Wardlaw
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
- UK Dementia Research Institute Centre at the University of EdinburghEdinburghUK
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Dixon M, Appleton JP, Scutt P, Woodhouse LJ, Haywood LJ, Havard D, Williams J, Siriwardena AN, Bath PM. Time intervals and distances travelled for prehospital ambulance stroke care: data from the randomised-controlled ambulance-based Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2). BMJ Open 2022; 12:e060211. [PMID: 36410799 PMCID: PMC9680177 DOI: 10.1136/bmjopen-2021-060211] [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] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Ambulances offer the first opportunity to evaluate hyperacute stroke treatments. In this study, we investigated the conduct of a hyperacute stroke study in the ambulance-based setting with a particular focus on timings and logistics of trial delivery. DESIGN Multicentre prospective, single-blind, parallel group randomised controlled trial. SETTING Eight National Health Service ambulance services in England and Wales; 54 acute stroke centres. PARTICIPANTS Paramedics enrolled 1149 patients assessed as likely to have a stroke, with Face, Arm, Speech and Time score (2 or 3), within 4 hours of symptom onset and systolic blood pressure >120 mm Hg. INTERVENTIONS Paramedics administered randomly assigned active transdermal glyceryl trinitrate or sham. PRIMARY AND SECONDARY OUTCOMES Modified Rankin scale at day 90. This paper focuses on response time intervals, distances travelled and baseline characteristics of patients, compared between ambulance services. RESULTS Paramedics enrolled 1149 patients between September 2015 and May 2018. FINAL DIAGNOSIS intracerebral haemorrhage 13%, ischaemic stroke 52%, transient ischaemic attack 9% and mimic 26%. Timings (min) were (median (25-75 centile)): onset to emergency call 19 (5-64); onset to randomisation 71 (45-116); total time at scene 33 (26-46); depart scene to hospital 15 (10-23); randomisation to hospital 24 (16-34) and onset to hospital 97 (71-141). Ambulances travelled (km) 10 (4-19) from scene to hospital. Timings and distances differed between ambulance service, for example, onset to randomisation (fastest 53 min, slowest 77 min; p<0.001), distance from scene to hospital (least 4 km, most 20 km; p<0.001). CONCLUSION We completed a large prehospital stroke trial involving a simple-to-administer intervention across multiple ambulance services. The time from onset to randomisation and modest distances travelled support the applicability of future large-scale paramedic-delivered ambulance-based stroke trials in urban and rural locations. TRIAL REGISTRATION NUMBER ISRCTN26986053.
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Affiliation(s)
- Mark Dixon
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
- Leicester, Leicestershire & Rutland Division, East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Jason P Appleton
- Stroke, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Polly Scutt
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Lisa J Woodhouse
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Lee J Haywood
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Diane Havard
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Julia Williams
- Division of Paramedic Science, School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | | | - Philip M Bath
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
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Kok YE, Pszczolkowski S, Law ZK, Ali A, Krishnan K, Bath PM, Sprigg N, Dineen RA, French AP. Semantic Segmentation of Spontaneous Intracerebral Hemorrhage, Intraventricular Hemorrhage, and Associated Edema on CT Images Using Deep Learning. Radiol Artif Intell 2022; 4:e220096. [PMID: 36523645 PMCID: PMC9745441 DOI: 10.1148/ryai.220096] [Citation(s) in RCA: 6] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/30/2022] [Accepted: 09/12/2022] [Indexed: 11/11/2022]
Abstract
This study evaluated deep learning algorithms for semantic segmentation and quantification of intracerebral hemorrhage (ICH), perihematomal edema (PHE), and intraventricular hemorrhage (IVH) on noncontrast CT scans of patients with spontaneous ICH. Models were assessed on 1732 annotated baseline noncontrast CT scans obtained from the Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage (ie, TICH-2) international multicenter trial (ISRCTN93732214), and different loss functions using a three-dimensional no-new-U-Net (nnU-Net) were examined to address class imbalance (30% of participants with IVH in dataset). On the test cohort (n = 174, 10% of dataset), the top-performing models achieved median Dice similarity coefficients of 0.92 (IQR, 0.89-0.94), 0.66 (0.58-0.71), and 1.00 (0.87-1.00), respectively, for ICH, PHE, and IVH segmentation. U-Net-based networks showed comparable, satisfactory performances on ICH and PHE segmentations (P > .05), but all nnU-Net variants achieved higher accuracy than the Brain Lesion Analysis and Segmentation Tool for CT (BLAST-CT) and DeepLabv3+ for all labels (P < .05). The Focal model showed improved performance in IVH segmentation compared with the Tversky, two-dimensional nnU-Net, U-Net, BLAST-CT, and DeepLabv3+ models (P < .05). Focal achieved concordance values of 0.98, 0.88, and 0.99 for ICH, PHE, and ICH volumes, respectively. The mean volumetric differences between the ground truth and prediction were 0.32 mL (95% CI: -8.35, 9.00), 1.14 mL (-9.53, 11.8), and 0.06 mL (-1.71, 1.84), respectively. In conclusion, U-Net-based networks provide accurate segmentation on CT images of spontaneous ICH, and Focal loss can address class imbalance. International Clinical Trials Registry Platform (ICTRP) no. ISRCTN93732214 Supplemental material is available for this article. © RSNA, 2022 Keywords: Head/Neck, Brain/Brain Stem, Hemorrhage, Segmentation, Quantification, Convolutional Neural Network (CNN), Deep Learning Algorithms, Machine Learning Algorithms.
