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Yassi N, Zhao H, Churilov L, Wu TY, Ma H, Nguyen HT, Cheung A, Meretoja A, Mai DT, Kleinig T, Jeng JS, Choi PMC, Duc PD, Brown H, Ranta A, Spratt N, Cloud GC, Wang HK, Grimley R, Mahawish K, Cho DY, Shah D, Nguyen TMP, Sharma G, Yogendrakumar V, Yan B, Harrison EL, Devlin M, Cordato D, Martinez-Majander N, Strbian D, Thijs V, Sanders LM, Anderson D, Parsons MW, Campbell BCV, Donnan GA, Davis SM. Tranexamic acid versus placebo in individuals with intracerebral haemorrhage treated within 2 h of symptom onset (STOP-MSU): an international, double-blind, randomised, phase 2 trial. Lancet Neurol 2024:S1474-4422(24)00128-5. [PMID: 38648814 DOI: 10.1016/s1474-4422(24)00128-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Tranexamic acid, an antifibrinolytic agent, might attenuate haematoma growth after an intracerebral haemorrhage. We aimed to determine whether treatment with intravenous tranexamic acid within 2 h of an intracerebral haemorrhage would reduce haematoma growth compared with placebo. METHODS STOP-MSU was an investigator-led, double-blind, randomised, phase 2 trial conducted at 24 hospitals and one mobile stroke unit in Australia, Finland, New Zealand, Taiwan, and Viet Nam. Eligible participants had acute spontaneous intracerebral haemorrhage confirmed on non-contrast CT, were aged 18 years or older, and could be treated with the investigational product within 2 h of stroke onset. Using randomly permuted blocks (block size of 4) and a concealed pre-randomised assignment procedure, participants were randomly assigned (1:1) to receive intravenous tranexamic acid (1 g over 10 min followed by 1 g over 8 h) or placebo (saline; matched dosing regimen) commencing within 2 h of symptom onset. Participants, investigators, and treating teams were masked to group assignment. The primary outcome was haematoma growth, defined as either at least 33% relative growth or at least 6 mL absolute growth on CT at 24 h (target range 18-30 h) from the baseline CT. The analysis was conducted within the estimand framework with primary analyses adhering to the intention-to-treat principle. The primary endpoint and secondary safety endpoints (mortality at days 7 and 90 and major thromboembolic events at day 90) were assessed in all participants randomly assigned to treatment groups who did not withdraw consent to use any data. This study was registered with ClinicalTrials.gov, NCT03385928, and the trial is now complete. FINDINGS Between March 19, 2018, and Feb 27, 2023, 202 participants were recruited, of whom one withdrew consent for any data use. The remaining 201 participants were randomly assigned to either placebo (n=98) or tranexamic acid (n=103; intention-to-treat population). Median age was 66 years (IQR 55-77), and 82 (41%) were female and 119 (59%) were male; no data on race or ethnicity were collected. CT scans at baseline or follow-up were missing or of inadequate quality in three participants (one in the placebo group and two in the tranexamic acid group), and were considered missing at random. Haematoma growth occurred in 37 (38%) of 97 assessable participants in the placebo group and 43 (43%) of 101 assessable participants in the tranexamic acid group (adjusted odds ratio [aOR] 1·31 [95% CI 0·72 to 2·40], p=0·37). Major thromboembolic events occurred in one (1%) of 98 participants in the placebo group and three (3%) of 103 in the tranexamic acid group (risk difference 0·02 [95% CI -0·02 to 0·06]). By 7 days, eight (8%) participants in the placebo group and eight (8%) in the tranexamic acid group had died (aOR 1·08 [95% CI 0·35 to 3·35]) and by 90 days, 15 (15%) participants in the placebo group and 19 (18%) in the tranexamic acid group had died (aOR 1·61 [95% CI 0·65 to 3·98]). INTERPRETATION Intravenous tranexamic acid did not reduce haematoma growth when administered within 2 h of intracerebral haemorrhage symptom onset. There were no observed effects on other imaging endpoints, functional outcome, or safety. Based on our results, tranexamic acid should not be used routinely in primary intracerebral haemorrhage, although results of ongoing phase 3 trials will add further context to these findings. FUNDING Australian Government Medical Research Future Fund.
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Affiliation(s)
- Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.
| | - Henry Zhao
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Melbourne Medical School, University of Melbourne, Parkville, VIC, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Huy-Thang Nguyen
- Department of Cerebrovascular Disease, 115 Hospital, Ho Chi Minh City, Viet Nam
| | - Andrew Cheung
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Duy Ton Mai
- Stroke Center, Bach Mai Hospital, Hanoi Medical University, VNU University of Medicine and Pharmacy, Hanoi, Viet Nam
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jiann-Shing Jeng
- Stroke Centre and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Philip M C Choi
- Department of Neuroscience, Box Hill Hospital, Eastern Health, Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - Phuc Dang Duc
- Stroke Department, 103 Military Hospital, Hanoi, Viet Nam
| | - Helen Brown
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, and School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Melbourne, VIC, Australia
| | - Hao-Kuang Wang
- Department of Neurosurgery, E-Da Hospital, I-Shou University, Yanchao, Taiwan
| | - Rohan Grimley
- Department of Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Karim Mahawish
- Department of Internal Medicine, Palmerston North Hospital, Palmerston North, New Zealand
| | - Der-Yang Cho
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan
| | - Darshan Shah
- Department of Neurology, Gold Coast University Hospital, Southport, QLD, Australia
| | | | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Emma L Harrison
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Michael Devlin
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Dennis Cordato
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland; Department of Neurology, University of Helsinki, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland; Department of Neurology, University of Helsinki, Helsinki, Finland
| | - Vincent Thijs
- The Florey, Stroke Theme, Heidelberg, VIC, Australia; Department of Neurology, Austin Hospital, Heidelberg, VIC, Australia; Department of Medicine, University of Melbourne, Heidelberg, VIC, Australia
| | - Lauren M Sanders
- Department of Neurosciences, St Vincent's Hospital, Melbourne, VIC, Australia
| | | | - Mark W Parsons
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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Lin CH, Chen YA, Jeng JS, Sun Y, Wei CY, Yeh PY, Chang WL, Fann YC, Hsu KC, Lee JT. Predicting ischemic stroke patients' prognosis changes using machine learning in a nationwide stroke registry. Med Biol Eng Comput 2024:10.1007/s11517-024-03073-4. [PMID: 38575823 DOI: 10.1007/s11517-024-03073-4] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 03/13/2024] [Indexed: 04/06/2024]
Abstract
Accurately predicting the prognosis of ischemic stroke patients after discharge is crucial for physicians to plan for long-term health care. Although previous studies have demonstrated that machine learning (ML) shows reasonably accurate stroke outcome predictions with limited datasets, to identify specific clinical features associated with prognosis changes after stroke that could aid physicians and patients in devising improved recovery care plans have been challenging. This study aimed to overcome these gaps by utilizing a large national stroke registry database to assess various prediction models that estimate how patients' prognosis changes over time with associated clinical factors. To properly evaluate the best predictive approaches currently available and avoid prejudice, this study employed three different prognosis prediction models including a statistical logistic regression model, commonly used clinical-based scores, and a latest high-performance ML-based XGBoost model. The study revealed that the XGBoost model outperformed other two traditional models, achieving an AUROC of 0.929 in predicting the prognosis changes of stroke patients followed for 3 months. In addition, the XGBoost model maintained remarkably high precision even when using only selected 20 most relevant clinical features compared to full clinical datasets used in the study. These selected features closely correlated with significant changes in clinical outcomes for stroke patients and showed to be effective for predicting prognosis changes after discharge, allowing physicians to make optimal decisions regarding their patients' recovery.
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Affiliation(s)
- Ching-Heng Lin
- Division of Intramural Research, Disorders and Stroke, National Institute of Neurological, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD, 20892, USA
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Bachelor Program in Artificial Intelligence, Chang Gung University, Taoyuan, Taiwan
| | - Yi-An Chen
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu Sun
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Cheng-Yu Wei
- Department of Exercise and Health Promotion, College of Kinesiology and Health, Chinese Culture University, Taipei, Taiwan
| | - Po-Yen Yeh
- Department of Neurology, St. Martin de Porres Hospital, Chiayi, Taiwan
| | - Wei-Lun Chang
- Department of Neurology, Show Chwan Memorial Hospital, Changhua County, Taiwan
| | - Yang C Fann
- Division of Intramural Research, Disorders and Stroke, National Institute of Neurological, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD, 20892, USA.
| | - Kai-Cheng Hsu
- Department of Medicine, China Medical University, Taichung, Taiwan.
- Artificial Intelligence Center for Medical Diagnosis, China Medical University Hospital, No. 2, Yude Rd., North Dist., Taichung, 404332, Taiwan.
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan.
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
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Egle M, Wang WC, Fann YC, Johansen MC, Lee JT, Yeh CH, Jason Lin CH, Jeng JS, Sun Y, Lien LM, Gottesman RF. Sex Differences in the Role of Multimorbidity on Poststroke Disability: The Taiwan Stroke Registry. Neurology 2024; 102:e209140. [PMID: 38330286 DOI: 10.1212/wnl.0000000000209140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/28/2023] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Multimorbidity is common in patients who experience stroke. Less is known about the effect of specific multimorbidity patterns on long-term disability in patients with stroke. Furthermore, given the increased poststroke disability frequently seen in female vs male patients, it is unknown whether multimorbidity has a similar association with disability in both sexes. We assessed whether specific multimorbidity clusters were associated with greater long-term poststroke disability burden overall and by sex. METHODS In the Taiwan Stroke Registry, an ongoing nationwide prospective registry, patients with first-ever ischemic stroke were enrolled; this analysis is restricted to those individuals surviving to at least 6 months poststroke. Using a hierarchical clustering approach, clusters of prestroke multimorbidity were generated based on 16 risk factors; the algorithm identified 5 distinct clusters. The association between clusters and 12-month poststroke disability, defined using the modified Rankin Scale (mRS), was determined using logistic regression models, with additional models stratified by sex. The longitudinal association between multimorbidity and functional status change was assessed using mixed-effects models. RESULTS Nine-thousand eight hundred eighteen patients with first-ever ischemic stroke were included. The cluster with no risk factors was the reference, "healthier" risk group (N = 1,373). Patients with a cluster profile of diabetes, peripheral artery disease (PAD), and chronic kidney disease (CKD) (N = 1882) had significantly greater disability (mRS ≥ 3) at 1 month (OR [95% CI] = 1.36 [1.13-1.63]), 3 months (OR [95% CI] = 1.27 [1.04-1.55]), and 6 months (OR [95% CI] = 1.30 [1.06-1.59]) but not at 12 months (OR [95% CI] = 1.16 [0.95-1.42]) than patients with a healthier risk factor profile. In the sex-stratified analysis, the associations with this risk cluster remained consistent in male patients (OR [95% CI] = 1.42 [1.06-1.89]) at 12 months, who also had a higher comorbidity burden, but not in female patients (OR [95% CI] = 0.95 [0.71-1.26]), who had higher proportions of severe strokes and severe disability (p-interaction = 0.04). DISCUSSION Taiwanese patients with multimorbidity, specifically the concurrent presence of diabetes, PAD, and CKD, had higher odds of a worse functional outcome in the first 6 months poststroke. Clusters of multimorbidity may be less informative for long-term disability in female patients. Further studies should evaluate other mechanisms for worse disability in female patients poststroke.
