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Altersberger VL, Sibolt G, Enz LS, Hametner C, Scheitz JF, Henon H, Bigliardi G, Strambo D, Martinez-Majander N, Stolze LJ, Heldner MR, Grisendi I, Jovanovic DR, Bejot Y, Pezzini A, Leker RR, Kägi G, Wegener S, Cereda CW, Ntaios G, De Marchis GM, Bonati LH, Psychogios M, Lyrer P, Räty S, Tiainen M, Wouters A, Caparros F, Heyse M, Erdur H, Padjen V, Zedde M, Arnold M, Nederkoorn PJ, Michel P, Zini A, Cordonnier C, Nolte CH, Ringleb PA, Curtze S, Engelter ST, Gensicke H. Intravenous Thrombolysis 4.5-9 Hours After Stroke Onset - a Cohort Study from the TRISP Collaboration. Ann Neurol 2023. [PMID: 37114466 DOI: 10.1002/ana.26669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/27/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE To investigate the safety and effectiveness of intravenous thrombolysis (IVT) >4.5-9 hours after stroke onset and the relevance of advanced neuroimaging for patient selection. METHODS Prospective multicenter cohort study from the ThRombolysis in Ischemic Stroke Patients (TRISP) collaboration. Outcomes were symptomatic intracranial hemorrhage (sICH), poor 3-month functional outcome (mRS 3-6) and mortality. We compared (i) IVT >4.5-9 hours versus 0-4.5 hours after stroke onset and (ii) within the >4.5-9 hours-group baseline advanced neuroimaging (CT perfusion, MR perfusion or MR DWI/FLAIR) versus non-advanced neuroimaging. RESULTS Of 15'827 patients, 663 (4.2%) received IVT >4.5-9 hours and 15'164 (95.8%) within 4.5 hours after stroke onset. The main baseline characteristics were evenly distributed between both groups. Time of stroke onset was known in 74.9% of patients treated between >4.5-9 hours. Using propensity score weighted binary logistic regression analysis (OTT >4.5-9 hours vs. OTT 0-4.5 hours), the probability of sICH (ORadjusted 0.80[0.53-1.17]), poor functional outcome (ORadjusted 1.01[0.83-1.22]) and mortality (ORadjusted 0.80[0.61-1.04]) did not differ significantly between both groups. In patients treated between >4.5-9 hours, the use of advanced neuroimaging was associated with a 50% lower mortality compared to non-advanced imaging only (9.9% vs 19.7%; ORadjusted 0.51[0.33-0.79]). INTERPRETATION This study showed no evidence in difference of sICH, poor outcome and mortality in selected stroke patients treated with IVT between >4.5-9 hours after stroke onset compared to those treated within 4.5 hours. Advanced neuroimaging for patient selection was associated with lower mortality. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Valerian L Altersberger
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| | - Gerli Sibolt
- Neurology, University of Helsinki and Helsinki University Hospital, Finland
| | - Lukas S Enz
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| | | | - Jan F Scheitz
- Klinik Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Germany
| | - Hilde Henon
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000, Lille, France
| | - Guido Bigliardi
- Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital, Modena, Italy
| | - Davide Strambo
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Lotte J Stolze
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Ilaria Grisendi
- Neurology Unit-Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Dejana R Jovanovic
- Neurology Clinic, University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Yannick Bejot
- Department of Neurology, University Hospital Dijon, France
| | - Alessandro Pezzini
- Neurology Clinic, Department of Clinical and Experimental Sciences, University of Brescia, Italy
- Department of Neurological Sciences and Vision, ASST Spedali Civili, Brescia, Italy
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, Switzerland
| | - Carlo W Cereda
- Stroke Center and department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Georges Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Gian Marco De Marchis
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| | - Leo H Bonati
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel and University of Basel, Switzerland
| | - Philippe Lyrer
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| | - Silja Räty
- Neurology, University of Helsinki and Helsinki University Hospital, Finland
| | - Marjaana Tiainen
- Neurology, University of Helsinki and Helsinki University Hospital, Finland
| | - Anke Wouters
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - François Caparros
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000, Lille, France
| | - Miriam Heyse
- Department of Neurology, University Hospital Heidelberg, Germany
| | - Hebun Erdur
- Klinik Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Germany
| | - Visnja Padjen
- Neurology Clinic, University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marialuisa Zedde
- Neurology Unit-Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000, Lille, France
| | - Christian H Nolte
- Klinik Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Germany
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Finland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
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Altersberger VL, Rusche N, Martinez-Majander N, Hametner C, Scheitz JF, Henon H, Dell’Acqua ML, Strambo D, Stolp J, Heldner MR, Grisendi I, Jovanovic DR, Bejot Y, Pezzini A, Leker RR, Kägi G, Wegener S, Cereda CW, Lindgren E, Ntaios G, Piot I, Polymeris AA, Lyrer PA, Räty S, Sibolt G, Tiainen M, Heyse M, Erdur H, Kaaouana O, Padjen V, Zedde M, Arnold M, Nederkoorn PJ, Michel P, Bigliardi G, Zini A, Cordonnier C, Nolte CH, Ringleb PA, Curtze S, Engelter ST, Gensicke H. Intravenous Thrombolysis in Patients With Ischemic Stroke Aged ≥90 Years: A Cohort Study From the TRISP Collaboration. Stroke 2022; 53:3557-3563. [DOI: 10.1161/strokeaha.122.039426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The probability to receive intravenous thrombolysis (IVT) for treatment of acute ischemic stroke declines with increasing age and is consequently the lowest in very elderly patients. Safety concerns likely influence individual IVT treatment decisions. Using data from a large IVT registry, we aimed to provide more evidence on safety of IVT in the very elderly.