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Affiliation(s)
- Yong En Kok
- Computer Vision Laboratory, School of Computer Science (Y.E.K., A.P.F.), Department of Radiological Sciences, Mental Health & Clinical Neuroscience (S.P., R.A.D.), Stroke Trials Unit, Mental Health & Clinical Neuroscience (Z.K.L., K.K., P.M.B., N.S.), and Sir Peter Mansfield Imaging Centre (R.A.D.), University of Nottingham, Jubilee Campus, 7301 Wollaton Rd, Lenton, Nottingham NG8 1BB, England; NIHR Nottingham Biomedical Research Centre, Nottingham, England (S.P., R.A.D.); Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia (Z.K.L.); School of Medical Imaging, Universiti Sultan Zainal Abidin, Terengganu, Malaysia (A.A.); and Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England (K.K., P.M.B., N.S.)
| | - Stefan Pszczolkowski
- Computer Vision Laboratory, School of Computer Science (Y.E.K., A.P.F.), Department of Radiological Sciences, Mental Health & Clinical Neuroscience (S.P., R.A.D.), Stroke Trials Unit, Mental Health & Clinical Neuroscience (Z.K.L., K.K., P.M.B., N.S.), and Sir Peter Mansfield Imaging Centre (R.A.D.), University of Nottingham, Jubilee Campus, 7301 Wollaton Rd, Lenton, Nottingham NG8 1BB, England; NIHR Nottingham Biomedical Research Centre, Nottingham, England (S.P., R.A.D.); Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia (Z.K.L.); School of Medical Imaging, Universiti Sultan Zainal Abidin, Terengganu, Malaysia (A.A.); and Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England (K.K., P.M.B., N.S.)
| | - Zhe Kang Law
- Computer Vision Laboratory, School of Computer Science (Y.E.K., A.P.F.), Department of Radiological Sciences, Mental Health & Clinical Neuroscience (S.P., R.A.D.), Stroke Trials Unit, Mental Health & Clinical Neuroscience (Z.K.L., K.K., P.M.B., N.S.), and Sir Peter Mansfield Imaging Centre (R.A.D.), University of Nottingham, Jubilee Campus, 7301 Wollaton Rd, Lenton, Nottingham NG8 1BB, England; NIHR Nottingham Biomedical Research Centre, Nottingham, England (S.P., R.A.D.); Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia (Z.K.L.); School of Medical Imaging, Universiti Sultan Zainal Abidin, Terengganu, Malaysia (A.A.); and Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England (K.K., P.M.B., N.S.)
| | - Azlinawati Ali
- Computer Vision Laboratory, School of Computer Science (Y.E.K., A.P.F.), Department of Radiological Sciences, Mental Health & Clinical Neuroscience (S.P., R.A.D.), Stroke Trials Unit, Mental Health & Clinical Neuroscience (Z.K.L., K.K., P.M.B., N.S.), and Sir Peter Mansfield Imaging Centre (R.A.D.), University of Nottingham, Jubilee Campus, 7301 Wollaton Rd, Lenton, Nottingham NG8 1BB, England; NIHR Nottingham Biomedical Research Centre, Nottingham, England (S.P., R.A.D.); Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia (Z.K.L.); School of Medical Imaging, Universiti Sultan Zainal Abidin, Terengganu, Malaysia (A.A.); and Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England (K.K., P.M.B., N.S.)
