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Boe NJ, Hald SM, Kristensen AR, Möller S, Bojsen JA, Elhakim MT, Rodrigues MA, Al-Shahi Salman R, Hallas J, García Rodríguez LA, Selim M, Goldstein LB, Gaist D. Association of Antithrombotic Drug Use With Incident Intracerebral Hemorrhage Location. Neurology 2024; 102:e209442. [PMID: 38771998 DOI: 10.1212/wnl.0000000000209442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Few population-based studies have assessed associations between the use of antithrombotic (platelet antiaggregant or anticoagulant) drugs and location-specific risks of spontaneous intracerebral hemorrhage (s-ICH). In this study, we estimated associations between antithrombotic drug use and the risk of lobar vs nonlobar incident s-ICH. METHODS Using Danish nationwide registries, we identified cases in the Southern Denmark Region of first-ever s-ICH in patients aged 50 years or older between 2009 and 2018. Each verified case was classified as lobar or nonlobar s-ICH and matched to controls in the general population by age, sex, and calendar year. Prior antithrombotic use was ascertained from a nationwide prescription registry. We calculated odds ratios (aORs) for associations between the use of clopidogrel, aspirin, direct oral anticoagulants (DOACs) or vitamin K antagonists (VKA), and lobar and nonlobar ICH in conditional logistic regression analyses that were adjusted for potential confounders. RESULTS A total of 1,040 cases of lobar (47.9% men, mean age [SD] 75.2 [10.7] years) and 1,263 cases of nonlobar s-ICH (54.2% men, mean age 73.6 [11.4] years) were matched to 41,651 and 50,574 controls, respectively. A stronger association with lobar s-ICH was found for clopidogrel (cases: 7.6%, controls: 3.5%; aOR 3.46 [95% CI 2.45-4.89]) vs aspirin (cases: 22.9%, controls: 20.4%; aOR 2.14 [1.74-2.63; p = 0.019). Corresponding estimates for nonlobar s-ICH were not different between clopidogrel (cases: 5.4%, controls: 3.4%; aOR 2.44 [1.71-3.49]) and aspirin (cases: 20.7%, controls: 19.2%; aOR 1.77 [1.47-2.15]; p = 0.12). VKA use was associated with higher odds of both lobar (cases: 14.3%, controls: 6.1%; aOR 3.66 [2.78-4.80]) and nonlobar (cases: 15.4%, controls: 5.5%; aOR 4.62 [3.67-5.82]) s-ICH. The association of DOAC use with lobar s-ICH (cases: 3.5%, controls: 2.7%; aOR 1.66 [1.02-2.70]) was weaker than that of VKA use (p = 0.006). Corresponding estimates for nonlobar s-ICH were not different between DOACs (cases: 5.1%, controls: 2.4%; aOR 3.44 [2.33-5.08]) and VKAs (p = 0.20). DISCUSSION Antithrombotics were associated with higher risks of s-ICH, but the strength of the associations varied by s-ICH location and drug, which may reflect differences in the cerebral microangiopathies associated with lobar vs nonlobar hemorrhages and the mechanisms of drug action.
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Affiliation(s)
- Nils Jensen Boe
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Stine Munk Hald
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Alexandra Redzkina Kristensen
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Sören Möller
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jonas A Bojsen
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Mohammad Talal Elhakim
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Mark A Rodrigues
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Rustam Al-Shahi Salman
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jesper Hallas
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Luis A García Rodríguez
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Magdy Selim
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Larry B Goldstein
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - David Gaist
- From the Neurology Research Unit (N.J.B., S.M.H., A.R.K., D.G.), Odense University Hospital; University of Southern Denmark; Open Patient Data Explorative Network (S.M.), Odense University Hospital; Department Clinical Research (S.M.), University of Southern Denmark; Department of Radiology (J.A.B., M.T.E.), Odense University Hospital, Denmark; Centre for Clinical Brain Sciences (M.A.R., R.A.-S.S.), University of Edinburgh, United Kingdom; Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (J.H.), University of Southern Denmark, Odense; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston, MA; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
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Ueno H, Tokugawa J, Saito R, Yamashiro K, Tsutsumi S, Yamamoto M, Ueno Y, Mieno M, Yamamoto T, Hishii M, Yasumoto Y, Maruki C, Kondo A, Urabe T, Hattori N, Arai H, Tanaka R. Trends in prior antithrombotic medication and risk of in-hospital mortality after spontaneous intracerebral hemorrhage: the J-ICH registry. Sci Rep 2024; 14:12009. [PMID: 38796624 PMCID: PMC11127931 DOI: 10.1038/s41598-024-62717-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/21/2024] [Indexed: 05/28/2024] Open
Abstract
Spontaneous intracerebral hemorrhage (SICH) remains a devastating form of stroke. Prior use of antiplatelets or warfarin before SICH is associated with poor outcomes, but the effects of direct oral anticoagulants (DOACs) remain unclear. This study aimed to clarify trends in prior antithrombotic use and to assess the associations between prior use of antithrombotics and in-hospital mortality using a multicenter prospective registry in Japan. In total, 1085 patients were analyzed. Prior antithrombotic medication included antiplatelets in 14.2%, oral anticoagulants in 8.1%, and both in 1.8%. Prior warfarin use was significantly associated with in-hospital mortality (odds ratio [OR] 5.50, 95% confidence interval [CI] 1.30-23.26, P < 0.05) compared to no prior antithrombotic use. No such association was evident between prior DOAC use and no prior antithrombotic use (OR 1.34, 95% CI 0.44-4.05, P = 0.606). Concomitant use of antiplatelets and warfarin further increased the in-hospital mortality rate (37.5%) compared to warfarin alone (17.2%), but no such association was found for antiplatelets plus DOACs (8.3%) compared to DOACs alone (11.9%). Prior use of warfarin remains an independent risk factor for in-hospital mortality after SICH in the era of DOACs. Further strategies are warranted to reduce SICH among patients receiving oral anticoagulants and to prevent serious outcomes.
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Affiliation(s)
- Hideaki Ueno
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Joji Tokugawa
- Department of Neurosurgery, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo, 177-8521, Japan
| | - Rikizo Saito
- Department of Neurosurgery, Koshigaya Municipal Hospital, 10-47-1 Higashikoshigaya, Koshigaya, Saitama, 343-0023, Japan
| | - Kazuo Yamashiro
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Satoshi Tsutsumi
- Department of Neurosurgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Munetaka Yamamoto
- Department of Neurosurgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Yuji Ueno
- Department of Neurology, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
- Department of Neurology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Makiko Mieno
- Department of Medical Informatics, Center for Information, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Makoto Hishii
- Department of Neurosurgery, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo, 177-8521, Japan
| | - Yukimasa Yasumoto
- Department of Neurosurgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Chikashi Maruki
- Department of Neurosurgery, Koshigaya Municipal Hospital, 10-47-1 Higashikoshigaya, Koshigaya, Saitama, 343-0023, Japan
| | - Akihide Kondo
- Department of Neurosurgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Ryota Tanaka
- Department of Neurology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan.