Methods:
In this prospective multicenter study from the TRISP (Thrombolysis in Ischemic Stroke Patients) registry, we compared patients ≥90 years with those <90 years using symptomatic intracranial hemorrhage (ECASS [European Cooperative Acute Stroke Study]-II criteria), death, and poor functional outcome in survivors (modified Rankin Scale score 3–5 for patients with prestroke modified Rankin Scale score ≤2 and modified Rankin Scale score 4–5 for patients prestroke modified Rankin Scale ≥3) at 3 months as outcomes. We calculated adjusted odds ratio with 95% CI using logistic regression models.
Results:
Of 16 974 eligible patients, 976 (5.7%) were ≥90 years. Patients ≥90 years had higher median National Institutes of Health Stroke Scale on admission (12 versus 8) and were more often dependent prior to the index stroke (prestroke modified Rankin Scale score of ≥3; 45.2% versus 7.4%). Occurrence of symptomatic intracranial hemorrhage (5.7% versus 4.4%, odds ratio
adjusted
1.14 [0.83–1.57]) did not differ significantly between both groups. However, the probability of death (odds ratio
adjusted
3.77 [3.14–4.53]) and poor functional outcome (odds ratio
adjusted
2.63 [2.13–3.25]) was higher in patients aged ≥90 years. Results for the sample of centenarians (n=21) were similar.
Conclusions:
The probability of symptomatic intracranial hemorrhage after IVT in very elderly patients with stroke did not exceed that of their younger counterparts. The higher probability of death and poor functional outcome during follow-up in the very elderly seems not to be related to IVT treatment. Very high age itself should not be a reason to withhold IVT.
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Affiliation(s)
- Valerian L. Altersberger
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
| | - Norman Rusche
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland (N.R., S.T.E., H.G.)
| | - Nicolas Martinez-Majander
- Neurology, University of Helsinki and Helsinki University Hospital, Finland (N.M.-M., S.R., G.S., M.T., S.C.)
| | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Germany C.H., M.H., P.A.R.)
| | - Jan F. Scheitz
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Germany (J.F.S., H.E., C.H.N.)
| | - Hilde Henon
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France (H.H., O.K., C.C.)
| | - Maria Luisa Dell’Acqua
- Neurology - Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital, Italy (M.L.D.A., G.B.)
| | - Davide Strambo
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland (D.S., P.M.)
| | - Jeffrey Stolp
- Amsterdam UMC location University of Amsterdam, Department of Neurology, the Netherlands (J.S., P.J.N.)
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland (M.R.H., G.K., M.A.)
| | - Ilaria Grisendi
- Neurology Unit-Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Italy (I.G., M.Z.)
| | - Dejana R. Jovanovic
- University of Belgrade, Faculty of Medicine, Neurology Clinic, University Clinical Centre of Serbia (D.R.J., V.P.)
| | - Yannick Bejot
- Department of Neurology, University Hospital Dijon, France (Y.B.)
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Italy (A.P.)
| | - Ronen R. Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel (R.R.L.)
| | - Georg Kägi
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland (M.R.H., G.K., M.A.)
- Department of Neurology, Kantonsspital St. Gallen, Switzerland (G.K.)
