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Rutten JW, Cerfontaine MN, Dijkstra KL, Mulder AA, Vreijling J, Kruit M, Koning RI, de Bot ST, van Nieuwenhuizen KM, Baelde HJ, Berendse HW, Mei LH, Ruijter GJG, Baas F, Jost CR, van Duinen SG, Nibbeling EAR, Gravesteijn G, Lesnik Oberstein SAJ. Bi-allelic NIT1 variants cause a brain small vessel disease characterized by movement disorders, massively dilated perivascular spaces, and intracerebral hemorrhage. Genet Med 2024; 26:101105. [PMID: 38430071 DOI: 10.1016/j.gim.2024.101105] [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: 10/18/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024] Open
Abstract
PURPOSE To describe a recessively inherited cerebral small vessel disease, caused by loss-of-function variants in Nitrilase1 (NIT1). METHODS We performed exome sequencing, brain magnetic resonance imaging, neuropathology, electron microscopy, western blotting, and transcriptomic and metabolic analyses in 7 NIT1-small vessel disease patients from 5 unrelated pedigrees. RESULTS The first identified patients were 3 siblings, compound heterozygous for the NIT1 c.727C>T; (p.Arg243Trp) variant and the NIT1 c.198_199del; p.(Ala68∗) variant. The 4 additional patients were single cases from 4 unrelated pedigrees and were all homozygous for the NIT1 c.727C>T; p.(Arg243Trp) variant. Patients presented in mid-adulthood with movement disorders. All patients had striking abnormalities on brain magnetic resonance imaging, with numerous and massively dilated basal ganglia perivascular spaces. Three patients had non-lobar intracerebral hemorrhage between age 45 and 60, which was fatal in 2 cases. Western blotting on patient fibroblasts showed absence of NIT1 protein, and metabolic analysis in urine confirmed loss of NIT1 enzymatic function. Brain autopsy revealed large electron-dense deposits in the vessel walls of small and medium sized cerebral arteries. CONCLUSION NIT1-small vessel disease is a novel, autosomal recessively inherited cerebral small vessel disease characterized by a triad of movement disorders, massively dilated basal ganglia perivascular spaces, and intracerebral hemorrhage.
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Affiliation(s)
- Julie W Rutten
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Minne N Cerfontaine
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Kyra L Dijkstra
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Aat A Mulder
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen Vreijling
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark Kruit
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Roman I Koning
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, The Netherlands
| | - Susanne T de Bot
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Hans J Baelde
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk W Berendse
- Department of Neurology, Amsterdam University Medical Center, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Leon H Mei
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - George J G Ruijter
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Frank Baas
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Carolina R Jost
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sjoerd G van Duinen
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther A R Nibbeling
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Gido Gravesteijn
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
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Schreuder FHBM, van Nieuwenhuizen KM, Hofmeijer J, Vermeer SE, Kerkhoff H, Zock E, Luijckx GJ, Messchendorp GP, van Tuijl J, Bienfait HP, Booij SJ, van den Wijngaard IR, Remmers MJM, Schreuder AHCML, Dippel DW, Staals J, Brouwers PJAM, Wermer MJH, Coutinho JM, Kwa VIH, van Gelder IC, Schutgens REG, Zweedijk B, Algra A, van Dalen JW, Jaap Kappelle L, Rinkel GJE, van der Worp HB, Klijn CJM. Apixaban versus no anticoagulation after anticoagulation-associated intracerebral haemorrhage in patients with atrial fibrillation in the Netherlands (APACHE-AF): a randomised, open-label, phase 2 trial. Lancet Neurol 2021; 20:907-916. [PMID: 34687635 DOI: 10.1016/s1474-4422(21)00298-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/29/2021] [Accepted: 09/01/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND In patients with atrial fibrillation who survive an anticoagulation-associated intracerebral haemorrhage, a decision must be made as to whether restarting or permanently avoiding anticoagulation is the best long-term strategy to prevent recurrent stroke and other vascular events. In APACHE-AF, we aimed to estimate the rates of non-fatal stroke or vascular death in such patients when treated with apixaban compared with when anticoagulation was avoided, to inform the design of a larger trial. METHODS APACHE-AF was a prospective, randomised, open-label, phase 2 trial with masked endpoint assessment, done at 16 hospitals in the Netherlands. Patients who survived intracerebral haemorrhage while treated with anticoagulation for atrial fibrillation were eligible for inclusion 7-90 days after the haemorrhage. Participants also had a CHA2DS2-VASc score of at least 2 and a score on the modified Rankin scale (mRS) of 4 or less. Participants were randomly assigned (1:1) to receive oral apixaban (5 mg twice daily or a reduced dose of 2·5 mg twice daily) or to avoid anticoagulation (oral antiplatelet agents could be prescribed at the discretion of the treating physician) by a central computerised randomisation system, stratified by the intention to start or withhold antiplatelet therapy in participants randomised to avoiding anticoagulation, and minimised for age and intracerebral haemorrhage location. The primary outcome was a composite of non-fatal stroke or vascular death, whichever came first, during a minimum follow-up of 6 months, analysed using Cox proportional hazards modelling in the intention-to-treat population. APACHE-AF is registered with ClinicalTrials.gov (NCT02565693) and the Netherlands Trial Register (NL4395), and the trial is closed to enrolment at all participating sites. FINDINGS Between Jan 15, 2015, and July 6, 2020, we recruited 101 patients (median age 78 years [IQR 73-83]; 55 [54%] were men and 46 [46%] were women; 100 [99%] were White and one [1%] was Black) a median of 46 days (IQR 21-74) after intracerebral haemorrhage. 50 were assigned to apixaban and 51 to avoid anticoagulation (of whom 26 [51%] started antiplatelet therapy). None were lost to follow-up. Over a median follow-up of 1·9 years (IQR 1·0-3·1; 222 person-years), non-fatal stroke or vascular death occurred in 13 (26%) participants allocated to apixaban (annual event rate 12·6% [95% CI 6·7-21·5]) and in 12 (24%) allocated to avoid anticoagulation (11·9% [95% CI 6·2-20·8]; adjusted hazard ratio 1·05 [95% CI 0·48-2·31]; p=0·90). Serious adverse events that were not outcome events occurred in 29 (58%) of 50 participants assigned to apixaban and 29 (57%) of 51 assigned to avoid anticoagulation. INTERPRETATION Patients with atrial fibrillation who had an intracerebral haemorrhage while taking anticoagulants have a high subsequent annual risk of non-fatal stroke or vascular death, whether allocated to apixaban or to avoid anticoagulation. Our data underline the need for randomised controlled trials large enough to allow identification of subgroups in whom restarting anticoagulation might be either beneficial or hazardous. FUNDING Dutch Heart Foundation (grant 2012T077).
