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De Matteis E, Ornello R, De Santis F, Foschi M, Romoli M, Tassinari T, Saia V, Cenciarelli S, Bedetti C, Padiglioni C, Censori B, Puglisi V, Vinciguerra L, Guarino M, Barone V, Zedde M, Grisendi I, Diomedi M, Bagnato MR, Petruzzellis M, Mezzapesa DM, Di Viesti P, Inchingolo V, Cappellari M, Zenorini M, Candelaresi P, Andreone V, Rinaldi G, Bavaro A, Cavallini A, Moraru S, Querzani P, Terruso V, Mannino M, Pezzini A, Frisullo G, Muscia F, Paciaroni M, Mosconi MG, Zini A, Leone R, Palmieri C, Cupini LM, Marcon M, Tassi R, Sanzaro E, Paci C, Viticchi G, Orsucci D, Falcou A, Diamanti S, Tarletti R, Nencini P, Rota E, Sepe FN, Ferrandi D, Caputi L, Volpi G, Spada SL, Beccia M, Rinaldi C, Mastrangelo V, Di Blasio F, Invernizzi P, Pelliccioni G, De Angelis MV, Bonanni L, Ruzza G, Caggia EA, Russo M, Tonon A, Acciarri MC, Anticoli S, Roberti C, Manobianca G, Scaglione G, Pistoia F, Fortini A, De Boni A, Sanna A, Chiti A, Barbarini L, Caggiula M, Masato M, Del Sette M, Passarelli F, Roberta Bongioanni M, Toni D, Ricci S, Sacco S. Beyond RCTs: Short-term dual antiplatelet therapy in secondary prevention of ischemic stroke and transient ischemic attack. Eur Stroke J 2024:23969873241255250. [PMID: 38869034 DOI: 10.1177/23969873241255250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND AND PURPOSE Randomized controlled trials (RCTs) proved the efficacy of short-term dual antiplatelet therapy (DAPT) in secondary prevention of minor ischemic stroke or high-risk transient ischemic attack (TIA). We aimed at evaluating effectiveness and safety of short-term DAPT in real-world, where treatment use is broader than in RCTs. METHODS READAPT (REAl-life study on short-term Dual Antiplatelet treatment in Patients with ischemic stroke or Transient ischemic attack) (NCT05476081) was an observational multicenter real-world study with a 90-day follow-up. We included patients aged 18+ receiving short-term DAPT soon after ischemic stroke or TIA. No stringent NIHSS and ABCD2 score cut-offs were applied but adherence to guidelines was recommended. Primary effectiveness outcome was stroke (ischemic or hemorrhagic) or death due to vascular causes, primary safety outcome was moderate-to-severe bleeding. Secondary outcomes were the type of ischemic and hemorrhagic events, disability, cause of death, and compliance to treatment. RESULTS We included 1920 patients; 69.9% started DAPT after an ischemic stroke; only 8.9% strictly followed entry criteria or procedures of RCTs. Primary effectiveness outcome occurred in 3.9% and primary safety outcome in 0.6% of cases. In total, 3.3% cerebrovascular ischemic recurrences occurred, 0.2% intracerebral hemorrhages, and 2.7% bleedings; 0.2% of patients died due to vascular causes. Patients with NIHSS score ⩽5 and those without acute lesions at neuroimaging had significantly higher primary effectiveness outcomes than their counterparts. Additionally, DAPT start >24 h after symptom onset was associated with a lower likelihood of bleeding. CONCLUSIONS In real-world, most of the patients who receive DAPT after an ischemic stroke or a TIA do not follow RCTs entry criteria and procedures. Nevertheless, short-term DAPT remains effective and safe in this population. No safety concerns are raised in patients with low-risk TIA, more severe stroke, and delayed treatment start.
