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Jacobsen E, Logallo N, Kvistad CE, Thomassen L, Idicula T. Characteristics and predictors of stroke mimics in young patients in the norwegian tenecteplase stroke trial (NOR-TEST). BMC Neurol 2023; 23:406. [PMID: 37968581 PMCID: PMC10647039 DOI: 10.1186/s12883-023-03425-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 10/05/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Several studies have shown that stroke mimics occur more often among young patients. Our aims were to identify the common mimics in young patients under the age of 60 years who received thrombolysis, to analyze the risk of hemorrhage after treatment with thrombolysis, and to identify risk factors and clinical parameters that might identify mimics in this group. METHODS Norwegian Tenecteplase Stroke Trial was a phase-3 trial investigating safety and efficacy of tenecteplase vs. alteplase in patients with acute ischemic stroke. Patients diagnosed with either acute cerebral ischemia or transient ischemic attack were categorized as stroke group, and patients with any diagnosis other than ischemic stroke or transient ischemic attack as mimics group. Patients were grouped post-hoc into young (< 60 years) and old (≥ 60 years). Logistic regression analyses were performed with mimics vs. stroke as dependent variable to identify predictors of mimics. RESULTS Of the 1091 patients included in the trial, 211 patients (19.3%) were under the age of 60 years. Out of the 1091 patients, 434 (39.8%) were female, median age 77 years (18-99 years), and median NIHSS was 4. Sixty-nine patients (32.7%) out of the 211 patients under the age of 60 were diagnosed as mimic. Mimics were significantly more frequent among the young (OR = 3.3, 32.7% vs. 12.8%, p = < 0.001). The most frequent mimics diagnoses among patients under 60 years of age were migraine (11.8%), no definite diagnosis (11.4%) and peripheral vertigo (3.3%). Mimics were independently associated with age < 50 years (OR = 4.97, p = < 0.001), not currently working/studying (OR = 3.38, p = 0.002) and not having aphasia on admission (OR = 2.95, p = 0.025). None of the mimics under the age of 60 years had symptomatic or asymptomatic intracerebral hemorrhage as a complication to thrombolysis. CONCLUSION We found significantly more mimics in the young, of which migraine was the most predominant diagnosis. Thrombolysis with alteplase or tenecteplase did not cause ICH in any mimics under 60 years.
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Affiliation(s)
- Eskil Jacobsen
- Norwegian University of Science and Technology, Trondheim (NTNU), Trondheim, 7034, Norway.
| | - Nicola Logallo
- Department of Neurology, Centre for Neurovascular Diseases, Haukeland University Hospital, Bergen, 5021, Norway
| | - Christopher Elnan Kvistad
- Department of Neurology, Centre for Neurovascular Diseases, Haukeland University Hospital, Bergen, 5021, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Thomassen
- Department of Neurology, Centre for Neurovascular Diseases, Haukeland University Hospital, Bergen, 5021, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Titto Idicula
- Norwegian University of Science and Technology (NTNU), Trondheim, 7034, Norway
- Department of Neurology, St Olav University Hospital, Trondheim, Norway
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Luijten SPR, van der Ende NAM, Cornelissen SAP, Kluijtmans L, van Hattem A, Lycklama A Nijeholt G, Postma AA, Bokkers RPH, Thomassen L, Waje-Andreassen U, Logallo N, Bracard S, Gory B, Roozenbeek B, Dippel DWJ, van der Lugt A. Comparison of diffusion weighted imaging b0 with T2*-weighted gradient echo or susceptibility weighted imaging for intracranial hemorrhage detection after reperfusion therapy for ischemic stroke. Neuroradiology 2023; 65:1649-1655. [PMID: 37380891 PMCID: PMC10567825 DOI: 10.1007/s00234-023-03180-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/08/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE Diffusion-weighted imaging (DWI) b0 may be able to substitute T2*-weighted gradient echo (GRE) or susceptibility-weighted imaging (SWI) in case of comparable detection of intracranial hemorrhage (ICH), thereby reducing MRI examination time. We evaluated the diagnostic accuracy of DWI b0 compared to T2*GRE or SWI for detection of ICH after reperfusion therapy for ischemic stroke. METHODS We pooled 300 follow-up MRI scans acquired within 1 week after reperfusion therapy. Six neuroradiologists each rated DWI images (b0 and b1000; b0 as index test) of 100 patients and, after a minimum of 4 weeks, T2*GRE or SWI images (reference standard) paired with DWI images of the same patients. Readers assessed the presence of ICH (yes/no) and type of ICH according to the Heidelberg Bleeding Classification. We determined the sensitivity and specificity of DWI b0 for detection of any ICH, and the sensitivity for detection of hemorrhagic infarction (HI1 & HI2) and parenchymal hematoma (PH1 & PH2). RESULTS We analyzed 277 scans of ischemic stroke patients with complete image series and sufficient image quality (median age 65 years [interquartile range, 54-75], 158 [57%] men). For detection of any ICH on DWI b0, the sensitivity was 62% (95% CI: 50-76) and specificity 96% (95% CI: 93-99). The sensitivity of DWI b0 was 52% (95% CI: 28-68) for detection of hemorrhagic infarction and 84% (95% CI: 70-92) for parenchymal hematoma. CONCLUSION DWI b0 is inferior for detection of ICH compared to T2*GRE/SWI, especially for smaller and more subtle hemorrhages. Follow-up MRI protocols should include T2*GRE/SWI for detection of ICH after reperfusion therapy.
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Affiliation(s)
- Sven P R Luijten
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Nadinda A M van der Ende
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sandra A P Cornelissen
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Leo Kluijtmans
- Department of Radiology, Isala Hospital, Zwolle, The Netherlands
| | - Antonius van Hattem
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Alida A Postma
- Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Nicola Logallo
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Bob Roozenbeek
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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Novotny V, Kvistad CE, Naess H, Logallo N, Fromm A, Khanevski AN, Thomassen L. Tenecteplase, 0.4 mg/kg, in Moderate and Severe Acute Ischemic Stroke: A Pooled Analysis of NOR-TEST and NOR-TEST 2A. J Am Heart Assoc 2023; 12:e030320. [PMID: 37830342 PMCID: PMC10757511 DOI: 10.1161/jaha.123.030320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
Background The optimal dose of tenecteplase in acute ischemic stroke remains to be defined. We present a pooled analysis of the 2 NOR-TESTs (Norwegian Tenecteplase Stroke Trials) exploring the efficacy and safety of tenecteplase, 0.4 mg/kg. Methods and Results We retrospectively reviewed 2 PROBE (Prospective Randomized Open, Blinded End-point) trials, NOR-TEST and NOR-TEST 2A. Patients were randomized to either tenecteplase, 0.4 mg/kg, or alteplase, 0.9 mg/kg. The primary end point was favorable functional outcome at 3 months (modified Rankin Scale score, 0-1) or return to baseline if prestroke modified Rankin Scale score was 2. Secondary end points included favorable functional and clinical outcome and safety data. The pooled analysis includes patients with National Institutes of Health Stroke Scale score ≥6 from both trials and an additional post hoc analysis of patients with National Institutes of Health Stroke Scale score ≤5 from NOR-TEST. The per-protocol analysis contains 483 patients, of whom 235 were assigned to tenecteplase and 248 were assigned to alteplase. In per-protocol analysis, functional outcome was better in the alteplase arm with cutoff modified Rankin Scale score of 2 (odds ratio [OR], 0.52 [95% CI, 0.33-0.80]; P=0.003) and expressed by ordinal shift analysis (OR, 1.64 [95% CI, 1.17-2.28]; P=0.004). Mortality at 3 months was higher in the tenecteplase arm (OR, 2.48 [95% CI, 1.20-5.10]; P=0.01). Mortality and intracranial hemorrhage rates were higher in the severe stroke group randomized to tenecteplase, whereas these rates were similar for alteplase and tenecteplase in moderate and mild stroke. Conclusions Tenecteplase, 0.4 mg/kg, is unsafe in moderate and severe stroke, and the risk of death and intracranial hemorrhage probably increases with stroke severity. A lower tenecteplase dose should be tested in future trials. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01949948, NCT03854500.