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Affiliation(s)
- Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Sarah E Vermeer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Elles Zock
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Gert-Jan Luijckx
- Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
| | - Gert P Messchendorp
- Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
| | - Julia van Tuijl
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - H Paul Bienfait
- Department of Neurology, Gelre Hospital, Apeldoorn, Netherlands
| | - Suzanne J Booij
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Ido R van den Wijngaard
- Department of Neurology, Haaglanden MC, The Hague, Netherlands; Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | | | | | - Diederik W Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands
| | | | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | | | | | - Isabelle C van Gelder
- Department of Cardiology, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Berber Zweedijk
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jan Willem van Dalen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands; Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands.
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Singh SD, Schreuder FHBM, van Nieuwenhuizen KM, Jolink WM, Senff JR, Goldstein JN, Boogaarts J, Klijn CJM, Rinkel GJE, Brouwers HB. Secondary Hematoma Evacuation and Outcome After Initial Conservative Approach for Patients with Cerebellar Hematoma Larger than 3 cm. Neurocrit Care 2021; 35:680-686. [PMID: 33650011 PMCID: PMC8692294 DOI: 10.1007/s12028-021-01203-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/30/2021] [Indexed: 11/29/2022]
Abstract
Background In patients with spontaneous cerebellar intracerebral hemorrhage (ICH) guidelines advocate evacuation when the hematoma diameter is > 3 cm. We studied outcome in patients with cerebellar ICH > 3 cm who did not undergo immediate hematoma evacuation. Methods We included consecutive patients with cerebellar ICH > 3 cm at two academic hospitals between 2008 and 2017. Patients who died < 24 h (h) were excluded because of probable confounding by indication. We determined patient characteristics, hematoma volumes, EVD placement, secondary hematoma evacuation, in-hospital and 3-month case-fatality, and functional outcome. Results Of 130 patients with cerebellar ICH, 98 (77%) had a hematoma > 3 cm of whom 22 (23%) died < 24 h and 28 (29%) underwent hematoma evacuation < 24 h. Thus, 48 patients were initially treated conservatively (mean age 70 ± 13, 24 (50%) female). Of these 48 patients, 7 (15%) underwent secondary hematoma evacuation > 24 h, of whom 1 (14%) had received an EVD < 24 h. Five others also received an EVD < 24 h without subsequent hematoma evacuation. Of the 41 patients without secondary hematoma evacuation, 11 (28%) died and 20 (51%) had a favorable outcome (mRS of 0–3) at 3 months. The 7 patients who underwent secondary hematoma evacuation had a decrease in GCS score of at least two points prior to surgery; two (29%) had deceased at 3 months; and 5 (71%) had a good functional outcome (mRS 0–3). Conclusions While cerebellar ICH > 3 cm is often considered an indication for immediate hematoma evacuation, there may be a subgroup of patients in whom surgery can be safely deferred. Further data are needed to assess the optimal timing and indications of surgical treatment in these patients. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01203-6.
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Affiliation(s)
- Sanjula D Singh
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands. .,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Center for Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wilmar M Jolink
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jasper R Senff
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Jeroen Boogaarts
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Center for Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Center for Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H Bart Brouwers
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
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van Nieuwenhuizen KM, Vaartjes I, Verhoeven JI, Rinkel GJ, Kappelle LJ, Schreuder FH, Klijn CJ. Long-term prognosis after intracerebral haemorrhage. Eur Stroke J 2020; 5:336-344. [PMID: 33598551 PMCID: PMC7856590 DOI: 10.1177/2396987320953394] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 07/29/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction The aim of this study was to determine the risk of recurrent intracerebral haemorrhage (ICH), ischaemic stroke, all stroke, any vascular event and all-cause mortality in 30-day survivors of ICH, according to age and sex. Patients and methods We linked national hospital discharge, population and cause of death registers to obtain a cohort of Dutch 30-day survivors of ICH from 1998 to 2010. We calculated cumulative incidences of recurrent ICH, ischaemic stroke, all stroke and composite vascular outcome, adjusted for competing risk of death and all-cause mortality. Additionally, we compared survival with the general population. Results We included 19,444 ICH-survivors (52% male; median age 72 years, interquartile range 61–79; 78,654 patient-years of follow-up). First-year cumulative incidence of recurrent ICH ranged from 1.5% (95% confidence interval 0.9–2.3; men 35–54 years) to 2.4% (2.0–2.9; women 75–94 years). Depending on age and sex, 10-year risk of recurrent ICH ranged from 3.7% (2.6–5.1; men 35–54 years) to 8.1% (6.9–9.4; women 55–74 years); ischaemic stroke 2.6% to 7.0%, of all stroke 9.9% to 26.2% and of any vascular event 15.0% to 40.4%. Ten-year mortality ranged from 16.7% (35–54 years) to 90.0% (75–94 years). Relative survival was lower in all age-groups of both sexes, ranging from 0.83 (0.80–0.87) in 35- to 54-year-old men to 0.28 (0.24–0.32) in 75- to 94-year-old women. Discussion ICH-survivors are at high risk of recurrent ICH, of ischaemic stroke and other vascular events, and have a sustained reduced survival rate compared to the general population. Conclusion The high risk of recurrent ICH, other vascular events and prolonged reduced survival-rates warrant clinical trials to determine optimal secondary prevention treatment after ICH.
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Affiliation(s)
- Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ilonca Vaartjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jamie I Verhoeven
- Department of Neurology, Donders Institute of Brain, Cognition and Behaviour, Center for Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gabriel Je Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Floris Hbm Schreuder
- Department of Neurology, Donders Institute of Brain, Cognition and Behaviour, Center for Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Catharina Jm Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Neurology, Donders Institute of Brain, Cognition and Behaviour, Center for Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
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Jolink WM, Lindenholz A, van Etten ES, van Nieuwenhuizen KM, Schreuder FH, Kuijf HJ, van Osch MJ, Hendrikse J, Rinkel GJ, Wermer MJ, Klijn CJ. Contrast leakage distant from the hematoma in patients with spontaneous ICH: A 7 T MRI study. J Cereb Blood Flow Metab 2020; 40:1002-1011. [PMID: 31142225 PMCID: PMC7178151 DOI: 10.1177/0271678x19852876] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Disruption of the blood-brain barrier (BBB) might play a role in the pathophysiology of cerebral small vessel disease-related ICH. The aim of this study was to assess presence and extent of contrast agent leakage distant from the hematoma as a marker of BBB disruption in patients with spontaneous ICH. We prospectively performed 7 tesla MRI in adult patients with spontaneous ICH and assessed contrast leakage distant from the hematoma on 3D FLAIR images. Thirty-one patients were included (mean age 60 years, 29% women). Median time between ICH and MRI was 20 days (IQR 9-67 days). Seventeen patients (54%; seven lobar, nine deep, one infratentorial ICH) had contrast leakage, located cortical in 16 and cortical and deep in one patient. Patients with contrast leakage more often had lobar cerebral microbleeds (CMBs; 77%) than those without (36%; RR 2.5, 95% CI 1.1-5.7) and a higher number of lobar CMBs (patients with contrast leakage: median 2, IQR 1-8 versus those without: median 0, IQR 0-2; p = 0.02). This study shows that contrast leakage distant from the hematoma is common in days to weeks after spontaneous ICH. It is located predominantly cortical and related to lobar CMBs and therefore possibly to cerebral amyloid angiopathy.