- Stroke Center and Division of Neurology, Department of Medicine, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
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Merella P, Casu G, Chessa P, Atzori E, Bandino S, Deiana G. When Atrial Fibrillation Meets Cerebral Amyloid Angiopathy: Current Evidence and Strategies. J Clin Med 2023; 12:7704. [PMID: 38137773 PMCID: PMC10743760 DOI: 10.3390/jcm12247704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/08/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Non-valvular atrial fibrillation (AF) and cerebral amyloid angiopathy (CAA) are two common diseases in elderly populations. Despite the effectiveness of oral anticoagulant therapy in cardioembolic stroke prevention, intracranial hemorrhage represents the most serious complication of these therapies. Cerebral amyloid angiopathy is one of the main risk factors for spontaneous intracranial bleeding, and this risk is highly increased by age and concomitant antithrombotic therapies. Cerebral amyloid angiopathy can be silent for years and then manifest with clinical features simulating TIA (TIA-mimics) or stroke in AF patients, pushing clinicians to rapidly start VKAs or DOACs, thus increasing the risk of intracranial bleeding if the diagnosis of CAA was unknown. Because the cerebral amyloid angiopathy is easily diagnosed with non-contrast MRI, suspecting the disease can avoid catastrophic complications. In this review, we will provide physicians managing anticoagulant therapies with key tips to familiarize themselves with cerebral amyloid angiopathy, with a focus on the possible clinical presentations and on the diagnostic criteria.
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Affiliation(s)
- Pierluigi Merella
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari, Via De Nicola 1, 07100 Sassari, Italy; (G.C.); (E.A.); (S.B.)
| | - Gavino Casu
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari, Via De Nicola 1, 07100 Sassari, Italy; (G.C.); (E.A.); (S.B.)
- Faculty of Medicine, University of Sassari, 07100 Sassari, Italy
| | - Paola Chessa
- Department of Pharmacy, San Francesco Hospital, 08100 Nuoro, Italy;
| | - Enrico Atzori
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari, Via De Nicola 1, 07100 Sassari, Italy; (G.C.); (E.A.); (S.B.)
| | - Stefano Bandino
- Department of Cardiology, Azienda Ospedaliero Universitaria di Sassari, Via De Nicola 1, 07100 Sassari, Italy; (G.C.); (E.A.); (S.B.)
| | - Gianluca Deiana
- Department of Neurology and Stroke Unit, San Francesco Hospital, 08100 Nuoro, Italy;
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Albakr A, Almatar A, AlFajri A, Zafar A, Nazish S, Shahid R, AlJaafari D, Soltan N, Alarfaj Z, Al Ghamdi O, Alfilw S, Abdelhady A, Albaker W. Important Factors to Expect the Outcome After Intracerebral Hemorrhage: An Observational Study From a University Hospital in Saudi Arabia. Neurologist 2023; 28:310-315. [PMID: 37027177 DOI: 10.1097/nrl.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) has worse clinical outcomes than other stroke types. The risk factors contributing to ICH outcomes are not entirely understood, and published literature from Saudi Arabia on ICH outcomes is limited. Our goal was to study the specific clinical and imaging determinants of ICH outcomes. METHODS We retrospectively retrieved all patients with spontaneous ICH (SICH) from a prospective King Fahd Hospital University registry between 2017 and 2019. The clinical characteristics of ICH events and data on clinical outcomes (6 to 12 mo) were recorded. Groups of patients with a favorable modified Rankin Scale of 0 to 2 and nonfavorable outcomes of a modified Rankin Scale of 3 to 6 were investigated. The relationship between the clinical characteristics of the SICH event and its outcomes was assessed using linear and logistic regression analyses. RESULTS A total of 148 patients with a mean age of 60.3 years (±15.2) and a median follow-up of 9 months were included. Unfavorable outcomes were reported in 98 patients (66.2%). The ICH event variables associated with unfavorable outcomes were impaired renal function, Glasgow Coma Score <8, hematoma volume, hematoma expansion, and intraventricular extension (IVE). CONCLUSIONS Our study demonstrated important clinical and radiologic features in patients with ICH that may affect their clinical long-term functional outcomes. A larger multicenter study is required to validate our results and evaluate the methods to improve health care in patients with SICH.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Suad Alfilw
- Department of Neurology, College of Nursing, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia
| | - Ahmed Abdelhady
- Department of critical care, College of Medicine, Alexandria University, Egypt
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Li Y, Liu X, Chen S, Wang J, Pan C, Li G, Tang Z. Effect of antiplatelet therapy on the incidence, prognosis, and rebleeding of intracerebral hemorrhage. CNS Neurosci Ther 2023; 29:1484-1496. [PMID: 36942509 PMCID: PMC10173719 DOI: 10.1111/cns.14175] [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: 02/02/2023] [Revised: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/23/2023] Open
Abstract
OBJECTIVE Antiplatelet medications are increasingly being used for primary and secondary prevention of ischemic attacks owing to the increasing prevalence of ischemic stroke occurrences. Currently, many patients receive antiplatelet therapy (APT) to prevent thromboembolic events. However, long-term use of APT might also lead to an increased occurrence of intracerebral hemorrhage (ICH) and affect the prognosis of patients with ICH. Furthermore, some research suggest that restarting APT for patients who have previously experienced ICH may result in rebleeding events. The precise relationship between APT and ICH remains unknown. METHODS We searched PubMed for the most recent related literature and summarized the findings from various studies. The search terms included "antiplatelet," "intracerebral hemorrhage," "cerebral microbleeds," "hematoma expansion," "recurrent," and "reinitiate." Clinical studies involving human subjects were ultimately included and interpreted in this review, and animal studies were not discussed. RESULTS When individuals are administered APT, the risk of thrombotic events should be weighted against the risk of bleeding. In general, for some patients' concomitant with risk factors of thrombotic events, the advantages of antiplatelet medication may outweigh the inherent risk of rebleeding. However, the use of antiplatelet medications for other patients with a higher risk of bleeding should be carefully evaluated and closely monitored. In the future, a quantifiable system for assessing thrombotic risk and bleeding risk will be necessary. After evaluation, the appropriate time to restart APT for ICH patients should be determined to prevent underlying ischemic stroke events. According to the present study results and expert experience, most patients now restart APT at around 1 week following the onset of ICH. Nevertheless, the precise time to restart APT should be chosen on a case-by-case basis as per the patient's risk of embolic events and recurrent bleeding. More compelling evidence-based medicine evidence is needed in the future. CONCLUSION This review thoroughly discusses the relationship between APT and the development of ICH, the impact of APT on the course and prognosis of ICH patients, and the factors influencing the decision to restart APT after ICH. However, different studies' conclusions are inconsistent due to the differences in quality control. To support future clinical decisions, more large-scale randomized controlled trials are required.