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Affiliation(s)
- Eleonora De Matteis
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Department of Brain Sciences, Imperial College London, London, UK
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Federico De Santis
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Michele Romoli
- Department of Neuroscience, Maurizio Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Tiziana Tassinari
- Department of Neurology, Santa Corona Hospital, Pietra Ligure, Italy
| | - Valentina Saia
- Department of Neurology, Santa Corona Hospital, Pietra Ligure, Italy
| | - Silvia Cenciarelli
- Department of Neurology, Città di Castello Hospital, Città di Castello, Italy
| | - Chiara Bedetti
- Department of Neurology, Città di Castello Hospital, Città di Castello, Italy
| | - Chiara Padiglioni
- Department of Neurology, Città di Castello Hospital, Città di Castello, Italy
| | - Bruno Censori
- Department of Neurology, ASST Cremona Hospital, Cremona, Italy
| | | | | | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Valentina Barone
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Ilaria Grisendi
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marina Diomedi
- Department of Systems Medicine, Tor Vergata University Hospital, Rome, Italy
| | | | - Marco Petruzzellis
- Department of Neurology and Stroke Unit, "F. Puca" AOU Consorziale Policlinico, Bari, Italy
| | | | - Pietro Di Viesti
- Department of Neurology, Fondazione IRCCS Casa sollievo della sofferenza, San Giovanni Rotondo, Italy
| | - Vincenzo Inchingolo
- Department of Neurology, Fondazione IRCCS Casa sollievo della sofferenza, San Giovanni Rotondo, Italy
| | - Manuel Cappellari
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona
| | - Mara Zenorini
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona
| | - Paolo Candelaresi
- Department of Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | - Vincenzo Andreone
- Department of Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | | | | | - Anna Cavallini
- UO Neurologia d'Urgenza e Stroke Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Stefan Moraru
- UO Neurologia d'Urgenza e Stroke Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Pietro Querzani
- Department of Neuroscience, S.Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Valeria Terruso
- Department of Neurology, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - Marina Mannino
- Department of Neurology, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - Alessandro Pezzini
- Department of Medicine and Surgery, University of Parma, Stroke Care Program, Department of Emergency, Parma University Hospital, Parma, Italy
| | - Giovanni Frisullo
- Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | | | - Maurizio Paciaroni
- Department of Internal and Cardiovascular Medicine - Stroke Unit, University Hospital Santa Maria della Misericordia, Perugia, Italy
| | - Maria Giulia Mosconi
- Department of Internal and Cardiovascular Medicine - Stroke Unit, University Hospital Santa Maria della Misericordia, Perugia, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Ruggiero Leone
- Department of Neurology and Stroke Unit, "M. R. Dimiccoli" General Hospital, Barletta, ASL BT, Italy
| | - Carmela Palmieri
- Medical Department, E. Agnelli Hospital - Local Health Company (ASL) TO3, Pinerolo, Italy
| | | | - Michela Marcon
- Department of Neurology, Cazzavillan Hospital Arzignano, Vicenza, Italy
| | - Rossana Tassi
- Stroke Unit, Urgency and Emergency Department, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Enzo Sanzaro
- Department of Neurology, Umberto I Hospital, Siracusa, Italy
| | - Cristina Paci
- UOC Neurologia, Ospedale "Madonna del Soccorso", San Benedetto del Tronto, Italy
| | - Giovanna Viticchi
- Experimental and Clinical Medicine Department, Marche Polytechnic University, Ancona
| | - Daniele Orsucci
- Unit of Neurology-San Luca Hospital, Lucca and Castelnuovo Garfagnana, Italy
| | - Anne Falcou
- Stroke Unit, Emergency Department, Policlinico Umberto I Hospital, Rome, Italy
| | - Susanna Diamanti
- Department of Neurology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Roberto Tarletti
- SCDU Neurologia - Stroke Unit, Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
| | | | - Eugenia Rota
- Department of Neurology, San Giacomo Hospital, Novi Ligure, Italy
| | | | - Delfina Ferrandi
- Stroke Unit-Department of Neurology, SS. Biagio e Arrigo Hospital, Alessandria, Italy
| | - Luigi Caputi
- Department of Cardiocerebrovascular diseases, Neurology-Stroke Unit-ASST Ospedale Maggiore di Crema, Crema, Italy
| | - Gino Volpi
- Department of Neurology, San Jacopo Hospital, Pistoia, Italy
| | | | - Mario Beccia
- Department of Neurology, Sant'Andrea Hospital, Rome, Italy
| | - Claudia Rinaldi
- Neurology Unit, "Infermi" Hospital, AUSL Romagna, Rimini, Italy