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Affiliation(s)
- Wilmar Mt Jolink
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arjen Lindenholz
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ellis S van Etten
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Floris Hbm Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Radboud university medical center, Nijmegen, The Netherlands
| | - Hugo J Kuijf
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Matthias Jp van Osch
- C.J. Gorter Center for High Field MRI, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gabriel Je Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Catharina Jm Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Radboud university medical center, Nijmegen, The Netherlands
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Ekker MS, Verhoeven JI, Vaartjes I, van Nieuwenhuizen KM, Klijn CJM, de Leeuw FE. Stroke incidence in young adults according to age, subtype, sex, and time trends. Neurology 2019; 92:e2444-e2454. [PMID: 31019103 DOI: 10.1212/wnl.0000000000007533] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/22/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate incidence of stroke and its subtypes in young adults, according to sex and age, and to study trends over time. METHODS We established a nationwide cohort through linkage of national registries (hospital discharge, cause of death, and population register) with patients aged 18-50 years and those ≥50 years with first-ever ischemic stroke, intracerebral hemorrhage, or unspecified stroke, using ICD-9/ICD-10 codes between 1998 and 2010 in the Netherlands. Outcomes were yearly incidence of stroke stratified by age, sex, and stroke subtype, its changes over time, and comparison of incidence in patients 18-50 years to patients ≥50 years. RESULTS We identified 15,257 patients (53% women; mean age 41.8 years). Incidence increased exponentially with age (R 2 = 0.99) and was higher for women than men, most prominently in the youngest patients (18-44 years). The relative proportion of ischemic stroke increased with age (18-24 years: 38.3%; 44-49 years: 56.5%), whereas the relative proportion of intracerebral hemorrhage decreased (18-24 years: 34.0%; 44-49 years: 18.3%). Incidence of any stroke in young adults increased (1998: 14.0/100,000 person-years: 2010: 17.2; +23%; p < 0.001), driven by an increase in those aged over 35 years and ischemic stroke incidence (46%), whereas incidence decreased in those ≥50 years (329.1%-292.2%; -11%; p = 0.009). CONCLUSIONS Incidence of any stroke in the young increases with age in patients over 35, is higher in women than men aged 18-44 years, and has increased by 23% in one decade, through an increase in ischemic stroke. Incidence of intracerebral hemorrhage is comparable for women and men and remained stable over time.
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Affiliation(s)
- Merel S Ekker
- From the Department of Neurology (M.S.E., J.I.V., C.J.M.K., F.-E.d.L.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; and Julius Center for Health Sciences and Primary Care (I.V.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (K.M.v.N., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Jamie I Verhoeven
- From the Department of Neurology (M.S.E., J.I.V., C.J.M.K., F.-E.d.L.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; and Julius Center for Health Sciences and Primary Care (I.V.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (K.M.v.N., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Ilonca Vaartjes
- From the Department of Neurology (M.S.E., J.I.V., C.J.M.K., F.-E.d.L.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; and Julius Center for Health Sciences and Primary Care (I.V.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (K.M.v.N., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Koen M van Nieuwenhuizen
- From the Department of Neurology (M.S.E., J.I.V., C.J.M.K., F.-E.d.L.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; and Julius Center for Health Sciences and Primary Care (I.V.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (K.M.v.N., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Catharina J M Klijn
- From the Department of Neurology (M.S.E., J.I.V., C.J.M.K., F.-E.d.L.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; and Julius Center for Health Sciences and Primary Care (I.V.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (K.M.v.N., C.J.M.K.), University Medical Center Utrecht, the Netherlands
| | - Frank-Erik de Leeuw
- From the Department of Neurology (M.S.E., J.I.V., C.J.M.K., F.-E.d.L.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; and Julius Center for Health Sciences and Primary Care (I.V.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (K.M.v.N., C.J.M.K.), University Medical Center Utrecht, the Netherlands.
