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Kleeberg A, Bauer G, Jung E, Purrucker JC. Inflammatory neuropathy with evidence of anti-GQ1b antibodies in angioimmunoblastic T cell lymphoma (AITL): a case report. J Neurol 2024; 271:2880-2885. [PMID: 38329539 PMCID: PMC11055795 DOI: 10.1007/s00415-024-12217-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 02/09/2024]
Affiliation(s)
- Antonia Kleeberg
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Gregor Bauer
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Erik Jung
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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2
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Geisler T, Keller T, Martus P, Poli K, Serna-Higuita LM, Schreieck J, Gawaz M, Tünnerhoff J, Bombach P, Nägele T, Klose U, Aidery P, Groga-Bada P, Kraft A, Hoffmann F, Hobohm C, Naupold K, Niehaus L, Wolf M, Bäzner H, Liman J, Wachter R, Kimmig H, Jung W, Huber R, Feurer R, Lindner A, Althaus K, Bode FJ, Petzold GC, Nguyen TN, Mac Grory B, Schrag M, Purrucker JC, Zuern CS, Ziemann U, Poli S. Apixaban versus Aspirin for Embolic Stroke of Undetermined Source. NEJM Evid 2024; 3:EVIDoa2300235. [PMID: 38320511 DOI: 10.1056/evidoa2300235] [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] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Apixaban versus Aspirin for Embolic StrokeIn a trial of 352 patients with embolic stroke of undetermined source, 5 mg of apixaban administered twice daily was compared with 100 mg of aspirin administered once daily for the prevention of recurrent ischemic strokes. At 12 months, 13.6% of patients given apixaban had new ischemic lesions on magnetic resonance imaging compared with 16.0% of patients given aspirin, and the rates of clinically relevant bleeding were also comparable.
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Affiliation(s)
- Tobias Geisler
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Timea Keller
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Lina Maria Serna-Higuita
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Juergen Schreieck
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Johannes Tünnerhoff
- Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Paula Bombach
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
- Department of Neurology and Interdisciplinary Neuro-Oncology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Thomas Nägele
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Uwe Klose
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Parwez Aidery
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Patrick Groga-Bada
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Andrea Kraft
- Department of Neurology, Krankenhaus Martha-Maria Halle-Doelau, Halle (Saale), Germany
| | - Frank Hoffmann
- Department of Neurology, Krankenhaus Martha-Maria Halle-Doelau, Halle (Saale), Germany
| | - Carsten Hobohm
- Department of Neurology, Carl-von-Basedow Klinikum Merseburg, Merseburg, Germany
| | - Katrin Naupold
- Department of Neurology, Carl-von-Basedow Klinikum Merseburg, Merseburg, Germany
| | - Ludwig Niehaus
- Department of Neurology, Rems-Murr Kliniken, Winnenden, Germany
| | - Marc Wolf
- Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany
| | - Jan Liman
- Department of Neurology, Klinikum Nürnberg, Nürnberg, Germany
- Clinic for Neurology, University Hospital Göttingen, Göttingen, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
- Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research, Göttingen, Germany
| | - Hubert Kimmig
- Department of Neurology, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Werner Jung
- Department of Cardiology, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Roman Huber
- Department of Neurology, Klinikum Friedrichshafen, Friedrichshafen, Germany
| | - Regina Feurer
- Department of Neurology, Klinikum Friedrichshafen, Friedrichshafen, Germany
| | - Alfred Lindner
- Department of Neurology, Marienhospital Stuttgart, Stuttgart, Germany
| | | | - Felix J Bode
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston
- Department of Neurology, Boston Medical Center, Boston
| | - Brian Mac Grory
- Duke Clinical Research Institute, Durham, NC
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | - Matthew Schrag
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, TN
| | - Jan C Purrucker
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christine S Zuern
- Department of Neurology, Klinikum Nürnberg, Nürnberg, Germany
- Department of Cardiology, Universitätsspital Basel, Basel, Switzerland
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
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3
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Poli S, Mbroh J, Baron JC, Singhal AB, Strbian D, Molina C, Lemmens R, Turc G, Mikulik R, Michel P, Tatlisumak T, Audebert HJ, Dichgans M, Veltkamp R, Hüsing J, Graessner H, Fiehler J, Montaner J, Adeyemi AK, Althaus K, Arenillas JF, Bender B, Benedikt F, Broocks G, Burghaus I, Cardona P, Deb-Chatterji M, Cviková M, Defreyne L, De Herdt V, Detante O, Ernemann U, Flottmann F, García Guillamón L, Glauch M, Gomez-Exposito A, Gory B, Sylvie Grand S, Haršány M, Hauser TK, Heck O, Hemelsoet D, Hennersdorf F, Hoppe J, Kalmbach P, Kellert L, Köhrmann M, Kowarik M, Lara-Rodríguez B, Legris L, Lindig T, Luntz S, Lusk J, Mac Grory B, Manger A, Martinez-Majander N, Mengel A, Meyne J, Müller S, Mundiyanapurath S, Naggara O, Nedeltchev K, Nguyen TN, Nilsson MA, Obadia M, Poli K, Purrucker JC, Räty S, Richard S, Richter H, Schilte C, Schlemm E, Stöhr L, Stolte B, Sykora M, Thomalla G, Tomppo L, van Horn N, Zeller J, Ziemann U, Zuern CS, Härtig F, Tuennerhoff J. Penumbral Rescue by normobaric O = O administration in patients with ischemic stroke and target mismatch proFile (PROOF): Study protocol of a phase IIb trial. Int J Stroke 2024; 19:120-126. [PMID: 37515459 PMCID: PMC10759237 DOI: 10.1177/17474930231185275] [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] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/12/2023] [Indexed: 07/30/2023]
Abstract
RATIONALE Oxygen is essential for cellular energy metabolism. Neurons are particularly vulnerable to hypoxia. Increasing oxygen supply shortly after stroke onset could preserve the ischemic penumbra until revascularization occurs. AIMS PROOF investigates the use of normobaric oxygen (NBO) therapy within 6 h of symptom onset/notice for brain-protective bridging until endovascular revascularization of acute intracranial anterior-circulation occlusion. METHODS AND DESIGN Randomized (1:1), standard treatment-controlled, open-label, blinded endpoint, multicenter adaptive phase IIb trial. STUDY OUTCOMES Primary outcome is ischemic core growth (mL) from baseline to 24 h (intention-to-treat analysis). Secondary efficacy outcomes include change in NIHSS from baseline to 24 h, mRS at 90 days, cognitive and emotional function, and quality of life. Safety outcomes include mortality, intracranial hemorrhage, and respiratory failure. Exploratory analyses of imaging and blood biomarkers will be conducted. SAMPLE SIZE Using an adaptive design with interim analysis at 80 patients per arm, up to 456 participants (228 per arm) would be needed for 80% power (one-sided alpha 0.05) to detect a mean reduction of ischemic core growth by 6.68 mL, assuming 21.4 mL standard deviation. DISCUSSION By enrolling endovascular thrombectomy candidates in an early time window, the trial replicates insights from preclinical studies in which NBO showed beneficial effects, namely early initiation of near 100% inspired oxygen during short temporary ischemia. Primary outcome assessment at 24 h on follow-up imaging reduces variability due to withdrawal of care and early clinical confounders such as delayed extubation and aspiration pneumonia. TRIAL REGISTRATIONS ClinicalTrials.gov: NCT03500939; EudraCT: 2017-001355-31.
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Affiliation(s)
- Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | - Joshua Mbroh
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Jean-Claude Baron
- Department of Neurology, Hopital Sainte-Anne, Universite de Paris, Paris, France
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Carlos Molina
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven, University of Leuven, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Guillaume Turc
- Department of Neurology, Hopital Sainte-Anne, Universite de Paris, Paris, France
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences INSERM U1266 Universite Paris Cite FHU NeuroVasc, Paris, France
| | - Robert Mikulik
- Department of Neurology, St. Anne’s University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Patrik Michel
- Neurosciences Cliniques, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Heinrich J Audebert
- Department of Neurology and Center for Stroke Research Berlin, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE, Munich), Munich, Germany
- German Centre for Cardiovascular Research (DZHK, Munich), Munich, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, UK
| | - Johannes Hüsing
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
- Landeskrebsregister Nordrhein-Westfalen, Bochum, Germany
| | - Holm Graessner
- Center for Rare Diseases, Eberhard-Karls University, Tubingen, Germany
| | - Jens Fiehler
- Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Eppdata GmbH, Hamburg, Germany
| | - Joan Montaner
- Vall d’Hebron Institut de Recerca, Neurovascular Research Lab, Barcelona, Spain
| | | | | | | | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Frank Benedikt
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ina Burghaus
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
| | - Pere Cardona
- Department of Neurology, Hospital University de Bellvitge, Barcelona, Spain
| | - Milani Deb-Chatterji
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Cviková
- Department of Neurology, St. Anne’s University Hospital in Brno, Faculty of Medicine Masaryk University, Brno, Czech Republic
| | - Luc Defreyne
- Department of Vascular and Interventional Radiology, Ghent University Hospital, Ghent, Belgium
| | - Veerle De Herdt
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Olivier Detante
- Neurology, CHU Grenoble Alpes, Grenoble, France
- Inserm, U1216, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Ulrike Ernemann
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Monika Glauch
- Center for Rare Diseases, Eberhard-Karls University, Tubingen, Germany
| | - Alexandra Gomez-Exposito
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospital Regional Universitaire de Nancy, Universite de Lorraine, INSERM U1254, Nancy, France
| | - Sylvie Sylvie Grand
- Inserm, U1216, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
- Neuroradiology / MRI Department, CHU Grenoble Alpes, Grenoble, France
| | - Michal Haršány
- Department of Neurology, St. Anne’s University Hospital in Brno, Faculty of Medicine Masaryk University, Brno, Czech Republic
- International Clinical Research Centre, St. Anne’s University Hospital in Brno, Brno, Czech Republic
| | - Till Karsten Hauser
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Olivier Heck
- Neuroradiology / MRI Department, CHU Grenoble Alpes, Grenoble, France
| | | | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Julia Hoppe
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pia Kalmbach
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University (LMU), Munich, Germany
| | - Martin Köhrmann
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Markus Kowarik
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | | | - Loic Legris
- Neurology, CHU Grenoble Alpes, Grenoble, France
- Inserm, U1216, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Tobias Lindig
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Steffen Luntz
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
| | - Jay Lusk
- Duke University School of Medicine, Durham, NC, USA
| | - Brian Mac Grory
- Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Andreas Manger
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tubingen, Germany
| | | | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Johannes Meyne
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Susanne Müller
- Department of Neurology, University Hospital of Ulm, Ulm, Germany
| | | | - Olivier Naggara
- Department of Neuroradiology, GHU Paris Psychiatrie et Neurosciences INSERM U1266 Universite Paris Cite FHU NeuroVasc, Paris, France
| | - Krassen Nedeltchev
- Department of Neurology, KSA Kantonsspital Aarau and University of Bern, Bern, Switzerland
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Maike A Nilsson
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
| | - Michael Obadia
- Department of Neurology and Stroke Center, Hopital fondation Adolphe de Rothschild, Paris, France
| | - Khouloud Poli
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Hardy Richter
- Department of Infectiology, Eberhard-Karls-University, Tuebingen, Germany
| | - Clotilde Schilte
- Department of Anaesthesia and Critical Care, CHU Grenoble Alpes, Grenoble, France
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Stöhr
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
| | - Benjamin Stolte
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Marek Sykora
- Department of Neurology, St. John’s Hospital, Vienna, Austria
| | - Götz Thomalla
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Liisa Tomppo
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Noel van Horn
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Zeller
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | - Christine S Zuern
- Department of Cardiology, Universitatsspital Basel, Basel, Switzerland
| | - Florian Härtig
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tubingen, Germany
| | - Johannes Tuennerhoff
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
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Purrucker JC, Röcken C, Reuss D. Iatrogenic cerebral amyloid angiopathy rather than sporadic CAA in younger adults with lobar intracerebral haemorrhage. Amyloid 2023; 30:434-436. [PMID: 37184951 DOI: 10.1080/13506129.2023.2212394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/04/2023] [Indexed: 05/16/2023]
Affiliation(s)
- J C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - C Röcken
- Department of Pathology, Christian-Albrechts-University, Kiel, Germany
| | - D Reuss
- Department of Neuropathology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
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Hölle T, Purrucker JC, Morath B, Weigand MA, Schmitt FCF. [Central anticholinergic, neuroleptic malignant and serotonin syndromes]. Wien Klin Mag 2023; 26:124-132. [PMID: 37251531 PMCID: PMC10123475 DOI: 10.1007/s00740-023-00492-1] [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] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Impaired consciousness is a frequent phenomenon after general anesthesia. In addition to the classical causes (e.g., overhang of sedatives), an impairment of consciousness can also be an adverse side effect of drugs. Many drugs used in anesthesia can trigger these symptoms. Alkaloids, such as atropine can trigger a central anticholinergic syndrome, opioids can promote the occurrence of serotonin syndrome and the administration of a neuroleptic can lead to neuroleptic malignant syndrome. These three syndromes are difficult to diagnose due to the individually very heterogeneous symptoms. Mutual symptoms, such as impaired consciousness, tachycardia, hypertension and fever further complicate the differentiation between the syndromes; however, more individual symptoms, such as sweating, muscle tension or bowl sounds can be helpful in distinguishing these syndromes. The time from the trigger event can also help to differentiate the syndromes. The central anticholinergic syndrome is the fastest to appear, usually taking just a few of hours from trigger to clinical signs, serotonin syndrome takes several hours up to 1 day to show and neuroleptic malignant syndrome usually takes days. The clinical symptoms can range from mild to life-threatening. Generally, mild cases are treated with discontinuation of the trigger and extended observation. More severe cases can require specific antidotes. The specific treatment recommended for central anticholinergic syndrome is physostigmine with an initial dose of 2 mg (0.04 mg/kg body weight, BW) administered over 5 min. For serotonin syndrome an initial dose of 12 mg cyproheptadine followed by 2 mg every 2 h is recommended (maximum 32 mg/day or 0.5 mg/kgBW day-1) but this medication is only available in Germany as an oral formulation. For neuroleptic malignant syndrome 25-120 mg dantrolene (1-2.5 mg/kgBW maximum 10 mg/kgBW day-1) is the recommended treatment.