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Affiliation(s)
- Yunjie Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xia Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiling Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jingyi Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gaigai Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Laviv Y, Schwartz N, Yassin S, Harnof S. Deep, spontaneous intracerebral hemorrhages: Clinical differences and risk factors associated with anterior versus posterior circulation. Clin Neurol Neurosurg 2023; 226:107594. [PMID: 36731163 DOI: 10.1016/j.clineuro.2023.107594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/26/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND spontaneous intracerebral hemorrhages (ICH) in different anatomical locations are considered different clinical entities, associated with different vascular etiologies. However, such a distinction between deep ICH in the posterior vs. the anterior circulation is not well documented. OBJECTIVE to look for different demographic, clinical, laboratory and radiological variables in order to clarify any distinction between deep ICH of the posterior versus the anterior circulations. MATERIAL AND METHODS Retrospective study on patients diagnosed with deep, spontaneous ICH at a single tertiary center. Patients were divided into two groups: posterior circulation (group 1) and anterior circulation (group 2). Computerized medical records were extracted for multiple variables. RESULTS A total of 142 patients with deep ICH were included in the study; 54.9 % (n = 78) with posterior (group 1) and 45.1 % (n = 64) with anterior circulation hemorrhages (group 2). In group 1, 67.9 % (n = 53) of hemorrhages were in the cerebellum and 28.2 % (n = 22) in the thalamus. Patients in group 1 were older at time of hemorrhage (68.69 ± 11.66 vs. 64.95 ± 13.34, p = 0.073) and had nearly threefold increased rate of BMI≥ 35 (22.0 % vs. 8.6 %, p = 0.071). In multivariate analysis, use of anti-aggregates (OR=2.391; 95 % CI 1.082-5.285, p = 0.031) and past medical history of HTN (OR=2.904; 95 % CI 1.102-7.654, p = 0.031) were significantly associated with ICH of the posterior circulation. When excluding patients with thalamic hemorrhages, BMI ≥ 35 was also associated with significant risk of having a deep hemorrhage in the posterior circulation vs. the anterior circulation (OR=3.420; 95 % CI 1.011-11.574, p = 0.048). No significant differences were found between the two groups in terms of functional and survival outcomes. CONCLUSION HTN, use of anti-aggregates and morbid obesity are associated with deep ICHs of the posterior circulation and should be considered significant risk factors for this major clinical event. The growing data on pathophysiology of distinct subgroups of ICH will provide useful tools that will aid in preventing and treating these neurological emergencies. Future epidemiological and clinical studies should use the distinction between ICH subgroups based on their anatomical location and vascular territories as accurately as possible in order to reach solid conclusions.
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Affiliation(s)
- Yosef Laviv
- Neurosurgery Department, Beilinson Hospital, Rabin Medical Center, Tel-Aviv University, Petah Tikva, Israel.
| | - Noa Schwartz
- Neurosurgery Department, Beilinson Hospital, Rabin Medical Center, Tel-Aviv University, Petah Tikva, Israel
| | - Saeed Yassin
- Neurosurgery Department, Beilinson Hospital, Rabin Medical Center, Tel-Aviv University, Petah Tikva, Israel
| | - Sagi Harnof
- Neurosurgery Department, Beilinson Hospital, Rabin Medical Center, Tel-Aviv University, Petah Tikva, Israel
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Albakr A. Spontaneous intracerebral hemorrhage among hypertensive patients in Saudi Arabia: Study from a tertiary center. SAUDI JOURNAL OF MEDICINE AND MEDICAL SCIENCES 2022; 10:139-145. [PMID: 35602389 PMCID: PMC9121708 DOI: 10.4103/sjmms.sjmms_73_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/31/2022] [Accepted: 04/19/2022] [Indexed: 11/04/2022] Open
Abstract
Background: Objectives: Patients and Methods: Results: Conclusion:
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Deep versus Superficial Spontaneous Cerebellar Hemorrhages: Separated Vascular Etiologies with Different Clinical Consequences. World Neurosurg 2021; 150:e436-e444. [PMID: 33727202 DOI: 10.1016/j.wneu.2021.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/05/2021] [Accepted: 03/06/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Spontaneous cerebellar hemorrhage (CH) is a critical neurosurgical event. It is usually categorized as a homogenous group under the general term of deep/nonlobar intracerebral hemorrhage. However, increasing evidence suggests it is composed of 2 subgroups, separated from each other by their anatomic location (deep vs. superficial), as well as by their vascular etiology (small vessel disease vs. cerebral amyloid angiopathy). OBJECTIVE To identify any clinically significant differences between anatomically separated subgroups of CHs: deep versus superficial. METHODS This is a retrospective study on patients who were diagnosed with spontaneous CHs at a single tertiary center. On the basis of the radiologic location of the hematoma, patients were divided into 2 groups: deep (group 1) and superficial (group 2). Computerized medical records were extracted for multiple variables. RESULTS A total of 69 patients fulfilled the inclusion criteria. Fifty-three (77%) were in group 1, and 16 (23%) were in group 2. Having any vascular risk factor was associated with the highest odds ratio for having a deep CH. Morbid obesity (body mass index ≥30) and the use of antiplatelets were also associated with increased odds ratios. Group 1 is also associated with high prevalence of intraventricular hemorrhage, acute hydrocephalus, and less favorable outcome. CONCLUSIONS This study supports the notion that CH is most likely a heterogenous condition, composed of 2 subgroups, separated from each other in terms of anatomic location, vascular etiologies, and clinical consequences. Further studies on large cohort of patients are needed in order to accurately define the subgroups of this life-threatening event.