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Marini S, Crawford K, Morotti A, Lee MJ, Pezzini A, Moomaw CJ, Flaherty ML, Montaner J, Roquer J, Jimenez-Conde J, Giralt-Steinhauer E, Elosua R, Cuadrado-Godia E, Soriano-Tarraga C, Slowik A, Jagiella JM, Pera J, Urbanik A, Pichler A, Hansen BM, McCauley JL, Tirschwell DL, Selim M, Brown DL, Silliman SL, Worrall BB, Meschia JF, Kidwell CS, Testai FD, Kittner SJ, Schmidt H, Enzinger C, Deary IJ, Rannikmae K, Samarasekera N, Salman RAS, Sudlow CL, Klijn CJM, van Nieuwenhuizen KM, Fernandez-Cadenas I, Delgado P, Norrving B, Lindgren A, Goldstein JN, Viswanathan A, Greenberg SM, Falcone GJ, Biffi A, Langefeld CD, Woo D, Rosand J, Anderson CD. Association of Apolipoprotein E With Intracerebral Hemorrhage Risk by Race/Ethnicity: A Meta-analysis. JAMA Neurol 2019; 76:480-491. [PMID: 30726504 PMCID: PMC6459133 DOI: 10.1001/jamaneurol.2018.4519] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [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: 08/17/2018] [Accepted: 11/09/2018] [Indexed: 12/18/2022]
Abstract
Importance Genetic studies of intracerebral hemorrhage (ICH) have focused mainly on white participants, but genetic risk may vary or could be concealed by differing nongenetic coexposures in nonwhite populations. Transethnic analysis of risk may clarify the role of genetics in ICH risk across populations. Objective To evaluate associations between established differences in ICH risk by race/ethnicity and the variability in the risks of apolipoprotein E (APOE) ε4 alleles, the most potent genetic risk factor for ICH. Design, Setting, and Participants This case-control study of primary ICH meta-analyzed the association of APOE allele status on ICH risk, applying a 2-stage clustering approach based on race/ethnicity and stratified by a contributing study. A propensity score analysis was used to model the association of APOE with the burden of hypertension across race/ethnic groups. Primary ICH cases and controls were collected from 3 hospital- and population-based studies in the United States and 8 in European sites in the International Stroke Genetic Consortium. Participants were enrolled from January 1, 1999, to December 31, 2017. Participants with secondary causes of ICH were excluded from enrollment. Controls were regionally matched within each participating study. Main Outcomes and Measures Clinical variables were systematically obtained from structured interviews within each site. APOE genotype was centrally determined for all studies. Results In total, 13 124 participants (7153 [54.5%] male with a median [interquartile range] age of 66 [56-76] years) were included. In white participants, APOE ε2 (odds ratio [OR], 1.49; 95% CI, 1.24-1.80; P < .001) and APOE ε4 (OR, 1.51; 95% CI, 1.23-1.85; P < .001) were associated with lobar ICH risk; however, within self-identified Hispanic and black participants, no associations were found. After propensity score matching for hypertension burden, APOE ε4 was associated with lobar ICH risk among Hispanic (OR, 1.14; 95% CI, 1.03-1.28; P = .01) but not in black (OR, 1.02; 95% CI, 0.98-1.07; P = .25) participants. APOE ε2 and ε4 did not show an association with nonlobar ICH risk in any race/ethnicity. Conclusions and Relevance APOE ε4 and ε2 alleles appear to affect lobar ICH risk variably by race/ethnicity, associations that are confirmed in white individuals but can be shown in Hispanic individuals only when the excess burden of hypertension is propensity score-matched; further studies are needed to explore the interactions between APOE alleles and environmental exposures that vary by race/ethnicity in representative populations at risk for ICH.
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Affiliation(s)
- Sandro Marini
- Center for Genomic Medicine, Massachusetts General Hospital, Boston
| | | | | | - Myung J. Lee
- Department of Neurology, Massachusetts General Hospital, Boston
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Charles J. Moomaw
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Matthew L. Flaherty
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joan Montaner
- Neurovascular Research Laboratory and Neurovascular Unit, Institut de Recerca, Hospital Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Seville, Spain
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Jaume Roquer
- Department of Neurology, Neurovascular Research Unit, Institut Hospital del Mar d’Investigacions Mèdiques, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Jordi Jimenez-Conde
- Department of Neurology, Neurovascular Research Unit, Institut Hospital del Mar d’Investigacions Mèdiques, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Eva Giralt-Steinhauer
- Department of Neurology, Neurovascular Research Unit, Institut Hospital del Mar d’Investigacions Mèdiques, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Roberto Elosua
- Department of Neurology, Neurovascular Research Unit, Institut Hospital del Mar d’Investigacions Mèdiques, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Elisa Cuadrado-Godia
- Department of Neurology, Neurovascular Research Unit, Institut Hospital del Mar d’Investigacions Mèdiques, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Carolina Soriano-Tarraga
- Department of Neurology, Neurovascular Research Unit, Institut Hospital del Mar d’Investigacions Mèdiques, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Joanna Pera
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Andrzej Urbanik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Alexander Pichler
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Björn M. Hansen
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
- Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Jacob L. McCauley
- John P. Hussman Institute for Human Genomics, University of Miami, Miller School of Medicine, Miami
| | | | - Magdy Selim
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Devin L. Brown
- Cardiovascular Center, University of Michigan, Ann Arbor
| | - Scott L. Silliman
- Department of Neurology, University of Florida College of Medicine, Jacksonville
| | - Bradford B. Worrall
- Department of Neurology and Public Health Sciences, University of Virginia Health System, Charlottesville
| | | | | | - Fernando D. Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago
| | - Steven J. Kittner
- Department of Neurology, Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine, Baltimore
| | - Helena Schmidt
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Ian J. Deary
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, United Kingdom
| | - Kristiina Rannikmae
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Neshika Samarasekera
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Catherine L. Sudlow
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Catharina J. M. Klijn
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Koen M. van Nieuwenhuizen
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Israel Fernandez-Cadenas
- Neurovascular Research Laboratory and Neurovascular Unit, Institut de Recerca, Hospital Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
- Stroke Pharmacogenomics and Genetics, Sant Pau Institute of Research, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Pilar Delgado
- Neurovascular Research Laboratory and Neurovascular Unit, Institut de Recerca, Hospital Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Bo Norrving
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
- Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Arne Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
- Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | | | | | | | - Guido J. Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Alessandro Biffi
- Division of Behavioral Neurology, Massachusetts General Hospital, Boston
| | - Carl D. Langefeld
- Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, North Carolina
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston
- Department of Neurology, Massachusetts General Hospital, Boston
- Program in Medical and Population Genetics, Broad Institute, Cambridge, Massachusetts
| | - Christopher D. Anderson
- Center for Genomic Medicine, Massachusetts General Hospital, Boston
- Department of Neurology, Massachusetts General Hospital, Boston
- Program in Medical and Population Genetics, Broad Institute, Cambridge, Massachusetts
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8
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Hilkens NA, van Asch CJJ, Werring DJ, Wilson D, Rinkel GJE, Algra A, Velthuis BK, de Kort GAP, Witkamp TD, van Nieuwenhuizen KM, de Leeuw FE, Schonewille WJ, de Kort PLM, Dippel DWJ, Raaymakers TWM, Hofmeijer J, Wermer MJH, Kerkhoff H, Jellema K, Bronner IM, Remmers MJM, Bienfait HP, Witjes RJGM, Jäger HR, Greving JP, Klijn CJM. Predicting the presence of macrovascular causes in non-traumatic intracerebral haemorrhage: the DIAGRAM prediction score. J Neurol Neurosurg Psychiatry 2018; 89:674-679. [PMID: 29348301 DOI: 10.1136/jnnp-2017-317262] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/27/2017] [Accepted: 12/20/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE A substantial part of non-traumatic intracerebral haemorrhages (ICH) arises from a macrovascular cause, but there is little guidance on selection of patients for additional diagnostic work-up. We aimed to develop and externally validate a model for predicting the probability of a macrovascular cause in patients with non-traumatic ICH. METHODS The DIagnostic AngioGRAphy to find vascular Malformations (DIAGRAM) study (n=298; 69 macrovascular cause; 23%) is a prospective, multicentre study assessing yield and accuracy of CT angiography (CTA), MRI/ magnetic resonance angiography (MRA) and intra-arterial catheter angiography in diagnosing macrovascular causes in patients with non-traumatic ICH. We considered prespecified patient and ICH characteristics in multivariable logistic regression analyses as predictors for a macrovascular cause. We combined independent predictors in a model, which we validated in an external cohort of 173 patients with ICH (78 macrovascular cause, 45%). RESULTS Independent predictors were younger age, lobar or posterior fossa (vs deep) location of ICH, and absence of small vessel disease (SVD). A model that combined these predictors showed good performance in the development data (c-statistic 0.83; 95% CI 0.78 to 0.88) and moderate performance in external validation (c-statistic 0.66; 95% CI 0.58 to 0.74). When CTA results were added, the c-statistic was excellent (0.91; 95% CI 0.88 to 0.94) and good after external validation (0.88; 95% CI 0.83 to 0.94). Predicted probabilities varied from 1% in patients aged 51-70 years with deep ICH and SVD, to more than 50% in patients aged 18-50 years with lobar or posterior fossa ICH without SVD. CONCLUSION The DIAGRAM scores help to predict the probability of a macrovascular cause in patients with non-traumatic ICH based on age, ICH location, SVD and CTA.
