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Deuschl C, Goertz L, Kabbasch C, Köhrmann M, Kleinschnitz C, Berlis A, Maurer CJ, Mühlen I, Kallmünzer B, Gawlitza M, Kaiser DPO, Klisch J, Lobsien D, Behme D, Thormann M, Flottmann F, Winkelmeier L, Gizewski ER, Mayer-Suess L, Holtmannspoetter M, Moenninghoff C, Schlunz-Hendann M, Grieb D, Arendt CT, Bohmann FO, Altenbernd J, Li Y, Sure U, Mühl-Benninghaus R, Rodt T, Kallenberg K, Durutya A, Elsharkawy M, Stracke CP, Schumann MG, Bock A, Nikoubashman O, Wiesmann M, Henkes H, Dolff S, Demircioglu A, Forsting M, Styczen H. Impact of Vaccination Status on Outcome of Patients With COVID-19 and Acute Ischemic Stroke Undergoing Mechanical Thrombectomy. J Am Heart Assoc 2024; 13:e031816. [PMID: 38639365 DOI: 10.1161/jaha.123.031816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Data on impact of COVID-19 vaccination and outcomes of patients with COVID-19 and acute ischemic stroke undergoing mechanical thrombectomy are scarce. Addressing this subject, we report our multicenter experience. METHODS AND RESULTS This was a retrospective analysis of patients with COVID-19 and known vaccination status treated with mechanical thrombectomy for acute ischemic stroke at 20 tertiary care centers between January 2020 and January 2023. Baseline demographics, angiographic outcome, and clinical outcome evaluated by the modified Rankin Scale score at discharge were noted. A multivariate analysis was conducted to test whether these variables were associated with an unfavorable outcome, defined as modified Rankin Scale score >3. A total of 137 patients with acute ischemic stroke (48 vaccinated and 89 unvaccinated) with acute or subsided COVID-19 infection who underwent mechanical thrombectomy attributable to vessel occlusion were included in the study. Angiographic outcomes between vaccinated and unvaccinated patients were similar (modified Thrombolysis in Cerebral Infarction ≥2b: 85.4% in vaccinated patients versus 86.5% in unvaccinated patients; P=0.859). The rate of functional independence (modified Rankin Scale score, ≤2) was 23.3% in the vaccinated group and 20.9% in the unvaccinated group (P=0.763). The mortality rate was 30% in both groups. In the multivariable analysis, vaccination status was not a significant predictor for an unfavorable outcome (P=0.957). However, acute COVID-19 infection remained significant (odds ratio, 1.197 [95% CI, 1.007-1.417]; P=0.041). CONCLUSIONS Our study demonstrated no impact of COVID-19 vaccination on angiographic or clinical outcome of COVID-19-positive patients with acute ischemic stroke undergoing mechanical thrombectomy, whereas worsening attributable to COVID-19 was confirmed.
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Affiliation(s)
- Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Essen Germany
| | - Lukas Goertz
- Department of Diagnostic and Interventional Radiology University Hospital Cologne Cologne Germany
| | - Christoph Kabbasch
- Department of Diagnostic and Interventional Radiology University Hospital Cologne Cologne Germany
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neurosciences and Behavioral Sciences University Hospital Essen Essen Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neurosciences and Behavioral Sciences University Hospital Essen Essen Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventional Neuroradiology University Hospital Augsburg Augsburg Germany
| | - Christoph Johannes Maurer
- Department of Diagnostic and Interventional Neuroradiology University Hospital Augsburg Augsburg Germany
| | - Iris Mühlen
- Department of Neuroradiology University of Erlangen-Nuremberg Erlangen Germany
| | - Bernd Kallmünzer
- Department of Neurology University of Erlangen-Nuremberg Erlangen Germany
| | - Matthias Gawlitza
- Faculty of Medicine, Institute and Policlinic of Neuroradiology, University Hospital Carl Gustav Carus Technische Universität Dresden Dresden Germany
- Department of Neuroradiology University Hospital Leipzig Leipzig Germany
| | - Daniel P O Kaiser
- Faculty of Medicine, Institute and Policlinic of Neuroradiology, University Hospital Carl Gustav Carus Technische Universität Dresden Dresden Germany
| | - Joachim Klisch
- Department of Diagnostic and Interventional Radiology and Neuroradiology Helios General Hospital Erfurt Erfurt Germany
| | - Donald Lobsien
- Department of Diagnostic and Interventional Radiology and Neuroradiology Helios General Hospital Erfurt Erfurt Germany
| | - Daniel Behme
- Department of Neuroradiology University Hospital Magdeburg Magdeburg Germany
| | | | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Elke Ruth Gizewski
- Department of Neuroradiology Medical University Innsbruck Innsbruck Austria
| | - Lukas Mayer-Suess
- Department of Neurology Medical University Innsbruck Innsbruck Austria
| | | | - Christoph Moenninghoff
- Department of Radiology, Neuroradiology and Nuclear Medicine Johannes Wesling University Hospital, Ruhr University Bochum Bochum Germany
| | - Martin Schlunz-Hendann
- Department of Radiology and Neuroradiology Klinikum Duisburg-Sana Kliniken Duisburg Germany
| | - Dominik Grieb
- Department of Radiology and Neuroradiology Klinikum Duisburg-Sana Kliniken Duisburg Germany
- Department of Diagnostic and Interventional Neuroradiology Medical School Hannover Hannover Germany
| | - Christophe T Arendt
- Institute of Neuroradiology, University Hospital Goethe University Frankfurt am Main Germany
| | - Ferdinand O Bohmann
- Institute of Neuroradiology, University Hospital Goethe University Frankfurt am Main Germany
| | - Jens Altenbernd
- Department of Radiology and Neuroradiology Gemeinschaftskrankenhaus Herdecke Herdecke Germany
| | - Yan Li
- Institute for Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Essen Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery University Hospital of Essen Essen Germany
| | | | - Thomas Rodt
- Department of Radiology Klinikum Lueneburg Lueneburg Germany
| | - Kai Kallenberg
- Department of Neuroradiology Klinikum Fulda Fulda Germany
| | | | | | | | | | - Alexander Bock
- Department of Neuroradiology Vivantes Klinikum Neukoelln Berlin Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology University Hospital, Rheinisch-Westfälische Technische Hochschule Aachen University Aachen Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology University Hospital, Rheinisch-Westfälische Technische Hochschule Aachen University Aachen Germany
| | - Hans Henkes
- Clinic for Neuroradiology Klinikum Stuttgart Stuttgart Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, West German Centre of Infectious Diseases University Hospital Essen Essen Germany
| | - Aydin Demircioglu
- Institute for Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Essen Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Essen Germany
| | - Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Essen Germany
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Wiestler H, Zickler P, Erdur H, Abu-Mugheisib M, Kallmünzer B, Klingner C, Müller-Barna P, Hubert G, Gumbinger C, Worthmann H. Recommendations for the organization of the teleconsultation service in a telestroke network. Neurol Res Pract 2024; 6:24. [PMID: 38659040 PMCID: PMC11044278 DOI: 10.1186/s42466-024-00318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/15/2024] [Indexed: 04/26/2024] Open
Abstract
Telestroke networks aim to improve acute stroke care within their catchment area. Through a teleconsultation service, the network centers provide support to network hospitals that lack continuous neurological expertise for acute stroke management decisions. Although the importance of telemedical treatment in stroke care is steadily increasing, so far no standards exist for the organization of the teleconsultation service in networks.To ensure a high-level of quality for all processes and measures concerning telemedical stroke treatment, the commission for telemedical stroke care of the German Stroke Society (Deutsche Schlaganfall-Gesellschaft, DSG) created the following recommendations on how to organize a teleconsultation service within a telestroke network. The recommendations are the result of an adjustment process between the authors and include guidance on requirements, qualifications, processes and quality management within the teleconsultation service.
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Affiliation(s)
- Hanni Wiestler
- Department of Neurology, Academic Teaching hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany.
| | - Philipp Zickler
- Department of Neurology and Clinical Neurophysiology, University Augsburg, Augsburg, Germany
| | - Hebun Erdur
- Department of Neurology, Asklepios Fachklinikum Teupitz, Teupitz, Germany
- Department of Neurology, Charité University Hospital, Berlin, Germany
| | - Mazen Abu-Mugheisib
- Department of Neurology, Municipal Hospital Braunschweig, Braunschweig, Germany
| | - Bernd Kallmünzer
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen- Nürnberg, Erlangen, Germany
| | | | - Peter Müller-Barna
- Department of Neurology, Academic Teaching hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
| | - Gordian Hubert
- Department of Neurology, Academic Teaching hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
| | | | - Hans Worthmann
- Department of Neurology, Hannover Medical School, Hannover, Germany
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Kölbl K, Hock SW, Xu M, Sembill JA, Mrochen A, Balk S, Lang S, Volbers B, Engelhorn T, Kallmünzer B, Kuramatsu JB. Association of non-contrast CT markers with long-term functional outcome in deep intracerebral hemorrhage. Front Neurol 2024; 14:1268839. [PMID: 38274884 PMCID: PMC10810138 DOI: 10.3389/fneur.2023.1268839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/14/2023] [Indexed: 01/27/2024] Open
Abstract
Objective Hematoma expansion (HE) is the most important therapeutic target during acute care of patients with intracerebral hemorrhage (ICH). Imaging biomarkers such as non-contrast CT (NCCT) markers have been associated with increasing risk for HE. The aim of the present study was to evaluate the influence of NCCT markers with functional long-term outcome and with HE in patients with deep (basal ganglia and thalamus) ICH who represent an important subgroup of patients at the highest risk for functional deterioration with HE due to the eloquence of the affected brain region. Methods From our prospective institutional database, all patients maximally treated with deep ICH were included and retrospectively analyzed. NCCT markers were recorded at diagnostic imaging, ICH volume characteristics were volumetrically evaluated, and all patients received follow-up imaging within 0-48 h. We explored associations of NCCT makers with unfavorable functional outcome, defined as modified Rankin scale 4-6, after 12 months and with HE. Bias and confounding were addressed by multivariable regression modeling. Results In 322 patients with deep ICH, NCCT markers were distributed as follows: irregular shape: 69.6%, heterogenous density: 55.9%, hypodensities: 52.5%, island sign: 19.3%, black hole sign: 11.5%, and blend sign: 4.7%. Upon multivariable regression analyses, independent associations were documented with the functional outcome for irregular shape (aOR: 2.73, 95%CI: 1.42-5.22, p = 0.002), heterogenous density (aOR: 2.62, 95%CI: 1.40-4.90, p = 0.003) and island sign (aOR: 2.54, 95%CI: 1.05-6.14, p = 0.038), and with HE for heterogenous density (aOR: 5.01, 95%CI: 1.93-13.05, p = 0.001) and hypodensities (aOR: 3.75, 95%CI: 1.63-8.62, p = 0.002). Conclusion NCCT markers are frequent in deep ICH patients and provide important clinical implications. Specifically, markers defined by diverging intra-hematomal densities provided associations with a 5-times higher risk for HE and a 2.5-times higher likelihood for unfavorable functional long-term outcome. Hence, these markers allow the identification of patients with deep ICH at high risk for clinical deterioration due to HE.
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Affiliation(s)
- Kathrin Kölbl
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stefan W. Hock
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Mingming Xu
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jochen A. Sembill
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Anne Mrochen
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stefanie Balk
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stefan Lang
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Bastian Volbers
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Joji B. Kuramatsu
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
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Palà E, Penalba A, Bustamante A, García‐Berrocoso T, Lamana‐Vallverdú M, Meisel C, Meisel A, van der Worp HB, R Macleod M, Kallmünzer B, Schwab S, Montaner J. Blood biomarker changes following therapeutic hypothermia in ischemic stroke. Brain Behav 2023; 13:e3230. [PMID: 37721534 PMCID: PMC10636403 DOI: 10.1002/brb3.3230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/23/2023] [Accepted: 08/09/2023] [Indexed: 09/19/2023] Open
Abstract
INTRODUCTION Therapeutic hypothermia is a promising candidate for stroke treatment although its efficacy has not yet been demonstrated in patients. Changes in blood molecules could act as surrogate markers to evaluate the efficacy and safety of therapeutic cooling. METHODS Blood samples from 54 patients included in the EuroHYP-1 study (27 treated with hypothermia, and 27 controls) were obtained at baseline, 24 ± 2 h, and 72 ± 4 h. The levels of a panel of 27 biomarkers, including matrix metalloproteinases and cardiac and inflammatory markers, were measured. RESULTS Metalloproteinase-3 (MMP-3), fatty-acid-binding protein (FABP), and interleukin-8 (IL-8) increased over time in relation to the hypothermia treatment. Statistically significant correlations between the minimum temperature achieved by each patient in the hypothermia group and the MMP-3 level measured at 72 h, FABP level measured at 24 h, and IL-8 levels measured at 24 and 72 h were found. No differential biomarker levels were observed in patients with poor or favorable outcomes according to modified Rankin Scale scores. CONCLUSION Although the exact roles of MMP3, FABP, and IL-8 in hypothermia-treated stroke patients are not known, further exploration is needed to confirm their roles in brain ischemia.
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Affiliation(s)
- Elena Palà
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
| | - Anna Penalba
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
| | - Alejandro Bustamante
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
- Stroke Unit, Hospital Universitari Germans Trias i PujolBadalonaSpain
| | - Teresa García‐Berrocoso
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
- CSIC/UAB Proteomics LaboratoryInstitute of Biomedical Research of BarcelonaSpanish National Research Council (IIBB‐CSIC/IDIBAPS)BarcelonaSpain
| | - Marcel Lamana‐Vallverdú
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
| | - Christian Meisel
- Institute for Medical ImmunologyCharité–Universitätsmedizin BerlinBerlinGermany
- Department of ImmunologyLabor Berlin–Charité VivantesBerlinGermany
| | - Andreas Meisel
- Department of Neurology and Center for Stroke Research BerlinCharité University Hospital BerlinBerlinGermany
| | - H. Bart van der Worp
- Department of Neurology and NeurosurgeryBrain CenterUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Malcolm R Macleod
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghScotlandUK
| | - Bernd Kallmünzer
- Department of NeurologyUniversitätsklinikum ErlangenErlangenGermany
| | - Stefan Schwab
- Department of NeurologyUniversitätsklinikum ErlangenErlangenGermany
| | - Joan Montaner
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville & Department of NeurologyHospital Universitario Virgen MacarenaSevilleSpain
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Uhe T, Wasser K, Weber-Krüger M, Schäbitz WR, Köhrmann M, Brachmann J, Laufs U, Dichgans M, Gelbrich G, Petroff D, Prettin C, Michalski D, Kraft A, Etgen T, Schellinger PD, Soda H, Bethke F, Ertl M, Kallmünzer B, Grond M, Althaus K, Hamann GF, Mende M, Wagner M, Gröschel S, Uphaus T, Gröschel K, Wachter R. Intensive heart rhythm monitoring to decrease ischemic stroke and systemic embolism-the Find-AF 2 study-rationale and design. Am Heart J 2023; 265:66-76. [PMID: 37422010 DOI: 10.1016/j.ahj.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is one of the most frequent causes of stroke. Several randomized trials have shown that prolonged monitoring increases the detection of AF, but the effect on reducing recurrent cardioembolism, ie, ischemic stroke and systemic embolism, remains unknown. We aim to evaluate whether a risk-adapted, intensified heart rhythm monitoring with consequent guideline conform treatment, which implies initiation of oral anticoagulation (OAC), leads to a reduction of recurrent cardioembolism. METHODS Find-AF 2 is a randomized, controlled, open-label parallel multicenter trial with blinded endpoint assessment. 5,200 patients ≥ 60 years of age with symptomatic ischemic stroke within the last 30 days and without known AF will be included at 52 study centers with a specialized stroke unit in Germany. Patients without AF in an additional 24-hour Holter ECG after the qualifying event will be randomized in a 1:1 fashion to either enhanced, prolonged and intensified ECG-monitoring (intervention arm) or standard of care monitoring (control arm). In the intervention arm, patients with a high risk of underlying AF will receive continuous rhythm monitoring using an implantable cardiac monitor (ICM) whereas those without high risk of underlying AF will receive repeated 7-day Holter ECGs. The duration of rhythm monitoring within the control arm is up to the discretion of the participating centers and is allowed for up to 7 days. Patients will be followed for at least 24 months. The primary efficacy endpoint is the time until recurrent ischemic stroke or systemic embolism occur. CONCLUSIONS The Find-AF 2 trial aims to demonstrate that enhanced, prolonged and intensified rhythm monitoring results in a more effective prevention of recurrent ischemic stroke and systemic embolism compared to usual care.