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Affiliation(s)
- Vojtech Novotny
- Department of NeurologyHaukeland University HospitalBergenNorway
| | - Christopher Elnan Kvistad
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | - Halvor Naess
- Department of NeurologyHaukeland University HospitalBergenNorway
- Centre for Age‐Related MedicineStavanger University HospitalStavangerNorway
| | - Nicola Logallo
- Department of NeurosurgeryHaukeland University HospitalBergenNorway
| | - Annette Fromm
- Department of NeurologyHaukeland University HospitalBergenNorway
| | | | - Lars Thomassen
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
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van der Ende NAM, Luijten SPR, Kluijtmans L, Postma AA, Cornelissen SA, van Hattem AMG, Lycklama À Nijeholt GJ, Bokkers RPH, Thomassen L, Waje-Andreassen U, Logallo N, Bracard S, Gory B, Roozenbeek B, Dippel DWJ, van der Lugt A. Interobserver Agreement on Intracranial Hemorrhage on Magnetic Resonance Imaging in Patients With Ischemic Stroke. Stroke 2023; 54:1587-1592. [PMID: 37154054 DOI: 10.1161/strokeaha.122.042145] [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: 05/10/2023]
Abstract
BACKGROUND The Heidelberg Bleeding Classification, developed for computed tomography, is also frequently used to classify intracranial hemorrhage (ICH) on magnetic resonance imaging. Additionally, the presence of any ICH is frequently used as (safety) outcome measure in clinical stroke trials that evaluate acute interventions. We assessed the interobserver agreement on the presence of any ICH and the type of ICH according to the Heidelberg Bleeding Classification on magnetic resonance imaging in patients treated with reperfusion therapy. METHODS We used 300 magnetic resonance imaging scans including susceptibility-weighted imaging or T2*-weighted gradient echo imaging of ischemic stroke patients within 1 week after reperfusion therapy. Six observers, blinded to clinical characteristics except for suspected location of the infarction, independently rated ICH according to the Heidelberg Bleeding Classification in random pairs. Percent agreement and Cohen's kappa (κ) were estimated for the presence of any ICH (yes/no), and for agreement on the Heidelberg Bleeding Classification class 1 and 2. For the Heidelberg Bleeding Classification class 1 and 2, weighted κ was estimated to take the degree of disagreement into account. RESULTS In 297 of 300 scans, the quality of scans was sufficient to score ICH. Observers agreed on the presence or absence of any ICH in 264 of 297 scans (88.9%; κ 0.78 [95% CI, 0.71-0.85]). There was agreement on the Heidelberg Bleeding Classification class 1 and 2 and no ICH in class 1 and 2 in 226 of 297 scans (76.1%; κ 0.63 [95% CI ,0.56-0.69]; weighted κ 0.90 [95% CI, 0.87-0.93]). CONCLUSIONS The presence of any ICH can be reliably scored on magnetic resonance imaging and can, therefore, be used as (safety) outcome measure in clinical stroke trials that evaluate acute interventions. Agreement of ICH types according to the Heidelberg Bleeding Classification is substantial and disagreements are small.
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Affiliation(s)
- Nadinda A M van der Ende
- Departments of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., S.P.R.L., B.R., D.W.J.D.)
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., S.P.R.L., S.A.C., A.M.G.v.H., B.R., A.v.d.L.)
| | - Sven P R Luijten
- Departments of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., S.P.R.L., B.R., D.W.J.D.)
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., S.P.R.L., S.A.C., A.M.G.v.H., B.R., A.v.d.L.)
| | - Leo Kluijtmans
- Department of Radiology and Nuclear Medicine, Isala, Zwolle, the Netherlands (L.K.)
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and School for Mental Health and Sciences (Mhens), the Netherlands (A.A.P.)
| | - Sandra A Cornelissen
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., S.P.R.L., S.A.C., A.M.G.v.H., B.R., A.v.d.L.)
| | - Antonius M G van Hattem
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., S.P.R.L., S.A.C., A.M.G.v.H., B.R., A.v.d.L.)
| | | | - Reinoud P H Bokkers
- Department of Radiology and Nuclear Medicine, Medical Imaging Center, University Medical Center Groningen, University of Groningen, the Netherlands (R.P.H.B.)
| | - Lars Thomassen
- Departments of Neurology, Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway. (L.T., U.W.-A.)
| | - Ulrike Waje-Andreassen
- Departments of Neurology, Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway. (L.T., U.W.-A.)
| | - Nicola Logallo
- Neurosurgery, Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway. (N.L.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (S.B., B.G.)
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, France (S.B., B.G.)
| | - Bob Roozenbeek
- Departments of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., S.P.R.L., B.R., D.W.J.D.)
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., S.P.R.L., S.A.C., A.M.G.v.H., B.R., A.v.d.L.)
| | - Diederik W J Dippel
- Departments of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., S.P.R.L., B.R., D.W.J.D.)
| | - Aad van der Lugt
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., S.P.R.L., S.A.C., A.M.G.v.H., B.R., A.v.d.L.)
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Nawaz B, Fromm A, Øygarden H, Eide GE, Saeed S, Meijer R, Bots ML, Sand KM, Thomassen L, Næss H, Waje-Andreassen U. Vascular risk factors and staging of atherosclerosis in patients and controls: The Norwegian Stroke in the Young Study. Eur Stroke J 2022; 7:289-298. [PMID: 36082261 PMCID: PMC9446327 DOI: 10.1177/23969873221098582] [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: 01/24/2022] [Accepted: 04/15/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives: We studied the prevalence of vascular risk factors (RFs) among 385 ischaemic
stroke patients ⩽60 years and 260 controls, and their association with
atherosclerosis in seven vascular areas. Methods: History of cardiovascular events (CVE), hypertension, diabetes mellitus (DM),
dyslipidaemia, pack-years of smoking (PYS), alcohol, and physical inactivity
were noted. Blood pressure, body mass index (BMI), waist-hip ratio (WHR),
lipid profile, epicardial adipose tissue (EAT), visceral abdominal adipose
tissue (VAT), and subcutaneous abdominal adipose tissue were measured.