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Affiliation(s)
- Nina A Hilkens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Charlotte J J van Asch
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Kempenhaeghe, Academic Centre for Epileptology, Heeze, The Netherlands
| | - David J Werring
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - Duncan Wilson
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - Gabriël J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ale Algra
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gérard A P de Kort
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Theo D Witkamp
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Paul L M de Kort
- Department of Neurology, St Elisabeth Hospital, Tilburg, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Korné Jellema
- Department of Neurology, MCH Westeinde, The Hague, The Netherlands
| | - Irene M Bronner
- Department of Neurology, Flevo Hospital, Almere, The Netherlands
| | | | | | - Ron J G M Witjes
- Department of Neurology, Tergooi Hospitals, Blaricum, The Netherlands
| | - H Rolf Jäger
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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9
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Abstract
Cerebral microbleeds are increasingly recognised as biomarkers of small vessel disease. Several preclinical and clinical studies have suggested that chronic disruption of the blood-brain barrier is one of the mechanisms for the development of cerebral microbleeds.A 51-year-old man experienced two left parieto-occipital lobar intracerebral haemorrhages (ICHs) in the timespan of 2 years. Multiple microbleeds surrounding the two haemorrhages were found on MRI, but not at location distant from the haemorrhages. Ten months after the last haemorrhage, an MRI demonstrated a right occipital focus of contrast enhancement. Twenty months after the last ICH, a new cerebral microbleed had developed exactly at the location of the earlier contrast enhancement.This case demonstrates that blood-brain barrier disruption may be an important factor preceding the development of cerebral microbleeds.
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Affiliation(s)
- Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Neurology, Donders Institute for Brain Cognition & Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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10
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Anderson CD, Falcone GJ, Phuah CL, Radmanesh F, Brouwers HB, Battey TWK, Biffi A, Peloso GM, Liu DJ, Ayres AM, Goldstein JN, Viswanathan A, Greenberg SM, Selim M, Meschia JF, Brown DL, Worrall BB, Silliman SL, Tirschwell DL, Flaherty ML, Kraft P, Jagiella JM, Schmidt H, Hansen BM, Jimenez-Conde J, Giralt-Steinhauer E, Elosua R, Cuadrado-Godia E, Soriano C, van Nieuwenhuizen KM, Klijn CJM, Rannikmae K, Samarasekera N, Al-Shahi Salman R, Sudlow CL, Deary IJ, Morotti A, Pezzini A, Pera J, Urbanik A, Pichler A, Enzinger C, Norrving B, Montaner J, Fernandez-Cadenas I, Delgado P, Roquer J, Lindgren A, Slowik A, Schmidt R, Kidwell CS, Kittner SJ, Waddy SP, Langefeld CD, Abecasis G, Willer CJ, Kathiresan S, Woo D, Rosand J. Genetic variants in CETP increase risk of intracerebral hemorrhage. Ann Neurol 2016; 80:730-740. [PMID: 27717122 PMCID: PMC5115931 DOI: 10.1002/ana.24780] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 09/13/2016] [Accepted: 09/13/2016] [Indexed: 12/26/2022]
Abstract
Objective In observational epidemiologic studies, higher plasma high‐density lipoprotein cholesterol (HDL‐C) has been associated with increased risk of intracerebral hemorrhage (ICH). DNA sequence variants that decrease cholesteryl ester transfer protein (CETP) gene activity increase plasma HDL‐C; as such, medicines that inhibit CETP and raise HDL‐C are in clinical development. Here, we test the hypothesis that CETP DNA sequence variants associated with higher HDL‐C also increase risk for ICH. Methods We performed 2 candidate‐gene analyses of CETP. First, we tested individual CETP variants in a discovery cohort of 1,149 ICH cases and 1,238 controls from 3 studies, followed by replication in 1,625 cases and 1,845 controls from 5 studies. Second, we constructed a genetic risk score comprised of 7 independent variants at the CETP locus and tested this score for association with HDL‐C as well as ICH risk. Results Twelve variants within CETP demonstrated nominal association with ICH, with the strongest association at the rs173539 locus (odds ratio [OR] = 1.25, standard error [SE] = 0.06, p = 6.0 × 10−4) with no heterogeneity across studies (I2 = 0%). This association was replicated in patients of European ancestry (p = 0.03). A genetic score of CETP variants found to increase HDL‐C by ∼2.85mg/dl in the Global Lipids Genetics Consortium was strongly associated with ICH risk (OR = 1.86, SE = 0.13, p = 1.39 × 10−6). Interpretation Genetic variants in CETP associated with increased HDL‐C raise the risk of ICH. Given ongoing therapeutic development in CETP inhibition and other HDL‐raising strategies, further exploration of potential adverse cerebrovascular outcomes may be warranted. Ann Neurol 2016;80:730–740
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Affiliation(s)
- Christopher D Anderson
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - Guido J Falcone
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA.,Departments of Epidemiology and Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Chia-Ling Phuah
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - Farid Radmanesh
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - H Bart Brouwers
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - Thomas W K Battey
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - Alessandro Biffi
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA.,Division of Behavioral Neurology, Department of Neurology, MGH, Boston, MA.,Division of Psychiatry, Department of Psychiatry, MGH, Boston, MA
| | - Gina M Peloso
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - Dajiang J Liu
- Department of Public Health Sciences, Institute of Personalized Medicine, Penn State College of Medicine, Hershey, PA
| | - Alison M Ayres
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA
| | | | - Anand Viswanathan
- J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA
| | - Steven M Greenberg
- J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Devin L Brown
- Stroke Program, Department of Neurology, University of Michigan Health System, Ann Arbor, MI
| | - Bradford B Worrall
- Departments of Neurology and Public Health Sciences, University of Virginia Health System, Charlottesville, VA
| | - Scott L Silliman
- Department of Neurology, University of Florida College of Medicine, Jacksonville, FL
| | - David L Tirschwell
- Stroke Center, Harborview Medical Center, University of Washington, Seattle, WA
| | - Matthew L Flaherty
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Peter Kraft
- Departments of Epidemiology and Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Jeremiasz M Jagiella
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Helena Schmidt
- Institute of Molecular Biology and Biochemistry, Medical University Graz, Graz, Austria
| | - Björn M Hansen
- Division of Neurology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Division of Neurology, Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Jordi Jimenez-Conde