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Affiliation(s)
- Tobias Uhe
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Katrin Wasser
- Department of Neurology, University of Göttingen Medical Center, Göttingen, Germany
| | - Mark Weber-Krüger
- Department of Palliative Medicine, University of Göttingen Medical Center, Göttingen, Germany
| | | | - Martin Köhrmann
- Department of Neurology, University of Essen, Essen, Germany
| | | | - Ulrich Laufs
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany; German Center for Neurodegenerative Diseases (DZNE, Munich), Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Götz Gelbrich
- Institute for Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany; Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - David Petroff
- Clinical Trial Centre (ZKS) Leipzig, Leipzig University, Leipzig, Germany
| | - Christiane Prettin
- Clinical Trial Centre (ZKS) Leipzig, Leipzig University, Leipzig, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | - Andrea Kraft
- Department of Neurology, Hospital Martha-Maria, Halle, Germany
| | - Thorleif Etgen
- Department of Neurology, Klinikum Traunstein, Traunstein, Germany
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatrics, University Hospital Minden, Minden, Germany
| | - Hassan Soda
- Department of Neurology, Rhön Hospital, Bad Neustadt, Germany
| | - Florian Bethke
- Department of Neurology, Ibbenbüren Hospital, Ibbenbüren, Germany
| | - Michael Ertl
- Clinic for Neurology and Clinical Neurophysiology, University Hospital Augsburg, Augsburg, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Martin Grond
- Department of Neurology, Siegen Hospital, Siegen, Germany
| | | | - Gerhard F Hamann
- Clinic for Neurology and Neurorehabilitation, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Meinhard Mende
- Clinical Trial Centre (ZKS) Leipzig, Leipzig University, Leipzig, Germany
| | - Marcus Wagner
- Clinical Trial Centre (ZKS) Leipzig, Leipzig University, Leipzig, Germany
| | - Sonja Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany; Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany.
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Volbers B, Kallmünzer B, Seiffge DJ. Editorial: Pushing the boundaries in acute ischemic stroke treatment. Front Neurol 2023; 14:1245890. [PMID: 37645608 PMCID: PMC10461547 DOI: 10.3389/fneur.2023.1245890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/03/2023] [Indexed: 08/31/2023] Open
Affiliation(s)
- Bastian Volbers
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - David J. Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Winder K, Villegas Millar C, Siedler G, Knott M, Dörfler A, Engel A, Achenbach S, Hilz MJ, Kallmünzer B, Schwab S, Seifert F, Fröhlich K. Acute right insular ischaemic lesions and poststroke left ventricular dysfunction. Stroke Vasc Neurol 2023; 8:301-306. [PMID: 36653066 PMCID: PMC10512080 DOI: 10.1136/svn-2022-001724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 12/15/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Myocardial injury related to acute ischaemic stroke is common even without primary cardiac disease. We intended to determine associations between values of left ventricular ejection fraction (LVEF) and ischaemic stroke lesion sites. METHODS Of a local database, patients with acute first-ever ischaemic stroke confirmed by brain imaging but without pre-existing heart disease were included. The cardiac morphology and LVEF were obtained from transthoracic or transesophageal echocardiography, and impaired LVEF was categorised as mild (35%-50%), moderate (34%-25%) and severe (<25%). Patient age, stroke severity, ischaemic lesion volume, prevalence of troponin I increase (>0.1 ng/mL), atrial fibrillation and cardiac wall motion abnormalities were assessed and compared between patients with and without impaired LVEF after stroke (significance: p<0.05). A multivariate voxelwise lesion analysis correlated LVEF after stroke with sites of ischaemic lesions. RESULTS Of 1209 patients who had a stroke, 231 (mean age 66.3±14.0 years) met the inclusion criteria; 40 patients (17.3%) had an impaired LVEF after stroke. Patients with impaired LVEF had higher infarct volumes (53.8 mL vs 30.0 mL, p=0.042), a higher prevalence of troponin increase (17.5% vs 4.2%, p=0.006), cardiac wall motion abnormalities (42.5% vs 5.2%, p<0.001) and atrial fibrillation (60.0% vs 26.2%, p<0.001) than patients with LVEF of >50%. The multivariate voxelwise lesion analysis yielded associations between decreased LVEF and damaged voxels in the insula, amygdala and operculum of the right hemisphere. CONCLUSION Our imaging analysis unveils a prominent role of the right hemispheric central autonomic network, especially of the insular cortex, in the brain-heart axis. Our results support preliminary evidence that acute ischaemic stroke in distinct brain regions of the central autonomic network may directly impair cardiac function and thus further supports the concept of a distinct stroke-heart syndrome.
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Affiliation(s)
- Klemens Winder
- Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
- Neurology, University Hospital and University of Zürich, Zürich, Switzerland
| | - Carolina Villegas Millar
- Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Gabriela Siedler
- Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Knott
- Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Arnd Dörfler
- Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Anna Engel
- Cardiology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan Achenbach
- Cardiology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Max J Hilz
- Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Schwab
- Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Frank Seifert
- Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Kilian Fröhlich
- Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
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8
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Lyrer F, Zietz A, Seiffge DJ, Koga M, Volbers B, Wilson D, Bonetti B, Schaedelin S, Gensicke H, Yoshimura S, Macha K, Ambler G, Thilemann S, Dittrich T, Inoue M, Miwa K, Wang R, Siedler G, Biburger L, Brown MM, Jäger RH, Muir K, Traenka C, Tanaka K, Shiozawa M, Bonati LH, Peters N, Lip GYH, Lyrer PA, Cappellari M, Toyoda K, Kallmünzer B, Schwab S, Werring DJ, Engelter ST, De Marchis GM, Polymeris AA. Atrial Fibrillation Detected before or after Stroke: Role of Anticoagulation. Ann Neurol 2023; 94:43-54. [PMID: 36975022 PMCID: PMC10953352 DOI: 10.1002/ana.26654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) known before ischemic stroke (KAF) has been postulated to be an independent category with a recurrence risk higher than that of AF detected after stroke (AFDAS). However, it is unknown whether this risk difference is confounded by pre-existing anticoagulation, which is most common in KAF and also indicates a high ischemic stroke recurrence risk. METHODS Individual patient data analysis from 5 prospective cohorts of anticoagulated patients following AF-associated ischemic stroke. We compared the primary (ischemic stroke recurrence) and secondary outcome (all-cause death) among patients with AFDAS versus KAF and among anticoagulation-naïve versus previously anticoagulated patients using multivariable Cox, Fine-Gray models, and goodness-of-fit statistics to investigate the relative independent prognostic importance of AF-category and pre-existing anticoagulation. RESULTS Of 4,357 patients, 1,889 (43%) had AFDAS and 2,468 (57%) had KAF, while 3,105 (71%) were anticoagulation-naïve before stroke and 1,252 (29%) were previously anticoagulated. During 6,071 patient-years of follow-up, we observed 244 recurrent strokes and 661 deaths. Only pre-existing anticoagulation (but not KAF) was independently associated with a higher hazard for stroke recurrence in both Cox and Fine-Gray models. Models incorporating pre-existing anticoagulation showed better fit than those with AF category; adding AF-category did not result in better model fit. Neither pre-existing anticoagulation nor KAF were independently associated with death. CONCLUSION Our findings challenge the notion that KAF and AFDAS are clinically relevant and distinct prognostic entities. Instead of attributing an independently high stroke recurrence risk to KAF, future research should focus on the causes of stroke despite anticoagulation to develop improved preventive treatments. ANN NEUROL 2023;94:43-54.
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Affiliation(s)
- Flurina Lyrer
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - David J. Seiffge
- Department of Neurology, Inselspital University Hospital BernUniversity of BernBernSwitzerland
| | - Masatoshi Koga
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Bastian Volbers
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
- New Zealand Brain Research InstituteChristchurchNew Zealand
| | - Bruno Bonetti
- Stroke Unit – Department of NeuroscienceAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical ResearchUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Sohei Yoshimura
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kosmas Macha
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Gareth Ambler
- Department of Statistical ScienceUniversity College LondonLondonUK
| | - Sebastian Thilemann
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Tolga Dittrich
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Manabu Inoue
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kaori Miwa
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Ruihao Wang
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Gabriela Siedler
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Luise Biburger
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Martin M. Brown
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
| | - Rolf H. Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic UnitDepartment of Brain Repair and Rehabilitation, UCL Institute of NeurologyLondonUK
| | - Keith Muir
- Institute of Neuroscience & PsychologyUniversity of Glasgow and Queen Elizabeth University HospitalGlasgowUK
| | - Christopher Traenka
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Kanta Tanaka
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Masayuki Shiozawa
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Leo H. Bonati
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Reha RheinfeldenRheinfeldenSwitzerland
| | - Nils Peters
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
- Stroke Center, Klinik HirslandenZurichSwitzerland
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Philippe A. Lyrer
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Manuel Cappellari
- Stroke Unit – Department of NeuroscienceAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | - Kazunori Toyoda
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Bernd Kallmünzer
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Stefan Schwab
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - David J. Werring
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
| | - Stefan T. Engelter
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Alexandros A. Polymeris
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
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9
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Styczen H, Maus V, Goertz L, Köhrmann M, Kleinschnitz C, Fischer S, Möhlenbruch M, Mühlen I, Kallmünzer B, Dorn F, Lakghomi A, Gawlitza M, Kaiser D, Klisch J, Lobsien D, Rohde S, Ellrichmann G, Behme D, Thormann M, Flottmann F, Winkelmeier L, Gizewski ER, Mayer-Suess L, Boeckh-Behrens T, Riederer I, Klingebiel R, Berger B, Schlunz-Hendann M, Grieb D, Khanafer A, du Mesnil de Rochemont R, Arendt C, Altenbernd J, Schlump JU, Ringelstein A, Sanio VJM, Loehr C, Dahlke AM, Brockmann C, Reder S, Sure U, Li Y, Mühl-Benninghaus R, Rodt T, Kallenberg K, Durutya A, Elsharkawy M, Stracke P, Schumann MG, Bock A, Nikoubashman O, Wiesmann M, Henkes H, Mosimann PJ, Chapot R, Forsting M, Deuschl C. Mechanical thrombectomy for acute ischemic stroke in COVID-19 patients: multicenter experience in 111 cases. J Neurointerv Surg 2022; 14:858-862. [PMID: 35292572 PMCID: PMC8931799 DOI: 10.1136/neurintsurg-2022-018723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/02/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Data on the frequency and outcome of mechanical thrombectomy (MT) for large vessel occlusion (LVO) in patients with COVID-19 is limited. Addressing this subject, we report our multicenter experience. METHODS A retrospective cohort study was performed of consecutive acute stroke patients with COVID-19 infection treated with MT at 26 tertiary care centers between January 2020 and November 2021. Baseline demographics, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at discharge and 90 days were noted. RESULTS We identified 111 out of 11 365 (1%) patients with acute or subsided COVID-19 infection who underwent MT due to LVO. Cardioembolic events were the most common etiology for LVO (38.7%). Median baseline National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score were 16 (IQR 11.5-20) and 9 (IQR 7-10), respectively. Successful reperfusion (mTICI ≥2b) was achieved in 97/111 (87.4%) patients and 46/111 (41.4%) patients were reperfused completely. The procedure-related complication rate was 12.6% (14/111). Functional independence was achieved in 20/108 (18.5%) patients at discharge and 14/66 (21.2%) at 90 days follow-up. The in-hospital mortality rate was 30.6% (33/108). In the subgroup analysis, patients with severe acute COVID-19 infection requiring intubation had a mortality rate twice as high as patients with mild or moderate acute COVID-19 infection. Acute respiratory failure requiring ventilation and time interval from symptom onset to groin puncture were independent predictors for an unfavorable outcome in a logistic regression analysis. CONCLUSION Our study showed a poor clinical outcome and high mortality, especially in patients with severe acute COVID-19 infection undergoing MT due to LVO.
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Affiliation(s)
- Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Medical Center Langendreer, Bochum, Germany
| | - Lukas Goertz
- Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neurosciences and Behavioral Sciences (CTNBS), University Hospital Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neurosciences and Behavioral Sciences (CTNBS), University Hospital Essen, Essen, Germany
| | - Sebastian Fischer
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Medical Center Langendreer, Bochum, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Iris Mühlen
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Asadeh Lakghomi
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Matthias Gawlitza
- Institute and Policlinic of Neuroradiology, Universitatsklinikum Carl Gustav Carus, Dresden, Sachsen, Germany
| | - Daniel Kaiser
- Institute and Policlinic of Neuroradiology, Universitatsklinikum Carl Gustav Carus, Dresden, Sachsen, Germany
| | - Joachim Klisch
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Helios General Hospital Erfurt, Erfurt, Germany
| | - Donald Lobsien
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Helios General Hospital Erfurt, Erfurt, Germany
| | - Stefan Rohde
- Department of Radiology and Neuroradiology, Klinikum Dortmund gGmbH, Dortmund, Germany
| | - Gisa Ellrichmann
- Department of Neurology, Klinikum Dortmund gGmbH, Dortmund, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | | | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Elke R Gizewski
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Mayer-Suess
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Isabelle Riederer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Randolf Klingebiel
- Department of Diagnostic and Interventional Neuroradiology, University Hospital OWL (Campus Bethel), Bielefeld, Germany
| | - Björn Berger
- Department of Diagnostic and Interventional Neuroradiology, University Hospital OWL (Campus Bethel), Bielefeld, Germany
| | - Martin Schlunz-Hendann
- Department of Radiology and Neuroradiology, Klinikum Duisburg - Sana Kliniken, Duisburg, Germany
| | - Dominik Grieb
- Department of Radiology and Neuroradiology, Klinikum Duisburg - Sana Kliniken, Duisburg, Germany
| | - Ali Khanafer
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | | | - Christophe Arendt
- Institute of Neuroradiology, University Hospital Frankfurt and Goethe University, Frankfurt am Main, Germany
| | - Jens Altenbernd
- Department of Radiology and Neuroradiology, Gemeinschaftskrankenhaus Herdecke, Herdecke, Germany
| | - Jan-Ulrich Schlump
- Department of Neuropediatrics, Gemeinschaftskrankenhaus Herdecke, Herdecke, Germany
| | - Adrian Ringelstein
- Department of Radiology and Neuroradiology, Kliniken Maria Hilf, Moenchengladbach, Germany
| | | | - Christian Loehr
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - Agnes Maria Dahlke
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
| | - Sebastian Reder
- Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Yan Li
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | | | - Thomas Rodt
- Department of Radiology, Klinikum Lueneburg, Lueneburg, Germany
| | - Kai Kallenberg
- Department of Neuroradiology, Klinikum Fulda, Fulda, Germany
| | | | | | - Paul Stracke
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany
| | | | - Alexander Bock
- Department of Neuroradiology, Vivantes Klinikum Neukoelln, Berlin, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Aachen, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Aachen, Aachen, Germany
| | - Hans Henkes
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Pascal J Mosimann
- Department of Neuroradiology, Alfried Krupp Hospital Ruttenscheid, Essen, Germany
| | - René Chapot
- Department of Neuroradiology, Alfried Krupp Hospital Ruttenscheid, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
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10
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Polymeris AA, Meinel TR, Oehler H, Hölscher K, Zietz A, Scheitz JF, Nolte CH, Stretz C, Yaghi S, Stoll S, Wang R, Häusler KG, Hellwig S, Klammer MG, Litmeier S, Leon Guerrero CR, Moeini-Naghani I, Michel P, Strambo D, Salerno A, Bianco G, Cereda C, Uphaus T, Gröschel K, Katan M, Wegener S, Peters N, Engelter ST, Lyrer PA, Bonati LH, Grunder L, Ringleb PA, Fischer U, Kallmünzer B, Purrucker JC, Seiffge DJ. Aetiology, secondary prevention strategies and outcomes of ischaemic stroke despite oral anticoagulant therapy in patients with atrial fibrillation. J Neurol Neurosurg Psychiatry 2022; 93:588-598. [PMID: 35396339 PMCID: PMC9148984 DOI: 10.1136/jnnp-2021-328391] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/05/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate the aetiology, subsequent preventive strategies and outcomes of stroke despite anticoagulation in patients with atrial fibrillation (AF). METHODS We analysed consecutive patients with AF with an index imaging-proven ischaemic stroke despite vitamin K-antagonist (VKA) or direct oral anticoagulant (DOAC) treatment across 11 stroke centres. We classified stroke aetiology as: (i) competing stroke mechanism other than AF-related cardioembolism; (ii) insufficient anticoagulation (non-adherence or low anticoagulant activity measured with drug-specific assays); or, (iii) AF-related cardioembolism despite sufficient anticoagulation. We investigated subsequent preventive strategies with regard to the primary (composite of recurrent ischaemic stroke, intracranial haemorrhage, death) and secondary endpoint (recurrent ischaemic stroke) within 3 months after index stroke. RESULTS Among 2946 patients (median age 81 years; 48% women; 43% VKA, 57% DOAC), stroke aetiology was competing mechanism in 713 patients (24%), insufficient anticoagulation in 934 (32%) and cardioembolism despite sufficient anticoagulation in 1299 (44%). We found high rates of the primary (27% of patients; completeness 91.6%) and secondary endpoint (4.6%; completeness 88.5%). Only DOAC (vs VKA) treatment after index stroke showed lower odds for both endpoints (primary: adjusted OR (aOR) (95% CI) 0.49 (0.32 to 0.73); secondary: 0.44 (0.24 to 0.80)), but not switching between different DOAC types. Adding antiplatelets showed higher odds for both endpoints (primary: aOR (95% CI) 1.99 (1.25 to 3.15); secondary: 2.66 (1.40 to 5.04)). Only few patients (1%) received left atrial appendage occlusion as additional preventive strategy. CONCLUSIONS Stroke despite anticoagulation comprises heterogeneous aetiologies and cardioembolism despite sufficient anticoagulation is most common. While DOAC were associated with better outcomes than VKA, adding antiplatelets was linked to worse outcomes in these high-risk patients. Our findings indicate that individualised and novel preventive strategies beyond the currently available anticoagulants are needed. TRIAL REGISTRATION NUMBER ISRCTN48292829.