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Affiliation(s)
- Tobias Hölle
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Jan C. Purrucker
- Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Benedict Morath
- Krankenhausapotheke, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Markus A. Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Felix C. F. Schmitt
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
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6
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Meinel TR, Wilson D, Gensicke H, Scheitz JF, Ringleb P, Goganau I, Kaesmacher J, Bae HJ, Kim DY, Kermer P, Suzuki K, Kimura K, Macha K, Koga M, Wada S, Altersberger V, Salerno A, Palanikumar L, Zini A, Forlivesi S, Kellert L, Wischmann J, Kristoffersen ES, Beharry J, Barber PA, Hong JB, Cereda C, Schlemm E, Yakushiji Y, Poli S, Leker R, Romoli M, Zedde M, Curtze S, Ikenberg B, Uphaus T, Giannandrea D, Portela PC, Veltkamp R, Ranta A, Arnold M, Fischer U, Cha JK, Wu TY, Purrucker JC, Seiffge DJ. Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants. JAMA Neurol 2023; 80:233-243. [PMID: 36807495 PMCID: PMC9857462 DOI: 10.1001/jamaneurol.2022.4782] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/21/2022] [Indexed: 02/07/2023]
Abstract
Importance International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC). Objective To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion. Design, Setting, and Participants This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021. Exposures Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation. Main Outcomes and Measures The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses. Results Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion. Conclusions and Relevance In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.
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Affiliation(s)
- Thomas R. Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Henrik Gensicke
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Jan F. Scheitz
- Department of Neurology, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research Partner Site Berlin, Germany
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ioana Goganau
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Do Yeon Kim
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Pawel Kermer
- Department of Neurology, Friesland Kliniken, Sande, Germany
- Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kosmas Macha
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Wada
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Valerian Altersberger
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Andrea Zini
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Stefano Forlivesi
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Espen S. Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, Institute of Health and Society (HELSAM), University of Oslo, Oslo, Norway
| | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - P. Alan Barber
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Jae Beom Hong
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Carlo Cereda
- Stroke Center and Department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Yusuke Yakushiji
- Department of Neurology Kansai Medical University, Hirakata, Japan
| | - Sven Poli
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ronen Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Benno Ikenberg
- Department of Neurology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - David Giannandrea
- Division of Neurology and Stroke Unit, Department of Neurology, Gubbio and Città di Castello Hospital, Perugia, Italy
| | - Pere Cardona Portela
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Klinik für Neurologie, Alfried Krupp Krankenhaus, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Capital and Coast District Health Board, Wellington, New Zealand
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J. Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Hölle T, Purrucker JC, Morath B, Weigand MA, Schmitt FCF. [Central anticholinergic, neuroleptic malignant and serotonin syndromes : Important differential diagnoses in postoperative impairment of consciousness]. Anaesthesiologie 2023; 72:157-165. [PMID: 36799968 PMCID: PMC9936123 DOI: 10.1007/s00101-023-01256-6] [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] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 02/18/2023]
Abstract
Impaired consciousness is a frequent phenomenon after general anesthesia. In addition to the classical causes (e.g., overhang of sedatives), an impairment of consciousness can also be an adverse side effect of drugs. Many drugs used in anesthesia can trigger these symptoms. Alkaloids, such as atropine can trigger a central anticholinergic syndrome, opioids can promote the occurrence of serotonin syndrome and the administration of a neuroleptic can lead to neuroleptic malignant syndrome. These three syndromes are difficult to diagnose due to the individually very heterogeneous symptoms. Mutual symptoms, such as impaired consciousness, tachycardia, hypertension and fever further complicate the differentiation between the syndromes; however, more individual symptoms, such as sweating, muscle tension or bowl sounds can be helpful in distinguishing these syndromes. The time from the trigger event can also help to differentiate the syndromes. The central anticholinergic syndrome is the fastest to appear, usually taking just a few of hours from trigger to clinical signs, serotonin syndrome takes several hours up to 1 day to show and neuroleptic malignant syndrome usually takes days. The clinical symptoms can range from mild to life-threatening. Generally, mild cases are treated with discontinuation of the trigger and extended observation. More severe cases can require specific antidotes. The specific treatment recommended for central anticholinergic syndrome is physostigmine with an initial dose of 2 mg (0.04 mg/kg body weight, BW) administered over 5 min. For serotonin syndrome an initial dose of 12 mg cyproheptadine followed by 2 mg every 2 h is recommended (maximum 32 mg/day or 0.5 mg/kgBW day-1) but this medication is only available in Germany as an oral formulation. For neuroleptic malignant syndrome 25-120 mg dantrolene (1-2.5 mg/kgBW maximum 10 mg/kgBW day-1) is the recommended treatment.
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Affiliation(s)
- Tobias Hölle
- grid.5253.10000 0001 0328 4908Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Jan C. Purrucker
- grid.5253.10000 0001 0328 4908Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Benedict Morath
- grid.5253.10000 0001 0328 4908Krankenhausapotheke, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Markus A. Weigand
- grid.5253.10000 0001 0328 4908Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Felix C. F. Schmitt
- grid.5253.10000 0001 0328 4908Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
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8
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Hohenstatt S, Ulfert C, Herweh C, Schönenberger S, Purrucker JC, Bendszus M, Möhlenbruch MA, Vollherbst DF. Acute Intraprocedural Thrombosis After Flow Diverter Stent Implantation: Risk Factors and Relevance of Standard Observation Time for Early Detection and Management. Clin Neuroradiol 2022; 33:343-351. [PMID: 36068407 DOI: 10.1007/s00062-022-01214-6] [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: 06/09/2022] [Accepted: 08/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Acute intraprocedural thrombosis (AIT) is a severe complication of flow diverter stent (FDS) implantation for the treatment of intracranial aneurysms. Even though device-related thromboembolic complications are well known, there are no acknowledged risk factors nor defined surveillance protocols for their early detection. This study aimed to demonstrate that an angiographic active surveillance is effective to detect and treat AIT. Furthermore, we investigated risk factors for the occurrence of AIT. METHODS A prospective institutional protocol consisting of a defined observation period of 30 min following FDS deployment was established to detect AIT. Overall incidence, as well as the efficacy and safety of AIT treatment were assessed. Moreover, radiological and clinical outcomes of patients with AIT were analyzed. The influence of various patient- and procedure-related factors on the occurrence of AIT was investigated using multivariable forward logistic regression. RESULTS During active surveillance twelve cases of AIT were observed among a total of 161 procedures (incidence: 7.5%). The median time of first observation was 15.5 min (IQR 9.5) after FDS implantation. The early recognition of AIT ensured a prompt treatment with intravenous application of a glycoprotein IIb/IIIa inhibitor, which led to complete thrombus resolution in all cases without hemorrhagic complications. Patients with pre-existing arterial hypertension and side branches originating from the aneurysmal sac had a higher risk of AIT (respectively OR, 9.844; OR, 3.553). There were two cases of re-thrombosis in the short-term postoperative period, of whom one died. The remaining patients with AIT had a good clinical outcome. CONCLUSION Active surveillance for 30 min after FDS implantation is an effective strategy for early detection and ensuing treatment of AIT and can thus prevent secondary sequalae. Hypertension and side branches originating from the aneurysmal sac may increase the risk of AIT.
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Affiliation(s)
- Sophia Hohenstatt
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Christian Ulfert
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany.
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9
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Kuramatsu JB, Gerner ST, Ziai W, Bardutzky J, Sembill JA, Sprügel MI, Mrochen A, Kölbl K, Ram M, Avadhani R, Falcone GJ, Selim MH, Lioutas VA, Endres M, Zweynert S, Vajkoczy P, Ringleb PA, Purrucker JC, Volkmann J, Neugebauer H, Erbguth F, Schellinger PD, Knappe UJ, Fink GR, Dohmen C, Minnerup J, Reichmann H, Schneider H, Röther J, Reimann G, Schwarz M, Bäzner H, Claßen J, Michalski D, Witte OW, Günther A, Hamann GF, Lücking H, Dörfler A, Ishfaq MF, Chang JJ, Testai FD, Woo D, Alexandrov AV, Staykov D, Goyal N, Tsivgoulis G, Sheth KN, Awad IA, Schwab S, Hanley DF, Huttner HB. Association of Intraventricular Fibrinolysis With Clinical Outcomes in Intracerebral Hemorrhage: An Individual Participant Data Meta-Analysis. Stroke 2022; 53:2876-2886. [PMID: 35521958 PMCID: PMC9398945 DOI: 10.1161/strokeaha.121.038455] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with intracerebral hemorrhage (ICH), the presence of intraventricular hemorrhage constitutes a promising therapeutic target. Intraventricular fibrinolysis (IVF) reduces mortality, yet impact on functional disability remains unclear. Thus, we aimed to determine the influence of IVF on functional outcomes. METHODS This individual participant data meta-analysis pooled 1501 patients from 2 randomized trials and 7 observational studies enrolled during 2004 to 2015. We compared IVF versus standard of care (including placebo) in patients treated with external ventricular drainage due to acute hydrocephalus caused by ICH with intraventricular hemorrhage. The primary outcome was functional disability evaluated by the modified Rankin Scale (mRS; range: 0-6, lower scores indicating less disability) at 6 months, dichotomized into mRS score: 0 to 3 versus mRS: 4 to 6. Secondary outcomes included ordinal-shift analysis, all-cause mortality, and intracranial adverse events. Confounding and bias were adjusted by random effects and doubly robust models to calculate odds ratios and absolute treatment effects (ATE). RESULTS Comparing treatment of 596 with IVF to 905 with standard of care resulted in an ATE to achieve the primary outcome of 9.3% (95% CI, 4.4-14.1). IVF treatment showed a significant shift towards improved outcome across the entire range of mRS estimates, common odds ratio, 1.75 (95% CI, 1.39-2.17), reduced mortality, odds ratio, 0.47 (95% CI, 0.35-0.64), without increased adverse events, absolute difference, 1.0% (95% CI, -2.7 to 4.8). Exploratory analyses provided that early IVF treatment (≤48 hours) after symptom onset was associated with an ATE, 15.2% (95% CI, 8.6-21.8) to achieve the primary outcome. CONCLUSIONS As compared to standard of care, the administration of IVF in patients with acute hydrocephalus caused by intracerebral and intraventricular hemorrhage was significantly associated with improved functional outcome at 6 months. The treatment effect was linked to an early time window <48 hours, specifying a target population for future trials.
