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Miwa K, Nakai M, Yoshimura S, Sasahara Y, Wada S, Koge J, Ishigami A, Yagita Y, Kamiyama K, Miyamoto Y, Kobayashi S, Minematsu K, Toyoda K, Koga M. Clinical impact of body mass index on ischemic and hemorrhagic stroke. Int J Stroke 2024:17474930241249370. [PMID: 38651751 DOI: 10.1177/17474930241249370] [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: 04/25/2024]
Abstract
BACKGROUND AND AIM To investigate the prognostic implication of body mass index (BMI) on clinical outcomes after acute ischemic and hemorrhagic stroke. METHODS The subjects of the study included adult patients with available baseline body weight and height data who had suffered an acute stroke and were registered in the Japan Stroke Data Bank-a hospital-based, multicenter stroke registration database-between January 2006 and December 2020. The outcome measures included unfavorable outcomes defined as a modified Rankin Scale [mRS] score of 5-6 and favorable outcomes (mRS 0-2) at discharge, and in-hospital mortality. Mixed effects logistic regression analysis was conducted to determine the relationship between BMI categories (underweight, normal weight, overweight, class I obesity, class II obesity;<18.5, 18.5-23.0, 23.0-25.0, 25-30, ≥30 kg/m2) and the outcomes, after adjustment for covariates. RESULTS A total of 56,230 patients were assigned to one of the following groups: ischemic stroke (IS, n=43,668), intracerebral hemorrhage (ICH, n=9,741), and subarachnoid hemorrhage (SAH, n=2,821). In the IS group, being underweight was associated with an increased likelihood of unfavorable outcomes (odds ratio, 1.47 [95%CI:1.31-1.65]) and in-hospital mortality (1.55 [1.31-1.83]) compared to outcomes in those with normal weight. Being overweight was associated with an increased likelihood of favorable outcomes (1.09 [1.01-1.18]). Similar associations were observed between underweight and these outcomes in specific IS subtypes (cardioembolic stroke, large artery stroke, and small vessel occlusion). Patients with a BMI≥30.0 kg/m2 was associated with an increased likelihood of unfavorable outcomes (1.44 [1.01-2.17]) and in-hospital mortality (2.42 [1.26-4.65]) in large artery stroke. In patients with ICH, but not those with SAH, being underweight was associated with an increased likelihood of unfavorable outcomes (1.41 [1.01-1.99]). CONCLUSIONS BMI substantially impacts functional outcomes following IS and ICH. Lower BMI consistently affected post-stroke disability and mortality, while higher BMI values similarly affected these outcomes after large artery stroke.
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Affiliation(s)
- Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yusuke Sasahara
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shinichi Wada
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akiko Ishigami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | | | - Yoshihiro Miyamoto
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | | | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Tanaka K, Miwa K, Koga M, Yoshimura S, Kamiyama K, Yagita Y, Nagakane Y, Hoshino H, Terasaki T, Okada Y, Yakushiji Y, Takahashi S, Ueda T, Hasegawa Y, Shiozawa M, Sasaki M, Kudo K, Tanaka J, Nishihara M, Yamaguchi Y, Fujita K, Honda Y, Kawano H, Ide T, Yoshimoto T, Ihara M, Hirano T, Toyoda K. Cerebral Small Vessel Disease Burden for Bleeding Risk during Antithrombotic Therapy: Bleeding with Antithrombotic Therapy 2 Study. Ann Neurol 2024; 95:774-787. [PMID: 38146238 DOI: 10.1002/ana.26868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVE This study was undertaken to determine the excess risk of antithrombotic-related bleeding due to cerebral small vessel disease (SVD) burden. METHODS In this observational, prospective cohort study, patients with cerebrovascular or cardiovascular diseases taking oral antithrombotic agents were enrolled from 52 hospitals across Japan between 2016 and 2019. Baseline multimodal magnetic resonance imaging acquired under prespecified conditions was assessed by a central diagnostic radiology committee to calculate total SVD score. The primary outcome was major bleeding. Secondary outcomes included bleeding at each site and ischemic events. RESULTS Of the analyzed 5,250 patients (1,736 women; median age = 73 years, 9,933 patient-years of follow-up), antiplatelets and anticoagulants were administered at baseline in 3,948 and 1,565, respectively. Median SVD score was 2 (interquartile range = 1-3). Incidence rate of major bleeding was 0.39 (per 100 patinet-years) in score 0, 0.56 in score 1, 0.91 in score 2, 1.35 in score 3, and 2.24 in score 4 (adjusted hazard ratio [aHR] for score 4 vs 0 = 5.47, 95% confidence interval [CI] = 2.26-13.23), that of intracranial hemorrhage was 0.11, 0.33, 0.58, 0.99, and 1.06, respectively (aHR = 9.29, 95% CI = 1.99-43.35), and that of ischemic event was 1.82, 2.27, 3.04, 3.91, and 4.07, respectively (aHR = 1.76, 95% CI = 1.08-2.86). In addition, extracranial major bleeding (aHR = 3.43, 95% CI = 1.13-10.38) and gastrointestinal bleeding (aHR = 2.54, 95% CI = 1.02-6.35) significantly increased in SVD score 4 compared to score 0. INTERPRETATION Total SVD score was predictive for intracranial hemorrhage and probably for extracranial bleeding, suggesting the broader clinical relevance of cerebral SVD as a marker for safe implementation of antithrombotic therapy. ANN NEUROL 2024;95:774-787.
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Affiliation(s)
- Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | | | - Haruhiko Hoshino
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Tadashi Terasaki
- Department of Neurology, Kumamoto Red Cross Hospital, Kumamoto, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Yusuke Yakushiji
- Department of Neurology, Kansai Medical University, Hirakata, Japan
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Shinichi Takahashi
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Toshihiro Ueda
- Department of Strokology, Stroke Center, St Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Yasuhiro Hasegawa
- Division of Neurology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan
| | - Kohsuke Kudo
- Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Jun Tanaka
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Masashi Nishihara
- Department of Radiology, Saga University Faculty of Medicine, Saga, Japan
| | - Yoshitaka Yamaguchi
- Department of Neurology, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Kyohei Fujita
- Department of Neurology and Neurological Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuko Honda
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Japan
| | - Hiroyuki Kawano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Japan
| | - Toshihiro Ide
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Takeshi Yoshimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Kamogawa N, Miwa K, Toyoda K, Jensen M, Inoue M, Yoshimura S, Fukuda-Doi M, Kitazono T, Boutitie F, Ma H, Ringleb P, Wu O, Schwamm LH, Warach S, Hacke W, Davis SM, Donnan GA, Gerloff C, Thomalla G, Koga M. Thrombolysis for Wake-Up Stroke Versus Non-Wake-Up Unwitnessed Stroke: EOS Individual Patient Data Meta-Analysis. Stroke 2024; 55:895-904. [PMID: 38456303 PMCID: PMC10978262 DOI: 10.1161/strokeaha.123.043358] [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] [Indexed: 03/09/2024]
Abstract
BACKGROUND Stroke with unknown time of onset can be categorized into 2 groups; wake-up stroke (WUS) and unwitnessed stroke with an onset time unavailable for reasons other than wake-up (non-wake-up unwitnessed stroke, non-WUS). We aimed to assess potential differences in the efficacy and safety of intravenous thrombolysis (IVT) between these subgroups. METHODS Patients with an unknown-onset stroke were evaluated using individual patient-level data of 2 randomized controlled trials (WAKE-UP [Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke], THAWS [Thrombolysis for Acute Wake-Up and Unclear-Onset Strokes With Alteplase at 0.6 mg/kg]) comparing IVT with placebo or standard treatment from the EOS (Evaluation of Unknown-Onset Stroke Thrombolysis trial) data set. A favorable outcome was prespecified as a modified Rankin Scale score of 0 to 1 at 90 days. Safety outcomes included symptomatic intracranial hemorrhage at 22 to 36 hours and 90-day mortality. The IVT effect was compared between the treatment groups in the WUS and non-WUS with multivariable logistic regression analysis. RESULTS Six hundred thirty-four patients from 2 trials were analyzed; 542 had WUS (191 women, 272 receiving alteplase), and 92 had non-WUS (42 women, 43 receiving alteplase). Overall, no significant interaction was noted between the mode of onset and treatment effect (P value for interaction=0.796). In patients with WUS, the frequencies of favorable outcomes were 54.8% and 45.5% in the IVT and control groups, respectively (adjusted odds ratio, 1.47 [95% CI, 1.01-2.16]). Death occurred in 4.0% and 1.9%, respectively (P=0.162), and symptomatic intracranial hemorrhage in 1.8% and 0.3%, respectively (P=0.194). In patients with non-WUS, no significant difference was observed in favorable outcomes relative to the control (37.2% versus 29.2%; adjusted odds ratio, 1.76 [0.58-5.37]). One death and one symptomatic intracranial hemorrhage were reported in the IVT group, but none in the control. CONCLUSIONS There was no difference in the effect of IVT between patients with WUS and non-WUS. IVT showed a significant benefit in patients with WUS, while there was insufficient statistical power to detect a substantial benefit in the non-WUS subgroup. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: CRD42020166903.
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Affiliation(s)
- Naruhiko Kamogawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mayumi Fukuda-Doi
- Center for Advancing Clinical and Translational Sciences, National Cerebral, and Cardiovascular Center, Suita, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France; Université Lyon 1, Villeurbanne, France; Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Peter Ringleb
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Ona Wu
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Steven Warach
- Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, the University of Melbourne, Melbourne, VIC, Australia
| | - Geoffrey A Donnan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, the University of Melbourne, Melbourne, VIC, Australia
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Yamazaki N, Koga M, Doijiri R, Inoue M, Miwa K, Yoshimura S, Fukuda-Doi M, Aoki J, Asakura K, Sasaki M, Kitazono T, Kimura K, Minematsu K, Yamamoto H, Ihara M, Toyoda K. Magnetic Resonance Imaging-Guided Intravenous Thrombolysis in Cardioembolic Stroke Patients With Unknown Time of Onset - Subanalysis of the THAWS Randomized Control Trial. Circ J 2024; 88:382-387. [PMID: 38220173 DOI: 10.1253/circj.cj-23-0662] [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] [Indexed: 01/16/2024]
Abstract
BACKGROUND We investigated the clinical effect of intravenous thrombolysis using a magnetic resonance imaging (MRI)-guided approach in cardioembolic stroke (CE) patients with unknown time of onset.Methods and Results: This subanalysis of the THAWS trial assessed the efficacy and safety of alteplase 0.6 mg/kg in CE patients with unknown time of onset and showing diffusion-weighted imaging-fluid-attenuated inversion recovery mismatch. Patients were classified as CE and non-CE using the SSS-TOAST classification system during the acute period. The efficacy outcome was a modified Rankin Scale score of 0-1 at 90 days. In all, 126 patients from the THAWS trial were included in this study, of whom 45 (35.7%) were diagnosed with CE. In the CE group, a favorable outcome was numerically more frequent in the alteplase than control group (52% vs. 35%; adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 0.50-9.99). However, in the non-CE group, favorable outcomes were comparable between the alteplase and control groups (44% vs. 55%, respectively; aOR 0.39; 95% CI 0.12-1.21). Treatment-by-cohort interaction for a favorable outcome was modestly significant between the CE and non-CE groups (P=0.069). In the CE group, no patients experienced symptomatic intracranial hemorrhage (ICH) or parenchymal hematoma Type II following thrombolysis. CONCLUSIONS When an MRI-guided approach is used, CE patients with unknown time of onset appear to be suitable candidates for thrombolysis.
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Affiliation(s)
- Naoya Yamazaki
- Department of Neurology, Iwate Prefectural Central Hospital
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mayumi Fukuda-Doi
- Department of Data Science, National Cerebral and Cardiovascular Center
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Koko Asakura
- Department of Data Science, National Cerebral and Cardiovascular Center
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | | | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
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Ishigami A, Toyoda K, Nakai M, Yoshimura S, Wada S, Sasahara Y, Sonoda K, Miwa K, Koge J, Shiozawa M, Iwanaga Y, Miyamoto Y, Nakahara J, Suzuki N, Kobayashi S, Minematsu K, Koga M. Improvement of Functional Outcomes in Patients with Stroke who Received Alteplase for Over 15 Years: Japan Stroke Data Bank. J Atheroscler Thromb 2024; 31:90-99. [PMID: 37587045 PMCID: PMC10776302 DOI: 10.5551/jat.64200] [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: 02/08/2023] [Accepted: 06/12/2023] [Indexed: 08/18/2023] Open
Abstract
AIM The nationwide verification of intravenous thrombolysis (IVT) was rarely performed after the extension of the therapeutic time window of alteplase or after the expansion of mechanical thrombectomy (MT). We aimed to examine the long-term change in accurate real-world outcomes of IVT in patients with acute ischemic stroke (AIS) using the Japan Stroke Databank, a representative Japan-wide stroke database. METHODS We extracted all patients with AIS who received IVT with alteplase between October 11, 2005, the approval date for alteplase use for AIS in Japan, and December 31, 2020. Patients were categorized into three groups using two critical dates in Japan as cutoffs: the official extension date of the therapeutic time window for IVT to within 4.5 h of symptom onset and the publication date of the revised guideline, where the evidence level of MT was heightened. We assessed the yearly trend of IVT implementation rates and the secular changes and three-group changes in clinical outcomes at discharge. RESULTS Of 124,382 patients with AIS, 9,569 (7.7%) received IVT (females, 41%; median age, 75 years). The IVT implementation rate has generally increased over time and plateaued in recent years. The proportion of favorable outcomes (modified Rankin Scale score of 0-2) increased yearly over 15 years. The results of the changes in the outcomes of the three groups were similar to those of the annual changes. CONCLUSIONS We revealed that IVT implementation rates in patients with AIS increased, and the functional outcome in these patients improved over 15 years. Therefore, the Japanese IVT dissemination strategy is considered appropriate and effective.
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Affiliation(s)
- Akiko Ishigami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Wada
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yusuke Sasahara
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazutaka Sonoda
- Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshitaka Iwanaga
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshihiro Miyamoto
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Norihiro Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | | | | | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
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Wada S, Yoshimura S, Toyoda K, Nakai M, Sasahara Y, Miwa K, Koge J, Ishigami A, Shiozawa M, Ogasawara K, Kitazono T, Nogawa S, Iwanaga Y, Miyamoto Y, Minematsu K, Koga M. Characteristics and outcomes of unknown onset stroke: The Japan Stroke Data Bank. J Neurol Sci 2023; 453:120798. [PMID: 37729754 DOI: 10.1016/j.jns.2023.120798] [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: 02/17/2023] [Revised: 08/14/2023] [Accepted: 09/06/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Clinical outcomes of unknown onset stroke (UOS) are influenced by the enlargement of the therapeutic time window for reperfusion therapy. This study aimed to investigate and describe the characteristics and clinical outcomes of patients with UOS. METHODS Patients with acute ischemic stroke (AIS) who were admitted within 24 h of their last known well time, from January 2017 to December 2020, were included. Data were obtained from a long-lasting nationwide hospital-based multicenter prospective registry: the Japan Stroke Data Bank. The co-primary outcomes were the National Institutes of Stroke Scale (NIHSS) scores on admission and unfavorable outcomes at discharge, corresponding to modified Rankin Scale (mRS) scores of 3-6. RESULTS Overall, 26,976 patients with AIS were investigated. Patients with UOS (N = 5783, 78 ± 12 years of age) were older than patients with known onset stroke (KOS) (N = 21,193, 75 ± 13 years of age). Age, female sex, higher premorbid mRS scores, atrial fibrillation, and congestive heart failure were associated with UOS in multivariate analysis. UOS was associated with higher NIHSS scores (median = 8 [interquartile range [IQR]: 3-19] vs. 4 [1-10], adjusted incidence rate ratio = 1.37 [95% CI: 1.35-1.38]) and unfavorable outcomes (52.1 vs. 33.6%, adjusted odds ratio = 1.27 [1.14-1.40]). Intergroup differences in unfavorable outcomes were attenuated among females (1.12 [0.95-1.32] vs. males 1.38 [1.21-1.56], P = 0.040) and in the subgroup that received reperfusion therapy (1.10 [0.92-1.33] vs. those who did not receive therapy 1.23 [1.08-1.39], P = 0.012). CONCLUSIONS UOS was associated with unfavorable outcomes but to a lesser degree among females and patients receiving reperfusion therapy.
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Affiliation(s)
- Shinichi Wada
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yusuke Sasahara
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Akiko Ishigami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University Hospital, Yahaba, Iwate, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shigeru Nogawa
- Department of Neurology, Tokai University Hachioji Hospital, Hachioji, Tokyo, Japan
| | - Yoshitaka Iwanaga
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiro Miyamoto
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | | | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Lyrer F, Zietz A, Seiffge DJ, Koga M, Volbers B, Wilson D, Bonetti B, Schaedelin S, Gensicke H, Yoshimura S, Macha K, Ambler G, Thilemann S, Dittrich T, Inoue M, Miwa K, Wang R, Siedler G, Biburger L, Brown MM, Jäger RH, Muir K, Traenka C, Tanaka K, Shiozawa M, Bonati LH, Peters N, Lip GYH, Lyrer PA, Cappellari M, Toyoda K, Kallmünzer B, Schwab S, Werring DJ, Engelter ST, De Marchis GM, Polymeris AA. Atrial Fibrillation Detected before or after Stroke: Role of Anticoagulation. Ann Neurol 2023; 94:43-54. [PMID: 36975022 PMCID: PMC10953352 DOI: 10.1002/ana.26654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) known before ischemic stroke (KAF) has been postulated to be an independent category with a recurrence risk higher than that of AF detected after stroke (AFDAS). However, it is unknown whether this risk difference is confounded by pre-existing anticoagulation, which is most common in KAF and also indicates a high ischemic stroke recurrence risk. METHODS Individual patient data analysis from 5 prospective cohorts of anticoagulated patients following AF-associated ischemic stroke. We compared the primary (ischemic stroke recurrence) and secondary outcome (all-cause death) among patients with AFDAS versus KAF and among anticoagulation-naïve versus previously anticoagulated patients using multivariable Cox, Fine-Gray models, and goodness-of-fit statistics to investigate the relative independent prognostic importance of AF-category and pre-existing anticoagulation. RESULTS Of 4,357 patients, 1,889 (43%) had AFDAS and 2,468 (57%) had KAF, while 3,105 (71%) were anticoagulation-naïve before stroke and 1,252 (29%) were previously anticoagulated. During 6,071 patient-years of follow-up, we observed 244 recurrent strokes and 661 deaths. Only pre-existing anticoagulation (but not KAF) was independently associated with a higher hazard for stroke recurrence in both Cox and Fine-Gray models. Models incorporating pre-existing anticoagulation showed better fit than those with AF category; adding AF-category did not result in better model fit. Neither pre-existing anticoagulation nor KAF were independently associated with death. CONCLUSION Our findings challenge the notion that KAF and AFDAS are clinically relevant and distinct prognostic entities. Instead of attributing an independently high stroke recurrence risk to KAF, future research should focus on the causes of stroke despite anticoagulation to develop improved preventive treatments. ANN NEUROL 2023;94:43-54.