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Affiliation(s)
- Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Hannah Oehler
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kyra Hölscher
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Jan F Scheitz
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Stretz
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Svenja Stoll
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Karl Georg Häusler
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Simon Hellwig
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus G Klammer
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Litmeier
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Iman Moeini-Naghani
- Department of Neurology, The George Washington University, Washington, DC, USA
| | - Patrik Michel
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alexander Salerno
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurology Department, Neurocenter of Southern Switzerland EOC, Lugano, Ticino, Switzerland
| | - Carlo Cereda
- Stroke Center, Neurology Department, Neurocenter of Southern Switzerland EOC, Lugano, Ticino, Switzerland
| | - Timo Uphaus
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Klaus Gröschel
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Center, Klinik Hirslanden Zurich, Zurich, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lorenz Grunder
- Department of Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | | | - Urs Fischer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
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11
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Rühl L, Kuramatsu JB, Sembill JA, Kallmünzer B, Madzar D, Gerner ST, Giede-Jeppe A, Balk S, Mueller T, Jäger J, Schwab S, Huttner HB, Sprügel MI. Amantadine treatment is associated with improved consciousness in patients with non-traumatic brain injury. J Neurol Neurosurg Psychiatry 2022; 93:582-587. [PMID: 35086939 PMCID: PMC9148986 DOI: 10.1136/jnnp-2021-327408] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 12/29/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This study determined the effect of amantadine treatment on consciousness in patients with non-traumatic brain injury. METHODS We pooled individual patient data of five single-centre observational studies to determine the effect of amantadine treatment among patients with ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, community-acquired bacterial meningitis and status epilepticus, admitted between January 2012 and December 2015 and ventilated ≥7 days. Patient selection and multivariable regression modelling were used to adjust for differences in intergroup comparison and for parameters associated with consciousness. Improvement of consciousness 5 days after treatment initiation was defined as primary outcome. Secondary outcomes included Glasgow Coma Scale (GCS) at day 5 and GCS at day 10, rate of ICU delirium, epileptic seizures and all-cause mortality at 90 days. RESULTS Overall, 84 of 294 (28.6%) eligible patients received amantadine. Amantadine treatment was associated with improvement of consciousness at day 5 (amantadine: 86.9% vs control: 54.0%; absolute difference: 32.9 (20.0-44.2); adjusted OR (aOR): 5.71 (2.50-13.05), p<0.001). Secondary outcomes showed differences in GCS 5 days (9 (8-11) vs 6 (3-9), p<0.001) and GCS 10 days (10(8-11) vs 9(6-11),p=0.003) after treatment initiation. There were no significant differences regarding all-cause mortality (aOR: 0.89 (0.44-1.82), p=0.758) and ICU delirium (aOR: 1.39 (0.58-3.31), p=0.462). Rate of epileptic seizures after initiation of amantadine treatment was numerically higher in the amantadine group (amantadine: 10.7% vs control: 3.0%; absolute difference: 7.7 (0.3-16.4); aOR: 3.68 (0.86-15.71), p=0.079). CONCLUSIONS Amantadine treatment is associated with improved consciousness among patients with different types of non-traumatic brain injury in this observational cohort analysis. Epileptic seizures should be considered as potential side effects and randomised controlled trials are needed to confirm these findings.
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Affiliation(s)
- Lena Rühl
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Jochen A Sembill
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Dominik Madzar
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Antje Giede-Jeppe
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stefanie Balk
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Tamara Mueller
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Jakob Jäger
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Maximilian I Sprügel
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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12
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Wang R, Köhrmann M, Kollmar R, Koehn J, Schwab S, Kallmünzer B, Hilz MJ. Posterior circulation ischemic stroke not involving the brainstem is associated with cardiovascular autonomic dysfunction. Eur J Neurol 2022; 29:2690-2700. [PMID: 35638371 DOI: 10.1111/ene.15427] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke may induce cardiovascular autonomic dysfunction. Yet, most previous studies included patients with anterior circulation ischemic stroke or brainstem stroke. It remains unclear whether posterior circulation ischemic stroke (PCIS) without brainstem involvement also compromises cardiovascular autonomic modulation (CAM). Therefore, we aimed to assess CAM in PCIS patients with and without brainstem involvement. METHODS In four subgroups of 61 PCIS-patients (14 occipital lobe, 16 thalamic, 12 cerebellar, and 19 brainstem strokes) and 30 healthy controls, we recorded RR-intervals (RRI), systolic, diastolic blood pressures (BPsys, BPdia), and respiration at supine rest during the first week after stroke-onset. We calculated parameters reflecting total CAM [RRI-standard-deviation (RRI-SD), RRI-total-powers], predominantly sympathetic CAM [RRI-low-frequency-powers (RRI-LF-powers) and BPsys-LF-powers] and parasympathetic CAM [Root-Mean-Square-of-Successive-RRI-Differences (RMSSD), RRI-high-frequency-powers (RRI-HF-powers)], sympathetic-parasympathetic balance (RRI-LF/HF-ratios), and baroreflex-sensitivity (BRS). Values were compared between the four PCIS-groups and controls using one-way ANOVA Kruskal-Wallis-tests, with post-hoc analyses. Significance was assumed for P<0.05. RESULTS In each PCIS-subgroup, values of RRI, RRI-SD, RMSSD, RRI-HF-powers, and BRS were significantly lower, while BPsys-LF-powers were higher than in the controls. Only in patients with occipital lobe stroke, RRI-LF/HF-ratios were significantly higher than in controls. Otherwise, autonomic parameters did not differ between the four PCIS-subgroups. CONCLUSIONS During the first week after stroke-onset, our PCIS patients with occipital lobe, thalamic, cerebellar, or brainstem strokes all had reduced cardiovagal modulation, compromised baroreflex, and increased peripheral sympathetic modulation. The RRI-LF/HF-ratios suggest that sympathetic predominance is slightly more prominent after occipital lobe stroke. PCIS may trigger cardiovascular autonomic dysfunction even without brainstem involvement.
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Affiliation(s)
- Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Rainer Kollmar
- Department of Neurology, General Hospital Darmstadt, Darmstadt, Germany
| | - Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.,Icahn School of Medicine at Mount Sinai, New York, NY, USA
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13
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Siedler G, Macha K, Stoll S, Plechschmidt J, Wang R, Gerner ST, Strasser E, Schwab S, Kallmünzer B. Monitoring of direct oral anticoagulants plasma levels for secondary stroke prevention. J Thromb Haemost 2022; 20:1138-1145. [PMID: 35171533 DOI: 10.1111/jth.15677] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 02/08/2022] [Accepted: 02/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with atrial fibrillation have a relevant risk for ischemic stroke despite the recommended use of direct oral anticoagulants (DOAC). The risk correlates with the functional DOAC plasma levels in clinical trials, but the value of their measurement in community use remains undetermined. OBJECTIVES We aim to investigate the clinical implications and the prognostic value of DOAC plasma level measurement during steady state. METHODS In this observational clinical cohort study among patients with ischemic stroke and atrial fibrillation, 397 individuals on oral anticoagulants for secondary stroke prevention were included between 2016 and 2020. The functional DOAC plasma levels were measured during steady state. Early stroke recurrence within 3 months was recorded as the main outcome parameter. RESULTS Three hundred ninety-seven patients (201 female, mean age 78 [±9] years, median CHA2 DS2 VASc-Score 6 [interquartile range 5-7]) were included. Mean DOAC plasma trough level was 95.9 (±66.9) ng/ml. A high glomerular filtration rate (GFR) was an independent predictor of lower levels in a multivariate model (R coefficient: -0.174, P = .014). During follow-up, 10 patients (3%) suffered from early ischemic stroke recurrence despite the use of DOAC, while 10 clinically relevant bleeding complications occurred (3%). Ischemic stroke recurrence was associated with numerical lower plasma levels for patients on apixaban and dabigatran after propensity score matching. CONCLUSIONS Monitoring of DOAC plasma levels could help to identify patients with increased risk for stroke recurrence and should be considered for certain subgroups, including patients with high GFR.
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Affiliation(s)
- Gabriela Siedler
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Kosmas Macha
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Svenja Stoll
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Johannes Plechschmidt
- Pharmacy Department, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Erwin Strasser
- Department of Transfusion Medicine and Haemostaseology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
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14
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Kimura S, Toyoda K, Yoshimura S, Minematsu K, Yasaka M, Paciaroni M, Werring DJ, Yamagami H, Nagao T, Yoshimura S, Polymeris A, Zietz A, Engelter ST, Kallmünzer B, Cappellari M, Chiba T, Yoshimoto T, Shiozawa M, Kitazono T, Koga M. Practical "1-2-3-4-Day" Rule for Starting Direct Oral Anticoagulants After Ischemic Stroke With Atrial Fibrillation: Combined Hospital-Based Cohort Study. Stroke 2022; 53:1540-1549. [PMID: 35105180 PMCID: PMC9022681 DOI: 10.1161/strokeaha.121.036695] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The "1-3-6-12-day rule" for starting direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation after acute ischemic stroke or transient ischemic attack recommends timings that may be later than used in clinical practice. We investigated more practical optimal timing of DOAC initiation according to stroke severity. METHODS The combined data of prospective registries in Japan, Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-nonvalvular atrial fibrillation (September 2011 to March 2014) and RELAXED (February 2014 to April 2016) were used. Patients were divided into transient ischemic attack and 3 stroke subgroups by the National Institutes of Health Stroke Scale score: mild (0-7), moderate (8-15), and severe (≥16). The early treatment group was defined as patients starting DOACs earlier than the median initiation day in each subgroup. Outcomes included a composite of recurrent stroke or systemic embolism, ischemic stroke, and severe bleeding within 90 days. Six European prospective registries were used for validation. RESULTS In the 1797 derivation cohort patients, DOACs were started at median 2 days after transient ischemic attack and 3, 4, and 5 days after mild, moderate, and severe strokes, respectively. Stroke or systemic embolism was less common in Early Group (n=785)-initiating DOACS within 1, 2, 3, and 4 days, respectively-than Late Group (n=1012) (1.9% versus 3.9%; adjusted hazard ratio, 0.50 [95% CI, 0.27-0.89]), as was ischemic stroke (1.7% versus 3.2%, 0.54 [0.27-0.999]). Major bleeding was similarly common in the 2 groups (0.8% versus 1.0%). On validation, both ischemic stroke (2.4% versus 2.2%) and intracranial hemorrhage (0.2% versus 0.6%) were similarly common in Early (n=547) and Late (n=1483) Groups defined using derivation data. CONCLUSIONS In Japanese and European populations, early DOAC initiation within 1, 2, 3, or 4 days according to stroke severity seemed to be feasible to decrease the risk of recurrent stroke or systemic embolism and no increase in major bleeding. These findings support ongoing randomized trials to better establish the optimal timing of DOAC initiation.
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Affiliation(s)
- Shunsuke Kimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (S.K., K.T., Sohei Yoshimura, T.C., M.S., M.K.)
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (S.K., K.T., Sohei Yoshimura, T.C., M.S., M.K.)
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (S.K., K.T., Sohei Yoshimura, T.C., M.S., M.K.)
| | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan (M.Y.)
| | - Maurizio Paciaroni
- Department of Neurology – Stroke Unit, Ospedale San Giuseppe MultiMedica IRCCS, Milano, Italy (M.P.)
| | - David J. Werring
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom (D.J.W.)
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan (H.Y.)
| | - Takehiko Nagao
- Department of Neurology, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan (T.N.)
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan (Shinichi Yoshimura)
| | - Alexandros Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland (A.P., A.Z., S.T.E.)
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland (A.P., A.Z., S.T.E.)
| | - Stefan T. Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland (A.P., A.Z., S.T.E.)
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Germany (B.K.)
| | - Manuel Cappellari
- Stroke Unit–Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata, Verona, Italy (M.C.)
| | - Tetsuya Chiba
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (S.K., K.T., Sohei Yoshimura, T.C., M.S., M.K.)
| | - Takeshi Yoshimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan (T.Y.)
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (S.K., K.T., Sohei Yoshimura, T.C., M.S., M.K.)
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan (T.K.)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (S.K., K.T., Sohei Yoshimura, T.C., M.S., M.K.)
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15
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Wang R, Macha K, Haupenthal D, Gaßmann L, Siedler G, Stoll S, Fröhlich K, Koehn J, Schwab S, Kallmünzer B. Acute care and secondary prevention of stroke with newly detected versus known atrial fibrillation. Eur J Neurol 2022; 29:1963-1971. [PMID: 35344638 DOI: 10.1111/ene.15338] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) in stroke patients can be classified as either "known AF (KAF)", which was confirmed before stroke-onset, or "AF detected after stroke (AFDAS)", which was diagnosed after stroke-onset. While KAF is considered primarily cardiogenic, AFDAS includes patients with stroke-triggered neurogenic arrhythmias. This study aimed to investigate the clinical course of stroke, functional outcome and the value of oral anticoagulation for secondary prevention according to AF subtype. METHODS Acute ischemic stroke patients were consecutively enrolled, AF was classified as AFDAS or KAF. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) and the three-month functional outcome was measured on the modified Rankin scale. Inverse probability weighting was applied to adjust baseline confounders in patients with AFDAS and KAF. Multivariate logistic regression models were calculated to investigate the value of oral anticoagulation for secondary prevention. RESULTS 822 stroke patients with AF were included, 234 patients (28.5%) had AFDAS. AFDAS patients had lower prevalence of coronary artery disease, heart failure, and sustained AF, but higher rates of large-vessel occlusion compared to KAF patients. NIHSS-scores were lower in patients on pre-stroke anticoagulation. Oral anticoagulation for secondary prevention was associated with a favorable three-month functional outcome (odds ratio 7.60, 95% confidence interval 3.42-16.88) independently from AF subtype. The rate of stroke recurrence did not differ significantly. CONCLUSIONS Clinical characteristics suggest that AFDAS might comprise a distinct pathophysiologic and clinical entity among stroke patients with AF. The benefit of anticoagulation for secondary prevention was not affected by AF subtype.
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Affiliation(s)
- Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Kosmas Macha
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - David Haupenthal
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Luise Gaßmann
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Gabriela Siedler
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Svenja Stoll
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Kilian Fröhlich
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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16
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De Marchis GM, Seiffge DJ, Schaedelin S, Wilson D, Caso V, Acciarresi M, Tsivgoulis G, Koga M, Yoshimura S, Toyoda K, Cappellari M, Bonetti B, Macha K, Kallmünzer B, Cereda CW, Lyrer P, Bonati LH, Paciaroni M, Engelter ST, Werring DJ. Early versus late start of direct oral anticoagulants after acute ischaemic stroke linked to atrial fibrillation: an observational study and individual patient data pooled analysis. J Neurol Neurosurg Psychiatry 2022; 93:119-125. [PMID: 34635567 DOI: 10.1136/jnnp-2021-327236] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/27/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The optimal timing to start direct oral anticoagulants (DOACs) after an acute ischaemic stroke (AIS) related to atrial fibrillation (AF) remains unclear. We aimed to compare early (≤5 days of AIS) versus late (>5 days of AIS) DOAC-start. METHODS This is an individual patient data pooled analysis of eight prospective European and Japanese cohort studies. We included patients with AIS related to non-valvular AF where a DOAC was started within 30 days. Primary endpoints were 30-day rates of recurrent AIS and ICH. RESULTS A total of 2550 patients were included. DOACs were started early in 1362 (53%) patients, late in 1188 (47%). During 212 patient-years, 37 patients had a recurrent AIS (1.5%), 16 (43%) before a DOAC was started; 6 patients (0.2%) had an ICH, all after DOAC-start. In the early DOAC-start group, 23 patients (1.7%) suffered from a recurrent AIS, while 2 patients (0.1%) had an ICH. In the late DOAC-start group, 14 patients (1.2%) suffered from a recurrent AIS; 4 patients (0.3%) suffered from ICH. In the propensity score-adjusted comparison of late versus early DOAC-start groups, there was no statistically significant difference in the hazard of recurrent AIS (aHR=1.2, 95% CI 0.5 to 2.9, p=0.69), ICH (aHR=6.0, 95% CI 0.6 to 56.3, p=0.12) or any stroke. CONCLUSIONS Our results do not corroborate concerns that an early DOAC-start might excessively increase the risk of ICH. The sevenfold higher risk of recurrent AIS than ICH suggests that an early DOAC-start might be reasonable, supporting enrolment into randomised trials comparing an early versus late DOAC-start.