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Affiliation(s)
| | - Stefan T. Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Johns Hopkins University, USA
| | | | | | | | - Anne Mrochen
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Kathrin Kölbl
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Malathi Ram
- Division of Brain Injury Outcomes, Johns Hopkins University, USA
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University, USA
| | - Guido J. Falcone
- Department of Neurology, Yale University School of Medicine, USA
- Department of Neurosurgery, Yale University School of Medicine, USA
| | - Magdy H. Selim
- Beth Israel Deaconess Medical Center, Harvard Medical School, USA
| | | | - Matthias Endres
- Department of Neurology, Charité–Universitätsmedizin Berlin, Germany
- Center for Stroke Research Berlin, Germany
- German Centre for Cardiovascular Research(DZHK), Germany
- German Center for Neurodegenerative Diseases(DZNE), Germany
| | - Sarah Zweynert
- Department of Neurology, Charité–Universitätsmedizin Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité–Universitätsmedizin Berlin, Germany
| | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Germany
| | - Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Germany
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Germany
| | - Hermann Neugebauer
- Department of Neurology, University of Würzburg, Germany
- Department of Neurology, University of Ulm, Germany
| | - Frank Erbguth
- Department of Neurology, Nuremberg General Hospital, Germany
| | - Peter D. Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, Germany
| | - Ulrich J. Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, Germany
| | | | - Christian Dohmen
- Department of Neurology, University of Cologne, Germany
- Department of Neurology, LVR-Hospital Bonn, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Germany
| | | | - Hauke Schneider
- Department of Neurology, University of Dresden, Germany
- Department of Neurology, Klinikum Augsburg, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinikum Hamburg Altona, Germany
| | | | | | | | - Joseph Claßen
- Department of Neurology, University of Leipzig, Germany
| | | | - Otto W. Witte
- Department of Neurology, University of Jena, Germany
| | | | - Gerhard F. Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen-Nuremberg, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Germany
| | | | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, USA
| | - Fernando D. Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, USA
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, USA
| | | | - Dimitre Staykov
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, USA
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, USA
- Second Department of Neurology, Attikon University Hospital, School of Medicine, Greece
| | - Kevin N Sheth
- Department of Neurosurgery, Yale University School of Medicine, USA
| | - Issam A. Awad
- Department of Neurosurgery, University of Chicago, USA
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, USA
| | - Hagen B. Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Germany
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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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Purrucker JC, Ringleb PA, Seker F, Potreck A, Nagel S, Schönenberger S, Berberich A, Neuberger U, Möhlenbruch M, Weyland C. Leaving the day behind: endovascular therapy beyond 24 h in acute stroke of the anterior and posterior circulation. Ther Adv Neurol Disord 2022; 15:17562864221101083. [PMID: 35646160 PMCID: PMC9136439 DOI: 10.1177/17562864221101083] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 03/11/2022] [Accepted: 04/28/2022] [Indexed: 11/15/2022] Open
Abstract
Background: There is little evidence of endovascular therapy (EVT) being performed in acute ischemic stroke beyond 24 h, and that evidence is limited to anterior circulation stroke. Objective: To extend evidence of efficacy and safety of EVT after more than 24 h in both anterior and posterior circulation stroke. Methods: Local, prospectively collected registries were screened for patients with acute ischemic stroke and large-vessel occlusion who had received either EVT > 24 h after last-seen-well but <24 h after symptom recognition (EVT>24LSW) or EVT > 24 h since first (definitive) symptom recognition (EVT>24DEF). Patients treated <24 h served as a group for comparison. Favorable outcome was defined as modified Rankin scale (mRS) 0–2 or return to prestroke mRS at 3 months. Results: Between January 2014 and August 2021, N = 2347 were treated with EVT at our comprehensive stroke center, of whom n = 43 met the inclusion criteria (EVT>24LSW, n = 16, EVT>24DEF, n = 27). EVT>24LSW patients were treated at a median of 28.7 h [interquartile range (IQR) = 27.3–32.8] after last-seen-well and 7.3 h (IQR = 2.8–14.3) after symptom recognition; EVT>24DEF patients were treated 52.5 h (IQR = 26.5–94.2) after first symptoms. Favorable outcome was achieved by 23.3% (10/43) in the EVT > 24 compared with 39.4% (886/2250) in the EVT < 24 group (p = 0.04). Bleeding rates were similar across groups. Mortality was also similar [EVT > 24, 27.9% (12/43) versus EVT < 24, 25.7% (584/2264), p = 0.727; posterior circulation, EVT > 24, 41.7% (5/12) versus EVT < 24, 36.5% (92/252) p = 0.764]. Conclusion: In selected patients, EVT seems effective and safe beyond 24 h for both anterior and posterior circulation stroke.
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Affiliation(s)
- Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arne Potreck
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Anne Berberich
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Charlotte Weyland
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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12
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Seiffge DJ, Poli S, Meinel TR, Wu T, Wilson D, Purrucker JC. Intravenous thrombolysis in patients taking direct oral anticoagulants (ESO IVT guidelines comment). Eur Stroke J 2022; 6:445-446. [PMID: 35342810 DOI: 10.1177/23969873211050848] [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: 11/16/2022] Open
Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital Bernand University of Bern, Switzerland
| | - Sven Poli
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Thomas R Meinel
- Department of Neurology, Inselspital University Hospital Bernand University of Bern, Switzerland
| | - Teddy Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Germany
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13
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Ungerer MN, Hund E, Purrucker JC, Huber L, Kimmich C, Aus dem Siepen F, Hein S, Kristen AV, Hinderhofer K, Kollmer J, Schönland S, Hegenbart U, Weiler M. Real-world outcomes in non-endemic hereditary transthyretin amyloidosis with polyneuropathy: a 20-year German single-referral centre experience. Amyloid 2021; 28:91-99. [PMID: 33283548 DOI: 10.1080/13506129.2020.1855134] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hereditary transthyretin amyloidosis is caused by pathogenic variants in the TTR gene and typically manifests, alongside cardiac and other organ dysfunctions, with a rapidly progressive sensorimotor and autonomic polyneuropathy (ATTRv-PN) leading to severe disability. While most prospective studies have focussed on endemic ATTRv-PN, real-world data on non-endemic, mostly late-onset ATTRv-PN are limited. METHODS This retrospective study investigated ATTRv-PN patients treated at the Amyloidosis Centre of Heidelberg University Hospital between November 1999 and July 2020. Clinical symptoms, survival, prognostic factors and efficacy of treatment with tafamidis were analysed. Neurologic outcome was assessed using the Coutinho ATTRv-PN stages, and the Peripheral Neuropathy Disability (PND) score. RESULTS Of 346 subjects with genetic TTR variants, 168 patients had symptomatic ATTRv-PN with 32 different TTR variants identified. Of these, 81.6% had the late-onset type of ATTRv-PN. Within a mean follow-up period of 4.1 ± 2.8 years, 40.5% of patients died. Baseline plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP) ≥900 ng/l (HR 3.259 [1.421-7.476]; p = .005) was the main predictor of mortality in multivariable analysis. 64 patients were treated with tafamidis and presented for regular follow-up examinations. The therapeutic benefit of tafamidis was more pronounced when treatment was started early in ATTRv-PN stage 1 (PND scores II vs. I; HR 2.718 [1.258-5.873]; p = .011). CONCLUSIONS In non-endemic, mostly late-onset ATTRv-PN, cardiac involvement assessed by NT-proBNP is a strong prognosticator for overall survival. Long-term treatment with tafamidis is safe and efficacious. Neurologic disease severity at the start of treatment is the main predictor for ATTRv-PN progression on tafamidis.
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Affiliation(s)
- Matthias N Ungerer
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ernst Hund
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan C Purrucker
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Laura Huber
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Kimmich
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Fabian Aus dem Siepen
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Medicine III, Heidelberg University Hospital, Heidelberg, Germany
| | - Selina Hein
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Medicine III, Heidelberg University Hospital, Heidelberg, Germany
| | - Arnt V Kristen
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Medicine III, Heidelberg University Hospital, Heidelberg, Germany
| | - Katrin Hinderhofer
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Institute of Human Genetics, Heidelberg University Hospital, Heidelberg, Germany
| | - Jennifer Kollmer
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Schönland
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Ute Hegenbart
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Weiler
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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14
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Abstract
Bereits früh nach Beginn der COVID‑19(„coronavirus disease 2019“)-Pandemie wurden Schlaganfälle als Manifestation oder Komplikation einer SARS-CoV-2(„severe acute respiratory syndrome coronavirus 2“)-Infektion beschrieben. Aktuelle Metaanalysen berichten eine Schlaganfallrate von etwa 1,5 %. Schlaganfälle bei COVID‑19-Patienten treten zwar häufiger bei schweren Verläufen der Infektion und bei älteren Patienten mit kardiovaskulären Risiken auf. Nicht selten sind aber auch junge Patienten ohne Risikofaktoren betroffen. Die Schlaganfallmechanismen sind vorwiegend embolisch, die Thromben verschließen häufig große intrakranielle Gefäße und betreffen in mehr als 20 % mehrere Gefäßterritorien, während mikroangiopathische Infarkte selten sind. Die genaue Emboliequelle bleibt bei über 40 % der Betroffenen kryptogen. Die durch das Zusammentreffen einer SARS-CoV-2-Infektion und eines Schlaganfalls bedingte Mortalität beträgt mehr als 15–30 %. Während es in manchen europäischen Regionen zu erheblichen Einschränkungen der Akutversorgung von Schlaganfällen gekommen ist, sind die Behandlungsraten für die Rekanalisationstherapie in Deutschland während der 1. Pandemiewelle weitgehend stabil geblieben. Es stellten sich aber 20–30 % weniger Patienten mit v. a. leichteren Schlaganfällen und transitorischen ischämischen Attacken in Krankenhäusern vor. Die vorliegende Übersichtsarbeit fasst die aktuellen Erkenntnisse zur Epidemiologie und Pathogenese COVID‑19-assoziierter Schlaganfälle zusammen und beschreibt die bisherigen Auswirkungen der Pandemie auf die Schlaganfallakutversorgung.
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Affiliation(s)
- Roland Veltkamp
- Neurologische Klinik, Alfried Krupp Krankenhaus Essen, Alfried Krupp Str. 21, 45131, Essen, Deutschland. .,Department of Brain Sciences, Imperial College London, London, Großbritannien. .,Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - Jan C Purrucker
- Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Ralph Weber
- Neurologische Klinik, Alfried Krupp Krankenhaus Essen, Alfried Krupp Str. 21, 45131, Essen, Deutschland
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15
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Kühne Escolà J, Nagel S, Verez Sola C, Doroszewski E, Jaschonek H, Gutschalk A, Gumbinger C, Purrucker JC. Diagnostic Accuracy in Teleneurological Stroke Consultations. J Clin Med 2021; 10:jcm10061170. [PMID: 33799590 PMCID: PMC7998723 DOI: 10.3390/jcm10061170] [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: 02/10/2021] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The accuracy of diagnosing acute cerebrovascular disease via a teleneurology service and the characteristics of misdiagnosed patients are insufficiently known. Methods: A random sample (n = 1500) of all teleneurological consultations conducted between July 2015 and December 2017 was screened. Teleneurological diagnosis and hospital discharge diagnosis were compared. Diagnoses were then grouped into two main categories: cerebrovascular disease (CVD) and noncerebrovascular disease. Test characteristics were calculated. Results: Out of 1078 consultations, 52% (n = 561) had a final diagnosis of CVD. Patients with CVD could be accurately identified via teleneurological consultation (sensitivity 95.2%, 95% CI 93.2–96.8), but we observed a tendency towards false-positive diagnosis (specificity 77.4%, 95% CI 73.6–80.8). Characteristics of patients with a false-negative CVD diagnosis were similar to those of patients with a true-positive diagnosis, but patients with a false-negative CVD diagnosis had ischemic heart disease less frequently. In retrospect, one patient would have been considered a candidate for intravenous thrombolysis (0.2%). Conclusions: Teleneurological consultations are accurate for identifying patients with CVD, and there is a very low rate of missed candidates for thrombolysis. Apart from a lower prevalence of ischemic heart disease, characteristics of “stroke chameleons” were similar to those of correctly identified CVD patients.
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16
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Ippen FM, Walter F, Hametner C, Gumbinger C, Nagel S, Purrucker JC, Mundiyanapurath S. Age-Dependent Differences in the Rate and Symptoms of TIA Mimics in Patients Presenting With a Suspected TIA to a Neurological Emergency Room. Front Neurol 2021; 12:644223. [PMID: 33658979 PMCID: PMC7917180 DOI: 10.3389/fneur.2021.644223] [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: 12/20/2020] [Accepted: 01/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Transient ischemic attack (TIA) needs further diagnostic evaluation to prevent future ischemic stroke. However, prophylaxis can be harmful in elderly if the diagnosis is wrong. We aimed at characterizing differences in TIA mimics in younger and older patients to enhance diagnostic accuracy in elderly patients. Methods: In a dedicated neurological emergency room (nER) of a tertiary care University hospital, patients with transient neurological symptoms suspicious of TIA (<24 h) were retrospectively analyzed regarding their final diagnoses and their symptoms. These parameters were compared between patients aged 18-70 and >70 years using descriptive, univariable, and multivariable statistics. Results: From November 2018 until August 2019, 386 consecutive patients were included. 271 (70%) had cardiovascular risk factors and all patients received cerebral imaging, mostly CT [376 (97%)]. There was no difference in the rate of diagnosed TIA between the age groups [85 (46%) vs. 58 (39%); p = 0.213].TIA mimics in the elderly were more often internal medicine diseases [35 (19%) vs. 7 (5%); p < 0.001] and epileptic seizures [48 (26%) vs. 24 (16%); p = 0.032] but less often migraine [2 (1%) vs. 20 (13%); p < 0.001]. The most frequent symptoms in all patients were aphasia and dysarthria [107 (28%) and 92 (24%)]. Sensory impairments were less frequent in elderly patients [23 (11%) vs. 54 (30%); p < 0.001]. Impaired consciousness and orientation were independent predictors for TIA mimics (p < 0.001) whereas facial palsy (p < 0.001) motor weakness (p < 0.001), dysarthria (p = 0.022) and sensory impairment (p < 0.001) were independent predictors of TIA. Conclusion: TIA mimics in elderly patients are more likely to be internal medicine diseases and epilepsy compared to younger patients. Excluding internal medicine diseases seems to be important in elderly patients. Facial palsy, motor weakness, dysarthria and sensory impairment are associated with TIA.