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Sprügel MI, Kuramatsu JB, Volbers B, Saam JI, Sembill JA, Gerner ST, Balk S, Hamer HM, Lücking H, Hölter P, Nolte CH, Scheitz JF, Rocco A, Endres M, Huttner HB. Impact of Statins on Hematoma, Edema, Seizures, Vascular Events, and Functional Recovery After Intracerebral Hemorrhage. Stroke 2021; 52:975-984. [PMID: 33517701 DOI: 10.1161/strokeaha.120.029345] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE The impact of statins on hematoma characteristics, perihemorrhagic edema (PHE), cardiovascular events, seizures, and functional recovery in patients with intracerebral hemorrhage (ICH) is insufficiently studied. METHODS Patients with ICH of the prospective UKER-ICH (Universitätsklinikum Erlangen Cohort of Patients With Spontaneous Intracerebral Hemorrhage) study (URL: https://www.clinicaltrials.gov; Unique identifier: NCT03183167) were analyzed by multivariable regression modeling and propensity score matching, and PHE volumes were volumetrically assessed. Outcomes comprised hematoma characteristics, the impact of continuation, discontinuation, and initiation of statins on peak PHE extent, and the influence of statin treatment on the occurrence of seizures, cardiovascular adverse events, and functional recovery after ICH. RESULTS A total of 1275 patients with ICH with information on statin treatment were analyzed. Statin treatment on hospital admission (21.7%) was associated with higher rates of lobar versus nonlobar ICH (odds ratio, 1.57 [1.03-2.40]; P=0.038). Initiation of statins after ICH was associated with increased peak PHE (β=0.12, SE=0.06, P=0.008), whereas continuation versus discontinuation of prior statin treatment was not significantly associated with edema formation (P>0.10). There were no significant differences in the incidence of remote symptomatic seizures according to statin exposure during follow-up (statins: 11.5% versus no statins: 7.8%, subdistribution hazard ratio: 1.15 [0.80-1.66]; P=0.512). Patients on statins revealed less cardiovascular adverse events and more frequently functional recovery after 12 months (functional recovery: 57.7% versus 45.0%, odds ratio 1.67 [1.09-2.56]; P=0.019). CONCLUSIONS Among statin users, lobar ICH occurs more frequently as compared with nonstatin users. While continuation of prior statin treatment appears to be safe regarding PHE formation, the initiation of statins during the first days after ICH may increase PHE extent. However, statins should be initiated thereafter (eg, at hospital discharge) to prevent cardiovascular events and potentially improve functional recovery.
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Affiliation(s)
- Maximilian I Sprügel
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Joji B Kuramatsu
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Bastian Volbers
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Justina I Saam
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Jochen A Sembill
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Stefan T Gerner
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Stefanie Balk
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Hajo M Hamer
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Hannes Lücking
- Department of Neuroradiology (H.L., P.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Philip Hölter
- Department of Neuroradiology (H.L., P.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (C.H.N., J.F.S., A.R., M.E.)
| | - Jan F Scheitz
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (C.H.N., J.F.S., A.R., M.E.)
| | - Andrea Rocco
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (C.H.N., J.F.S., A.R., M.E.)
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Germany (C.H.N., J.F.S., A.R., M.E.).,Center for Stroke Research Berlin (M.E.).,German Center for Neurodegenerative Diseases (DZNE) (M.E.), partner site Berlin.,German Centre for Cardiovascular Research (DZHK) (M.E.), partner site Berlin
| | - Hagen B Huttner
- Department of Neurology (M.I.S., J.B.K., B.V., J.I.S., J.A.S., S.T.G., S.B., H.M.H., H.B.H.), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
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Antithrombotics in intracerebral hemorrhage in the era of novel agents and antidotes: A review. JOURNAL OF POPULATION THERAPEUTICS AND CLINICAL PHARMACOLOGY 2020; 27:e1-e18. [PMID: 32320168 DOI: 10.15586/jptcp.v27i2.660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH)1 is characterized by the pathological accumulation of blood within the brain parenchyma, most commonly associated with hypertension, arteriovenous malformations, or trauma. However, it can also present in patients receiving antithrombotic drugs, either anticoagulants such as acenocoumarol/warfarin-novel oral anticoagulants or antiplatelets, for the prevention and treatment of thromboembolic disease. OBJECTIVE The purpose of this review is to present current bibliographic data regarding ICH irrespective of the cause, as well as post-hemorrhage use of antithrombotic agents. Moreover, this review attempts to provide guidelines concerning the termination, inversion, and of course resumption of antithrombotic therapy. METHODS AND MATERIALS We reviewed the most recently presented available data for patients who dealt with intracerebral hemorrhagic events while on antithrombotic agents (due to atrial fibrillation, prosthetic mechanical valves or recent/recurrent deep vein thrombosis). Furthermore, we examined and compared the thromboembolic risk, the bleeding risk, as well as the re-bleeding risk in two groups: patients receiving antithrombotic therapy versus patients not on antithrombotic therapy. CONCLUSION Antithrombotic therapy is of great importance when indicated, though it does not come without crucial side-effects, such as ICH. Optimal timing of withdrawal, reversal, and resumption of antithrombotic treatment should be determined by a multidisciplinary team consisting of a stroke specialist, a cardiologist, and a neurosurgeon, who will individually approach the needs and risks of each patient.
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Miyares LC, Falcone GJ, Leasure A, Adeoye O, Shi FD, Kittner SJ, Langefeld C, Vagal A, Sheth KN, Woo D. Race/ethnicity influences outcomes in young adults with supratentorial intracerebral hemorrhage. Neurology 2020; 94:e1271-e1280. [PMID: 31969467 DOI: 10.1212/wnl.0000000000008930] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 10/02/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES We investigated the predictors of functional outcome in young patients enrolled in a multiethnic study of intracerebral hemorrhage (ICH). METHODS The Ethnic/Racial Variations in Intracerebral Hemorrhage (ERICH) study is a prospective multicenter study of ICH among adult (age ≥18 years) non-Hispanic white, non-Hispanic black, and Hispanic participants. The study recruited 1,000 participants per racial/ethnic group. The present study utilized the subset of ERICH participants aged <50 years with supratentorial ICH. Functional outcome was ascertained using the modified Rankin Scale (mRS) at 3 months. Logistic regression was used to identify factors associated with poor outcome (mRS 4-6), and analyses were compared by race/ethnicity to identify differences across these groups. RESULTS Of the 3,000 patients with ICH enrolled in ERICH, 418 were studied (mean age 43 years, 69% male), of whom 48 (12%) were white, 173 (41%) were black, and 197 (47%) were Hispanic. For supratentorial ICH, black participants (odds ratio [OR], 0.42; p = 0.046) and Hispanic participants (OR, 0.34; p = 0.01) had better outcomes than white participants after adjustment for other factors associated with poor outcome: age, baseline disability, admission blood pressure, admission Glasgow Coma Scale score, ICH volume, deep ICH location, and intraventricular extension. CONCLUSIONS In young patients with supratentorial ICH, black and Hispanic race/ethnicity is associated with better functional outcomes, compared with white race. Additional studies are needed to identify the biological and social mediators of this association.