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Affiliation(s)
- Flurina Lyrer
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - David J. Seiffge
- Department of Neurology, Inselspital University Hospital BernUniversity of BernBernSwitzerland
| | - Masatoshi Koga
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Bastian Volbers
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
- New Zealand Brain Research InstituteChristchurchNew Zealand
| | - Bruno Bonetti
- Stroke Unit – Department of NeuroscienceAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical ResearchUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Sohei Yoshimura
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kosmas Macha
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Gareth Ambler
- Department of Statistical ScienceUniversity College LondonLondonUK
| | - Sebastian Thilemann
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Tolga Dittrich
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Manabu Inoue
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kaori Miwa
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Ruihao Wang
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Gabriela Siedler
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Luise Biburger
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Martin M. Brown
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
| | - Rolf H. Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic UnitDepartment of Brain Repair and Rehabilitation, UCL Institute of NeurologyLondonUK
| | - Keith Muir
- Institute of Neuroscience & PsychologyUniversity of Glasgow and Queen Elizabeth University HospitalGlasgowUK
| | - Christopher Traenka
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Kanta Tanaka
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Masayuki Shiozawa
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Leo H. Bonati
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Reha RheinfeldenRheinfeldenSwitzerland
| | - Nils Peters
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
- Stroke Center, Klinik HirslandenZurichSwitzerland
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Philippe A. Lyrer
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Manuel Cappellari
- Stroke Unit – Department of NeuroscienceAzienda Ospedaliera Universitaria IntegrataVeronaItaly
| | - Kazunori Toyoda
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Bernd Kallmünzer
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - Stefan Schwab
- Department of NeurologyUniversity Hospital ErlangenErlangenGermany
| | - David J. Werring
- Stroke Research Centre, Department of Brain Repair and RehabilitationUCL Queen Square Institute of Neurology and The National Hospital for Neurology and NeurosurgeryLondonUK
| | - Stefan T. Engelter
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
- Neurology and NeurorehabilitationUniversity Hospital for Geriatric Medicine Felix Platter, University of BaselBaselSwitzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Alexandros A. Polymeris
- Department of Neurology and Stroke CenterUniversity Hospital Basel and University of BaselBaselSwitzerland
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8
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Makita N, Ishii R, Yamaguchi Y, Nakamura Y, Miwa K, Yoshimura S, Hosoki S, Ihara M, Toyoda K, Mizuno T, Koga M. Recurrence of intracranial artery dissection more than a half year after the initial event. J Neurol Sci 2023; 451:120716. [PMID: 37379727 DOI: 10.1016/j.jns.2023.120716] [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: 01/30/2023] [Revised: 06/13/2023] [Accepted: 06/17/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION The management of intracranial artery dissection (IAD) has not been established, partly because the long-term course of the disease is not well-known. We retrospectively investigated the long-term course of IAD without subarachnoid hemorrhage (SAH) as an initial clinical presentation. METHODS Of 147 consecutive spontaneous first-ever IAD patients hospitalized between March 2011 and July 2018, 44 with SAH were excluded, and the remaining 103 were investigated. We divided the patients into two groups: Recurrence group as those with recurrent intracranial dissection >1 month after the initial dissection, and Non-recurrence group as those without them. Clinical characteristics were compared between those two groups. RESULTS The mean follow-up period was 33 months from the initial event. Recurrent dissection occurred in 4 patients (3.9%) >7 months after the initial dissection, none of whom were on antithrombotic treatments at recurrence. Three had ischemic stroke and the other had local symptoms [range: 8 to 44 months]. Nine (8.7%) had an ischemic stroke within 1 month of the initial event. There was no recurrent dissection between 1 and 7 months after the initial event. There was no significant difference in baseline characteristics between Recurrence and Non-recurrence groups. CONCLUSIONS Four out of the 103 (3.9%) IAD patients had recurrent IAD >7 months after the initial event. IAD patients should be followed up for more than a half year after the initial event, with consideration given to the recurrence of IAD. Further research is needed on recurrence prevention measures to IAD patients.
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Affiliation(s)
- Naoki Makita
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Ryotaro Ishii
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshitaka Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuki Nakamura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Hosoki
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Toshiki Mizuno
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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9
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Yoshimura S, Koga M, Okada T, Inoue M, Miwa K, Fukuda-Doi M, Kondo R, Inoue T, Ichijo M, Ohtaki M, Nagakane Y, Itabashi R, Sakai N, Kimura K, Kamiyama K, Shiokawa Y, Yagita Y, Iwama T, Yakushiji Y, Kusumi M, Yamaki T, Uemura J, Yasuura A, Noshiro S, Fukunaga D, Yazawa Y, Aoki J, Yoshikawa M, Ihara M, Toyoda K. Thrombolysis for Acute Wake-Up and Unclear-Onset Strokes with Alteplase at 0.6 mg/kg in Clinical Practice: THAWS2 Study. Cerebrovasc Dis 2023; 53:46-53. [PMID: 37263235 DOI: 10.1159/000530995] [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: 12/14/2022] [Accepted: 04/12/2023] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION The aim of this study was to determine the safety and efficacy of intravenous (IV) alteplase at 0.6 mg/kg for patients with acute wake-up or unclear-onset strokes in clinical practice. METHODS This multicenter observational study enrolled acute ischemic stroke patients with last-known-well time >4.5 h who had mismatch between DWI and FLAIR and were treated with IV alteplase. The safety outcomes were symptomatic intracranial hemorrhage (sICH) after thrombolysis, all-cause deaths, and all adverse events. The efficacy outcomes were favorable outcome defined as an mRS score of 0-1 or recovery to the same mRS score as the premorbid score, complete independence defined as an mRS score of 0-1 at 90 days, and change in NIHSS at 24 h from baseline. RESULTS Sixty-six patients (35 females; mean age, 74 ± 11 years; premorbid complete independence, 54 [82%]; median NIHSS on admission, 11) were enrolled at 15 hospitals. Two patients (3%) had sICH. Median NIHSS changed from 11 (IQR, 6.75-16.25) at baseline to 5 (3-12.25) at 24 h after alteplase initiation (change, -4.8 ± 8.1). At discharge, 31 patients (47%) had favorable outcome and 29 (44%) had complete independence. None died within 90 days. Twenty-three (35%) also underwent mechanical thrombectomy (no sICH, NIHSS change of -8.5 ± 7.3), of whom 11 (48%) were completely independent at discharge. CONCLUSIONS In real-world clinical practice, IV alteplase for unclear-onset stroke patients with DWI-FLAIR mismatch provided safe and efficacious outcomes comparable to those in previous trials. Additional mechanical thrombectomy was performed safely in them.
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Affiliation(s)
- Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan,
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takashi Okada
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mayumi Fukuda-Doi
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Rei Kondo
- Department of Neurosurgery, Stroke Center, Yamagata City Hospital Saiseikan, Yamagata, Japan
| | - Takeshi Inoue
- Department of Stroke Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Masahiko Ichijo
- Department of Neurology, Musashino Japanese Red Cross Hospital, Musashino, Japan
| | - Masafumi Ohtaki
- Department of Neurosurgery, Obihiro Kosei Hospital, Obihiro, Japan
| | | | - Ryo Itabashi
- Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Yoshiaki Shiokawa
- Department of Neurosurgery, Kyorin University School of Medicine, Mitaka, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University School of Medicine, Gifu, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
- Department of Neurology, Kansai Medical University, Hirakata, Japan
| | | | - Tetsu Yamaki
- Department of Neurosurgery, Stroke Center, Yamagata City Hospital Saiseikan, Yamagata, Japan
| | - Jyunichi Uemura
- Department of Stroke Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Asuka Yasuura
- Department of Neurology, Musashino Japanese Red Cross Hospital, Musashino, Japan
| | - Shouhei Noshiro
- Department of Neurosurgery, Obihiro Kosei Hospital, Obihiro, Japan
| | - Daiki Fukunaga
- Department of Neurology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Yukako Yazawa
- Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Masaaki Yoshikawa
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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10
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Hayashi K, Tanaka Y, Tsuda T, Nomura A, Fujino N, Furusho H, Sakai N, Iwata Y, Usui S, Sakata K, Kato T, Tada H, Kusayama T, Usuda K, Kawashiri MA, Passman RS, Wada T, Yamagishi M, Takamura M, Fujino N, Nohara A, Kawashiri MA, Hayashi K, Sakata K, Yoshimuta T, Konno T, Funada A, Tada H, Nakanishi C, Hodatsu A, Mori M, Tsuda T, Teramoto R, Nagata Y, Nomura A, Shimojima M, Yoshida S, Yoshida T, Hachiya S, Tamura Y, Kashihara Y, Kobayashi T, Shibayama J, Inaba S, Matsubara T, Yasuda T, Miwa K, Inoue M, Fujita T, Yakuta Y, Aburao T, Matsui T, Higashi K, Koga T, Hikishima K, Namura M, Horita Y, Ikeda M, Terai H, Gamou T, Tama N, Kimura R, Tsujimoto D, Nakahashi T, Ueda K, Ino H, Higashikata T, Kaneda T, Takata M, Yamamoto R, Yoshikawa T, Ohira M, Suematsu T, Tagawa S, Inoue T, Okada H, Kita Y, Fujita C, Ukawa N, Inoguchi Y, Ito Y, Araki T, Oe K, Minamoto M, Yokawa J, Tanaka Y, Mori K, Taguchi T, Kaku B, Katsuda S, Hirase H, Haraki T, Fujioka K, Terada K, Ichise T, Maekawa N, Higashi M, Okeie K, Kiyama M, Ota M, Todo Y, Aoyama T, Yamaguchi M, Noji Y, Mabuchi T, Yagi M, Niwa S, Takashima Y, Murai K, Nishikawa T, Mizuno S, Ohsato K, Misawa K, Kokado H, Michishita I, Iwaki T, Nozue T, Katoh H, Nakashima K, Ito S, Yamagishi M. Correction: Characterization of baseline clinical factors associated with incident worsening kidney function in patients with non-valvular atrial fibrillation: the Hokuriku-Plus AF Registry. Heart Vessels 2023; 38:412. [PMID: 36508013 DOI: 10.1007/s00380-022-02218-5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Yoshihiro Tanaka
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.,Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Toyonobu Tsuda
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Akihiro Nomura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Noboru Fujino
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hiroshi Furusho
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.,Department of Cardiology, Ishikawa Prefectural Central Hospital, 2-1, Kuratsuki-higashi, Kanazawa, Japan
| | - Norihiko Sakai
- Department of Nephrology and Laboratory Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa, Japan
| | - Yasunori Iwata
- Department of Nephrology and Laboratory Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa, Japan
| | - Soichiro Usui
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Kenji Sakata
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Takeshi Kato
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hayato Tada
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Takashi Kusayama
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Keisuke Usuda
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Masa-Aki Kawashiri
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Rod S Passman
- Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa, Japan
| | - Masakazu Yamagishi
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.,Osaka University of Human Sciences, Settsu, Osaka, Japan
| | - Masayuki Takamura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
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Yamashiro T, Wada S, Yoshimura S, Toyoda K, nakai M, Sasahara Y, Shiozawa M, Koge J, Ishigami A, Miwa K, Iwanaga Y, Miyamoto Y, Koga M. Abstract WMP12: Initial Severity And Functional Outcomes Of Acute Ischemic Stroke With Atrial Fibrillation On Direct Oral Anticoagulants(DOACs): Japan Stroke Data Bank. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wmp12] [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
Purpose:
The purpose of this study was to examine the associations between oral anticoagulants (OACs) at onset and outcomes in acute ischemic stroke (AIS) patients with atrial fibrillation.
Methods:
AIS patients with comorbidity of atrial fibrillation (aged ≥18 years, pre-stroke modified Rankin Scale [mRS] 0-2) admitted within 24 hours after onset from January 2017 to December 2020 were examined from a long-lasting nationwide hospital-based multicenter prospective registry, the Japan Stroke Data Bank. Patients were classified into 3 groups according to anticoagulants at onset: no-anticoagulant group, warfarin group and DOAC group. The co-primary outcomes were the National Institutes of Stroke Scale (NIHSS) on admission and favorable outcome at discharge, corresponding to the mRS of 0-2. Mixed effects logistic regression was performed to examine the association between antithrombotic agents and these outcomes.
Results:
Of a total of 6,838 patients, 4,249 (62.1 %) patients were classified into the no-anticoagulant group, 907 (13.3 %) into warfarin group and 1,682 (24.6 %) into DOACs group. Median NIHSS score on admission was 7 [interquartile range: 2-19] in the warfarin group and 5 [2-15] in the DOAC group, versus 9 [3-20] in the no-anticoagulant group. Both warfarin and DOAC groups had lower NIHSS scores as compared to no-antithrombotic group (adjusted incidence rate ratio 0.96 [95% confidence interval 0.94-0.99] and 0.81 [0.79-0.83], respectively) after adjustment by age, sex, hypertension (HT), dyslipidemia (DL), diabetes mellitus (DM) and history of stroke. The rate of favorable outcome at discharge was 41.5 % in no-anticoagulant group, 42.0% in warfarin group and 48.1 % in DOACs group. In multivariable analysis, sex, NIHSS on admission, HT, DL, DM, history of stroke and intravenous thrombolysis and mechanical thrombectomy, DOACs group more frequently had favorable outcome (odds ratio 1.20 [95% CI 1.03-1.40]) than no-anticoagulant group, but warfarin group did not (1.05 [0.86-1.27]).
Conclusion:
Taking DOACs prior to onset appears associated with milder stroke severity and a more favorable outcome following acute ischemic stroke in patients with atrial fibrillation.
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Affiliation(s)
- Takayuki Yamashiro
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
| | - Shinichi Wada
- Dept of Med and Health information Management, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
| | - Sohei Yoshimura
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
| | - Kazunori Toyoda
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
| | - michikazu nakai
- Dept of Med and Health information Management, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
| | - Yusuke Sasahara
- Dept of Med and Health information Management, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
| | - Masayuki Shiozawa
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
| | - Junpei Koge
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
| | - Akiko Ishigami
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
| | - Kaori Miwa
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
| | - Yoshitaka Iwanaga
- Dept of Med and Health information Management, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
| | - Yoshihiro Miyamoto
- Dept of Med and Health information Management, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
| | - Masatoshi Koga
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan, Suita, Japan
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12
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Toyoda K, Yoshimura S, Nakai M, Wada S, Sasahara Y, Miwa K, Koge J, Ishigami A, Iwanaga Y, Miyamoto Y, Minematsu K, Kobayashi S, Koga M. Abstract WMP71: Changes In Severity And Outcomes Of Ischemic Stroke Associated With Atrial Fibrillation In A Long-lasting Nationwide Hospital-based Registry: Japan Stroke Data Bank. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wmp71] [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 determine secular changes in severity and functional outcomes of acute atrial fibrillation (AF)-associated stroke patients using a large population.
Methods:
Ischemic stroke patients with known AF or AF diagnosed after stroke onset, who were registered within 7 days after symptom onset into a hospital-based prospective registry, Japan Stroke Data Bank, from Jan 2000 to Dec 2020 were compared with those without AF. The co-primary outcomes were the initial neurological severity assessed by NIHSS and favorable outcome assessed by mRS of 0 to 2 at hospital discharge. Secondary outcomes included unfavorable outcome assessed by mRS of 5 to 6 and in-hospital death.
Results:
Of 142,351 patients studied, 33,870 had AF (women 45.1%, median age 79 years, non-valvular 94.3%). Patients with AF had higher initial NIHSS score (median 9 vs. 3, adjusted coefficient 5.383, 95% CI 5.245 - 5.520) as compared to patients without AF (women 38.2%, median age 79 years). Anticoagulation prior to the index stroke showed a significant interaction with the frequency of the NIHSS score ≥10 in patients with AF relative to those without AF (aOR: 2.047 for anticoagulated patients vs. 4.189 for the others). The NIHSS score decreased over the 21-year period in AF patients (adjusted coefficient -0.104, 95% CI -0.133 - -0.074 per year). Favorable outcome was less common in patients with AF than those without AF in unadjusted analysis (48.4% vs. 70.4%) but was more common after multivariable adjustment including the initial NIHSS score (aOR 1.096, 95% CI 1.040 - 1.156). Unfavorable outcome (aOR 1.108) and in-hospital death (1.506) were also more common in AF patients. The proportion of favorable outcome showed an increase over time (aOR 1.018, 95% CI 1.009 - 1.026 per year) in AF patients but the increase was no longer significant after further adjustment by receiving reperfusion therapy (1.007, 0.998 - 1.016). The proportion of unfavorable outcome and that of in-hospital death showed a yearly decrease over time.
Conclusions:
AF patients showed favorable clinical outcome after ischemic stroke relative to patients without AF by adjustment using the NIHSS score and others. Initial stroke severity became milder and functional outcomes tended to improve in AF patients during the past 21 years.
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Affiliation(s)
| | - Sohei Yoshimura
- National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan
| | | | - Shinichi Wada
- National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Yusuke Sasahara
- National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan
| | - Kaori Miwa
- National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan
| | | | | | | | | | | | | | - Masatoshi Koga
- National Cerebral and Cardiovascular Cntr, Suita Osaka, Japan
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13
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Koge J, Yoshimura S, Koga M, nakai M, Wada S, Sasahara Y, Shiozawa M, Miwa K, Ishigami A, Sonoda K, Iihara K, Ikawa F, Itabashi R, Iwanaga Y, Miyamoto Y, Kobayashi S, Minematsu K, Toyoda K. Abstract WP88: Discrepant Nationwide Trends In Outcomes Of Acute Ischemic Stroke Depending On Severity: The Japan Stroke Data Bank. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp88] [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 and Purpose:
Whether specific patient groups have benefited from advances of treatment technologies including acute reperfusion therapy is uncertain. We aimed to investigate long-term trends of acute reperfusion therapy and functional outcomes according to the stroke severity using a large clinical registry.
Methods:
In the nationwide, hospital-based, multicenter, prospective registry cohort from the Japan Stroke Data Bank between January 2000 and December 2020, patients with ischemic stroke were studied. The baseline National Institutes of Health Stroke Scale (NIHSS) score of 10 or more was considered as possible large vessel occlusions (LVOs). Secular changes were assessed per 5-year categories (2000-2005, 2006-2010, 2011-2015, 2016-2020). Outcomes included favorable outcome (mRS score was 0 to 2 at discharge), and in-hospital mortality.
Results:
Of 235,695 patients, 127,741 ischemic stroke patients (76,850 men [60.2 %]; median age 75, [interquartile range, 66-82] years) with available data on NIHSS score were analyzed. NIHSS score was ≥10 in 31,747 patients (24.9%). In both patients with NIHSS ≥10 and those with NIHSS <10, the frequencies of intravenous thrombolysis (1.6% to 26.5%, and 0.3% to 6.9%, respectively) and endovascular therapy (2.0% to 29.8%, and 0.8% to 3.8%, respectively) increased from the 2000-2005 period to the 2015-2020 period. In patients with NIHSS ≥10, favorable outcome was more frequent in the 2015-2020 cohort than that in the 2000-2005 cohort (adjusted odds ratio, 1.63; [95% CI, 1.44-1.85]). In contrast, patients with NIHSS <10 had a decreased favorable outcome in the 2015-2020 cohort than that in the 2000-2005 cohort (adjusted odds ratio, 0.80; 95% CI, [0.75-0.85]). In-hospital mortality decreased in both patients with NIHSS ≥10 and NIHSS <10 per step on the 5-year categories.
Conclusions:
Over the 20-year period, acute reperfusion therapy has increasingly been provided to patients with NIHSS ≥10. Favorable outcomes significantly increased in patients with NIHSS ≥10 but decreased in those with NIHSS <10 over time. In-hospital mortality decreased across all NIHSS scores.