Numeric staging of atherosclerosis was done by standardized examination of
seven vascular areas by right and left carotid and femoral intima-media
thickness, electrocardiogram, abdominal aorta plaques, and the ankle-arm
index. All results were age and sex-adjusted. Poisson regression analysis
was applied. Results: At age ⩽49 years at least one RF was present in 95.6% patients versus 90.0%
controls. Compared to controls, male patients and middle-aged female
patients showed no significant differences. Young female patients compared
to young female controls had a higher burden of RFs (94.3% vs 88.6%,
p = 0.049). Poisson regression analysis combined for
patients and controls, adjusted for age and sex, showed numeric staging of
atherosclerosis associated with age, prior CVE, hypertension, DM,
dyslipidaemia, PYS, alcohol, BMI, WHR, EAT, VAT, and an increased number of
risk factors. Adjusted for all risk factors, numeric staging of
atherosclerosis was associated with increasing age, hypertension, DM, PYS,
and BMI. Conclusion: Vascular risk factors are highly prevalent in young- and middle-aged patients
and controls, and are predictors of established atherosclerosis at study
inclusion. Focus on main modifiable vascular RFs in primary prevention, and
early and aggressive secondary treatment of patients are necessary to reduce
further progression of atherosclerosis.
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Affiliation(s)
- Beenish Nawaz
- Department of Clinical Medicine 1, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Annette Fromm
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Halvor Øygarden
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway
- Department of Health and Nursing Sciences, University of Agder, Kristiansand, Norway
| | - Geir Egil Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Sahrai Saeed
- Department of Cardiology, Haukeland University Hospital, Bergen, Norway
| | - Rudy Meijer
- Julius Center of Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center of Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kristin Modalsli Sand
- Department of Medicine, Sørlandet Hospital, Flekkefjord, Norway
- The Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Halvor Næss
- Department of Clinical Medicine 1, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Kvistad CE, Næss H, Helleberg BH, Idicula T, Hagberg G, Nordby LM, Jenssen KN, Tobro H, Rörholt DM, Kaur K, Eltoft A, Evensen K, Haasz J, Singaravel G, Fromm A, Thomassen L. Tenecteplase versus alteplase for the management of acute ischaemic stroke in Norway (NOR-TEST 2, part A): a phase 3, randomised, open-label, blinded endpoint, non-inferiority trial. Lancet Neurol 2022; 21:511-519. [DOI: 10.1016/s1474-4422(22)00124-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 12/18/2022]
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Nawaz B, Fromm A, Øygarden H, Eide GE, Saeed S, Meijer R, Bots ML, Sand KM, Thomassen L, Næss H, Waje-Andreassen U. Prevalence of atherosclerosis and association with 5-year outcome: The Norwegian Stroke in the Young Study. Eur Stroke J 2022; 6:374-384. [PMID: 35342817 PMCID: PMC8948509 DOI: 10.1177/23969873211059472] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 10/20/2021] [Indexed: 01/05/2023] Open
Abstract
Objectives: We studied the prevalence of atherosclerosis among ischaemic stroke patients ≤60 years and controls at the time of the index stroke, and its association with occurrence of new cardiovascular events (CVEs) and mortality at a 5-year follow-up. Methods: Prevalent atherosclerosis was assessed for 385 patients and 260 controls in seven vascular areas by electrocardiogram (ECG), ankle–arm index (AAI) and measurement of right and left carotid and femoral intima-media thickness (cIMT and fIMT) and abdominal aorta plaques (AAP). Clinical end-points were any new CVE (stroke, angina, myocardial infarction or peripheral arterial disease) or death from any cause at 5-year follow-up. All results were sex- and age-adjusted; logistic regression and Cox proportional hazards models were applied. Results: Young patients ≤49 years had prevalent atherosclerosis in 1/2 of males and 1/3 of females. Compared with controls, young female patients showed significantly higher prevalent atherosclerosis, p = 0.024. Ischaemic ECG and mean cIMT were higher in young and middle-aged female patients (p = 0.044, p = 0.020, p = 0.023 and p <0.001, respectively). Mean fIMT was higher in middle-aged female patients (p <0.001). Cardiovascular events were associated with ischaemic ECG; AAI ≤0.9, fIMT ≥0.9 mm and increased number of areas with atherosclerosis (NAA) among patients, and with AAP, cIMT ≥0.9 mm, fIMT ≥0.9 mm and NAA among controls. Mortality was associated with higher age, ischaemic ECG and NAA among patients, and cIMT ≥0.9 mm among controls. Conclusion: Atherosclerosis is highly prevalent even in young stroke patients. Some areas and increasing NAA are associated with CVEs and death.
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Affiliation(s)
- Beenish Nawaz
- Department of Clinical Medicine 1, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Annette Fromm
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Halvor Øygarden
- Department of Neurology, Sørlandet Hospital, Kristiansand, Norway.,Department of Health and Nursing Sciences, Univeristy of Agder, Kristiansand, Norway
| | - Geir E Eide
- Centre of Clinical Research, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Sahrai Saeed
- Department of Cardiology, Haukeland University Hospital, Bergen, Norway
| | - Rudy Meijer
- Julius Center of Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center of Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kristin M Sand
- Department of Medicine, Sørlandet Hospital, Flekkefjord, Norway.,The Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,SESAM, Centre for Age-related Medicine, Stavanger University Hospital, Stavanger, Norway
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Thomassen L, Kurz M, Rønning OM. Stroke as a separate field of medicine. Tidsskr Nor Laegeforen 2021; 141:21-0618. [PMID: 34813214 DOI: 10.4045/tidsskr.21.0618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Ihle-Hansen H, Sandset EC, Ihle-Hansen H, Hagberg G, Thommessen B, Rønning OM, Kvistad CE, Novotny V, Naess H, Waje-Andreassen U, Thomassen L, Logallo N. Sex differences in the Norwegian Tenecteplase Trial (NOR-TEST). Eur J Neurol 2021; 29:609-614. [PMID: 34564893 DOI: 10.1111/ene.15126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Sex differences in acute ischemic stroke is of increasing interest in the era of precision medicine. We aimed to explore sex disparities in baseline characteristics, management and outcomes in patients treated with intravenous thrombolysis included in the Norwegian Tenecteplase trial (NOR-TEST). METHODS NOR-TEST was an open-label, randomized, blinded endpoint trial, performed from 2012 to 2016, comparing treatment with tenecteplase to treatment with alteplase within 4.5 h after acute ischemic stroke symptom onset. Sex differences at baseline, treatment and outcomes were compared using multivariable logistic regression models. Heterogeneity in treatment was evaluated by including an interaction term in the model. RESULTS Of 1100 patients enrolled, 40% were women, and in patients aged >80 years, the proportion of women was greater than men (19% vs. 14%; p = 0.02). Women had a lower burden of cardiovascular risk factors, such as diabetes mellitus (11% vs. 15%; p = 0.05) and a higher mean high-density lipoprotein cholesterol level (1.7 ± 0.6 mmol/L vs. 1.3 ± 0.4 mmol/L; p < 0.001), and a higher proportion of women had never smoked (45% vs. 33%; p < 0.001) compared with men. While there was no sex difference in time from onset of symptoms to admission, door to needle time or in-hospital workup, women were admitted with more severe stroke (National Institutes of Health Stroke Scale [NIHSS] score 6.2 ± 5.6 vs. 5.3 ± 5.1; p = 0.01). Stroke mimic diagnosis was more common in women (21% vs. 15%; p = 0.01). There were no significant sex differences in clinical outcome, measured by the NIHSS, the modified Rankin Scale, intracranial hemorrhage and mortality. CONCLUSION Women were underrepresented in number in NOR-TEST. The included women had a lower cardiovascular risk factor burden and more severe strokes.