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Affiliation(s)
- Marco Egle
- From the National Institute of Neurological Disorders and Stroke (M.E., W.-C.W., Y.C.F., R.F.G.), Intramural Research Program, National Institutes of Health, Bethesda, MD; Department of Neurology (W.-C.W.), China Medical University Hospital, Taichung, Taiwan; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (J.-T.L.), Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Nursing (C.-H.Y.), College of Nursing and Health, Da-Yeh University; Department of Neurology (C.-H.Y.), Yuan Rung Hospital, Changhua, Taiwan; Director of Stroke Center (C.-H.J.L.), Department of Neurology Stroke Center, Lin Shin Hospital; Stroke Center and Department of Neurology (J.-S.J.), National Taiwan University Hospital; Department of Neurology (Y.S.), En Chu Kong Hospital, New Taipei City; and Department of Neurology (L.-M.L.), Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Wei-Chun Wang
- From the National Institute of Neurological Disorders and Stroke (M.E., W.-C.W., Y.C.F., R.F.G.), Intramural Research Program, National Institutes of Health, Bethesda, MD; Department of Neurology (W.-C.W.), China Medical University Hospital, Taichung, Taiwan; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (J.-T.L.), Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Nursing (C.-H.Y.), College of Nursing and Health, Da-Yeh University; Department of Neurology (C.-H.Y.), Yuan Rung Hospital, Changhua, Taiwan; Director of Stroke Center (C.-H.J.L.), Department of Neurology Stroke Center, Lin Shin Hospital; Stroke Center and Department of Neurology (J.-S.J.), National Taiwan University Hospital; Department of Neurology (Y.S.), En Chu Kong Hospital, New Taipei City; and Department of Neurology (L.-M.L.), Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Yang C Fann
- From the National Institute of Neurological Disorders and Stroke (M.E., W.-C.W., Y.C.F., R.F.G.), Intramural Research Program, National Institutes of Health, Bethesda, MD; Department of Neurology (W.-C.W.), China Medical University Hospital, Taichung, Taiwan; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (J.-T.L.), Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Nursing (C.-H.Y.), College of Nursing and Health, Da-Yeh University; Department of Neurology (C.-H.Y.), Yuan Rung Hospital, Changhua, Taiwan; Director of Stroke Center (C.-H.J.L.), Department of Neurology Stroke Center, Lin Shin Hospital; Stroke Center and Department of Neurology (J.-S.J.), National Taiwan University Hospital; Department of Neurology (Y.S.), En Chu Kong Hospital, New Taipei City; and Department of Neurology (L.-M.L.), Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Michelle C Johansen
- From the National Institute of Neurological Disorders and Stroke (M.E., W.-C.W., Y.C.F., R.F.G.), Intramural Research Program, National Institutes of Health, Bethesda, MD; Department of Neurology (W.-C.W.), China Medical University Hospital, Taichung, Taiwan; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (J.-T.L.), Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Nursing (C.-H.Y.), College of Nursing and Health, Da-Yeh University; Department of Neurology (C.-H.Y.), Yuan Rung Hospital, Changhua, Taiwan; Director of Stroke Center (C.-H.J.L.), Department of Neurology Stroke Center, Lin Shin Hospital; Stroke Center and Department of Neurology (J.-S.J.), National Taiwan University Hospital; Department of Neurology (Y.S.), En Chu Kong Hospital, New Taipei City; and Department of Neurology (L.-M.L.), Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Jiunn-Tay Lee
- From the National Institute of Neurological Disorders and Stroke (M.E., W.-C.W., Y.C.F., R.F.G.), Intramural Research Program, National Institutes of Health, Bethesda, MD; Department of Neurology (W.-C.W.), China Medical University Hospital, Taichung, Taiwan; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (J.-T.L.), Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Nursing (C.-H.Y.), College of Nursing and Health, Da-Yeh University; Department of Neurology (C.-H.Y.), Yuan Rung Hospital, Changhua, Taiwan; Director of Stroke Center (C.-H.J.L.), Department of Neurology Stroke Center, Lin Shin Hospital; Stroke Center and Department of Neurology (J.-S.J.), National Taiwan University Hospital; Department of Neurology (Y.S.), En Chu Kong Hospital, New Taipei City; and Department of Neurology (L.-M.L.), Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chung-Hsin Yeh
- From the National Institute of Neurological Disorders and Stroke (M.E., W.-C.W., Y.C.F., R.F.G.), Intramural Research Program, National Institutes of Health, Bethesda, MD; Department of Neurology (W.-C.W.), China Medical University Hospital, Taichung, Taiwan; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (J.-T.L.), Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Nursing (C.-H.Y.), College of Nursing and Health, Da-Yeh University; Department of Neurology (C.-H.Y.), Yuan Rung Hospital, Changhua, Taiwan; Director of Stroke Center (C.-H.J.L.), Department of Neurology Stroke Center, Lin Shin Hospital; Stroke Center and Department of Neurology (J.-S.J.), National Taiwan University Hospital; Department of Neurology (Y.S.), En Chu Kong Hospital, New Taipei City; and Department of Neurology (L.-M.L.), Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chih-Hao Jason Lin
- From the National Institute of Neurological Disorders and Stroke (M.E., W.-C.W., Y.C.F., R.F.G.), Intramural Research Program, National Institutes of Health, Bethesda, MD; Department of Neurology (W.-C.W.), China Medical University Hospital, Taichung, Taiwan; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (J.-T.L.), Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Nursing (C.-H.Y.), College of Nursing and Health, Da-Yeh University; Department of Neurology (C.-H.Y.), Yuan Rung Hospital, Changhua, Taiwan; Director of Stroke Center (C.-H.J.L.), Department of Neurology Stroke Center, Lin Shin Hospital; Stroke Center and Department of Neurology (J.-S.J.), National Taiwan University Hospital; Department of Neurology (Y.S.), En Chu Kong Hospital, New Taipei City; and Department of Neurology (L.-M.L.), Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- From the National Institute of Neurological Disorders and Stroke (M.E., W.-C.W., Y.C.F., R.F.G.), Intramural Research Program, National Institutes of Health, Bethesda, MD; Department of Neurology (W.-C.W.), China Medical University Hospital, Taichung, Taiwan; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (J.-T.L.), Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Nursing (C.-H.Y.), College of Nursing and Health, Da-Yeh University; Department of Neurology (C.-H.Y.), Yuan Rung Hospital, Changhua, Taiwan; Director of Stroke Center (C.-H.J.L.), Department of Neurology Stroke Center, Lin Shin Hospital; Stroke Center and Department of Neurology (J.-S.J.), National Taiwan University Hospital; Department of Neurology (Y.S.), En Chu Kong Hospital, New Taipei City; and Department of Neurology (L.-M.L.), Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Yu Sun
- From the National Institute of Neurological Disorders and Stroke (M.E., W.-C.W., Y.C.F., R.F.G.), Intramural Research Program, National Institutes of Health, Bethesda, MD; Department of Neurology (W.-C.W.), China Medical University Hospital, Taichung, Taiwan; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (J.-T.L.), Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Nursing (C.-H.Y.), College of Nursing and Health, Da-Yeh University; Department of Neurology (C.-H.Y.), Yuan Rung Hospital, Changhua, Taiwan; Director of Stroke Center (C.-H.J.L.), Department of Neurology Stroke Center, Lin Shin Hospital; Stroke Center and Department of Neurology (J.-S.J.), National Taiwan University Hospital; Department of Neurology (Y.S.), En Chu Kong Hospital, New Taipei City; and Department of Neurology (L.-M.L.), Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Li-Ming Lien
- From the National Institute of Neurological Disorders and Stroke (M.E., W.-C.W., Y.C.F., R.F.G.), Intramural Research Program, National Institutes of Health, Bethesda, MD; Department of Neurology (W.-C.W.), China Medical University Hospital, Taichung, Taiwan; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (J.-T.L.), Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Nursing (C.-H.Y.), College of Nursing and Health, Da-Yeh University; Department of Neurology (C.-H.Y.), Yuan Rung Hospital, Changhua, Taiwan; Director of Stroke Center (C.-H.J.L.), Department of Neurology Stroke Center, Lin Shin Hospital; Stroke Center and Department of Neurology (J.-S.J.), National Taiwan University Hospital; Department of Neurology (Y.S.), En Chu Kong Hospital, New Taipei City; and Department of Neurology (L.-M.L.), Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Rebecca F Gottesman
- From the National Institute of Neurological Disorders and Stroke (M.E., W.-C.W., Y.C.F., R.F.G.), Intramural Research Program, National Institutes of Health, Bethesda, MD; Department of Neurology (W.-C.W.), China Medical University Hospital, Taichung, Taiwan; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (J.-T.L.), Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Nursing (C.-H.Y.), College of Nursing and Health, Da-Yeh University; Department of Neurology (C.-H.Y.), Yuan Rung Hospital, Changhua, Taiwan; Director of Stroke Center (C.-H.J.L.), Department of Neurology Stroke Center, Lin Shin Hospital; Stroke Center and Department of Neurology (J.-S.J.), National Taiwan University Hospital; Department of Neurology (Y.S.), En Chu Kong Hospital, New Taipei City; and Department of Neurology (L.-M.L.), Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
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Tsai HH, Liu CJ, Lee BC, Chen YF, Yen RF, Jeng JS, Tsai LK. Cerebral tau pathology in cerebral amyloid angiopathy. Brain Commun 2024; 6:fcae086. [PMID: 38638152 PMCID: PMC11024817 DOI: 10.1093/braincomms/fcae086] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/01/2024] [Accepted: 03/11/2024] [Indexed: 04/20/2024] Open
Abstract
Tau, a hallmark of Alzheimer's disease, is poorly characterized in cerebral amyloid angiopathy. We aimed to assess the clinico-radiological correlations between tau positron emission tomography scans and cerebral amyloid angiopathy. We assessed cerebral amyloid and hyperphosphorylated tau in patients with probable cerebral amyloid angiopathy (n = 31) and hypertensive small vessel disease (n = 27) using 11C-Pittsburgh compound B and 18F-T807 positron emission tomography. Multivariable regression models were employed to assess radio-clinical features related to cerebral tau pathology in cerebral amyloid angiopathy. Cerebral amyloid angiopathy exhibited a higher cerebral tau burden in the inferior temporal lobe [1.25 (1.17-1.42) versus 1.08 (1.05-1.22), P < 0.001] and all Braak stage regions of interest (P < 0.05) than hypertensive small vessel disease, although the differences were attenuated after age adjustment. Cerebral tau pathology was significantly associated with cerebral amyloid angiopathy-related vascular markers, including cortical superficial siderosis (β = 0.12, 95% confidence interval 0.04-0.21) and cerebral amyloid angiopathy score (β = 0.12, 95% confidence interval 0.03-0.21) after adjustment for age, ApoE4 status and whole cortex amyloid load. Tau pathology correlated significantly with cognitive score (Spearman's ρ=-0.56, P = 0.001) and hippocampal volume (-0.49, P = 0.007), even after adjustment. In conclusion, tau pathology is more frequent in sporadic cerebral amyloid angiopathy than in hypertensive small vessel disease. Cerebral amyloid angiopathy-related vascular pathologies, especially cortical superficial siderosis, are potential markers of cerebral tau pathology suggestive of concomitant Alzheimer's disease.
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Affiliation(s)
- Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Chia-Ju Liu
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Bo-Ching Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Ruoh-Fang Yen
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei 100225, Taiwan
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Chung CT, Chen CH, Lin YH, Cheng CJ, Chu HJ, Fu CH, Chen KW, Lee CW, Tang SC, Jeng JS. Prevalence and clinical features of carotid artery web in patients undergoing endovascular thrombectomy for acute ischemic stroke. J Formos Med Assoc 2024:S0929-6646(24)00107-4. [PMID: 38438298 DOI: 10.1016/j.jfma.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 01/20/2024] [Accepted: 02/16/2024] [Indexed: 03/06/2024] Open
Abstract
PURPOSE Carotid artery web (CaW) is a rare focal fibromuscular dysplasia that can lead to embolic strokes with large vessel occlusion. This condition can be effectively treated with endovascular thrombectomy (EVT). Our study aims to assess the prevalence of CaW among patients with acute ischemic stroke (AIS) who underwent EVT and to compare the clinical characteristics of CaW with other carotid artery pathologies. METHODS We enrolled consecutive patients with AIS who underwent EVT at a single medical center and two regional teaching hospitals in Taiwan from September 2014 to December 2021. We compared CaW with carotid dissection (CaD) and carotid large artery atherosclerosis (CaLAA) in terms of patient demographics and thrombus histological findings. RESULTS Of the 576 AIS patients who underwent EVT, four (mean age: 50 years) were diagnosed with CaW, resulting in a prevalence of 0.69%. Among these four patients, three experienced successful reperfusion after EVT and achieved functional independence (defined as a modified Rankin Scale score ≤2) three months post-stroke. Importantly, none of the CaW patients suffered a recurrent stroke within one year. Patients with CaW were younger than those with CaD or CaLAA, and exhibited fewer vascular risk factors. Additionally, CaW was associated with distal occlusion sites. The thrombus composition in CaW patients was similar to that in CaD patients. CONCLUSIONS In conclusion, CaW is a rare finding among Asian patients with carotid artery disease who undergo for AIS. It is more prevalent in younger patients with a limited number of vascular risk factors.
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Affiliation(s)
- Chi-Ting Chung
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Chih-Hao Chen
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Jie Cheng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Hai-Jui Chu
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Chuan-Hsiu Fu
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kuo-Wei Chen
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan.
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Yen HC, Pan GS, Jeng JS, Chen WS. Impact of Early Mobilization on Patients With Acute Ischemic Stroke Treated With Thrombolysis or Thrombectomy: A Randomized Controlled Trial. Neurorehabil Neural Repair 2024:15459683241236443. [PMID: 38426480 DOI: 10.1177/15459683241236443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Early mobilization (EM) within 24 to 72 hours post-stroke may improve patients' performance and ability. However, after intravenous thrombolysis (IVT) or mechanical thrombectomy (MT), the increased risk of hemorrhagic complications impacts the implementation of early out-of-bed mobilization. Few studies have investigated EM after IVT or MT for acute ischemic stroke (AIS), and its impact in these patients is unknown. OBJECTIVE To investigate the effect of EM on AIS treated with IVT or MT.|. METHODS We recruited 122 patients with first AIS; 60 patients were treated with IVT, and 62 patients were treated with MT. For each IVT and MT cohort, the control groups received standard early rehabilitation, and the intervention groups received an EM protocol. The training lasted 30 minutes/day, 5 days/week until discharge. MAIN OUTCOMES MEASURES The effectiveness of the interventions was evaluated using the motor domain of the Functional Independence Measure (FIM-motor) and the Postural Assessment Scale for Stroke Patients (PASS) at baseline, 2-week, 4-week, and 3-month post-stroke, the Functional Ambulation Category 2-week post-stroke, and the total length of stay at the stroke center. RESULTS Both IVT and MT treatment groups showed improved FIM-motor and PASS scores over time; however, only the IVT EM group had significantly improved FIM-motor performance within 1 month after stroke than the control group. Conclusion. An EM protocol with the same intervention time and session frequency per day as in the standard care protocol was effective in improving the functional ability of stroke patients after IVT.
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Affiliation(s)
- Hsiao-Ching Yen
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Guan-Shuo Pan
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center & Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Shiang Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
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Chen CH, Lee CW, Hsieh YC, Lin CJ, Chen YW, Lin KH, Sung PS, Tang CW, Chu HJ, Tsai KC, Chou CL, Lin CH, Wei CY, Yen SY, Chen PL, Yeh HL, Chan L, Sung SF, Lee M, Liu HM, Lin YH, Lee IH, Yeh SJ, Lien LM, Chiou HY, Lee JT, Tang SC, Jeng JS. Comparing Low- or Standard-Dose Alteplase in Endovascular Thrombectomy: Insights From a Nationwide Registry. Stroke 2024; 55:532-540. [PMID: 38314590 PMCID: PMC10896194 DOI: 10.1161/strokeaha.123.045851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/15/2023] [Accepted: 12/15/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Timely intravenous thrombolysis and endovascular thrombectomy are the standard reperfusion treatments for large vessel occlusion stroke. Currently, it is unknown whether a low-dose thrombolytic agent (0.6 mg/kg alteplase) can offer similar efficacy to the standard dose (0.9 mg/kg alteplase). METHODS We enrolled consecutive patients in the multicenter Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke who had received combined thrombolysis (within 4.5 hours of onset) and thrombectomy treatment from January 2019 to April 2023. The choice of low- or standard-dose alteplase was based on the physician's discretion. The outcomes included successful reperfusion (modified Thrombolysis in Cerebral Infarction score, 2b-3), symptomatic intracerebral hemorrhage, 90-day modified Rankin Scale score, and 90-day mortality. The outcomes between the 2 groups were compared using multivariable logistic regression and inverse probability of treatment weighting-adjusted analysis. RESULTS Among the 2242 patients in the Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke, 734 (33%) received intravenous alteplase. Patients in the low-dose group (n=360) were older, had more women, more atrial fibrillation, and longer onset-to-needle time compared with the standard-dose group (n=374). In comparison to low-dose alteplase, standard-dose alteplase was associated with a lower rate of successful reperfusion (81% versus 87%; adjusted odds ratio, 0.63 [95% CI, 0.40-0.98]), a numerically higher incidence of symptomatic intracerebral hemorrhage (6.7% versus 3.9%; adjusted odds ratio, 1.81 [95% CI, 0.88-3.69]), but better 90-day modified Rankin Scale score (functional independence [modified Rankin Scale score, 0-2], 47% versus 31%; adjusted odds ratio, 1.91 [95% CI, 1.28-2.86]), and a numerically lower mortality rate (9% versus 15%; adjusted odds ratio, 0.73 [95% CI, 0.43-1.25]) after adjusting for covariates. Similar results were observed in the inverse probability of treatment weighting-adjusted models. The results were consistent across predefined subgroups and age strata. CONCLUSIONS Despite the lower rate of successful reperfusion and higher risk of symptomatic intracerebral hemorrhage with standard-dose alteplase, standard-dose alteplase was associated with a better functional outcome in patients receiving combined thrombolysis and thrombectomy.
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Affiliation(s)
- Chih-Hao Chen
- Departments of Neurology (C.-H.C., S.-J.Y., S.-C.T., J.-S.J.), National Taiwan University Hospital, Taipei
| | - Chung-Wei Lee
- Medical Imaging (C.-W.L., Y.-H.L.), National Taiwan University Hospital, Taipei
| | - Yi-Chen Hsieh
- Program in Medical Neuroscience (Y.-C.H.), Taipei Medical University, Taiwan
| | - Chun-Jen Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan (C.-J.L., I.-H.L)
| | - Yu-Wei Chen
- Department of Neurology, Landseed International Hospital, Taoyuan, Taiwan (Y.-W.C.)
| | - Kuan-Hung Lin
- Department of Neurology, Chi Mei Medical Center, Tainan, Taiwan (K.-H.L.)
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (P.-S.S.)
| | - Chih-Wei Tang
- Department of Neurology, Far Eastern Memorial Hospital, New Taipei City, Taiwan (C.-W.T.)
| | - Hai-Jui Chu
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan (H.-J.C.)
| | - Kun-Chang Tsai
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City (K.-C.T.)
| | - Chao-Liang Chou
- Department of Neurology, Mackay Memorial Hospital, Taipei, Taiwan (C.-L.C.)
| | - Ching-Huang Lin
- Department of Neurology, Kaohsiung Veterans General Hospital, Taiwan (C.-H.L.)
| | - Cheng-Yu Wei
- Department of Neurology, Chang Bing Show Chwan Memorial Hospital, Changhwa County, Taiwan (C.-Y.W.)
| | - Shang-Yih Yen
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (S.-Y.Y., J.-T.L.)
| | - Po-Lin Chen
- Department of Neurology, Taichung Veterans General Hospital, Taiwan (P.-L.C.)
| | - Hsu-Ling Yeh
- Department of Neurology, Shin Kong WHS Memorial Hospital, Taipei, Taiwan (H.-L.Y., L.-M.L.)
| | - Lung Chan
- Department of Neurology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan (L.C.)
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan (S.-F.S.)