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Affiliation(s)
- Junpei Koge
- National Cerebral and Cardiovascular Cntr, Suita, Japan
| | | | - Masatoshi Koga
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | | | - Shinichi Wada
- National Cerebral and Cardiovascular Cntr, Suita, Japan
| | | | | | - Kaori Miwa
- National Cerebral and Cardiovascular Cntr, Suita, Japan
| | | | | | - Koji Iihara
- National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Fusao Ikawa
- Shimane Prefectural Central Hospita, Izumo, Japan
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14
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Tanaka K, Miwa K, Yoshimura S, Kamiyama K, Yagita Y, Nagakane Y, Hoshino H, Terasaki T, Okada Y, Yakushiji Y, Takahashi S, Ueda T, Hasegawa Y, Shiozawa M, Sasaki M, Kudo K, Tanaka J, Nishihara M, Yamaguchi Y, Fujita K, Honda Y, Kawano H, Ide T, Yoshimoto T, Ihara M, Koga M, Hirano T, Toyoda K. Abstract 3: Cerebral Small Vessel Disease Burden For Bleeding Risk During Antithrombotic Therapy -BAT2-. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Cerebral small vessel disease (SVD) has received attention as a risk stratification tool for antithrombotic-related intracranial hemorrhage but may also be a predictor for bleeding in other organs.
Purpose:
To determine the excess risk of antithrombotic-related bleeding due to cerebral SVD burden.
Methods:
Patients with cerebrovascular or cardiovascular diseases taking oral antithrombotic agents were prospectively enrolled from 52 hospitals across Japan between 2016 and 2019. Multimodal brain MRI was acquired at baseline for all patients under prespecified conditions. All MRI examinations were interpreted by a central diagnostic radiology committee for cerebral microbleeds, lacunes, white matter hyperintensities, and enlarged basal ganglia perivascular spaces, for calculation of a total SVD score (range 0-4). The primary outcome was major bleeding during 2-year follow-up. Secondary outcomes included bleeding in each site and ischemic events. Event risks according to SVD score were estimated with multivariable Cox proportional hazards models.
Results:
Of the analyzed 5250 patients (1736 women; median age, 73 years; 9933 patient-years follow-up), antiplatelets and anticoagulants were administered at baseline in 3948 and 1565, respectively. Median of the total SVD score was 2 (IQR 1-3). As SVD score increased, advanced age, hypertension, anemia, and chronic kidney disease were more prevalent (P<0.001 for each). A unit increase of SVD score was associated with a higher risk of major bleeding (adjusted hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.29-1.85) and intracranial hemorrhage (adjusted HR 1.61, 95% CI 1.28-2.03). With SVD score 4 compared to score 0, extracranial major bleeding (adjusted HR 3.37, 95% CI 1.12-10.15) and gastrointestinal bleeding (adjusted HR 2.54, 95% CI 1.02-6.35) were also significantly increased. A higher SVD score was associated with a mild but significant elevation of ischemic event risk (adjusted HR per unit increase 1.17, 95% CI 1.06-1.29).
Conclusions:
The total SVD score was predictive for intracranial hemorrhage and probably for extracranial bleeding, suggesting a broader clinical relevance of cerebral SVD as a marker for safe implementation of antithrombotic therapy.
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Affiliation(s)
- Kanta Tanaka
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Kaori Miwa
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Sohei Yoshimura
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | | | | | | | | | | | - Yasushi Okada
- National Hosp Organization Kyushu Med Cntr, Fukuoka, Japan
| | | | | | | | | | | | | | - Kohsuke Kudo
- Dept of Diagnostic Imaging, Hokkaido Univ Graduate Sch of Medicine, Sapporo, Japan
| | - Jun Tanaka
- Div of Neurology, Dept of Internal Medicine, Saga Univ Faculty of Medicine, Saga, Japan
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15
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Arakaki Y, Wada S, Yoshimura S, Toyoda K, Sonoda K, Nakai M, Sasahara Y, Shiozawa M, Koge J, Ishigami A, Miwa K, Iwanaga Y, Miyamoto Y, Koga M. Abstract WP124: Stroke Severity And In-hospital Death In Intracerebral Hemorrhage Patients Taking Antithrombotic Agents: Japan Stroke Data Bank. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp124] [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
Purpose:
The purpose of this study was to determine the associations between antithrombotic agents at onset and outcomes in intracerebral hemorrhage (ICH) patients.
Methods:
ICH patients admitted within 24 hours after onset from January 2017 to December 2020 were examined from a long-lasting nationwide hospital-based multicenter prospective registry, the Japan Stroke Data Bank. Patients were classified into 4 groups according to types of antithrombotic agents at onset: no-antithrombotic, antiplatelet, warfarin, and DOAC groups. Patients with combination of antiplatelet and anticoagulant agents were classified into respective anticoagulant groups. The outcomes were NIHSS on admission, in-hospital death and unfavorable outcome corresponding to mRS of 5-6 at discharge.
Results:
Of a total of 9,948 ICH patients (female: 4,329, age 70±15 years old), 77.4% of patients were classified into the no-antithrombotic group, 13.0% into the antiplatelet group, 3.9% into the warfarin group and 5.7% into the DOAC group. Median NIHSS on admission was 12 (interquartile range: 5-22), 13 (5-26), 15 (5-30) and 13 (6-24), respectively. In multivariable analysis, the warfarin group was significantly associated with higher NIHSS on admission (adjusted incidence rate ratio, 1.08 [95% CI, 1.05-1.12], setting the no-antithrombotic group as reference), but the antiplatelet group (1.01 [0.99-1.03]) or the DOAC group (0.97 [0.94-1.00]) was not. The rate of in-hospital death was 13.0% in the no-antithrombotic group, 17.8% in the antiplatelet group, 27.3% in the warfarin group and 18.9% in the DOAC group and that of unfavorable outcome was 30,8%, 41.9%, 48.6% and 41.5%, respectively. In multivariable analysis, the warfarin group was significantly associated with in-hospital death and unfavorable outcome (adjusted odds ratio: 1.62 [95% CI, 1.07-2.46] and 1.79 [1.23-2.6], respectively, setting the no-antithrombotic group as reference), but the antiplatelet group (1.14 [0.87-1.36], 1.11 [0.90-1.36]) or the DOAC group (1.07 [0.72-1.60], 1.27 [0.90-1.78]) was not.
Conclusion:
ICH patients taking warfarin at onset had higher NIHSS on admission, in-hospital death and unfavorable outcome compared to those without antithrombotic agents, but those taking DOAC did not.
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Affiliation(s)
- Yoshito Arakaki
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
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16
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Hosoki S, Fukuda-Doi M, Miwa K, Yoshimura S, Morita Y, Chiba T, Noda K, Yamaguchi Y, Ikenouchi H, Makita N, Mizoguchi T, Nakamura Y, Satow T, Kataoka H, Toyoda K, Ihara M, Koga M. Sequential detection rates of intramural hematoma for diagnosing spontaneous intracranial artery dissection. Eur J Neurol 2023; 30:1320-1326. [PMID: 36695192 DOI: 10.1111/ene.15715] [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: 11/06/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial artery dissection (IAD) can be definitively diagnosed by detecting intramural hematoma (IMH) on arterial wall imaging. However, evidence of a time-dependent natural history for the development of radiological findings is lacking. Therefore, this study aimed to determine when imaging detects IAD. METHODS We obtained data from our cohort databases between March 2011 and August 2018 on consecutive patients who had definite, probable, or possible IAD based on the multidisciplinary expert consensus criteria. We assessed IMH on initial and follow-up high-resolution three-dimensional T1-weighted imaging (HR-3D-T1WI). We retrospectively investigated the association between IMH detection and days from symptom onset to initial HR-3D-T1WI and compared the IMH detection rate with other definitive diagnostic arterial dissection findings. RESULTS We analyzed 106 patients (mean age = 51 ± 13 years, 31 women) with at least initial HR-3D-T1WI data. The final diagnoses were definite, probable, and possible IAD in 83, 18, and 5 patients, respectively. IMHs were observed in 63 patients (59%, 95% confidence interval [CI] = 49%-69%). Overall IMH detection rate was 55% (95% CI = 45%-64%), 20% (95% CI = 3%-60%), 40% (95% CI = 21%-64%), and 50% (95% CI = 37%-63%) on the initial HR-3D-T1WI and Days 3, 7, and 13, respectively. Among 68 patients evaluated with digital subtraction angiography and HR-3D-T1WI, IMH was confirmed more frequently than other definitive diagnostic arterial dissection findings. CONCLUSIONS The overall IMH detection rate on HR-3D-T1WI was >50% and peaked in 1-2 weeks. IMH was a frequently detectable finding for the diagnosis of IAD compared to other radiological findings.
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Affiliation(s)
- Satoshi Hosoki
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshiaki Morita
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tetsuya Chiba
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kotaro Noda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshitaka Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hajime Ikenouchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Naoki Makita
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tadataka Mizoguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuki Nakamura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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17
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Koga M, Inoue M, Miwa K, Yoshimura S, Fukuda-Doi M, Aoki J, Asakura K, Kanzawa T, Ohtaki M, Kamiyama K, Yakushiji Y, Igarashi S, Doijiri R, Ito Y, Takagi Y, Sasaki M, Kitazono T, Kimura K, Minematsu K, Yamamoto H, Toyoda K. Intravenous Alteplase at 0.6 mg/kg for Unknown Onset Stroke with Prior Antithrombotic Medication: THAWS Randomized Clinical Trial. J Atheroscler Thromb 2023; 30:15-22. [PMID: 35197420 PMCID: PMC9899700 DOI: 10.5551/jat.63337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
AIM This study aimed to assess the potential effect of prior antithrombotic medication for thrombolysis in an unknown onset stroke. METHODS This was a predefined sub-analysis of the THAWS trial. Stroke patients with a time last known well >4.5 h who had a DWI-fluid-attenuated inversion recovery mismatch were randomly assigned (1:1) to receive alteplase at 0.6 mg/kg (alteplase group) or standard medical treatment (control group). Patients were dichotomized by prior antithrombotic medication. RESULTS Of 126 patients (intention-to-treat population), 40 took antithrombotic medication (24 with antiplatelets alone, 13 with anticoagulants alone, and 3 with both), and the remaining 86 did not before stroke onset. Of these, 17 and 52 patients, respectively, received alteplase, and 23 and 34, respectively, had standard medical treatment. Antithrombotic therapy was initiated within 24 h after randomization less frequently in the alteplase group (12% vs. 86%, p<0.01). Both any intracranial hemorrhage within 22-36 h (26% vs. 14%) and a modified Rankin Scale score of 0-1 at 90 days (good outcome) (47% vs. 48%) were comparable between the two groups. A good outcome was more common in the alteplase group than in the control group in patients with prior antithrombotic medication [relative risk (RR) 2.25, 95% confidence interval (CI) 1.02-4.99], but it tended to be less common in the alteplase group in those without (RR 0.69, 95% CI 0.46-1.03) (p<0.01 for interaction). The frequency of any intracranial hemorrhage did not significantly differ between the two groups in any patients dichotomized by prior antithrombotic medication. CONCLUSION Alteplase appears more beneficial in patients with prior antithrombotic medication.
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Affiliation(s)
- Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mayumi Fukuda-Doi
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Koko Asakura
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Isesaki, Japan
| | - Masafumi Ohtaki
- Department of Neurosurgery, Obihiro Kosei Hospital, Obihiro, Japan
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Japan,Department of Neurology, Kansai Medical University, Hirakata, Japana
| | - Shuichi Igarashi
- Department of Neurology, Niigata City General Hospital, Niigata, Japan
| | - Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Yasuhiro Ito
- Department of Neurology, TOYOTA Memorial Hospital, Toyota, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazuo Minematsu
- Headquarters of the Medical Corporation ISEIKAI, Osaka, Japan
| | - Haruko Yamamoto
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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18
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Wada S, Yoshimura S, Miwa K, Iwanaga Y, Koga M, Toyoda K. Current status and future aspects in the Japan Stroke Data Bank. Front Neurol 2023; 14:1090136. [PMID: 37034094 PMCID: PMC10075325 DOI: 10.3389/fneur.2023.1090136] [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: 11/04/2022] [Accepted: 02/07/2023] [Indexed: 04/11/2023] Open
Abstract
The Japanese National Plan for the Promotion of Measures Against Cerebrovascular and Cardiovascular Diseases was formulated on October 27, 2020. One purpose of this plan was to promote research on cerebrovascular and cardiovascular diseases. Therefore, it is necessary to clarify the actual status of stroke treatment in Japan and operate a national stroke database with high public interest completely and accurately. The Japan Stroke Data Bank (JSDB; https://strokedatabank.ncvc.go.jp/en/) was established by the Ministry of Health, Labor and Welfare Scientific Research in Shimane University (Shimane, Japan) in 1999 and was transferred to the National Cerebral and Cardiovascular Center (Osaka, Japan) as a part of the Cardiovascular Disease Registry in 2015. More than 200,000 of stroke cases have been registered using individual forms from more than 100 nationwide stroke centers over ~20 years. Since there are few large-scale stroke registries with nationwide coverage in Asia, including Japan, compared with those in Europe and North America, the role of the JSDB in the plan will be important in the future. To construct a high-quality stroke registry, we aimed to (1) collect detailed data through individual questionnaires for each participating stroke center, (2) link to external databases (e.g., insurance claims and public death registries), (3) improve the quality of treatment at participating hospitals through benchmarking, and (4) obtain stable funding through sustained support from government and academic societies. We also describe the history of the JSDB and changes in the trend of real-world stroke treatment in Japan based on the results of analysis of data in the JSDB.
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Affiliation(s)
- Shinichi Wada
- Department of Information and Health, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- *Correspondence: Shinichi Wada
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshitaka Iwanaga
- Department of Information and Health, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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19
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Fujii H, Taniguchi Y, Yoneda S, Miwa K, Yanaka K, Emoto N, Hirata K. Efficacy and safety of balloon pulmonary angioplasty for patients with chronic thromboembolic pulmonary hypertension comorbid to chronic obstructive pulmonary disease. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1884] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Balloon pulmonary angioplasty (BPA) would be promising treatment option for non-operable chronic thromboembolic pulmonary hypertension (CTEPH). However, BPA for CTEPH with Chronic obstructive pulmonary disease (COPD) might exacerbate ventilation perfusion mismatch. The aim is to evaluate the efficacy and safety of BPA for CTEPH with moderate or severe COPD.
Method
Data from 149 CTEPH patients were collected retrospectively who underwent BPA from March 2011 to June 2021. Patients were divided according to the comorbidity of COPD: a COPD group (defined as forced expiratory volume in one second (FEV1.0) / forced vital capacity (FVC)<70% and FEV1.0<80% predicted [n=32]) or a non-COPD group [n=101]. Mild COPD patients (n=16) were excluded. Hemodynamics and respiratory parameters were compared.
Results
Hemodynamics improved similarly in both group (percent decrease of pulmonary vascular resistance; −61.1±12.3% in a COPD group, −65.8±11.1% in a non-COPD group, p=N.S). Patients in a COPD group showed improved respiratory function and oxygenation with FEV1.0% from 61.8±7.0% to 66.5±10.2% (p=0.02), and partial pressure of arterial oxygen from 60.9±10.6mmHg to 69.3±13.6mmHg (p<0.01). Higher vital capacity (r2=0.123, p=0.024), higher diffusing capacity for lung carbon monoxide (r2=0.308, p=0.028) at baseline were correlated with larger improvement of oxygenation after BPA in multivariate linear analyses. Lung injury per session was 1.6% in a COPD group.
Conclusion
The efficacy and safety of BPA for non-operable CTEPH with COPD were equivalent to those of patients without COPD. Oxygenation and FEV1.0% also improved in COPD patients. BPA might be considered even though patients comorbid COPD.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- H Fujii
- Kobe University Hospital , Kobe , Japan
| | | | - S Yoneda
- Kobe University Hospital , Kobe , Japan
| | - K Miwa
- Kobe University Hospital , Kobe , Japan
| | - K Yanaka
- Kobe University Hospital , Kobe , Japan
| | - N Emoto
- Kobe University Hospital , Kobe , Japan
| | - K Hirata
- Kobe University Hospital , Kobe , Japan
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Miwa K, Koga M, Jensen M, Inoue M, Yoshimura S, Fukuda-Doi M, Boutitie F, Ma H, Ringleb PA, Wu O, Schwamm LH, Warach S, Hacke W, Davis SM, Donnan GA, Gerloff C, Thomalla G, Toyoda K. Alteplase for Stroke With Unknown Onset Time in Chronic Kidney Disease: A Pooled Analysis of Individual Participant Data. Stroke 2022; 53:3295-3303. [PMID: 35997023 DOI: 10.1161/strokeaha.122.039086] [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: 11/16/2022]
Abstract
BACKGROUND Although chronic kidney disease (CKD) is associated with worse stroke outcomes, data regarding the influence of CKD on intravenous thrombolysis outcomes are scarce. We sought to assess the efficacy and safety of intravenous thrombolysis for acute ischemic stroke with unknown onset time in patients with CKD. METHODS Patients with an acute stroke of unknown onset time from the EOS trials (Evaluation of Unknown Onset Stroke Thrombolysis) collaboration were evaluated using an individual patient-level database of randomized controlled trials comparing intravenous thrombolysis with placebo/standard treatment. CKD was defined as baseline estimated glomerular filtration rate of <60 ml/min/1.73m2 Mixed-effect logistic-regression analysis was performed to evaluate treatment effects. A favorable outcome was defined as a modified Rankin Scale score of 0 to 1 at 90 days. Safety outcomes were symptomatic intracranial hemorrhage at 22 to 36 hours and 90-day mortality. RESULTS Baseline data on renal function were available for 688 of 843 patients. Of these, CKD was present in 146 (21%), including 69 of 351 patients receiving alteplase and 77 of 337 patients receiving placebo/standard treatment. Overall, treatment with alteplase was associated with higher odds of favorable outcome, and CKD did not modify the treatment effect (Pinteraction=0.834). A favorable outcome was observed in 31 of 69 (46%) patients with CKD in the alteplase group and in 28 of 77 (36%) patients with CKD in the control group (adjusted odds ratio, 1.19 [95% CI, 0.55-2.58]). Among patients with CKD, symptomatic intracranial hemorrhage occurred in 2 patients (3%) in the alteplase group but in none of the controls (P=0.133). At 90 days, death was reported in 3 patients (4%) in the alteplase group compared with 2 patients (3%) in the controls (P=0.539). CONCLUSIONS The present analysis indicates that the benefit of alteplase does not differ between stroke patients with unknown onset time with and without CKD, although the statistical power was lacking to confirm the efficacy in subgroups. This study only applies to mild-to-moderate or predialysis CKD.
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Affiliation(s)
- Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. (K.M., M.K., M.I., S.Y., K.T.)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. (K.M., M.K., M.I., S.Y., K.T.)
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany (M.J., C.G., G.T.)
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. (K.M., M.K., M.I., S.Y., K.T.)
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. (K.M., M.K., M.I., S.Y., K.T.)
| | - Mayumi Fukuda-Doi
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan. (M.F.-D.)
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France (F.B.).,Université Lyon 1, Villeurbanne, France; Laboratoire de Biométrie et Biologie Evolutive, France (F.B.)
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia (H.M.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg, Germany (P.A.R., W.H.)
| | - Ona Wu
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA (O.W.)
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.)
| | - Steven Warach
- Dell Medical School, University of Texas at Austin (S.W.)
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Germany (P.A.R., W.H.)
| | - Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, VIC, Australia (S.M.D., G.A.D.)
| | - Geoffrey A Donnan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, VIC, Australia (S.M.D., G.A.D.)
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany (M.J., C.G., G.T.)
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany (M.J., C.G., G.T.)
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. (K.M., M.K., M.I., S.Y., K.T.)