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Affiliation(s)
| | - Fabian Walter
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Gumbinger
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan C Purrucker
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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17
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Millán M, Nagel S, Gumbinger C, Busetto L, Purrucker JC, Hametner C, Ringleb PA, Mundiyanapurath S. Differential effects of the SARS-CoV-2 pandemic on patients presenting to a neurological emergency room depending on their triage score in an area with low COVID-19 incidence. Eur J Neurol 2020; 28:3332-3338. [PMID: 33377248 DOI: 10.1111/ene.14709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 11/06/2020] [Revised: 12/15/2020] [Accepted: 12/27/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND We analyzed the effects of the SARS-CoV-2 pandemic on neurologic emergencies, depending on the patients' triage score in a setting with relatively few COVID-19 cases and without lack of resources. METHODS Consecutive patients of a tertiary care center with a dedicated neurologic emergency room (nER) were analyzed. The time period of the first lockdown in Germany (calendar weeks 12-17, 2020) was retrospectively compared to the corresponding period in 2019 regarding the number of patients presenting to the nER, the number of patients with specific triage scores (Heidelberg Neurological Triage Score), the number of patients with stroke, and the quality of stroke care. RESULTS A total of 4330 patients were included. Fewer patients presented themselves in 2020 compared to 2019 (median [interquartile range] per week: 134 [118-143] vs. 187 [182-192]; p = 0.015). The median numbers of patients per week with triage 1 (emergent) and 4 (non-urgent) were comparable (51 [43-58] vs. 59 [54-62]; p = 0.132, and 10 [4-16] vs. 16 [7-18]; p = 0.310, respectively).The median number of patients per week declined in categories 2 and 3 in 2020 (41 [37-45] vs. 57 [52-61]; p = 0.004, and 28 [23-35] vs. 61 [52-63]; p = 0.002, respectively. No change was observed in the absolute number of strokes (138 in 2019 and 141 in 2020). Quality metrics of stroke revascularization therapies (symptom-to-door time, door-to-needle time or relative number of therapies) and stroke severity remained constant. CONCLUSION During the lockdown period in 2020, the number of patients with emergent symptoms remained constant, while fewer patients with urgent symptoms presented to the nER. This may imply behavioral changes in care-seeking behavior.
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Affiliation(s)
- Margit Millán
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Gumbinger
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Loraine Busetto
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan C Purrucker
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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18
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Purrucker JC, Hölscher K, Kollmer J, Ringleb PA. Etiology of Ischemic Strokes of Patients with Atrial Fibrillation and Therapy with Anticoagulants. J Clin Med 2020; 9:jcm9092938. [PMID: 32932971 PMCID: PMC7564370 DOI: 10.3390/jcm9092938] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 08/05/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 01/20/2023] Open
Abstract
Background: Reducing the number of ischemic strokes in patients with atrial fibrillation despite oral anticoagulation remains an important, yet largely unsolved challenge. Therefore, we assessed the etiology of ischemic strokes despite anticoagulation with vitamin K antagonists (VKA) or non-VKA oral anticoagulants (NOACs). Methods: Patients with known atrial fibrillation (AF), treatment with VKA or NOAC, and acute ischemic stroke admitted between 2015 and 2018 (1st half) were identified from the hospital database. Brain imaging data were independently reviewed. An integrated etiologic classification according to the ASCOD system was made. Medication errors (admission INR <2.0 in the VKA- or NOAC-specific concentration <10 ng/mL) or dosage/dosing errors were also analyzed. Results: Of 3610 patients screened, n = 341 were included (VKA, n = 127; NOAC, n = 214). An overall increasing rate of OAC-associated stroke per year was observed. In 95.3% of patients with adequate diagnostic work-up (n = 321/337), at least one additional potential, uncertain, or unlikely non-cardiac cause of stroke was identified. More patients in the VKA than in the NOAC group had a medication error (81/127, 63.8% vs. 102/205, 49.8%; p = 0.013). Conclusions: Stroke risk factors despite atrial fibrillation were highly prevalent. Although less common with NOACs than VKAs, medication errors are still frequent.
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Affiliation(s)
- Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.H.); (P.A.R.)
- Correspondence:
| | - Kyra Hölscher
- Department of Neurology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.H.); (P.A.R.)
| | - Jennifer Kollmer
- Department of Neuroradiology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
| | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.H.); (P.A.R.)
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19
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Kollmer J, Hegenbart U, Kimmich C, Hund E, Purrucker JC, Hayes JM, Lentz SI, Sam G, Jende JME, Schönland SO, Bendszus M, Heiland S, Weiler M. Magnetization transfer ratio quantifies polyneuropathy in hereditary transthyretin amyloidosis. Ann Clin Transl Neurol 2020; 7:799-807. [PMID: 32333729 PMCID: PMC7261747 DOI: 10.1002/acn3.51049] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 12/13/2022] Open
Abstract
Objective To quantify peripheral nerve lesions in symptomatic and asymptomatic hereditary transthyretin amyloidosis with polyneuropathy (ATTRv‐PNP) by analyzing the magnetization transfer ratio (MTR) of the sciatic nerve, and to test its potential as a novel biomarker for macromolecular changes. Methods Twenty‐five patients with symptomatic ATTRv‐PNP, 30 asymptomatic carriers of the mutant transthyretin gene (mutTTR), and 20 age‐/sex‐matched healthy controls prospectively underwent magnetization transfer contrast imaging at 3 Tesla. Two axial three‐dimensional gradient echo sequences with and without an off‐resonance saturation rapid frequency pulse were conducted at the right distal thigh. Sciatic nerve regions of interest were manually drawn on 10 consecutive axial slices in the images without off‐resonance saturation, and then transferred to the corresponding slices that were generated by the sequence with the off‐resonance saturation pulse. Subsequently, the MTR and cross‐sectional area (CSA) of the sciatic nerve were evaluated. Detailed neurologic and electrophysiologic examinations were conducted in all ATTRv‐PNP patients and mutTTR‐carriers. Results Sciatic nerve MTR and CSA reliably differentiated between ATTRv‐PNP, mutTTR‐carriers, and controls. MTR was lower in ATTRv‐PNP (26.4 ± 0.7; P < 0.0001) and in mutTTR‐carriers (32.6 ± 0.8; P = 0.0005) versus controls (39.4 ± 2.1), and was also lower in ATTRv‐PNP versus mutTTR‐carriers (P = 0.0009). MTR correlated negatively with the NIS‐LL and positively with CMAPs and SNAPs. CSA was higher in ATTRv‐PNP (34.3 ± 1.7 mm3) versus mutTTR‐carriers (26.0 ± 1.1 mm3; P = 0.0005) and versus controls (20.4 ± 1.2 mm3; P < 0.0001). CSA was also higher in mutTTR‐carriers versus controls. Interpretation MTR is a novel imaging marker that can quantify macromolecular changes in ATTRv‐PNP and differentiate between symptomatic ATTRv‐PNP and asymptomatic mutTTR‐carriers and correlates with electrophysiology.
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Affiliation(s)
- Jennifer Kollmer
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany.,Amyloidosis Center Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
| | - Ute Hegenbart
- Amyloidosis Center Heidelberg, Heidelberg University Hospital, Heidelberg, Germany.,Medical Department V, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Kimmich
- Amyloidosis Center Heidelberg, Heidelberg University Hospital, Heidelberg, Germany.,Medical Department V, Heidelberg University Hospital, Heidelberg, Germany
| | - Ernst Hund
- Amyloidosis Center Heidelberg, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan C Purrucker
- Amyloidosis Center Heidelberg, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - John M Hayes
- Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Stephen I Lentz
- Department of Internal Medicine, Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI
| | - Georges Sam
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johann M E Jende
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan O Schönland
- Amyloidosis Center Heidelberg, Heidelberg University Hospital, Heidelberg, Germany.,Medical Department V, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany.,Division of Experimental Radiology, Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Weiler
- Amyloidosis Center Heidelberg, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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20
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Huppertz A, Grond-Ginsbach C, Dumschat C, Foerster KI, Burhenne J, Weiss J, Czock D, Purrucker JC, Rizos T, Haefeli WE. Unexpected excessive apixaban exposure: case report of a patient with polymorphisms of multiple apixaban elimination pathways. BMC Pharmacol Toxicol 2019; 20:53. [PMID: 31464657 PMCID: PMC6716843 DOI: 10.1186/s40360-019-0331-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/23/2019] [Indexed: 12/22/2022] Open
Abstract
Background Apixaban effectively lowers the risk of ischemic stroke and systemic embolism in patients with non-valvular atrial fibrillation. Systemic exposure to a given apixaban dose depends on multiple clearance pathways. Though routine quantification of direct oral anticoagulants (DOACs) in neurological emergency situations has not been widely established, suspected associations of DOAC peak concentrations with bleeding events and DOAC trough concentrations with efficacy and safety suggest that such information might support clinical decision making. Case presentation We describe the case of a 75 year-old woman with atrial fibrillation maintained on apixaban who was admitted due to suspected acute stroke. Clinical work-up did not confirm ischemic or hemorrhagic stroke but routine quantification of apixaban revealed an excessively high apixaban plasma concentration (~ 3 h after the last drug intake: 1100 ng/ml (expected range: 91–321 ng/ml); ~ 12 h after drug intake: 900 ng/ml (expected range: 41–230 ng/ml)) and a substantially prolonged elimination half-life (~ 31 h). The corresponding apixaban concentration-to-dose ratio was 9900 (ng/ml)/(mg/kg/d) and 8100 (ng/ml)/(mg/kg/d), respectively (expected range: 249–463 (ng/ml)/(mg/kg/d)). Renal function was only moderately impaired (creatinine 1.36 mg/dl (0.5–1.1 mg/dl), creatinine clearance 40 ml/min). Genotype analyses revealed that the patient was a CYP3A5*3/*3 non-expressor, a heterozygous carrier of the ABCG2 c.421C/A alleles, and a homozygous carrier of ABCB1 c.2677 T/T and ABCB1 c.3435 T/T. In the absence of known drug interactions explaining apixaban clearance impairment, excessive apixaban concentrations were most probably caused by moderate renal impairment combined with multiple functional polymorphisms of apixaban clearance pathways. Conclusions This case suggests that concurrent genetic polymorphisms can impair multiple apixaban elimination pathways and thus substantially increase its exposure.
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Affiliation(s)
- Andrea Huppertz
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Caspar Grond-Ginsbach
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Chris Dumschat
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Johanna Weiss
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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21
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Purrucker JC, Nagel S, Gumbinger C. Letter by Purrucker et al Regarding Article, “Door-In-Door-Out Time at Primary Stroke Centers May Predict Outcome for Emergent Large Vessel Occlusion Patients”. Stroke 2019; 50:e212. [DOI: 10.1161/strokeaha.118.024791] [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: 11/16/2022]
Affiliation(s)
- Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Germany
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22
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Gerner ST, Kuramatsu JB, Sembill JA, Sprügel MI, Hagen M, Knappe RU, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker JC, Rizos T, Volkmann J, Müllges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Rahmig J, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Claßen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Günther A, Hamann GF, Engelhorn T, Lücking H, Dörfler A, Schwab S, Huttner HB. Characteristics in Non-Vitamin K Antagonist Oral Anticoagulant-Related Intracerebral Hemorrhage. Stroke 2019; 50:1392-1402. [PMID: 31092170 DOI: 10.1161/strokeaha.118.023492] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background and Purpose- Given inconclusive studies, it is debated whether clinical and imaging characteristics, as well as functional outcome, differ among patients with intracerebral hemorrhage (ICH) related to vitamin K antagonists (VKA) versus non-vitamin K antagonist (NOAC)-related ICH. Notably, clinical characteristics according to different NOAC agents and dosages are not established. Methods- Multicenter observational cohort study integrating individual patient data of 1328 patients with oral anticoagulation-associated ICH, including 190 NOAC-related ICH patients, recruited from 2011 to 2015 at 19 tertiary centers across Germany. Imaging, clinical characteristics, and 3-months modified Rankin Scale (mRS) outcomes were compared in NOAC- versus VKA-related ICH patients. Propensity score matching was conducted to adjust for clinically relevant differences in baseline parameters. Subgroup analyses were performed regarding NOAC agent, dosing and present clinically relevant anticoagulatory activity (last intake <12h/24h or NOAC level >30 ng/mL). Results- Despite older age in NOAC patients, there were no relevant differences in clinical and hematoma characteristics between NOAC- and VKA-related ICH regarding baseline hematoma volume (median [interquartile range]: NOAC, 14.7 [5.1-42.3] mL versus VKA, 16.4 [5.8-40.6] mL; P=0.33), rate of hematoma expansion (NOAC, 49/146 [33.6%] versus VKA, 235/688 [34.2%]; P=0.89), and the proportion of patients with unfavorable outcome at 3 months (mRS, 4-6: NOAC 126/179 [70.4%] versus VKA 473/682 [69.4%]; P=0.79). Subgroup analyses revealed that NOAC patients with clinically relevant anticoagulatory effect had higher rates of intraventricular hemorrhage (n/N [%]: present 52/109 [47.7%] versus absent 9/35 [25.7%]; P=0.022) and hematoma expansion (present 35/90 [38.9%] versus absent 5/30 [16.7%]; P=0.040), whereas type of NOAC agent or different NOAC-dosing regimens did not result in relevant differences in imaging characteristics or outcome. Conclusions- If effectively anticoagulated, there are no differences in hematoma characteristics and functional outcome among patients with NOAC- or VKA-related ICH. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT03093233.