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Chiayi County, Taiwan (M.L.)
| | - Hon-Man Liu
- Department of Medical Imaging, Fu Jen Catholic University Hospital, New Taipei City, Taiwan (H.-M.L.)
| | - Yen-Heng Lin
- Medical Imaging (C.-W.L., Y.-H.L.), National Taiwan University Hospital, Taipei
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan (C.-J.L., I.-H.L)
| | - Shin-Joe Yeh
- Departments of Neurology (C.-H.C., S.-J.Y., S.-C.T., J.-S.J.), National Taiwan University Hospital, Taipei
| | - Li-Ming Lien
- Department of Neurology, Shin Kong WHS Memorial Hospital, Taipei, Taiwan (H.-L.Y., L.-M.L.)
| | - Hung-Yi Chiou
- School of Public Health, College of Public Health, (H.-Y.C.), Taipei Medical University, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (S.-Y.Y., J.-T.L.)
| | - Sung-Chun Tang
- Departments of Neurology (C.-H.C., S.-J.Y., S.-C.T., J.-S.J.), National Taiwan University Hospital, Taipei
| | - Jiann-Shing Jeng
- Departments of Neurology (C.-H.C., S.-J.Y., S.-C.T., J.-S.J.), National Taiwan University Hospital, Taipei
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Lin SY, Chen YF, Chen CH, Kuo CH, Liu YB, Chao YC, Peng YF, Huang CF, Tang SC, Jeng JS. Impact of cerebral small vessel disease burden and drug level at admission on direct oral anticoagulant associated intracerebral hemorrhage. Eur Stroke J 2024; 9:209-218. [PMID: 37803968 PMCID: PMC10916812 DOI: 10.1177/23969873231205673] [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: 07/25/2023] [Accepted: 09/19/2023] [Indexed: 10/08/2023] Open
Abstract
INTRODUCTION Direct oral anticoagulant (DOAC)-associated intracerebral hemorrhage (ICH) is a catastrophic complication. The aim of this study was to investigate the association between computed tomography (CT)-based cerebrovascular small vessel disease (SVD) burden and DOAC-ICH as well as the DOAC concentration upon hospital admission and ICH outcome. PATIENTS AND METHODS The study included two cohorts: (1) DOAC-ICH: patients who suffered from DOAC-ICH and underwent drug level measurements upon admission; (2) DOAC-non-ICH: stable DOAC users who underwent head CT without ICH during treatment. We categorized the DOAC levels of the DOAC-ICH patients as low (<50 ng/mL), medium (50-300 ng/mL), and high (>300 ng/mL). The CT-based SVD burden (including white matter lesions [WML], lacunes, and cerebral atrophy) was evaluated, and SVD scores (range, 0-3) were used to evaluate SVD severity. RESULTS A total of 43 DOAC-ICH patients and 177 DOAC-non-ICH patients were enrolled. DOAC-ICH patients were more likely to have WML, lacunes, or cerebral atrophy compared to DOAC-non-ICH patients. After adjustment, the SVD burden was associated with DOAC-ICH, with a higher risk of more severe SVD (SVD score of 2; odds ratio [OR], 10.3 [3.17, 33.3]; score of 3; OR, 16.8 [4.50, 62.6]). The proportions of patients with high, medium, and low drug levels in the DOAC-ICH group were 16.3%, 55.8%, and 27.9%, respectively. Additionally, the high-level group displayed a larger hematoma size and had worse functional outcomes at 3 months than the other two groups. DISCUSSION AND CONCLUSION The severity of SVD burden was associated with DOAC-ICH. Furthermore, high DOAC levels in ICH were associated with unfavorable clinical outcomes. To address the potential selection bias from these two cohorts, a prospective study to investigate the co-contribution of drug levels and SVD to DOAC-ICH is essential.
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Affiliation(s)
- Shin-Yi Lin
- Department of Pharmacy, National Taiwan University Hospital, Taipei
- School of Pharmacy, National Taiwan University, Taipei
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei
| | - Chih-Hao Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei
| | - Ching-Hua Kuo
- School of Pharmacy, National Taiwan University, Taipei
| | - Yen-Bin Liu
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Yuan-Chang Chao
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei
| | - Yu-Fong Peng
- School of Pharmacy, National Taiwan University, Taipei
| | - Chih-Fen Huang
- Department of Pharmacy, National Taiwan University Hospital, Taipei
- School of Pharmacy, National Taiwan University, Taipei
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei
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Kuo PY, Tsai HH, Lee BC, Chiang PT, Liu CJ, Chen YF, Jeng JS, Yen RF, Tsai LK. Differences in lobar microbleed topography in cerebral amyloid angiopathy and hypertensive arteriopathy. Sci Rep 2024; 14:3774. [PMID: 38355951 PMCID: PMC10866968 DOI: 10.1038/s41598-024-54243-1] [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] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 02/10/2024] [Indexed: 02/16/2024] Open
Abstract
Lobar cerebral microbleeds are a characteristic neuroimaging finding in cerebral amyloid angiopathy (CAA) but can also be found in hypertensive arteriolosclerosis. We aimed to investigate whether CAA is more associated with intracortical lobar microbleeds than hypertensive arteriosclerosis. Ninety-one survivors of spontaneous intracerebral hemorrhage with at least one lobar microbleed were included and underwent brain MRI and amyloid PET. We categorized lobar microbleeds as intracortical, juxtacortical, or subcortical. We assessed the associations between the lobar microbleed categories and microangiopathy subtypes or cerebral amyloid load based on the Pittsburgh Compound-B PET standardized uptake value ratio (SUVR). Patients with CAA had a higher prevalence of intracortical lobar microbleeds (80.0% vs. 50.8%, P = 0.011) and lower prevalence of subcortical lobar microbleeds (13.3% vs. 60.1%, P < 0.001) than patients with hypertensive arteriolosclerosis. Strictly intracortical/juxtacortical lobar microbleeds were associated with CAA (OR 18.9 [1.9-191.4], P = 0.013), while the presence of subcortical lobar microbleeds was associated with hypertensive arteriolosclerosis (OR 10.9 [1.8-68.1], P = 0.010). Amyloid retention was higher in patients with strictly intracortical/juxtacortical CMBs than those without (SUVR = 1.15 [1.05-1.52] vs. 1.08 [1.02-1.19], P = 0.039). Amyloid retention positively correlated with the number of intracortical lobar microbleeds (P < 0.001) and negatively correlated with the number of subcortical lobar microbleeds (P = 0.018). CAA and cortical amyloid deposition are more strongly associated with strictly intracortical/juxtacortical microbleeds than subcortical lobar microbleeds. Categorization of lobar microbleeds based on anatomical location may help differentiate the underlying microangiopathy and potentially improve the accuracy of current neuroimaging criteria for cerebral small vessel disease.
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Affiliation(s)
- Pin-Yan Kuo
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Bo-Ching Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Pu-Tien Chiang
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei, Taiwan
| | - Chia-Ju Liu
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ruoh-Fang Yen
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
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Cheon S, Li CY, Jeng JS, Wang JD, Ku LJE. Dynamic changes and lifetime effect of functional disability profiles for stroke patients: real-world evidence from South Korea. Qual Life Res 2024:10.1007/s11136-023-03579-8. [PMID: 38285281 DOI: 10.1007/s11136-023-03579-8] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE This work aimed to investigate the long-term dynamic changes of functional disabilities and estimate lifetime outcomes of different functional disabilities after a stroke, using real-world data from a nationally representative South Korean cohort. METHODS Patients aged 18 and above with ischemic and hemorrhagic strokes were identified from the Korea Health Panel (KHP) data (2008-2018). Functional disabilities were repeatedly measured for patients aged 55 and over for the prevalence of disabilities associated with activities of daily living (ADL), and kernel smoothing means were estimated for each item. The lifetime survival function of stroke patients in Korea was adopted from another study utilizing the National Health Insurance Service of Korea's national sample cohort. By multiplying the disability-free proportion with the survival function throughout life, disability-free life expectancy (DFLE) for each ADL item was estimated. The loss-of-DFLE was calculated by subtracting the DFLE from age-, sex-, and calendar year-matched referents simulated from Korean life tables. RESULTS The KHP dataset included 466 stroke patients. The overall functional disability needs increased over time after stroke diagnosis. DFLE was lowest for bathing (10.1 years for ischemic stroke and 12.8 years for hemorrhagic stroke), followed by those for dressing and washing. Loss-of-DFLE was highest for bathing for ischemic and hemorrhagic strokes (7.2 and 10.7 years, respectively), indicating that this task required the most assistance for stroke patients compared with the other tasks. DFLEs were slightly lower than the quality-adjusted life expectancy of stroke patients. CONCLUSION Our findings provide valuable insights for resource allocation and policy decisions in long-term stroke care, potentially enhancing the quality of life for stroke survivors and caregivers.
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Affiliation(s)
- Soyeon Cheon
- Department of Public Health, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan, 70101, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan, 70101, Taiwan
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jung-Der Wang
- Department of Public Health, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan, 70101, Taiwan
| | - Li-Jung Elizabeth Ku
- Department of Public Health, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan, 70101, Taiwan.
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Huang YH, Chen WY, Liu YH, Li TY, Lin CP, Cheong PL, Wang YM, Jeng JS, Sun CW, Wu CC. Mild cognitive impairment estimation based on functional near-infrared spectroscopy. J Biophotonics 2024; 17:e202300251. [PMID: 37697821 DOI: 10.1002/jbio.202300251] [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] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 09/13/2023]
Abstract
Patients with mild cognitive impairment (MCI) are at a high risk of developing future dementia. However, early identification and active intervention could potentially reduce its morbidity and the incidence of dementia. Functional near-infrared spectroscopy (fNIRS) has been proposed as a noninvasive modality for detecting oxygenation changes in the time-varying hemodynamics of the prefrontal cortex. This study sought to provide an effective method for detecting patients with MCI using fNIRS and the Wisconsin card sorting test (WCST) to evaluate changes in blood oxygenation. The results revealed that all groups with a lower mini-mental state examination grade had a higher increase in HHb concentration during a modified WCST (MCST). The increase in the change in oxygenated hemoglobin concentration in the stroke group was smaller than that in the normal group due to weak cerebrovascular reactivity.
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Affiliation(s)
- Yi-Hua Huang
- Institute of Neuroscience, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Yu Chen
- Biomedical Optical Imaging Lab, Department of Photonics, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Yao-Hong Liu
- Biomedical Optical Imaging Lab, Department of Photonics, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Ting-Ying Li
- Biomedical Optical Imaging Lab, Department of Photonics, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Ching-Po Lin
- Institute of Neuroscience, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Medical Device Innovation and Translation Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Pou-Leng Cheong
- Department of Pediatrics, National Taiwan University Hospital, Hsinchu, Taiwan
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Yi-Min Wang
- Biomedical Optical Imaging Lab, Department of Photonics, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Wei Sun
- Biomedical Optical Imaging Lab, Department of Photonics, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Medical Device Innovation and Translation Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Biomedical Engineering, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Chau-Chung Wu
- Department of Internal Medicine (Cardiology Section), National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Medical Education and Bioethics, College of Medicine, National Taiwan University, Taipei, Taiwan
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12
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Lin HJ, Chen CH, Su MW, Lin CW, Cheng YW, Tang SC, Jeng JS. Modifiable vascular risk factors contribute to stroke in 1080 NOTCH3 R544C carriers in Taiwan Biobank. Int J Stroke 2024; 19:105-113. [PMID: 37485895 DOI: 10.1177/17474930231191991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
BACKGROUND AND AIM Previous studies have suggested cardiovascular risk factors increase the risk of not only common sporadic stroke but also of stroke in patients with monogenic stroke disorders including CADASIL. We investigated the effects of the NOTCH3 Arg544Cys (R544C) variant and associated vascular risk factors on stroke in the Taiwanese population. METHODS This study was conducted using data from the Taiwan Biobank, consisting of at least 130,000 Han Chinese participants. The genotype was derived from customized genome-wide arrays for 650,000 to 750,000 single-nucleotide polymorphisms (SNPs). Individuals with NOTCH3 R544C were subsequently matched with noncarriers based on the propensity score at a 1:10 ratio by demographic and cardiovascular risk factors. The odds ratio (OR) for stroke or other phenotypes in NOTCH3 R544C carriers and matched noncarriers was then calculated. Univariate and multivariate regression analyses were performed on cardiovascular risk factors in NOTCH3 R544C carriers with and without stroke. The polygenic risk score (PRS) model, adopted from the UK Biobank, was then applied to evaluate the role of NOTCH3 R544C in stroke. RESULTS From the 114,282 participants with both genotype and questionnaire results, 1080 (0.95%) harbored the pathogenic NOTCH3 R544C variant. When compared to the matched controls (n = 10,800), the carriers presented with a history of stroke (OR: 2.52, 95% confidence interval (CI) (1.45, 4.37)), dementia (OR: 30.1, 95% CI (3.13, 289.43)), and sibling history of stroke (OR: 2.48, 95% CI (1.85, 3.34)) phenotypes. The risk of stroke increased with every 10-year increase in age (p = 0.006, Cochran-Mantel-Haenszel test). Among NOTCH3 R544C carriers, 16 (1.3%) of the 1080 carriers with a stroke history were older, male, and more likely to have hypertension, diabetes, dyslipidemia, and a family history of stroke. In the stepwise multivariate analysis, hypertension (OR: 11.28, 95% CI (3.54, 43.3)) and diabetes mellitus (OR: 4.10, 95% CI (1.31, 12.4)) were independently associated with stroke. Harboring the NOTCH3 R544C variant in the Taiwan Biobank is comparable with a 6.74 standard deviations increase in individual's polygenic risk score for stroke. CONCLUSION While the NOTCH3 R544C variant alone increased the risk of stroke, modifiable vascular risk factors also played a role in the occurrence of stroke in Taiwanese community-dwelling individuals carrying the NOTCH3 variant.
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Affiliation(s)
- Hung-Jen Lin
- Department of Medical Education, National Taiwan University Hospital, Taipei
| | - Chih-Hao Chen
- Department of Neurology, National Taiwan University Hospital, Taipei
| | - Ming-Wei Su
- Institute of Biomedical Sciences, Academia Sinica, Taipei
| | - Chien-Wei Lin
- Institute of Biomedical Sciences, Academia Sinica, Taipei
| | - Yu-Wen Cheng
- Department of Neurology, National Taiwan University Hospital, Taipei
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei
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Chen KW, Chen CH, Lin YH, Lee CW, Tsai KC, Tsai LK, Tang SC, Jeng JS. Outcome of endovascular thrombectomy in patients with end-stage renal disease undergoing dialysis. J Neurointerv Surg 2023; 15:e337-e342. [PMID: 36539275 DOI: 10.1136/jnis-2022-019666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) are often excluded from clinical trials of endovascular thrombectomy (EVT). This study investigated the outcome in these patients. METHODS From September 2014 to July 2021, all patients undergoing EVT for anterior circulation stroke in two stroke centers in Taiwan were included. They were divided into no renal dysfunction (non-RD, estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2), RD (eGFR <60 mL/min/1.73 m2 but no dialysis), and ESRD undergoing dialysis (ESRD-dialysis). The clinical features and outcomes were compared. RESULTS Of 482 patients included, there were 20 ESRD-dialysis, 110 RD, and 352 non-RD patients. The Alberta Stroke Program Early CT Score (ASPECTS), National Institutes of Health Stroke Scale (NIHSS), use of intravenous thrombolysis, EVT-related time metrics, and successful recanalization rates were comparable among the three groups. However, the ESRD-dialysis patients had more symptomatic intracerebral hemorrhage (ICH, 15% vs 3.6% vs 3.7%), more contrast-induced encephalopathy (15% vs 1.8% vs 0.9%), and a higher mortality at 90 days (35% vs 18% vs 11%) than the other groups. Multivariable analysis revealed that ESRD-dialysis was associated with a less favorable outcome (OR 0.21, 95% CI 0.04 to 0.77) and more severe disability or mortality (modified Rankin Scale 5 or 6; OR 13.1, 95% CI 3.93 to 48.1) at 90 days. In the ESRD-dialysis group, the patients with premorbid functional dependence had a significantly higher mortality than those without (75% vs 8.3%; P=0.004). CONCLUSION ESRD-dialysis patients were associated with symptomatic ICH and less favorable outcome at 90 days. Patients with premorbid functional dependency had an excessively high mortality.