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Miwa K, Toyoda K. Covert vascular brain injury in chronic kidney disease. Front Neurol 2022; 13:824503. [PMID: 35959397 PMCID: PMC9358355 DOI: 10.3389/fneur.2022.824503] [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: 11/29/2021] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic kidney disease (CKD) contributes to the increased risk of stroke and dementia. Accumulating evidence indicates that structural brain abnormalities, such as cerebral small vessel disease, including white matter hyperintensities, lacunes, perivascular spaces, and cerebral microbleeds, as well as brain atrophy, are common in patients with CKD. All of these imaging findings have been implicated in the development of stroke and dementia. The brain and kidney exhibit similar impairments and promote structural brain abnormalities due to shared vascular risk factors and similar anatomical and physiological susceptibility to vascular injury in patients with CKD. This indicates that kidney function has a significant effect on brain aging. However, as most results are derived from cross-sectional observational studies, the exact pathophysiology of structural brain abnormalities in CKD remains unclear. The early detection of structural brain abnormalities in CKD in the asymptomatic or subclinical phase (covert) should enable stroke risk prediction and guide clinicians on more targeted interventions to prevent stroke in patients with CKD. This article summarizes the currently available clinical evidence linking covert vascular brain injuries with CKD.
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Imajima T, Shirakawa T, Shimokawa M, Otsuka T, Shibuki T, Nakazawa J, Arima S, Miwa K, Okabe Y, Koga F, Kubotsu Y, Ueda Y, Hosokawa A, Takeshita S, Shimokawa H, Komori A, Kawahira M, Oda H, Sakai K, Arita S, Mizuta T, Mitsugi K. P-113 A multicenter observational study of liposomal irinotecan and fluorouracil/leucovorin in patients with unresectable or recurrent pancreatic cancer (NAPOLEON-2): Retrospective part. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.04.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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23
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Tanaka K, Koga M, Fukuda-Doi M, Qureshi AI, Yamamoto H, Miwa K, Ihara M, Toyoda K. Temporal Trajectory of Systolic Blood Pressure and Outcomes in Acute Intracerebral Hemorrhage: ATACH-2 Trial Cohort. Stroke 2022; 53:1854-1862. [PMID: 35400202 PMCID: PMC9126256 DOI: 10.1161/strokeaha.121.037186] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 02/07/2022] [Accepted: 03/09/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND To highlight the heterogeneity of acute temporal blood pressure (BP) changes in the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage-2) and associations with the outcomes of intracerebral hemorrhage. METHODS One thousand patients with acute intracerebral hemorrhage, who had been randomized to intensive (110-139 mm Hg) or standard (140-179 mm Hg) systolic BP (SBP) lowering with intravenous nicardipine in ATACH-2 from 2011 to 2015, were analyzed about temporal changes in hourly maximum SBP up to 24 hours after randomization using group-based trajectory modeling. Outcomes included death or disability (modified Rankin Scale score 4-6) at 3 months, neurological deterioration within 24 hours (≥2-point decrease in Glasgow Coma Scale score or ≥4-point increase in National Institutes of Health Stroke Scale score), and acute kidney injury (≥0.3 mg/dL within 48 hours or ≥1.5-fold increase in serum creatinine) within 7 days after onset. RESULTS Group-based trajectory modeling revealed 4 SBP trajectory groups: moderate SBP (from ≈190 mm Hg at hospital arrival to 150-160 mm Hg after randomization; n=298), moderate-to-low SBP (from ≈190 mm Hg to <140 mm Hg; n=395), high-to-low SBP (from >210 mm Hg to <140 mm Hg; n=134), and high SBP (from >210 mm Hg to 160-170 mm Hg; n=173). Patients with intensive treatment accounted for 11.1%, 88.6%, 85.1%, and 1.7% of each group, respectively. Compared with the moderate-to-low SBP group, the high-to-low SBP group showed increased risks of death or disability at 3 months (adjusted odds ratio, 2.29 [95% CI, 1.24-4.26]) and acute kidney injury (adjusted odds ratio, 3.50 [95% CI, 1.83-6.69]), while no increase in neurological deterioration was seen in this group (adjusted odds ratio, 0.48 [95% CI, 0.20-1.13]). The moderate SBP and high SBP groups showed no significant risk differences for such outcomes. CONCLUSIONS Data-driven observation using a group-based trajectory modeling approach may be useful to clarify the relationship between antihypertensive treatment, temporal SBP changes, and outcomes in acute intracerebral hemorrhage. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01176565.
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Affiliation(s)
- Kanta Tanaka
- Department of Cerebrovascular Medicine (K. Tanaka, M.K., M.F.-D., K.M., K. Toyoda), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine (K. Tanaka, M.K., M.F.-D., K.M., K. Toyoda), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine (K. Tanaka, M.K., M.F.-D., K.M., K. Toyoda), National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Data Science (M.F.-D., H.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Adnan I. Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Mineapolis (A.I.Q.)
| | - Haruko Yamamoto
- Department of Data Science (M.F.-D., H.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine (K. Tanaka, M.K., M.F.-D., K.M., K. Toyoda), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ihara
- Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine (K. Tanaka, M.K., M.F.-D., K.M., K. Toyoda), National Cerebral and Cardiovascular Center, Suita, Japan
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Miwa K, Koga M, Nakai M, Yoshimura S, Sasahara Y, Koge J, Sonoda K, Ishigami A, Iwanaga Y, Miyamoto Y, Kobayashi S, Minematsu K, Toyoda K. Etiology and Outcome of Ischemic Stroke in Patients With Renal Impairment Including Chronic Kidney Disease: Japan Stroke Data Bank. Neurology 2022; 98:e1738-e1747. [PMID: 35260440 PMCID: PMC9071372 DOI: 10.1212/wnl.0000000000200153] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 01/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background and Objectives Chronic kidney disease is a worldwide public health problem that is recognized as an established risk factor for stroke. It remains unclear whether its distribution and clinical impact are consistent across ischemic stroke subtypes in patients with renal impairment. We examined whether renal impairment was associated with the proportion of each stroke subtype vs ischemic stroke overall and with functional outcomes after each stroke subtype. Methods Study participants were 10,392 adult patients with an acute stroke from the register of the Japan Stroke Data Bank, a hospital-based multicenter stroke registration database, between October 2016 and December 2019, whose baseline serum creatinine levels or a dipstick proteinuria result were available. All ischemic strokes were classified according to the Trial of Org 10172 in Acute Stroke Treatment criteria. Unfavorable functional outcome was defined as modified Rankin Scale (mRS) score 3–6 at discharge. Mixed effect logistic regression was used to determine the relationship between the outcomes and the estimated glomerular filtration rate (eGFR), eGFR strata (<45, 45–59, ≥60 mL/min/1.73 m2), or dipstick proteinuria ≥1 adjusted for covariates. Results Overall, 2,419 (23%) patients had eGFR 45–59 mL/min/1.73 m2 and 1,976 (19%) had eGFR <45 mL/min/1.73 m2, including 185 patients (1.8%) receiving hemodialysis. Both eGFR 45–59 and eGFR <45 mL/min/1.73 m2 were associated with a higher proportion of cardioembolic stroke (odds ratio [OR], 1.21 [95% CI, 1.05–1.39] and 1.55 [1.34–1.79], respectively) and a lower proportion of small vessel occlusion (0.79 [0.69–0.90] and 0.68 [0.59–0.79], respectively). A similar association with the proportion of these 2 subtypes was proven in the analyses using decreased eGFR as continuous values. Both eGFR <45 mL/min/1.73 m2 and proteinuria were associated with unfavorable functional outcomes in patients with cardioembolic stroke (OR, 1.30 [95% CI, 1.01–1.69] and 3.18 [2.03–4.98], respectively) and small vessel occlusion (OR, 1.44 [1.01–2.07] and 2.08 [1.08–3.98], respectively). Discussion Renal impairment contributes to the different distributions and clinical effects across specific stroke subtypes, particularly evident in cardioembolic stroke and small vessel occlusion. This possibly indicates shared mechanisms of susceptibility and potentially enhancing pathways.
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Affiliation(s)
- Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Michikazu Nakai
- Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yusuke Sasahara
- Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazutaka Sonoda
- Department of Neurology, Saiseikai Fukuoka Hospital, Fukuoka, Japan
| | - Akiko Ishigami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshitaka Iwanaga
- Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiro Miyamoto
- Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | | | | | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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25
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Tanaka K, Miwa K, Takagi M, Sasaki M, Yakushiji Y, Kudo K, Shiozawa M, Tanaka J, Nishihara M, Yamaguchi Y, Fujita K, Honda Y, Kawano H, Ide T, Yoshimura S, Koga M, Hirano T, Toyoda K. Increased Cerebral Small Vessel Disease Burden With Renal Dysfunction and Albuminuria in Patients Taking Antithrombotic Agents: The Bleeding With Antithrombotic Therapy 2. J Am Heart Assoc 2022; 11:e024749. [PMID: 35253443 PMCID: PMC9075282 DOI: 10.1161/jaha.121.024749] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The aim of this study was to determine the associations of cerebral small vessel disease (SVD) burden with renal dysfunction and albuminuria in patients taking oral antithrombotic agents. Methods and Results Patients who newly started or continued taking oral antiplatelets or anticoagulants were enrolled in a prospective, multicenter, observational study. Obligatorily acquired multimodal magnetic resonance imaging at registration with prespecified imaging conditions was assessed for cerebral microbleeds, white matter hyperintensities, enlarged basal ganglia perivascular spaces, or lacunes, and an ordinal SVD score was calculated (range, 0–4). Multivariable adjusting covariates were age, sex, hypertension, diabetes, dyslipidemia, current smoking, drinking, and estimated glomerular filtration rate (eGFR). Of 5324 patients (1762 women; median age, 73 years), 4797 (90.1%) patients were taking oral antithrombotic agents for secondary stroke prevention. Cerebral microbleeds were present in 32.7%, confluent white matter hyperintensities in 51.8%, extensive basal ganglia perivascular spaces in 38.9%, and lacunes in 59.4%. Median SVD score was 2. Compared with eGFR category G1 (eGFR ≥90 mL/min per 1.73 m2), adjusted odds ratios for SVD score increment were 1.63 (95% CI, 1.11–2.39) at category G4 (eGFR 15–<30 mL/min per 1.73 m2) and 2.05 (95% CI, 1.33–3.16) at G5 (eGFR <15 mL/min per 1.73 m2). Corresponding odds ratios relative to urinary albumin‐to‐creatinine ratio (ACR) category A1 (ACR <30 mg/g) were 1.29 (95% CI, 1.12–1.49) for category A2 (ACR 30–<300 mg/g) and 1.37 (95% CI, 1.05–1.77) for A3 (ACR ≥300 mg/g). When combined eGFR and ACR categories were assessed, risks for SVD score increment generally increased as eGFR decreased and ACR increased. Conclusions Both reduced eGFR and albuminuria were independently associated with increased cerebral SVD burden in patients requiring oral antithrombotic medication mainly for secondary stroke prevention. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01581502; URL: https://www.umin.ac.jp/ctr; Unique identifier: UMIN000023669.
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Affiliation(s)
- Kanta Tanaka
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masahito Takagi
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Makoto Sasaki
- Institute for Biomedical SciencesIwate Medical University Yahaba Japan
| | - Yusuke Yakushiji
- Division of Neurology Department of Internal Medicine Saga University Faculty of Medicine Saga Japan
- Department of Neurology Kansai Medical University Hirakata Japan
| | - Kohsuke Kudo
- Department of Diagnostic Imaging Hokkaido University Graduate School of Medicine Sapporo Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Jun Tanaka
- Division of Neurology Department of Internal Medicine Saga University Faculty of Medicine Saga Japan
| | - Masashi Nishihara
- Department of Radiology Saga University Faculty of Medicine Saga Japan
| | - Yoshitaka Yamaguchi
- Department of Neurology Yamagata Prefectural Central Hospital Yamagata Japan
| | - Kyohei Fujita
- Department of Neurology and Neurological Science Tokyo Medical and Dental University Tokyo Japan
| | - Yuko Honda
- Department of Stroke and Cerebrovascular Medicine Kyorin University Mitaka Japan
| | - Hiroyuki Kawano
- Department of Stroke and Cerebrovascular Medicine Kyorin University Mitaka Japan
| | - Toshihiro Ide
- Division of Neurology Department of Internal Medicine Saga University Faculty of Medicine Saga Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine Kyorin University Mitaka Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
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26
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Miwa K, Ahn JK, Akazawa Y, Aramaki T, Ashikaga S, Callier S, Chiga N, Choi SW, Ekawa H, Evtoukhovitch P, Fujioka N, Fujita M, Gogami T, Harada T, Hasegawa S, Hayakawa SH, Honda R, Hoshino S, Hosomi K, Ichikawa M, Ichikawa Y, Ieiri M, Ikeda M, Imai K, Ishikawa Y, Ishimoto S, Jung WS, Kajikawa S, Kanauchi H, Kanda H, Kitaoka T, Kang BM, Kawai H, Kim SH, Kobayashi K, Koike T, Matsuda K, Matsumoto Y, Nagao S, Nagatomi R, Nakada Y, Nakagawa M, Nakamura I, Nanamura T, Naruki M, Ozawa S, Raux L, Rogers TG, Sakaguchi A, Sakao T, Sako H, Sato S, Shiozaki T, Shirotori K, Suzuki KN, Suzuki S, Tabata M, Taille CDL, Takahashi H, Takahashi T, Takahashi TN, Tamura H, Tanaka M, Tanida K, Tsamalaidze Z, Ukai M, Umetsu H, Wada S, Yamamoto TO, Yoshida J, Yoshimura K. Precise Measurement of Differential Cross Sections of the Σ^{-}p→Λn Reaction in Momentum Range 470-650 MeV/c. Phys Rev Lett 2022; 128:072501. [PMID: 35244436 DOI: 10.1103/physrevlett.128.072501] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 06/14/2023]
Abstract
The differential cross sections of the Σ^{-}p→Λn reaction were measured accurately for the Σ^{-} momentum (p_{Σ}) ranging from 470 to 650 MeV/c at the J-PARC Hadron Experimental Facility. Precise angular information about the Σ^{-}p→Λn reaction was obtained for the first time by detecting approximately 100 reaction events at each angular step of Δcosθ=0.1. The obtained differential cross sections show a slightly forward-peaking structure in the measured momentum regions. The cross sections integrated for -0.7≤cosθ≤1.0 were obtained as 22.5±0.68 [statistical error(stat.)] ±0.65 [systematic error(syst.)] mb and 15.8±0.83(stat)±0.52(syst) mb for 470<p_{Σ}(MeV/c)<550 and 550<p_{Σ}(MeV/c)<650, respectively. These results show a drastic improvement compared with past measurements of the hyperon-proton scattering experiments. They will play essential roles in updating the theoretical models of the baryon-baryon interactions.
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Affiliation(s)
- K Miwa
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - J K Ahn
- Department of Physics, Korea University, Seoul 02841, Korea
| | - Y Akazawa
- Institute of Particle and Nuclear Studies (IPNS), High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - T Aramaki
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - S Ashikaga
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - S Callier
- OMEGA Ecole Polytechnique-CNRS/IN2P3, 3 rue Michel-Ange, 75794 Paris 16, France
| | - N Chiga
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - S W Choi
- Department of Physics, Korea University, Seoul 02841, Korea
| | - H Ekawa
- High Energy Nuclear Physics Laboratory, RIKEN, Wako 351-0198, Japan
| | - P Evtoukhovitch
- Joint Institute for Nuclear Research (JINR), Dubna, Moscow Region 141980, Russia
| | - N Fujioka
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - M Fujita
- Advanced Science Research Center (ASRC), Japan Atomic Energy Agency (JAEA), Tokai, Ibaraki 319-1195, Japan
| | - T Gogami
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - T Harada
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - S Hasegawa
- Advanced Science Research Center (ASRC), Japan Atomic Energy Agency (JAEA), Tokai, Ibaraki 319-1195, Japan
| | - S H Hayakawa
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - R Honda
- Institute of Particle and Nuclear Studies (IPNS), High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - S Hoshino
- Department of Physics, Osaka University, Toyonaka 560-0043, Japan
| | - K Hosomi
- Advanced Science Research Center (ASRC), Japan Atomic Energy Agency (JAEA), Tokai, Ibaraki 319-1195, Japan
| | - M Ichikawa
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
- Meson Science Laboratory, Cluster for Pioneering Research, RIKEN, Wako 351-0198, Japan
| | - Y Ichikawa
- Advanced Science Research Center (ASRC), Japan Atomic Energy Agency (JAEA), Tokai, Ibaraki 319-1195, Japan
| | - M Ieiri
- Institute of Particle and Nuclear Studies (IPNS), High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - M Ikeda
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - K Imai
- Advanced Science Research Center (ASRC), Japan Atomic Energy Agency (JAEA), Tokai, Ibaraki 319-1195, Japan
| | - Y Ishikawa
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - S Ishimoto
- Institute of Particle and Nuclear Studies (IPNS), High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - W S Jung
- Department of Physics, Korea University, Seoul 02841, Korea
| | - S Kajikawa
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - H Kanauchi
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - H Kanda
- Research Center for Nuclear Physics (RCNP), Osaka University, Ibaraki 567-0047, Japan
| | - T Kitaoka
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - B M Kang
- Department of Physics, Korea University, Seoul 02841, Korea
| | - H Kawai
- Department of Physics, Chiba University, Chiba 263-8522, Japan
| | - S H Kim
- Department of Physics, Korea University, Seoul 02841, Korea
| | - K Kobayashi
- Department of Physics, Osaka University, Toyonaka 560-0043, Japan
| | - T Koike
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - K Matsuda
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - Y Matsumoto
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - S Nagao
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - R Nagatomi
- Department of Physics, Osaka University, Toyonaka 560-0043, Japan
| | - Y Nakada
- Department of Physics, Osaka University, Toyonaka 560-0043, Japan
| | - M Nakagawa
- High Energy Nuclear Physics Laboratory, RIKEN, Wako 351-0198, Japan
| | - I Nakamura
- Institute of Particle and Nuclear Studies (IPNS), High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - T Nanamura
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
- Advanced Science Research Center (ASRC), Japan Atomic Energy Agency (JAEA), Tokai, Ibaraki 319-1195, Japan
| | - M Naruki
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - S Ozawa
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - L Raux
- OMEGA Ecole Polytechnique-CNRS/IN2P3, 3 rue Michel-Ange, 75794 Paris 16, France
| | - T G Rogers
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - A Sakaguchi
- Department of Physics, Osaka University, Toyonaka 560-0043, Japan
| | - T Sakao
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - H Sako
- Advanced Science Research Center (ASRC), Japan Atomic Energy Agency (JAEA), Tokai, Ibaraki 319-1195, Japan
| | - S Sato
- Advanced Science Research Center (ASRC), Japan Atomic Energy Agency (JAEA), Tokai, Ibaraki 319-1195, Japan
| | - T Shiozaki
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - K Shirotori
- Research Center for Nuclear Physics (RCNP), Osaka University, Ibaraki 567-0047, Japan
| | - K N Suzuki
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - S Suzuki
- Institute of Particle and Nuclear Studies (IPNS), High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - M Tabata
- Department of Physics, Chiba University, Chiba 263-8522, Japan
| | - C D L Taille
- OMEGA Ecole Polytechnique-CNRS/IN2P3, 3 rue Michel-Ange, 75794 Paris 16, France
| | - H Takahashi
- Institute of Particle and Nuclear Studies (IPNS), High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - T Takahashi
- Institute of Particle and Nuclear Studies (IPNS), High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - T N Takahashi
- Nishina Center for Accelerator-based Science, RIKEN, Wako 351-0198, Japan
| | - H Tamura
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
- Advanced Science Research Center (ASRC), Japan Atomic Energy Agency (JAEA), Tokai, Ibaraki 319-1195, Japan
| | - M Tanaka
- Institute of Particle and Nuclear Studies (IPNS), High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - K Tanida
- Advanced Science Research Center (ASRC), Japan Atomic Energy Agency (JAEA), Tokai, Ibaraki 319-1195, Japan
| | - Z Tsamalaidze
- Joint Institute for Nuclear Research (JINR), Dubna, Moscow Region 141980, Russia
- Georgian Technical University (GTU), Tbilisi 0175, Georgia
| | - M Ukai
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
- Institute of Particle and Nuclear Studies (IPNS), High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - H Umetsu
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - S Wada
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - T O Yamamoto
- Advanced Science Research Center (ASRC), Japan Atomic Energy Agency (JAEA), Tokai, Ibaraki 319-1195, Japan
| | - J Yoshida
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - K Yoshimura
- Department of Physics, Okayama University, Okayama 700-8530, Japan
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27
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Hosoki S, Fukuda-doi M, Miwa K, Yoshimura S, Chiba T, Ikenouchi H, Morita Y, Toyoda K, Ihara M, Koga M. Abstract WMP71: Sequential Detection Rates Of Intramural Hematoma For Diagnosing Spontaneous Intracranial Artery Dissection. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wmp71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Spontaneous intracranial artery dissection (IAD) can be diagnosed with the detection of intramural hematoma (IMH). We previously reported that high-resolution 3-dimensional T1-weighted magnetic resonance imaging (HR-3D-T1WI) is useful to detect IMH. Limited evidence is available regarding sequential detection rates of IMH and appropriate timing of the detection.
