152 research outputs found
Thrombolysis for ischaemic stroke despite direct oral anticoagulation.
Intravenous thrombolysis is not recommended in anticoagulated patients receiving direct oral anticoagulants (DOACs) and a recent intake within the last 48 hours in US and European guidelines. However, three observational studies now suggest safety of thrombolysis in patients with recent intake of DOACs, and thus support previous experimental data. In this perspective, the current evidence and practical consequences are discussed
A Score for Risk of Thrombolysis-Associated Hemorrhage Including Pretreatment with Statins
Background: Symptomatic intracranial hemorrhage (sICH) after intravenous
thrombolysis with recombinant tissue-plasminogen activator (rt-PA) for acute
ischemic stroke is associated with a poor functional outcome. We aimed to
develop a score assessing risk of sICH including novel putative
predictors—namely, pretreatment with statins and severe renal impairment.
Methods: We analyzed our local cohort (Berlin) of patients receiving rt-PA for
acute ischemic stroke between 2006 and 2016. Outcome was sICH according to
ECASS-III criteria. A multiple regression model identified variables
associated with sICH and receiver operating characteristics were calculated
for the best discriminatory model for sICH. The model was validated in an
independent thrombolysis cohort (Basel). Results: sICH occurred in 53 (4.0%)
of 1,336 patients in the derivation cohort. Age, baseline National Institutes
of Health Stroke Scale, systolic blood pressure on admission, blood glucose on
admission, and prior medication with medium- or high-dose statins were
associated with sICH and included into the risk of intracranial hemorrhage
score. The validation cohort included 983 patients of whom 33 (3.4%) had a
sICH. c-Statistics for sICH was 0.72 (95% CI 0.66–0.79) in the derivation
cohort and 0.69 (95% CI 0.60–0.77) in the independent validation cohort.
Inclusion of severe renal impairment did not improve the score. Conclusion: We
developed a simple score with fair discriminating capability to predict rt-PA-
related sICH by adding prior statin use to known prognostic factors of sICH.
This score may help clinicians to identify patients with higher risk of sICH
requiring intensive monitoring
The Venular Side of Cerebral Amyloid Angiopathy: Proof of Concept of a Neglected Issue.
Small vessel diseases (SVD) is an umbrella term including several entities affecting small arteries, arterioles, capillaries, and venules in the brain. One of the most relevant and prevalent SVDs is cerebral amyloid angiopathy (CAA), whose pathological hallmark is the deposition of amyloid fragments in the walls of small cortical and leptomeningeal vessels. CAA frequently coexists with Alzheimer's Disease (AD), and both are associated with cerebrovascular events, cognitive impairment, and dementia. CAA and AD share pathophysiological, histopathological and neuroimaging issues. The venular involvement in both diseases has been neglected, although both animal models and human histopathological studies found a deposition of amyloid beta in cortical venules. This review aimed to summarize the available information about venular involvement in CAA, starting from the biological level with the putative pathomechanisms of cerebral damage, passing through the definition of the peculiar angioarchitecture of the human cortex with the functional organization and consequences of cortical arteriolar and venular occlusion, and ending to the hypothesized links between cortical venular involvement and the main neuroimaging markers of the disease
Small vessel disease burden and intracerebral haemorrhage in patients taking oral anticoagulants
OBJECTIVE
We investigated the contribution of small vessel disease (SVD) to anticoagulant-associated intracerebral haemorrhage (ICH).
METHODS
Clinical Relevance of Microbleeds in Stroke-2 comprised two independent multicentre observation studies: first, a cross-sectional study of patients with ICH; and second, a prospective study of patients taking anticoagulants for atrial fibrillation (AF) after cerebral ischaemia. In patients with ICH, we compared SVD markers on CT and MRI according to prior anticoagulant therapy. In patients with AF and cerebral ischaemia treated with anticoagulants, we compared the rates of ICH and ischaemic stroke according to SVD burden score during 2 years follow-up.
RESULTS
We included 1030 patients with ICH (421 on anticoagulants), and 1447 patients with AF and cerebral ischaemia. Medium-to-high severity SVD was more prevalent in patients with anticoagulant-associated ICH (CT 56.1%, MRI 78.7%) than in those without prior anticoagulant therapy (CT 43.5%, p<0.001; MRI 64.5%, p=0.072). Leukoaraiosis and atrophy were more frequent and severe in ICH associated with prior anticoagulation. In the cerebral ischaemia cohort (779 with SVD), during 3366 patient-years of follow-up the rate of ICH was 0.56%/year (IQR 0.27-1.03) in patients with SVD, and 0.06%/year (IQR 0.00-0.35) in those without (p=0.001); ICH was independently associated with severity of SVD (HR 5.0, 95% CI 1.9 to 12.2,p=0.001), and was predicted by models including SVD (c-index 0.75, 95% CI 0.63 to 0.85).