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Affiliation(s)
- Håkon Ihle-Hansen
- Department of Medicine, Baerum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Else Charlotte Sandset
- Oslo Stroke Unit, Department of Neurology, Oslo University Hospital, Ullevål, Norway.,Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Hege Ihle-Hansen
- Department of Medicine, Baerum Hospital, Vestre Viken Hospital Trust, Drammen, Norway.,Oslo Stroke Unit, Department of Neurology, Oslo University Hospital, Ullevål, Norway
| | - Guri Hagberg
- Department of Medicine, Baerum Hospital, Vestre Viken Hospital Trust, Drammen, Norway.,Oslo Stroke Unit, Department of Neurology, Oslo University Hospital, Ullevål, Norway
| | - Bente Thommessen
- Division of Medicine, Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Ole Morten Rønning
- Division of Medicine, Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Christopher Elnan Kvistad
- Centre for Neurovascular Diseases, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Vojtech Novotny
- Centre for Neurovascular Diseases, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Halvor Naess
- Centre for Neurovascular Diseases, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Ulrike Waje-Andreassen
- Centre for Neurovascular Diseases, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Thomassen
- Centre for Neurovascular Diseases, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Nicola Logallo
- Centre for Neurovascular Diseases, Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Aarli SJ, Thomassen L, Waje-Andreassen U, Logallo N, Kvistad CE, Næss H, Fromm A. The Course of Carotid Plaque Vulnerability Assessed by Advanced Neurosonology. Front Neurol 2021; 12:702657. [PMID: 34489850 PMCID: PMC8417551 DOI: 10.3389/fneur.2021.702657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Carotid artery atherosclerosis is a major risk factor for ischemic stroke. This risk is related to plaque vulnerability and is characterized by plaque morphology, intraplaque neovascularization, and cerebral microembolization. Advanced neurosonology can identify vulnerable plaques and aid in preventing subsequent stroke. We aimed to assess the time course of cerebral microembolization and intraplaque neovascularization during 6 months of follow-up and to explore the utility of advanced neurosonology in patients with acute cerebral ischemia. Methods: Fifteen patients with acute cerebral ischemia and carotid artery plaques underwent comprehensive extra- and intracranial ultrasound examinations, including microemboli detection and contrast-enhanced ultrasound. The examinations were repeated after 3 and 6 months. Results: We examined 28 plaques in 15 patients. The ultrasonographic features of plaque vulnerability were frequent in symptomatic and asymptomatic plaques. There were no significant differences in stenosis degree, plaque composition, plaque surface, neovascularization, or cerebral microembolization between symptomatic and asymptomatic plaques, but symptomatic plaques had a higher number of vulnerable features. None of the patients had recurrent clinical stroke or transient ischemic attack during the follow-up period. We observed a decrease in cerebral microembolization at 6 months, but no significant change in intraplaque neovascularization. Conclusions: In patients with acute cerebral ischemia and carotid artery plaques, cerebral microembolization decreased during 6 months of follow-up, indicating plaque stabilization. Clinical Trial Registration:ClinicalTrial.gov, identifier NCT02759653.
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Affiliation(s)
- Sander Johan Aarli
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ulrike Waje-Andreassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - Nicola Logallo
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Christopher Elnan Kvistad
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,SESAM - Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Annette Fromm
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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11
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Tsivgoulis G, Katsanos AH, Eggers J, Larrue V, Thomassen L, Grotta JC, Seitidis G, Schellinger PD, Mavridis D, Demchuk A, Novotny V, Molina CA, Veroniki AA, Köhrmann M, Soinne L, Khanevski AN, Barreto AD, Saqqur M, Psaltopoulou T, Muir KW, Fiebach JB, Rothlisberger T, Kent TA, Mandava P, Alexandrov AW, Alexandrov AV. Sonothrombolysis in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: An Individual Patient Data Meta-Analysis. Stroke 2021; 52:3786-3795. [PMID: 34428930 DOI: 10.1161/strokeaha.120.030960] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Evidence about the utility of ultrasound-enhanced thrombolysis (sonothrombolysis) in patients with acute ischemic stroke (AIS) is conflicting. We aimed to evaluate the safety and efficacy of sonothrombolysis in patients with AIS with large vessel occlusion, by analyzing individual patient data of available randomized-controlled clinical trials. METHODS We included all available randomized-controlled clinical trials comparing sonothrombolysis with or without addition of microspheres (treatment group) to intravenous thrombolysis alone (control group) in patients with AIS with large vessel occlusion. The primary outcome measure was the rate of complete recanalization at 1 to 36 hours following intravenous thrombolysis initiation. We present crude odds ratios (ORs) and ORs adjusted for the predefined variables of age, sex, baseline stroke severity, systolic blood pressure, and onset-to-treatment time. RESULTS We included 7 randomized controlled clinical trials that enrolled 1102 patients with AIS. A total of 138 and 134 confirmed large vessel occlusion patients were randomized to treatment and control groups respectively. Patients randomized to sonothrombolysis had increased odds of complete recanalization compared with patients receiving intravenous thrombolysis alone (40.3% versus 22.4%; OR, 2.17 [95% CI, 1.03-4.54]; adjusted OR, 2.33 [95% CI, 1.02-5.34]). The likelihood of symptomatic intracranial hemorrhage was not significantly different between the 2 groups (7.3% versus 3.7%; OR, 2.03 [95% CI, 0.68-6.11]; adjusted OR, 2.55 [95% CI, 0.76-8.52]). No differences in the likelihood of asymptomatic intracranial hemorrhage, 3-month favorable functional and 3-month functional independence were documented. CONCLUSIONS Sonothrombolysis was associated with a nearly 2-fold increase in the odds of complete recanalization compared with intravenous thrombolysis alone in patients with AIS with large vessel occlusions. Further study of the safety and efficacy of sonothrombolysis is warranted.
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Affiliation(s)
- Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis (G.T., A.W.A., A.V.A.).,Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (G.T.)
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K.)
| | - Jürgen Eggers
- Department of Neurology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany (J.E.).,Department of Neurology, Sana Hospital Lübeck, Germany (J.E.)
| | - Vincent Larrue
- Department of Neurology, University of Toulouse, Hospital Pierre Paul Riquet, France (V.L.)
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.).,Institute of Clinical Medicine, University of Bergen, Norway (L.T., V.N., A.N.K.)
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital-Texas Medical Center, Houston (J.C.G.)
| | - Georgios Seitidis
- Department of Primary Education, School of Education, University of Ioannina, Greece (G.S., D.M.)
| | - Peter D Schellinger
- Departments of Neurology and Neurogeriatry, John Wesling Medical Center Minden, Ruhr University Bochum, Germany (P.D.S.)
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Greece (G.S., D.M.).,Faculté de Médecine, Université Paris Descartes, France (D.M.)
| | - Andrew Demchuk
- Cumming School of Medicine, University of Calgary, AB, Canada (A.D.).,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Calgary, AB, Canada (A.D.)
| | - Vojtech Novotny
- Institute of Clinical Medicine, University of Bergen, Norway (L.T., V.N., A.N.K.)