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Affiliation(s)
- Laura C Miyares
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Guido J Falcone
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Audrey Leasure
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Opeolu Adeoye
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Fu-Dong Shi
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Steven J Kittner
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Carl Langefeld
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Achala Vagal
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Kevin N Sheth
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville
| | - Daniel Woo
- From the Division of Neurocritical Care and Emergency Neurology, Department of Neurology (L.C.M., G.J.F., A.L., K.N.S.), Yale School of Medicine, New Haven, CT; Department of Emergency Medicine (O.A.), Department of Radiology (A.V.), Gardner Neuroscience Institute (O.A., A.V.), Department of Neurology & Rehabilitation Medicine (D.W.), and Comprehensive Stroke Center (D.W.), University of Cincinnati, OH; Barrow Neurological Institute (F.-D.S.), Phoenix, AZ; Department of Neurology (S.J.K.), Baltimore Veterans Administration Medical Center, University of Maryland; Division of Public Health Sciences, Department of Biostatistical Sciences (C.L.), Wake Forest University School of Medicine, Winston-Salem, NC; and Center for Public Health Genomics (C.L.), University of Virginia, Charlottesville.
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Sprügel MI, Kuramatsu JB, Gerner ST, Sembill JA, Madžar D, Reindl C, Bobinger T, Müller T, Hoelter P, Lücking H, Engelhorn T, Huttner HB. Age-dependent clinical outcomes in primary versus oral anticoagulation-related intracerebral hemorrhage. Int J Stroke 2019; 16:83-92. [PMID: 31870241 DOI: 10.1177/1747493019895662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIMS This study determined the influence of age on bleeding characteristics and clinical outcomes in primary spontaneous (non-OAC), vitamin K antagonist-related (VKA-) and non-vitamin K antagonist oral anticoagulant-related (NOAC-) ICH. METHODS Pooled individual patient data of multicenter cohort studies were analyzed by logistic regression modelling and propensity-score-matching (PSM) to explore the influence of advanced age on clinical outcomes among non-OAC-, VKA-, and NOAC-ICH. Primary outcome measure was functional outcome at three months assessed by the modified Rankin Scale, dichotomized into favorable (mRS = 0-3) and unfavorable (mRS = 4-6) functional outcome. Secondary outcome measures included mortality, hematoma characteristics, and frequency of invasive interventions. RESULTS In VKA-ICH 33.5% (670/2001), in NOAC-ICH 44.2% (69/156) and in non-OAC-ICH 25.2% (254/1009) of the patients were ≥80 years. After adjustment for treatment interventions and relevant parameters, elderly ICH patients comprised worse functional outcome at three months (adjusted odds ratio (aOR) in VKA-ICH: 1.49 (1.21-1.84); p < 0.001; NOAC-ICH: 2.01 (0.95-4.26); p = 0.069; non-OAC-ICH: 3.54 (2.50-5.03); p < 0.001). Anticoagulation was significantly associated with worse functional outcome below the age of 70 years, (aOR: 2.38 (1.78-3.16); p < 0.001), but not in patients of ≥70 years (aOR: 1.21 (0.89-1.65); p = 0.217). The differences in initial ICH volume and extent of ICH enlargement between OAC-ICH and non-OAC-ICH gradually decreased with increasing patient age. CONCLUSIONS As compared to elderly ICH-patients, in patients <70 years OAC-ICH showed worse clinical outcomes compared to non-OAC-ICH because of larger baseline ICH-volumes and extent of hematoma enlargement. Treatment strategies aiming at neutralizing altered coagulation should be aware of these findings.
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Affiliation(s)
- Maximilian I Sprügel
- Department of Neurology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Jochen A Sembill
- Department of Neurology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Dominik Madžar
- Department of Neurology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Caroline Reindl
- Department of Neurology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Bobinger
- Department of Neurology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Tamara Müller
- Department of Neurology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Philip Hoelter
- Department of Neuroradiology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Hannes Lücking
- Department of Neuroradiology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
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Cheng Y, Wang Y, Song Q, Qiu K, Liu M. Use of anticoagulant therapy and cerebral microbleeds: a systematic review and meta-analysis. J Neurol 2019; 268:1666-1679. [PMID: 31616992 DOI: 10.1007/s00415-019-09572-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Anticoagulant therapy increases the risk that cerebral microbleeds (CMBs) progress to intracerebral hemorrhage, but whether the therapy increases risk of CMB occurrence is unclear. We performed a systematic review and meta-analysis to investigate the potential association between anticoagulant use and CMB occurrence in stroke and stroke-free individuals. METHODS We searched observational studies in PubMed, Ovid EMBASE, and Cochrane Library from their inception until September 2019. We calculated the pooled odds ratio (OR) and 95% confidence interval (CI) for the prevalence and incidence of CMBs in anticoagulant users relative to non-anticoagulant users. RESULTS Forty-seven studies with 25,245 participants were included. The pooled analysis showed that anticoagulant use was associated with CMB prevalence (OR 1.54, 95% CI 1.26-1.88). The association was observed in subgroups stratified by type of participants: stroke-free, OR 1.86, 95% CI 1.25-2.77; ischemic stroke/transient ischemic attack, OR 1.33, 95% CI 1.06-1.67; and intracerebral hemorrhage, OR 2.26, 95% CI 1.06-4.83. Anticoagulant use was associated with increased prevalence of strictly lobar CMBs (OR 1.68, 95% CI 1.22-2.32) but not deep/infratentorial CMBs. Warfarin was associated with increased CMB prevalence (OR 1.64, 95% CI 1.23-2.18), but novel oral anticoagulants were not. Anticoagulant users showed higher incidence of CMBs during long-term follow-up (OR 1.72, 95% CI 1.22-2.44). CONCLUSION Anticoagulant use is associated with higher prevalence and incidence of CMBs. This association appears to depend on location of CMBs and type of anticoagulants. More longitudinal investigations with adjustment for confounders are required to establish the causality.