CONCLUSIONS
Medium-to-high severity SVD is associated with ICH occurring on anticoagulants, and independently predicts ICH in patients with AF taking anticoagulants; its absence identifies patients at low risk of ICH. Findings from these two complementary studies suggest that SVD is a contributory factor in ICH in patients taking anticoagulants and suggest that anticoagulation alone should no longer be regarded as a sufficient 'cause' of ICH.
TRIAL REGISTRATION
NCT02513316
Magnetic resonance imaging-based scores of small vessel diseases: Associations with intracerebral haemorrhage location
Introduction: Total small vessel disease (SVD) score and cerebral amyloid angiopathy (CAA) score are magnetic
resonance imaging-based composite scores built to preferentially capture deep perforator arteriopathy-related
and CAA-related SVD burden, respectively. Non-lobar intracerebral haemorrhage (ICH) is related to deep
perforator arteriopathy, while lobar ICH can be associated with deep perforator arteriopathy or CAA; however,
the associations between ICH location and these scores are not established.
Methods: In this post-hoc analysis from a prospective cohort study, we included 153 spontaneous non-cerebellar
ICH patients. Wald test, univariable and multivariable logistic regression analysis were performed to investigate
the association between each score (and individual score components) and ICH location.
Results: Total SVD score was associated with non-lobar ICH location (Wald test: unadjusted, p = 0.017; adjusted,
p = 0.003); however, no individual component of total SVD score was significantly associated with non-lobar
ICH. CAA score was not significantly associated with lobar location (Wald test: unadjusted, p = 0.056;
adjusted, p = 0.126); cortical superficial siderosis (OR 8.85 [95%CI 1.23–63.65], p = 0.030) and ≥ 2 strictly
lobar microbleeds (OR 1.63 [95%CI 1.04–2.55], p = 0.035) were related with lobar ICH location, while white
matter hyperintensities showed an inverse relation (OR 0.53 [95%CI 0.26–1.08; p = 0.081]).
Conclusions: Total SVD score was associated with non-lobar ICH location. The lack of significant association
between CAA score and lobar ICH may in part be due to the mixed aetiology of lobar ICH, and to the inclusion of
white matter hyperintensities, a non-specific marker of SVD type, in the CAA score
Stent-Based Retrieval Techniques in Acute Ischemic Stroke Patients with and Without Susceptibility Vessel Sign.
BACKGROUND AND PURPOSE
Randomized controlled trials have challenged the assumption that reperfusion success after mechanical thrombectomy varies depending on the retrieval techniques applied; however, recent analyses have suggested that acute ischemic stroke (AIS) patients showing susceptibility vessel sign (SVS) may respond differently. We aimed to compare different stent retriever (SR)-based thrombectomy techniques with respect to interventional outcome parameters depending on SVS status.
METHODS
We retrospectively reviewed 497 patients treated with SR-based thrombectomy for anterior circulation AIS. Imaging was conducted using a 1.5 T or 3 T magnetic resonance imaging (MRI) scanner. Logistic regression analyses were performed to test for the interaction of SVS status and first-line retrieval technique. Results are shown as percentages, total values or adjusted odds ratio (aOR) with 95% confidence intervals (CI).
RESULTS
An SVS was present in 87.9% (n = 437) of patients. First-line SR thrombectomy was used to treat 293 patients, whereas 204 patients were treated with a combined approach (COA) of SR and distal aspiration. An additional balloon-guide catheter (BGC) was used in 273 SR-treated (93.2%) and 89 COA-treated (43.6%) patients. On logistic regression analysis, the interaction variable of SVS status and first-line retrieval technique was not associated with first-pass reperfusion (aOR 1.736, 95% CI 0.491-6.136; p = 0.392), overall reperfusion (aOR 3.173, 95% CI 0.752-13.387; p = 0.116), periinterventional complications, embolization into new territories, or symptomatic intracerebral hemorrhage. The use of BGC did not affect the results.
CONCLUSION
While previous analyses indicated that first-line SR thrombectomy may promise higher rates of reperfusion than contact aspiration in AIS patients with SVS, our data show no superiority of any particular SR-based retrieval technique regardless of SVS status
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