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Affiliation(s)
- Kuo-Wei Chen
- Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Chih-Hao Chen
- Taipei, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Heng Lin
- Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Kun-Chang Tsai
- Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Li-Kai Tsai
- Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Sung-Chun Tang
- Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Lin KW, Chen YJ, Hou SW, Tang SC, Chiang WC, Tsai LK, Lee CW, Lee YC, Chien YC, Hsieh MJ, Jeng JS, Huei-Ming Ma M. Effect of using G-FAST to recognize emergent large vessel occlusion: A city-wide community experience. J Formos Med Assoc 2023; 122:1069-1076. [PMID: 37120338 DOI: 10.1016/j.jfma.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 03/19/2023] [Accepted: 04/10/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND/PURPOSE A prehospital bypass strategy was suggested for large vessel occlusion. This study aimed to evaluate the effect of a bypass strategy using the gaze-face-arm-speech-time test (G-FAST) implemented in a metropolitan community. METHODS Pre-notified patients with positive Cincinnati Prehospital Stroke Scale and symptom onset <3 h from July 2016 to December 2017 (pre-intervention period) and those with positive G-FAST and symptom onset <6 h from July 2019 to December 2020 (intervention period) were included. Patients aged <20 years and those with missing in-hospital data were excluded. The primary outcomes were the rates of receiving endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT). The secondary outcomes were total prehospital time, door-to-computed tomography (CT) time, door-to-needle (DTN) time, and door-to-puncture (DTP) time. RESULTS We included 802 and 695 pre-notified patients from the pre-intervention and intervention periods, respectively. The characteristics of the patients in the two periods were similar. In the primary outcomes, pre-notified patients during the intervention period showed higher rates of receiving EVT (4.49% vs. 15.25%, p < 0.001) and IVT (15.34% vs. 21.58%, p = 0.002). In the secondary outcomes, pre-notified patients during intervention period had longer total prehospital time (mean 23.38 vs 25.23 min, p < 0.001), longer door-to-CT time (median 10 vs 11 min, p < 0.001), longer DTN time (median 53 vs 54.5 min, p < 0.001) but shorter DTP time (median 141 vs 139.5 min, p < 0.001). CONCLUSION The prehospital bypass strategy with G-FAST showed benefits for stroke patients.
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Affiliation(s)
- Kai-Wei Lin
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Ju Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Sheng-Wen Hou
- Department of Emergency Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Ching Lee
- Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan
| | - Yu-Chun Chien
- Emergency Medical Services Division, National Fire Agency, Ministry of the Interior, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
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Yeh SJ, Chen CH, Lin YH, Tsai LK, Lee CW, Tang SC, Jeng JS. Association of Ferroptosis with Severity and Outcomes in Acute Ischemic Stroke Patients Undergoing Endovascular Thrombectomy: A Case-control Study. Mol Neurobiol 2023; 60:5902-5914. [PMID: 37357230 DOI: 10.1007/s12035-023-03448-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 02/21/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023]
Abstract
Ferroptosis, an iron-dependent form of cell death, is characterized by intracellular accumulation of iron and reactive oxygen species-induced lipid peroxidation. Animal experiments have shown the important roles of ferroptosis in ischemic stroke, but the evidence in human stroke is insufficient. This prospective study evaluated the associations between plasma ferroptosis biomarkers at hyperacute stage and long-term outcomes in patients with acute ischemic stroke undergoing endovascular thrombectomy (EVT). The plasma samples were collected immediately before and after EVT (T1 and T2) and at 24 h (T3) for the 126 stroke patients and once for the 50 stroke-free control subjects. Compared with controls, stroke patients had higher 4-hydroxynonenal (4-HNE) levels at T1 and T2 while lower homocysteine and soluble transferrin receptor (sTfR) levels at T3. In stroke patients, higher National Institutes of Health Stroke Scale scores at admission were correlated with higher 4-HNE and lower sTfR levels. Lower Alberta Stroke Program Early CT (ASPECT) scores and larger infarct core volumes on CT perfusion before EVT were correlated with higher 4-HNE and homocysteine levels. After adjusting for significant parameters, homocysteine levels at T2 were significantly associated with poor functional outcome and mortality at 3 months. In the receiver operating characteristic (ROC) models, adding homocysteine levels at T2 and hemoglobin levels to the reference model for predicting poor functional outcome significantly increased the area under the ROC curve. In summary, this study provides evidence that ferroptosis is associated with stroke severity and outcomes in patients with acute ischemic stroke undergoing EVT.
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Affiliation(s)
- Shin-Joe Yeh
- Department of Neurology, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist, Taipei, 100225, Taiwan
| | - Chih-Hao Chen
- Department of Neurology, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist, Taipei, 100225, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist, Taipei, 100225, Taiwan
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist, Taipei, 100225, Taiwan
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist, Taipei, 100225, Taiwan.
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist, Taipei, 100225, Taiwan.
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist, Taipei, 100225, Taiwan
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Yeh HL, Hsieh FI, Lien LM, Kuo WH, Jeng JS, Sun Y, Wei CY, Yeh PY, Yip HT, Lin CL, Huang N, Hsu KC. Patient and hospital characteristics associated with do-not-resuscitate/do-not-intubate orders: a cross-sectional study based on the Taiwan stroke registry. BMC Palliat Care 2023; 22:138. [PMID: 37715158 PMCID: PMC10503153 DOI: 10.1186/s12904-023-01257-7] [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: 04/01/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Previous studies of do-not-resuscitate (DNR) or do-not-intubate (DNI) orders in stroke patients have primarily been conducted in North America or Europe. However, characteristics associated with DNR/DNI orders in stroke patients in Asia have not been reported. METHODS Based on the Taiwan Stroke Registry, this nationwide cross-sectional study enrolled hospitalized stroke patients from 64 hospitals between 2006 and 2020. We identified characteristics associated with DNR/DNI orders using a two-level random effects model. RESULTS Among the 114,825 patients, 5531 (4.82%) had DNR/DNI orders. Patients with acute ischemic stroke (AIS) had the highest likelihood of having DNR/DNI orders (adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 1.61-1.93), followed by patients with intracerebral hemorrhage (ICH), and patients with subarachnoid hemorrhage (SAH) had the lowest likelihood (aOR 0.53, 95% CI 0.43-0.66). From 2006 to 2020, DNR/DNI orders increased in all three types of stroke. In patients with AIS, women were significantly more likely to have DNR/DNI orders (aOR 1.23, 95% CI 1.15-1.32), while patients who received intravenous alteplase had a lower likelihood (aOR 0.74, 95% CI 0.65-0.84). Patients with AIS who were cared for by religious hospitals (aOR 0.55, 95% CI 0.35-0.87) and patients with SAH who were cared for by medical centers (aOR 0.40, 95% CI 0.17-0.96) were significantly less likely to have DNR/DNI orders. CONCLUSIONS In Taiwan, DNR/DNI orders increased in stroke patients between 2006 and 2020. Hospital characteristics were found to play a significant role in the use of DNR/DNI orders.
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Affiliation(s)
- Hsu-Ling Yeh
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Fang-I Hsieh
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Li-Ming Lien
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Wen-Hua Kuo
- Institute of Science, Technology, and Society, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center, Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu Sun
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Cheng-Yu Wei
- Department of Exercise and Health Promotion, College of Kinesiology and Health, Chinese Culture University, Taipei, Taiwan
| | - Po-Yen Yeh
- Department of Neurology, St. Martin de Porres Hospital, Chiayi City, Taiwan
| | - Hei-Tung Yip
- Management office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, No. 155, Section 2, Li-Nong Street, Taipei 112, Taipei, Taiwan.
| | - Kai-Cheng Hsu
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
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Chen SJ, Tsai HH, Lo YL, Chen YF, Tang SC, Jeng JS, Tsai LK. Interaction between cerebral small vessel disease, blood pressure, and remote ischemic lesions in acute spontaneous intracerebral hemorrhage. Eur Stroke J 2023; 8:828-835. [PMID: 37641548 PMCID: PMC10472944 DOI: 10.1177/23969873231170989] [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: 02/11/2023] [Accepted: 04/04/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Acute blood pressure (BP) reduction is the first-line treatment for acute spontaneous intracerebral hemorrhage (ICH); however, recent research suggests that intensive BP reduction along with cerebral small vessel disease (cSVD) is a risk factor for remote DWI lesions (RDWILs). We aimed to delineate the interplay between cSVD and BP reduction therapy on the risk of RDWILs. METHODS We enrolled 303 patients who underwent brain magnetic resonance imaging within 7 days after acute spontaneous ICH. RDWILs were categorized as occurring in borderzone (BZ) or non-BZ areas. We examined the effect of cSVD, acute BP reduction, and their interaction on RDWILs. RESULTS RDWILs were observed in 34 (11%) patients (59.8 ± 10.3-years-old, 24% male). RDWILs were associated with a larger acute weighted average mean arterial pressure (MAP) reduction in the initial 24 h after ICH onset and a higher total cerebral microbleed (CMB) count. Intensive MAP changes (odds ratio (OR) per 10 mmHg 1.76, 95% confidence interval (CI) 1.03-3.20), total CMBs burden (OR per 10 CMBs 1.21, 95% CI 1.08-1.39), and presence of lobar CMBs (OR 7.33, 95% CI 1.59-55.6) were risk factors for RDWILs at BZ, but not at non-BZ. Furthermore, a significant interaction was observed between lobar CMBs and MAP reduction on increased risk of RDWILs at BZ (p = 0.030). CONCLUSION cSVD modulates the effect of acute BP reduction on the risk of RDWILs. Patients with extensive microangiopathy have a higher risk of developing cerebral ischemic changes in BZ during unstable hemodynamic status.
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Affiliation(s)
- Szu-Ju Chen
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei
- Department of Neurology, National Taiwan University Hospital, Taipei
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei
| | - Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei
- Department of Neurology, National Taiwan University Hospital, Taipei
| | - Yen-Ling Lo
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu
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18
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Hsiao YC, Lee TL, Lin FJ, Hsuan CF, Yeh CF, Wei-Tien Chang, Hsien-Li Kao, Jiann-Shing Jeng, Wu YW, I-Chang Hsieh, Fang CC, Wang KY, Kuan-Cheng Chang, Tsung-Hsien Lin, Huey-Herng Sheu W, Yi-Heng Li, Yin WH, Yeh HI, Chen JW, Wu CC. A risk stratification model modified from the U.S. guideline could be applied in an Asian population with or without ASCVD. Biomed J 2023:100653. [PMID: 37579816 DOI: 10.1016/j.bj.2023.100653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/06/2023] [Accepted: 08/09/2023] [Indexed: 08/16/2023] Open
Abstract
AIM This study aimed to evaluate the performance of a modified US (MUS) model for risk prediction of cardiovascular (CV) events in Asian patients and compare it to European and Japanese models. MATERIAL AND METHODS The MUS model, based on the US ACC/AHA 2018 lipid treatment guideline, was employed to stratify patients under primary or secondary prevention. Two multi-center prospective observational registry cohorts, T-SPARCLE and T-PPARCLE, were used to validate the scoring system, and the primary outcome was the time to first occurrence/recurrence of major adverse cardiac events (MACEs). The MUS model's performance was compared to other models from Europe and Japan. RESULTS A total of 10,733 patients with the mean age of 64.2 (SD: 11.9) and 36.5% female were followed up for a median of 5.4 years. The MUS model was validated, with an AUC score of 0.73 (95% CI 0.68-0.78). The European and Japanese models had AUC scores ranging from 0.6 to 0.7. The MUS model categorized patients into four distinct CV risk groups, with hazard ratios (HRs) as follows: very high-vs. high-risk group (HR=1.91, 95% CI 1.53-2.39), high-vs. moderate-risk group (HR=2.08, 95% CI 1.60-2.69), and moderate-vs. low-risk group (HR=3.14, 95% CI 1.63-6.03). After adjusting for the MUS model, a history of ASCVD was not a significant predictor of adverse cardiovascular outcomes within each risk group. CONCLUSION The MUS model is an effective tool for risk stratification in Asian patients with and without ASCVD, accurately predicting MACEs and performing comparably or better than other established risk models. Our findings suggest that patient management should focus on background risk factors instead of solely on primary or secondary prevention.
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Affiliation(s)
- Yu-Chung Hsiao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Thung-Lip Lee
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Fang-Ju Lin
- Graduate Institute of Clinical Pharmacy & School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Feng Hsuan
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan; Division of Cardiology, Department of Internal Medicine, E-Da Dachang Hospital, Kaohsiung, Taiwan
| | - Chih-Fan Yeh
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Tien Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Wen Wu
- Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ching-Chang Fang
- Division of Cardiology, Tainan Municipal Hospital, Tainan, Taiwan
| | - Kuo-Yang Wang
- Division of Cardiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wayne Huey-Herng Sheu
- Division of Endocrinology and Metabolism and Department of Internal Medicine, Taipei Veterans General Hospital, Taichung, Taiwan
| | - Yi-Heng Li
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wei-Hsian Yin
- Division of Cardiology, Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Hung-I Yeh
- Mackay Memorial Hospital, Mackay Medical College, Taipei, Taiwan
| | - Jaw-Wen Chen
- Department of Medical Research and Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chau-Chung Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Medical Education & Bioethics, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Lin CJ, Chung CP, Liao NC, Chen PL, Chi NF, Lai YJ, Tang CW, Wu CH, Chang FC, Luo CB, Fay LY, Lin CF, Chou CH, Lee TH, Lee JT, Jeng JS, Lee IH. The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease. J Chin Med Assoc 2023; 86:697-714. [PMID: 37341526 DOI: 10.1097/jcma.0000000000000952] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.
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Affiliation(s)
- Chun-Jen Lin
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chih-Ping Chung
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Nien-Chen Liao
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Po-Lin Chen
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Nai-Fang Chi
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yen-Jun Lai
- Radiology Department, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chih-Wei Tang
- Neurology Department and Stroke Center, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chia-Hung Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Li-Yu Fay
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chun-Fu Lin
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chung-Hsing Chou
- Neurology Department, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Jiunn-Tay Lee
- Neurology Department, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Jiann-Shing Jeng
- Department of Neurology and Stroke Center, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - I-Hui Lee
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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20
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Cheng YW, Chen CH, Yeh SJ, Tsai LK, Wang CW, Tang SC, Jeng JS. Association between modifiable vascular risk factors and rapid progression of postradiation carotid artery stenosis. J Chin Med Assoc 2023; 86:627-632. [PMID: 37191944 DOI: 10.1097/jcma.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Postradiotherapy carotid vasculopathy is a clinically relevant complication in patients with head and neck cancer receiving radiotherapy. In this study, we investigated the factors associated with the development and progression of carotid artery stenosis (CAS) in such patients. METHODS Patients who received radiotherapy for head and neck cancers between October 2011 and May 2019 at a medical center in Taiwan were eligible for inclusion in this study. This study included patients who underwent two consecutive carotid duplex examinations within an interval of 1 to 3 years. The factors associated with ≥50% CAS at baseline and follow-up were analyzed. RESULTS In total, 694 patients (mean age, 57.8 ± 9.9 years; men, 75.2%; nasopharyngeal cancer, 73.3%) were included. The mean interval between radiotherapy and carotid duplex examination was 9.9 ± 5.9 years. At baseline, 103 patients had ≥50% CAS, which was significantly associated with tobacco smoking, hypercholesterolemia, and a prolonged interval between radiotherapy and carotid duplex examination. A total of 586 patients did not have CAS at baseline; of them, 68 developed ≥50% CAS during follow-up. Hypertension and hypercholesterolemia were identified as independent risk factors for CAS progression. CONCLUSION Modifiable vascular risk factors, such as hypertension and hypercholesterolemia, appear to be significantly associated with the rapid progression of postradiotherapy CAS in patients with head and neck cancer.