Methods:
We retrieved data on consecutive patients from our prospective cohort databases from March 2011 to August 2018 who had definite, probable, or possible IAD based on the multidisciplinary expert consensus criteria. We detected IMH on initial and follow-up HR-3D-T1WI. We explored the association between detection of IMH and days from symptom onset to initial or follow-up HR-3D-T1WI.
Results:
A total of 104 patients (mean age 51 ± 13; 30 female; 68 patients, definite IAD; 31 patients; probable IAD, 5 patients; possible IAD) with at least initial HR-3D-T1WI data were included in the analysis. Clinical diagnoses included ischemic stroke (46%), subarachnoid hemorrhage (6%), transient ischemic attack (2%), and head or neck pain alone (46%). Age, Sex, vascular risk factors and modified Rankin Scale at 3 months were comparable between patients with IMH and without. Among them, follow-up HR-3D-T1WI was performed in 54 patients (52%). IMH was observed in 61 patients, 59% of all and 90% of definite IAD. The median days from symptom onset to initial or follow-up HR-3D-T1WI were 11 (interquartile range[IQR] 8–15) and 29 (IQR 19–57) days, respectively. The median days from symptom onset to first IMH detection were 12 (IQR range 8–17). The detection rate of IMH on initial HR-3D-T1WI was 55% overall, reaching 20% on day 3, 40% on day 7, and 50% on day 8–12 (
Figure
). Of the 23 patients who did not have an IMH on the initial HR-3D-T1WI, 4 (17%) had an IMH detected on the follow-up imaging.
Conclusion:
The detection rate of IMH on HR-3D-T1WI was approximately 60%, which reached the maximum in 1-2 weeks.
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Affiliation(s)
| | | | | | | | - Tetsuya Chiba
- Natl Cerebral and Cardiovascular Ct, Suita, Osaka, Japan
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28
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Chiba T, Miwa K, Takahashi A, Mizoguchi T, Yi K, Hosoki S, Yoshimura S, Toyoda K, Ihara M, Koga M. Abstract TP199: Genome Wide Association Study Of Intracranial Artery Dissection Reveals Potential Novel Loci. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.tp199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Cervico-cephalic dissections (extracranial artery dissection [EAD] and intracranial artery dissection [IAD]) are defined by a mural hematoma in the wall of a cervical or intracranial artery and represent an important cause of stroke in young adults. It is relatively uncommon in the general population and likely to represent the ethnic difference with higher frequency of IAD in Asian than European populations. A few studies examining the genetic contributions for these phenotypes were reported. In EAD, the
PHACTR1
genes which had previously been identified as common genetic risk variants of hypertension and migraine was associated with EAD using genome-wide association study (GWAS) approaches.
RNF213
, an important susceptibility gene for Moyamoya disease was associated with IAD in one small study (n=24) using a candidate-SNP analysis but no GWAS of IAD have been reported so far. We performed GWAS to identify common variants associated with IAD.
Methods:
A total of 100 Japanese patients with IAD based on imaging diagnostic criteria from multidisciplinary expert consensus were prospectively enrolled in National Cerebral and Cardiovascular Center from March 2011 to August 2018.
Results:
We performed GWAS in 100 IAD cases (61 men, 50 years of median age[IQR, 45-61]) and 8380 controls from the Tohoku Medical Megabank Project which is a publicly available healthy cohort. No variant reached to genome-wide significant but 14 variants (7 regions) showed nominal significant association with IAD (p < 10
-5
). Among 14 variants, rs73828631 on
RBMS3
gene showed highest association with IAD (odds ratio = 2.16, 95% confidence interval = 1.59-2.92; P = 3.08 х 10
-7
).
RBMS3
was previously identified as genetic loci associated with brain aneurysm. According to the Genotype-Tissue Expression (GTEx) project database,
RBMS3
is highly expressed in artery.
Conclusions:
We identified potential 14 variants associated with IAD. We need to increase the number of IAD cases for further confirmation.
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Affiliation(s)
- Tetsuya Chiba
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Kaori Miwa
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Atsushi Takahashi
- Genomic medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Tadataka Mizoguchi
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Kenichiro Yi
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Satoshi Hosoki
- Neurology, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Sohei Yoshimura
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | | | - Masafumi Ihara
- Neurology, National Cerebral and Cardiovascular Cntr, Suita, Japan
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29
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Toyoda K, Yoshimura S, nakai M, Koga M, Sasahara Y, Sonoda K, Kamiyama K, Yazawa Y, Kawada S, SASAKI MASAHIRO, Terasaki T, Miwa K, Koge J, Ishigami A, Wada S, Iwanaga Y, Miyamoto Y, Minematsu K, Kobayashi S. Abstract TMP53: Nationwide Secular Changes In Severity And Outcome Of Ischemic And Hemorrhagic Strokes: A 20-Year Analysis From Japan Stroke Data Bank Involving 183,082 Patients. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.tmp53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
The Japan Stroke Data Bank (JSDB) is a 20-year long ongoing hospital-based multicenter prospective registry of hospitalized patients with acute stroke/TIA based on a web database from 130 stroke centers distributed evenly over Japan.
Hypothesis:
Secular changes in the severity and functional outcome of stroke patients would be clarified by long-lasting hospital-based registries.
Methods:
Patients registered in JSDB within 7 days after stroke onset from Jan 2000 through Dec 2019 were studied. The initial severity was assessed by the NIHSS for ischemic stroke (IS) and intracerebral hemorrhage (ICH) and by the WFNS grading for subarachnoid hemorrhage (SAH). Outcomes at hospital discharge was assessed by the mRS.
Results:
Of a total 183,082 stroke patients, 135,268 (women in 39.8%) developed IS, 36,014 (women in 42.7%) developed ICH, and 11,800 (women in 67.2%) developed SAH. Median ages at onset increased and the NIHSS and WFNS scores decreased after multivariable-adjustment in all three stroke types. Patients with favorable outcome, corresponding to the mRS 0-2, significantly increased after age-adjustment in all three IS subtypes, remained increasing after further adjustment by NIHSS and stroke history only in cardioembolic stroke (OR 1.014, 95% CI 1.008-1.020, per year), and no longer increased after further adjustment by reperfusion therapy in any subtypes. Both the frequencies of unfavorable outcome, corresponding to the mRS 5-6, and in-hospital death, significantly decreased in cardioembolic stroke (OR 0.974, 95% CI 0.968-0.980) and large-artery atherosclerosis (OR 0.975, 95% CI 0.967-0.982, both for unfavorable outcome) after multivariable-adjustment. In ICH and SAH, favorable outcome significantly decreased after multivariable-adjustment, except for SAH in men. Both the frequencies of unfavorable outcome and death after SAH significantly decreased, but those after ICH were not. These findings were generally common to both sexes when separately analyzed.
Conclusions:
Short-term functional outcome improved in IS patients during the past 20 years presumably partly due to development of acute reperfusion therapy. The outcome of hemorrhagic stroke patients did not clearly show the improvement during the same duration.
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Affiliation(s)
| | - Sohei Yoshimura
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan
| | | | - Masatoshi Koga
- National Cerebral and Cardiovascular Cntr, Suita Osaka, Japan
| | | | | | | | | | | | | | | | - Kaori Miwa
- National Cerebral and Cardiovascular Cntr, Suita, Osaka, Japan
| | - Junpei Koge
- National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Akiko Ishigami
- National Cerebral and Cardiovascular Cntr, Suita Osaka, Japan
| | - Shinichi Wada
- National Cerebral and Cardiovascular Cntr, Osaka, Japan
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30
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Fukuda-doi M, Koga M, Thomalla G, Jensen M, Inoue M, Yoshimura S, Miwa K, Gerloff CP, Davis S, Donnan GA, Ma H, Hacke W, Ringleb P, Wu O, Schwamm LH, Warach SJ, Boutitie F, Toyoda K. Abstract WMP10: Sex Difference In Imaging-based Intravenous Thrombolysisfor Ischemic Stroke With Unknown Onset Time: A Pooled Analysis Of Clinical Trials. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wmp10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Our prior meta-analysis reported that imaging-based intravenous thrombolysis (IVT) was safe and effective for patients who have had a stroke with an unknown onset time. The aim of this study is to investigate whether sex differences exist in clinical outcomes among this population.
Methods:
This is a pooled analysis of individual patient-level data acquired from the EOS project, a meta-analysis of clinical trials (PROSPERO, CRD42020166903). Patients treated with imaging-based IVT for stroke with an unknown time of onset were included. The primary outcome was a favorable functional outcome (mRS 0-1) at 90 days. Secondary outcomes were mRS shift towards a better functional outcome and death within 90 days. Sex differences were investigated using mixed-effect logistic or ordinal regression models adjusted for covariates, considering potential heterogeneity across trials.
Results:
Among 509 patients treated with imaging-based IVT, 204 (40.1%) were women. Compared to men, women were older (70
±
12 vs. 67
±
13, p=0.003), more frequently had atrial fibrillation (27.6% vs. 17.2%, p=0.005), and were taking antiplatelets prior to the onset (45.5% vs. 36.4%, p=0.045). Baseline NIHSS score was higher (8.0 (IQR 5-15) vs.6 (4-11), p<0.001), and hours from last-known-well to treatment were longer (11.2 (9.3-12.9) vs. 10.3 (8.1-11.9), p<0.001) in women than men. Favorable outcomes occurred in 80 (40.6%) women and in 150 (49.7%) men (p=0.047). Among women, 19 (9.6%) patients died, compared with 15 (5.0%) patients in men (p=0.042). After multivariate adjustment, female sex was not significantly associated with favorable functional outcome (adjusted odds ratio (OR) 1.01[95% confidential intervals (CI) 0.66-1.54]; p=0.97) nor death (adjusted OR 1.28 [95%CI 0.59-2.76]; p=0.59). Female sex was not associated with a significant shift towards the better functional outcome (common OR 1.07 [95%CI 0.77-1.49]; p=0.70).
Conclusions:
Pooled data from clinical trials show that in univariate analysis, women had numerically less good functional outcomes following imaging-based IVT among ischemic stroke patients with unknown onset time. However, this sex difference can be explained by higher age and more severe clinical status in women at stroke onset.
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Affiliation(s)
| | | | | | | | - Manabu Inoue
- Natl Cerebral and Cardiovascular Ctr, Suita, Japan
| | | | - Kaori Miwa
- Natl Cerebral and Cardiovascular Ctr, Suita, Japan
| | | | | | | | - Henry Ma
- MONASH HEALTH, Clayton, Australia
| | - Werner Hacke
- RUPRECHT KARLS UNIV HEIDELBERG, Heidelberg, Germany
| | | | - Ona Wu
- Massachusetts General Hosp, Boston, MA
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31
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Toyoda K, Omae K, Hoshino H, Uchiyama S, Kimura K, Miwa K, Minematsu K, Yamaguchi K, Suda Y, Toru S, Kitagawa K, Ihara M, Koga M, Yamaguchi T. Association of Timing for Starting Dual Antiplatelet Treatment With Cilostazol and Recurrent Stroke: A CSPS.com Trial Post Hoc Analysis. Neurology 2022; 98:e983-e992. [PMID: 35074890 PMCID: PMC8967394 DOI: 10.1212/wnl.0000000000200064] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/27/2021] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives Long-term treatment with the combination of cilostazol with aspirin or clopidogrel showed a lower risk of stroke recurrence compared to aspirin or clopidogrel alone after high-risk noncardioembolic ischemic stroke in a randomized trial. We aimed to determine whether the effect of the dual medication compared to monotherapy on risk of recurrent ischemic stroke differs according to timing of starting medication after stroke onset. Methods In a subanalysis of the randomized controlled trial, patients between 8 and 180 days after stroke onset were randomly assigned to receive aspirin or clopidogrel alone or a combination of cilostazol with aspirin or clopidogrel. They were divided into 3 groups according to the timing of starting trial treatment: between 8 and 14 days after stroke onset (8–14 days group), between 15 and 28 days after stroke onset (15–28 days group), and between 29 and 180 days after stroke onset (29–180 days group). The primary efficacy outcome was the first recurrence of ischemic stroke. Safety outcomes included severe or life-threatening bleeding. Results Of 1,879 patients, 498 belonged to the 8–14 days group, 467 to the 15–28 days group, and 914 to the 29–180 days group. There was a significant treatment-by-subgroup interaction for the recurrence of ischemic stroke between trial treatment and trichotomized groups. The recurrence of ischemic stroke was less common with dual therapy than with monotherapy in the 15–28 days group (annualized rate 1.5% vs 4.9%, respectively; adjusted hazard ratio 0.34 [95% CI 0.12–0.95]) and the 29–180 days group (1.9% vs 4.4%, respectively; 0.27 [0.12–0.63]) and similarly common in the 8–14 days group (4.5% for both; 1.02 [0.51–2.04]). Severe or life-threatening bleeding occurred similarly between patients on dual therapy and those on monotherapy in any of the trichotomized groups (crude hazard ratio 0.22 [95% CI 0.03–1.88] in the 8–14 days group, 1.07 [0.15–7.60] in the 15–28 days group, and 0.76 [0.24–2.39] in the 29–180 days group). Discussion Long-term dual antiplatelet therapy using cilostazol starting 15–180 days after stroke onset, compared to therapy started 8–14 days after onset, was more effective for secondary stroke prevention than monotherapy without increasing hemorrhage risk. Trial Registration Information ClinicalTrials.gov NCT01995370; UMIN Clinical Trials Registry 000012180. Classification of Evidence This study provides Class II evidence that for patients with acute noncardioembolic stroke taking either aspirin or clopidogrel, the addition of cilostazol 15–180 days after stroke onset decreases the risk of recurrent ischemic stroke.
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Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Katsuhiro Omae
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Haruhiko Hoshino
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Medical Center, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuo Minematsu
- Headquarters of the Iseikai Medical Corporation, Osaka, Japan
| | - Keiji Yamaguchi
- Department of Neurology, Ichinomiya Nishi Hospital, Ichinomiya, Japan
| | - Yoshitaka Suda
- Department of Neurosurgery, Yuri Kumiai General Hospital, Yurihonjo, Japan
| | - Shuta Toru
- Department of Neurology, Nitobe Memorial Nakano General Hospital, Tokyo, Japan
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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32
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Yamamoto TO, Fujita M, Gogami T, Harada TK, Hayakawa SH, Hosomi K, Ichikawa Y, Ishikawa Y, Kamada K, Kanauchi H, Koike T, Miwa K, Nagae T, Oura F, Takahashi T, Tamura H, Tanida K, Ukai M. X ray spectroscopy on 𝚵 − atoms (J-PARC E03, E07 and future). EPJ Web Conf 2022. [DOI: 10.1051/epjconf/202227103001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
X-ray spectroscopy of hadronic atoms is a powerful method to study strong interaction between hadrons and nuclei. At J-PARC, we have conducted two experiments, J-PARC E07 and E03, for hadronic atoms with a doubly strange hyperon, Ξ−, aiming at the world-first detection of their X-rays. The first measurement is performed as a byproduct of J-PARC E07 experiment with the hybrid emulsion technique. The second one, J-PARC E03, is a dedicated experiment for detection of Ξ− Fe atom X rays. The preliminary results and the present status of E07 and E03 are shown in this article. Future prospects of Ξ−-atomic X-ray spectroscopy are also discussed. A new measurement has been proposed for detecting Ξ− C atom X rays, where a novel Ξ− tracking method will be applied to realize an improved signal to noise ratio.
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33
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Ebata K, Fujioka H, Fujita M, Gogami T, Harada TK, Hayakawa SH, Honda R, Ichikawa Y, Kamada K, Kobori T, Miwa K, Nagae T, Nanamura T, Negishi R, Oura F, Sakao T, Son C, Takahashi T, Takahashi H, Tamura H, Tokiyasu AO, Ukai M, Yamamoto TO. Preparation status of missing-mass spectroscopy for 𝚵 hypernuclei with S-2S magnetic spectrometer. EPJ Web Conf 2022. [DOI: 10.1051/epjconf/202227103008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
J-PARC E70 experiment measures the missing-mass of Ξ hypernuclei (12ΞBe) in Hadron Experimental Facility at J-PARC. We aim to reach the best missing-mass resolution of 2 MeV/c2 in FWHM with a new magnetic spectrometer S-2S. The high-resolution spectroscopy of Ξ hypernuclei will play an important role to understand the unknown ΞN interaction. The experiment will start at the beginning of 2023. This article presents the preparation status.
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34
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Harada TK, Ebata K, Gogami T, Hayakawa SH, Honda R, Ichikawa Y, Miwa K, Nagae T, Nanamura T, Takahashi T, Ukai M, Yamamoto TO. High resolution spectroscopy of 𝚵 hypernuclei with active fiber target. EPJ Web Conf 2022. [DOI: 10.1051/epjconf/202227103006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
We are planning to carry out a high-resolution spectroscopy of Ξ hypernucleus at the J-PARC K1.8 beamline, which provides a highintensity K− beam (J-PARC E70 experiment). The high-resolution spectroscopy aims to be realized by introducing a new magnetic spectrometer S-2S and an active fiber target AFT. In this article, the role of the AFT in this experiment and its development status are described.