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, Switzerland (S.W.)
| | - Carlo W. Cereda
- Stroke Center EOC, Neurology, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland (C.W.C.)
| | - Erik Lindgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.L.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N.)
| | - Ines Piot
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
| | - Alexandros A. Polymeris
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
| | - Philippe A. Lyrer
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
| | - Silja Räty
- Neurology, University of Helsinki and Helsinki University Hospital, Finland (N.M.-M., S.R., G.S., M.T., S.C.)
| | - Gerli Sibolt
- Neurology, University of Helsinki and Helsinki University Hospital, Finland (N.M.-M., S.R., G.S., M.T., S.C.)
| | - Marjaana Tiainen
- Neurology, University of Helsinki and Helsinki University Hospital, Finland (N.M.-M., S.R., G.S., M.T., S.C.)
| | - Miriam Heyse
- Department of Neurology, University Hospital Heidelberg, Germany C.H., M.H., P.A.R.)
| | - Hebun Erdur
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Germany (J.F.S., H.E., C.H.N.)
| | - Olfa Kaaouana
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France (H.H., O.K., C.C.)
| | - Visnja Padjen
- University of Belgrade, Faculty of Medicine, Neurology Clinic, University Clinical Centre of Serbia (D.R.J., V.P.)
| | - Marialuisa Zedde
- Neurology Unit-Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Italy (I.G., M.Z.)
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland (M.R.H., G.K., M.A.)
| | - Paul J. Nederkoorn
- Amsterdam UMC location University of Amsterdam, Department of Neurology, the Netherlands (J.S., P.J.N.)
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland (D.S., P.M.)
| | - Guido Bigliardi
- Neurology - Stroke Unit, Department of Neuroscience, Ospedale Civile di Baggiovara, Modena University Hospital, Italy (M.L.D.A., G.B.)
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy (A.Z.)
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France (H.H., O.K., C.C.)
| | - Christian H. Nolte
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Germany (J.F.S., H.E., C.H.N.)
| | - Peter A. Ringleb
- Department of Neurology, University Hospital Heidelberg, Germany C.H., M.H., P.A.R.)
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Finland (N.M.-M., S.R., G.S., M.T., S.C.)
| | - Stefan T. Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland (N.R., S.T.E., H.G.)
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (V.L.A., N.R., I.P., A.A.P., P.A.L., S.T.E., H.G.)
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland (N.R., S.T.E., H.G.)
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Purrucker JC, Heyse M, Nagel S, Gumbinger C, Seker F, Möhlenbruch M, Ringleb PA. Efficacy and safety of bridging thrombolysis initiated before transfer in a drip-and-ship stroke service. Stroke Vasc Neurol 2021; 7:22-28. [PMID: 34312320 PMCID: PMC8899648 DOI: 10.1136/svn-2021-001024] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/30/2021] [Indexed: 01/13/2023] Open
Abstract
Objective Data regarding the efficacy and safety of bridging thrombolysis (BT) initiated before transfer for evaluation of endovascular therapy is heterogeneous. We, therefore, analyse efficacy and safety of BT in patients treated within a drip-and-ship stroke service. Methods Consecutive adult patients suffering from acute ischaemic stroke and large-vessel occlusions (LVO) transferred to our comprehensive stroke centre for evaluation of endovascular therapy in 2017–2020 were identified from a local prospective stroke database and categorised according to BT and no-BT. BT was defined as intravenous thrombolysis initiated before transfer. LVO was assessed before and after transfer. Functional outcome before stroke and at 3 months using the modified Rankin scale (mRS) was determined. Excellent outcome was defined as mRS 0–1 or return to prestroke mRS. For safety analysis, intracranial haemorrhages and mortality at 3 months were analysed. Main analysis was limited to patients with anterior circulation stroke. Results Of N=714 patients, n=394 (55.2%) received BT. More patients in the BT group with documented LVO before transfer recanalised without endovascular therapy (n=46, 11.7%) than patients who did not receive BT before transfer (n=4, 1.3%, p<0.001). In multivariate analysis, BT was the strongest independent predictor of early recanalisation (adjusted OR 10.9, 95% CI 3.8 to 31.1, p<0.001). BT tended to be an independent predictor of an excellent outcome at 3 months (adjusted OR 1.38, 95% CI 0.97 to 1.96, p=0.077). There were no differences in safety between the BT and no-BT groups. Conclusions BT initiated before transfer was a strong independent predictor of early recanalisation.