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Affiliation(s)
- Yajun Cheng
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yanan Wang
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Quhong Song
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Ke Qiu
- West China School of Medicine, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Ming Liu
- Department of Neurology, Center of Cerebrovascular Disease, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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15
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Sprügel MI, Kuramatsu JB, Gerner ST, Sembill JA, Beuscher VD, Hagen M, Roeder SS, Lücking H, Struffert T, Dörfler A, Schwab S, Huttner HB. Antiplatelet Therapy in Primary Spontaneous and Oral Anticoagulation-Associated Intracerebral Hemorrhage. Stroke 2019; 49:2621-2629. [PMID: 30355188 DOI: 10.1161/strokeaha.118.021614] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- This study determined the influence of concomitant antiplatelet therapy (APT) on hematoma characteristics and outcome in primary spontaneous intracerebral hemorrhage (ICH), vitamin K antagonist (VKA)- and non-VKA oral anticoagulant-associated ICH. Methods- Data of retrospective cohort studies and a prospective single-center study were pooled. Functional outcome, mortality, and radiological characteristics were defined as primary and secondary outcomes. Propensity score matching and logistic regression analyses were performed to determine the association between single or dual APT and hematoma volume. Results- A total of 3580 patients with ICH were screened, of whom 3545 with information on APT were analyzed. Three hundred forty-six (32.4%) patients in primary spontaneous ICH, 260 (11.4%) in VKA-ICH, and 30 (16.0%) in non-VKA oral anticoagulant-associated ICH were on APT, and these patients had more severe comorbidities. After propensity score matching VKA-ICH patients on APT presented with less favorable functional outcome (modified Rankin Scale score, 0-3; APT, 48/202 [23.8%] versus no APT, 187/587 [31.9%]; P=0.030) and higher mortality (APT, 103/202 [51.0%] versus no APT, 237/587 [40.4%]; P=0.009), whereas no significant differences were present in primary spontaneous ICH and non-VKA oral anticoagulant-associated ICH. In VKA-ICH, hematoma volume was significantly larger in patients with APT (21.9 [7.4-61.4] versus 15.7 [5.7-44.5] mL; P=0.005). Multivariable regression analysis revealed an association of APT and larger ICH volumes (odds ratio, 1.80 [1.20-2.70]; P=0.005), which was more pronounced in dual APT and supratherapeutically anticoagulated patients. Conclusions- APT does not affect ICH characteristics and outcome in primary spontaneous ICH patients; however, it is associated with larger ICH volume and worse functional outcome in VKA-ICH, presumably by additive antihemostatic effects. Combination of anticoagulation and APT should, therefore, be diligently evaluated and restricted to the shortest possible time frame.
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Affiliation(s)
- Maximilian I Sprügel
- From the Department of Neurology (M.I.S., J.B.K., S.T.G., J.A.S., V.D.B., M.H., S.S.R., S.S., H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Joji B Kuramatsu
- From the Department of Neurology (M.I.S., J.B.K., S.T.G., J.A.S., V.D.B., M.H., S.S.R., S.S., H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Stefan T Gerner
- From the Department of Neurology (M.I.S., J.B.K., S.T.G., J.A.S., V.D.B., M.H., S.S.R., S.S., H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Jochen A Sembill
- From the Department of Neurology (M.I.S., J.B.K., S.T.G., J.A.S., V.D.B., M.H., S.S.R., S.S., H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Vanessa D Beuscher
- From the Department of Neurology (M.I.S., J.B.K., S.T.G., J.A.S., V.D.B., M.H., S.S.R., S.S., H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Manuel Hagen
- From the Department of Neurology (M.I.S., J.B.K., S.T.G., J.A.S., V.D.B., M.H., S.S.R., S.S., H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Sebastian S Roeder
- From the Department of Neurology (M.I.S., J.B.K., S.T.G., J.A.S., V.D.B., M.H., S.S.R., S.S., H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Hannes Lücking
- Department of Neuroradiology (H.L., T.S., A.D.), University of Erlangen-Nuremberg, Germany
| | - Tobias Struffert
- Department of Neuroradiology (H.L., T.S., A.D.), University of Erlangen-Nuremberg, Germany
| | - Arnd Dörfler
- Department of Neuroradiology (H.L., T.S., A.D.), University of Erlangen-Nuremberg, Germany
| | - Stefan Schwab
- From the Department of Neurology (M.I.S., J.B.K., S.T.G., J.A.S., V.D.B., M.H., S.S.R., S.S., H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Hagen B Huttner
- From the Department of Neurology (M.I.S., J.B.K., S.T.G., J.A.S., V.D.B., M.H., S.S.R., S.S., H.B.H.), University of Erlangen-Nuremberg, Germany
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16
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Morotti A, Goldstein JN. WITHDRAWN: Anticoagulant-associated intracerebral hemorrhage. BRAIN HEMORRHAGES 2019. [DOI: 10.1016/j.hest.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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17
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Seiffge DJ, Curtze S, Dequatre-Ponchelle N, Pezzini A, Tatlisumak T, Cordonnier C, Werring D. Hematoma location and morphology of anticoagulation-associated intracerebral hemorrhage. Neurology 2019; 92:e782-e791. [PMID: 30674603 DOI: 10.1212/wnl.0000000000006958] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 10/15/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To study hematoma location and morphology of intracerebral hemorrhage (ICH) associated with oral anticoagulants (OAC) and delineate causes and mechanism. METHODS We performed a systematic literature research and meta-analysis of studies comparing neuroimaging findings in patients with OAC-ICH compared to those with ICH not associated with OAC (non-OAC ICH). We calculated pooled risk ratios (RRs) for ICH location using the Mantel-Haenszel random-effects method and corresponding 95% confidence intervals (95% CI). RESULTS We identified 8 studies including 6,259 patients (OAC-ICH n = 1,107, pooled OAC-ICH population 17.7%). There was some evidence for deep ICH location (defined as ICH in the thalamus, basal ganglia, internal capsule, or brainstem) being less frequent in patients with OAC-ICH (OAC-ICH: 450 of 1,102/40.8% vs non-OAC ICH: 2,656 of 4,819/55.1%; RR 0.94, 95% CI 0.88-1.00, p = 0.05, I 2 = 0%) while cerebellar ICH location was significantly more common in OAC-ICH (OAC-ICH: 111 of 1,069/10.4% vs non-OAC ICH: 326 of 4,787/6.8%; RR 1.45, 95% CI 1.12-1.89, p = 0.005, I 2 = 21%) compared to non-OAC ICH. There was no statistically significant relationship to OAC use for lobar (OAC-ICH: 423 of 1,107/38.2% vs non-OAC ICH: 1,884 of 5,152/36.6%; RR 1.02, 95% CI 0.89-1.17, p = 0.75, I 2 = 53%, p for heterogeneity = 0.04) or brainstem ICH (OAC-ICH: 36 of 546/6.6% vs non-OAC ICH: 172 of 2,626/6.5%; RR 1.04, 95% CI 0.58-1.87, p = 0.89, I 2 = 59%, p for heterogeneity = 0.04). The risk for intraventricular extension (OAC-ICH: 436 of 840/51.9% vs non-OAC ICH: 1,429 of 3,508/40.7%; RR 1.26, 95% CI 1.16-1.36, p < 0.001, I 2 = 0%) was significantly increased in patients with OAC-ICH. We found few data on ICH morphology in OAC-ICH vs non-OAC ICH. CONCLUSION The overrepresentation of cerebellar ICH location and intraventricular extension in OAC-ICH might have mechanistic relevance for the underlying arteriopathy, pathophysiology, or bleeding pattern of OAC-ICH, and should be investigated further.