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35
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Toyoda K, Yoshimura S, Nakai M, Koga M, Sasahara Y, Sonoda K, Kamiyama K, Yazawa Y, Kawada S, Sasaki M, Terasaki T, Miwa K, Koge J, Ishigami A, Wada S, Iwanaga Y, Miyamoto Y, Minematsu K, Kobayashi S. Twenty-Year Change in Severity and Outcome of Ischemic and Hemorrhagic Strokes. JAMA Neurol 2021; 79:61-69. [PMID: 34870689 PMCID: PMC8649912 DOI: 10.1001/jamaneurol.2021.4346] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Question Did the initial neurological severity and functional outcomes of patients with stroke change throughout a 20-year period? Findings In this hospital-based, multicenter, prospective registry involving 183 080 patients with acute stroke, initial neurological severity showed a decrease over time in all stroke types. Functional outcome at hospital discharge improved in patients with ischemic stroke but no longer showed improvement after adjustment by reperfusion therapy and others; it did not clearly improve in patients with hemorrhagic stroke. Meaning Twenty-year changes in functional outcomes after ischemic and hemorrhagic strokes showed different trends presumably partly owing to differences in the development of acute therapeutic strategies. Importance Whether recent changes in demographic characteristics and therapeutic technologies have altered stroke outcomes remains unknown. Objective To determine secular changes in initial neurological severity and short-term functional outcomes of patients with acute stroke by sex using a large population. Design, Setting, and Participants This nationwide, hospital-based, multicenter, prospective registry cohort study used the Japan Stroke Data Bank and included patients who developed acute stroke from January 2000 through December 2019. Patients with stroke, including ischemic and hemorrhagic strokes, who registered within 7 days after symptom onset were studied. Modified Rankin Scale scores were assessed at hospital discharge for all patients. Exposure Time. Main Outcomes and Measures Initial severity was assessed by the National Institutes of Health Stroke Scale for ischemic stroke and intracerebral hemorrhage and by the World Federation of Neurological Surgeons grading for subarachnoid hemorrhage. Outcomes were judged as favorable if the modified Rankin Scale score was 0 to 2 and unfavorable if 5 to 6. Results Of 183 080 patients, 135 266 (53 800 women [39.8%]; median [IQR] age, 74 [66-82] years) developed ischemic stroke, 36 014 (15 365 women [42.7%]; median [IQR] age, 70 [59-79] years) developed intracerebral hemorrhage, and 11 800 (7924 women [67.2%]; median [IQR] age, 64 [53-75] years) developed subarachnoid hemorrhage. In all 3 stroke types, median ages at onset increased, and the National Institutes of Health Stroke Scale and World Federation of Neurological Surgeons scores decreased throughout the 20-year period on multivariable analysis. In ischemic stroke, the proportion of favorable outcomes showed an increase over time after age adjustment (odds ratio [OR], 1.020; 95% CI, 1.015-1.024 for women vs OR, 1.015; 95% CI, 1.011-1.018 for men) but then stagnated, or even decreased in men, on multivariate adjustment including reperfusion therapy (OR, 0.997; 95% CI, 0.991-1.003 for women vs OR, 0.990; 95% CI, 0.985-0.994 for men). Unfavorable outcomes and in-hospital deaths decreased in both sexes. In intracerebral hemorrhage, favorable outcomes decreased in both sexes, and unfavorable outcomes and deaths decreased only in women. In subarachnoid hemorrhage, the proportion of favorable outcomes was unchanged, and that of unfavorable outcomes and deaths decreased in both sexes. Conclusions and Relevance In this study, functional outcomes improved in patients with ischemic stroke during the past 20 years in both sexes presumably partly owing to the development of acute reperfusion therapy. The outcomes of patients with hemorrhagic stroke did not clearly improve in the same period.
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Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yusuke Sasahara
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazutaka Sonoda
- Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Yukako Yazawa
- Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Sanami Kawada
- Stroke Center, Okayama Kyokuto Hospital, Okayama, Japan
| | - Masahiro Sasaki
- Department of Stroke Science, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Tadashi Terasaki
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akiko Ishigami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shinichi Wada
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshitaka Iwanaga
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshihiro Miyamoto
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
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Debette S, Mazighi M, Bijlenga P, Pezzini A, Koga M, Bersano A, Kõrv J, Haemmerli J, Canavero I, Tekiela P, Miwa K, J Seiffge D, Schilling S, Lal A, Arnold M, Markus HS, Engelter ST, Majersik JJ. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J 2021; 6:XXXIX-LXXXVIII. [PMID: 34746432 PMCID: PMC8564160 DOI: 10.1177/23969873211046475] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [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] [Received: 07/17/2021] [Accepted: 08/26/2021] [Indexed: 11/15/2022] Open
Abstract
The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of extracranial artery dissection (EAD) and intracranial artery dissection (IAD). EAD and IAD represent leading causes of stroke in the young, but are uncommon in the general population, thus making it challenging to conduct clinical trials and large observational studies. The guidelines were prepared following the Standard Operational Procedure for European Stroke Organisation guidelines and according to GRADE methodology. Our four recommendations result from a thorough analysis of the literature comprising two randomized controlled trials (RCTs) comparing anticoagulants to antiplatelets in the acute phase of ischemic stroke and twenty-six comparative observational studies. In EAD patients with acute ischemic stroke, we recommend using intravenous thrombolysis (IVT) with alteplase within 4.5 hours of onset if standard inclusion/exclusion criteria are met, and mechanical thrombectomy in patients with large vessel occlusion of the anterior circulation. We further recommend early endovascular or surgical intervention for IAD patients with subarachnoid hemorrhage (SAH). Based on evidence from two phase 2 RCTs that have shown no difference between the benefits and risks of anticoagulants versus antiplatelets in the acute phase of symptomatic EAD, we strongly recommend that clinicians can prescribe either option. In post-acute EAD patients with residual stenosis or dissecting aneurysms and in symptomatic IAD patients with an intracranial dissecting aneurysm and isolated headache, there is insufficient data to provide a recommendation on the benefits and risks of endovascular/surgical treatment. Finally, nine expert consensus statements, adopted by 8 to 11 of the 11 experts involved, propose guidance for clinicians when the quality of evidence was too low to provide recommendations. Some of these pertain to the management of IAD (use of IVT, endovascular treatment, and antiplatelets versus anticoagulation in IAD with ischemic stroke and use of endovascular or surgical interventions for IAD with headache only). Other expert consensus statements address the use of direct anticoagulants and dual antiplatelet therapy in EAD-related cerebral ischemia, endovascular treatment of the EAD/IAD lesion, and multidisciplinary assessment of the best therapeutic approaches in specific situations.
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Affiliation(s)
- Stephanie Debette
- Bordeaux Population Health research
center, INSERM U1219, University of Bordeaux, Bordeaux, France
- Department of Neurology and
Institute for Neurodegenerative Diseases, Bordeaux University
Hospital, France
| | - Mikael Mazighi
- Department of Neurology, Hopital Lariboisière, Paris, France
- Interventional Neuroradiology
Department, Hôpital Fondation Ophtalmologique
Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- FHU NeuroVasc, Paris, France
- Laboratory of Vascular Translational
Science, INSERM U1148, Paris, France
| | - Philippe Bijlenga
- Neurosurgery, Département de
Neurosciences Cliniques, Hôpitaux Universitaires et Faculté de
Médecine de Genève, Switzerland
| | - Alessandro Pezzini
- Department of Clinical and
Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Masatoshi Koga
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular
Center, Suita, Osaka, Japan
| | - Anna Bersano
- Fondazione IRCCS Istituto Neurologico
'Carlo Besta', Milano
| | - Janika Kõrv
- Department of Neurology and
Neurosurgery, University of Tartu, Tartu, Estonia
- Department of Neurology, Tartu University
Hospital, Tartu, Estonia
| | - Julien Haemmerli
- Neurosurgery, Département de
Neurosciences Cliniques, Hôpitaux Universitaires et Faculté de
Médecine de Genève, Switzerland
| | | | - Piotr Tekiela
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Kaori Miwa
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular
Center, Suita, Osaka, Japan
| | - David J Seiffge
- University Hospital
Bern, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Sabrina Schilling
- Guidelines Methodologist, European Stroke
Organization, Basel, Switzerland
| | - Avtar Lal
- Guidelines Methodologist, European Stroke
Organization, Basel, Switzerland
| | - Marcel Arnold
- University Hospital
Bern, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Hugh S Markus
- Department of Clinical
Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan T Engelter
- Department of Neurology and
Stroke Center, University Hospital and University of
Basel, Basel, Switzerland
- Neurology and
Neurorehabilitation, University Department of Geriatric
Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
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Miwa K, Koga M, Fukuda-Doi M, Yamamoto H, Tanaka K, Yoshimura S, Ihara M, Qureshi AI, Toyoda K. Effect of Heart Rate Variabilities on Outcome After Acute Intracerebral Hemorrhage: A Post Hoc Analysis of ATACH-2. J Am Heart Assoc 2021; 10:e020364. [PMID: 34387101 PMCID: PMC8475052 DOI: 10.1161/jaha.120.020364] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background To explore how the clinical impact of heart rate (HR) and heart rate variabilities (HRV) during the initial 24 hours after acute intracerebral hemorrhage (ICH) contribute to worse clinical outcomes. Methods and Results In the ATACH‐2 (Antihypertensive Treatment in Intracerebral Hemorrhage 2) trial, the HR was recorded for every 15 minutes from baseline to 1 hour and hourly during the initial 24 hours post‐randomization. We calculated the following: mean, standard deviation, coefficient of variation, successive variation, and average real variability (ARV). Outcomes were hematoma expansion at 24 hours and unfavorable functional outcome, defined as modified Rankin Scale score 4 to 6 at 90 days. Of the 1000 subjects in ATACH‐2, 994 with available HR data were included in the analyses. Overall, 262 experienced hematoma expansion, and 362 had unfavorable outcomes. Increased mean HR was linearly associated with unfavorable outcome (per 10 bpm increase adjusted odds ratio [aOR], 1.31, 95% CI, 1.14–1.50) but not with hematoma expansion, while HR‐ARV was associated with hematoma expansion (aOR, 1.06, 95% CI, 1.01–1.12) and unfavorable outcome (aOR, 1.07, 95% CI, 1.01–1.3). Every 10‐bpm increase in mean HR increased the probability of unfavorable outcome by 4.3%, while every 1 increase in HR‐ARV increased the probability of hematoma expansion by 1.1% and unfavorable outcome by 1.3%. Conclusions Increased mean HR and HR‐ARV within the initial 24 hours were independently associated with unfavorable outcome in acute ICH. Moreover, HR‐ARV was associated with hematoma expansion at 24 hours. This may have future therapeutic implications to accommodate HR and HRV in acute ICH. Registration URL: https://www.clinicaltrials.gov; Unique Identifier: NCT01176565.
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Affiliation(s)
- Kaori Miwa
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Mayumi Fukuda-Doi
- Center for Advancing Clinical and Translational Sciences National Cerebral and Cardiovascular Center Suita Japan
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences National Cerebral and Cardiovascular Center Suita Japan
| | - Kanata Tanaka
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masafumi Ihara
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology University of Missouri Columbia MO
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
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Miwa K, Koga M, Inoue M, Yoshimura S, Sasaki M, Yakushiji Y, Fukuda-Doi M, Okada Y, Nakase T, Ihara M, Nagakane Y, Takizawa S, Asakura K, Aoki J, Kimura K, Yamamoto H, Toyoda K. Cerebral microbleeds development after stroke thrombolysis: A secondary analysis of the THAWS randomized clinical trial. Int J Stroke 2021; 17:628-636. [PMID: 34282985 DOI: 10.1177/17474930211035023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIM We determined to investigate the incidence and clinical impact of new cerebral microbleeds after intravenous thrombolysis in patients with acute stroke. METHODS The THAWS was a multicenter, randomized trial to study the efficacy and safety of intravenous thrombolysis with alteplase in patients with wake-up stroke or unknown onset stroke. Prescheduled T2*-weighted imaging assessed cerebral microbleeds at three time points: baseline, 22-36 h, and 7-14 days. Outcomes included new cerebral microbleeds development, modified Rankin Scale (mRS) ≥3 at 90 days, and change in the National Institutes of Health Stroke Scale (NIHSS) score from 24 h to 7 days. RESULTS Of all 131 patients randomized in the THAWS trial, 113 patients (mean 74.3 ± 12.6 years, 50 female, 62 allocated to intravenous thrombolysis) were available for analysis. Overall, 46 (41%) had baseline cerebral microbleeds (15 strictly lobar cerebral microbleeds, 14 mixed cerebral microbleeds, and 17 deep cerebral microbleeds). New cerebral microbleeds only emerged in the intravenous thrombolysis group (seven patients, 11%) within a median of 28.3 h, and did not additionally increase within a median of 7.35 days. In adjusted models, number of cerebral microbleeds (relative risk (RR) 1.30, 95% confidence interval (CI): 1.17-1.44), mixed distribution (RR 19.2, 95% CI: 3.94-93.7), and cerebral microbleeds burden ≥5 (RR 44.9, 95% CI: 5.78-349.8) were associated with new cerebral microbleeds. New cerebral microbleeds were associated with an increase in NIHSS score (p = 0.023). Treatment with alteplase in patients with baseline ≥5 cerebral microbleeds resulted in a numerical shift toward worse outcomes on ordinal mRS (median [IQR]; 4 [3-4] vs. 0 [0-3]), compared with those with <5 cerebral microbleeds (common odds ratio 17.1, 95% CI: 0.76-382.8). The association of baseline ≥5 cerebral microbleeds with ordinal mRS score differed according to the treatment group (p interaction = 0.042). CONCLUSION New cerebral microbleeds developed within 36 h in 11% of the patients after intravenous thrombolysis, and they were significantly associated with mixed-distribution and ≥5 cerebral microbleeds. New cerebral microbleeds development might impede neurological improvement. Furthermore, cerebral microbleeds burden might affect the effect of alteplase.
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Affiliation(s)
- Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan.,Department of Neurology, Kansai Medical University, Hirakata, Japan
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Taizen Nakase
- Department of Stroke Science, Research Institute for Brain and Blood Vessels, Akita, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Shunya Takizawa
- 0Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Koko Asakura
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junya Aoki
- 1Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Fukuda-Doi M, Yamamoto H, Koga M, Doi Y, Qureshi AI, Yoshimura S, Miwa K, Ishigami A, Shiozawa M, Omae K, Ihara M, Toyoda K. Impact of Renal Impairment on Intensive Blood-Pressure-Lowering Therapy and Outcomes in Intracerebral Hemorrhage: Results From ATACH-2. Neurology 2021; 97:e913-e921. [PMID: 34210824 PMCID: PMC8408509 DOI: 10.1212/wnl.0000000000012442] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/27/2021] [Indexed: 12/02/2022] Open
Abstract
Background and Objective The clinical effect of renal impairment on intracerebral hemorrhage (ICH) is unknown. This study sought to assess whether estimated glomerular filtration rate (eGFR) affects clinical outcomes or modifies the efficacy of intensive systolic blood pressure (BP) control (target, 110–139 mm Hg) against the standard (target, 140–179 mm Hg) among patients with ICH. Methods We conducted post hoc analyses of ATACH-2, a randomized, 2-group, open-label trial. The baseline eGFR of each eligible patient was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. The outcome of interest was death or disability at 90 days. Multivariate logistic regression models were used for analysis. Results Among the 1,000 patients randomized, 974 were analyzed. The median baseline eGFR was 88 (interquartile range, 68, 99) mL/min/1.73 m2; 451 (46.3%), 363 (37.3%), and 160 (16.4%) patients had baseline eGFR values of ≥90, 60–89, and <60 mL/min/1.73 m2, respectively. Compared with normal eGFR (≥90 mL/min/1.73 m2), higher odds of death or disability were noted among those with eGFR values of <60 mL/min/1.73 m2 (adjusted odds ratio [OR], 2.02; 95% confidence interval [CI], 1.25–3.26) but not among those with eGFR values of 60–89 mL/min/1.73 m2 (OR, 1.01; 95% CI, 0.70–1.46). The odds of death or disability were significantly higher in the intensive arm among patients with decreased eGFR; the ORs were 0.89 (95% CI, 0.55–1.44), 1.13 (0.68–1.89), and 3.60 (1.47–8.80) in patients with eGFR values of ≥90, 60–89, and <60 mL/min/1.73 m2, respectively (p for interaction = 0.02). Discussion Decreased eGFR is associated with unfavorable outcomes following ICH. The statistically significant interaction between the eGFR group and treatment assignment raised safety concerns for the intensive BP-lowering therapy among patients with renal impairment. Trial Registration Information Clinicaltrials.gov identifier: NCT01176565. Classification of Evidence This study provides Class II evidence that in spontaneous ICH, decreased eGFR identifies patients at risk of death or disability following intensive BP control.
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Affiliation(s)
- Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Haruko Yamamoto
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yohei Doi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, St. Cloud, MN, USA.,Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akiko Ishigami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Katsuhiro Omae
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Koga M, Inoue M, Miwa K, Yoshimura S, Fukuda-doi M, Aoki J, Asakura K, Ohtaki M, Kamiyama K, Igarashi S, Doijiri R, Ito Y, Takagi Y, Ihara M, Sasaki M, Kitazono T, Kimura K, Minematsu K, Yamamoto H, Toyoda K. Abstract P7: Prior Antithrombotic Medication May Affect Outcomes Following Alteplase at 0.6mg for Unknown Onset Stroke: THAWS Randomized Clinical Trial. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and purpose:
To assess the potential effect of prior antithrombotic medication for thrombolysis using alteplase at 0.6mg/kg in unknown onset stroke.
Methods:
This was a prespecified sub-analysis of a THAWS trial (an investigator-initiated, multicenter, randomized, open, blinded-endpoint trial). Stroke patients with a time last-known-well >4.5 h who had a mismatch between diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery were randomly assigned (1:1) to receive alteplase at 0.6mg/kg or standard medical treatment (SMT). Patients were dichotomized by taking prior antithrombotic medication. The favorable outcome defined as a modified Rankin Scale score of 0-1 at 90 days and any intracranial hemorrhage within 22-36 h were compared in each group.
Results:
Of 126 patients (intention-to-treat population), 68 received alteplase and 58 had SMT. Seventeen in the alteplase group and 23 in the SMT group took antithrombotic medication (10 with antiplatelet alone, 5 with anticoagulant alone and 2 with both in the IVT group, and 14, 8 and 1, respectively, in the SMT group) before stroke onset. Antithrombotic therapy was more frequently initiated within 24 hours after randomization in the SMT group than in the alteplase group (86% vs. 12%, p<0.0001). Both any intracranial hemorrhage (26% in the alteplase group vs. 14% in the SMT group) and favorable outcome (47% vs. 48%) were comparable between the two treatment groups. There was a significant treatment-by-cohort interaction for favorable outcome between patients with prior antithrombotic medication and those without (p=0.006). Favorable outcome was more common in the alteplase group than in the SMT group in patients with prior antithrombotic medication (59% vs. 26%; RR 2.25, 95% CI 1.02 to 4.99), but it tended to be less common in the alteplase group than in the SMT group in those without prior antithrombotic medication (43% vs. 63%; RR 0.69, 95% CI 0.46 to 1.03). The frequency of any intracranial hemorrhage did not differ significantly between the two treatment groups in any dichotomized patients.
Conclusions:
Alteplase at 0.6mg/kg appears more beneficial in patients with prior antithrombotic medication.
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Affiliation(s)
- Masatoshi Koga
- National Cerebral and Cardiovascular Cntr, Suita Osaka, Japan
| | - Manabu Inoue
- National Cerebral and Cardiovascular Cntr, Suita Osaka, Japan
| | - Kaori Miwa
- National Cerebral and Cardiovascular Cntr, Suita Osaka, Japan
| | - Sohei Yoshimura
- National Cerebral and Cardiovascular Cntr, Suita Osaka, Japan
| | | | | | - Koko Asakura
- National Cerebral and Cardiovascular Cntr, Suita Osaka, Japan
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Ikenouchi H, Yoshimura S, Miwa K, Chiba T, Hosoki S, Ihara M, Toyoda K, Koga M. Abstract P715: Vertebral Artery Occlusive Dissection Score in Acute Ischemic Stroke. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and purpose:
The discrimination of vertebral artery (VA) occlusive dissection from other etiologies is critical for acute stroke management but sometimes difficult. We aimed to assess the factors associated with VA occlusive dissection and develop the discrimination score.
Methods:
We examined consecutive patients with acute posterior ischemic stroke due to unilateral VA occlusion from our prospective stroke registry between 2012 and 2019. Unilateral VA occlusion was confirmed by magnetic resonance angiography and cervical ultrasonography. The diagnosis of VA dissection was based on the magnetic resonance imaging or digital subtraction angiography. Dissection score was developed from associated factors to discriminate VA occlusive dissection by logistic regression analysis. Discriminative performance was analyzed by receiver operating curve (ROC) analysis.