| | - Kailash Krishnan
- Computer Vision Laboratory, School of Computer Science (Y.E.K., A.P.F.), Department of Radiological Sciences, Mental Health & Clinical Neuroscience (S.P., R.A.D.), Stroke Trials Unit, Mental Health & Clinical Neuroscience (Z.K.L., K.K., P.M.B., N.S.), and Sir Peter Mansfield Imaging Centre (R.A.D.), University of Nottingham, Jubilee Campus, 7301 Wollaton Rd, Lenton, Nottingham NG8 1BB, England; NIHR Nottingham Biomedical Research Centre, Nottingham, England (S.P., R.A.D.); Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia (Z.K.L.); School of Medical Imaging, Universiti Sultan Zainal Abidin, Terengganu, Malaysia (A.A.); and Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England (K.K., P.M.B., N.S.)
| | - Philip M Bath
- Computer Vision Laboratory, School of Computer Science (Y.E.K., A.P.F.), Department of Radiological Sciences, Mental Health & Clinical Neuroscience (S.P., R.A.D.), Stroke Trials Unit, Mental Health & Clinical Neuroscience (Z.K.L., K.K., P.M.B., N.S.), and Sir Peter Mansfield Imaging Centre (R.A.D.), University of Nottingham, Jubilee Campus, 7301 Wollaton Rd, Lenton, Nottingham NG8 1BB, England; NIHR Nottingham Biomedical Research Centre, Nottingham, England (S.P., R.A.D.); Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia (Z.K.L.); School of Medical Imaging, Universiti Sultan Zainal Abidin, Terengganu, Malaysia (A.A.); and Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England (K.K., P.M.B., N.S.)
| | - Nikola Sprigg
- Computer Vision Laboratory, School of Computer Science (Y.E.K., A.P.F.), Department of Radiological Sciences, Mental Health & Clinical Neuroscience (S.P., R.A.D.), Stroke Trials Unit, Mental Health & Clinical Neuroscience (Z.K.L., K.K., P.M.B., N.S.), and Sir Peter Mansfield Imaging Centre (R.A.D.), University of Nottingham, Jubilee Campus, 7301 Wollaton Rd, Lenton, Nottingham NG8 1BB, England; NIHR Nottingham Biomedical Research Centre, Nottingham, England (S.P., R.A.D.); Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia (Z.K.L.); School of Medical Imaging, Universiti Sultan Zainal Abidin, Terengganu, Malaysia (A.A.); and Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England (K.K., P.M.B., N.S.)
| | - Robert A Dineen
- Computer Vision Laboratory, School of Computer Science (Y.E.K., A.P.F.), Department of Radiological Sciences, Mental Health & Clinical Neuroscience (S.P., R.A.D.), Stroke Trials Unit, Mental Health & Clinical Neuroscience (Z.K.L., K.K., P.M.B., N.S.), and Sir Peter Mansfield Imaging Centre (R.A.D.), University of Nottingham, Jubilee Campus, 7301 Wollaton Rd, Lenton, Nottingham NG8 1BB, England; NIHR Nottingham Biomedical Research Centre, Nottingham, England (S.P., R.A.D.); Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia (Z.K.L.); School of Medical Imaging, Universiti Sultan Zainal Abidin, Terengganu, Malaysia (A.A.); and Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England (K.K., P.M.B., N.S.)
| | - Andrew P French
- Computer Vision Laboratory, School of Computer Science (Y.E.K., A.P.F.), Department of Radiological Sciences, Mental Health & Clinical Neuroscience (S.P., R.A.D.), Stroke Trials Unit, Mental Health & Clinical Neuroscience (Z.K.L., K.K., P.M.B., N.S.), and Sir Peter Mansfield Imaging Centre (R.A.D.), University of Nottingham, Jubilee Campus, 7301 Wollaton Rd, Lenton, Nottingham NG8 1BB, England; NIHR Nottingham Biomedical Research Centre, Nottingham, England (S.P., R.A.D.); Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia (Z.K.L.); School of Medical Imaging, Universiti Sultan Zainal Abidin, Terengganu, Malaysia (A.A.); and Stroke, Nottingham University Hospitals NHS Trust, Nottingham, England (K.K., P.M.B., N.S.)