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (C.A.M)
| | - Areti Angeliki Veroniki
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada (A.A.V.).,Institute of Reproductive and Developmental Biology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, United Kingdom (A.A.V.)
| | - Martin Köhrmann
- Department of Neurology, University Duisburg-Essen, Germany (M.K.)
| | - Lauri Soinne
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, Neurology, University of Helsinki Finland (L.S.)
| | | | - Andrew D Barreto
- Department of Neurology, University of Texas Health Science Center at Houston (A.D.B.)
| | - Maher Saqqur
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada (M.S.).,Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar (M.S.)
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Greece (T.P.)
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, United Kingdom (K.W.M.)
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité-University Medicine Berlin, Germany (J.B.F.)
| | | | - Thomas A Kent
- Texas A&M Health Science Center-Houston campus, University of Texas (T.A.K.).,Department of Neurology, Houston Methodist Hospital, TX (T.A.K.)
| | - Pitchaiah Mandava
- Michael E. DeBakey VA Medical Center, Houston, TX (P.M.).,Department of Neurology, Baylor College of Medicine, Houston, TX (P.M.)
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis (G.T., A.W.A., A.V.A.)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis (G.T., A.W.A., A.V.A.)
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13
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Novotny V, Aarli SJ, Netland Khanevski A, Bjerkreim AT, Elnan Kvistad C, Fromm A, Waje‐Andreassen U, Naess H, Thomassen L, Logallo N. Clinical manifestation of acute cerebral infarcts in multiple arterial territories. Brain Behav 2021; 11:e2296. [PMID: 34333856 PMCID: PMC8413735 DOI: 10.1002/brb3.2296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/18/2021] [Accepted: 07/08/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES We aimed to assess frequencies and radiological aspects of single- and multiterritory clinical manifestation among patients with acute cerebral infarcts in multiple arterial territories (MACI). MATERIALS & METHODS We retrospectively reviewed admission records and diffusion-weighted magnetic resonance imaging of patients with MACI admitted to our stroke unit between 2006 and 2017. MACI was defined as acute cerebral ischemic lesions in at least two out of three arterial cerebral territories, that is, the left anterior, right anterior and the bilateral posterior territory. Patients with single- and multiterritory clinical manifestation were then compared for topographical distribution of the ischemic lesions, the number of ischemic lesions, and The Oxfordshire Community Stroke Project classification. RESULTS Out of 311 patients with MACI, 222 (71.4%) presented with single-territory clinical manifestation. Involvement of the left hemisphere (OR = 0.37, 95% CI 0.16-0.82), less than five ischemic lesions (OR = 0.58, 95% CI 0.35-0.97), and partial anterior circulation infarct clinical stroke syndrome (OR = 0.57, 95% CI 0.34-0.97) were associated with single-territory clinical manifestation. Involvement of all three territories (OR = 2.58, 95% = 1.48-4.50), more than 10 ischemic lesions (OR = 2.30, 95% CI 1.32-4.01) and total anterior circulation infarct clinical stroke syndrome (OR = 3.31, 95% CI 1.39-7.86) were associated with multiterritory clinical manifestation. CONCLUSION Most patients with MACI present with single-territory clinical manifestation on admission. Diffusion-weighted magnetic resonance imaging is therefore necessary for a definite diagnosis.
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Affiliation(s)
- Vojtech Novotny
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | - Sander Johan Aarli
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | | | - Anna Therese Bjerkreim
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | - Christopher Elnan Kvistad
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | - Annette Fromm
- Department of NeurologyHaukeland University HospitalBergenNorway
| | | | - Halvor Naess
- Department of NeurologyHaukeland University HospitalBergenNorway
- Centre for Age‐related MedicineStavanger University HospitalStavangerNorway
| | - Lars Thomassen
- Department of NeurologyHaukeland University HospitalBergenNorway
| | - Nicola Logallo
- Department of NeurosurgeryHaukeland University HospitalBergenNorway
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14
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Ahmed HK, Logallo N, Thomassen L, Novotny V, Mathisen SM, Kurz MW. Clinical outcomes and safety profile of Tenecteplase in wake-up stroke. Acta Neurol Scand 2020; 142:475-479. [PMID: 32511749 DOI: 10.1111/ane.13296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/25/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Tenecteplase has probably pharmacological and clinical advantages in the treatment of acute ischemic stroke. There are lacking data about safety and efficacy of tenecteplase in wake-up stroke (WUPS). AIMS To investigate safety and efficacy of tenecteplase compared to alteplase in WUPS patients included in NOR-TEST. METHODS WUPS patients in NOR-TEST were included in the study based on DWI-FLAIR mismatch. Included patients randomly assigned (1:1) to receive intravenous tenecteplase 0.4 mg/kg (to a maximum of 40 mg) or alteplase 0.9 mg/kg (to a maximum of 90 mg). Neurological improvement was defined as 1) favorable functional outcome at 90 days modified Rankin Scale (mRS) of 0 or 1 and 2) neurological improvement measured with the National Institutes of Health Stroke Scale (NIHSS) of 4 points within 24 hours as compared to admission NIHSS or NIHSS 0 at 24 hours. RESULTS Of 1100 patients from 13 stroke centers included in NOR-TEST, 45 were WUPS patients. Of these, 5 patients were stroke mimics and excluded. Of the remaining 40 patients (3.6%), 24 were treated with alteplase (60%). There was no difference in the number of patients achieving a good clinical outcome (mRS 0-1) in either treatment group. Patients treated with tenecteplase showed a better early neurological improvement (87.5% vs 54.2%, P = 0.027). No ICH was detected on MRI/CT 24-28 hours after thrombolysis. CONCLUSIONS In WUPS patients treated in NOR-TEST, there was no difference in clinical outcomes at 90 days and no ICH events or deaths were observed in either alteplase- or tenecteplase-treated patients. Clinical Trial Registration-URL: https://www.clinicaltrials.gov. Unique identifier: NCT01949948.