- Neurovascular Research Unit, Department of Neurology, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain.,Program in Inflammation and Cardiovascular Disorders, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain
| | - Eva Giralt-Steinhauer
- Neurovascular Research Unit, Department of Neurology, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain.,Program in Inflammation and Cardiovascular Disorders, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain
| | - Roberto Elosua
- Neurovascular Research Unit, Department of Neurology, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain.,Program in Inflammation and Cardiovascular Disorders, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain
| | - Elisa Cuadrado-Godia
- Neurovascular Research Unit, Department of Neurology, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain.,Program in Inflammation and Cardiovascular Disorders, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain
| | - Carolina Soriano
- Neurovascular Research Unit, Department of Neurology, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain.,Program in Inflammation and Cardiovascular Disorders, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain
| | - Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kristiina Rannikmae
- Division of Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Neshika Samarasekera
- Division of Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Catherine L Sudlow
- Division of Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Institute for Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Ian J Deary
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrea Morotti
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Joanna Pera
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Andrzej Urbanik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Christian Enzinger
- Department of Neurology, Medical University of Graz, Graz, Austria.,Division of Neuroradiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Bo Norrving
- Division of Neurology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Division of Neurology, Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Joan Montaner
- Neurovascular Research Laboratory and Neurovascular Unit, Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Israel Fernandez-Cadenas
- Neurovascular Research Laboratory and Neurovascular Unit, Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain.,Stroke Pharmacogenomics and Genetics, Terrassa Mutual Teaching and Research Foundation, Terrassa Mutual Hospital, Terrassa, Spain
| | - Pilar Delgado
- Neurovascular Research Laboratory and Neurovascular Unit, Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Jaume Roquer
- Neurovascular Research Unit, Department of Neurology, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain.,Program in Inflammation and Cardiovascular Disorders, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain
| | - Arne Lindgren
- Division of Neurology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Division of Neurology, Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Reinhold Schmidt
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Steven J Kittner
- Department of Neurology, Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine, Baltimore, MD
| | - Salina P Waddy
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Carl D Langefeld
- Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC
| | - Goncalo Abecasis
- Center for Statistical Genetics, Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Cristen J Willer
- Division of Cardiology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI.,Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI
| | - Sekar Kathiresan
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA.,Cardiovascular Disease Prevention Center, MGH, Boston, MA
| | - Daniel Woo
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jonathan Rosand
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
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11
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van Asch CJJ, Velthuis BK, Rinkel GJE, Algra A, de Kort GAP, Witkamp TD, de Ridder JCM, van Nieuwenhuizen KM, de Leeuw FE, Schonewille WJ, de Kort PLM, Dippel DW, Raaymakers TWM, Hofmeijer J, Wermer MJH, Kerkhoff H, Jellema K, Bronner IM, Remmers MJM, Bienfait HP, Witjes RJGM, Greving JP, Klijn CJM. Diagnostic yield and accuracy of CT angiography, MR angiography, and digital subtraction angiography for detection of macrovascular causes of intracerebral haemorrhage: prospective, multicentre cohort study. BMJ 2015; 351:h5762. [PMID: 26553142 PMCID: PMC4637845 DOI: 10.1136/bmj.h5762] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2015] [Indexed: 11/29/2022]
Abstract
STUDY QUESTION What are the diagnostic yield and accuracy of early computed tomography (CT) angiography followed by magnetic resonance imaging/angiography (MRI/MRA) and digital subtraction angiography (DSA) in patients with non-traumatic intracerebral haemorrhage? METHODS This prospective diagnostic study enrolled 298 adults (18-70 years) treated in 22 hospitals in the Netherlands over six years. CT angiography was performed within seven days of haemorrhage. If the result was negative, MRI/MRA was performed four to eight weeks later. DSA was performed when the CT angiography or MRI/MRA results were inconclusive or negative. The main outcome was a macrovascular cause, including arteriovenous malformation, aneurysm, dural arteriovenous fistula, and cavernoma. Three blinded neuroradiologists independently evaluated the images for macrovascular causes of haemorrhage. The reference standard was the best available evidence from all findings during one year's follow-up. STUDY ANSWER AND LIMITATIONS A macrovascular cause was identified in 69 patients (23%). 291 patients (98%) underwent CT angiography; 214 with a negative result underwent additional MRI/MRA and 97 with a negative result for both CT angiography and MRI/MRA underwent DSA. Early CT angiography detected 51 macrovascular causes (yield 17%, 95% confidence interval 13% to 22%). CT angiography with MRI/MRA identified two additional macrovascular causes (18%, 14% to 23%) and these modalities combined with DSA another 15 (23%, 18% to 28%). This last extensive strategy failed to detect a cavernoma, which was identified on MRI during follow-up (reference strategy). The positive predictive value of CT angiography was 72% (60% to 82%), of additional MRI/MRA was 35% (14% to 62%), and of additional DSA was 100% (75% to 100%). None of the patients experienced complications with CT angiography or MRI/MRA; 0.6% of patients who underwent DSA experienced permanent sequelae. Not all patients with negative CT angiography and MRI/MRA results underwent DSA. Although the previous probability of finding a macrovascular cause was lower in patients who did not undergo DSA, some small arteriovenous malformations or dural arteriovenous fistulas may have been missed. WHAT THIS STUDY ADDS CT angiography is an appropriate initial investigation to detect macrovascular causes of non-traumatic intracerebral haemorrhage, but accuracy is modest. Additional MRI/MRA may find cavernomas or alternative diagnoses, but DSA is needed to diagnose macrovascular causes undetected by CT angiography or MRI/MRA. FUNDING, COMPETING INTERESTS, DATA SHARING Dutch Heart Foundation and The Netherlands Organisation for Health Research and Development, ZonMw. The authors have no competing interests. Direct requests for additional data to the corresponding author.