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Affiliation(s)
- Gian Marco De Marchis
- Neurology and Stroke Center, University Hospital Basel & University of Basel, Basel, Switzerland
| | - David J Seiffge
- Neurology and Stroke Center, University Hospital Basel & University of Basel, Basel, Switzerland.,Neurology and Stroke Center, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Sabine Schaedelin
- Clinical Trial Unit, University Hospital of Basel & University of Basel, Basel, Switzerland
| | - Duncan Wilson
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - Valeria Caso
- Stroke Unit, Santa Maria Misericordia Hospital, Perugia, Italy
| | - Monica Acciarresi
- Department of Neurology, San Giovanni Battista Hospital of Foligno, Foligno, Umbria, Italy
| | - Georgios Tsivgoulis
- Second Department of Neurology, 'Attikon' Hospital, University of Athens, School of Medicine, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Manuel Cappellari
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Bruno Bonetti
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Kosmas Macha
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Carlo W Cereda
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Philippe Lyrer
- Neurology and Stroke Center, University Hospital Basel & University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Neurology and Stroke Center, University Hospital Basel & University of Basel, Basel, Switzerland
| | - Maurizio Paciaroni
- Department of Neurology & Stroke Unit, San Giuseppe Hospital IRCSS Multimedica, Milano, Italy
| | - Stefan T Engelter
- Neurology and Stroke Center, University Hospital Basel & University of Basel, Basel, Switzerland.,Department of Neurology & Neurorehabilitation, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, Basel, Switzerland
| | - David J Werring
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
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17
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Muehlen I, Sprügel M, Hoelter P, Hock S, Knott M, Huttner HB, Schwab S, Kallmünzer B, Doerfler A. Comparison of Two Automated Computed Tomography Perfusion Applications to Predict the Final Infarct Volume After Thrombolysis in Cerebral Infarction 3 Recanalization. Stroke 2021; 53:1657-1664. [PMID: 34872342 DOI: 10.1161/strokeaha.121.035626] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Several automated computed tomography perfusion software applications have been developed to provide support in the definition of ischemic core and penumbra in acute ischemic stroke. However, the degree of interchangeability between software packages is not yet clear. Our study aimed to evaluate 2 commonly used automated perfusion software applications (Syngo.via and RAPID) for the indication of ischemic core with respect to the follow-up infarct volume (FIV) after successful recanalization and with consideration of the clinical impact. METHODS Retrospectively, 154 patients with large vessel occlusion of the middle cerebral artery or the internal carotid artery, who underwent endovascular therapy with a consequent Thrombolysis in Cerebral Infarction 3 result within 2 hours after computed tomography perfusion, were included. Computed tomography perfusion core volumes were assessed with both software applications with different thresholds for relative cerebral blood flow (rCBF). The results were compared with the FIV on computed tomography within 24 to 36 hours after recanalization. Bland-Altman was applied to display the levels of agreement and to evaluate systematic differences. RESULTS Highest correlation between ischemic core volume and FIV without significant differences was found at a threshold of rCBF<38% for the RAPID software (r=0.89, P<0.001) and rCBF<25% for the Syngo software (r=0.87, P<0.001). Bland-Altman analysis revealed best agreement in these settings. In the vendor default settings (rCBF<30% for RAPID and rCBF<20% for Syngo) correlation between ischemic core volume and FIV was also high (RAPID: r=0.88, Syngo: r=0.86, P<0.001), but mean differences were significant (P<0.001). The risk of critical overestimation of the FIV was higher with rCBF<38% (RAPID) and rCBF<25% (Syngo) than in the default settings. CONCLUSIONS By adjusting the rCBF thresholds, comparable results with reliable information on the FIV after complete recanalization can be obtained both with the RAPID and Syngo software. Keeping the software specific default settings means being more inclusive in patient selection, but forgo the highest possible accuracy in the estimation of the FIV.
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Affiliation(s)
- Iris Muehlen
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Germany. (I.M., P.H., S.H., M.K., A.D.)
| | - Maximilian Sprügel
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Germany. (M.S., H.B.H., S.S., B.K.)
| | - Philip Hoelter
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Germany. (I.M., P.H., S.H., M.K., A.D.)
| | - Stefan Hock
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Germany. (I.M., P.H., S.H., M.K., A.D.)
| | - Michael Knott
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Germany. (I.M., P.H., S.H., M.K., A.D.)
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Germany. (M.S., H.B.H., S.S., B.K.)
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Germany. (M.S., H.B.H., S.S., B.K.)
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Germany. (M.S., H.B.H., S.S., B.K.)
| | - Arnd Doerfler
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Germany. (I.M., P.H., S.H., M.K., A.D.)
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Volbers B, Gröger R, Engelhorn T, Marsch A, Macha K, Schwab S, Dörfler A, Lang S, Kallmünzer B. Acute Stroke With Large Vessel Occlusion and Minor Clinical Deficits: Prognostic Factors and Therapeutic Implications. Front Neurol 2021; 12:736795. [PMID: 34744977 PMCID: PMC8568768 DOI: 10.3389/fneur.2021.736795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/16/2021] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: The optimal acute management of patients with large vessel occlusion (LVO) and minor clinical deficits on admission [National Institutes of Health Stroke Scale (NIHSS) ≤ 4] remains to be elucidated. The aim of the present study was to investigate the prognostic factors and therapeutic management of those patients. Methods: In this retrospective cohort study, we investigated (1) all patients with acute ischemic stroke due to an LVO who underwent mechanical thrombectomy (MT) and (2) all patients with minor clinical deficits (NIHSS ≤ 4) on admission due to an LVO between January 2013 and December 2016 at the University Medical Center Erlangen. We dichotomized management of patients with minor deficits treated with MT for analysis according to immediate mechanical thrombectomy (IT) and initial medical management with rescue intervention (MM) in case of secondary deterioration. Primary endpoints were secondary deterioration, in-hospital mortality, and functional outcome on day 90 (dichotomized modified Rankin Scale 0–2: favorable, 3–6: poor). Results: Two hundred twenty-three patients (83% with anterior circulation stroke, 13 (6%) with minor deficits) treated with MT and 88 patients with minor deficits due to LVO [13 (15%) treated with MT] were included. Secondary deterioration (n = 19) was independently associated with poor outcome in patients with minor deficits and LVO [odds ratio (OR), 0.060; 95% confidence interval (CI), 0.013–0.280], which in turn was associated with the occlusion site [especially M1 occlusion: 11 (58%) vs. 3 (4%) in patients without secondary deterioration, p < 0.0001]. IT (n = 8) was associated with a lower intrahospital mortality compared to MM (n = 5; 13 vs. 80%; OR, 0.036; 95% CI, 0.002–0.741). Seven of eight patients with IT survived until discharge, with 29% showing a favorable functional outcome on day 90. Conclusions: Secondary deterioration is associated with poor outcome in patients with LVO and minor deficits, which in turn was associated with occlusion site. Future randomized controlled trials should assess whether selected patients, depending on occlusion site and associated characteristics, may benefit from MT.
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Affiliation(s)
- Bastian Volbers
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.,Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Rebecca Gröger
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Armin Marsch
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Kosmas Macha
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Lang
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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Macha K, Hoelter P, Siedler G, Wang R, Knott M, Stoll S, Engelhorn T, Doerfler A, Schwab S, Mühlen I, Kallmünzer B. IV-Thrombolysis in Ischemic Stroke With Unknown Time of Onset-Safety and Outcomes in Posterior vs. Anterior Circulation Stroke. Front Neurol 2021; 12:692067. [PMID: 34512513 PMCID: PMC8430341 DOI: 10.3389/fneur.2021.692067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/09/2021] [Indexed: 12/03/2022] Open
Abstract
Background: rt-PA for ischemic stroke in the unknown or extended time window beyond the first 4. 5 h after symptom onset is safe and effective for certain patients after selection by multimodal neuroimaging. However, the evidence for this approach comes mainly from patients with anterior circulation stroke (ACS), while the data on posterior circulation stroke (PCS) are scarce. Methods: Ischemic stroke patients treated with IV-thrombolysis in the unknown or extended time window between January 2011 and May 2019 were identified from an institutional registry. The patients were categorized into PCS or ACS based on clinico-radiological findings. We analyzed the hemorrhagic complications, clinical and imaging efficacy outcomes, and mortality rates by comparing the PCS and ACS patient groups. Adjusted outcome analyses were performed after propensity score matching for the relevant factors. Results: Of the 182 patients included, 38 (20.9%) had PCS and 144 (79.1%) had ACS. Symptomatic acute large vessel occlusion (LVO) was present in 123 patients on admission [27 (22.0%) PCS and 96 (78.0%) ACS]. The score on the National Institutes of Health Stroke Scale (NIHSS), the time from last seen normal, and the door-to-needle times were similar in PCS and ACS. In patients with LVO, the NIHSS score was lower [8 (5–15) vs. 14 (9–18), p = 0.005], and infarction visible on follow-up imaging was less common [70.4 vs. 87.5%; aRD, −18.9% (−39.8 to −2.2%)] in the PCS patient group. There was a trend toward a lower risk for intracranial hemorrhage (ICH) following intravenous thrombolysis in PCS vs. ACS, without reaching a statistical significance [5.3 vs. 16.9%; aRD, −10.4% (−20.4 to 4.0%)]. The incidence of symptomatic ICH [according to the ECASS III criteria: 2.6 vs. 3.5%; aRD, −2.9% (−10.3 to 9.2%)], efficacy outcomes, and mortality rates were similar in PCS and ACS patients. Conclusions: In this real-world clinical cohort, the safety and the efficacy of rt-PA for ischemic stroke in the unknown or extended time window did not show relevant differences between PCS and ACS, with a trend toward less hemorrhagic complications in PCS. The findings reconfirm the clinician in the usage of rt-PA beyond the first 4.5 h also in selected patients with PCS.
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Affiliation(s)
- Kosmas Macha
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Philip Hoelter
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Gabriela Siedler
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Michael Knott
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Svenja Stoll
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Iris Mühlen
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
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20
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Koehn J, Wang R, de Rojas Leal C, Kallmünzer B, Winder K, Köhrmann M, Kollmar R, Schwab S, Hilz MJ. Correction to: Neck cooling induces blood pressure increase and peripheral vasoconstriction in healthy persons. Neurol Sci 2021; 42:3517. [PMID: 34224027 PMCID: PMC8342398 DOI: 10.1007/s10072-021-05355-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A Correction to this paper has been published: https://doi.org/10.1007/s10072-021-05355-3
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Affiliation(s)
- Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Carmen de Rojas Leal
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Klemens Winder
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Rainer Kollmar
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.,Department of Neurology, General Hospital Darmstadt, Grafenstr. 9, 64283, Darmstadt, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany. .,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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21
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Macha K, Hoelter P, Kallmünzer B. Author Response: Multimodal CT or MRI for IV Thrombolysis in Ischemic Stroke With Unknown Time of Onset. Neurology 2021; 96:1013. [PMID: 34031174 DOI: 10.1212/wnl.0000000000012008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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22
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Osterloh J, Heim C, Siedler G, Engelhorn T, Doerfler A, Schwab S, Kallmünzer B. Pearls & Oy-sters: Moyamoya Vasculopathy and Its Association With Congenital Heart Disease. Neurology 2021; 96:e2896-e2898. [PMID: 33853893 DOI: 10.1212/wnl.0000000000012049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Justus Osterloh
- From the Departments of Neurology (J.O., G.S., S.S., B.K.) and Neuroradiology (T.E., A.D.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU); and Department of Cardiac Surgery (C.H.), University of Erlangen-Nuremberg, Germany.
| | - Christian Heim
- From the Departments of Neurology (J.O., G.S., S.S., B.K.) and Neuroradiology (T.E., A.D.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU); and Department of Cardiac Surgery (C.H.), University of Erlangen-Nuremberg, Germany
| | - Gabriela Siedler
- From the Departments of Neurology (J.O., G.S., S.S., B.K.) and Neuroradiology (T.E., A.D.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU); and Department of Cardiac Surgery (C.H.), University of Erlangen-Nuremberg, Germany
| | - Tobias Engelhorn
- From the Departments of Neurology (J.O., G.S., S.S., B.K.) and Neuroradiology (T.E., A.D.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU); and Department of Cardiac Surgery (C.H.), University of Erlangen-Nuremberg, Germany
| | - Arnd Doerfler
- From the Departments of Neurology (J.O., G.S., S.S., B.K.) and Neuroradiology (T.E., A.D.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU); and Department of Cardiac Surgery (C.H.), University of Erlangen-Nuremberg, Germany
| | - Stefan Schwab
- From the Departments of Neurology (J.O., G.S., S.S., B.K.) and Neuroradiology (T.E., A.D.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU); and Department of Cardiac Surgery (C.H.), University of Erlangen-Nuremberg, Germany
| | - Bernd Kallmünzer
- From the Departments of Neurology (J.O., G.S., S.S., B.K.) and Neuroradiology (T.E., A.D.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU); and Department of Cardiac Surgery (C.H.), University of Erlangen-Nuremberg, Germany
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Macha K, Hoelter P, Siedler G, Knott M, Schwab S, Doerfler A, Kallmünzer B, Engelhorn T. Multimodal CT or MRI for IV thrombolysis in ischemic stroke with unknown time of onset. Neurology 2020; 95:e2954-e2964. [DOI: 10.1212/wnl.0000000000011059] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 08/03/2020] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo investigate differences in procedure times, safety, and efficacy outcomes comparing 2 different protocols to enable thrombolysis in the extended or unknown time window after stroke onset with either multimodal CT or MRI.MethodsPatients with ischemic stroke in the extended or unknown time window who received IV thrombolysis between January 2011 and May 2019 were identified from an institutional registry. Imaging-based selection was done by multimodal CT or MRI according to institutional treatment algorithms.ResultsIV thrombolysis was performed in 100 patients (54.3%) based on multimodal CT imaging and in 84 patients (45.7%) based on MRI. Baseline clinical data, including stroke severity and time from last seen normal to hospital admission, were similar in patients with CT and MRI. Door-to-needle times were shorter in patients with CT-based selection (median [interquartile range] 45 [37–62] minutes vs 75 [59–90] minutes; mean difference [95% confidence interval (CI)] −28 minutes [−35 to −21]). No differences were detected regarding the incidence of symptomatic intracranial hemorrhage (2 [2.0%] vs 4 [4.8%]; adjusted odds ratio [aOR] [95% CI] 0.47 [0.08–2.83]) and favorable outcome at day 90 (25 [33.8%] vs 33 [42.9%]; aOR 0.95 [0.45–2.02]).ConclusionIV thrombolysis in ischemic stroke in the unknown or extended time window appeared safe in CT- and MRI-selected patients, while the use of CT imaging led to faster door-to-needle times.Classification of evidenceThis study provides Class IV evidence that for patients with ischemic stroke in the extended or unknown time window, imaging-based selection for IV thrombolysis by multimodal CT compared to MRI led to shorter door-to-needle times.
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Gerner ST, Reichl J, Custal C, Brandner S, Eyüpoglu IY, Lücking H, Hölter P, Kallmünzer B, Huttner HB. Long-Term Complications and Influence on Outcome in Patients Surviving Spontaneous Subarachnoid Hemorrhage. Cerebrovasc Dis 2020; 49:307-315. [DOI: 10.1159/000508577] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/06/2020] [Indexed: 11/19/2022] Open
Abstract
Background: While the short-term clinical outcome of patients with subarachnoid hemorrhage (SAH) is well described, there are limited data on long-term complications and their impact on social reintegration. This study aimed to assess the frequency of complications post-SAH and to investigate whether these complications attribute to functional and self-reported outcomes as well as the ability to return to work in these patients. Methods: This retrospective single-center study included patients with atraumatic SAH over a 5-year period at a tertiary care center. Patients received a clinical follow-up for 12 months. In addition to demographics, imaging data, and parameters of acute treatment, the rate and extent of long-term complications after SAH were recorded. The functional outcome was assessed using the modified Rankin Scale (mRS; favorable outcome defined as mRS = 0–2). Further outcomes comprised self-reported subjective health measured by the EQ-5D and return to work for SAH patients with appropriate age. Multivariable analyses including in-hospital parameters and long-term complications were conducted to identify parameters independently associated with outcomes in SAH survivors. Results: This study cohort consisted of 505 SAH patients of whom 405 survived the follow-up period of 12 months (i.e., mortality rate of 19.8%). Outcome data were available in 359/405 (88.6%) patients surviving SAH. At 12 months, a favorable functional outcome was achieved in 287/359 (79.9%) and 145/251 (57.8%) SAH patients returned to work. The rates of post-acute complications were headache (32.3%), chronic hydrocephalus requiring permanent ventriculoperitoneal shunting (VP shunt 25.4%) and epileptic seizures (9.5%). Despite patient’s and clinical characteristics, both presence of epilepsy and need for VP shunt were independently and negatively associated with a favorable functional outcome (epilepsy: adjusted odds ratio [aOR] (95% confidence interval [95% CI]): 0.125 [0.050–0.315]; VP shunt: 0.279 [0.132–0.588]; both p < 0.001) as well as with return to work (aOR [95% CI]: epilepsy 0.195 [0.065–0.584], p = 0.003; VP shunt 0.412 [0.188–0.903], p = 0.027). Multivariable analyses revealed presence of headache, VP shunt, or epilepsy to be significantly related to subjective health impairment (aOR [95% CI]: headache 0.248 [0.143–0.430]; epilepsy 0.223 [0.085–0.585]; VP shunt 0.434 [0.231–0.816]; all p < 0.01). Conclusions: Long-term complications occur frequently after SAH and are associated with an impairment of functional and social outcomes. Further studies are warranted to investigate if treatment strategies specifically targeting these complications, including preventive aspects, may improve the outcomes after SAH.