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Affiliation(s)
- Hassan Khan Ahmed
- Department of Neurology Stavanger University Hospital Stavanger Norway
- Neuroscience Research Group Stavanger University Hospital Stavanger Norway
| | - Nicola Logallo
- Department of Neurosurgery Haukeland University Hospital Bergen Norway
- Center for Neurovascular Diseases Haukeland University Hospital Bergen Norway
- Department of Clinical Science University of Bergen Bergen Norway
| | - Lars Thomassen
- Center for Neurovascular Diseases Haukeland University Hospital Bergen Norway
- Department of Clinical Science University of Bergen Bergen Norway
- Department of Neurology Haukeland University Hospital Bergen Norway
| | - Vojtech Novotny
- Center for Neurovascular Diseases Haukeland University Hospital Bergen Norway
- Department of Clinical Science University of Bergen Bergen Norway
| | - Sara M. Mathisen
- Department of Neurology Stavanger University Hospital Stavanger Norway
- Neuroscience Research Group Stavanger University Hospital Stavanger Norway
| | - Martin W. Kurz
- Department of Neurology Stavanger University Hospital Stavanger Norway
- Neuroscience Research Group Stavanger University Hospital Stavanger Norway
- Department of Clinical Science University of Bergen Bergen Norway
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Thommessen B, Næss H, Logallo N, Kvistad CE, Waje-Andreassen U, Ihle-Hansen H, Ihle-Hansen H, Thomassen L, Morten Rønning O. Tenecteplase versus alteplase after acute ischemic stroke at high age. Int J Stroke 2020; 16:295-299. [PMID: 32631157 DOI: 10.1177/1747493020938306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Stroke prevalence is increasing with age. Alteplase is the only agent approved for thrombolytic treatment for patients with ischemic stroke, including patients ≥80 years. In the present study, the aim was to compare efficacy and safety of tenecteplase and alteplase in patients ≥80 years. METHODS Data from the Norwegian Tenecteplase Stroke Trial, a randomized controlled trial comparing alteplase and tenecteplase, were assessed. RESULTS Of the 273 patients ≥80 years included, mean age was 85.5 years.In the intention-to-treat analyses, 43.1% receiving tenecteplase and 39.9% receiving alteplase reached excellent functional outcome (modified Rankin Scale score 0-1) after 3 months (odds ratio (OR) 1.14, 95% confidence interval (CI) 0.70-1.85, p=0.59). No significant differences among patients in the two treatment groups regarding frequency of symptomatic intracranial hemorrhage during the first 48 h were identified (11 (8.5%) in the tenecteplase group, 10 (7.0%) in the alteplase group, OR 1.23, 95% CI 0.50-3.00, p 0.65). Death within 3 months occurred in 18 patients (14.3%) in the tenecteplase group and in 21 (15.3%) in the alteplase group (p 0.84). After excluding stroke mimics, the proportion of patients with excellent functional outcome was 44.1% in the tenecteplase group and 34.4% in the alteplase group (OR 1.50 CI 0.90-2.52, p 0.12). CONCLUSION No differences in the efficacy and safety of tenecteplase versus alteplase in patients ≥80 years were identified. TRIAL REGISTRATION Clinicaltrials.gov (NCT01949948).
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Affiliation(s)
- Bente Thommessen
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lorenskog, Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Center for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Nicola Logallo
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Christopher E Kvistad
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Hege Ihle-Hansen
- Department of Internal Medicine, Bærum Hospital, Drammen, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Håkon Ihle-Hansen
- Department of Internal Medicine, Bærum Hospital, Drammen, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ole Morten Rønning
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lorenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Tharaldsen AR, Sand KM, Dalen I, Wilhelmsen G, Næss H, Midelfart A, Rødahl E, Thomassen L, Hoff JM, Frid LM, Tandstad HK, Hegreberg G, Lundberg K, Karlsen TR, Setseng B, Rohweder G, Indredavik B, Kurz MW, Idicula T. Vision-related quality of life in patients with occipital stroke. Acta Neurol Scand 2020; 141:509-518. [PMID: 32078166 DOI: 10.1111/ane.13232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/24/2020] [Accepted: 02/09/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The aim of this study was to detect visual field defects (VFDs) after occipital infarction, investigate the rate of recovery and the impact of VFD upon vision-related quality of life (QoL). MATERIALS AND METHODS Multicenter, prospective study including patients with MRI verified acute occipital infarction (NOR-OCCIP project). Ophthalmological examination including perimetry was performed within 2 weeks and after 6 months. Vision-related QoL was assessed by the National Eye Institute Visual Function Questionnaire 25 (VFQ-25) at one and 6 months post-stroke. RESULTS We included 76 patients, reliable perimetry results were obtained in 66 patients (87%) at a median of 8 days after admittance and VFD were found in 52 cases (79%). Evaluation of VFD after 6 months revealed improvement in 52%. Patients with VFD had significantly lower composite score in VFQ-25 at both test points (77 vs 96, P = .001 and 87 vs 97, P = .009), in nine out of eleven subscales of VFQ-25 at 1 month and seven subscales after 6 months, including mental health, dependency, near and distance activities. Milder VFD had better results on VFQ-25 modified composite score (95 vs 74, P = .002).VFD improvement was related to improved VFQ-25 modified composite score (9.6 vs 0.8, P = .018). About 10% of patients with VFD reported driving 1 month post-stroke and 38% after 6 months. CONCLUSION VFD substantially reduces multiple aspects of vision-related QoL. Severity of VFD is related to QoL and VFD improvement results in better QoL. Neglecting visual impairment after stroke may result in deterioration of rehabilitation efforts. Driving post-stroke deserves particular attention.
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Affiliation(s)
| | - Kristin Modalsli Sand
- Department of Clinical Medicine University of Bergen Bergen Norway
- Department of Internal Medicine Sørlandet Hospital Flekkefjord Flekkefjord Norway
| | - Ingvild Dalen
- Section of Biostatistics Department of Research Stavanger University Hospital Stavanger Norway
| | - Gunvor Wilhelmsen
- Department of Pedagogy in Teacher Education Faculty of Education Western Norway University of Applied Sciences Bergen Norway
| | - Halvor Næss
- Department of Clinical Medicine University of Bergen Bergen Norway
- Centre for Age‐Related Medicine Stavanger University Hospital Stavanger Norway
- Department of Neurology Haukeland University Hospital Bergen Norway
| | - Anna Midelfart
- Faculty of Medicine Norwegian University of Science and Technology Trondheim Norway
| | - Eyvind Rødahl
- Department of Clinical Medicine University of Bergen Bergen Norway
- Department of Ophthalmology Haukeland University Hospital Bergen Norway
| | - Lars Thomassen
- Department of Clinical Medicine University of Bergen Bergen Norway
- Department of Neurology Haukeland University Hospital Bergen Norway
| | - Jana Midelfart Hoff
- Department of Neurology Haukeland University Hospital Bergen Norway
- Faculty of Health VID Specialized University Bergen Norway
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Tsivgoulis G, Katsanos AH, Eggers J, Larrue V, Thomassen L, Grotta JC, Mavridis D, Schellinger PD, Seitidis G, Demchuk A, Novotny V, Molina C, Veroniki AA, Köhrmann M, Soinne L, Khanevski AN, Barreto AD, Saqqur M, Psaltopoulou T, Muir KW, Fiebach JB, Rothlisberger T, Kent T, Mandava P, Alexandrov AW, Alexandrov AV. Abstract 106: Safety and Efficacy of Sonothrombolysis in Acute Ischemic Stroke Patients With Large Vessel Occlusion: International Collaborative Individual Patient Data Meta-Analysis. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.106] [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:
Conflicting evidence has been published regarding the safety and efficacy of ultrasound-enhanced thrombolysis (sonothrombolysis) in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO).
Methods:
We conducted an individual participant data meta-analysis of available randomized controlled trials (RCTs) comparing sonothrombolysis with or without addition of microspheres (treatment group) to intravenous thrombolysis alone (control group) in AIS patients with LVO.