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Affiliation(s)
- Stefan T Gerner
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Joji B Kuramatsu
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Jochen A Sembill
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Maximilian I Sprügel
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Manuel Hagen
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Ruben U Knappe
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Matthias Endres
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.).,German Centre for Cardiovascular Research (DZHK), Oudenarder Straße, Berlin (M.E.).,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin (M.E.)
| | - Karl Georg Haeusler
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.).,Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Jan Sobesky
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.)
| | - Johannes Schurig
- Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.)
| | - Sarah Zweynert
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany
| | - Miriam Bauer
- Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.)
| | - Peter Vajkoczy
- Department of Neurosurgery (P.V.), Charité-Universitätsmedizin Berlin, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, Germany (P.A.R., J.C.B., T.R.)
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Germany (P.A.R., J.C.B., T.R.)
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Germany (P.A.R., J.C.B., T.R.)
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Wolfgang Müllges
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Peter Kraft
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Anna-Lena Schubert
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Frank Erbguth
- Department of Neurology, Community Hospital Nuremberg, Germany (F.E., M.N.)
| | - Martin Nueckel
- Department of Neurology, Community Hospital Nuremberg, Germany (F.E., M.N.)
| | | | - Jörg Glahn
- Department of Neurology and Neurogeriatry (P.D.S., J.G.)
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, University Clinic Ruhr University Bochum, Germany (U.J.K.)
| | - Gereon R Fink
- Department of Neurology, University of Cologne, Germany (G.R.F. C.D., H. Stetefeld)
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Germany (G.R.F. C.D., H. Stetefeld).,Department of Neurology, LVR Klinik Bonn, Germany (C.D.)
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Germany (G.R.F. C.D., H. Stetefeld)
| | - Anna Lena Fisse
- Department of Neurology, University of Münster, Germany (A.L.F., J.M.)
| | - Jens Minnerup
- Department of Neurology, University of Münster, Germany (A.L.F., J.M.)
| | - Georg Hagemann
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Germany (G.H., F.R.)
| | - Florian Rakers
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Germany (G.H., F.R.)
| | - Heinz Reichmann
- Department of Neurology, University of Dresden, Germany (H.R., H. Schneider, J. Rahmig).,Department of Neurology, Klinikum Augsburg, Germany (H. Schneider)
| | - Hauke Schneider
- Department of Neurology, University of Dresden, Germany (H.R., H. Schneider, J. Rahmig)
| | - Jan Rahmig
- Department of Neurology, University of Dresden, Germany (H.R., H. Schneider, J. Rahmig)
| | | | - Sebastian Stösser
- Department of Neurology, University of Ulm, Germany (A.C.L., S. Stösser, H.N.)
| | - Hermann Neugebauer
- Department of Neurology, University of Ulm, Germany (A.C.L., S. Stösser, H.N.)
| | - Joachim Röther
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Germany (J. Röther, P.M.)
| | - Peter Michels
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Germany (J. Röther, P.M.)
| | - Michael Schwarz
- Department of Neurology, Community Hospital Klinikum Dortmund, Germany (M.S., G.R.)
| | - Gernot Reimann
- Department of Neurology, Community Hospital Klinikum Dortmund, Germany (M.S., G.R.)
| | - Hansjörg Bäzner
- Department of Neurology, Community Hospital Klinikum Stuttgart, Germany (H.B., H. Schwert)
| | - Henning Schwert
- Department of Neurology, Community Hospital Klinikum Stuttgart, Germany (H.B., H. Schwert)
| | - Joseph Claßen
- Department of Neurology, University of Leipzig, Germany (J.C., D.M.)
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Germany (J.C., D.M.)
| | - Armin Grau
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Germany (A. Grau, F.P., C.U.)
| | - Frederick Palm
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Germany (A. Grau, F.P., C.U.)
| | - Christian Urbanek
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Germany (A. Grau, F.P., C.U.)
| | - Johannes C Wöhrle
- Department of Neurology, Community Hospital Klinikum Koblenz, Germany (J.C.W., F.A.)
| | - Fahid Alshammari
- Department of Neurology, Community Hospital Klinikum Koblenz, Germany (J.C.W., F.A.)
| | - Markus Horn
- Department of Neurology, Community Hospital Bad Hersfeld, Germany (M. Horn, D.B.)
| | - Dirk Bahner
- Department of Neurology, Community Hospital Bad Hersfeld, Germany (M. Horn, D.B.)
| | - Otto W Witte
- Department of Neurology, University of Jena, Germany (O.W.W., A. Günther)
| | - Albrecht Günther
- Department of Neurology, University of Jena, Germany (O.W.W., A. Günther)
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Germany (J.F.H.)
| | - Tobias Engelhorn
- Department of Neuroradiology (T.E., H.L., A.D.), University of Erlangen-Nuremberg, Germany
| | - Hannes Lücking
- Department of Neuroradiology (T.E., H.L., A.D.), University of Erlangen-Nuremberg, Germany
| | - Arnd Dörfler
- Department of Neuroradiology (T.E., H.L., A.D.), University of Erlangen-Nuremberg, Germany
| | - Stefan Schwab
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Hagen B Huttner
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
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Christensen H, Cordonnier C, Kõrv J, Lal A, Ovesen C, Purrucker JC, Toni D, Steiner T. European Stroke Organisation Guideline on Reversal of Oral Anticoagulants in Acute Intracerebral Haemorrhage. Eur Stroke J 2019; 4:294-306. [PMID: 31903428 DOI: 10.1177/2396987319849763] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [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: 02/21/2019] [Accepted: 04/03/2019] [Indexed: 12/20/2022] Open
Abstract
The aim of the present European Stroke Organisation guideline document is to provide clinically useful evidence-based recommendation on reversal of anticoagulant activity VKA (warfarin, phenprocoumon and acenocoumarol), direct factor II (thrombin) inhibitors (dabigatran etexilat) and factor-Xa-inhibitors (apixaban, edoxaban and rivaroxaban) in patients with acute intracerebral haemorrhage. The guideline was prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined use of oral anticoagulation pragmatically: oral anticoagulation use is assumed by positive medical history unless relevant anticoagulant activity is regarded unlikely by medical history or has been ruled out by laboratory testing. Overall, we strongly recommend using prothrombin complex over no treatment and fresh-frozen plasma in patients on VKA plus vitamin K. We further strongly recommend using idarucizumab in patients on dabigatran and make a recommendation for andexanet alfa in patients on rivaroxaban and apixaban over no treatment. We make a weak recommendation on using high-dose prothrombin complex concentrate (50 IU/kg) for all patients taking edoxaban and for patients on rivaroxaban or apixaban in case andexanet alfa is not available. We recommend against using tranexamic acid and rFVIIa, outside of trials. The presented treatment recommendations aim to normalise coagulation, there is no or only indirect data on effects on functional outcome or mortality, and only little data from randomised controlled trials.
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Affiliation(s)
- Hanne Christensen
- Department of Neurology, Bispebjerg Hospital & Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Cordonnier
- Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Department of Neurology, Université Lille, Lille, France
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu & Tartu University Hospital, Tartu, Estonia
| | - Avtar Lal
- Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Christian Ovesen
- Department of Neurology, Bispebjerg Hospital & Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
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24
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Haas K, Purrucker JC, Rizos T, Heuschmann PU, Veltkamp R. Rationale and design of the Registry of Acute Stroke Under Novel Oral Anticoagulants-prime (RASUNOA-prime). Eur Stroke J 2018; 4:181-188. [PMID: 31259266 DOI: 10.1177/2396987318812644] [Citation(s) in RCA: 9] [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: 03/22/2018] [Accepted: 08/08/2018] [Indexed: 01/01/2023] Open
Abstract
Background Anticoagulation with vitamin K antagonists and non-vitamin K antagonists oral anticoagulants (NOAC) is effective in stroke prevention in patients with atrial fibrillation. However, anticoagulation also poses a major challenge for emergency treatment of patients suffering ischaemic stroke or intracerebral haemorrhage. Aim The registry RASUNOA-prime is designed to describe current patterns of emergency management, clinical course and outcome of patients with atrial fibrillation experiencing an acute ischaemic stroke or intracerebral haemorrhage under different anticoagulation schemes prior to stroke (NOAC, vitamin K antagonists or no anticoagulation). Methods and design RASUNOA-prime (ClinicalTrials.gov, NCT02533960) is a prospective, investigator-initiated, multicentre, observational cohort study aiming to recruit 3000 patients with acute ischaemic stroke and atrial fibrillation, and 1000 patients with acute intracerebral haemorrhage and atrial fibrillation with different anticoagulation schemes pre-stroke. It is a non-interventional triple-armed study aiming at a balanced inclusion of ischaemic stroke and intracerebral haemorrhage patients according to the different anticoagulation schemes. Patients will be followed up for clinical course, management and outcome up to three months after the event. Findings in ischaemic stroke and intracerebral haemorrhage patients on NOAC will be compared with patients taking vitamin K antagonists or no anticoagulant pre-stroke. Study outcomes Primary endpoint for ischaemic stroke patients: occurrence of symptomatic intracerebral haemorrhage, for intracerebral haemorrhage patients: occurrence of secondary haematoma expansion. Secondary endpoints include assessment of coagulation, use of thrombolysis and/or mechanical thrombectomy, occurrence of complications, implementation of secondary prevention. Summary Describing the current patterns of early management as well as outcome of stroke patients with atrial fibrillation will help guide physicians to develop recommendations for emergency treatment of stroke patients under different anticoagulation schemes.