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Kallmünzer B, Pott M, Schwab S. Letter by Kallmünzer et al Regarding Article, "Safety of Intravenous Thrombolysis Among Patients Taking Direct Oral Anticoagulants: a Systematic Review and Meta-Analysis". Stroke 2020; 51:e130-e131. [PMID: 32539671 DOI: 10.1161/strokeaha.120.029631] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Germany (B.K., S.S.). Department of Neurology, Klinikum Bayreuth GmbH, Bayreuth, Germany
| | | | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Germany (B.K., S.S.). Department of Neurology, Klinikum Bayreuth GmbH, Bayreuth, Germany
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26
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Hoyer C, Ebert A, Huttner HB, Puetz V, Kallmünzer B, Barlinn K, Haverkamp C, Harloff A, Brich J, Platten M, Szabo K. Acute Stroke in Times of the COVID-19 Pandemic: A Multicenter Study. Stroke 2020; 51:2224-2227. [PMID: 32516064 DOI: 10.1161/strokeaha.120.030395] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE This study aims to assess the number of patients with acute ischemic cerebrovascular events seeking in-patient medical emergency care since the implementation of social distancing measures in the coronavirus disease 2019 (COVID-19) pandemic. METHODS In this retrospective multicenter study, data on the number of hospital admissions due to acute ischemic stroke or transient ischemic attack and numbers of reperfusion therapies performed in weeks 1 to 15 of 2020 and 2019 were collected in 4 German academic stroke centers. Poisson regression was used to test for a change in admission rates before and after the implementation of extensive social distancing measures in week 12 of 2020. The analysis of anonymized regional mobility data allowed for correlations between changes in public mobility as measured by the number and length of trips taken and hospital admission for stroke/transient ischemic attack. RESULTS Only little variation of admission rates was observed before and after week 11 in 2019 and between the weeks 1 and 11 of 2019 and 2020. However, reflecting the impact of the COVID-19 pandemic, a significant decrease in the number of admissions for transient ischemic attack was observed (-85%, -46%, -42%) in 3 of 4 centers, while in 2 of 4 centers, stroke admission rates decreased significantly by 40% and 46% after week 12 in 2020. A relevant effect on reperfusion therapies was found for 1 center only (thrombolysis, -60%; thrombectomy, -61%). Positive correlations between number of ischemic events and mobility measures in the corresponding cities were identified for 3 of 4 centers. CONCLUSIONS These data demonstrate and quantify decreasing hospital admissions due to ischemic cerebrovascular events and suggest that this may be a consequence of social distancing measures, in particular because hospital resources for acute stroke care were not limited during this period. Hence, raising public awareness is necessary to avoid serious healthcare and economic consequences of undiagnosed and untreated strokes and transient ischemic attacks.
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Affiliation(s)
- Carolin Hoyer
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Germany (C. Hoyer, A.E., M.P., K.S.)
| | - Anne Ebert
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Germany (C. Hoyer, A.E., M.P., K.S.)
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Germany (H.B.H., B.K.)
| | - Volker Puetz
- Department of Neurology, Dresden Neurovascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Germany (V.P., K.B.)
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Germany (H.B.H., B.K.)
| | - Kristian Barlinn
- Department of Neurology, Dresden Neurovascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Germany (V.P., K.B.)
| | - Christian Haverkamp
- Institute of Digitalization in Medicine (C. Haverkamp), Faculty of Medicine, University of Freiburg, Germany
| | - Andreas Harloff
- Department of Neurology and Clinical Neuroscience (A.H., J.B.), Faculty of Medicine, University of Freiburg, Germany
| | - Jochen Brich
- Department of Neurology and Clinical Neuroscience (A.H., J.B.), Faculty of Medicine, University of Freiburg, Germany
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Germany (C. Hoyer, A.E., M.P., K.S.)
| | - Kristina Szabo
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Germany (C. Hoyer, A.E., M.P., K.S.)
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Tsivgoulis G, Katsanos AH, Seiffge DJ, Paciaroni M, Wilson D, Koga M, Macha K, Cappellari M, Kallmünzer B, Polymeris AA, Toyoda K, Caso V, Werring DJ, Engelter ST, De Marchis GM. Fatal intracranial haemorrhage occurring after oral anticoagulant treatment initiation for secondary stroke prevention in patients with atrial fibrillation. Eur J Neurol 2020; 27:1612-1617. [PMID: 32333493 DOI: 10.1111/ene.14280] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE In this pooled analysis of seven multicentre cohorts potential differences were investigated in the incidence, characteristics and outcomes between intracranial haemorrhages (ICHs) associated with the use of non-vitamin K antagonist oral anticoagulants (NOAC-ICH) or with vitamin K antagonists (VKA-ICH) in ischaemic stroke patients after oral anticoagulant treatment initiation for atrial fibrillation (AF). METHODS Data from 4912 eligible AF patients who were admitted in a stroke unit with ischaemic stroke or transient ischaemic attack and who were treated with either VKAs or NOACs within 3 months post-stroke were included. Fatal ICH was defined as death occurring during the first 30 days after ICH onset. A meta-analysis of available observational studies reporting 30-day mortality rates from NOAC-ICH or VKA-ICH onset was additionally performed. RESULTS During 5970 patient-years of follow-up 71 participants had an ICH, of whom 20 were NOAC-ICH and 51 VKA-ICH. Patients in the two groups had comparable baseline characteristics, except for the higher prevalence of kidney disease in VKA-ICH patients. There was a non-significant higher number of fatal ICH in patients with VKAs (11 events per 3385 patient-years) than in those with NOACs (three events per 2623 patient-years; hazard ratio 0.32, 95% confidence interval 0.09-1.14). Three-month functional outcomes were similar (P > 0.2) in the two groups. The meta-analysis showed a lower 30-day mortality risk for patients with NOAC-ICH compared to VKA-ICH (relative risk 0.70, 95% confidence interval 0.51-0.95). CONCLUSIONS Non-vitamin K oral anticoagulants for intracranial haemorrhages and VKA-ICH occurring during secondary stroke prevention of AF patients have comparable baseline characteristics and outcomes except for the risk of fatal ICH within 30 days, which might be greater in VKA-ICH.
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Affiliation(s)
- G Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens School of Medicine, Attikon' University Hospital, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - A H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - D J Seiffge
- Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland.,Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK.,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - M Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - D Wilson
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - M Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - K Macha
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - M Cappellari
- Stroke Unit, Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - B Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - A A Polymeris
- Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland
| | - K Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - V Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - D J Werring
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - S T Engelter
- Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - G M De Marchis
- Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland
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28
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Koehn J, Wang R, de Rojas Leal C, Kallmünzer B, Winder K, Köhrmann M, Kollmar R, Schwab S, Hilz MJ. Neck cooling induces blood pressure increase and peripheral vasoconstriction in healthy persons. Neurol Sci 2020; 41:2521-2529. [PMID: 32219592 PMCID: PMC8197712 DOI: 10.1007/s10072-020-04349-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/16/2020] [Indexed: 12/18/2022]
Abstract
Introduction Noninvasive temperature modulation by localized neck cooling might be desirable in the prehospital phase of acute hypoxic brain injuries. While combined head and neck cooling induces significant discomfort, peripheral vasoconstriction, and blood pressure increase, localized neck cooling more selectively targets blood vessels that supply the brain, spares thermal receptors of the face and skull, and might therefore cause less discomfort cardiovascular side effects compared to head- and neck cooling. The purpose of this study is to assess the effects of noninvasive selective neck cooling on cardiovascular parameters and cerebral blood flow velocity (CBFV). Methods Eleven healthy persons (6 women, mean age 42 ± 11 years) underwent 90 min of localized dorsal and frontal neck cooling (EMCOOLS Brain.Pad™) without sedation. Before and after cooling onset, and after every 10 min of cooling, we determined rectal, tympanic, and neck skin temperatures. Before and after cooling onset, after 60- and 90-min cooling, we monitored RR intervals (RRI), systolic, diastolic blood pressures (BPsys, BPdia), laser Doppler skin blood flow (SBF) at the index finger pulp, and CBFV at the proximal middle cerebral artery (MCA). We compared values before and during cooling by analysis of variance for repeated measurements with post hoc analysis (significance: p < 0.05). Results Neck skin temperature dropped significantly by 9.2 ± 4.5 °C (minimum after 40 min), while tympanic temperature decreased by only 0.8 ± 0.4 °C (minimum after 50 min), and rectal temperature by only 0.2 ± 0.3 °C (minimum after 60 min of cooling). Index finger SBF decreased (by 83.4 ± 126.0 PU), BPsys and BPdia increased (by 11.2 ± 13.1 mmHg and 8.0 ± 10.1 mmHg), and heart rate slowed significantly while MCA-CBFV remained unchanged during cooling. Conclusions While localized neck cooling prominently lowered neck skin temperature, it had little effect on tympanic temperature but significantly increased BP which may have detrimental effects in patients with acute brain injuries.
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Affiliation(s)
- Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Carmen de Rojas Leal
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Klemens Winder
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Rainer Kollmar
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.,Department of Neurology, General Hospital Darmstadt, Grafenstr. 9, 64283, Darmstadt, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany. .,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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29
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Seiffge DJ, De Marchis GM, Koga M, Paciaroni M, Wilson D, Cappellari M, Macha, MD K, Tsivgoulis G, Ambler G, Arihiro S, Bonati LH, Bonetti B, Kallmünzer B, Muir KW, Bovi P, Gensicke H, Inoue M, Schwab S, Yaghi S, Brown MM, Lyrer P, Takagi M, Acciarrese M, Jager HR, Polymeris AA, Toyoda K, Venti M, Traenka C, Yamagami H, Alberti A, Yoshimura S, Caso V, Engelter ST, Werring DJ. Ischemic Stroke despite Oral Anticoagulant Therapy in Patients with Atrial Fibrillation. Ann Neurol 2020; 87:677-687. [PMID: 32052481 PMCID: PMC7383617 DOI: 10.1002/ana.25700] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 01/27/2020] [Accepted: 02/07/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE It is not known whether patients with atrial fibrillation (AF) with ischemic stroke despite oral anticoagulant therapy are at increased risk for further recurrent strokes or how ongoing secondary prevention should be managed. METHODS We conducted an individual patient data pooled analysis of 7 prospective cohort studies that recruited patients with AF and recent cerebral ischemia. We compared patients taking oral anticoagulants (vitamin K antagonists [VKA] or direct oral anticoagulants [DOAC]) prior to index event (OACprior ) with those without prior oral anticoagulation (OACnaive ). We further compared those who changed the type (ie, from VKA or DOAC, vice versa, or DOAC to DOAC) of anticoagulation (OACchanged ) with those who continued the same anticoagulation as secondary prevention (OACunchanged ). Time to recurrent acute ischemic stroke (AIS) was analyzed using multivariate competing risk Fine-Gray models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS We included 5,413 patients (median age = 78 years [interquartile range (IQR) = 71-84 years]; 5,136 [96.7%] had ischemic stroke as the index event, median National Institutes of Health Stroke Scale on admission = 6 [IQR = 2-12]). The median CHA2 DS2 -Vasc score (congestive heart failure, hypertension, age≥ 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category) was 5 (IQR = 4-6) and was similar for OACprior (n = 1,195) and OACnaive (n = 4,119, p = 0.103). During 6,128 patient-years of follow-up, 289 patients had AIS (4.7% per year, 95% CI = 4.2-5.3%). OACprior was associated with an increased risk of AIS (HR = 1.6, 95% CI = 1.2-2.3, p = 0.005). OACchanged (n = 307) was not associated with decreased risk of AIS (HR = 1.2, 95% CI = 0.7-2.1, p = 0.415) compared with OACunchanged (n = 585). INTERPRETATION Patients with AF who have an ischemic stroke despite previous oral anticoagulation are at a higher risk for recurrent ischemic stroke despite a CHA2 DS2 -Vasc score similar to those without prior oral anticoagulation. Better prevention strategies are needed for this high-risk patient group. ANN NEUROL 2020.
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Affiliation(s)
- David J. Seiffge
- Stroke Research Center, Department of Brain Repair and RehabilitationUniversity College London Queen Square Institute of Neurology, and the National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
- Department of Neurology and Stroke CenterUniversity Hospital of BernBernSwitzerland
| | - Gian Marco De Marchis
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
| | - Masatoshi Koga
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular MedicineUniversity of PerugiaPerugiaItaly
| | - Duncan Wilson
- Stroke Research Center, Department of Brain Repair and RehabilitationUniversity College London Queen Square Institute of Neurology, and the National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | - Manuel Cappellari
- Stroke Unit, Department of NeuroscienceUniversity Hospital Integrated Trust of VeronaVeronaItaly
| | - Kosmas Macha, MD
- Department of NeurologyUniversity of Erlangen‐NürnbergErlangenGermany
| | - Georgios Tsivgoulis
- Second Department of NeurologyNational and Kapodistrian University of Athens School of Medicine, Attikon University HospitalAthensGreece
- Department of NeurologyUniversity of Tennessee Health Science CenterMemphisTN
| | - Gareth Ambler
- Department of Statistical ScienceUniversity College LondonLondonUnited Kingdom
| | - Shoji Arihiro
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Leo H. Bonati
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
| | - Bruno Bonetti
- Stroke Unit, Department of NeuroscienceUniversity Hospital Integrated Trust of VeronaVeronaItaly
| | - Bernd Kallmünzer
- Department of NeurologyUniversity of Erlangen‐NürnbergErlangenGermany
| | - Keith W. Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University HospitalGlasgowUnited Kingdom
| | - Paolo Bovi
- Stroke Unit, Department of NeuroscienceUniversity Hospital Integrated Trust of VeronaVeronaItaly
| | - Henrik Gensicke
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
- Neurorehabilitation UnitUniversity Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of BaselBaselSwitzerland
| | - Manabu Inoue
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Stefan Schwab
- Department of NeurologyUniversity of Erlangen‐NürnbergErlangenGermany
| | | | - Martin M. Brown
- Stroke Research Center, Department of Brain Repair and RehabilitationUniversity College London Queen Square Institute of Neurology, and the National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
| | - Philippe Lyrer
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
| | - Masahito Takagi
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Monica Acciarrese
- Stroke Unit and Division of Cardiovascular MedicineUniversity of PerugiaPerugiaItaly
| | - Hans Rolf Jager
- Neuroradiological Academic Unit, Department of Brain Repair and RehabilitationUniversity College London Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Alexandros A. Polymeris
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
| | - Kazunori Toyoda
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Michele Venti
- Stroke Unit and Division of Cardiovascular MedicineUniversity of PerugiaPerugiaItaly
| | - Christopher Traenka
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
| | - Hiroshi Yamagami
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular MedicineUniversity of PerugiaPerugiaItaly
| | - Sohei Yoshimura
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular MedicineUniversity of PerugiaPerugiaItaly
| | - Stefan T. Engelter
- Neurology and Stroke Center, Department of Clinical ResearchUniversity Hospital of Basel, University of BaselBaselSwitzerland
- Neurorehabilitation UnitUniversity Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of BaselBaselSwitzerland
| | - David J. Werring
- Stroke Research Center, Department of Brain Repair and RehabilitationUniversity College London Queen Square Institute of Neurology, and the National Hospital for Neurology and NeurosurgeryQueen SquareLondonUnited Kingdom
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30
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De Marchis GM, Seiffge DJ, Schädelin S, Wilson D, Caso V, Acciarresi M, Tsivgoulis G, Koga M, Yoshimura S, Toyoda K, Cappellari M, Bonetti B, Macha K, Kallmünzer B, Lyrer PA, Cereda C, Paciaroni M, Engelter ST, Werring DJ. Abstract TMP18: Early versus Late Start of Direct Oral Anticoagulants After an Ischemic Stroke Related to Atrial Fibrillation - An Individual Patient Data Analysis. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tmp18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The optimal timepoint of starting DOAC after an acute ischemic stroke (IS) related to atrial fibrillation (AF) remains unclear. We aimed to compare an early (≤ 5 days of IS) versus late (>5 days of IS) DOAC-start.