| | | | | | - Paolo Invernizzi
- Departiment of Neurology, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | | | - Maria Vittoria De Angelis
- Stroke Unit, "S.Spirito" Hospital, Pescara, Italy
- Department of Neurology and Stroke Unit, SS Annunziata Hospital, Chieti, Italy
| | - Laura Bonanni
- Dipartimento di Medicina e Scienze dell'Invecchiamento, Università G. d'Annunzio di Chieti-Pescara e Clinica Neurologica e Stroke Unit Ospedale Clinicizzato SS. Annunziata di Chieti, Chieti, Italy
| | | | | | - Monia Russo
- Department of Neurology, St Misericordia Hospital, Rovigo, Italy
| | - Agnese Tonon
- Department of Neurology, Ospedale Civile Ss. Giovanni e Paolo, Venice, Italy
| | | | | | - Cinzia Roberti
- Department of Neurology, San Filippo Neri Hospital, Rome, Italy
| | - Giovanni Manobianca
- Department of Neurology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Gaspare Scaglione
- Department of Neurology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Alberto Fortini
- Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | | | | | - Alberto Chiti
- Unit of Neurology, Apuane Hospital, Massa Carrara, Italy
| | | | | | - Maela Masato
- Department of Neurology, Mirano Hospital, Mirano, Italy
| | - Massimo Del Sette
- Department of Neuroscience, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | - Danilo Toni
- Department of Human neurosciences, University of Rome La Sapienza, Rome, Italy
| | - Stefano Ricci
- Department of Neurology, Città di Castello Hospital, Città di Castello, Italy
- Coordinatore Comitato Scientifico ISA-AII
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Ryu WS, Schellingerhout D, Lee H, Lee KJ, Kim CK, Kim BJ, Chung JW, Lim JS, Kim JT, Kim DH, Cha JK, Sunwoo L, Kim D, Suh SI, Bang OY, Bae HJ, Kim DE. Deep Learning-Based Automatic Classification of Ischemic Stroke Subtype Using Diffusion-Weighted Images. J Stroke 2024; 26:300-311. [PMID: 38836277 PMCID: PMC11164582 DOI: 10.5853/jos.2024.00535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/04/2024] [Accepted: 05/07/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Accurate classification of ischemic stroke subtype is important for effective secondary prevention of stroke. We used diffusion-weighted image (DWI) and atrial fibrillation (AF) data to train a deep learning algorithm to classify stroke subtype. METHODS Model development was done in 2,988 patients with ischemic stroke from three centers by using U-net for infarct segmentation and EfficientNetV2 for subtype classification. Experienced neurologists (n=5) determined subtypes for external test datasets, while establishing a consensus for clinical trial datasets. Automatically segmented infarcts were fed into the model (DWI-only algorithm). Subsequently, another model was trained, with AF included as a categorical variable (DWI+AF algorithm). These models were tested: (1) internally against the opinion of the labeling experts, (2) against fresh external DWI data, and (3) against clinical trial dataset. RESULTS In the training-and-validation datasets, the mean (±standard deviation) age was 68.0±12.5 (61.1% male). In internal testing, compared with the experts, the DWI-only and the DWI+AF algorithms respectively achieved moderate (65.3%) and near-strong (79.1%) agreement. In external testing, both algorithms again showed good agreements (59.3%-60.7% and 73.7%-74.0%, respectively). In the clinical trial dataset, compared with the expert consensus, percentage agreements and Cohen's kappa were respectively 58.1% and 0.34 for the DWI-only vs. 72.9% and 0.57 for the DWI+AF algorithms. The corresponding values between experts were comparable (76.0% and 0.61) to the DWI+AF algorithm. CONCLUSION Our model trained on a large dataset of DWI (both with or without AF information) was able to classify ischemic stroke subtypes comparable to a consensus of stroke experts.
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Affiliation(s)
- Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
- Artificial Intelligence Research Center, JLK Inc., Seoul, Korea
| | - Dawid Schellingerhout
- Department of Neuroradiology and Imaging Physics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Hoyoun Lee
- Artificial Intelligence Research Center, JLK Inc., Seoul, Korea
| | - Keon-Joo Lee
- Department of Neurology, Korea University Guro Hospital, Seoul, Korea
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital, Seoul, Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Sung Lim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Leonard Sunwoo
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dongmin Kim
- Artificial Intelligence Research Center, JLK Inc., Seoul, Korea
| | - Sang-Il Suh
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
- National Priority Research Center for Stroke, Goyang, Korea
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