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Affiliation(s)
- Kirsten Haas
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany.,Clinical Trial Center, University Hospital Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Alfried Krupp Hospital, Essen, Germany
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25
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Tsivgoulis G, Wilson D, Katsanos AH, Sargento-Freitas J, Marques-Matos C, Azevedo E, Adachi T, von der Brelie C, Aizawa Y, Abe H, Tomita H, Okumura K, Hagii J, Seiffge DJ, Lioutas VA, Traenka C, Varelas P, Basir G, Krogias C, Purrucker JC, Sharma VK, Rizos T, Mikulik R, Sobowale OA, Barlinn K, Sallinen H, Goyal N, Yeh SJ, Karapanayiotides T, Wu TY, Vadikolias K, Ferrigno M, Hadjigeorgiou G, Houben R, Giannopoulos S, Schreuder FHBM, Chang JJ, Perry LA, Mehdorn M, Marto JP, Pinho J, Tanaka J, Boulanger M, Al-Shahi Salman R, Jäger HR, Shakeshaft C, Yakushiji Y, Choi PMC, Staals J, Cordonnier C, Jeng JS, Veltkamp R, Dowlatshahi D, Engelter ST, Parry-Jones AR, Meretoja A, Mitsias PD, Alexandrov AV, Ambler G, Werring DJ. Neuroimaging and clinical outcomes of oral anticoagulant-associated intracerebral hemorrhage. Ann Neurol 2018; 84:694-704. [PMID: 30255970 DOI: 10.1002/ana.25342] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/13/2018] [Accepted: 09/14/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Whether intracerebral hemorrhage (ICH) associated with non-vitamin K antagonist oral anticoagulants (NOAC-ICH) has a better outcome compared to ICH associated with vitamin K antagonists (VKA-ICH) is uncertain. METHODS We performed a systematic review and individual patient data meta-analysis of cohort studies comparing clinical and radiological outcomes between NOAC-ICH and VKA-ICH patients. The primary outcome measure was 30-day all-cause mortality. All outcomes were assessed in multivariate regression analyses adjusted for age, sex, ICH location, and intraventricular hemorrhage extension. RESULTS We included 7 eligible studies comprising 219 NOAC-ICH and 831 VKA-ICH patients (mean age = 77 years, 52.5% females). The 30-day mortality was similar between NOAC-ICH and VKA-ICH (24.3% vs 26.5%; hazard ratio = 0.94, 95% confidence interval [CI] = 0.67-1.31). However, in multivariate analyses adjusting for potential confounders, NOAC-ICH was associated with lower admission National Institutes of Health Stroke Scale (NIHSS) score (linear regression coefficient = -2.83, 95% CI = -5.28 to -0.38), lower likelihood of severe stroke (NIHSS > 10 points) on admission (odds ratio [OR] = 0.50, 95% CI = 0.30-0.84), and smaller baseline hematoma volume (linear regression coefficient = -0.24, 95% CI = -0.47 to -0.16). The two groups did not differ in the likelihood of baseline hematoma volume < 30cm3 (OR = 1.14, 95% CI = 0.81-1.62), hematoma expansion (OR = 0.97, 95% CI = 0.63-1.48), in-hospital mortality (OR = 0.73, 95% CI = 0.49-1.11), functional status at discharge (common OR = 0.78, 95% CI = 0.57-1.07), or functional status at 3 months (common OR = 1.03, 95% CI = 0.75-1.43). INTERPRETATION Although functional outcome at discharge, 1 month, or 3 months was comparable after NOAC-ICH and VKA-ICH, patients with NOAC-ICH had smaller baseline hematoma volumes and less severe acute stroke syndromes. Ann Neurol 2018;84:702-712.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom, New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Aristeidis H Katsanos
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - João Sargento-Freitas
- Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Cláudia Marques-Matos
- Department of Neurology, São João University Hospital Center, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology, São João University Hospital Center, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Tomohide Adachi
- Department of Neurology and General Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | | | - Yoshifusa Aizawa
- Department of Research and Development, Tachikawa Medical Center, Nagaoka, Japan
| | - Hiroshi Abe
- Department of Research and Development, Tachikawa Medical Center, Nagaoka, Japan
| | - Hirofumi Tomita
- Department of Cardiology and Department of Hypertension and Stroke Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Ken Okumura
- Advanced Arrhythmia Therapeutic Branch, Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Joji Hagii
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, Japan
| | - David J Seiffge
- Stroke Center and Neurology, University Hospital and University of Basel, Basel, Switzerland
| | | | - Christopher Traenka
- Stroke Center and Neurology, University Hospital and University of Basel, Basel, Switzerland
| | | | - Ghazala Basir
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Christos Krogias
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Vijay K Sharma
- Division of Neurology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St Anne's Hospital and Masaryk University, Brno, Czech Republic
| | - Oluwaseun A Sobowale
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Kristian Barlinn
- Department of Neurology, Dresden Neurovascular Center, Dresden, Germany
| | - Hanne Sallinen
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taiwan
| | - Theodore Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Marc Ferrigno
- Department of Neurology, Lille University, INSERM U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Lille, France
| | | | - Rik Houben
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Floris H B M Schreuder
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jason J Chang
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Luke A Perry
- Department of Neurosciences, Eastern Health, Melbourne, Victoria, Australia
| | - Maximilian Mehdorn
- Department of Neurosurgery, Georg August University of Göttingen, Göttingen, Germany
| | - João-Pedro Marto
- Neurology Department, Egas Moniz Hospital, West Lisbon Hospital Center, Lisbon, Portugal.,CEDOC, Nova Medical School, New University of Lisbon, Lisbon, Portugal
| | - João Pinho
- Department of Neurology, Braga Hospital, Braga, Portugal
| | - Jun Tanaka
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Marion Boulanger
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Hans R Jäger
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, United Kingdom
| | - Clare Shakeshaft
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom, New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Philip M C Choi
- Department of Neurosciences, Eastern Health, Melbourne, Victoria, Australia
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Charlotte Cordonnier
- Department of Neurology, Lille University, INSERM U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Lille, France
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taiwan
| | - Roland Veltkamp
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College London, United Kingdom
| | - Dar Dowlatshahi
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Stefan T Engelter
- Stroke Center and Neurology, University Hospital and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland
| | - Adrian R Parry-Jones
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland.,Department of Medicine and Neurology at Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Panayiotis D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, MI.,Department of Neurology, School of Medicine, University of Crete, Crete, Greece
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, United Kingdom
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom, New Zealand Brain Research Institute, Christchurch, New Zealand
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26
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Purrucker JC, Rizos T, Haas K, Wolf M, Khan S, Heuschmann PU, Veltkamp R. Coagulation Testing in Intracerebral Hemorrhage Related to Non-vitamin K Antagonist Oral Anticoagulants. Neurocrit Care 2018; 27:208-213. [PMID: 28477151 DOI: 10.1007/s12028-017-0403-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 11/28/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a life-threatening complication of non-vitamin K antagonist oral anticoagulants (NOAC). Little is known about the effect of intensity of anticoagulation on NOAC-ICH. We describe the current use of coagulation testing in the emergency setting and explore associations with baseline size and expansion of hematoma as determined in a previous study. METHODS Data from the prospective multicenter RASUNOA registry were analyzed. Patients with NOAC-ICH were enrolled between February 2012 and December 2014. Frequency of local test performance of specific (anti-factor Xa tests, diluted thrombin time) and non-specific tests (international normalized ratio (INR), activated partial thromboplastin time (aPTT), thrombin time) was analyzed. The association of anticoagulation intensity at admission with hematoma volume and hematoma expansion was explored. RESULTS In 61 NOAC-ICH patients enrolled at 21 centers, drug-specific coagulation testing was performed in 16 cases (26%), and only 29% of centers appeared to use drug-specific tests in NOAC-ICH at all. In some cases, INR and aPTT values were normal despite drug concentrations in the peak range. In patients with available drug-specific concentrations, 50% had drug levels in the peak range at admission. Higher intensity of anticoagulation was not associated with higher hematoma volume at admission or with subsequent hematoma expansion. CONCLUSION Drug-specific tests are only infrequently used in NOAC-ICH. Normal results in non-specific coagulation do not reliably rule out peak range concentrations. Anticoagulation intensity at admission does not predict baseline hematoma volume or subsequent hematoma expansion.
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Affiliation(s)
- Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kirsten Haas
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | - Marcel Wolf
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Shujah Khan
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany.,Clinical Trial Center, University Hospital Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany. .,Department of Stroke Medicine, Imperial College London, Charing Cross Campus, Fulham Palace Road, London, W6 8RF, UK.
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27
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Kollmer J, Sahm F, Hegenbart U, Purrucker JC, Kimmich C, Schönland SO, Hund E, Heiland S, Hayes JM, Kristen AV, Röcken C, Pham M, Bendszus M, Weiler M. Sural nerve injury in familial amyloid polyneuropathy: MR neurography vs clinicopathologic tools. Neurology 2017; 89:475-484. [PMID: 28679600 DOI: 10.1212/wnl.0000000000004178] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 05/04/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To detect and quantify lesions of the small-caliber sural nerve (SN) in symptomatic and asymptomatic transthyretin familial amyloid polyneuropathy (TTR-FAP) by high-resolution magnetic resonance neurography (MRN) in correlation with electrophysiologic and histopathologic findings. METHODS Twenty-five patients with TTR-FAP, 10 asymptomatic carriers of the mutated transthyretin gene (mutTTR), and 35 age- and sex-matched healthy controls were prospectively included in this cross-sectional case-control study. All participants underwent 3T MRN with high-structural resolution (fat-saturated, T2-weighted, and double-echo sequences). Total imaging time was ≈45 minutes per patient. Manual SN segmentation was performed from its origin at the sciatic nerve bifurcation to the lower leg with subsequent evaluation of quantitative microstructural and morphometric parameters. Additional time needed for postprocessing was ≈1.5 hours per participant. Detailed neurologic and electrophysiologic examinations were conducted in the TTR group. RESULTS T2 signal and proton spin density (ρ) reliably differentiated between TTR-FAP (198.0 ± 13.3, 429.6 ± 15.25), mutTTR carriers (137.0 ± 16.9, p = 0.0009; 354.7 ± 21.64, p = 0.0029), and healthy controls (90.0 ± 3.4, 258.2 ± 9.10; p < 0.0001). Marked differences between mutTTR carriers and controls were found for T2 signal (p = 0.0065) and ρ (p < 0.0001). T2 relaxation time was higher in patients with TTR-FAP only (p = 0.015 vs mutTTR carriers, p = 0.0432 vs controls). SN caliber was higher in patients with TTR-FAP vs controls and in mutTTR carriers vs controls (p < 0.0001). Amyloid deposits were histopathologically detectable in 10 of 14 SN specimens. CONCLUSIONS SN injury in TTR-FAP is detectable and quantifiable in vivo by MRN even in asymptomatic mutTTR carriers. Differences in SN T2 signal between controls and asymptomatic mutTTR carriers are derived mainly from an increase of ρ, which overcomes typical limitations of established diagnostic methods as a highly sensitive imaging biomarker for early detection of peripheral nerve lesions. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that MRN accurately identifies asymptomatic mutTTR carriers.
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Affiliation(s)
- Jennifer Kollmer
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany.
| | - Felix Sahm
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany
| | - Ute Hegenbart
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany
| | - Jan C Purrucker
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany
| | - Christoph Kimmich
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany
| | - Stefan O Schönland
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany
| | - Ernst Hund
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany
| | - Sabine Heiland
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany
| | - John M Hayes
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany
| | - Arnt V Kristen
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany
| | - Christoph Röcken
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany
| | - Mirko Pham
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany
| | - Martin Bendszus
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany
| | - Markus Weiler
- From the Department of Neuroradiology (J.K., S.H., M.P., M.B.), Amyloidosis Center Heidelberg (J.K., U.H., J.C.P., C.K., S.O.S., E.H., A.V.K., M.W.), Department of Neuropathology (F.S.), Medical Department V (U.H., C.K., S.O.S.), Department of Neurology (J.C.P., E.H., M.W.), Division of Experimental Radiology (S.H.), Department of Neuroradiology, and Medical Department III (A.V.K.), Heidelberg University Hospital; CCU Neuropathology (F.S.), German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany; Department of Neurology (J.M.H.), University of Michigan, Ann Arbor; Department of Pathology (C.R.), University of Kiel; and Department of Neuroradiology (M.P.), Würzburg University Hospital, Germany.
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Wilson D, Seiffge DJ, Traenka C, Basir G, Purrucker JC, Rizos T, Sobowale OA, Sallinen H, Yeh SJ, Wu TY, Ferrigno M, Houben R, Schreuder FHBM, Perry LA, Tanaka J, Boulanger M, Al-Shahi Salman R, Jäger HR, Ambler G, Shakeshaft C, Yakushiji Y, Choi PMC, Staals J, Cordonnier C, Jeng JS, Veltkamp R, Dowlatshahi D, Engelter ST, Parry-Jones AR, Meretoja A, Werring DJ. Outcome of intracerebral hemorrhage associated with different oral anticoagulants. Neurology 2017; 88:1693-1700. [PMID: 28381513 PMCID: PMC5409844 DOI: 10.1212/wnl.0000000000003886] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 01/18/2017] [Indexed: 11/15/2022] Open
Abstract
Objective: In an international collaborative multicenter pooled analysis, we compared mortality, functional outcome, intracerebral hemorrhage (ICH) volume, and hematoma expansion (HE) between non–vitamin K antagonist oral anticoagulation–related ICH (NOAC-ICH) and vitamin K antagonist–associated ICH (VKA-ICH). Methods: We compared all-cause mortality within 90 days for NOAC-ICH and VKA-ICH using a Cox proportional hazards model adjusted for age; sex; baseline Glasgow Coma Scale score, ICH location, and log volume; intraventricular hemorrhage volume; and intracranial surgery. We addressed heterogeneity using a shared frailty term. Good functional outcome was defined as discharge modified Rankin Scale score ≤2 and investigated in multivariable logistic regression. ICH volume was measured by ABC/2 or a semiautomated planimetric method. HE was defined as an ICH volume increase >33% or >6 mL from baseline within 72 hours. Results: We included 500 patients (97 NOAC-ICH and 403 VKA-ICH). Median baseline ICH volume was 14.4 mL (interquartile range [IQR] 3.6–38.4) for NOAC-ICH vs 10.6 mL (IQR 4.0–27.9) for VKA-ICH (p = 0.78). We did not find any difference between NOAC-ICH and VKA-ICH for all-cause mortality within 90 days (33% for NOAC-ICH vs 31% for VKA-ICH [p = 0.64]; adjusted Cox hazard ratio (for NOAC-ICH vs VKA-ICH) 0.93 [95% confidence interval (CI) 0.52–1.64] [p = 0.79]), the rate of HE (NOAC-ICH n = 29/48 [40%] vs VKA-ICH n = 93/140 [34%] [p = 0.45]), or functional outcome at hospital discharge (NOAC-ICH vs VKA-ICH odds ratio 0.47; 95% CI 0.18–1.19 [p = 0.11]). Conclusions: In our international collaborative multicenter pooled analysis, baseline ICH volume, hematoma expansion, 90-day mortality, and functional outcome were similar following NOAC-ICH and VKA-ICH.