Methods:
Individual patient data analysis of 7 European and Japanese prospective observational cohort studies. We included patients with IS or TIA related to non-valvular AF where a DOAC was started within 30 days. We excluded patients with an intracranial bleeding (ICH) after the index event but prior to DOAC-start. We compared the 30-day rates of recurrent IS and ICH between the groups of early versus late DOAC-start with a landmark analysis at day 5.
Results:
Overall, 2550 patients were included. Median age was 77 years (IQR 70-84). DOAC were started early in 1362 (53%) patients, late in 1188 (47%). In the whole cohort, 37 patients suffered from a recurrent IS (1.5%), 16 patients (43%) of whom before any DOAC was started. 6 patients (0.2%) had an ICH. In the early DOAC-start group, 23 patients (1.7%) suffered from a recurrent IS after DOAC-start and within 30 days; two patients (0.1%) suffered from ICH after DOAC-start. In the late DOAC-start group, 14 patients (1.2%) suffered from a recurrent IS before DOAC was started; 4 patients (0.3%) suffered from ICH after DOAC-start. In the comparison of late versus early DOAC-groups, no difference in the hazard ratios was observed for the endpoint of recurrent IS (HR
= 1.15, 95%CI 0.48-2.73, p=0.76) and ICH (HR = 4.71, 95%CI 0.51-43.10, p=0.17).
Conclusion:
Our results do not corroborate the concern that early anticoagulation - at least when performed with DOACs - increases the risk of hemorrhagic transformation of the brain infarct compared to late anticoagulation. Given the seven times higher risk of recurrent IS - with almost half of recurrent IS occurring before any DOAC-start - an early DOAC-start after AF-related IS may be reasonable, if inclusion in the ongoing trials (the recommended option) is not possible.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Carlo Cereda
- Neurocentro della Svizzera Italiana, Lugano, Switzerland
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31
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Cheng B, Boutitie F, Nickel A, Wouters A, Cho TH, Ebinger M, Endres M, Fiebach JB, Fiehler J, Galinovic I, Puig J, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Gerloff C, Thomalla G, Golsari A, Alegiani A, Beck C, Choe CU, Voget D, Hoppe J, Schröder J, Rozanski M, Nave AH, Wollboldt C, van Sloten I, Göhler J, Herm J, Jungehülsing J, Lückl J, Kröber JM, Schurig J, Koehler L, Schlemm L, Knops M, Roennefarth M, Ipsen N, Harmel P, Bathe-Peters R, Fleischmann R, Ganeshan R, Geran R, Hellwig S, Schmidt S, Tütüncü S, Krause T, Gramse V, Röther J, Michels P, Michalski D, Pelz J, Schulz A, Hobohm C, Weise C, Weise G, Orthgieß J, Pomrehn K, Wegscheider M, Mueller AK, Hennerici M, Griebe M, Alonso A, Filipov A, Marzina A, Anders B, Bähr C, Hoyer C, Schwarzbach C, Weber C, Hornberger E, Pledl HW, Klockziem M, Stuermlinger M, Wittayer M, Wolf M, Meyer N, Eisele P, Steinert S, Sauer T, Held V, Ringleb P, Nagel S, Veltkamp R, Schwarting S, Schwarz A, Gumbinger C, Hametner C, Amiri H, Purrucker J, Ciatipis M, Menn O, Mundiyanapurath S, Schieber S, Kessler T, Reiff T, Panitz V, Singer O, Foerch C, Lauer A, Männer A, Seiler A, Guerzoglu D, Schäfer JH, Filipski K, Lorenz M, Kurka N, Zeiner P, Pfeilschifter W, Dziewas R, Minnerup J, Albiker C, Ritter M, Seidel M, Dittrich R, Kallmünzer B, Bobinger T, Madzar D, Stark D, Sembill J, Macha K, Winder K, Breuer L, Koehrmann M, Spruegel M, Gerner S, Kraft P, Mackenrodt D, Kleinschnitz C, Elhfnawy A, Heinen F, Gunreben I, Poli S, Ziemann U, Gaenslen A, Schlak D, Haertig F, Russo F, Richter H, Ebner M, Ribitsch M, Wolf M, Weimar C, Zegarac V, Chen HC, Althaus K, Neugebauer H, Jüttler E, Meier J, Stösser S, Puetz V, Bodechtel U, Ostergaard L, Møller A, Damgaard D, Dupont KH, Poulsen M, Hjort N, de Morales NR, von Weitzel P, Harbo T, Marstrand J, Hansen A, Christensen H, Aegidius K, Jeppesen L, Meden P, Rosenbaum S, Iversen H, Hansen J, Michelsen L, Truelsen T, Modrau B, Vestergaard K, Oppel L, Sygehus A, Aalborg S, Swinnen B, Smets I, Demeestere J, Dobbels L, Brouns R, De Smedt A, DeKeyser J, Yperzeele L, Van Hooff RJ, Peeters A, Dusart A, Etexberria A, Hanseeuw B, London F, Leempoel J, Hohenbichler K, Younan N, Maqueda V, Laloux P, De Coene B, De Maeseneire C, Turine G, Vandermeeren Y, De Klippel N, Willems C, de Hollander I, Soors P, Hermans S, Hemelsoet D, Desfontaines P, Vanacker P, Rutgers M, Druart C, Peeters D, Bruneel B, Vancaester E, Vanhee F, Meersman G, Bourgeois P, Vanderdonckt P, Benoit A, Derex L, Mechthouff L, Berhoune N, Ritzenthaler T, Amarenco P, Hobeanu C, Gancedo EM, Calvet D, Ladoux A, Machet A, Lamy C, Mellerio C, Oppenheim C, Rodriguez-Regent C, Bodiguel E, Turc G, Birchenall J, Legrand L, Morin L, Edjali-Goujon M, Naggara O, Raphaelle S, Godon-Hardy S, Domigo V, Guiraud V, Samson Y, Leger A, Rosso C, Baronnet-Chauvet F, Crozier S, Deltour S, Yger M, Sibon I, Renou P, Sagnier S, Zuber M, Tamazyan R, Rodier G, Morel N, Felix S, Vadot W, Wolff V, Aniculaesei A, Yalo B, Bindila D, Quenardelle V, Blanc-Lasserre K, Landrault E, Breynaert L, Cakmak S, Peysson S, Viguier A, Lebely C, Raposo N, Vallet AE, Vallet P, Brugirard S, Cheripelli B, Kalladka D, Moreton F, Dani K, Tawil SE, Ramachandran S, Huang X, Warburton E, Evans N, Perry R, Patel B, Cloud G, Pereira A, Moynihan B, Lovelock C, Choy L, Khan U, Roffe C, Tyrell P, Smith C, Dixit A, Louw S, Broughton D, Shetty A, Appleton J, Sprigg N, Acosta BR, van Eendenburg C, Leal JS, Mar Castellanos Rodrigo MD, Izaga MT, Guillamon OB, Arenillas J, Calleja A, Cortijo E, Mulero P, de la Ossa NP, Garrido A, Martinez A, Esperón CG, Guerrero C, Carrera D, Vilas D, Lopez-cancio E, Palomeras E, Lucente G, Gomis M, Isern I, Becerra JL, Vicente JH, Sánchez J, Dorado L, Grau L, Ispierto L, Prats L, Almendrote M, Hernández M, Jimenez M, Sánchez ML, Torne MM, Presas S, Ustrell X, Pellisé A, Navalpotro I, Luna A, Schonewille W, Nederkoorn P, Majoie C, van den Berg L, van den Berg S, Zonneveld T, Remmers M, Fazekas F, Pichler A, Fandler S, Gattringer T, Mutzenbach J, Weber J, Höfner E, Kohlfürst H, Weinstich K, Kellert L, Bayer-Karpinska A, Opherk C, Wollenweber F, Klein M, Neumann- Haefelin T, Pierskalla A, Harloff A, Bardutzky J, Buggle F, von Schrader J, Kollmar R, Schill J, Löbbe AM, Moulin T, Bouamra B, Bonnet L, Touzé E, Bonnet AL, Touze E, Cogez J, Li L, Guettier S, Kar A, Sivagnanaratham A, Geraghty O, Bojaryn U, Nallasivan A, Gonzales MB, Rodríguez-Yáñez M, Tembl J, Gorriz D, Oberndorfer S, Prohaska E. Quantitative Signal Intensity in Fluid-Attenuated Inversion Recovery and Treatment Effect in the WAKE-UP Trial. Stroke 2020; 51:209-215. [DOI: 10.1161/strokeaha.119.027390] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Relative signal intensity of acute ischemic stroke lesions in fluid-attenuated inversion recovery (fluid-attenuated inversion recovery relative signal intensity [FLAIR-rSI]) magnetic resonance imaging is associated with time elapsed since stroke onset with higher intensities signifying longer time intervals. In the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke Trial), intravenous alteplase was effective in patients with unknown onset stroke selected by visual assessment of diffusion weighted imaging fluid-attenuated inversion recovery mismatch, that is, in those with no marked fluid-attenuated inversion recovery hyperintensity in the region of the acute diffusion weighted imaging lesion. In this post hoc analysis, we investigated whether quantitatively measured FLAIR-rSI modifies treatment effect of intravenous alteplase.
Methods—
FLAIR-rSI of stroke lesions was measured relative to signal intensity in a mirrored region in the contralesional hemisphere. The relationship between FLAIR-rSI and treatment effect on functional outcome assessed by the modified Rankin Scale (mRS) after 90 days was analyzed by binary logistic regression using different end points, that is, favorable outcome defined as mRS score of 0 to 1, independent outcome defined as mRS score of 0 to 2, ordinal analysis of mRS scores (shift analysis). All models were adjusted for National Institutes of Health Stroke Scale at symptom onset and stroke lesion volume.
Results—
FLAIR-rSI was successfully quantified in stroke lesions in 433 patients (86% of 503 patients included in WAKE-UP). Mean FLAIR-rSI was 1.06 (SD, 0.09). Interaction of FLAIR-rSI and treatment effect was not significant for mRS score of 0 to 1 (
P
=0.169) and shift analysis (
P
=0.086) but reached significance for mRS score of 0 to 2 (
P
=0.004). We observed a smooth continuing trend of decreasing treatment effects in relation to clinical end points with increasing FLAIR-rSI.
Conclusions—
In patients in whom no marked parenchymal fluid-attenuated inversion recovery hyperintensity was detected by visual judgement in the WAKE-UP trial, higher FLAIR-rSI of diffusion weighted imaging lesions was associated with decreased treatment effects of intravenous thrombolysis. This parallels the known association of treatment effect and elapsing time of stroke onset.
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Affiliation(s)
- Bastian Cheng
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Florent Boutitie
- Service de Biostatistique, Hospices Civils de Lyon, France (F.B.)
- Université Lyon 1, Villeurbanne, France (F.B.)
- CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France (F.B.)
| | - Alina Nickel
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Anke Wouters
- Department of Neurology, University Hospitals Leuven, Belgium (A.W., R.L.)
- Department of Neurosciences, Experimental Neurology, KU Leuven–University of Leuven, Belgium (A.W., R.L.)
- VIB, Center for Brain and Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Leuven, Belgium (A.W., R.L.)
| | - Tae-Hee Cho
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon, France (T.-H.C., N.N.)
- Hospices Civils de Lyon, France (T.-H.C., N.N.)
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
- Neurologie der Rehaklinik Medical Park Humboldtmühle, Berlin, Germany (M. Ebinger)
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany (M. Endres)
| | - Jochen B. Fiebach
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Ivana Galinovic
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
| | - Josep Puig
- Department of Radiology, Institut de Diagnostic per la Image, Hospital Dr Josep Trueta, Institut d’Investigació Biomèdica de Girona, Parc Hospitalari Martí i Julià de Salt, Girona, Spain (J.P., S.P.)
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia (V.T.)
- Austin Health, Department of Neurology, VIC, Australia (V.T.)
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Belgium (A.W., R.L.)
- Department of Neurosciences, Experimental Neurology, KU Leuven–University of Leuven, Belgium (A.W., R.L.)
- VIB, Center for Brain and Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Leuven, Belgium (A.W., R.L.)
| | - Keith W. Muir
- Institute of Neuroscience and Psychology, University of Glasgow, United Kingdom (K.W.M.)
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon, France (T.-H.C., N.N.)
- Hospices Civils de Lyon, France (T.-H.C., N.N.)
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image, Hospital Dr Josep Trueta, Institut d’Investigació Biomèdica de Girona, Parc Hospitalari Martí i Julià de Salt, Girona, Spain (J.P., S.P.)
| | - Claus Z. Simonsen
- Department of Neurology, Aarhus University Hospital, Denmark (C.Z.S.)
| | - Christian Gerloff
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
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Siedler G, Sommer K, Macha K, Marsch A, Breuer L, Stoll S, Engelhorn T, Dörfler A, Arnold M, Schwab S, Kallmünzer B. Heart Failure in Ischemic Stroke. Stroke 2019; 50:3051-3056. [DOI: 10.1161/strokeaha.119.026139] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background and Purpose—
Heart failure (HF) in patients with acute ischemic stroke constitutes the source of various detrimental pathophysiologic mechanisms including prothrombotic and proinflammatory states, worsening of cerebral tissue oxygenation, and hemodynamic impairment. In addition, HF might affect the safety and efficacy of the acute recanalization stroke therapies.
Methods—
Patients treated with intravenous recombinant tissue-type plasminogen activator or mechanical recanalization at a universitary stroke center were included into a prospective registry. Patients received cardiological evaluation, including echocardiography, during acute care. Functional outcome was assessed after 90 days by structured telephone interviews. Safety and efficacy of intravenous thrombolysis and mechanical thrombectomy were investigated among patients with HF and compared with patients with normal cardiac function after propensity score matching.
Results—
One thousand two hundred nine patients were included. HF was present in 378 patients (31%) and an independent predictor of unfavorable functional outcome. Recanalization rates were equal among patients with HF after intravenous thrombolysis and after mechanical recanalization or combined treatment. The rate of secondary intracranial hemorrhage was not different (7% versus 8%;
P
=0.909 after thrombolysis and 15% versus 20%,
P
=0.364 after mechanical recanalization or combined therapy). Early mortality within 48 hours after admission was equal (<1.5% in both groups).
Conclusions—
In this real-world cohort of patients with stroke, HF was an independent predictor of unfavorable functional long-term outcome, while the safety and efficacy of intravenous thrombolysis and mechanical recanalization appeared unaffected.
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Affiliation(s)
- Gabriela Siedler
- From the Department of Neurology (G.S., K.S., K.M., A.M., L.B., S. Stoll, S. Schwab, B.K.), University Hospital Erlangen, Germany
| | - Kim Sommer
- From the Department of Neurology (G.S., K.S., K.M., A.M., L.B., S. Stoll, S. Schwab, B.K.), University Hospital Erlangen, Germany
| | - Kosmas Macha
- From the Department of Neurology (G.S., K.S., K.M., A.M., L.B., S. Stoll, S. Schwab, B.K.), University Hospital Erlangen, Germany
| | - Armin Marsch
- From the Department of Neurology (G.S., K.S., K.M., A.M., L.B., S. Stoll, S. Schwab, B.K.), University Hospital Erlangen, Germany
| | - Lorenz Breuer
- From the Department of Neurology (G.S., K.S., K.M., A.M., L.B., S. Stoll, S. Schwab, B.K.), University Hospital Erlangen, Germany
| | - Svenja Stoll
- From the Department of Neurology (G.S., K.S., K.M., A.M., L.B., S. Stoll, S. Schwab, B.K.), University Hospital Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology (T.E., A.D.), University Hospital Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology (T.E., A.D.), University Hospital Erlangen, Germany
| | - Martin Arnold
- Department of Cardiology (M.A.), University Hospital Erlangen, Germany
| | - Stefan Schwab
- From the Department of Neurology (G.S., K.S., K.M., A.M., L.B., S. Stoll, S. Schwab, B.K.), University Hospital Erlangen, Germany
| | - Bernd Kallmünzer
- From the Department of Neurology (G.S., K.S., K.M., A.M., L.B., S. Stoll, S. Schwab, B.K.), University Hospital Erlangen, Germany
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Siedler G, Kallmünzer B, Schwab S. [Diagnostik Lumbar Puncture - Step by Step]. Dtsch Med Wochenschr 2019; 144:1361-1366. [PMID: 31559618 DOI: 10.1055/a-0665-6476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Performing a diagnostic lumbar puncture is an essential clinical skill for the clinician. The procedure is of high importance for both, the emergency care for patients with suspected infection of the cerebral nervous system or subarachnoidal hemorrhage, as well as the elective diagnostic work up of chronic disease including multiple sclerosis and dementia. Furthermore the technique's principles are applied for spinal anesthesia or the intrathecal administration of drugs. This article describes a Standard Operating Procedure for the lumbar puncture step by step. Based on the latest evidence, it particularly focusses on clinically relevant questions and practical aspects.