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Affiliation(s)
- Ya-Wen Cheng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan, ROC
- Department of Neurology, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan, ROC
| | - Chih-Hao Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan, ROC
- Department of Neurology, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan, ROC
| | - Chun-Wei Wang
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan, ROC
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Lin SY, Tang SC, Kuo CH, Chen CH, Chao YC, Huang CF, Jeng JS. The association between direct oral anticoagulant concentration upon acute stroke and stroke outcome. Eur J Intern Med 2023; 113:31-37. [PMID: 36990874 DOI: 10.1016/j.ejim.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/14/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND This study aimed to investigate the association between direct oral anticoagulant (DOAC) concentration upon acute ischemic stroke (IS) or intracranial hemorrhage (ICH) and stroke outcomes. METHODS Patients aged ≥20 years treated with DOACs, including dabigatran, rivaroxaban, apixaban, or edoxaban, and developed acute IS or ICH were enrolled to measure DOAC concentration at the time of hospital presentation by using ultrahigh-performance liquid chromatography with tandem mass spectrometry. Ischemic stroke patients was categorized into low (<50 ng/mL) and effective (≥50 ng/mL) groups. The primary outcome was poor functional outcomes at 3 months (modified Rankin Scale scores of 4-6). RESULTS A total of 138 patients were enrolled, including 105 IS (76.1%) and 33 ICH patients. In the IS cohort, the average DOAC concentration was 85.7 ± 88.6 ng/mL (low DOAC concentration: 42.9%). Low level group had numerically higher NIHSS (14 versus 9, p = 0.37), significantly poorer functional outcomes at 3 months (odds ratio [OR], 5.08 [1.32, 19.63]), and higher chance of stroke-in-evolution (OR, 6.83 [1.64, 28.41]). In the ICH cohort, the average DOAC concentration was 128.9 ± 111.9 ng/mL. Reversal therapy was administered in 60.6% of patients. Hematoma growth occurred in 35.7% patients. The DOAC concentration was similar across patients with or without reversal therapy, and with or without hematoma growth. CONCLUSION Among DOAC users who developed IS, low drug concentrations at hospital presentation predicted poor outcomes.
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Affiliation(s)
- Shin-Yi Lin
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, No. 7, ZhongShan South Road, Taipei 100, Taipei, Taiwan.
| | - Ching-Hua Kuo
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Hao Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, No. 7, ZhongShan South Road, Taipei 100, Taipei, Taiwan
| | - Yuan-Chang Chao
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Fen Huang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, No. 7, ZhongShan South Road, Taipei 100, Taipei, Taiwan
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Chen CH, Chen SF, Tsai HH, Chen YF, Tang SC, Jeng JS. Associations of Cerebral Small Vessel Disease on the Features of Hematoma and Hematoma Expansion in Intracerebral Hemorrhage. Cerebrovasc Dis 2023; 53:136-143. [PMID: 37263251 DOI: 10.1159/000531152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/15/2023] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION Several early noncontrast CT (NCCT) signs of spontaneous intracerebral hemorrhage (ICH) can predict hematoma expansion (HE). However, the associations of underlying cerebral small vessel disease (SVD) on early NCCT signs and HE have been less explored. METHODS We conducted an analysis of all patients with spontaneous supratentorial ICH and received follow-up imaging between 2016 and 2020 at a stroke center. The early NCCT signs were categorized as shape or density signs. HE was defined as an increase in hematoma volume ≥6 mL or 33% from baseline. The severity of SVD was assessed by both a 3-point CT-based and a 4-point magnetic resonance imaging (MRI)-based SVD score. Regression models were used to examine the associations between SVD score and hematoma volume, NCCT signs, and HE. RESULTS A total of 328 patients (median age: 64 years; 38% female) were included. The median baseline ICH volume was 8.6 mL, with 38% of the patients had shape signs and 52% had density signs on the initial NCCT. Higher MRI-SVD scores were associated with smaller ICH volumes (p = 0.0006), fewer shape (p = 0.001), or density signs (p = 0.0003). Overall, 16% of patients experienced HE. A higher MRI-SVD score was inversely associated with HE (adjusted odds ratio 0.71, 95% CI: 0.53-0.96). Subgroup analysis revealed that this association was primarily observed in patients who were younger (<65 years), male, had deep hemorrhage, or did not meet the criteria for cerebral amyloid angiopathy diagnosis. CONCLUSIONS In patients with spontaneous ICH, a more severe SVD was associated with smaller hematoma volume, fewer NCCT signs, and a lower risk of HE. Further research is required to investigate why a higher burden of severely diseased cerebral small blood vessels is associated with less bleeding.
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Affiliation(s)
- Chih-Hao Chen
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan,
| | - Shuo-Fu Chen
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Neurology, National Taiwan University Hospital Beihu Branch, Taipei, Taiwan
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Lin SY, Tang SC, Kuo CH, Ho LT, Liu YB, Peng YF, Tsai LK, Huang CF, Jeng JS. Impact of direct oral anticoagulant concentration on clinical outcomes in Asian patients with atrial fibrillation. Clin Pharmacol Ther 2023. [PMID: 37132484 DOI: 10.1002/cpt.2927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/12/2023] [Indexed: 05/04/2023]
Abstract
A real-world association between direct oral anticoagulant (DOAC) concentration and clinical outcomes among Asian patients with atrial fibrillation (AF) is reported herein. Patients with AF aged ≥20 years who used DOAC for ≥3 days were enrolled. Trough and peak DOAC concentrations were measured and compared to the expected range reported in clinical trials. The Cox proportional hazard model was used to investigate the association between concentration and outcomes. From January 2016 to July 2022, a total of 859 patients were enrolled. Among them, 22.5%, 24.7%, 36.4%, and 16.4% were on dabigatran, rivaroxaban, apixaban, and edoxaban, respectively. Compared to clinical trials, the proportion of DOAC concentrations higher or lower than the expected range were 9.0% and 14.6% for trough, respectively, and 20.9% and 12.1% for peak, respectively. The average follow-up duration was 2.4±1.6 years. The incidence of stroke and systemic thromboembolism (SSE) was 1.31 per 100-person years, and low trough concentration predicted SSE (hazard ratio [HR]=2.78 [1.20, 6.46]). The incidence of major bleeding was 1.64 per 100-person years, and high trough was associated with major bleeding (HR=2.63 [1.09, 6.39]). The association between peak concentration and SSE or major bleeding was non-significant. Off label under dosing (odds ratio [OR]=2.69 [1.70, 4.26]), once daily DOAC dosing (OR=3.22 [2.07, 5.01]), and high creatinine clearance (OR=1.02 [1.01, 1.03]) caused low trough concentration. Contrarily, congestive heart failure was significantly associated with high trough concentration (OR=1.71 [1.01, 2.92]). In conclusion, trough DOAC concentration measurements should be considered among patients at risk of out-of-expected range DOAC concentrations.
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Affiliation(s)
- Shin-Yi Lin
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Hua Kuo
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Li-Ting Ho
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Bin Liu
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Fong Peng
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Fen Huang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Lin YH, Chung CT, Chen CH, Cheng CJ, Chu HJ, Chen KW, Yeh SJ, Tsai LK, Lee CW, Tang SC, Jeng JS. Association of temporalis muscle thickness with functional outcomes in patients undergoing endovascular thrombectomy. Eur J Radiol 2023; 163:110808. [PMID: 37080063 DOI: 10.1016/j.ejrad.2023.110808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/25/2023] [Accepted: 04/03/2023] [Indexed: 04/22/2023]
Abstract
INTRODUCTION Temporalis muscle thickness (TMT) is a surrogate marker for sarcopenia. This study investigated the association of TMT with clinical outcomes in patients receiving endovascular thrombectomy (EVT) for stroke involving acute large vessel occlusion (LVO). MATERIAL AND METHODS We enrolled consecutive patients who had undergone EVT between September 2014 and December 2021 at three thrombectomy-capable institutes. TMT was measured through preprocedural computerized tomography angiography. The clinical variables affecting TMT were investigated. The associations between TMT and clinical functional outcomes, defined using the modified Rankin scale, were also studied. RESULTS A total of 657 patients were included (mean age: 72.0 ± 12.7 years; male: 52.1%). The mean TMT was 6.35 ± 1.84 mm. Younger age, male sex, higher body mass index, and premorbid functional independence were associated with larger TMT in both univariate and multivariate linear regression (P <.05). Ordinal logistic regression revealed that TMT was associated with better clinical outcomes at 90 days (Ptrend = 0.047); multivariate logistic regression indicated that larger TMT was an independent predictor (adjusted odds ratio: 1.14, 95% confidence interval: 1.03-1.27, P = 0.02) of favorable functional independence (modified Rankin scale score: 0-2). The effect was stronger in older patients (≥80 years) than younger patients, as revealed by interaction modeling analysis (Pinteraction = 0.06). CONCLUSION TMT is associated with age, sex, body mass index, and premorbid functional status. Larger TMT is associated with better outcomes after EVT. The effects of TMT are more pronounced in older adults, indicating that sarcopenia may have influence on stroke outcomes.
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Affiliation(s)
- Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Ting Chung
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Hao Chen
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Jie Cheng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Hai-Jui Chu
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Kuo-Wei Chen
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Shin-Joe Yeh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan.
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Cheon S, Li CY, Jeng JS, Wang JD, Ku LJE. The lifetime burden following stroke: Long term impact of stroke on survival and quality of life. Int J Stroke 2023:17474930231165607. [PMID: 36912208 DOI: 10.1177/17474930231165607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Background The absolute burden of stroke in Korea is ever growing. Many studies have explored the outcomes of mortality, quality of life (QOL), and/or economic burden with limited periods of observation. Relatively few have addressed the lifetime outcomes that are estimated beyond the limited observation period of study samples.Aims By combining QOL and the survival functions over a lifetime horizon, our aims were to estimate the quality-adjusted life expectancy (QALE) and loss-of-QALE of patients with ischemic and hemorrhagic stroke in South Korea, and to compare them between genders.Methods The survival function of stroke patients (n=13,994) was estimated by the Kaplan-Meier's method from the National Health Insurance Service-National Sample Cohort of Korea (2002-2015), and then extrapolated to lifetime through a rolling-over algorithm. The QOL measurements, assessed by EuroQol 5-dimension (EQ-5D) questionnaire, of stroke patients (n=474) were extracted from the Korea Health Panel (KHP, 2008-2018) to estimate the QALE. All stroke patients were categorized by sex and two types of stroke: ischemic and hemorrhagic. Age-, sex-, and calendar year-matched referents were simulated from the Korean life tables to be integrated with the general population's QOL from the KHP to estimate the QALE of the referents. We calculated the loss-of-QALE by comparing the above two sets of QALE.Results The QALE and loss-of-QALE for ischemic stroke were 10.8 and 6.1 QALYs (quality-adjusted life years), respectively, and 14.0 and 9.0 QALYs for hemorrhagic stroke. The loss-of-QALE in men was 3.0 QALYs larger than that of women with hemorrhagic stroke (p < 0.05), while the difference for ischemic stroke was much smaller and statistically insignificant at 0.6 QALYs.Conclusions The lifetime impact of stroke in Korea is large, especially for males who survived hemorrhagic stroke. Future studies assessing the lifetime needs for long-term care of stroke patients are warranted to quantify the burden of stroke from the societal perspective.
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Affiliation(s)
- Soyeon Cheon
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan 34912
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan 34912.,Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan.,Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan 38006
| | - Jung-Der Wang
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan 34912.,Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Li-Jung Elizabeth Ku
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan 34912
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Liu PYT, Lin FJ, Yeh CF, Hsiao YC, Hsuan CF, Chang WT, Kao HL, Jeng JS, Wu YW, Hsieh IC, Fang CC, Wang KY, Chang KC, Lin TH, Sheu WHH, Li YH, Yin WH, Yeh HI, Chen JW, Wu CC. Association of Major Adverse Cardiac Events and Beta-Blockers in Patients with and without Atherosclerotic Cardiovascular Disease: Long-Term Follow-Up Results of the T-SPARCLE and T-PPARCLE Registry in Taiwan. J Clin Med 2023; 12:jcm12062162. [PMID: 36983164 PMCID: PMC10057487 DOI: 10.3390/jcm12062162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/18/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023] Open
Abstract
Beta-blockers are widely used, but the benefit is now challenged in patients at risk of atherosclerotic cardiovascular disease (ASCVD) in the present coronary reperfusion era. We aimed to identify the risk factors of a major adverse cardiac event (MACE) and the long-term effect of beta-blockers in two large cohorts in Taiwan. Two prospective observational cohorts, including patients with known atherosclerosis cardiovascular disease (T-SPARCLE) and patients with at least one risk factor of ASCVD but without clinically evident ASCVD (T-PPARCLE), were conducted in Taiwan. The primary endpoint is the time of first occurrence of a MACE (cardiovascular death, nonfatal stroke, nonfatal myocardial infarction, and cardiac arrest with resuscitation). Between December 2009 and November 2014, with a median 2.4 years follow-up, 11,747 eligible patients (6921 and 4826 in T-SPARCLE and T-PPARCLE, respectively) were enrolled. Among them, 273 patients (2.3%) met the primary endpoint. With multivariate Cox PH model analysis, usage of beta-blocker was lower in patients with MACE (42.9% vs. 52.4%, p < 0.01). In patients with ASCVD, beta-blocker usage was associated with lower MACEs (hazard ratio 0.72; p < 0.001), but not in patients without ASCVD. The event-free survival of beta-blocker users remained higher during the follow-up period (p < 0.005) of ASCVD patients. In conclusion, in ASCVD patients, reduced MACE was associated with beta-blocker usage, and the effect was maintained during a six-year follow-up. Prescribing beta-blockers as secondary prevention is reasonable in the Taiwanese population.
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Affiliation(s)
- Patrick Yan-Tyng Liu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei 10002, Taiwan
- Cardiovascular Center, Department of Internal Medicine (Cardiology), National Taiwan University Hospital, Taipei 10002, Taiwan
- Division of Cardiology, Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan 33044, Taiwan
| | - Fang-Ju Lin
- Graduate Institute of Clinical Pharmacy, School of Pharmacy, College of Medicine, National Taiwan University, Taipei 10617, Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei 10002, Taiwan
| | - Chih-Fan Yeh
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei 10002, Taiwan
- Cardiovascular Center, Department of Internal Medicine (Cardiology), National Taiwan University Hospital, Taipei 10002, Taiwan
| | - Yu-Chung Hsiao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei 10002, Taiwan
| | - Chin-Feng Hsuan
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, Kaohsiung 82445, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung 84001, Taiwan
| | - Wei-Tien Chang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei 10002, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei 10002, Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei 10002, Taiwan
- Cardiovascular Center, Department of Internal Medicine (Cardiology), National Taiwan University Hospital, Taipei 10002, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei 10002, Taiwan
| | - Yen-Wen Wu
- Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City 220, Taiwan
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Ching-Chang Fang
- Division of Cardiology, Tainan Municipal Hospital, Tainan 701, Taiwan
| | - Kuo-Yang Wang
- Division of Cardiology, Taichung Veterans General Hospital, Taichung 407219, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, Taichung 404327, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Wayne Huey-Herng Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan
| | - Yi-Heng Li
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan 704, Taiwan
| | - Wei-Hsian Yin
- Division of Cardiology, Heart Center, Cheng-Hsin General Hospital, Taipei 112, Taiwan
| | - Hung-I Yeh
- Departments of Internal Medicine and Medical Research, Mackay Memorial Hospital, Taipei 10449, Taiwan
| | - Jaw-Wen Chen
- Department of Medical Research and Education, Taipei Veterans General Hospital, Taipei 112201, Taiwan
| | - Chau-Chung Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei 10002, Taiwan
- Cardiovascular Center, Department of Internal Medicine (Cardiology), National Taiwan University Hospital, Taipei 10002, Taiwan
- Graduate Institute of Medical Education & Bioethics, College of Medicine, National Taiwan University, Taipei 10051, Taiwan
- Correspondence: ; Tel.: +886-2-2312-3456 (ext. 288560); Fax: +886-2-2321-7485
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Lin SY, Liu YB, Ho LT, Peng YF, Kuo CH, Tang SC, Huang CF, Jeng JS. Impact of amiodarone on plasma concentration of direct oral anticoagulant in patients with atrial fibrillation. J Formos Med Assoc 2023:S0929-6646(23)00066-9. [PMID: 36890017 DOI: 10.1016/j.jfma.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/30/2022] [Accepted: 02/23/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND/PURPOSE Amiodarone increases exposure of direct oral anticoagulants (DOACs). We aimed to analyze the effects of concurrent amiodarone use on DOAC concentrations and clinical outcomes. METHODS Patients who were ≥20 years of age, had atrial fibrillation, and took DOAC were enrolled to provide trough and peak samples for DOAC concentration measurements using ultra-high-performance liquid chromatography-tandem mass spectrometry. The results were compared with concentrations reported in clinical trials to define above, within, or under the expected range. The outcomes of interest were major bleeding and any gastrointestinal bleeding. Multivariate logistic regression and Cox proportional hazards model were used to determine the impact of amiodarone on above-range concentration and clinical outcomes, respectively. RESULTS A total of 722 participants (420 men, 58.2%) were enrolled to provide 691 trough samples and 689 peak samples. Among them, 21.3% concurrently used amiodarone. The proportion of patients with above-range trough and peak concentrations was 16.4% and 30.2%, respectively, for amiodarone users, in contrast to 9.4% and 19.8% for amiodarone non-users. The use of amiodarone was associated with above-range trough and peak concentrations (odds ratio [OR] = 2.00 [1.16, 3.47] and 1.82 [1.19, 2.79], respectively). However, amiodarone was not a significant predictor of major bleeding or any gastrointestinal bleeding. CONCLUSION Concurrent amiodarone use led to increased DOAC concentration but was not associated with a higher risk of major bleeding or any gastrointestinal bleeding. Therapeutic monitoring of DOAC users concurrently taking amiodarone may be recommended for patients with an additional risk of increased DOAC exposure.