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Affiliation(s)
- Duncan Wilson
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - David J Seiffge
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Christopher Traenka
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Ghazala Basir
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Jan C Purrucker
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Timolaos Rizos
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Oluwaseun A Sobowale
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Hanne Sallinen
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Shin-Joe Yeh
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Teddy Y Wu
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Marc Ferrigno
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Rik Houben
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Floris H B M Schreuder
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Luke A Perry
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Jun Tanaka
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Marion Boulanger
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Rustam Al-Shahi Salman
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Hans R Jäger
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Gareth Ambler
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Clare Shakeshaft
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Yusuke Yakushiji
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Philip M C Choi
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Julie Staals
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Charlotte Cordonnier
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Jiann-Shing Jeng
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Roland Veltkamp
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Dar Dowlatshahi
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Stefan T Engelter
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Adrian R Parry-Jones
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - Atte Meretoja
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland
| | - David J Werring
- From the Stroke Research Center (D.W., C.S., D.J.W.) and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, Institute of Neurology, and Department of Statistical Science (G.A.), UCL, London, UK; Stroke Center and Neurology (D.J.S., C.T., S.T.E.), University Hospital Basel, University of Basel, Switzerland; Ottawa Hospital Research Institute and University of Ottawa (G.B., D.D.), Canada; Department of Neurology (J.C.P., T.R.), Heidelberg University Hospital, Germany; Manchester Academic Health Sciences Center (O.A.S., A.R.P.-J.), Salford Royal NHS Foundation Trust, UK; Department of Neurology (H.S., A.M.), Helsinki University Hospital, Finland; Stroke Center & Department of Neurology (S.-J.Y., J.-S.J.), Department of Neurology, National Taiwan University Hospital, Taipei; Department of Medicine and neurology at the Royal Melbourne Hospital (T.Y.W., A.M.), University of Melbourne, Parkville, Australia; U1171-Degenerative & Vascular Cognitive Disorders (M.F., C.C.), Univ Lille, Inserm, CHU Lille, France; Department of Neurology (R.H., F.H.B.M.S., J.S.), Maastricht University Medical Center, the Netherlands; Department of Neurosciences (J.A.P., P.M.C.C.), Eastern Health, Melbourne, Australia; Division of Neurology, Department of Internal Medicine (J.T., Y.Y.), Saga University Faculty of Medicine, Japan; Division of Clinical Neurosciences (M.B., R.A.-S.S.), Center for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; Department of Stroke Medicine, Division of Brain Sciences (R.V.), Imperial College London, UK; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland.
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Purrucker JC, Haas K, Wolf M, Rizos T, Khan S, Kraft P, Poli S, Dziewas R, Meyne J, Palm F, Jander S, Möhlenbruch M, Heuschmann PU, Veltkamp R. Haemorrhagic Transformation after Ischaemic Stroke in Patients Taking Non-vitamin K Antagonist Oral Anticoagulants. J Stroke 2017; 19:67-76. [PMID: 28178406 PMCID: PMC5307942 DOI: 10.5853/jos.2016.00542] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 06/16/2016] [Revised: 10/11/2016] [Accepted: 11/28/2016] [Indexed: 02/07/2023] Open
Abstract
Background and Purpose To evaluate the frequency and outcome of haemorrhagic transformation (HT) after ischaemic stroke in patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). Methods Patients with stroke on treatment with a NOAC were prospectively enrolled in this multicentre observational study between February 2012 and 2015. Brain imaging at admission and follow-up imaging until day 7 were reviewed for HT. Functional outcome was assessed by the modified Rankin scale (mRS) before the index event, at discharge, and at 3-months. Results 231 patients without recanalisation therapy (no-RT), and 32 patients with RT were eligible for analysis. Any HT was present at admission in 9/231 no-RT patients (3.9%, 95% CI 2.0 to 7.3) and in none of the patients with RT. In patients with follow-up imaging (no-RT, n=129, and RT, n=32), HT was present in 14.0% (no-RT; 95% CI, 8.9 to 21.1), and 40.6% (RT, 95% CI, 25.5 to 57.8), respectively. After adjustment for stroke severity, this difference between the no-RT and RT groups became non-significant. Symptomatic ICH was observed in 1 patient per group. HT was not associated with unfavourable outcome (mRS 3-6) at 3-months in multivariable analysis. Resumption of OAC after stroke was delayed in patients with HT compared to those without (15 d [IQR, 5–26] vs. 1 d [0–4], P<0.001). Conclusions The frequency and severity of HT after stroke on NOAC appears similar to previous reports for vitamin K antagonists and no anticoagulation. Whether asymptomatic HT should delay resumption of preventive anticoagulation requires further investigation.
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Affiliation(s)
- Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kirsten Haas
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Germany
| | - Marcel Wolf
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Shujah Khan
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Kraft
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Sven Poli
- Department of Neurology, Tübingen University, Tübingen, Germany
| | - Rainer Dziewas
- Department of Neurology, University Hospital Münster, Germany
| | - Johannes Meyne
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Frederick Palm
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Sebastian Jander
- Department of Neurology, Heinrich-Heine-University, Medical Faculty, Düsseldorf, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Germany.,Comprehensive Heart Failure Center, and Clinical Trial Center, University Hospital Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Stroke Medicine, Imperial College London, London, United Germany
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Schönenberger S, Uhlmann L, Hacke W, Schieber S, Mundiyanapurath S, Purrucker JC, Nagel S, Klose C, Pfaff J, Bendszus M, Ringleb PA, Kieser M, Möhlenbruch MA, Bösel J. Effect of Conscious Sedation vs General Anesthesia on Early Neurological Improvement Among Patients With Ischemic Stroke Undergoing Endovascular Thrombectomy: A Randomized Clinical Trial. JAMA 2016; 316:1986-1996. [PMID: 27785516 DOI: 10.1001/jama.2016.16623] [Citation(s) in RCA: 326] [Impact Index Per Article: 40.8] [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: 11/14/2022]
Abstract
IMPORTANCE Optimal management of sedation and airway during thrombectomy for acute ischemic stroke is controversial due to lack of evidence from randomized trials. OBJECTIVE To assess whether conscious sedation is superior to general anesthesia for early neurological improvement among patients receiving stroke thrombectomy. DESIGN, SETTING, AND PARTICIPANTS SIESTA (Sedation vs Intubation for Endovascular Stroke Treatment), a single-center, randomized, parallel-group, open-label treatment trial with blinded outcome evaluation conducted at Heidelberg University Hospital in Germany (April 2014-February 2016) included 150 patients with acute ischemic stroke in the anterior circulation, higher National Institutes of Health Stroke Scale (NIHSS) score (>10), and isolated/combined occlusion at any level of the internal carotid or middle cerebral artery. INTERVENTION Patients were randomly assigned to an intubated general anesthesia group (n = 73) or a nonintubated conscious sedation group (n = 77) during stroke thrombectomy. MAIN OUTCOMES AND MEASURES Primary outcome was early neurological improvement on the NIHSS after 24 hours (0-42 [none to most severe neurological deficits; a 4-point difference considered clinically relevant]). Secondary outcomes were functional outcome by modified Rankin Scale (mRS) after 3 months (0-6 [symptom free to dead]), mortality, and peri-interventional parameters of feasibility and safety. RESULTS Among 150 patients (60 women [40%]; mean age, 71.5 years; median NIHSS score, 17), primary outcome was not significantly different between the general anesthesia group (mean NIHSS score, 16.8 at admission vs 13.6 after 24 hours; difference, -3.2 points [95% CI, -5.6 to -0.8]) vs the conscious sedation group (mean NIHSS score, 17.2 at admission vs 13.6 after 24 hour; difference, -3.6 points [95% CI, -5.5 to -1.7]); mean difference between groups, -0.4 (95% CI, -3.4 to 2.7; P = .82). Of 47 prespecified secondary outcomes analyzed, 41 showed no significant differences. In the general anesthesia vs the conscious sedation group, substantial patient movement was less frequent (0% vs 9.1%; difference, 9.1%; P = .008), but postinterventional complications were more frequent for hypothermia (32.9% vs 9.1%; P < .001), delayed extubation (49.3% vs 6.5%; P < .001), and pneumonia (13.7% vs 3.9%; P = .03). More patients were functionally independent (unadjusted mRS score, 0 to 2 after 3 months [37.0% in the general anesthesia group vs 18.2% in the conscious sedation group P = .01]). There were no differences in mortality at 3 months (24.7% in both groups). CONCLUSIONS AND RELEVANCE Among patients with acute ischemic stroke in the anterior circulation undergoing thrombectomy, conscious sedation vs general anesthesia did not result in greater improvement in neurological status at 24 hours. The study findings do not support an advantage for the use of conscious sedation. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02126085.
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Affiliation(s)
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Werner Hacke
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Schieber
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Johannes Pfaff
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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Purrucker JC, Wolf M, Haas K, Rizos T, Khan S, Dziewas R, Kleinschnitz C, Binder A, Gröschel K, Hennerici MG, Lobotesis K, Poli S, Seidel G, Neumann-Haefelin T, Ringleb PA, Heuschmann PU, Veltkamp R. Safety of Endovascular Thrombectomy in Patients Receiving Non–Vitamin K Antagonist Oral Anticoagulants. Stroke 2016; 47:1127-30. [DOI: 10.1161/strokeaha.116.012684] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 01/29/2016] [Indexed: 01/19/2023]
Affiliation(s)
- Jan C. Purrucker
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Marcel Wolf
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Kirsten Haas
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Timolaos Rizos
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Shujah Khan
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Rainer Dziewas
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Christoph Kleinschnitz
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Andreas Binder
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Klaus Gröschel
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Michael G. Hennerici
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Kyriakos Lobotesis
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Sven Poli
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Günter Seidel
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Tobias Neumann-Haefelin
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Peter A. Ringleb
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Peter U. Heuschmann
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
| | - Roland Veltkamp
- From the Departments of Neurology (J.C.P., T.R., S.K., P.A.R., R.V.) and Neuroradiology (M.W.), University Hospital Heidelberg, Heidelberg, Germany; Institute of Clinical Epidemiology and Biometry (K.H., P.U.H.), University of Würzburg, Würzburg, Germany; Department of Neurology, University Hospital Münster, Münster, Germany (R.D.); Department of Neurology (C.K.), and Comprehensive Heart Failure Center and Clinical Trial Center (P.U.H.), University Hospital Würzburg, Würzburg, Germany; Department of
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Purrucker JC, Haas K, Rizos T, Khan S, Wolf M, Hennerici MG, Poli S, Kleinschnitz C, Steiner T, Heuschmann PU, Veltkamp R. Early Clinical and Radiological Course, Management, and Outcome of Intracerebral Hemorrhage Related to New Oral Anticoagulants. JAMA Neurol 2016; 73:169-77. [PMID: 26660118 DOI: 10.1001/jamaneurol.2015.3682] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Intracerebral hemorrhage (ICH) is the most devastating adverse event in patients receiving oral anticoagulation. There is only sparse evidence regarding ICH related to the use of non-vitamin K antagonist oral anticoagulant (NOAC) agents. OBJECTIVE To evaluate the early clinical and radiological course, acute management, and outcome of ICH related to NOAC use. DESIGN, SETTING, AND PARTICIPANTS Prospective investigator-initiated, multicenter observational study. All diagnostic and treatment decisions, including administration of hemostatic factors (eg, prothrombin complex concentrate), were left to the discretion of the treating physicians. The setting was 38 stroke units across Germany (February 1, 2012, to December 31, 2014). The study included 61 consecutive patients with nontraumatic NOAC-associated ICH, of whom 45 (74%) qualified for the hematoma expansion analysis. MAIN OUTCOMES AND MEASURES Hematoma expansion, intraventricular hemorrhage, and reversal of anticoagulation during the acute phase. Recorded were the 3-month functional outcome, factors associated with an unfavorable outcome (modified Rankin Scale score, 3-6), any new intraventricular extension or an increase in the modified Graeb score by at least 2 points, and the frequency of substantial hematoma expansion (defined as relative [≥ 33%] or absolute [≥ 6-mL] volume increase). RESULTS In total, 41% (25 of 61) of patients with NOAC-associated ICH were female, and the mean (SD) patient age was 76.1 (11.6) years. At admission, the median National Institutes of Health Stroke Scale score was 10 (interquartile range, 4-18). The mean (SD) baseline hematoma volume was 23.7 (31.3) mL. In patients with sequential imaging for the hematoma expansion analysis, substantial hematoma expansion occurred in 38% (17 of 45). New or increased intraventricular hemorrhage was observed in 18% (8 of 45). Overall mortality was 28% (17 of 60 [follow-up data were missing in 1 patient]) at 3 months, and 65% (28 of 43) of survivors had an unfavorable outcome (modified Rankin Scale score, 3-6). Overall, 57% (35 of 61) of the patients received prothrombin complex concentrate, with no statistically significant effect on the frequency of substantial hematoma expansion (43% [12 of 28] for prothrombin complex concentrate vs 29% [5 of 17] for no prothrombin complex concentrate, P = .53), or on the occurrence of an unfavorable outcome (modified Rankin Scale score, 3-6) (odds ratio, 1.20; 95% CI, 0.37-3.87; P = .76). CONCLUSIONS AND RELEVANCE Non-vitamin K antagonist oral anticoagulant-associated ICH has a high mortality and an unfavorable outcome, and hematoma expansion is frequent. Larger-scale prospective studies are needed to determine whether the early administration of specific antidotes can improve the poor prognosis of NOAC-associated ICH.