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Marsch A, Macha K, Siedler G, Breuer L, Strasser E, Engelhorn T, Dörfler A, Schwab S, Kallmünzer B. Direct Oral Anticoagulant Plasma Levels for the Management of Acute Ischemic Stroke. Cerebrovasc Dis 2019; 48:17-25. [DOI: 10.1159/000502335] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 07/23/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction: The management of acute ischemic stroke in patients on direct oral anticoagulants (DOACs) is challenging. However, the substance-specific plasma level could guide treatment decisions on recanalization therapies. We present a plasma-level-based protocol for emergency treatment of stroke patients on oral anticoagulants. Bleeding complications and clinical outcome for patients on DOACs are reported and compared to patients on vitamin K antagonists (VKAs). Methods: In patients with acute ischemic stroke and suspected use of DOACs within 48 h prior to hospital admission, plasma levels were measured using the calibrated Xa-activity (apixaban, edoxaban, rivaroxaban) or the Hemoclot®-assay (dabigatran). Levels <50 ng/mL were supportive for thrombolysis, while high values >100 ng/mL excluded patients from recombinant tissue plasminogen activator use. For patients on VKAs, the cutoff was set at international normalized ratio of 1.7. Endovascular thrombectomy of a large vessel occlusion was performed independently from coagulation testing. Consecutive patients were included in an observational registry. Results: Five hundred and twenty-two patients (261 on VKAs and 261 on DOACs) were included. Thirty patients (11.5%) on VKAs and 24 (9.2%) on DOACs received thrombolysis, followed by mechanical thrombectomy in 10 and 14 patients, respectively. Seventeen patients in each group received thrombectomy only. Symptomatic intracranial hemorrhage associated with thrombolysis occurred in 1 patient on VKA (3.3%) and 1 on DOAC (4.2%; p = 0.872). The turnaround time of specific assays did not show a significant delay in comparison to standard coagulation parameters. Conclusion: DOAC plasma levels could support decisions on emergency treatment of ischemic stroke. Systemic thrombolysis below suggested thresholds appears preliminary feasible and safe without an excess in bleeding complications.
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Hoelter P, Schmidt M, Breuer L, Kallmünzer B, Schwab S, Doerfler A, Engelhorn T. Endovascular treatment in patients with large vessel occlusion: reduced mortality despite minimal penumbra. Neuroradiology 2019; 61:1469-1476. [DOI: 10.1007/s00234-019-02280-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 08/12/2019] [Indexed: 02/01/2023]
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Fröhlich K, Macha K, Gerner ST, Bobinger T, Schmidt M, Dörfler A, Hilz MJ, Schwab S, Seifert F, Kallmünzer B, Winder K. Angioedema in Stroke Patients With Thrombolysis. Stroke 2019; 50:1682-1687. [PMID: 31182002 DOI: 10.1161/strokeaha.119.025260] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Oral angioedema (OA) is a rare but life-threatening complication in patients with ischemic stroke receiving intravenous thrombolysis with r-tPA (recombinant tissue-type plasminogen activator). This study intended to determine associations between thrombolysis-related OA and ischemic stroke lesion sites using a voxel-wise lesion analysis. Methods- Prospective registry data were used to identify ischemic stroke patients with thrombolysis-related OA between 2002 and 2018. For the study registry, ethics approval was obtained by the Ethics Committee of the Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg (clinical registry registration: 377_17Bc). Ischemic stroke patients with thrombolysis treatment but without OA admitted in the years 2011 and 2012 comprised the control group. Ischemic lesions were manually outlined on magnetic resonance imaging (1.5T or 3T) or computed tomographic scans and transformed into stereotaxic space. We determined the lesion overlap and compared the absence or presence of OA voxel-wise between patients with and without lesions in a given voxel using the Liebermeister test. Stroke severity was rated using the National Institutes of Health Stroke Scale score, and blood pressure, heart rate, blood glucose levels, and body temperature were determined on admission. Results- Fifteen ischemic stroke patients with thrombolysis-related OA were identified. The voxel-wise analysis yielded associations between OA and ischemic lesions in the insulo-opercular region with a right hemispheric dominance. Mean blood pressure was significantly lower in patients with OA than in controls. Age, National Institutes of Health Stroke Scale scores, infarct volumes, heart rate, and blood glucose levels did not differ between patients with and without OA. Conclusions- The voxel-wise analysis linked thrombolysis-related OA to right insulo-opercular lesions. The lower blood pressure in patients with thrombolysis-related OA may reflect bradykinin effects causing vasodilatation and increasing vascular permeability.
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Affiliation(s)
- Kilian Fröhlich
- From the Department of Neurology (K.F., K.M., S.T.G., T.B., M.J.H., S.S., F.S., B.K., K.W.), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Kosmas Macha
- From the Department of Neurology (K.F., K.M., S.T.G., T.B., M.J.H., S.S., F.S., B.K., K.W.), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Stefan T Gerner
- From the Department of Neurology (K.F., K.M., S.T.G., T.B., M.J.H., S.S., F.S., B.K., K.W.), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Tobias Bobinger
- From the Department of Neurology (K.F., K.M., S.T.G., T.B., M.J.H., S.S., F.S., B.K., K.W.), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Manuel Schmidt
- Department of Neuroradiology (M.S., A.D.), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Arnd Dörfler
- Department of Neuroradiology (M.S., A.D.), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Max J Hilz
- From the Department of Neurology (K.F., K.M., S.T.G., T.B., M.J.H., S.S., F.S., B.K., K.W.), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (M.J.H.)
| | - Stefan Schwab
- From the Department of Neurology (K.F., K.M., S.T.G., T.B., M.J.H., S.S., F.S., B.K., K.W.), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Frank Seifert
- From the Department of Neurology (K.F., K.M., S.T.G., T.B., M.J.H., S.S., F.S., B.K., K.W.), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Bernd Kallmünzer
- From the Department of Neurology (K.F., K.M., S.T.G., T.B., M.J.H., S.S., F.S., B.K., K.W.), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Klemens Winder
- From the Department of Neurology (K.F., K.M., S.T.G., T.B., M.J.H., S.S., F.S., B.K., K.W.), University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
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Diener HC, Sacco RL, Easton JD, Granger CB, Bernstein RA, Uchiyama S, Kreuzer J, Cronin L, Cotton D, Grauer C, Brueckmann M, Chernyatina M, Donnan G, Ferro JM, Grond M, Kallmünzer B, Krupinski J, Lee BC, Lemmens R, Masjuan J, Odinak M, Saver JL, Schellinger PD, Toni D, Toyoda K. Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source. N Engl J Med 2019; 380:1906-1917. [PMID: 31091372 DOI: 10.1056/nejmoa1813959] [Citation(s) in RCA: 481] [Impact Index Per Article: 96.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cryptogenic strokes constitute 20 to 30% of ischemic strokes, and most cryptogenic strokes are considered to be embolic and of undetermined source. An earlier randomized trial showed that rivaroxaban is no more effective than aspirin in preventing recurrent stroke after a presumed embolic stroke from an undetermined source. Whether dabigatran would be effective in preventing recurrent strokes after this type of stroke was unclear. METHODS We conducted a multicenter, randomized, double-blind trial of dabigatran at a dose of 150 mg or 110 mg twice daily as compared with aspirin at a dose of 100 mg once daily in patients who had had an embolic stroke of undetermined source. The primary outcome was recurrent stroke. The primary safety outcome was major bleeding. RESULTS A total of 5390 patients were enrolled at 564 sites and were randomly assigned to receive dabigatran (2695 patients) or aspirin (2695 patients). During a median follow-up of 19 months, recurrent strokes occurred in 177 patients (6.6%) in the dabigatran group (4.1% per year) and in 207 patients (7.7%) in the aspirin group (4.8% per year) (hazard ratio, 0.85; 95% confidence interval [CI], 0.69 to 1.03; P = 0.10). Ischemic strokes occurred in 172 patients (4.0% per year) and 203 patients (4.7% per year), respectively (hazard ratio, 0.84; 95% CI, 0.68 to 1.03). Major bleeding occurred in 77 patients (1.7% per year) in the dabigatran group and in 64 patients (1.4% per year) in the aspirin group (hazard ratio, 1.19; 95% CI, 0.85 to 1.66). Clinically relevant nonmajor bleeding occurred in 70 patients (1.6% per year) and 41 patients (0.9% per year), respectively. CONCLUSIONS In patients with a recent history of embolic stroke of undetermined source, dabigatran was not superior to aspirin in preventing recurrent stroke. The incidence of major bleeding was not greater in the dabigatran group than in the aspirin group, but there were more clinically relevant nonmajor bleeding events in the dabigatran group. (Funded by Boehringer Ingelheim; RE-SPECT ESUS ClinicalTrials.gov number, NCT02239120.).
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Affiliation(s)
- Hans-Christoph Diener
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Ralph L Sacco
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - J Donald Easton
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Christopher B Granger
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Richard A Bernstein
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Shinichiro Uchiyama
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Jörg Kreuzer
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Lisa Cronin
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Daniel Cotton
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Claudia Grauer
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Martina Brueckmann
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Marina Chernyatina
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Geoffrey Donnan
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - José M Ferro
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Martin Grond
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Bernd Kallmünzer
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Jerzy Krupinski
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Byung-Chul Lee
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Robin Lemmens
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Jaime Masjuan
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Miroslav Odinak
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Jeffrey L Saver
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Peter D Schellinger
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Danilo Toni
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
| | - Kazunori Toyoda
- From the University Duisburg-Essen and University Hospital Essen, Essen (H.-C.D.), Boehringer Ingelheim Pharma GmbH K.G., Biberach (C.G.), Boehringer Ingelheim International GmbH, Ingelheim, Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim (M.B.), Kreisklinikum Siegen, Siegen, and the University of Marburg, Marburg (M.G.), University Hospital Erlangen, Erlangen (B.K.), and Johannes Wesling Klinikum Minden and Ruhr University Bochum, Minden (P.D.S.) - all in Germany; Miller School of Medicine, University of Miami, Miami (R.L.S.); University of California at San Francisco, San Francisco (J.D.E.), and the Department of Neurology and Comprehensive Stroke Center, University of California at Los Angeles, Los Angeles (J.L.S.) - both in California; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.); Feinberg School of Medicine of Northwestern University, Chicago (R.A.B.); International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo (S.U.), and the National Cerebral and Cardiovascular Center, Osaka (K.T.) - both in Japan; Boehringer Ingelheim, Singapore, Singapore (J. Kreuzer); Boehringer Ingelheim, Burlington, ON, Canada (L.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (D.C.); City Clinical Emergency Care Hospital, Kursk (M.C.), and the Military Medical Academy, St. Petersburg (M.O.) - both in Russia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia (G.D.); Serviço de Neurologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal (J.M.F.); F. Ass. Mutua Terrassa, Terrassa (J. Krupinski), and Servicio de Neurología, Hospital Universitario Ramón y Cajal (IRYCIS), Departamento de Medicina, Universidad de Alcalá, Madrid (J.M.) - both in Spain; Hallym University Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, University Hospitals Leuven, Department of Neurology, Leuven, Belgium (R.L.); and Hospital Policlinico Umberto I, Sapienza University, Rome (D.T.)
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Seiffge DJ, Paciaroni M, Wilson D, Koga M, Macha K, Cappellari M, Schaedelin S, Shakeshaft C, Takagi M, Tsivgoulis G, Bonetti B, Kallmünzer B, Arihiro S, Alberti A, Polymeris AA, Ambler G, Yoshimura S, Venti M, Bonati LH, Muir KW, Yamagami H, Thilemann S, Altavilla R, Peters N, Inoue M, Bobinger T, Agnelli G, Brown MM, Sato S, Acciarresi M, Jager HR, Bovi P, Schwab S, Lyrer P, Caso V, Toyoda K, Werring DJ, Engelter ST, De Marchis GM. Direct oral anticoagulants versus vitamin K antagonists after recent ischemic stroke in patients with atrial fibrillation. Ann Neurol 2019; 85:823-834. [PMID: 30980560 PMCID: PMC6563449 DOI: 10.1002/ana.25489] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 02/04/2023]
Abstract
Objective We compared outcomes after treatment with direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) and a recent cerebral ischemia. Methods We conducted an individual patient data analysis of seven prospective cohort studies. We included patients with AF and a recent cerebral ischemia (<3 months before starting oral anticoagulation) and a minimum follow‐up of 3 months. We analyzed the association between type of anticoagulation (DOAC versus VKA) with the composite primary endpoint (recurrent ischemic stroke [AIS], intracerebral hemorrhage [ICH], or mortality) using mixed‐effects Cox proportional hazards regression models; we calculated adjusted hazard ratios (HRs) with 95% confidence intervals (95% CIs). Results We included 4,912 patients (median age, 78 years [interquartile range {IQR}, 71–84]; 2,331 [47.5%] women; median National Institute of Health Stroke Severity Scale at onset, 5 [IQR, 2–12]); 2,256 (45.9%) patients received VKAs and 2,656 (54.1%) DOACs. Median time from index event to starting oral anticoagulation was 5 days (IQR, 2–14) for VKAs and 5 days (IQR, 2–11) for DOACs (p = 0.53). There were 262 acute ischemic strokes (AISs; 4.4%/year), 71 intracranial hemorrrhages (ICHs; 1.2%/year), and 439 deaths (7.4%/year) during the total follow‐up of 5,970 patient‐years. Compared to VKAs, DOAC treatment was associated with reduced risks of the composite endpoint (HR, 0.82; 95% CI, 0.67–1.00; p = 0.05) and ICH (HR, 0.42; 95% CI, 0.24–0.71; p < 0.01); we found no differences for the risk of recurrent AIS (HR, 0.91; 95% CI, 0.70–1.19; p = 0.5) and mortality (HR, 0.83; 95% CI, 0.68–1.03; p = 0.09). Interpretation DOAC treatment commenced early after recent cerebral ischemia related to AF was associated with reduced risk of poor clinical outcomes compared to VKA, mainly attributed to lower risks of ICH. ANN NEUROL 2019;85:823–834.
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Affiliation(s)
- David J Seiffge
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom.,Neurology and Stroke Center, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Duncan Wilson
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kosmas Macha
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Manuel Cappellari
- Stroke Unit-Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Clare Shakeshaft
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Masahito Takagi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens School of Medicine, "Attikon" University Hospital, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Bruno Bonetti
- Stroke Unit-Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Shoji Arihiro
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Alexandros A Polymeris
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gareth Ambler
- Department of Statistical Science, UCL, London, United Kingdom
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michele Venti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Leo H Bonati
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Hiroshi Yamagami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sebastian Thilemann
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Riccardo Altavilla
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Nils Peters
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Basel, Switzerland
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tobias Bobinger
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Giancarlo Agnelli
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Martin M Brown
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Shoichiro Sato
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Monica Acciarresi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Hans Rolf Jager
- Neuroradiological Academic Unit, Department of Brain Repair & Rehabilitation, University College London, Institute of Neurology, London, United Kingdom
| | - Paolo Bovi
- Stroke Unit-Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Philippe Lyrer
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - David J Werring
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Stefan T Engelter
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
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van der Worp HB, Macleod MR, Bath PM, Bathula R, Christensen H, Colam B, Cordonnier C, Demotes-Mainard J, Durand-Zaleski I, Gluud C, Jakobsen JC, Kallmünzer B, Kollmar R, Krieger DW, Lees KR, Michalski D, Molina C, Montaner J, Roine RO, Petersson J, Perry R, Sprigg N, Staykov D, Szabo I, Vanhooren G, Wardlaw JM, Winkel P, Schwab S. Therapeutic hypothermia for acute ischaemic stroke. Results of a European multicentre, randomised, phase III clinical trial. Eur Stroke J 2019; 4:254-262. [PMID: 31984233 PMCID: PMC6960691 DOI: 10.1177/2396987319844690] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/27/2019] [Indexed: 01/24/2023] Open
Abstract
Introduction We assessed whether modest systemic cooling started within 6 hours of symptom
onset improves functional outcome at three months in awake patients with
acute ischaemic stroke. Patients and methods In this European randomised open-label clinical trial with blinded outcome
assessment, adult patients with acute ischaemic stroke were randomised to
cooling to a target body temperature of 34.0–35.0°C, started within 6 h
after stroke onset and maintained for 12 or 24 h , versus standard
treatment. The primary outcome was the score on the modified Rankin Scale at
91 days, as analysed with ordinal logistic regression. Results The trial was stopped after inclusion of 98 of the originally intended 1500
patients because of slow recruitment and cessation of funding. Forty-nine
patients were randomised to hypothermia versus 49 to standard treatment.