Results:
Consecutive 84 patients (70±13 years; male, 77%) involved 16 (19%) with VA occlusive dissection. On logistic regression analysis, each of younger age (
≤
70 years), absence of hypertension, absence of dyslipidemia, head or neck pain, medullary infarction and non-dominance side VA occlusion were significantly associated with VA occlusive dissection (Table). Dissection score was created with these factors by assigning respective points based on the corresponding regression coefficients, and the score were ranged from 0 to 9 (Table). High discriminative performance for VA occlusive dissection was observed (area under the curve: 0.91) and optimal cut-off value was 5 or more (accuracy, 79%; sensitivity, 94%; specificity, 75%).
Conclusions:
In patients with acute posterior ischemic stroke due to unilateral VA occlusion, dissection score had high discriminative performance for diagnosing VA dissection.
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Affiliation(s)
| | | | - Kaori Miwa
- Cerebrovascular Medicine, NCVC, Osaka, Japan
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Yoshimura S, Koga M, Okada T, Inoue M, Miwa K, Fukuda-doi M, Kondo R, Inoue T, Ichijo M, Ohtaki M, Nagakane Y, Itabashi R, Sakai N, Aoki J, Shiokawa Y, Yagita Y, Iwama T, Yakushiji Y, Kusumi M, Kamiyama K, Doijiri R, Igarashi S, Kanzawa T, Matsumoto S, Ito Y, Yoshimura S, Ohsaki M, Ihara M, Toyoda K. Abstract MP6: Thrombolysis for Acute Wake-Up And Unclear Onset Strokes With Alteplase at 0.6mg /kg in Clinical Practice: THAWS2 Study. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.mp6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
IV alteplase at 0.6 mg/kg for acute wake-up and unclear onset strokes was recommended in Japanese stroke guidelines in March 2019. We determined the safety and effectiveness of this newly recommended thrombolysis in clinical practice.
Methods:
This is a multicenter observational study, enrolling acute ischemic stroke patients with a time last-known-well >4.5 h who have a mismatch between DWI and FLAIR treated with intravenous alteplase. The safety outcomes are intracranial hemorrhage (ICH) with neurological deterioration within 36 h after thrombolysis, all cause deaths within 90 days, and adverse events. The efficacy outcomes are functionally independence defined as a mRS score of 0-1 at 90 days, and NIHSS change at 24h from baseline.
Results:
Between 2019 March and 2020 March, 63 patients (33 females; age, 74±11y; premorbid functionally independence, 50 (82%); median NIHSS on admission, 11) were enrolled at 14 hospitals. Of them, 40 patients (63%) recognized stroke symptoms at wake-up time, and median time between last-known-well and admission was 6.5 h. Baseline MRA showed any vessel occlusion in 52 patients (88%). IV alteplase was disrupted in one patient. Two patients (3%) had symptomatic ICH (≥4 increase in NIHSS) within 36 h. NIHSS change was -5.1±8.1. Twenty-one patients (36%) had functionally independence at discharge and there was no death during acute hospitalization. Of the overall 63 patients, 22 also underwent mechanical thrombectomy (36%, 72±9y, median NIHSS 16), showing no symptomatic ICH, mean NIHSS change of -8.9±7.5, and 8 patients (42%) had functionally independence at discharge.
Conclusions:
In clinical practice, IV alteplase for wake-up and unclear onset stroke patients with DWI-FLAIR mismatch seemed to be safe and effective compared with previous randomized control trials. Mechanical thrombectomy could be combined with alteplase safely and effectively.
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Affiliation(s)
- Sohei Yoshimura
- Dept of Cerebrovascular Medicine,, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Masatoshi Koga
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Takashi Okada
- Dept of Cerebrovascular Medicine,, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Manabu Inoue
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Kaori Miwa
- Dept of Cerebrovascular Medicine,, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Mayumi Fukuda-doi
- Dept of Data Science, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Rei Kondo
- Dept of Neurosurgery, Stroke Cntr, Yamagata City Hosp Saiseikan, Yamagata, Japan
| | - Takeshi Inoue
- Dept of Stroke Medicine, Kawasaki Med Sch General Med Cntr, Okayama, Japan
| | - Masahiko Ichijo
- Dept of Neurology, Japanese Red Cross Musashino Hosp, Musashino, Japan
| | | | | | - Ryo Itabashi
- Dept of Stroke Neurology, Kohnan Hosp, Sendai, Japan
| | - Nobuyuki Sakai
- Dept of Neurosurgery, Kobe City Med Cntr General Hosp, Kobe, Japan
| | - Junya Aoki
- Dept of Neurology, Graduate Sch of Medicine, Nippon Med Sch, Tokyo, Japan
| | | | - Yoshiki Yagita
- Dept of Stroke Medicine, Kawasaki Med Sch, Kurashiki, Japan
| | - Toru Iwama
- Dept of Neurosurgery, Gifu Univ Sch of Medicine, Gifu, Japan
| | - Yusuke Yakushiji
- Div of Neurology, Dept of Internal Medicine, Saga Univ Faculty of Medicine, Saga, Japan
| | | | - Kenji Kamiyama
- Dept of Neurosurgery, Nakamura Memorial Hosp, Sapporo, Japan
| | - Ryosuke Doijiri
- Dept of Neurology, Iwate Prefectural Central Hosp, Morioka, Japan
| | | | - Takao Kanzawa
- Dept of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hosp, Isesaki, Japan
| | - Shoji Matsumoto
- Dept of Comprehensive Strokology, Fujita Health Univ Hosp, Toyoake, Japan
| | - Yasuhiro Ito
- Dept of Neurology, TOYOTA Memorial Hosp,, Toyota, Japan
| | | | - Masato Ohsaki
- Dept of Cerebrovascular Medicine, Stroke Cntr,, Steel Memorial Yawata Hosp, Kitakyushu, Japan
| | - Masafumi Ihara
- Dept of Neurology, National Cerebral and Cardiovascular Cntr, Suita, Japan
| | - Kazunori Toyoda
- Dept of Cerebrovascular Medicine, National Cerebral and Cardiovascular Cntr, Suita, Japan
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Takagi M, Tanaka K, Miwa K, Sasaki M, Koga M, Hirano T, Kamiyama K, Yagita Y, Nagakane Y, Hoshino H, Terasaki T, Yakushiji Y, Kudo K, Ihara M, Yoshimura S, Yamaguchi Y, Shiozawa M, Toyoda K. The bleeding with antithrombotic therapy study 2: Rationale, design, and baseline characteristics of the participants. Eur Stroke J 2021; 5:423-431. [PMID: 33598561 DOI: 10.1177/2396987320960618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 08/21/2020] [Indexed: 11/16/2022] Open
Abstract
Aims The bleeding risk of current antithrombotic strategies in clinical settings, including recently developed agents, needs to be clarified. Methods and Design In an investigator-initiated, prospective, multicentre, observational study, patients with cerebrovascular or cardiovascular diseases who were taking oral antiplatelet or anticoagulant agents were enrolled. Compulsory multimodal magnetic resonance images were acquired at baseline to assess cerebral small vessel disease. Six-month follow-up will be performed for two years. The primary outcome is major bleeding as defined by the International Society on Thrombosis and Hemostasis. Results Between October 2016 and March 2019, 5306 patients (71.7 ± 11.2 years old, 1762 women) were enrolled. Previous intracranial haemorrhage was documented in 181 patients (3.4%), cerebrovascular disease (including asymptomatic) requiring antithrombotic therapy in 5006 patients (94.3%), and atrial fibrillation in 1061 patients (20.0%). At entry, 3726 patients (70.2%) were taking antiplatelet agents alone, including 551 (10.4%) using dual antiplatelet agents, 1317 (24.8%) taking anticoagulants alone, and the remaining 263 (5.0%) taking both. The leading antiplatelet agent was clopidogrel (2014 patients), and the leading combination of dual antiplatelet medication was clopidogrel plus aspirin (362). Use of direct oral anticoagulants (1029 patients, 19.4%) exceeded warfarin use (554, 10.4%). The number of pivotal bleeding events exceeded 200 in April 2020. Conclusions This study is expected to provide the incidence of bleeding complications of recent oral antithrombotics in clinical practice and identify their associations with underlying small vessel disease and other biomarkers. Novel risk stratification models for bleeding risk will be able to be created based on the study results.
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Affiliation(s)
- Masahito Takagi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Japan
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | | | - Haruhiko Hoshino
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Tadashi Terasaki
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Kohsuke Kudo
- Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshitaka Yamaguchi
- Department of Neurology, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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44
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Hayakawa SH, Agari K, Ahn JK, Akaishi T, Akazawa Y, Ashikaga S, Bassalleck B, Bleser S, Ekawa H, Endo Y, Fujikawa Y, Fujioka N, Fujita M, Goto R, Han Y, Hasegawa S, Hashimoto T, Hayakawa T, Hayata E, Hicks K, Hirose E, Hirose M, Honda R, Hoshino K, Hoshino S, Hosomi K, Hwang SH, Ichikawa Y, Ichikawa M, Imai K, Inaba K, Ishikawa Y, Ito H, Ito K, Jung WS, Kanatsuki S, Kanauchi H, Kasagi A, Kawai T, Kim MH, Kim SH, Kinbara S, Kiuchi R, Kobayashi H, Kobayashi K, Koike T, Koshikawa A, Lee JY, Ma TL, Matsumoto SY, Minakawa M, Miwa K, Moe AT, Moon TJ, Moritsu M, Nagase Y, Nakada Y, Nakagawa M, Nakashima D, Nakazawa K, Nanamura T, Naruki M, Nyaw ANL, Ogura Y, Ohashi M, Oue K, Ozawa S, Pochodzalla J, Ryu SY, Sako H, Sato S, Sato Y, Schupp F, Shirotori K, Soe MM, Soe MK, Sohn JY, Sugimura H, Suzuki KN, Takahashi H, Takahashi T, Takeda T, Tamura H, Tanida K, Theint AMM, Tint KT, Toyama Y, Ukai M, Umezaki E, Watabe T, Watanabe K, Yamamoto TO, Yang SB, Yoon CS, Yoshida J, Yoshimoto M, Zhang DH, Zhang Z. Observation of Coulomb-Assisted Nuclear Bound State of Ξ^{-}-^{14}N System. Phys Rev Lett 2021; 126:062501. [PMID: 33635678 DOI: 10.1103/physrevlett.126.062501] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/19/2020] [Accepted: 12/23/2020] [Indexed: 06/12/2023]
Abstract
In an emulsion-counter hybrid experiment performed at J-PARC, a Ξ^{-} absorption event was observed which decayed into twin single-Λ hypernuclei. Kinematic calculations enabled a unique identification of the reaction process as Ξ^{-}+^{14}N→_{Λ}^{10}Be+_{Λ}^{5}He. For the binding energy of the Ξ^{-} hyperon in the Ξ^{-}-^{14}N system a value of 1.27±0.21 MeV was deduced. The energy level of Ξ^{-} is likely a nuclear 1p state which indicates a weak ΞN-ΛΛ coupling.
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Affiliation(s)
- S H Hayakawa
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
| | - K Agari
- Institute of Particle and Nuclear Studies, High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - J K Ahn
- Department of Physics, Korea University, Seoul 02841, Korea
| | - T Akaishi
- Department of Physics, Osaka University, Toyonaka 560-0043, Japan
| | - Y Akazawa
- Institute of Particle and Nuclear Studies, High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - S Ashikaga
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - B Bassalleck
- Department of Physics and Astronomy, University of New Mexico, Albuquerque, New Mexico 87131, USA
| | - S Bleser
- Helmholtz Institute Mainz, 55099 Mainz, Germany
| | - H Ekawa
- High Energy Nuclear Physics Laboratory, RIKEN, Wako 351-0198, Japan
| | - Y Endo
- Faculty of Education, Gifu University, Gifu 501-1193, Japan
| | - Y Fujikawa
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - N Fujioka
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - M Fujita
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
| | - R Goto
- Faculty of Education, Gifu University, Gifu 501-1193, Japan
| | - Y Han
- Institute of Nuclear Energy Safety Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei 230031, China
| | - S Hasegawa
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
| | - T Hashimoto
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
| | - T Hayakawa
- Department of Physics, Osaka University, Toyonaka 560-0043, Japan
| | - E Hayata
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - K Hicks
- Department of Physics & Astronomy, Ohio University, Athens, Ohio 45701, USA
| | - E Hirose
- Institute of Particle and Nuclear Studies, High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - M Hirose
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - R Honda
- Institute of Particle and Nuclear Studies, High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - K Hoshino
- Faculty of Education, Gifu University, Gifu 501-1193, Japan
| | - S Hoshino
- Department of Physics, Osaka University, Toyonaka 560-0043, Japan
| | - K Hosomi
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
| | - S H Hwang
- Korea Research Institute of Standards and Science, Daejeon 34113, Korea
| | - Y Ichikawa
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
| | - M Ichikawa
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
- Meson Science Laboratory, RIKEN, Wako 351-0198, Japan
| | - K Imai
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
| | - K Inaba
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - Y Ishikawa
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - H Ito
- Faculty of Education, Gifu University, Gifu 501-1193, Japan
| | - K Ito
- Department of Physics, Nagoya University, Nagoya 464-8601, Japan
| | - W S Jung
- Department of Physics, Korea University, Seoul 02841, Korea
| | - S Kanatsuki
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - H Kanauchi
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - A Kasagi
- High Energy Nuclear Physics Laboratory, RIKEN, Wako 351-0198, Japan
- Graduate School of Engineering, Gifu University, Gifu 501-1193, Japan
| | - T Kawai
- Center for Advanced Photonics, RIKEN, Wako 351-0198, Japan
| | - M H Kim
- Department of Physics, Korea University, Seoul 02841, Korea
| | - S H Kim
- Department of Physics, Korea University, Seoul 02841, Korea
| | - S Kinbara
- Graduate School of Engineering, Gifu University, Gifu 501-1193, Japan
| | - R Kiuchi
- Institute of High Energy Physics, Beijing 100049, China
| | - H Kobayashi
- Faculty of Education, Gifu University, Gifu 501-1193, Japan
| | - K Kobayashi
- Department of Physics, Osaka University, Toyonaka 560-0043, Japan
| | - T Koike
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - A Koshikawa
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - J Y Lee
- Department of Physics, Seoul National University, Seoul 08826, Korea
| | - T L Ma
- Institute of Modern Physics, Shanxi Normal University, Linfen 041004, China
| | - S Y Matsumoto
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
- Meson Science Laboratory, RIKEN, Wako 351-0198, Japan
| | - M Minakawa
- Institute of Particle and Nuclear Studies, High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - K Miwa
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - A T Moe
- Department of Physics, Lashio University, Lashio 06301, Myanmar
| | - T J Moon
- Department of Physics, Seoul National University, Seoul 08826, Korea
| | - M Moritsu
- Institute of Particle and Nuclear Studies, High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - Y Nagase
- Faculty of Education, Gifu University, Gifu 501-1193, Japan
| | - Y Nakada
- Department of Physics, Osaka University, Toyonaka 560-0043, Japan
| | - M Nakagawa
- High Energy Nuclear Physics Laboratory, RIKEN, Wako 351-0198, Japan
| | - D Nakashima
- Faculty of Education, Gifu University, Gifu 501-1193, Japan
| | - K Nakazawa
- Faculty of Education, Gifu University, Gifu 501-1193, Japan
- Graduate School of Engineering, Gifu University, Gifu 501-1193, Japan
| | - T Nanamura
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - M Naruki
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - A N L Nyaw
- Graduate School of Engineering, Gifu University, Gifu 501-1193, Japan
| | - Y Ogura
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - M Ohashi
- Faculty of Education, Gifu University, Gifu 501-1193, Japan
| | - K Oue
- Department of Physics, Osaka University, Toyonaka 560-0043, Japan
| | - S Ozawa
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - J Pochodzalla
- Helmholtz Institute Mainz, 55099 Mainz, Germany
- Institut fur Kernphysik, Johannes Gutenberg-Universitat, 55099 Mainz, Germany
| | - S Y Ryu
- Research Center for Nuclear Physics, Osaka University, Osaka 567-0047, Japan
| | - H Sako
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
| | - S Sato
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
| | - Y Sato
- Institute of Particle and Nuclear Studies, High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - F Schupp
- Helmholtz Institute Mainz, 55099 Mainz, Germany
| | - K Shirotori
- Research Center for Nuclear Physics, Osaka University, Osaka 567-0047, Japan
| | - M M Soe
- Department of Physics, University of Yangon, Yangon 11041, Myanmar
| | - M K Soe
- Graduate School of Engineering, Gifu University, Gifu 501-1193, Japan
| | - J Y Sohn
- Research Institute of Natural Science, Gyeongsang National University, Jinju 52828, Korea
| | - H Sugimura
- Accelerator Laboratory, High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - K N Suzuki
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - H Takahashi
- Institute of Particle and Nuclear Studies, High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - T Takahashi
- Institute of Particle and Nuclear Studies, High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
| | - T Takeda
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - H Tamura
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - K Tanida
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
| | - A M M Theint
- Graduate School of Engineering, Gifu University, Gifu 501-1193, Japan
| | - K T Tint
- Faculty of Education, Gifu University, Gifu 501-1193, Japan
| | - Y Toyama
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - M Ukai
- Institute of Particle and Nuclear Studies, High Energy Accelerator Research Organization (KEK), Tsukuba 305-0801, Japan
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - E Umezaki
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - T Watabe
- Department of Physics, Nagoya University, Nagoya 464-8601, Japan
| | - K Watanabe
- Department of Physics, Kyoto University, Kyoto 606-8502, Japan
| | - T O Yamamoto
- Advanced Science Research Center, Japan Atomic Energy Agency, Tokai 319-1195, Japan
| | - S B Yang
- Department of Physics, Korea University, Seoul 02841, Korea
| | - C S Yoon
- Research Institute of Natural Science, Gyeongsang National University, Jinju 52828, Korea
| | - J Yoshida
- High Energy Nuclear Physics Laboratory, RIKEN, Wako 351-0198, Japan
- Department of Physics, Tohoku University, Sendai 980-8578, Japan
| | - M Yoshimoto
- Faculty of Education, Gifu University, Gifu 501-1193, Japan
| | - D H Zhang
- Institute of Modern Physics, Shanxi Normal University, Linfen 041004, China
| | - Z Zhang
- Institute of Modern Physics, Shanxi Normal University, Linfen 041004, China
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45
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Toyoda K, Inoue M, Yoshimura S, Yamagami H, Sasaki M, Fukuda-Doi M, Kimura K, Asakura K, Miwa K, Kanzawa T, Ihara M, Kondo R, Shiozawa M, Ohtaki M, Kamiyama K, Itabashi R, Iwama T, Aoki J, Minematsu K, Yamamoto H, Koga M. Magnetic Resonance Imaging-Guided Thrombolysis (0.6 mg/kg) Was Beneficial for Unknown Onset Stroke Above a Certain Core Size: THAWS RCT Substudy. Stroke 2020; 52:12-19. [PMID: 33297866 DOI: 10.1161/strokeaha.120.030848] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We determined to identify patients with unknown onset stroke who could have favorable 90-day outcomes after low-dose thrombolysis from the THAWS (Thrombolysis for Acute Wake-Up and Unclear-Onset Strokes With Alteplase at 0.6 mg/kg) database. METHODS This was a subanalysis of an investigator-initiated, multicenter, randomized, open-label, blinded-end point trial. Patients with stroke with a time last-known-well >4.5 hours who showed a mismatch between diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery were randomly assigned (1:1) to receive alteplase at 0.6 mg/kg intravenously or standard medical treatment. The patients were dichotomized by ischemic core size or National Institutes of Health Stroke Scale score, and the effects of assigned treatments were compared in each group. The efficacy outcome was favorable outcome at 90 days, defined as a modified Rankin Scale score of 0 to 1. RESULTS The median DWI-Alberta Stroke Program Early CT Score (ASPECTS) was 9, and the median ischemic core volume was 2.5 mL. Both favorable outcome (47.1% versus 48.3%) and any intracranial hemorrhage (26% versus 14%) at 22 to 36 hours were comparable between the 68 thrombolyzed patients and the 58 control patients. There was a significant treatment-by-cohort interaction for favorable outcome between dichotomized patients by ASPECTS on DWI (P=0.026) and core volume (P=0.035). Favorable outcome was more common in the alteplase group than in the control group in patients with DWI-ASPECTS 5 to 8 (RR, 4.75 [95% CI, 1.33-30.2]), although not in patients with DWI-ASPECTS 9 to 10. Favorable outcome tended to be more common in the alteplase group than in the control group in patients with core volume >6.4 mL (RR, 6.15 [95% CI, 0.87-43.64]), although not in patients with volume ≤6.4 mL. The frequency of any intracranial hemorrhage did not differ significantly between the 2 treatment groups in any dichotomized patients. CONCLUSIONS Patients developing unknown onset stroke with DWI-ASPECTS 5 to 8 showed favorable outcomes more commonly after low-dose thrombolysis than after standard treatment. Registration: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT02002325. URL: https://www.umin.ac.jp/ctr; Unique Identifier: UMIN000011630.