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Affiliation(s)
- David J Seiffge
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sami Curtze
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nelly Dequatre-Ponchelle
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alessandro Pezzini
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Turgut Tatlisumak
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Charlotte Cordonnier
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Werring
- From the Stroke Research Group (D.J.S., D.W.), UCL Queen Square Institute of Neurology, University College London and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; Stroke Centre and Neurology (D.J.S.), University Hospital and University Basel, Switzerland; Department of Neurology (S.C., T.T.), Helsinki University Hospital, Finland; Degenerative & Vascular Cognitive Disorders, Department of Neurology (N.D.-P., C.C.), INSERM U1171, CHU Lille, University of Lille, France; Department of Clinical and Experimental Sciences, Neurology Clinic (A.P.), University of Brescia, Italy; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden.
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18
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Grove EL, Skjøth F, Nielsen PB, Christensen TD, Larsen TB. Effectiveness and safety of self-managed oral anticoagulant therapy compared with direct oral anticoagulants in patients with atrial fibrillation. Sci Rep 2018; 8:15805. [PMID: 30361687 PMCID: PMC6202319 DOI: 10.1038/s41598-018-33531-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/01/2018] [Indexed: 12/24/2022] Open
Abstract
We compared the effectiveness and safety of direct oral anticoagulants (DOAC) vs patient self-managed warfarin therapy (PSM) in patients with atrial fibrillation. We linked prospectively registered data from university hospital clinics to nationwide Danish health registries. Primary effectiveness and safety outcomes were ischaemic stroke (incl. systemic embolism) and major bleeding. All-cause mortality and all-cause stroke were secondary outcomes. An inverse probability of treatment propensity-weighted approach was applied to adjust for potential confounding. The study cohorts included 534 patients treated with PSM and 2,671 patients treated with DOAC. Weighted rates of ischaemic stroke were 0.46 and 1.30 percent per year with PSM vs DOAC, hazard ratio (HR) 0.27 (95% confidence interval 0.11-0.68) with 2.5 years follow-up. Rates of major bleeding were 2.32 and 2.13 percent per year (HR 1.06 [0.69-1.63]). All-cause mortality was not statistically different (HR 0.67 [0.39-1.17]), whereas the incidence of all-cause stroke was significantly lower among patients treated with PSM with rates of 0.61 vs 1.45 percent per year (HR 0.36 [0.16-0.78]). In patients with atrial fibrillation, self-managed oral anticoagulant treatment was associated with a significantly lower risk of all-cause and ischaemic stroke compared to treatment with DOAC, whereas no significant differences were observed for major bleeding and mortality.
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Affiliation(s)
- Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
| | - Flemming Skjøth
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Thomas Decker Christensen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Torben Bjerregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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19
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Romem R, Tanne D, Geva D, Einhorn-Cohen M, Shlomo N, Bar-Yehuda S, Harnof S. Antithrombotic Treatment Prior to Intracerebral Hemorrhage: Analysis in the National Acute Stroke Israeli Registry. J Stroke Cerebrovasc Dis 2018; 27:3380-3386. [PMID: 30205997 DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/18/2018] [Accepted: 07/24/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage (ICH) is the most disastrous stroke subtype. Prognosis is considered worse with prior antithrombotic treatment. Our aim was to evaluate the association of prior antithrombotic treatment on the radiological and clinical outcome after ICH in a subgroup of patients included in a national registry. METHODS Based on the National Acute Stroke Israeli (NASIS) registry during 2004, 2007, 2010, and 2013 (2-month periods), characteristics, volumetric parameters, and prognosis of a subgroup of patients with ICH were analyzed. RESULTS Among the 634 patients with ICH in the NASIS registry, 310 (49%) were not treated previously with antithrombotic medications, 232 (37%) were treated with an antiplatelet agent, and 92 (14.5%) patients were on oral anticoagulant therapy, of them 30 patients (33%) with an international normalised ratio (INR) value below 2, 33 (36%) patients with an INR value of 2-3, and 29 patients (31%) with an INR value above 3 upon admission. Patients with deep hemorrhage on prior anticoagulants treatment had the highest probability for poor outcome at hospital discharge. Patients with low bleeding volume (0-30 cm3), were likely to have admission National Institute of Health Stroke Scale < 10 (62%), while those with higher volumes (30-59 cm3 and > 60 cm3), had only 16.7% and 14.3% chance, respectively. We did not observe a significant difference between prior antithrombotic treatment and functional outcome at discharge, yet prior anticoagulant treatment was associated with higher long-term mortality rates. CONCLUSIONS Our findings, based on a national registry, support the high mortality and poor outcome of anticoagulant related ICH.
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Affiliation(s)
- Roy Romem
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - David Tanne
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Diklah Geva
- The Israeli Association for Cardiovascular Trials, Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Michal Einhorn-Cohen
- The Israeli Association for Cardiovascular Trials, Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Nir Shlomo
- The Israeli Association for Cardiovascular Trials, Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Sara Bar-Yehuda
- The Israeli Association for Cardiovascular Trials, Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Sagi Harnof
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Department of Neurosurgery, Rabin Medical Center, Petah Tikva, Israel
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20
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Charidimou A, Morotti A, Valenti R, Giese AK, Boulouis G, Pasi M, Roongpiboonsopit D, Lauer A, Xiong L, Van Harten TW, Karadeli H, Fotiadis P, Jessel MJ, Viswanathan A. Journal Club: Time trends in incidence, case fatality, and mortality of intracerebral hemorrhage. Neurology 2018; 86:e206-9. [PMID: 27185900 DOI: 10.1212/wnl.0000000000002678] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Andreas Charidimou
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA.