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Affiliation(s)
- Charlotte J J van Asch
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gabriël J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gérard A P de Kort
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Theo D Witkamp
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Johanna C M de Ridder
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands
| | - Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Paul L M de Kort
- Department of Neurology, St Elisabeth Hospital, Tilburg, Netherlands
| | - Diederik W Dippel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | | | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Korné Jellema
- Department of Neurology, MCH Westeinde, The Hague, Netherlands
| | - Irene M Bronner
- Department of Neurology, Flevo Hospital, Almere, Netherlands
| | | | | | - Ron J G M Witjes
- Department of Neurology, Tergooi Hospitals, Blaricum, Netherlands
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
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12
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van Nieuwenhuizen KM, van der Worp HB, Algra A, Kappelle LJ, Rinkel GJE, van Gelder IC, Schutgens REG, Klijn CJM. Apixaban versus Antiplatelet drugs or no antithrombotic drugs after anticoagulation-associated intraCerebral HaEmorrhage in patients with Atrial Fibrillation (APACHE-AF): study protocol for a randomised controlled trial. Trials 2015; 16:393. [PMID: 26340977 PMCID: PMC4560912 DOI: 10.1186/s13063-015-0898-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 08/03/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There is a marked lack of evidence on the optimal prevention of ischaemic stroke and other thromboembolic events in patients with non-valvular atrial fibrillation and a recent intracerebral haemorrhage during treatment with oral anticoagulation. These patients are currently treated with oral anticoagulants, antiplatelet drugs, or no antithrombotic treatment, depending on personal and institutional preferences. Compared with warfarin, the direct oral anticoagulant apixaban reduces the risk of stroke or systemic embolism, intracranial haemorrhage, and case fatality in patients with atrial fibrillation. Compared with aspirin, apixaban reduces the risk of stroke or systemic embolism in patients with atrial fibrillation, and has a similar risk of intracerebral haemorrhage. Novel oral anticoagulants have not been evaluated in patients with atrial fibrillation and a recent intracerebral haemorrhage. To inform a phase III trial, the phase II Apixaban versus Antiplatelet drugs or no antithrombotic drugs after anticoagulation-associated intraCerebral HaEmorrhage in patients with Atrial Fibrillation (APACHE-AF) trial aims to obtain estimates of the rates of vascular death or non-fatal stroke in patients with atrial fibrillation and a recent anticoagulation-associated intracerebral haemorrhage treated with apixaban and in those in whom oral anticoagulation is avoided. METHODS/DESIGN APACHE-AF is a phase II, multicentre, open-label, parallel-group, randomised clinical trial with masked outcome assessment. One hundred adults with a history of atrial fibrillation and a recent intracerebral haemorrhage during treatment with anticoagulation in whom clinical equipoise exists on the optimal stroke prevention strategy will be enrolled in 14 hospitals in The Netherlands. These patients will be randomly assigned in a 1:1 ratio to either apixaban or to avoiding oral anticoagulation. Patients in the control group may be treated with antiplatelet drugs at the discretion of the treating physician. The primary outcome is the composite of vascular death or non-fatal stroke during follow-up. We aim to include 100 patients in 2.5 years. All patients will be followed-up for the duration of the study, but at least for 1 year. Recruitment commenced in September 2014 and is ongoing. This trial is funded by the Dutch Heart Foundation (2012 T077) and ZonMW (015008048). TRIAL REGISTRATION NTR4526 (16 April 2014).
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Affiliation(s)
- Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, G03.232, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, G03.232, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, G03.232, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, STR. 7.140, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, G03.232, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, G03.232, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Isabelle C van Gelder
- Department of Cardiology, University Medical Center Groningen, PO Box 30.001, 9700, RB, Groningen, The Netherlands.
| | - Roger E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, C01.425, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, G03.232, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
- Department of Neurology, Radboud University Medical Center, PO Box 9101, 6500, HB, Nijmegen, The Netherlands.
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13
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Parry-Jones AR, Di Napoli M, Goldstein JN, Schreuder FHBM, Tetri S, Tatlisumak T, Yan B, van Nieuwenhuizen KM, Dequatre-Ponchelle N, Lee-Archer M, Horstmann S, Wilson D, Pomero F, Masotti L, Lerpiniere C, Godoy DA, Cohen AS, Houben R, Al-Shahi Salman R, Pennati P, Fenoglio L, Werring D, Veltkamp R, Wood E, Dewey HM, Cordonnier C, Klijn CJM, Meligeni F, Davis SM, Huhtakangas J, Staals J, Rosand J, Meretoja A. Reversal strategies for vitamin K antagonists in acute intracerebral hemorrhage. Ann Neurol 2015; 78:54-62. [PMID: 25857223 PMCID: PMC4654243 DOI: 10.1002/ana.24416] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 03/26/2015] [Accepted: 03/27/2015] [Indexed: 11/11/2022]
Abstract
Objective There is little evidence to guide treatment strategies for intracerebral hemorrhage on vitamin K antagonists (VKA‐ICH). Treatments utilized in clinical practice include fresh frozen plasma (FFP) and prothrombin complex concentrate (PCC). Our aim was to compare case fatality with different reversal strategies. Methods We pooled individual ICH patient data from 16 stroke registries in 9 countries (n = 10 282), of whom 1,797 (17%) were on VKA. After excluding 250 patients with international normalized ratio < 1.3 and/or missing data required for analysis, we compared all‐cause 30‐day case fatality using Cox regression. Results We included 1,547 patients treated with FFP (n = 377, 24%), PCC (n = 585, 38%), both (n = 131, 9%), or neither (n = 454, 29%). The crude case fatality and adjusted hazard ratio (HR) were highest with no reversal (61.7%, HR = 2.540, 95% confidence interval [CI] = 1.784–3.616, p < 0.001), followed by FFP alone (45.6%, HR = 1.344, 95% CI = 0.934–1.934, p = 0.112), then PCC alone (37.3%, HR = 1.445, 95% CI = 1.014–2.058, p = 0.041), compared to reversal with both FFP and PCC (27.8%, reference). Outcomes with PCC versus FFP were similar (HR = 1.075, 95% CI = 0.874–1.323, p = 0.492); 4‐factor PCC (n = 441) was associated with higher case fatality compared to 3‐factor PCC (n = 144, HR = 1.441, 95% CI = 1.041–1.995, p = 0.027). Interpretation The combination of FFP and PCC might be associated with the lowest case fatality in reversal of VKA‐ICH, and FFP may be equivalent to PCC. Randomized controlled trials with functional outcomes are needed to establish the most effective treatment. Ann Neurol 2015;78:54–62
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Affiliation(s)
- Adrian R Parry-Jones
- University of Manchester, Manchester Academic Health Sciences Centre, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom.,Greater Manchester Neurosciences Centre, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Mario Di Napoli
- Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy.,Neurological Section, Center for Cardiovascular Medicine and Cerebrovascular Disease Prevention (SMDN), Sulmona, Italy