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Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Japan (H. Yamagami)
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan (M. Sasaki, H. Yamamoto)
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan.,Center for Advancing Clinical and Translational Sciences (M.F.-D., K.A.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan (K. Kimura, J.A.)
| | - Koko Asakura
- Center for Advancing Clinical and Translational Sciences (M.F.-D., K.A.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Isesaki, Japan (T.K.)
| | - Masafumi Ihara
- Department of Neurology (M. Ihara), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Rei Kondo
- Department of Neurosurgery, Yamagata City Hospital Saiseikan, Japan (R.K.)
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ohtaki
- Department of Neurosurgery, Obihiro Kosei Hospital, Japan (M.O.)
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama)
| | - Ryo Itabashi
- Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (R.I.)
| | - Toru Iwama
- Department of Neurosurgery, Gifu University School of Medicine, Japan (T.I.)
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan (K. Kimura, J.A.)
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Haruko Yamamoto
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan (M. Sasaki, H. Yamamoto)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
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Cappellari M, Seiffge DJ, Koga M, Paciaroni M, Forlivesi S, Turcato G, Bovi P, Yoshimura S, Tanaka K, Shiozawa M, Yoshimoto T, Miwa K, Takagi M, Inoue M, Yamagami H, Caso V, Tsivgoulis G, Venti M, Acciarresi M, Alberti A, Toni D, Polymeris A, Bonetti B, Agnelli G, Toyoda K, Engelter ST, De Marchis GM. A nomogram to predict unfavourable outcome in patients receiving oral anticoagulants for atrial fibrillation after stroke. Eur Stroke J 2020; 5:384-393. [PMID: 33598557 DOI: 10.1177/2396987320945840] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 07/04/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction It is unknown whether the type of treatment (direct oral anticoagulant versus vitamin K antagonist) and the time of treatment introduction (early versus late) may affect the functional outcome in stroke patients with atrial fibrillation. We aimed to develop and validate a nomogram model including direct oral anticoagulant/vitamin K antagonist and early/late oral anticoagulant introduction for predicting the probability of unfavourable outcome after stroke in atrial fibrillation-patients. Patients and Methods We conducted an individual patient data analysis of four prospective studies. Unfavourable functional outcome was defined as three-month modified Rankin Scale score 3 -6. To generate the nomogram, five independent predictors including age (<65 years, reference; 65--79; or 80), National Institutes of Health Stroke Scale score (0--5 points, reference; 6--15; 16--25; or >25), acute revascularisation treatments (yes, reference, or no), direct oral anticoagulant (reference) or vitamin K antagonist, and early (7 days, reference) or late (8--30) anticoagulant introduction entered into a final logistic regression model. The discriminative performance of the model was assessed by using the area under the receiver operating characteristic curve. Results A total of 2102 patients with complete data for generating the nomogram was randomly dichotomised into training (n = 1553) and test (n = 549) sets. The area under the receiver operating characteristic curve was 0.822 (95% confidence interval, CI: 0.800--0.844) in the training set and 0.803 (95% CI: 0.764--0.842) in the test set. The model was adequately calibrated (9.852; p = 0.276 for the Hosmer--Lemeshow test). Discussion and Conclusion Our nomogram is the first model including type of oral anticoagulant and time of treatment introduction to predict the probability of three-month unfavourable outcome in a large multicentre cohort of stroke patients with atrial fibrillation.
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Affiliation(s)
- Manuel Cappellari
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - David J Seiffge
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK.,Neurology and Stroke Center, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Stefano Forlivesi
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Gianni Turcato
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Neurology and Stroke Unit, Maggiore Hospital, Bologna, Italy
| | - Paolo Bovi
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Yoshimoto
- Emergency Department - Franz Tappeiner Hospital Merano, Bolzano, Italy
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Emergency Department - Franz Tappeiner Hospital Merano, Bolzano, Italy
| | - Masahito Takagi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Yamagami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Georgios Tsivgoulis
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan.,Second Department of Neurology, National and Kapodistrian University of Athens School of Medicine, 'Attikon' University Hospital, Athens, Greece
| | - Michele Venti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Monica Acciarresi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Danilo Toni
- Department of Neurology, University of Tennessee Health Science Center, Memphis, USA
| | - Alexandros Polymeris
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Bruno Bonetti
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giancarlo Agnelli
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Stefan T Engelter
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Dipartimento di Neurologia e Psichiatria, Università degli Studi di ROMA 'La Sapienza', Roma, Italy
| | - Gian Marco De Marchis
- Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
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Toyoda K, Palesch YY, Koga M, Foster L, Yamamoto H, Yoshimura S, Ihara M, Fukuda-Doi M, Okazaki S, Tanaka K, Miwa K, Hasegawa Y, Shiokawa Y, Iwama T, Kamiyama K, Hoshino H, Steiner T, Yoon BW, Wang Y, Hsu CY, Qureshi AI. Regional Differences in the Response to Acute Blood Pressure Lowering After Cerebral Hemorrhage. Neurology 2020; 96:e740-e751. [PMID: 33219136 PMCID: PMC7884997 DOI: 10.1212/wnl.0000000000011229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 09/25/2020] [Indexed: 01/10/2023] Open
Abstract
Objective To compare the impact of intensive blood pressure (BP) lowering right after intracerebral hemorrhage (ICH) on clinical and hematoma outcomes among patients from different geographic locations, we performed a prespecified subanalysis of a randomized, multinational, 2-group, open-label trial to determine the efficacy of rapidly lowering BP in hyperacute ICH (Antihypertensive Treatment of Acute Cerebral Hemorrhage [ATACH]-2), involving 537 patients from East Asia and 463 recruited outside of Asia. Methods Eligible patients were randomly assigned to a systolic BP target of 110 to 139 mm Hg (intensive treatment) or 140 to 179 mm Hg (standard treatment). Predefined outcomes were poor functional outcome (modified Rankin Scale score 4–6 at 90 days), death within 90 days, hematoma expansion at 24 hours, and cardiorenal adverse events within 7 days. Results Poor functional outcomes (32.0% vs 45.9%), death (1.9% vs 13.3%), and cardiorenal adverse events (3.9% vs 11.2%) occurred significantly less frequently in patients from Asia than those outside of Asia. The treatment-by-cohort interaction was not significant for any outcomes. Only patients from Asia showed a lower incidence of hematoma expansion with intensive treatment (adjusted relative risk [RR] 0.56, 95% confidence interval [CI] 0.38–0.83). Both Asian (RR 3.53, 95% CI 1.28–9.64) and non-Asian (RR 1.71, 95% CI 1.00–2.93) cohorts showed a higher incidence of cardiorenal adverse events with intensive treatment. Conclusions Poor functional outcomes and death 90 days after ICH were less common in patients from East Asia than those outside of Asia. Hematoma expansion, a potential predictor for poor clinical outcome, was attenuated by intensive BP lowering only in the Asian cohort. ClinicalTrials.gov Identifier NCT01176565. Classification of Evidence This study provides Class II evidence that, for patients from East Asia with ICH, intensive blood pressure lowering significantly reduces the risk of hematoma expansion.
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Affiliation(s)
- Kazunori Toyoda
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis.
| | - Yuko Y Palesch
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Masatoshi Koga
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Lydia Foster
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Haruko Yamamoto
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Sohei Yoshimura
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Masafumi Ihara
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Mayumi Fukuda-Doi
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Shuhei Okazaki
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Kanta Tanaka
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Kaori Miwa
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Yasuhiro Hasegawa
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Yoshiaki Shiokawa
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Toru Iwama
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Kenji Kamiyama
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Haruhiko Hoshino
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Thorsten Steiner
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Byung-Woo Yoon
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Yongjun Wang
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Chung Y Hsu
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
| | - Adnan I Qureshi
- From the Department of Cerebrovascular Medicine (K. Toyoda, M.K., S.Y., K. Tanaka, K.M.), Center for Advancing Clinical and Translational Sciences (H.Y., M.F.-D., S.O.), and Department of Neurology (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Public Health Sciences (Y.Y.P., L.F.), Medical University of South Carolina, Charleston; Department of Neurology (Y.H.), St. Marianna University School of Medicine, Kawasaki; Department of Neurosurgery and Stroke Center (Y.S.), Kyorin University School of Medicine, Mitaka; Department of Neurosurgery (T.I.), Gifu University Graduate School of Medicine; Department of Neurosurgery (K.K.), Nakamura Memorial Hospital, Sapporo; Department of Neurology (H.H.), Tokyo Saiseikai Central Hospital, Japan; Department of Neurology (T.S.), Klinikum Frankfurt Höchst, Germany; Department of Neurology (B.-W.Y.), Seoul National University Hospital, South Korea; Beijing Tiantan Hospital (Y.W.), China; China Medical University (C.Y.H.), Taichung, Taiwan; and Zeenat Qureshi Stroke Research Center (A.I.Q.), University of Minnesota, Minneapolis
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Thomalla G, Boutitie F, Ma H, Koga M, Ringleb P, Schwamm LH, Wu O, Bendszus M, Bladin CF, Campbell BCV, Cheng B, Churilov L, Ebinger M, Endres M, Fiebach JB, Fukuda-Doi M, Inoue M, Kleinig TJ, Latour LL, Lemmens R, Levi CR, Leys D, Miwa K, Molina CA, Muir KW, Nighoghossian N, Parsons MW, Pedraza S, Schellinger PD, Schwab S, Simonsen CZ, Song SS, Thijs V, Toni D, Hsu CY, Wahlgren N, Yamamoto H, Yassi N, Yoshimura S, Warach S, Hacke W, Toyoda K, Donnan GA, Davis SM, Gerloff C. Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data. Lancet 2020; 396:1574-1584. [PMID: 33176180 PMCID: PMC7734592 DOI: 10.1016/s0140-6736(20)32163-2] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/03/2020] [Accepted: 10/12/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Patients who have had a stroke with unknown time of onset have been previously excluded from thrombolysis. We aimed to establish whether intravenous alteplase is safe and effective in such patients when salvageable tissue has been identified with imaging biomarkers. METHODS We did a systematic review and meta-analysis of individual patient data for trials published before Sept 21, 2020. Randomised trials of intravenous alteplase versus standard of care or placebo in adults with stroke with unknown time of onset with perfusion-diffusion MRI, perfusion CT, or MRI with diffusion weighted imaging-fluid attenuated inversion recovery (DWI-FLAIR) mismatch were eligible. The primary outcome was favourable functional outcome (score of 0-1 on the modified Rankin Scale [mRS]) at 90 days indicating no disability using an unconditional mixed-effect logistic-regression model fitted to estimate the treatment effect. Secondary outcomes were mRS shift towards a better functional outcome and independent outcome (mRS 0-2) at 90 days. Safety outcomes included death, severe disability or death (mRS score 4-6), and symptomatic intracranial haemorrhage. This study is registered with PROSPERO, CRD42020166903. FINDINGS Of 249 identified abstracts, four trials met our eligibility criteria for inclusion: WAKE-UP, EXTEND, THAWS, and ECASS-4. The four trials provided individual patient data for 843 individuals, of whom 429 (51%) were assigned to alteplase and 414 (49%) to placebo or standard care. A favourable outcome occurred in 199 (47%) of 420 patients with alteplase and in 160 (39%) of 409 patients among controls (adjusted odds ratio [OR] 1·49 [95% CI 1·10-2·03]; p=0·011), with low heterogeneity across studies (I2=27%). Alteplase was associated with a significant shift towards better functional outcome (adjusted common OR 1·38 [95% CI 1·05-1·80]; p=0·019), and a higher odds of independent outcome (adjusted OR 1·50 [1·06-2·12]; p=0·022). In the alteplase group, 90 (21%) patients were severely disabled or died (mRS score 4-6), compared with 102 (25%) patients in the control group (adjusted OR 0·76 [0·52-1·11]; p=0·15). 27 (6%) patients died in the alteplase group and 14 (3%) patients died among controls (adjusted OR 2·06 [1·03-4·09]; p=0·040). The prevalence of symptomatic intracranial haemorrhage was higher in the alteplase group than among controls (11 [3%] vs two [<1%], adjusted OR 5·58 [1·22-25·50]; p=0·024). INTERPRETATION In patients who have had a stroke with unknown time of onset with a DWI-FLAIR or perfusion mismatch, intravenous alteplase resulted in better functional outcome at 90 days than placebo or standard care. A net benefit was observed for all functional outcomes despite an increased risk of symptomatic intracranial haemorrhage. Although there were more deaths with alteplase than placebo, there were fewer cases of severe disability or death. FUNDING None.
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Affiliation(s)
- Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France; Université Lyon 1, Villeurbanne, France; Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Peter Ringleb
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Ona Wu
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Christopher F Bladin
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - Bruce C V Campbell
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Leonid Churilov
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Klinik für Neurologie Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany; German Centre of Cardiovascular Research, Berlin, Germany; German Center of Neurodegenerative Diseases, Berlin, Germany
| | - Jochen B Fiebach
- Centrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Lawrence L Latour
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven, University of Leuven, Leuven, Belgium; VIB Center for Brain and Disease Research Leuven, Belgium; Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Christopher R Levi
- The Department of Neurology, Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Didier Leys
- Université de Lille, Inserm U1171, Lille, France
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CarMeN Laboratory, INSERM U1060/INRA 1397, Lyon, France
| | - Mark W Parsons
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnòstic per la Imatge, Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona, Spain
| | - Peter D Schellinger
- Universitätsklinik für Neurologie, Mühlenkreiskliniken, Johannes Wesling Klinikum Minden, Universitätsklinikum der Ruhr-Universität Bochum, Minden, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Shlee S Song
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia; Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Danilo Toni
- Department of Human Neurosciences, University of Rome "La Sapienza", Rome, Italy
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Nils Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nawaf Yassi
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Steven Warach
- Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Geoffrey A Donnan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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49
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Tokunaga K, Koga M, Yoshimura S, Okada Y, Yamagami H, Todo K, Itabashi R, Kimura K, Sato S, Terasaki T, Inoue M, Shiokawa Y, Takagi M, Kamiyama K, Tanaka K, Takizawa S, Shiozawa M, Okuda S, Kameda T, Nagakane Y, Hasegawa Y, Shibuya S, Ito Y, Matsuoka H, Takamatsu K, Nishiyama K, Kario K, Yagita Y, Mizoguchi T, Fujita K, Ando D, Kumamoto M, Miwa K, Arihiro S, Toyoda K. Left Atrial Size and Ischemic Events after Ischemic Stroke or Transient Ischemic Attack in Patients with Nonvalvular Atrial Fibrillation. Cerebrovasc Dis 2020; 49:619-624. [DOI: 10.1159/000511393] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 09/01/2020] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> The present study aimed to clarify the association between left atrial (LA) size and ischemic events after ischemic stroke or transient ischemic attack (TIA) in patients with nonvalvular atrial fibrillation (NVAF). <b><i>Methods:</i></b> Acute ischemic stroke or TIA patients with NVAF were enrolled. LA size was classified into normal LA size, mild LA enlargement (LAE), moderate LAE, and severe LAE. The ischemic event was defined as ischemic stroke, TIA, carotid endarterectomy, carotid artery stenting, acute coronary syndrome or percutaneous coronary intervention, systemic embolism, aortic aneurysm rupture or dissection, peripheral artery disease requiring hospitalization, or venous thromboembolism. <b><i>Results:</i></b> A total of 1,043 patients (mean age, 78 years; 450 women) including 1,002 ischemic stroke and 41 TIA were analyzed. Of these, 351 patients (34%) had normal LA size, 298 (29%) had mild LAE, 198 (19%) had moderate LAE, and the remaining 196 (19%) had severe LAE. The median follow-up duration was 2.0 years (interquartile range, 0.9–2.1). During follow-up, 117 patients (11%) developed at least one ischemic event. The incidence rate of total ischemic events increased with increasing LA size. Severe LAE was independently associated with increased risk of ischemic events compared with normal LA size (multivariable-adjusted hazard ratio, 1.75; 95% confidence interval, 1.02–3.00). <b><i>Conclusion:</i></b> Severe LAE was associated with increased risk of ischemic events after ischemic stroke or TIA in patients with NVAF.
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50
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Hosoki S, Saito S, Tonomura S, Ishiyama H, Yoshimoto T, Ikeda S, Ikenouchi H, Yamamoto Y, Hattori Y, Miwa K, Friedland RP, Carare RO, Nakahara J, Suzuki N, Koga M, Toyoda K, Nomura R, Nakano K, Takegami M, Ihara M. Oral Carriage of Streptococcus mutans Harboring the cnm Gene Relates to an Increased Incidence of Cerebral Microbleeds. Stroke 2020; 51:3632-3639. [PMID: 33148146 PMCID: PMC7678651 DOI: 10.1161/strokeaha.120.029607] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Supplemental Digital Content is available in the text. Cerebral microbleeds (CMB) are associated with stroke and cognitive impairment. We previously reported a high prevalence of CMB in people with Streptococcus mutans expressing Cnm, a collagen-binding protein in the oral cavity. S.mutans is a major pathogen responsible for dental caries. Repeated challenge with S.mutans harboring the cnm gene encoding Cnm induced cerebral bleeding in stroke-prone spontaneously hypertensive rats. The purpose of this longitudinal study is to examine the relationship of cnm-positive S.mutans to the development of CMB.
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Affiliation(s)
- Satoshi Hosoki
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Neurology, Keio University School of Medicine, Tokyo, Japan (S.H., J.N., N.S., K.T.)
| | - Satoshi Saito
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Suita, Japan (S.S., R.N., K.N.).,Faculty of Medicine, University of Southampton, United Kingdom (S.S., R.O.C.)
| | - Shuichi Tonomura
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Neurology, Graduate School of Medicine, Kyoto University, Japan (S.T.)
| | - Hiroyuki Ishiyama
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Yoshimoto
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shuhei Ikeda
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hajime Ikenouchi
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yumi Yamamoto
- Department of Molecular Innovation in Lipidemiology (Y.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yorito Hattori
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine (K.M., M.K., K.T.), National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Roxana O Carare
- Faculty of Medicine, University of Southampton, United Kingdom (S.S., R.O.C.)
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan (S.H., J.N., N.S., K.T.)
| | - Norihiro Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan (S.H., J.N., N.S., K.T.)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine (K.M., M.K., K.T.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine (K.M., M.K., K.T.), National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Neurology, Keio University School of Medicine, Tokyo, Japan (S.H., J.N., N.S., K.T.)
| | - Ryota Nomura
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Suita, Japan (S.S., R.N., K.N.)
| | - Kazuhiko Nakano
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Suita, Japan (S.S., R.N., K.N.)
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiology (M.T.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ihara
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
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