| | - Andrea Morotti
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
| | - Raffaella Valenti
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
| | - Anne-Katrin Giese
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
| | - Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
| | - Marco Pasi
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
| | - Duangnapa Roongpiboonsopit
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
| | - Arne Lauer
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
| | - Li Xiong
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
| | - Thijs Wijnzen Van Harten
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
| | - Hasan Karadeli
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
| | - Panagiotis Fotiadis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
| | - Michael James Jessel
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA
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Liu CH, Lin JR, Liou CW, Lee JD, Peng TI, Lee M, Lee TH. Causes of Death in Different Subtypes of Ischemic and Hemorrhagic Stroke. Angiology 2017; 69:582-590. [DOI: 10.1177/0003319717738687] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Causes of death in both ischemic stroke (IS) and hemorrhagic stroke (HS) subtypes are not comprehensively studied. Between 2008 and 2011, we enrolled 11 215 first-ever stroke patients from the Stroke Registry of Chang-Gung Healthcare System and linked these data to the national death registry. The main causes of death in each stroke subtype were assessed. Patients with HS had higher overall mortality than IS (32.0% vs 18.1%, P < .001). In IS subtypes, large-artery atherosclerosis plus cardioembolism had the worst mortality (40.7%, P < .001). Stroke was the leading cause of death in both IS and HS within the first year. Stroke remained the major cause of death in HS, but cancer was the leading cause of death in IS after the first year. After excluding the patients with previous cancer history, cancer was still an important cause of death in IS and HS, particularly in the IS subtypes of small vessel occlusion, stroke of undetermined etiology, and transient ischemic attack.
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Affiliation(s)
- Chi-Hung Liu
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jr-Rung Lin
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Wei Liou
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Tsung-I Peng
- Department of Neurology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Meng Lee
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Taoyuan, Taiwan
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DeSimone CV, Graff-Radford J, El-Harasis MA, Rabinstein AA, Asirvatham SJ, Holmes DR. Cerebral Amyloid Angiopathy: Diagnosis, Clinical Implications, and Management Strategies in Atrial Fibrillation. J Am Coll Cardiol 2017; 70:1173-1182. [PMID: 28838368 DOI: 10.1016/j.jacc.2017.07.724] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 01/16/2023]
Abstract
With an aging population, clinicians are more frequently encountering patients with atrial fibrillation who are also at risk of intracerebral hemorrhage due to cerebral amyloid angiopathy, the result of β-amyloid deposition in cerebral vessels. Cerebral amyloid angiopathy is common among elderly patients, and is associated with an increased risk of intracerebral bleeding, especially with the use of anticoagulation. Despite this association, this entity is absent in current risk-benefit analysis models, which may result in underestimation of the chance of bleeding in the subset of patients with this disease. Determining the presence and burden of cerebral amyloid angiopathy is particularly important when planning to start or restart anticoagulation after an intracerebral hemorrhage. Given the lack of randomized trial data to guide management strategies, we discuss a heart-brain team approach that includes clinician-patient shared decision making for the use of pharmacologic and nonpharmacologic approaches to diminish stroke risk.
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Affiliation(s)
| | | | | | | | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Division of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
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Becattini C, Sembolini A, Paciaroni M. Resuming anticoagulant therapy after intracerebral bleeding. Vascul Pharmacol 2016; 84:15-24. [PMID: 27260938 DOI: 10.1016/j.vph.2016.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/14/2016] [Accepted: 05/28/2016] [Indexed: 12/24/2022]
Abstract
The clinical benefit of resuming anticoagulant treatment after an anticoagulants-associated intracranial hemorrhage (ICH) is debated. No randomized trial has been conducted on this particular clinical issue. The risk of ICH recurrence from resuming anticoagulant therapy is expected to be higher after index lobar than deep ICH and in patients with not amendable risk factors for ICH. Retrospective studies have recently shown improved survival with resumption of treatment after index anticoagulants-associated ICH. Based on these evidences and on the risk for thromboembolic events without anticoagulant treatment, resumption of anticoagulation should be considered in all patients with mechanical heart valve prosthesis and in those with amendable risk factors for anticoagulants-associated ICH. Resumption with direct oral anticoagulants appears a reasonable option for non-valvular atrial fibrillation (NVAF) patients at moderate to high thromboembolic risk after deep ICH and for selected NVAF patients at high thromboembolic risk after lobar ICH. For VTE patients at high risk for recurrence, resumption of anticoagulation or insertion of vena cava filter should be tailored on the estimated risk for ICH recurrence.
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Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Italy.
| | - Agnese Sembolini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Italy
| | - Maurizio Paciaroni
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Italy
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Kremer PHC, Jolink WMT, Kappelle LJ, Algra A, Klijn CJM. Risk Factors for Lobar and Non-Lobar Intracerebral Hemorrhage in Patients with Vascular Disease. PLoS One 2015; 10:e0142338. [PMID: 26540190 PMCID: PMC4634984 DOI: 10.1371/journal.pone.0142338] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 10/20/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Lobar and non-lobar non-traumatic intracerebral hemorrhage (ICH) are presumably caused by different types of small vessel diseases. The aim of this study was to assess risk factors for ICH according to location. METHODS In two large prospective studies, SMART (n = 9088) and ESPRIT (n = 2625), including patients with manifest cardiovascular, cerebrovascular or peripheral artery disease or with vascular risk factors, we investigated potential risk factors for ICH during follow-up according to lobar or non-lobar location by Cox proportional hazards analyses. RESULTS During 65,156 patient years of follow up 19 patients had lobar ICH (incidence rate 29, 95% CI 19-42 per 100,000 person-years) and 24 non-lobar ICH (incidence rate 37, 95% CI 26-51 per 100,000 person-years). Age significantly increased the risk of lobar ICH (HR per 10 years increase 1.90; 95% CI 1.17-3.10) in the multivariable analysis, but not of non-lobar hemorrhage. Anticoagulant medication (HR 3.49; 95% CI 1.20-10.2) and male sex (HR 3.79; 95% CI 1.13-12.8) increased the risk of non-lobar but not lobar ICH. CONCLUSION This study shows an elevated risk of future ICH in patients with manifestations of, or risk factors for, cardiovascular, cerebrovascular or peripheral artery disease. Our data suggest that risk factors for ICH vary according to location, supporting the hypothesis of a differential pathophysiology of lobar and non-lobar ICH.
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Affiliation(s)
- Philip H. C. Kremer
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wilmar M. T. Jolink
- 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
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center, 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, Centre for Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
- * E-mail:
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Braksick SA, Klaas JP, Brown RD, Rabinstein AA, Hocker SE, Fugate JE. Influence of Antithrombotics on the Etiology of Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2015; 24:699-703. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/04/2014] [Accepted: 11/14/2014] [Indexed: 10/24/2022] Open
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26
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Diener HC, Stanford S, Abdul-Rahim A, Christensen L, Hougaard KD, Bakhai A, Veltkamp R, Worthmann H. Anti-thrombotic therapy in patients with atrial fibrillation and intracranial hemorrhage. Expert Rev Neurother 2014; 14:1019-28. [DOI: 10.1586/14737175.2014.945435] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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