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Wang A, Xie X, Tian X, Johnston SC, Li H, Bath PM, Zuo Y, Jing J, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Meng X, Wang Y. Ticagrelor-Aspirin Versus Clopidogrel-Aspirin Among CYP2C19 Loss-of-Function Carriers With Minor Stroke or Transient Ischemic Attack in Relation to Renal Function: A Post Hoc Analysis of the CHANCE-2 Trial. Ann Intern Med 2022; 175:1534-1542. [PMID: 36315949 DOI: 10.7326/m22-1667] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Evidence on the risk-benefit ratio of dual antiplatelet therapies among patients with stroke and impaired renal function is limited and inconsistent. OBJECTIVE To investigate the effect of renal function on the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin treatment. DESIGN Post hoc analysis of a multicenter, randomized, double-blind, placebo-controlled trial. (ClinicalTrials.gov: NCT04078737). SETTING 202 centers in China. PATIENTS CYP2C19 loss-of-function allele carriers with minor stroke or transient ischemic attack. INTERVENTION Ticagrelor-aspirin and clopidogrel-aspirin. MEASUREMENTS Renal function was evaluated by estimated glomerular filtration rate (eGFR) levels. The primary efficacy and safety outcomes were recurrent stroke and severe or moderate bleeding within 90 days, respectively. RESULTS Among 6378 patients, 4050 (63.5%) had normal (eGFR ≥90 mL/min/1.73 m2), 2010 (31.5%) had mildly decreased (eGFR 60 to 89 mL/min/1.73 m2), and 318 (5.0%) had moderately to severely decreased (eGFR <60 mL/min/1.73 m2) renal function. The corresponding differences in recurrent stroke between ticagrelor-aspirin and clopidogrel-aspirin for normal, mildly decreased, and moderately to severely decreased renal function was -2.8 percentage points (95% CI, -4.4 to -1.3 percentage points) (hazard ratio [HR], 0.63 [CI, 0.49 to 0.81]), -0.2 percentage point (CI, -2.4 to 2.0 percentage points) (HR, 0.98 [CI, 0.69 to 1.39]), and 3.7 percentage points (CI, -2.3 to 10.1 percentage points) (HR, 1.31 [CI, 0.48 to 3.55]), respectively. Rates of severe or moderate bleeding did not substantially differ by treatment assignments across eGFR categories. LIMITATION Renal function was only evaluated by using eGFR, and the proportion of patients with severely decreased renal function was low. CONCLUSION Patients with normal, rather than impaired, renal function received greater benefit from ticagrelor-aspirin versus clopidogrel-aspirin. PRIMARY FUNDING SOURCE Ministry of Science and Technology of the People's Republic of China.
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Affiliation(s)
- Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Xue Tian
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China National Clinical Research Center for Neurological Diseases, Beijing, Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, and Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China (X.T., Y.Z.)
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yingting Zuo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China National Clinical Research Center for Neurological Diseases, Beijing, Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, and Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China (X.T., Y.Z.)
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China National Clinical Research Center for Neurological Diseases, Beijing, and Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.W.)
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Krishnan K, Law ZK, Woodhouse LJ, Dineen RA, Sprigg N, Wardlaw JM, Bath PM. Measures of intracranial compartments in acute intracerebral haemorrhage: data from the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke-2 Trial (RIGHT-2). Stroke Vasc Neurol 2022; 8:151-160. [PMID: 36202546 PMCID: PMC10176998 DOI: 10.1136/svn-2021-001375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 05/11/2022] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND AND PURPOSE Intracerebral haemorrhage volume (ICHV) is prognostically important but does not account for intracranial volume (ICV) and cerebral parenchymal volume (CPV). We assessed measures of intracranial compartments in acute ICH using computerised tomography scans and whether ICHV/ICV and ICHV/CPV predict functional outcomes. We also assessed if cistern effacement, midline shift, old infarcts, leukoaraiosis and brain atrophy were associated with outcomes. METHODS Data from 133 participants from the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke-2 Trial trial were analysed. Measures included ICHV (using ABC/2) and ICV (XYZ/2) (by independent observers); ICHV, ICV and CPV (semiautomated segmentation, SAS); atrophy (intercaudate distance, ICD, Sylvian fissure ratio, SFR); midline shift; leukoaraiosis and cistern effacement (visual assessment). The effects of these measures on death at day 4 and poor functional outcome at day 90 (modified Rankin scale, mRS of >3) was assessed. RESULTS ICV was significantly different between XYZ and SAS: mean (SD) of 1357 (219) vs 1420 (196), mean difference (MD) 62 mL (p<0.001). There was no significant difference in ICHV between ABC/2 and SAS. There was very good agreement for ICV measured by SAS, CPV, ICD, SFR, leukoaraiosis and cistern score (all interclass correlations, n=10: interobserver 0.72-0.99, intraobserver 0.73-1.00). ICHV/ICV and ICHV/CPV were significantly associated with mRS at day 90, death at day 4 and acute neurological deterioration (all p<0.05), similar to ICHV. Midline shift and cistern effacement at baseline were associated with poor functional outcome but old infarcts, leukoaraiosis and brain atrophy were not. CONCLUSIONS Intracranial compartment measures and visual estimates are reproducible. ICHV adjusted for ICH and CPV could be useful to prognosticate in acute stroke. The presence of midline shift and cistern effacement may predict outcome but the mechanisms need validation in larger studies.