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Affiliation(s)
- Shin-Yi Lin
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yen-Bin Liu
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Ting Ho
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Fong Peng
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ching-Hua Kuo
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Chih-Fen Huang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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28
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Lee BC, Tsai HH, Liu CJ, Chen YF, Tsai LK, Jeng JS, Yen RF. Cerebral Venous Reflux and Cerebral Amyloid Angiopathy: An Magnetic Resonance Imaging/Positron Emission Tomography Study. Stroke 2023; 54:1046-1055. [PMID: 36866674 DOI: 10.1161/strokeaha.122.040503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Cerebral venous outflow alterations contribute to central nervous system pathology in aging and neurodegenerative disorders and are potentially linked to underlying cerebral microangiopathy. We investigated whether cerebral venous reflux (CVR) is more closely associated with cerebral amyloid angiopathy (CAA) than hypertensive microangiopathy in intracerebral hemorrhage (ICH) survivors. METHODS This cross-sectional study included 122 patients of spontaneous ICH with magnetic resonance and positron emission tomography imaging studies (2014-2022) in Taiwan. The presence of CVR was defined as abnormal signal intensity in the dural venous sinus or internal jugular vein on magnetic resonance angiography. Cerebral amyloid load was measured using the Pittsburgh compound B standardized uptake value ratio. Clinical and imaging characteristics associated with CVR were evaluated in univariable and multivariable analyses. In the subset of patients with CAA, we applied univariable and multivariable linear regression analyses to evaluate the association between CVR and cerebral amyloid retention. RESULTS Compared with patients without CVR (n=84, 64.5±12.1 years), patients with CVR (n=38, 69.4±11.5 years) were significantly more likely to have CAA-ICH (53.7% versus 19.8%; P<0.001) and had a higher cerebral amyloid load (standardized uptake value ratio [interquartile range], 1.28 [1.12-1.60] versus 1.06 [1.00-1.14]; P<0.001). In a multivariable model, CVR was independently associated with CAA-ICH (odds ratio, 4.81 [95% CI, 1.74-13.27]; P=0.002) after adjustment for age, sex and conventional small vessel disease markers. In CAA-ICH, higher PiB retention was observed in patients with CVR than patients without CVR (standardized uptake value ratio [interquartile range], 1.34 [1.08-1.56] versus 1.09 [1.01-1.26]; P<0.001). In multivariable analysis after adjustment for potential confounders, the presence of CVR was independently associated with a higher amyloid load (standardized β=0.40; P=0.001). CONCLUSIONS In spontaneous ICH, CVR is associated with CAA and a higher amyloid burden. Our results suggest venous drainage dysfunction potentially plays a role in CAA and cerebral amyloid deposition.
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Affiliation(s)
- Bo-Ching Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei. (B.-C.L., Y.-F.C.).,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University Hospital, Taipei.(B.-C.L.).,Department of Medical Imaging, National Taiwan University Hospital Yun-Lin Branch (B.-C.L.)
| | - Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei. (H.-H.T., L.-K.T., J.-S.J.).,Departments of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei (H.-H.T.)
| | - Chia-Ju Liu
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei. (C.-J.L., R.-F.Y.)
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei. (B.-C.L., Y.-F.C.)
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei. (H.-H.T., L.-K.T., J.-S.J.).,Departments of Neurology, National Taiwan University Hospital Hsin-Chu Branch (L.-K.T.)
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei. (H.-H.T., L.-K.T., J.-S.J.)
| | - Ruoh-Fang Yen
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei. (C.-J.L., R.-F.Y.)
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Tsai HHC, Tsai YC, Liu CJ, Lin SS, Chuang YC, Chen YF, Jeng JS, Tsai LK, Yen RF. Abstract 163: Cerebral Amyloid Deposition Predicts Long-term Cognitive Decline In Intracerebral Hemorrhage Survivors. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
To investigate the role of cerebral amyloid deposition for long-term cognitive outcomes in spontaneous intracerebral hemorrhage (ICH) survivors.
Methods:
Patients experiencing an ICH without over dementia were included (n = 68). Each patient received the brain MRI and Pittsburgh Compound B (PiB) PET at baseline, and the cognitive function was followed up using Mini-mental Status Examination (MMSE) and clinical dementia rating (CDR) with an overall median of 3.8 years. The association between follow-up cognitive outcomes and neuroimaging markers was explored using multivariable Cox regression models. Positive amyloid scan was defined as global PiB standardized uptake value ratio > 1.2.
Results:
Patients with PiB(+) were older (72.1 ± 7.8 vs. 59.9 ± 11.7,
p
= 0.002) and were more frequently associated with probable CAA (54.5% vs. 8.8%, p=0.001) than patients with PiB(-). PiB(+) was associated with a higher risk of dementia conversion (32.9 vs. 4.0 per 100-person-years, HR=16.4 [3.5-75.5],
p
<0.001) and cognitive decline (defined as MMSE decline≥ 2, 58.8 vs.9.9 per 100-person-years, HR=6.1 [2.0-18.8], p=0.002) compared to PiB(-). Higher lobar microbleed number and the presence of lacune were also associated with cognitive worsening (both p<0.005). In the cox models, PiB(+) was an independent predictor of dementia conversion (HR=12.3 [2.9-52.6], p=0.001) or cognitive decline (HR=7.9 [2.4-26.0], p=0.001) after adjustment for age, sex, educational years, lobar microbleeds and lacune. In the subgroup of patients who were non-CAA (n=57), PiB(+) remained an independent predictor of cognitive worsening (both p<0.005).
Conclusions:
We demonstrate the strong association between positive amyloid scan and long-term cognitive change in ICH survivors, suggesting cerebral amyloid deposition as an important driving factor for cognitive impairment in hemorrhagic small vessel disease.
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Affiliation(s)
| | - Ya-Chin Tsai
- National Taiwan Univ Hosp Hsin-Chu Branch, Taipei, Taiwan
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30
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Lin CJ, Chung CP, Cheng HM, Liu CH, Hsu LC, Chi NF, Tang SC, Lee JT, Po HL, Jeng JS, Wang TD, Lee IH. The 2020 Taiwan Stroke Society guidelines for blood pressure control at the acute stage of ischemic stroke. J Formos Med Assoc 2023; 122:98-105. [PMID: 36041989 DOI: 10.1016/j.jfma.2022.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 03/11/2022] [Accepted: 08/11/2022] [Indexed: 02/01/2023] Open
Abstract
The 2020 Taiwan Stroke Society (TSS) guidelines for blood pressure (BP) control related to ischemic stroke update the 2015 TSS BP guidelines. The early management of acute ischemic stroke has evolved rapidly in the previous two decades. Since the publication of the previous version of the TSS BP guidelines, many studies have addressed BP management in ischemic stroke. Particularly, several successful endovascular thrombectomy (EVT) trials published in 2015 led to a new era of acute treatment for ischemic stroke. With the ever-increasing use of EVT, evidence-based guidelines for ideal BP management during and after EVT are urgently needed. Consequently, the 2020 guidelines are updating and providing recommendations on BP control for the treatment and prevention of ischemic stroke based on new evidence. The present study encompasses the most important chapter of the 2020 Taiwan BP guidelines: BP control at the acute stage of ischemic stroke. We incorporated the most updated evidence regarding BP control at the acute stage of ischemic stroke in patients receiving or not receiving acute reperfusion therapy and provided specific recommendations for different treatment subgroups accordingly.
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Affiliation(s)
- Chun-Jen Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Chih-Ping Chung
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan.
| | - Hao-Ming Cheng
- Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Institute of Public Health, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Center for Evidence-based Medicine & Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chi-Hung Liu
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Li-Chi Hsu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Nai-Fang Chi
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, Taipei, Taiwan
| | - Helen L Po
- Department of Neurology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzung-Dau Wang
- Department of Cardiology, National Taiwan University, Taipei, Taiwan
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
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31
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Chiu YC, Tang SC, Tsai LK, Hsieh MJ, Chiang WC, Jeng JS, Ma MHM. Development and Validation of a Risk Score for Predicting Ischemic Stroke After Transient Ischemic Attack. J Emerg Med 2023; 64:167-174. [PMID: 36813643 DOI: 10.1016/j.jemermed.2022.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 02/24/2023]
Abstract
BACKGROUND A risk stratification scale is essential to identify high-risk patients who had transient ischemic attack (TIA) to prevent subsequent permanent disability caused by ischemic stroke. OBJECTIVE This study aimed to develop and validate a scoring system to predict acute ischemic stroke within 90 days after TIA in an emergency department (ED). METHODS We retrospectively analyzed the data of patients with TIA in a stroke registry between January 2011 and September 2018. Characteristics, medication history, electrocardiogram (ECG), and imaging findings were collected. Univariable and multivariable stepwise logistic regression analyses were performed to create an integer point system. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration. Youden's Index was also used to determine the best cutoff value. RESULTS A total of 557 patients were included, and the occurrence rate of acute ischemic stroke within 90 days after TIA was 5.03%. After multivariable analysis, a new integer point system was created-MESH (Medication Electrocardiogram Stenosis Hypodense) score-which contained medication history (antiplatelet medication taken before admission, 1 point), right bundle branch block on electrocardiogram (1 point), intracranial stenosis ≥ 50% (1 point), and size of the hypodense area on computed tomography (diameter ≥ 4 cm, 2 points). The MESH score showed adequate discrimination (AUC = 0.78) and calibration (HL test = 0.78). The best cutoff value was 2 points, with a sensitivity of 60.71% and specificity of 81.66%. CONCLUSIONS The MESH score indicated improved accuracy for TIA risk stratification in the ED setting.
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Affiliation(s)
- Yu-Chen Chiu
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
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32
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Yang JY, Chu YT, Tsai HH, Jeng JS. Amyloid and tau PET in cerebral amyloid angiopathy-related inflammation two case reports and literature review. Front Neurol 2023; 14:1153305. [PMID: 37188315 PMCID: PMC10175602 DOI: 10.3389/fneur.2023.1153305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/06/2023] [Indexed: 05/17/2023] Open
Abstract
Background Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a clinical syndrome characterized by MRI findings of amyloid-related imaging abnormalities-edema (ARIA-E) suggestive of autoimmune and inflammatory reaction and hemorrhagic evidence of cerebral amyloid angiopathy. The longitudinal variation of amyloid PET and its imaging association with CAA-ri are undetermined. Moreover, tau PET in CAA-ri has been rarely investigated. Method We retrospectively described two cases of CAA-ri. We provided the temporal change of amyloid and tau PET in the first case, and the cross-sectional finding of amyloid and tau PET in the second case. We also performed a literature review of the imaging features of amyloid PET in reported cases of CAA-ri. Results In the first case, an 88-year-old male presented with progressive consciousness and gait disturbances over 2 months. MRI showed disseminated cortical superficial siderosis. Amyloid PET prior to and after the CAA-ri revealed focally decreased amyloid load in the region of ARIA-E. In the second case, a 72-year-old male was initially suspected to have central nervous system cryptococcosis but later diagnosed with CAA-ri because of the characteristic MRI features and good response to corticosteroid treatment; a subsequent amyloid scan revealed positive amyloid deposition of the brain. Neither case suggested an association between the region of ARIA-E and higher amyloid uptake on PET before or after onset of CAA-ri. Our literature review revealed variable findings related to amyloid burden in post-inflammatory regions in previously reported CAA-ri cases with available amyloid PET. Our case is the first report of longitudinal changes on amyloid PET and show focal decreases in amyloid load after the inflammatory process. Conclusion This case series highlights the need to better explore the potential of longitudinal amyloid PET in the understanding of the mechanisms of CAA-ri.
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Affiliation(s)
- Jhih-Yong Yang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yung-Tsai Chu
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei, Taiwan
- *Correspondence: Hsin-Hsi Tsai
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Lee TH, Cheng CN, Lee CW, Kuo CH, Tang SC, Jeng JS. Investigating sphingolipids as biomarkers for the outcomes of acute ischemic stroke patients receiving endovascular treatment. J Formos Med Assoc 2023; 122:19-28. [PMID: 36184387 DOI: 10.1016/j.jfma.2022.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/27/2022] [Accepted: 08/30/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Long-chain ceramides are associated with the mechanisms and clinical outcomes of acute ischemic stroke (AIS). This study aimed to investigate the plasma ceramides and sphingosine-1-phosphate in AIS patients undergoing endovascular thrombectomy (EVT) and their associations with outcomes. METHODS Plasma samples were collected from 75 AIS patients who underwent EVT before (T1), immediately after (T2), and 24 h after (T3) the procedures and 19 controls that were matched with age, sex, and co-morbidities. The levels of ceramides with different fatty acyl chain lengths and sphingosine-1-phosphate were measured by UHPLC-ESI-MS/MS. A poor outcome was defined as a modified Rankin Scale score of 3-6 at 3 months after stroke. RESULTS The plasma levels of long-chain ceramides Cer (d18:1/16:0) at all three time points, Cer (d18:1/18:0) at T1 and T3, and Cer (d18:1/20:0) at T1 and very-long-chain ceramide Cer (d18:1/24:1) at T1 were significantly higher in AIS patients than those in the controls. In contrast, the plasma levels of sphingosine-1-phosphate in AIS patients were significantly lower than those in the controls at all three time points. Among the AIS patients, 34 (45.3%) had poor functional outcomes at 3 months poststroke. Multivariable analysis showed that higher levels of Cer (d18:1/16:0) and Cer (d18:1/18:0) at all three time points, Cer (d18:1/20:0) at T1 and T2, and Cer (d18:1/24:0) at T2 remained significantly associated with poor functional outcomes after adjustment for potential confounding factors. CONCLUSION Plasma ceramides were elevated early in AIS patients with acute large artery occlusion. Furthermore, Cer (d18:1/16:0) and Cer (d18:1/18:0) could be early prognostic indicators for AIS patients undergoing EVT.
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Affiliation(s)
- Tsung-Heng Lee
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; The Metabolomics Core Laboratory, Centers of Genomic and Precision Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Ning Cheng
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; The Metabolomics Core Laboratory, Centers of Genomic and Precision Medicine, National Taiwan University, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Hua Kuo
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; The Metabolomics Core Laboratory, Centers of Genomic and Precision Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Yeh SJ, Chen CH, Lin YH, Tsai LK, Lee CW, Tang SC, Jeng JS. Serum amyloid A predicts poor functional outcome in patients with ischemic stroke receiving endovascular thrombectomy: a case control study. J Neurointerv Surg 2023; 15:75-81. [PMID: 35058315 DOI: 10.1136/neurintsurg-2021-018234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/18/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Post-stroke inflammation contributes to poor outcomes, but its impact on patients with stroke receiving endovascular thrombectomy (EVT) remains unknown. METHODS We enrolled adult patients with stroke who received EVT, with blood sampling immediately before (T1) and after EVT (T2), and at 24 hours after EVT (T3). Non-stroke controls and patients with non-EVT stroke were also enrolled. The medical information, image findings and levels of serum amyloid A (SAA) and C-reactive protein (CRP) were analyzed to clarify the association with poor functional outcome (modified Rankin Scale 4-6) at 3 months after stroke. RESULTS A total of 93 patients with stroke receiving EVT, 51 non-stroke controls, and 64 with non-EVT stroke were enrolled in this study. The SAA and CRP levels at T1 to T3 in patients with stroke receiving EVT were higher compared with those in controls (all p<0.001), and their levels at T3 were significantly higher than those at T1 (both p<0.0001) while similar to those in patients with non-EVT stroke. The SAA levels at the three time points were significantly associated with poor functional outcome (p=0.003 to 0.009). Furthermore, adding SAA level at T3 significantly improved the basic prediction model for 3-month poor functional outcome by receiver operating characteristic (ROC) analysis (areas under ROC curves from 0.803 to 0.878, p=0.03). CONCLUSIONS Our findings demonstrate that plasma levels of SAA at an early stage are significant predictors for poor functional outcomes at 3 months in patients with stroke receiving EVT, indicating the substantial role of systemic inflammation in shaping stroke outcomes following EVT.