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Affiliation(s)
- Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kirsten Haas
- Institute of Clinical Epidemiology and Biometry, Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Shujah Khan
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Marcel Wolf
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael G Hennerici
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Sven Poli
- Department of Neurology and Stroke, Tübingen University, Tübingen, Germany
| | | | - Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany7Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt am Main, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany8Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany9Department of Stroke Medicine, Imperial College London, London, England
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Purrucker JC, Hametner C, Engelbrecht A, Bruckner T, Popp E, Poli S. Comparison of stroke recognition and stroke severity scores for stroke detection in a single cohort. J Neurol Neurosurg Psychiatry 2015; 86:1021-8. [PMID: 25466259 DOI: 10.1136/jnnp-2014-309260] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [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: 08/17/2014] [Accepted: 11/03/2014] [Indexed: 11/04/2022]
Abstract
OBJECTIVE First, to determine the sensitivity and specificity of six stroke recognition scores in a single cohort to improve interscore comparability. Second, to test four stroke severity scores repurposed to recognise stroke in parallel. METHODS Of 9154 emergency runs, 689 consecutive cases of preclinically 'suspected central nervous system disorder' admitted to the emergency room (ER) of the Heidelberg University Hospital were included in the validation cohort. Using data abstracted from the neurological ER medical reports, retrospective assessment of stroke recognition scores became possible for the Cincinnati Prehospital Stroke Scale (CPSS), Face Arm Speech Test (FAST), Los Angeles Prehospital Stroke Screen (LAPSS), Melbourne Ambulance Stroke Screen (MASS), Medic Prehospital Assessment for Code Stroke (Med PACS) and Recognition of Stroke in the Emergency Room score (ROSIER), and that of stroke severity scores became possible for the Kurashiki Prehospital Stroke Scale (KPSS), Los Angeles Motor Scale (LAMS) and shortened National Institutes of Health Stroke Scale (sNIHSS)-8/sNIHSS-5. Test characteristics were calculated using the hospital discharge diagnosis as the reference standard. RESULTS The CPSS and FAST had a sensitivity of 83% (95% CI 76 to 88) and 85% (78% to 90%) and a specificity of 69% (64% to 73%) and 68% (63% to 72%), respectively. The more complex LAPSS, MASS and Med PACS had a high specificity (92% to 98%) but low sensitivity (44% to 71%). In the ROSIER, sensitivity (80%, 73 to 85) and specificity (79%, 75 to 83) were similar. Test characteristics for KPSS, sNIHSS-8 and sNIHSS-5 were similar to the simple recognition scores (sensitivity 83% to 86%, specificity 60% to 69%). The LAMS offered only low sensitivity. CONCLUSIONS The simple CPSS and FAST scores provide good sensitivity for stroke recognition. More complex scores do not result in better diagnostic performance. Stroke severity scores can be repurposed to recognise stroke at the same time because test characteristics are comparable with pure stroke recognition scores. Particular shortcomings of the individual scores are discussed.
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Affiliation(s)
- Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Hametner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas Engelbrecht
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Erik Popp
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany
| | - Sven Poli
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany Department of Neurology & Stroke, Tübingen University, Tübingen, Germany
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Purrucker JC, Renzland J, Uhlmann L, Bruckner T, Hacke W, Steiner T, Bösel J. Volatile sedation with sevoflurane in intensive care patients with acute stroke or subarachnoid haemorrhage using AnaConDa®: an observational study. Br J Anaesth 2015; 114:934-43. [PMID: 25823541 DOI: 10.1093/bja/aev070] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The anaesthetic conserving device, AnaConDa(®), allows use of inhaled anaesthetics for sedation in the intensive care unit. We prospectively measured cerebral and cardiopulmonary parameters in patients with acute stroke or subarachnoid haemorrhage during a switch from i.v. to inhalative sedation. METHODS 25 patients were switched from i.v. to an indefinite period of inhaled sedation with sevoflurane. Mean arterial (MAP), intracranial (ICP), and cerebral perfusion pressure (CPP), middle cerebral artery mean flow velocity (MFV) and fractional tissue oxygen extraction (FTOE), systemic cardiopulmonary parameters, and administered drugs were assessed before and after the change (-6 to +12 h). RESULTS In 8 patients, critically reduced MAP or ICP crisis led to premature termination of sevoflurane sedation. In the other 17 patients, after the first hour, mean ICP increased [2.4 (4.5) mm Hg; P=0.046], MAP decreased [7.8 (14.1) mm Hg; P=0.036] and thus CPP decreased also [-10.2 (15.1) mm Hg; P=0.014]. MFV and FTOE did not change. Over a 12 hour post switch observational period, [Formula: see text] increased slightly [0.3 (0.8) kPa; P=0.104], ICP did not change [0.2 (3.9) mm Hg; P=0.865], but MAP [-6 (6.9) mm Hg; P=0.002] and thus CPP decreased [-6 (8.5) mm Hg; P=0.010]. CONCLUSION Sevoflurane led to sufficient sedation, but decreased MAP and CPP in a selected cerebrovascular neurocritical care population. In about a third of these patients, severe adverse reactions, including intolerable ICP increases, were observed.
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Affiliation(s)
- J C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - J Renzland
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - L Uhlmann
- Department of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - T Bruckner
- Department of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - W Hacke
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - T Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt am Main, Germany
| | - J Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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Purrucker JC, Herrmann O, Lutsch JK, Zorn M, Schwaninger M, Bruckner T, Auffarth GU, Veltkamp R. Serum protein S100β is a diagnostic biomarker for distinguishing posterior circulation stroke from vertigo of nonvascular causes. Eur Neurol 2014; 72:278-84. [PMID: 25323105 DOI: 10.1159/000363569] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 05/11/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients presenting with acute vertigo or dizziness, identifying the posterior fossa stroke as the underlying cause can be a major challenge. We therefore evaluated the serum biomarkers for the differential diagnosis of nonvascular vertigo and posterior circulation stroke. METHODS Of a total of 80 patients, 31 patients had an ischemic stroke in the posterior circulation and 12 infratentorial hemorrhage. Findings in these patients were compared with those in 22 patients with vertigo of nonvascular origin and 15 matched control patients without neurological symptoms. Blood samples drawn <24 h after symptom onset were analyzed for S100 calcium-binding protein B (S100β), matrix metalloproteinase 9 (MMP-9), soluble vascular cellular adhesion molecule-1 (sVCAM-1), and glial fibrillary acidic protein (GFAP). RESULTS/CONCLUSION Serum levels of S100β were significantly higher in stroke patients than in nonvascular vertigo patients. Serum concentrations of MMP-9 tended to be higher in stroke patients, whereas no significant differences among groups were found for sVCAM-1 and GFAP. Receiver-operating characteristic analysis revealed a sensitivity of 94.4% and a specificity of 31.8% for detecting stroke in patients presenting with vertigo for S100β. S100β may serve as a biomarker for distinguishing between vertigo of vascular causes and nonvascular, acute vertigo.
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Affiliation(s)
- Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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Purrucker JC, Capper D, Behrens L, Veltkamp R. Secondary hematoma expansion in intracerebral hemorrhage during rivaroxaban therapy. Am J Emerg Med 2014; 32:947.e3-5. [DOI: 10.1016/j.ajem.2014.01.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 01/24/2014] [Indexed: 11/16/2022] Open
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Purrucker JC, Hund E, Hinderhofer K, Kollmer J, Schönland S, Hegenbart U. Doxycycline in ATTRY69H (p.ATTRY89H) amyloidosis with predominant leptomeningeal manifestation. Amyloid 2013; 20:279-80. [PMID: 24047503 DOI: 10.3109/13506129.2013.829439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Purrucker JC, Hund E, Ringleb PA, Hartmann C, Rohde S, Schönland S, Steiner T. Cerebral amyloid angiopathy--an underdiagnosed entity in younger adults with lobar intracerebral hemorrhage? Amyloid 2013; 20:45-7. [PMID: 23231422 DOI: 10.3109/13506129.2012.746937] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cerebral amyloid angiopathy (CAA) is a progressive microvascular amyloidosis affecting the small- and medium-sized arterioles and the capillaries of brain parenchyma and leptomeninges, and is recognized as a cause of lobar intracerebral hemorrhage (ICH). We report two patients who experienced recurrent ICH due to CAA at an age of 37 (A) and 42 (B) years, respectively. The classic and modified Boston criteria for the diagnosis of CAA include an age limit of 55 years if no biopsy or postmortem examination is performed; CAA is typically not considered in the differential diagnosis of lobar ICH in younger patients. We assume that sporadic CAA is an underdiagnosed entity in younger adults with lobar ICH.
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Affiliation(s)
- Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.
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Bösel J, Purrucker JC, Nowak F, Renzland J, Schiller P, Pérez EB, Poli S, Brunn B, Hacke W, Steiner T. Volatile isoflurane sedation in cerebrovascular intensive care patients using AnaConDa(®): effects on cerebral oxygenation, circulation, and pressure. Intensive Care Med 2012; 38:1955-64. [PMID: 23096426 DOI: 10.1007/s00134-012-2708-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 08/12/2012] [Indexed: 12/11/2022]
Abstract
PURPOSE The anesthetic-conserving device AnaConDa(®), a miniature vaporizer, allows volatile sedation in the intensive care unit (ICU). We investigated the effects of isoflurane sedation on cerebral and systemic physiology parameters in neuromonitored ICU stroke patients. METHODS Included in the study were 19 consecutive ventilated patients with intracerebral hemorrhage (12), subarachnoid hemorrhage (4), and ischemic stroke (3) who were switched from intravenous propofol or midazolam to inhalative isoflurane sedation for an average of 3.5 days. During the sedation transition, the following parameters were assessed: mean arterial pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), middle cerebral artery mean flow velocity (MFV) and cerebral fractional tissue oxygen extraction (FTOE), as well as systemic cardiopulmonary parameters and administered drugs. RESULTS After the first hour, mean ICP showed an increase of 2.1 mmHg that was not clinically relevant. Likewise, MFV did not change. MAP and CPP, however, decreased by 6.5 and 6.3 mmHg, respectively. FTOE was reduced slightly from 0.24 to 0.21 (p = 0.03). Over an observation period of 12 h, ICP remained stable, while MAP and thus CPP showed distinct decreases (CPP: -10 mmHg at 6 h, p < 0.001; -7.5 mmHg at 12 h, p = 0.005, when compared to preswitch levels) despite a 1.5-fold increase in vasopressor administration. CONCLUSIONS We suggest that that it is possible to reach sufficient sedation levels in cerebrovascular ICU patients by applying volatile isoflurane long-term without a relevant increase in ICP, if baseline ICP values are low or only moderately elevated. However, caution should be exercised in view of isoflurane's decreasing effect on MAP and CPP. Multimodal neuromonitoring is strongly recommended when applying this off-label sedation method.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany.
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Purrucker JC, Rohde S, Stampfl S, Ringleb PA. Observation of Indirect Neorevascularization after Leptomeningeal Biopsy in a 34-Year-Old Woman with Moyamoya Syndrome – Should Burr Holes Be Considered as an Alternative Revascularization Technique in Younger Adults with Moyamoya? Cerebrovasc Dis 2012; 33:94-5. [DOI: 10.1159/000332808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Purrucker JC, Mahlknecht U. Targeting the epigenome: effects of epigenetic treatment strategies on genomic stability in healthy human cells. Clin Epigenetics 2010; 1:45-54. [PMID: 22704088 PMCID: PMC3365366 DOI: 10.1007/s13148-010-0007-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 07/12/2010] [Indexed: 02/02/2023] Open
Abstract
Epigenetic treatment concepts have long been ascribed as being tumour-selective. Over the last decade, it has become evident that epigenetic mechanisms are essential for a wide range of intracellular functions in healthy cells as well. Evaluation of possible side-effects and their underlying mechanisms in healthy human cells is necessary in order to improve not only patient safety, but also to support future drug development. Since epigenetic regulation directly interacts with genomic and chromosomal packaging density, increasing genomic instability may be a result subsequent to drug-induced epigenetic modifications. This review highlights past and current research efforts on the influence of epigenetic modification on genomic stability in healthy human cells.
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Affiliation(s)
- Jan C Purrucker
- Division of Immunotherapy and Gene Therapy, José Carreras Center for Immunotherapy and Gene Therapy, Department of Internal Medicine, Saarland University Medical Center, 66421 Homburg/Saar, Germany
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Purrucker JC, Fricke A, Ong MF, Rübe C, Rübe CE, Mahlknecht U. HDAC inhibition radiosensitizes human normal tissue cells and reduces DNA Double-Strand Break repair capacity. Oncol Rep 2010; 23:263-269. [PMID: 19956891] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
HDAC inhibitors (HDACi) are gaining increasing attention in the treatment of cancer, particularly in view of their therapeutic effectiveness and assumed mild toxicity profile. While numerous studies have investigated the role of HDACi in tumor cells, little is known about their effects on normal tissue cells. We studied the effect of suberoylanilide hydroxamic acid (SAHA), MS275, sodium-butyrate and valproic acid in healthy human fibroblasts and found HDACi-treatment to go along with increased radiosensitivity and reduced DSB repair capacity. In view of the potential genotoxic effects of HDACi-treatment, particularly when being administered long-term for chronic disease or when given to children, to women of childbearing age or their partners or in combination with radiotherapy, an extensive education of patients and prescribing physicians as well as a stringent definition of clinical indications is urgently required.
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Affiliation(s)
- Jan C Purrucker
- Division of Immunotherapy and Gene Therapy, Department of Internal Medicine I, José Carreras Research Center, Saarland University Medical Center, Homburg/Saar, Germany
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