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Affiliation(s)
- Jan Christoph Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Miriam Heyse
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Christoph Gumbinger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Peter Arthur Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
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Heyse M, Schneider C, Monostori P, Schwarz KV, Hauke J, Drüschler K, Berberich A, Zorn M, Ringleb PA, Okun JG, Mundiyanapurath S. Trimethylamine-N-Oxide Levels Are Similar in Asymptomatic vs. Symptomatic Cerebrovascular Atherosclerosis. Front Neurol 2021; 12:617944. [PMID: 33815248 PMCID: PMC8017230 DOI: 10.3389/fneur.2021.617944] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/22/2021] [Indexed: 01/02/2023] Open
Abstract
Introduction: Trimethylamine-N-oxide (TMAO) is correlated with atherosclerosis and vascular diseases such as coronary heart disease and ischemic stroke. The aim of the study was to investigate whether TMAO levels are different in symptomatic vs. asymptomatic cerebrovascular atherosclerosis. Methods: This was a prospective, case-control study, conducted at a tertiary care university hospital. Patients were included if they had large-artery atherosclerosis (TOAST criteria). Symptomatic patients with ischemic stroke were compared with asymptomatic patients. As primary endpoint, TMAO levels on admission were compared between symptomatic and asymptomatic patients. Univariable analysis was performed using Mann-Whitney U test and multivariable analysis using binary logistic regression. TMAO values were adjusted for glomerular filtration rate (GFR), age, and smoking. Results: Between 2018 and 2020, 82 symptomatic and asymptomatic patients were recruited. Median age was 70 years; 65% were male. Comparing symptomatic (n = 42) and asymptomatic (n = 40) patients, no significant differences were found in univariable analysis in TMAO [3.96 (IQR 2.30-6.73) vs. 5.36 (3.59-8.68) μmol/L; p = 0.055], GFR [87 (72-97) vs. 82 (71-90) ml/min*1.73 m2; p = 0.189] and age [71 (60-79) vs. 69 (67-75) years; p = 0.756]. In multivariable analysis, TMAO was not a predictor of symptomatic cerebrovascular disease after adjusting for age and GFR [OR 1.003 (95% CI: 0.941-1.070); p = 0.920]. In a sensitivity analysis, we only analyzed patients with symptomatic stenosis and excluded patients with occlusion of brain-supplying arteries. Again, TMAO was not a significant predictor of symptomatic stenosis [OR 1.039 (0.965-1.120), p = 0.311]. Conclusion: TMAO levels could not be used to differentiate between symptomatic and asymptomatic cerebrovascular disease in our study.
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Affiliation(s)
- Miriam Heyse
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christine Schneider
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Monostori
- Metabolic and Newborn Screening Laboratory, Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - Kathrin V Schwarz
- Division of Child Neurology and Metabolic Medicine, Dietmar-Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jana Hauke
- Division of Child Neurology and Metabolic Medicine, Dietmar-Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Katharina Drüschler
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Anne Berberich
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Zorn
- Central Laboratory, Department of Internal Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen G Okun
- Division of Child Neurology and Metabolic Medicine, Dietmar-Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Ungerer M, Begli NH, Heyse M, Purrucker J, Regula J, Berberich A, Ciolli L, Nagel S, Ringleb P, Gumbinger C. Patient profiles contribute to differences in quality metrics of stroke centers. NSJ 2020; 25:292-300. [PMID: 33130810 PMCID: PMC8015612 DOI: 10.17712/nsj.2020.4.20190100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives: To examine this association by comparing patient profiles in 2 closely affiliated hospitals and by examining their association with quality metrics. Methods: We performed a retrospective cohort study comparing a university level comprehensive stroke centers (CSC) with its teaching hospital and local stroke unit (LSU) using routinely collected quality assurance data over a 2 year period. Both hospitals were closely affiliated, shared important resources and medical staff rotated amongst both hospitals. We compared patient profiles as well as internationally recognized quality metrics and examined the association of profiles with quality metrics. Results: A total of 2,462 patients were treated in the CSC and 726 in the LSU. The LSU had a longer door-to-image and door-to-needle times. Rate of systemic thrombolysis was lower in the LSU. Patient profiles differed significantly and were associated with door-to-image and door-to-needle times as well as intravenous thrombolysis rates, even when adjusted for stroke service level. The diagnostic procedures for stroke work-up were similar. Discharge management differed strongly. Conclusion: Although LSUs and CSCs are the primary care providers in their respective regions, differences in patient profiles may contribute to differences in performance parameters. Adjusting for patient profiles may improve the comparability of the quality of stroke care provided by hospitals belonging to different stroke service levels.
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Affiliation(s)
- Matthias Ungerer
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Nima Haji Begli
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Miriam Heyse
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Jan Purrucker
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Jens Regula
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Anne Berberich
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Ludovico Ciolli
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Simon Nagel
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Peter Ringleb
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Christoph Gumbinger
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
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Felsenberg D, Kalender WA, Banzer D, Schmilinsky G, Heyse M, Fischer E, Schneider U. [Quantitative computerized tomographic determination of bone mineral content]. ROFO-FORTSCHR RONTG 1988; 148:431-6. [PMID: 2834792 DOI: 10.1055/s-2008-1048225] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Quantitative computed tomography (QCT) for measuring bone mineral content of lumbar vertebrae is increasingly used internationally. The effect of using conventional CT (single energy CT, SE-CT) and dual energy CT (DE-CT) on reproducibility has been examined. We defined a standard measurement protocol, which automatically evaluates a calibration phantom. This should ensure an in vivo reproducibility of 1 to 2%. Reference data, which has been obtained with this protocol from 113 normal subjects, using SE-CT and DE-CT, are presented.
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