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Affiliation(s)
- Shin-Joe Yeh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Hao Chen
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Lin YW, Yeh SJ, Tang SC, Tsai LK, Jeng JS. Improvement After Celecoxib Treatment in Patients with Thalamic Hemorrhage - A Case Report. Acta Neurol Taiwan 2022; 31(4):84-89. [PMID: 35470409] [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] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE Perihematomal edema of intracerebral hemorrhage (ICH) is caused by a hematoma-induced inflammatory reaction, which usually contributes to delayed deterioration of neurological function and poor outcomes. Celecoxib is a commonly used nonsteroidal anti-inflammatory drug that selectively inhibits cyclooxygenase-2. High-dose celecoxib (400 mg twice daily) for 14 days has been shown to reduce perihematomal edema and hematoma enlargement in patients with ICH, but without improvement in long-term functional outcome, which may be confounded by the heterogeneity of hematoma location. Low-dose celecoxib may be an effective management for symptoms caused by perihematomal edema in patients with ICH, particularly those involving the thalamus. CASE REPORT We reported two patients with acute thalamic ICH; a common symptom between the two was delayed onset of drowsiness caused by perihematomal edema involving the thalamus. Their consciousness improved after low-dose celecoxib (200 mg once daily) administration for 3 and 2 days in case A and B, respectively. Furthermore, other symptoms that concomitantly improved included poor appetite caused by perihematomal edema involving the left hypothalamus in case A, and limb weakness caused by perihematomal edema of the internal capsule in case B. CONCLUSION These cases revealed that low-dose celecoxib may be an effective management for symptoms caused by perihematomal edema in patients with ICH, particularly those involving the thalamus.
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Affiliation(s)
- Yu-Wei Lin
- School of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shin-Joe Yeh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Chang TY, Chen PS, Yeh SJ, Tang SC, Tsai LK, Jeng JS. Concomitant Sympathetic and Parasympathetic Dysfunction after Acute Ischemic Stroke. Acta Neurol Taiwan 2022; 31(4):174-178. [PMID: 35470411] [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] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE Autonomic dysfunction is an underrecognized complication of acute ischemic stroke. The cortical regulation of sympathetic activation is predominantly lateralized to the right hemisphere and parasympathetic activation to the left hemisphere. However, prior evidence is lacking regarding ischemic lesions in unilateral hemisphere that concomitantly cause sympathetic and parasympathetic dysfunction. CASE REPORT We present the case of a 73-year-old woman with acute ischemic stroke in the left middle cerebral artery territory, whose neurological symptoms improved significantly after thrombolysis and endovascular thrombectomy. She presented residual scattered small infarctions involving the left insula and lateral parietal cortex. However, she experienced obvious autonomic symptoms that included orthostatic hypotension, which is indicative of sympathetic dysfunction, and micturition difficulty with exaggerated reflex tachycardia, indicative of parasympathetic dysfunction. The sympathetic and parasympathetic functions sequentially resolved on days 10 and 20 after stroke onset, respectively. CONCLUSION The case revealed insight into the phenomenon and recovery course of concurrent sympathetic and parasympathetic dysfunction associated with ischemic lesions in the left hemisphere.
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Affiliation(s)
- Ting-Yu Chang
- Department of School of Medicine, National Taiwan University, Taipei, Taiwan
| | - Pin-Shiuan Chen
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Shin-Joe Yeh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Chen CH, Sung CW, Jeng JS, Fan CY, Chang JH, Chen JW, Tang SC, Huang EPC. Utility of carotid ultrasound on prediction of 1-year mortality in emergency department patients with neurological deficits: A 10-year population-based cohort study. PLoS One 2022; 17:e0277951. [PMID: 36534671 PMCID: PMC9762588 DOI: 10.1371/journal.pone.0277951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/07/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This study aimed to investigate the association between the carotid ultrasound results and 1-yr mortality of patients with neurological deficits in the emergency department (ED). METHODS This study included patients with neurological symptoms who presented to the ED between January 1, 2009 and December 31, 2018, and underwent sonographic imaging of the bilateral carotid bulb, common carotid artery (CCA), internal carotid artery (ICA), and external carotid arteries. A stenosis degree of >50% was defined as significant carotid stenosis. Carotid plaque score (CPS) was calculated by adding the score of stenosis severity of all segments. The association between carotid ultrasound results and 1-yr mortality was investigated using the Cox regression model. RESULTS The analysis included 7,961 patients (median age: 69 yr; men: 58.7%). Among them, 247 (3.1%) passed away from cardiovascular (CV)-related causes, and 746 (9.4%) died within a year. The mortality group presented with more significant carotid stenosis of the carotid bulb, CCA, or ICA and had a higher median CPS. A higher CPS was associated with a greater 1-yr all-cause mortality (adjusted hazard ratio [aHR] = 1.08; 95% confidence interval [CI] = 1.03-1.13; p = 0.001; log-rank p < 0.001) and CV-related mortality (aHR = 1.13; 95% CI = 1.04-1.22; p = 0.002, log-rank p < 0.001). Significant stenosis of either carotid artery segment did not result in a higher risk of 1-yr mortality. CONCLUSIONS We comprehensively investigated the utility of carotid ultrasound parameters on predicting mortality in this 10-yr population-based cohort, which included over 7,000 patients with acute neurological deficits presented to the ED. The result showed that CPS could be used as risk stratification tools for 1-yr all-cause and CV mortality.
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Affiliation(s)
- Chi-Hsin Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center & Department of Neurology, National Taiwan University Hospital, Taipei City, Taiwan
| | - Cheng-Yi Fan
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Jia-How Chang
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Jiun-Wei Chen
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Sung-Chun Tang
- Stroke Center & Department of Neurology, National Taiwan University Hospital, Taipei City, Taiwan
- * E-mail: (SCT); (EPCH)
| | - Edward Pei-Chuan Huang
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei City, Taiwan
- * E-mail: (SCT); (EPCH)
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Lin YH, Chen CH, Tang SC, Lee CW, Yeh SJ, Tsai LK, Jeng JS. Posterior Limb of Internal Capsule Infarct Predicts Functional Outcome in Acute Terminal Internal Carotid Artery Occlusion After Thrombectomy. Clin Neuroradiol 2022; 32:951-959. [PMID: 35238949 DOI: 10.1007/s00062-022-01148-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/31/2022] [Indexed: 12/15/2022]
Abstract
PURPOSES This study investigated the impact of posterior limb of internal capsule (PLIC) infarct on outcomes of acute internal carotid artery (ICA) occlusion after endovascular thrombectomy (EVT) and the diagnostic accuracy of pretreatment noncontrast computerized tomography (NCCT) and computerized tomography angiography (CTA) findings. METHODS Patients who underwent EVT for acute ICA occlusion between September 2014 and August 2020 were included in the study. The patients were dichotomized as PLIC infarct or spared. The risk factors for PLIC infarct were investigated, and the association between infarct patterns and clinical outcomes were assessed using logistic regression analysis. Pretreatment NCCT and CTA findings, including PLIC hypodensity, choroid plexus enhancement (CPE), and posterior cerebral artery (PCA) flow status, were calculated for diagnosis of PLIC infarct. RESULTS Among 72 patients, the mean age was 70.9 years, and the mean stroke scale was 19.4. PLIC infarct was identified in 15 patients (20.8%). PLIC infarct was associated with worse 90-day functional outcome (P = 0.01, shift test). Lack of CPE is the only independent predictor of PLIC infarct (odds ratio: 127.48, P = 0.001). Lack of CPE and impaired PCA flow produce greater diagnostic accuracy for PLIC infarct than does NCCT hypodensity (area under the receiver operating characteristics curve: 0.85 and 0.76, P = 0.0005 and 0.02, respectively). CONCLUSIONS In acute ICA occlusion, PLIC infarct is an independent risk factor for worse clinical outcome at 90 days. The lack of CPE was associated with PLIC infarct, and pretreatment CTA can be useful for early diagnosis.
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Affiliation(s)
- Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, 10055, Taipei, Taiwan
| | - Chih-Hao Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, 10055, Taipei, Taiwan.
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Yoon BW, Lee JT, Chang KC, Toyoda K, Jeng JS, Venketasubramanian N. Asia Pacific Stroke Conference 2022: Stroke Care Reform through Collaboration and Cooperation. Cerebrovasc Dis 2022; 51 Suppl 1:III-IV. [PMID: 36417844 DOI: 10.1159/000527790] [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] [Received: 10/26/2022] [Accepted: 10/26/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Byung-Woo Yoon
- Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Republic of Korea
| | - Jiunn-Tay Lee
- Department of Neurology, National Defense Medical Center, Taipei, Taiwan
| | - Ku-Chou Chang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Yeh SJ, Tang SC, Tsai LK, Chen TC, Li PL, Chen YF, Kuo MF, Jeng JS. Postoperative vascular event prediction using angiography and ultrasonography in patients with Moyamoya disease. J Neurol Sci 2022; 442:120408. [PMID: 36108529 DOI: 10.1016/j.jns.2022.120408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/15/2022] [Accepted: 08/29/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Indirect revascularization surgery reduce the risk of recurrent vascular events in patients with moyamoya disease (MMD), but the roles of postoperative angiography and ultrasonography in predicting these events remain unclear. METHODS This prospective study enrolled patients with MMD who would undergo their first unilateral indirect revascularization surgery. They received preoperative and postoperative ultrasound examination at 1, 3, and 6 months and conventional cerebral angiography. On ultrasonography, postoperative emerging flow (PEF) in an intracranial artery was defined as emerging flow postoperatively with absence of flow preoperatively. Predictors of vascular event frequency reduction were identified from angiographic and ultrasonographic parameters. RESULTS In total, 52 patients (including 24 pediatric and 24 male patients), who underwent 52 preoperative and 82 postoperative ultrasound examinations, were enrolled. Significant postoperative changes were noted in all the ultrasonographic parameters of ipsilateral superficial temporal artery (STA) and the end-diastolic velocity and flow volume in contralateral STA. During a median follow-up of 5.3 years, indirect revascularization surgery significantly reduced the occurrence of ipsilateral vascular events. Predictors of vascular event frequency reduction included Matsushima grade A or B on the ipsilateral side on angiography (odds ratio [OR] = 22.00, P = 0.002) and lower resistance index (RI) in ipsilateral STA (OR = 0.0001, P = 0.012) but no PEF pattern in ipsilateral middle cerebral artery (OR = 0.14, P = 0.029) on ultrasonography performed within 6 months. CONCLUSIONS Reduction of long-term vascular event frequency probably can be predicted through postoperative angiography and ultrasonography within 6 months after indirect revascularization surgery.
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Affiliation(s)
- Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Tzu-Ching Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Lin Li
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Fai Kuo
- Department of Neurosurgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
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Tsai HH, Lee BC, Chen YF, Jeng JS, Tsai LK. Cerebral Venous Reflux and Dilated Basal Ganglia Perivascular Space in Hypertensive Intracerebral Hemorrhage. J Stroke 2022; 24:363-371. [PMID: 36221939 PMCID: PMC9561214 DOI: 10.5853/jos.2022.01004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/30/2022] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose Cerebral venous flow alterations potentially contribute to age-related white matter changes, but their role in small vessel disease has not been investigated.Methods This study included 297 patients with hypertensive intracerebral hemorrhages (ICH) who underwent magnetic resonance imaging. Cerebral venous reflux (CVR) was defined as the presence of abnormal signal intensity in the dural venous sinuses or internal jugular vein on time-of-flight angiography. We investigated the association between CVR, dilated perivascular spaces (PVS), and recurrent stroke risk.Results CVR was observed in 38 (12.8%) patients. Compared to patients without CVR those with CVR were more likely to have high grade (>20 in the number) dilated PVS in the basal ganglia (60.5% vs. 35.1%; adjusted odds ratio [aOR], 2.64; 95% confidence interval [CI], 1.25 to 5.60; <i>P</i>=0.011) and large PVS (>3 mm in diameter) (50.0% vs. 18.5%; aOR, 3.87; 95% CI, 1.85 to 8.09; <i>P</i><0.001). During a median follow-up of 18 months, patients with CVR had a higher recurrent stroke rate (13.6%/year vs. 6.2%/year; aOR, 2.53; 95% CI, 1.09 to 5.84; <i>P</i>=0.03) than those without CVR.Conclusions CVR may contribute to the formation of enlarged PVS and increase the risk of recurrent stroke in patients with hypertensive ICH.
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Affiliation(s)
- Hsin-Hsi Tsai
- Department of Neurology, National Taiwan University Hospital Bei-Hu Branch, Taipei, Taiwan
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Bo-Ching Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
- Correspondence: Ya-Fang Chen Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei 100, Taiwan Tel: +886-2-23123456 ext.51623 Fax: +886-2-23224552 E-mail:
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Chen PL, Chen YJ, Chung CP, Seak CJ, Jeng JS, Hsieh MJ, Lien LM, Chen JH, Chen YW, Chiu TF, Lee JT, Ng CJ. Dual Antiplatelet Therapy in the Management of Acute Minor Ischemic Stroke and High-Risk Transient Ischemic Attack: An Expert Consensus Statement From Taiwan Stroke Society and Taiwan Society of Emergency Medicine. J Acute Med 2022; 12:85-95. [PMID: 36313610 PMCID: PMC9561483 DOI: 10.6705/j.jacme.202209_12(3).0001] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 07/24/2022] [Indexed: 06/16/2023]
Abstract
The aim of this review is to achieve a consensus between Taiwan Stroke Society (TSS) and Taiwan Society of Emergency Medicine (TSEM) to manage acute non-cardioembolic minor ischemic stroke (MIS) and high-risk transient ischemic attack (TIA). The methodology is to review the recent findings from clinical trials of dual antiplatelet therapy (DAPT) from 2010 to 2021 and updates in clinical practice guidelines from 2018 to 2022 for non-cardioembolic MIS/TIA management at the acute stage. Four leading clinical studies, CHANCE, POINT, THALES, and CHANCE-2 along with other relevant studies introducing DAPT, are discussed in this review. The risk-benefit profile between stroke recurrence reduction and major bleeding increase is also elucidated. TSS and TSEM concluded that for patients presenting with non-cardioembolic MIS or high-risk TIA who did not receive intravenous alteplase, initiation of DAPT within 24 hours after stroke onset and continued up to 21 days, followed by antiplatelet monotherapy, is effective in reducing recurrent ischemic stroke for a period of up to 90 days.