Results:
We included 6 in total RCTs that enrolled 1077 AIS patients. A total of 138 and 134 confirmed LVO patients were randomized to treatment and control groups respectively (median age 68 years, 58% men, median baseline NIHSS score 16). Patients randomized to sonothrombolysis had increased odds of complete recanalization compared to patients receiving intravenous thrombolysis alone (40.3% vs. 22.4%; OR=2.30, 95%CI: 1.05-5.02; adjusted OR=2.33, 95%CI: 1.02-5.34). They also tended to have increased odds of any (complete or partial recanalization (66.4% vs. 53.0%; OR=1.78, 95%CI: 0.95-3.33; adjusted OR=1.85, 95%CI: 0.97-3.53). The likelihood of symptomatic intracranial hemorrhage did not differ between the two groups (7.3% vs. 3.7%, OR=2.52, 95%CI: 0.77-8.29; adjusted OR=2.55, 95%CI: 0.76-8.52). No differences in the likelihood of asymptomatic intracranial hemorrhage (adjusted OR: 1.30, 95%CI: 0.38-4.39), three-month mortality (adjusted OR: 1.23, 95%CI: 0.25-6.05), three-month favorable functional outcome (mRS-scores of 0-1; adjusted OR: 1.43, 95%CI: 0.64-3.19) and three-month functional independence (mRS-scores of 0-2; adjusted OR: 1.43, 95%CI: 0.77-2.64) were documented.
Conclusion:
Sonothrombolysis was associated with a two-fold increase in the odds of complete recanalization compared to intravenous thrombolysis alone in AIS patients with LVOs. Further study of the safety and efficacy of sonothrombolysis is warranted.
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Affiliation(s)
- Georgios Tsivgoulis
- Attikon Univ Hosp, Sch of Medicine, National and Kapodistrian Univ of Athens, Athens, Greece
| | | | - Jürgen Eggers
- Dept of Neurology, Univ Hosp Schleswig-Holstein, Lübeck, Germany
| | - Vincent Larrue
- Univ of Toulouse, Hosp Pierre Paul Riquet, Toulouse, France
| | | | | | | | | | | | | | | | | | | | | | - Lauri Soinne
- Helsinki Univ Hosp and Clinical Neurosciences, Helsinki, Finland
| | | | | | | | | | - Keith W Muir
- Univ of Glasgow, Queen Elizabeth Univ Hosp, Glasgow, United Kingdom
| | | | | | - Thomas Kent
- NEUROLOGY, Houston Methodist Hosp, Houston, TX
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Bøthun ML, Haaland ØA, Logallo N, Svendsen F, Thomassen L, Helland CA. Corrigendum to “Cerebrovascular reactivity after treatment of unruptured intracranial aneurysms - A transcranial Doppler sonography and acetazolamide study” [Journal of the Neurological Sciences 363 (2016) 97–103]. J Neurol Sci 2020; 408:116591. [DOI: 10.1016/j.jns.2019.116591] [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: 11/30/2022]
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Nawaz B, Eide GE, Fromm A, Øygarden H, Sand KM, Thomassen L, Næss H, Waje-Andreassen U. Young ischaemic stroke incidence and demographic characteristics - The Norwegian stroke in the young study - A three-generation research program. Eur Stroke J 2019; 4:347-354. [PMID: 31903433 PMCID: PMC6921944 DOI: 10.1177/2396987319863601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 06/22/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Norwegian Stroke in the Young Study (NOR-SYS) is a three-generation research program of young ischaemic stroke. In this study, we assessed ischaemic stroke incidence, education and work status among young stroke patients. Furthermore, we evaluated the participation of family members for future validated information on hereditary cardiovascular events. PATIENTS AND METHODS Patients aged 15-60 years with radiologically verified acute ischaemic stroke, admitted to Haukeland University Hospital in Bergen, Norway from 2010 to 2015, were included. Patients' partners, common offspring ≥ 18 years and biological parents of patients and partners were invited to participate. Ischaemic stroke incidence was analysed with respect to year, age and sex using multiple logistic regression. RESULTS A total of 385 patients, 260 partners (80.0%) and 414 offspring (74.6%) were clinically examined. The mean annual ischaemic stroke incidence rate was 30.2 per 100,000. Incidence was higher in men, and the difference was accentuated with increasing age (p = 0.008). There was no sex difference in educational status (p = 0.104) in contrast to work status (p < 0.001) for patients. In all, 84.1% of men worked, and of these, 80.3% are fulltime. In all, 74.4% of women worked, and of these, 52.9% are fulltime. Parents participated by returning a questionnaire. For patients, 91 fathers (55.2%) and 142 mothers (57.3%) participated. For partners, 48 fathers (38.4%) and 68 mothers (40.2%) participated. CONCLUSION The mean annual incidence rate of young stroke was 30.2 per 100,000, and the incidence rate was higher in men. Work status was high among both sexes. Active participation rates were high for patients, partners and offspring.
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Affiliation(s)
- Beenish Nawaz
- Department of Clinical Medicine, University of Bergen, Bergen,
Norway
| | - Geir E Eide
- Centre for Clinical Research, Haukeland University Hospital,
Bergen, Norway
- Department of Global Public Health and Primary Care, University
of Bergen, Bergen, Norway
| | - Annette Fromm
- Department of Neurology, Haukeland University Hospital, Bergen,
Norway
| | - Halvor Øygarden
- Department of Neurology, Sørlandet Hospital, Kristiansand,
Norway
| | - Kristin M Sand
- Department of Medicine, Sørlandet Hospital, Flekkefjord,
Norway
| | - Lars Thomassen
- Department of Clinical Medicine, University of Bergen, Bergen,
Norway
- Department of Neurology, Haukeland University Hospital, Bergen,
Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen,
Norway
- SESAM, Centre for Age-related Medicine, Stavanger University
Hospital, Stavanger, Norway
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Novotny V, Khanevski AN, Bjerkreim AT, Kvistad CE, Fromm A, Waje-Andreassen U, Næss H, Thomassen L, Logallo N. Short-Term Outcome and In-Hospital Complications After Acute Cerebral Infarcts in Multiple Arterial Territories. Stroke 2019; 50:3625-3627. [DOI: 10.1161/strokeaha.119.027049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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—
Patients with acute cerebral infarcts in multiple arterial territories (MACI) represent a substantial portion of the stroke population. There are no data on short-term outcome and in-hospital complications in patients with MACI. We compared patients with MACI with patients having acute cerebral infarct(s) in a single arterial territory.
Methods—
We analyzed 3343 patients with diffusion-weighted imaging-confirmed acute cerebral infarcts. MACI was defined as at least 2 acute cerebral ischemic lesions in at least 2 arterial cerebral territories. Patients with MACI were compared with patients with acute cerebral infarct(s) in a single arterial territory for relevant in-hospital complications and short-term outcome, namely National Institutes of Health Stroke Scale and modified Rankin Scale at day 7 after admission or at discharge when earlier.
Results—
A total of 311 patients (9.3%) met the definition of MACI. Both median National Institutes of Health Stroke Scale (2 [1–7] versus 1 [0–4]) and modified Rankin Scale (3 [1–4] versus 2 [1–3]) were higher in patients with MACI. MACI was independently associated with higher National Institutes of Health Stroke Scale and modified Rankin Scale. Deep venous thrombosis, myocardial infarction, and any complications were more frequent in patients with MACI.
Conclusions—
In-hospital complications were more frequent in patients with MACI, which may adversely affect short-term clinical and functional outcome. Closer follow-up of patients with MACI during hospitalization may prevent such events and negative progression.