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Floris H B M Schreuder
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sami Tetri
- Department of Neurology, Oulu University Hospital, Oulu, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Bernard Yan
- Department of Neurology, Royal Melbourne Hospital, Parkville, Australia
| | - Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Rudolf Magnus Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nelly Dequatre-Ponchelle
- Department of Neurology, University of Lille Nord de France (UDSL), Lille University Hospital Center, Lille, France
| | | | - Solveig Horstmann
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | | | - Fulvio Pomero
- Department of Internal Medicine, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Luca Masotti
- Internal Medicine, Cecina Hospital, Cecina, Italy
| | - Christine Lerpiniere
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Daniel Agustin Godoy
- Neurointensive Care Unit, Pasteur Sanatorium, Catamarca, Argentina.,Intensive Care Unit, San Juan Bautista Hospital, Catamarca, Argentina
| | - Abigail S Cohen
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Rik Houben
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | | | - Luigi Fenoglio
- Department of Internal Medicine, Santa Croce e Carle Hospital, Cuneo, Italy
| | | | - Roland Veltkamp
- Department of Neurology, University of Heidelberg, Heidelberg, Germany.,Department of Medicine, Imperial College London, London, United Kingdom
| | - Edith Wood
- Greater Manchester Neurosciences Centre, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Helen M Dewey
- Department of Neurology, Austin Hospital, Heidelberg, Australia
| | - Charlotte Cordonnier
- Department of Neurology, University of Lille Nord de France (UDSL), Lille University Hospital Center, Lille, France
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Rudolf Magnus Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Fabrizio Meligeni
- Department of Medical Emergency, San Camillo de' Lellis General Hospital, Rieti, Italy
| | - Stephen M Davis
- Department of Neurology, Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine and Florey Institute, University of Melbourne, Melbourne, Australia
| | - Juha Huhtakangas
- Department of Neurology, Oulu University Hospital, Oulu, Finland
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jonathan Rosand
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Atte Meretoja
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.,Department of Neurology, Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine and Florey Institute, University of Melbourne, Melbourne, Australia
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14
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Kappelle LJJ, Hofmeijer J, Chamuleau SA, van Nieuwenhuizen KM, Hemels MEW, Klijn CJMK. [Resumption of antithrombotic treatment after an intracerebral haemorrhage]. Ned Tijdschr Geneeskd 2015; 159:A8507. [PMID: 25873219] [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] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
There is no evidence from randomised clinical trials with regard to the question if and when to resume antithrombotic medication in patients who have suffered an intracerebral haemorrhage and in whom medication continues to be indicated. It is unknown whether new oral anticoagulants are more suitable than vitamin K antagonists in this group of patients. Oral anticoagulants should probably not be resumed in patients with a lobar intracerebral haemorrhage caused by cerebral amyloid angiopathy. They can be considered in patients with a haemorrhage in subcortical regions of the brain, the brain stem or the cerebellum, provided that blood pressure levels are under control. Depending on the risk of a cardiac embolus, antithrombotic medication can be resumed from 1 to 10 weeks after the intracerebral haemorrhage. In patients with atrial fibrillation this risk can be calculated using the CHA2DS2-VASc score. In patients with a cardiac indication for antithrombotic medication the decision whether or not to resume medication should be made by a cardiologist and a neurologist in collaboration.
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Affiliation(s)
- L J Jaap Kappelle
- Universitair Medisch Centrum Utrecht, Hersencentrum Rudolf Magnus, Utrecht
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15
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Brouwers HB, Raffeld MR, van Nieuwenhuizen KM, Falcone GJ, Ayres AM, McNamara KA, Schwab K, Romero JM, Velthuis BK, Viswanathan A, Greenberg SM, Ogilvy CS, van der Zwan A, Rinkel GJE, Goldstein JN, Klijn CJM, Rosand J. CT angiography spot sign in intracerebral hemorrhage predicts active bleeding during surgery. Neurology 2014; 83:883-9. [PMID: 25098540 DOI: 10.1212/wnl.0000000000000747] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To determine whether the CT angiography (CTA) spot sign marks bleeding complications during and after surgery for spontaneous intracerebral hemorrhage (ICH). METHODS In a 2-center study of consecutive spontaneous ICH patients who underwent CTA followed by surgical hematoma evacuation, 2 experienced readers (blinded to clinical and surgical data) reviewed CTAs for spot sign presence. Blinded raters assessed active intraoperative and postoperative bleeding. The association between spot sign and active intraoperative bleeding, postoperative rebleeding, and residual ICH volumes was evaluated using univariable and multivariable logistic regression. RESULTS A total of 95 patients met inclusion criteria: 44 lobar, 17 deep, 33 cerebellar, and 1 brainstem ICH; ≥1 spot sign was identified in 32 patients (34%). The spot sign was the only independent marker of active bleeding during surgery (odds ratio [OR] 3.4; 95% confidence interval [CI] 1.3-9.0). Spot sign (OR 4.1; 95% CI 1.1-17), female sex (OR 6.9; 95% CI 1.7-37), and antiplatelet use (OR 4.6; 95% CI 1.2-21) were predictive of postoperative rebleeding. Larger residual hematomas and postoperative rebleeding were associated with higher discharge case fatality (OR 3.4; 95% CI 1.1-11) and a trend toward increased case fatality at 3 months (OR 2.9; 95% CI 0.9-8.8). CONCLUSIONS The CTA spot sign is associated with more intraoperative bleeding, more postoperative rebleeding, and larger residual ICH volumes in patients undergoing hematoma evacuation for spontaneous ICH. The spot sign may therefore be useful to select patients for future surgical trials.
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Affiliation(s)
- H Bart Brouwers
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - Miriam R Raffeld
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Koen M van Nieuwenhuizen
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Guido J Falcone
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Alison M Ayres
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Kristen A McNamara
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Kristin Schwab
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Javier M Romero
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Birgitta K Velthuis
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Anand Viswanathan
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Steven M Greenberg
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Christopher S Ogilvy
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Albert van der Zwan
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Gabriel J E Rinkel
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Joshua N Goldstein
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Catharina J M Klijn
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jonathan Rosand
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
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