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Affiliation(s)
- Po-Lin Chen
- Neurological Institute Division of Neurology Taichung Veterans General Hospital, Taichung Taiwan
| | - Ying-Ju Chen
- Taipei Veterans General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Chih-Ping Chung
- Neurological Institute Department of Neurology Taipei Veterans General Hospital, Taipei Taiwan
| | - Chen-June Seak
- New Taipei Municipal Tucheng Hospital Department of Emergency Medicine New Taipei City Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
| | - Jiann-Shing Jeng
- National Taiwan University Hospital Department of Neurology and Stroke Center Taipei Taiwan
| | - Ming-Ju Hsieh
- National Taiwan University Hospital Department of Emergency Medicine Taipei Taiwan
| | - Li-Ming Lien
- Shin Kong Wu Ho-Su Memorial Hospital Department of Neurology Taipei Taiwan
| | - Jiann-Hwa Chen
- Cathay General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Yu-Wei Chen
- Landseed International Hospital Department of Neurology Taoyuan Taiwan
| | - Te-Fa Chiu
- China Medical University Hospital Department of Emergency Medicine Taichung Taiwan
| | - Jiunn-Tay Lee
- Tri-Service General Hospital Department of Neurology National Defense Medical Center, Taipei Taiwan
| | - Chip-Jin Ng
- Chang Gung University College of Medicine Taoyuan Taiwan
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
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Cheng YW, Chao CC, Chen CH, Yeh TY, Jeng JS, Tang SC, Hsieh ST. Small Fiber Pathology in CADASIL: Clinical Correlation With Cognitive Impairment. Neurology 2022; 99:e583-e593. [PMID: 35584924 PMCID: PMC9442619 DOI: 10.1212/wnl.0000000000200672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/16/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES This study investigated the cutaneous small fiber pathology of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) and its clinical significance, that is, the NOTCH3 deposition in cutaneous vasculatures and CNS neurodegeneration focusing on cognitive impairment. METHODS Thirty-seven patients with CADASIL and 59 age-matched healthy controls were enrolled to evaluate cutaneous small fiber pathology by quantitative measures of intraepidermal nerve fiber density (IENFD), sweat gland innervation, and vascular innervation. Cognitive performance of patients with CADASIL was evaluated by a comprehensive neuropsychological assessment, and its association with small fiber pathology was tested using multivariable linear regression analysis adjusted for age and diabetes mellitus. We further assessed the relationships of IENFD with cutaneous vascular NOTCH3 ectodomain (NOTCH3ECD) deposition and biomarkers of neurodegeneration including structural brain MRI measures, serum neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), tau, and ubiquitin carboxy-terminal hydrolase L1. RESULTS Patients with CADASIL showed reduced IENFD (5.22 ± 2.42 vs 7.88 ± 2.89 fibers/mm, p = 0.0001) and reduced sweat gland (p < 0.0001) and vascular (p < 0.0001) innervations compared with age-matched controls. Reduced IENFD was associated with impaired global cognition measured by Mini-Mental State Examination (B = 1.062, 95% CI = 0.370-1.753, p = 0.004), and this association remained after adjustment for age and diabetes mellitus (p = 0.043). In addition, IENFD in patients with CADASIL was associated with mean cortical thickness (Pearson r = 0.565, p = 0.0023) but not white matter hyperintensity volume, total lacune count, or total microbleed count. Reduced IENFD was associated with cutaneous vascular NOTCH3ECD deposition amount among patients harboring pathogenic variants in exon 11 (mainly p.R544C) (B = -0.092, 95% CI = -0.175 to -0.009, p = 0.031). Compared with those with normal cognition, patients with CADASIL with cognitive impairment had an elevated plasma NfL level regardless of concurrent small fiber denervation, whereas only patients with both cognitive impairment and small fiber denervation showed an elevated plasma GFAP level. DISCUSSION Cutaneous small fiber pathology correlates with cognitive impairment and CNS neurodegeneration in patients with CADASIL, indicating a peripheral neurodegenerative process related to NOTCH3ECD aggregation.
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Affiliation(s)
- Yu-Wen Cheng
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei
| | - Chi-Chao Chao
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei
| | - Chih-Hao Chen
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei
| | - Ti-Yen Yeh
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei
| | - Jiann-Shing Jeng
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei
| | - Sung-Chun Tang
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei
| | - Sung-Tsang Hsieh
- From the Department of Neurology (Y.-W.C.), National Taiwan University Hospital, Hsin-Chu Branch; Graduate Institute of Clinical Medicine (Y.-W.C.), College of Medicine, National Taiwan University; Department of Neurology (C.-C.C., C.-H.C., J.-S.J., S.-C.T., S.-T.H.), National Taiwan University Hospital; Department of Anatomy and Cell Biology (T.-Y.Y., S.-T.H.), College of Medicine, National Taiwan University; Graduate Institute of Brain and Mind Sciences (S.-T.H.), College of Medicine, National Taiwan University; and Center of Precision Medicine (S.-T.H.), National Taiwan University College of Medicine, Taipei.
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Chen PS, Lee M, Tang SC, Huang PH, Yeh HI, Jia-Yin Hou C, Hsieh IC, Lee JT, Jeng JS, Li YH. 2022 focused update of the 2017 Taiwan lipid guidelines for high risk patients: Coronary artery disease, peripheral artery disease and ischemic stroke. J Formos Med Assoc 2022; 121:1363-1370. [PMID: 35410823 DOI: 10.1016/j.jfma.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/27/2021] [Accepted: 03/02/2022] [Indexed: 12/24/2022] Open
Abstract
The previously published 2017 Taiwan Lipid Guidelines for High Risk Patients becomes the standard guidance of dyslipidemia management for patients with atherosclerotic cardiovascular disease (ASCVD) in Taiwan. New clinical trials of lipid lowering therapy were published successively after 2017. The study results changed the treatment concept of ASCVD. Therefore, an update focusing on the lipid treatment strategy for patients with ASCVD becomes necessary. In this focused update of the 2017 guideline, the treatment targets of low-density lipoprotein cholesterol (LDL-C) for patients with ASCVD were modified. The algorithm of LDL-C lowering therapy was revised. The recommendations in this focused update were made mainly based on the scientific evidence from recently published clinical trials and endorsed by the major medical societies in Taiwan.
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Affiliation(s)
- Po-Sheng Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Meng Lee
- Department of Neurology, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Po-Hsun Huang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hung-I Yeh
- Departments of Internal Medicine and Medical Research, MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | | | - I-Chang Hsieh
- Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Yi-Heng Li
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Chen CH, Chu YT, Chen YF, Ko TY, Cheng YW, Lee MJ, Chen PL, Tang SC, Jeng JS. Comparison of clinical and neuroimaging features between NOTCH3 mutations and nongenetic spontaneous intracerebral haemorrhage. Eur J Neurol 2022; 29:3243-3254. [PMID: 35781912 DOI: 10.1111/ene.15485] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/25/2022] [Accepted: 06/29/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The NOTCH3 mutation is a common cause of hereditary cerebral small vessel disease (CSVD) and may be a cause of spontaneous intracerebral haemorrhage (ICH). We aimed to investigate the clinical/imaging features for identifying the NOTCH3 mutations related ICH. METHODS The study was based on a cohort of 749 CSVD patients in Taiwan who received next-generation sequencing of CSVD genes including NOTCH3. Patients with history of ICH (n=206) were included for analysis. The CSVD neuroimaging markers were compared between the patients with NOTCH3 and without known genetic mutations. RESULTS After excluding the patients with other causes of ICH (structural lesions, systemic/medication-related, or amyloid angiopathy) and those without neuroimaging, 45 NOTCH3 mutation patients and 109 nongenetic ICH patients were included. The NOTCH3 mutation patients were more likely to have thalamic haemorrhage, a family history of stroke, and more severe CSVD neuroimaging markers. A five-point NOTCH3-ICH score was constructed and consisted of: history of stroke in siblings, thalamic haemorrhage, any deep nuclei lacunae, any hippocampal cerebral microbleed (CMB), and a thalamic CMB >5 (one point for each). A score ≥2 had a sensitivity of 88.9% and a specificity of 64.2% in identifying the NOTCH3 mutation. The NOTCH3 mutation patients had a higher risk of recurrent stroke (9.1 vs. 4.5 per 100 person-years; log-rank p = 0.03) during follow-up. CONCLUSION The patients with NOTCH3 mutation-related ICH had a higher burden of CMB in the hippocampus/thalamus and a higher recurrent stroke risk. The NOTCH3-ICH score may assist identifying genetic causes of ICH.
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Affiliation(s)
- Chih-Hao Chen
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yung-Tsai Chu
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzu-Yu Ko
- Graduate Institute of Medical Genomics and Proteomics, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Wen Cheng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Neurology, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
| | - Ming-Jen Lee
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Lung Chen
- Graduate Institute of Medical Genomics and Proteomics, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Su CH, Jeng JS, Tu ST, Huang CN, Yeh HI. An Effective Strategy to Activate Physicians to Promote High Cardiovascular Risk Patients to Quit Smoking. Acta Cardiol Sin 2022; 38:521-525. [PMID: 35873124 PMCID: PMC9295038 DOI: 10.6515/acs.202207_38(4).20220224a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/24/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Adult patients cared for by cardiologists, neurologists, and diabetologists are highly vulnerable to cardiovascular diseases (CVDs), which are worsened by smoking. In the past, physicians of these three specialties at major hospitals in Taiwan always referred patients to family medicine and chest medicine departments for smoking cessation programs. However, the participation rate in these programs was unsatisfactory. OBJECTIVES To encourage cardiologists, neurologists, and diabetologists to provide smoking cessation treatment services (SCTSs) to their patients through an annual contest. METHODS Sequential expert meetings, group training, a contest to reward service quantity and abstinence rate, and an annual awards ceremony were held over the past 3 years. RESULTS More than 350 cardiologists, neurologists, and diabetologists were certified to provide SCTSs, and in the second half of 2020, 3716 high CVD risk patients entered smoking cessation treatment programs, with an abstinence rate exceeding 30% at 3 months. CONCLUSIONS The strategy used in this study was effective in overcoming physician inertia to provide SCTSs and encourage high CVD risk smokers to quit smoking.
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Affiliation(s)
- Cheng-Huang Su
- Cardiovascular Center, MacKay Memorial Hospital, Taipei & MacKay Medical College, New Taipei City
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei
| | - Shih-Te Tu
- Endocrinology & Metabolism Division, Changhua Christian Hospital, Changhua
| | - Chien-Ning Huang
- Institute of Medicine, Chung Shan Medical University & Hospital, Taichung, Taiwan
| | - Hung-I Yeh
- Cardiovascular Center, MacKay Memorial Hospital, Taipei & MacKay Medical College, New Taipei City
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Chi NF, Chung CP, Cheng HM, Liu CH, Lin CJ, Hsu LC, Tang SC, Lee JT, Po HL, Jeng JS, Wang TD, Lee IH. 2021 Taiwan Stroke Society Guidelines of blood pressure control for ischemic stroke prevention. J Chin Med Assoc 2022; 85:651-664. [PMID: 35507097 DOI: 10.1097/jcma.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Since the publication of the 2015 Taiwan Stroke Society Blood Pressure for Treatment and Prevention of Stroke Guideline (2015 TSS BP Guideline), several new clinical studies have addressed whether a stricter blood pressure (BP) target would be effective for stroke prevention. METHODS TSS guideline consensus group provides recommendations on BP targets for stroke prevention based on updated evidences. RESULTS The present guideline covers five topics: (1) diagnosis of hypertension; (2) BP control and primary prevention of ischemic stroke; (3) BP control and secondary prevention of ischemic stroke; (4) BP control and secondary prevention of large artery atherosclerosis ischemic stroke; and (5) BP control and secondary prevention of small vessel occlusion ischemic stroke. CONCLUSION The BP target for most stroke patients with hypertension is <130/80 mm Hg.
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Affiliation(s)
- Nai-Fang Chi
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Chih-Ping Chung
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Hao-Ming Cheng
- Center for Evidence-based Medicine & Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
- Institute of Public Health, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Chi-Hung Liu
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan, ROC
| | - Chun-Jen Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Li-Chi Hsu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Helen L Po
- Department of Neurology, Mackay Memorial Hospital, Taipei, Taiwan, ROC
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Tzung-Dau Wang
- Department of Cardiology, National Taiwan University, Taipei, Taiwan, ROC
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
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Lin CW, Yang ZW, Chen CH, Cheng YW, Tang SC, Jeng JS. Reduced macular vessel density and inner retinal thickness correlate with the severity of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). PLoS One 2022; 17:e0268572. [PMID: 35617208 PMCID: PMC9135286 DOI: 10.1371/journal.pone.0268572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/02/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), caused by mutations in NOTCH3, is the most common cause of hereditary cerebral small vessel disease. Whether it will involve systemic vasculopathy such as retinal vessel remains unknown. Optical coherence tomography angiography (OCT-A) is a noninvasive technique for visualising retinal blood flow. We analysed vessel density and retinal thickness in patients with CADASIL and investigated their correlations with disease severity. METHODS This prospective study enrolled 35 patients with CADASIL (59 eyes) and 35 healthy controls (54 eyes). OCT-A was used to measure the vessel density of the macular region and the thickness of retinal layers. Patients with CADASIL were divided into stroke (n = 20) and nonstroke (n = 15) subgroups and underwent cognition and gait speed evaluation. Neuroimaging markers of cortical thickness, white matter hyperintensity, lacunae, and cerebral microbleeds were examined through brain magnetic resonance imaging. RESULTS The OCT-A parameters, including vessel density, were comparable between the patients with CADASIL and the controls. In patients with CADASIL, vessel density in the superficial retinal plexus in the macula as was inner retinal thickness was significantly lower in the stroke than the nonstroke subgroup. Macular vessel density and inner retinal thickness were positively correlated with gait speed, while negatively correlated with number of lacunae. CONCLUSIONS OCT-A is potentially a useful tool for evaluating disease severity, ischaemic burden, and neurodegeneration in patients with advanced CADASIL.
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Affiliation(s)
- Chao-Wen Lin
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Zih-Wei Yang
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Hao Chen
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Wen Cheng
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Lin SY, Kuo CH, Ho LT, Liu YB, Huang CF, Tang SC, Jeng JS. Association Between Apixaban Concentration and Clinical Outcomes in Asians With Atrial Fibrillation. Circ Arrhythm Electrophysiol 2022; 15:e010693. [PMID: 35471038 DOI: 10.1161/circep.121.010693] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shin-Yi Lin
- Department of Pharmacy (S.-Y.L., C.-F.H.), National Taiwan University, Taipei.,School of Pharmacy, College of Medicine (S.-Y.L., C.-H.K., C.-F.H.), National Taiwan University, Taipei
| | - Ching-Hua Kuo
- School of Pharmacy, College of Medicine (S.-Y.L., C.-H.K., C.-F.H.), National Taiwan University, Taipei
| | - Li-Ting Ho
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine (L.-T.H., Y.-B.L.), National Taiwan University, Taipei
| | - Yen-Bin Liu
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine (L.-T.H., Y.-B.L.), National Taiwan University, Taipei
| | - Chih-Fen Huang
- Department of Pharmacy (S.-Y.L., C.-F.H.), National Taiwan University, Taipei.,School of Pharmacy, College of Medicine (S.-Y.L., C.-H.K., C.-F.H.), National Taiwan University, Taipei
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital (S.-C.T.), National Taiwan University, Taipei
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Hsieh PF, Liu SY, Chen CH, Chen PL, Tang SC, Jeng JS. Genetic analysis of a family presenting with coexisting cerebral cavernous malformations and polycystic kidney disease. J Formos Med Assoc 2022; 121:2331-2337. [PMID: 35370030 DOI: 10.1016/j.jfma.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/07/2022] [Accepted: 03/14/2022] [Indexed: 10/31/2022]
Abstract
Hereditary cerebral cavernous malformations (CCMs) are characterized by clustered dilated capillary-like vessels in the brain. Autosomal dominant polycystic kidney disease (PKD) is characterized by renal cysts and extra-renal abnormalities. We report a Taiwanese family in which the index case exhibited coexisting phenotypes of both CCMs and PKD. The index case was a 55-year-old woman with known PKD who developed an intracerebral hemorrhage (ICH) in the right medulla. Neuroimaging revealed numerous microbleeds in the bilateral cerebrum and cerebellum. Radiological CCMs were suspected given the absence of other imaging markers of small vessel disease. A comprehensive panel of 183 cerebral vascular malformation genes were investigated through genome sequencing. A novel CCM2 frameshift variant (c.607_608delCT, p.Leu203Valfs∗53) causing a pathogenic premature stop codon, and a known PKD2 nonsense variant (c.2407C > T, p.Arg803∗), were found. Segregation analysis revealed that four siblings were affected by either isolated aforementioned PKD2 or CCM2 variant. Notably, radiological CCMs were exclusively found in siblings who had this CCM2 variant, and bilateral internal carotid artery aneurysms were restricted to one sibling who had the PKD2 variant but not the CCM2 variant. Our study expands the genetic spectrum of CCM2 and demonstrates unambiguous cosegregation of CCM2 and PKD2 variants with their respective phenotypes.
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Affiliation(s)
- Pei-Feng Hsieh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Yao Liu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Hao Chen
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Pei-Lung Chen
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Medical Genomics and Proteomics, National Taiwan University, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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