Four patients were lost to follow-up. Of patients randomised to hypothermia,
15 (31%) achieved the predefined cooling targets. The primary outcome did
not differ between the groups (odds ratio for good outcome, 1.01; 95%
confidence interval, 0.48–2.13; p = 0.97). The number of
patients with one or more serious adverse events did not differ between
groups (relative risk, 1.22; 95% confidence interval, 0.65–1.94;
p = 0.52). Discussion In this trial, cooling to a target of 34.0–35.0°C and maintaining this for 12
or 24 h was not feasible in the majority of patients. The final sample was
underpowered to detect clinically relevant differences in outcomes. Conclusion Before new trials are launched, the feasibility of cooling needs to be
improved.
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Affiliation(s)
- H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Malcolm R Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland, UK
| | - Philip Mw Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Raj Bathula
- Stroke Department, Northwick Park Hospital, London, UK
| | - Hanne Christensen
- Department of Neurology, Bispebjerg og Frederiksberg Hospitaler, University of Copenhagen, Copenhagen, Denmark
| | - Bridget Colam
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland, UK
| | - Charlotte Cordonnier
- University of Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, Centre Hospitalier Universitaire Lille, Lille, France
| | | | | | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Holbæk Hospital, Copenhagen, Denmark
| | - Bernd Kallmünzer
- Department of Neurology, University Medical Centre Erlangen, Erlangen, Germany
| | - Rainer Kollmar
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | | | - Kennedy R Lees
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | | | - Carlos Molina
- Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Risto O Roine
- Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Jesper Petersson
- Department of Neurology, Skane University Hospital, Malmö, Sweden
| | - Richard Perry
- Stroke Service, National Hospital for Neurology & Neurosurgery, Queen Square, London, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Dimitre Staykov
- Department of Neurology, University Medical Centre Erlangen, Erlangen, Germany.,Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria
| | - Istvan Szabo
- European Stroke Research Network for Hypothermia, Brussels, Belgium
| | | | - Joanna M Wardlaw
- Edinburgh Imaging, Centre for Clinical Brain Sciences and UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Per Winkel
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Stefan Schwab
- Department of Neurology, University Medical Centre Erlangen, Erlangen, Germany
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Macha K, Marsch A, Siedler G, Breuer L, Strasser EF, Engelhorn T, Schwab S, Kallmünzer B. Cerebral Ischemia in Patients on Direct Oral Anticoagulants. Stroke 2019; 50:873-879. [DOI: 10.1161/strokeaha.118.023877] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
In patients with ischemic stroke on therapy with vitamin K antagonists, stroke severity and clinical course are affected by the quality of anticoagulation at the time of stroke onset, but clinical data for patients using direct oral anticoagulants (DOACs) are limited.
Methods—
Data from our registry including all patients admitted with acute cerebral ischemia while taking oral anticoagulants for atrial fibrillation between November 2014 and October 2017 were investigated. The activity of vitamin K antagonists was assessed using the international normalized ratio on admission and categorized according to a threshold of 1.7. DOAC plasma levels were measured using the calibrated Xa-activity (apixaban, rivaroxaban, and edoxaban) or the Hemoclot-assay (dabigatran) and categorized into low (<50 ng/mL), intermediate (50–100 ng/mL), or high (>100 ng/mL). Primary objective was the association between anticoagulant activity and clinical and imaging characteristics.
Results—
Four hundred sixty patients were included (49% on vitamin K antagonists and 51% on DOAC). Patients on vitamin K antagonists with low international normalized ratio values had higher scores on the National Institutes of Health Stroke Scale and a higher risk of large vessel occlusion on admission. For patients on DOAC, plasma levels were available in 75.6% and found to be low in 49 (27.7%), intermediate in 41 (23.2%), and high in 87 patients (49.2%). Low plasma levels were associated with higher National Institutes of Health Stroke Scale scores on admission (low: 8 [interquartile range, 3–15] versus intermediate: 4 [1–11] versus high: 3 [0–8];
P
<0.001) and higher risk of persisting neurological deficits or cerebral infarction on imaging (85.7% versus 75.6% versus 54.0%;
P
<0.001). Low DOAC plasma levels were an independent predictor of large vessel occlusion (odds ratio, 3.84 [95% CI, 1.80–8.20];
P
=0.001).
Conclusions—
The activity of anticoagulation measured by specific DOAC plasma levels on admission is associated with stroke severity and presence of large vessel occlusion.
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Affiliation(s)
- Kosmas Macha
- From the Department of Neurology (K.M., A.M., G.S., L.B., S.S., B.K.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Germany
| | - Armin Marsch
- From the Department of Neurology (K.M., A.M., G.S., L.B., S.S., B.K.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Germany
| | - Gabriela Siedler
- From the Department of Neurology (K.M., A.M., G.S., L.B., S.S., B.K.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Germany
| | - Lorenz Breuer
- From the Department of Neurology (K.M., A.M., G.S., L.B., S.S., B.K.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Germany
| | - Erwin F. Strasser
- Transfusion and Haemostaseology Department (E.F.S.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Germany
| | - Tobias Engelhorn
- Department of Neuroradiology (T.E.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Germany
| | - Stefan Schwab
- From the Department of Neurology (K.M., A.M., G.S., L.B., S.S., B.K.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Germany
| | - Bernd Kallmünzer
- From the Department of Neurology (K.M., A.M., G.S., L.B., S.S., B.K.), University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Germany
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Seiffge DJ, De Marchis GM, Koga M, Paciaroni M, Cappellari M, Cappellari M, Kallmünzer B, Macha K, Wilson D, Engelter S, Werring DJ. Abstract WP519: Ischemic Stroke Despite Oral Anticoagulant Therapy in Patients With AF - What is the Risk of Recurrence and How to Prevent Further Events? Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
It is unknown whether patients with atrial fibrillation (AF) having an ischemic stroke despite preventive oral anticoagulant therapy are at increased risk for further recurrent strokes and how secondary prevention should be managed.
Methods:
We conducted a pooled individual patient data analysis of 7 prospective cohort studies recruiting patients with AF and an index event (ischemic stroke or TIA). We compared patients taking oral anticoagulants (Vitamin K antagonists [VKA] or direct oral anticoagulants [DOAC]) prior to index event (OAC
prior
) with those without prior anticoagulation (OAC
naive
). We further compared those who changed the type (i.e. from VKA or DOAC or vice versa) of anticoagulation (OAC
changed
) with those who continued the same anticoagulation as secondary prevention (OAC
unchanged
). Time-to-endpoint was analysed using multivariate cox proportional hazard regression models with frailty term for study and calculating hazard ratios (HR) with corresponding 95% confidence intervals.
Results:
We included 5413 patients (median age 78years [IQR 71-84years], 5136 [96.7%] had ischemic stroke as index event, median NIHSS-on-admission 6 [IQR 2-12]). The median CHA
2
DS
2
-Vasc score was 5 (IQR4-6) and not different (p=0.103) between
prior
OAC (n=1195) and OAC
naive
(n=4119). During follow-up of 6128 patient years, 289 patients had recurrent ischemic stroke (AIS, 4.7%/year, 95%CI 4.2-5.3%).
prior
OAC was independently associated with an increased risk of AIS (HR 1.6, 95%CI 1.1-2.1, p=0.006). OAC
changed
(n=307) was not associated with decreased risk of AIS (HR 1.3, 95%CI 0.8-2.2, p=0.326) compared to OAC
unchanged
(n=585).
Conclusion:
Patients with AF who failed oral anticoagulation once are at a higher risk for further ischemic strokes although the CHA
2
DS
2
-Vasc scores did not differ between both groups.
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Affiliation(s)
- David J Seiffge
- Stroke Cntr and Neurology, Univ Hosp Basel, Basel, Switzerland
| | | | - Masatoshi Koga
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Maurizio Paciaroni
- Stroke Unit and Div of Cardiovascular Medicine, Univ of Perugia, Perugia, Italy
| | - Manuel Cappellari
- Stroke Unit - Dept of Neuroscience,, Azienda Ospedaliera Universitaria Integrata, Verona, Verona, Italy
| | - Manuel Cappellari
- Stroke Unit - Dept of Neuroscience,, Azienda Ospedaliera Universitaria Integrata, Verona, Verona, Italy
| | - Bernd Kallmünzer
- Dept of Neurology, Univ of Erlangen-Nuremberg, Erlangen, Erlangen, Germany
| | - Kosmas Macha
- Dept of Neurology, Univ of Erlangen-Nuremberg, Erlangen, Erlangen, Germany
| | - Duncan Wilson
- Stroke Rsch Cntr, Univ College London, London, United Kingdom
| | - Stefan Engelter
- Stroke Cntr and Neurology, Univ Hosp Basel, Basel, Switzerland
| | - David J Werring
- Stroke Rsch Cntr, Univ College London, London, United Kingdom
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Abstract
The standard of care for patients with acute stroke of the anterior circulation and large vessel occlusion is the combined treatment with intravenous rt-PA (recombinant tissue-type plasminogen activator) and endovascular thrombectomy. The therapy is highly effective while reducing functional deficits and long-term disability. International guidelines recommend thrombectomy during the first 6 h after symptom onset, but new evidence supports its use in selected patients within a time window of up to 24 h. Eligible patients show a clinical core mismatch, i. e. severe neurologic deficits contrasting to a small core of cerebral infarction. Future research questions regard the treatment of vessel occlusion at the M2 segments as well as the best anesthetic management during the intervention. The infrastructure of stroke care especially in rural areas is based on the drip-and-ship paradigm that implies emergency treatment with the start of intravenous thrombolysis at the nearest hospital followed by transport to an interventional center in case of large vessel occlusion.
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Affiliation(s)
- B Kallmünzer
- Neurologische Klinik, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland.
| | - M Köhrmann
- Klinik für Neurologie, Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Deutschland
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43
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Bobinger T, Kallmünzer B, Kopp M, Kurka N, Arnold M, Heider S, Schwab S, Köhrmann M. Diagnostic value of prehospital ECG in acute stroke patients. Neurology 2017; 88:1894-1898. [DOI: 10.1212/wnl.0000000000003940] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 02/10/2017] [Indexed: 11/15/2022] Open
Abstract
Objective:To investigate the diagnostic yield of prehospital ECG monitoring provided by emergency medical services in the case of suspected stroke.Methods:Consecutive patients with acute stroke admitted to our tertiary stroke center via emergency medical services and with available prehospital ECG were prospectively included during a 12-month study period. We assessed prehospital ECG recordings and compared the results to regular 12-lead ECG on admission and after continuous ECG monitoring at the stroke unit.Results:Overall, 259 patients with prehospital ECG recording were included in the study (90.3% ischemic stroke, 9.7% intracerebral hemorrhage). Atrial fibrillation (AF) was detected in 25.1% of patients, second-degree or greater atrioventricular block in 5.4%, significant ST-segment elevation in 5.0%, and ventricular ectopy in 9.7%. In 18 patients, a diagnosis of new-onset AF with direct clinical consequences for the evaluation and secondary prevention of stroke was established by the prehospital recordings. In 2 patients, the AF episodes were limited to the prehospital period and were not detected by ECG on admission or during subsequent monitoring at the stroke unit. Of 126 patients (48.6%) with relevant abnormalities in the prehospital ECG, 16.7% received medical antiarrhythmic therapy during transport to the hospital, and 6.4% were transferred to a cardiology unit within the first 24 hours in the hospital.Conclusions:In a selected cohort of patients with stroke, the in-field recordings of the ECG detected a relevant rate of cardiac arrhythmia. The results can add to the in-hospital evaluation and should be considered in prehospital care of acute stroke.
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Kallmünzer B, Schwab S. Herzrhythmusstörungen nach Schlaganfall. Akt Neurol 2017. [DOI: 10.1055/s-0043-101374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Volbers B, Köhrmann M, Kallmünzer B, Kurka N, Breuer L, Ringwald J, Schwab S. Dabigatran Plasma Levels in Acute Cerebrovascular Events. J Stroke Cerebrovasc Dis 2016; 25:877-82. [PMID: 26809705 DOI: 10.1016/j.jstrokecerebrovasdis.2015.12.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/07/2015] [Accepted: 12/22/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Oral anticoagulation with dabigatran was shown to be effective for stroke prevention in patients with nonvalvular atrial fibrillation without the need for laboratory monitoring. However, a recent publication based on data of the Randomized Evaluation of Long-Term Anticoagulation Therapy study reported that ischemic stroke and bleeding outcomes are correlated with dabigatran plasma concentration (DPC). DPC was determined at a prespecified time point and correlated with cardiovascular events at any time during follow-up. Because of the known variability of DPC, among others depending on renal function, this approach might compromise data evaluation. We report on dabigatran plasma levels in acute cerebrovascular events. METHODS Consecutive patients with acute ischemic stroke (AIS) or intracerebral hemorrhage (ICH) while taking dabigatran were retrospectively identified if admission DPC was available. DPC was determined using the diluted thrombin time (Hemoclot (HYPHEN BioMed, Neuville sur Oise, France)). Creatinine clearance (CrCl) was determined by measuring creatinine in plasma and 24-hour urine. RESULTS Fifteen AIS and 4 ICH patients were included. Median DPC on admission was significantly higher in ICH patients than in AIS patients (135 ng/mL [interquartile range {IQR} 79-218] and 69.1 ng/mL [IQR 20.6-85.0], respectively; P = .035). Increased CrCl (values above published normal range) was correlated with lower median DPC (60 ng/mL [IQR 10-69] versus 100 ng/mL [IQR 79-157] in patients with normal CrCl, P = .01). CONCLUSIONS Higher DPC was found in ICH patients than in AIS patients in temporal proximity to the event. Both decreased and increased renal functions seem to have an important influence on DPC.
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Affiliation(s)
- Bastian Volbers
- Neurology Department, University of Erlangen-Nuremberg, Germany.
| | - Martin Köhrmann
- Neurology Department, University of Erlangen-Nuremberg, Germany
| | | | - Natalia Kurka
- Neurology Department, University of Erlangen-Nuremberg, Germany
| | - Lorenz Breuer
- Neurology Department, University of Erlangen-Nuremberg, Germany
| | - Jürgen Ringwald
- Hemostaseology Department, University of Erlangen-Nuremberg, Germany
| | - Stefan Schwab
- Neurology Department, University of Erlangen-Nuremberg, Germany
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Kallmünzer B, Bobinger T, Kopp M, Kurka N, Arnold M, Hilz MJ, Schwab S, Köhrmann M. Impact of Heart Rate Dynamics on Mortality in the Early Phase after Ischemic Stroke: A Prospective Observational Trial. J Stroke Cerebrovasc Dis 2015; 24:946-51. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 12/05/2014] [Indexed: 11/28/2022] Open
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Seifert F, Kallmünzer B, Gutjahr I, Breuer L, Winder K, Kaschka I, Kloska S, Doerfler A, Hilz MJ, Schwab S, Köhrmann M. Neuroanatomical correlates of severe cardiac arrhythmias in acute ischemic stroke. J Neurol 2015; 262:1182-90. [DOI: 10.1007/s00415-015-7684-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 02/14/2015] [Accepted: 02/16/2015] [Indexed: 12/19/2022]
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Kallmünzer B, Köhrmann M. Author response. Neurology 2015; 84:963. [PMID: 25905116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
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Bobinger T, Kallmünzer B, Kopp M, Kurka N, Arnold M, Hilz MJ, Huttner HB, Schwab S, Köhrmann M. Prevalence and impact on outcome of electrocardiographic early repolarization patterns among stroke patients: a prospective observational study. Clin Res Cardiol 2015; 104:666-71. [DOI: 10.1007/s00392-015-0831-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 02/18/2015] [Indexed: 11/24/2022]
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Waschbisch A, Kallmünzer B, Schwab S, Gölitz P, Vincent A, Lee DH, Linker RA. Demyelinating disease and anti-N-methyl-D-aspartate receptor immunoglobulin G antibodies: a case report. BMC Res Notes 2014; 7:948. [PMID: 25539977 PMCID: PMC4307172 DOI: 10.1186/1756-0500-7-948] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/11/2014] [Indexed: 02/07/2023] Open
Abstract
Background Anti–N-methyl-D-aspartate receptor immunoglobulin G antibodies directed against the GluN1 subunit are considered highly specific for anti-N-methyl-D-aspartate receptor encephalitis, a severe clinical syndrome characterized by seizures, psychiatric symptoms, orofacial dyskinesia and autonomic dysfunction. Case presentation Here we report a 33 year old Caucasian male patient with clinically definite multiple sclerosis who was found to be positive for anti-N-methyl-D-aspartate receptor antibodies. Rituximab therapy was initiated. On the 18 months follow-up visit the patient was found to be clinically stable, without typical signs of anti-N-methyl-D-aspartate receptor encephalitis. Conclusion Our findings add to the growing evidence for a possible association between anti-N-methyl-D-aspartate receptor encephalitis and demyelinating diseases.
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Affiliation(s)
- Anne Waschbisch
- Department of Neurology, Friedrich-Alexander University of Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany.
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