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Affiliation(s)
- Kailash Krishnan
- Stroke, Department of Acute Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK .,Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Zhe Kang Law
- Department of Medicine, National University of Malaysia Faculty of Medicine, Kuala Lumpur, Malaysia
| | | | - Rob A Dineen
- Radiological Sciences Research Group, University of Nottingham, Nottingham, UK.,National Institute of Health Research Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke, Department of Acute Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, Chancellor's Building, University of Edinburgh, Edinburgh, UK
| | - Philip M Bath
- Stroke, Department of Acute Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Stroke Trials Unit, University of Nottingham, Nottingham, UK
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50
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Bath PM, Mhlanga I, Woodhouse LJ, Doubal F, Oatey K, Montgomery AA, Wardlaw JM. Cilostazol and isosorbide mononitrate for the prevention of progression of cerebral small vessel disease: baseline data and statistical analysis plan for the Lacunar Intervention Trial-2 (LACI-2) (ISRCTN14911850). Stroke Vasc Neurol 2022; 8:134-143. [PMID: 36219567 PMCID: PMC10176977 DOI: 10.1136/svn-2022-001816] [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: 06/29/2022] [Accepted: 08/16/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Cerebral small vessel disease (SVD) causes lacunar strokes (25% of all ischaemic strokes), physical frailty and cognitive impairment and vascular and mixed dementia. There is no specific treatment to prevent progression of SVD. METHODS The LACunar Intervention Trial-2 is an investigator-initiated prospective randomised open-label blinded-endpoint phase II feasibility study assessing cilostazol and isosorbide mononitrate for preventing SVD progression. We aimed to recruit 400 patients with clinically evident lacunar ischaemic stroke and randomised to cilostazol, isosorbide mononitrate, both or neither, in addition to guideline secondary ischaemic stroke prevention, in a partial factorial design. The primary outcome is feasibility of recruitment and adherence to medication; key secondary outcomes include: drug tolerability; recurrent vascular events, cognition and function at 1 year after randomisation; and safety (bleeding, falls, death). Data are number (%) and median (IQR). RESULTS The trial commenced on 5 February 2018 and ceased recruitment on 31 May 2021 with 363 patients randomised, with the following baseline characteristics: average age 64 (56.0, 72.0) years, female 112 (30.9%), stroke onset to randomisation 79.0 (27.0, 244.0) days, hypertension 267 (73.6%), median blood pressures 143.0 (130.0, 157.0)/83.0 (75.0, 90.0) mm Hg, current smokers 67 (18.5%), educationally achieved end of school examinations (A-level) or higher 118 (32.5%), modified Rankin scale 1.0 (0.0, 1.0), National Institutes Health stroke scale 1.0 (1.4), Montreal Cognitive Assessment 26.0 (23.0, 28.0) and total SVD score on brain imaging 1.0 (0.0, 2.0). This publication summarises the baseline data and presents the statistical analysis plan. SUMMARY The trial is currently in follow-up which will complete on 31 May 2022 with results expected in October 2022. TRIAL REGISTRATION NUMBER ISRCTN14911850.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Iris Mhlanga
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Fergus Doubal
- Centre for Clinical Brain Sciences, UK Dementia Research Institute Centre, University of Edinburgh, Edinburgh, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute Centre, University of Edinburgh, Edinburgh, UK
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