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Affiliation(s)
- Vojtech Novotny
- From the Department of Neurology, Center for Neurovascular Diseases (V.N., A.N.K., A.T.B., C.E.K., A.F., U.W.-A., H.N., L.T), Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway (V.N., A.N.K., A.T.B., C.E.K., A.F., L.T., N.L.)
| | - Andrej N. Khanevski
- From the Department of Neurology, Center for Neurovascular Diseases (V.N., A.N.K., A.T.B., C.E.K., A.F., U.W.-A., H.N., L.T), Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway (V.N., A.N.K., A.T.B., C.E.K., A.F., L.T., N.L.)
- The National Association for Public Health, Oslo, Norway (A.N.K.)
| | - Anna T. Bjerkreim
- From the Department of Neurology, Center for Neurovascular Diseases (V.N., A.N.K., A.T.B., C.E.K., A.F., U.W.-A., H.N., L.T), Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway (V.N., A.N.K., A.T.B., C.E.K., A.F., L.T., N.L.)
| | - Christopher E. Kvistad
- From the Department of Neurology, Center for Neurovascular Diseases (V.N., A.N.K., A.T.B., C.E.K., A.F., U.W.-A., H.N., L.T), Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway (V.N., A.N.K., A.T.B., C.E.K., A.F., L.T., N.L.)
| | - Annette Fromm
- From the Department of Neurology, Center for Neurovascular Diseases (V.N., A.N.K., A.T.B., C.E.K., A.F., U.W.-A., H.N., L.T), Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway (V.N., A.N.K., A.T.B., C.E.K., A.F., L.T., N.L.)
| | - Ulrike Waje-Andreassen
- From the Department of Neurology, Center for Neurovascular Diseases (V.N., A.N.K., A.T.B., C.E.K., A.F., U.W.-A., H.N., L.T), Haukeland University Hospital, Bergen, Norway
| | - Halvor Næss
- From the Department of Neurology, Center for Neurovascular Diseases (V.N., A.N.K., A.T.B., C.E.K., A.F., U.W.-A., H.N., L.T), Haukeland University Hospital, Bergen, Norway
- Center for Age-related Medicine, Stavanger University Hospital, Norway (H.N.)
| | - Lars Thomassen
- From the Department of Neurology, Center for Neurovascular Diseases (V.N., A.N.K., A.T.B., C.E.K., A.F., U.W.-A., H.N., L.T), Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway (V.N., A.N.K., A.T.B., C.E.K., A.F., L.T., N.L.)
| | - Nicola Logallo
- Department of Neurosurgery (N.L.), Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway (V.N., A.N.K., A.T.B., C.E.K., A.F., L.T., N.L.)
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Aarli SJ, Novotny V, Thomassen L, Kvistad CE, Logallo N, Fromm A. Persistent Microembolic Signals in the Cerebral Circulation on Transcranial Doppler after Intravenous Sulfur Hexafluoride Microbubble Infusion. J Neuroimaging 2019; 30:146-149. [DOI: 10.1111/jon.12680] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Sander Johan Aarli
- Department of Neurology Haukeland University Hospital Bergen Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
| | - Vojtech Novotny
- Department of Neurology Haukeland University Hospital Bergen Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
| | - Lars Thomassen
- Department of Neurology Haukeland University Hospital Bergen Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
| | - Christopher Elnan Kvistad
- Department of Neurology Haukeland University Hospital Bergen Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
| | - Nicola Logallo
- Department of Neurosurgery Haukeland University Hospital Bergen Norway
| | - Annette Fromm
- Department of Neurology Haukeland University Hospital Bergen Norway
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Rønning OM, Logallo N, Thommessen B, Tobro H, Novotny V, Kvistad CE, Aamodt AH, Næss H, Waje-Andreassen U, Thomassen L. Tenecteplase Versus Alteplase Between 3 and 4.5 Hours in Low National Institutes of Health Stroke Scale. Stroke 2019; 50:498-500. [PMID: 30602354 DOI: 10.1161/strokeaha.118.024223] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Thrombolysis with alteplase has beneficial effect on outcome and is safe within 4.5 hours. The present study compares the efficacy and safety of tenecteplase and alteplase in patients treated 3 to 4.5 hours after ischemic stroke. Methods- The data are from a prespecified substudy of patients included in The NOR-TEST (Norwegian Tenecteplase Stroke Trial), a randomized control trial comparing tenecteplase with alteplase. Results- The median admission National Institutes of Health Stroke Scale for this study population was 3 (interquartile range, 2-6). In the intention-to-treat analysis, 57% of patients that received tenecteplase and 53% of patients that received alteplase reached good functional outcome (modified Rankin Scale score of 0-1) at 3 months (odds ratio, 1.19; 95% CI, 0.68-2.10). The rates of intracranial hemorrhage in the first 48 hours were 5.7% in the tenecteplase group and 6.7% in the alteplase group (odds ratio, 0.84; 95% CI, 0.26-2.70). At 3 months, mortality was 5.7% and 4.5%, respectively. After excluding stroke mimics and patients with modified Rankin Scale score of >1 before stroke, the proportion of patients with good functional outcome was 61% in the tenecteplase group and 57% in the alteplase group (odds ratio, 1.24; 95% CI, 0.65-2.37). Conclusions- Tenecteplase is at least as effective as alteplase to achieve a good clinical outcome in patients with mild stroke treated between 3 and 4.5 hours after ischemic stroke. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT01949948.
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Affiliation(s)
- Ole Morten Rønning
- From the Division of Medicine, Department of Neurology, Akershus University Hospital, Lorenskog, Norway (O.M.R., B.T).,Institute of Clinical Medicine, University of Oslo, Norway (O.M.R.)
| | - Nicola Logallo
- Department of Neurosurgery (N.L.), Haukeland University Hospital, Bergen, Norway
| | - Bente Thommessen
- From the Division of Medicine, Department of Neurology, Akershus University Hospital, Lorenskog, Norway (O.M.R., B.T)
| | - Håkon Tobro
- Department of Neurology, Telemark Hospital, Skien, Norway (H.T.)
| | - Vojtech Novotny
- Department of Neurology (V.N., C.E.K., H.N., U.W.-A., L.T.), Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Norway (V.N., C.E.K., H.N., L.T.)
| | - Christopher E Kvistad
- Department of Neurology (V.N., C.E.K., H.N., U.W.-A., L.T.), Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Norway (V.N., C.E.K., H.N., L.T.)
| | - Anne Hege Aamodt
- Department of Neurology, Oslo University Hospital, Norway (A.H.A.)
| | - Halvor Næss
- Department of Neurology (V.N., C.E.K., H.N., U.W.-A., L.T.), Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Norway (V.N., C.E.K., H.N., L.T.).,Center for Age-Related Medicine, Stavanger University Hospital, Norway (H.N.)
| | - Ulrike Waje-Andreassen
- Department of Neurology (V.N., C.E.K., H.N., U.W.-A., L.T.), Haukeland University Hospital, Bergen, Norway
| | - Lars Thomassen
- Department of Neurology (V.N., C.E.K., H.N., U.W.-A., L.T.), Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Norway (V.N., C.E.K., H.N., L.T.)
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Khanevski AN, Kvistad CE, Novotny V, Næss H, Thomassen L, Logallo N, Bjerkreim AT. Incidence and Etiologies of Stroke Mimics After Incident Stroke or Transient Ischemic Attack. Stroke 2019; 50:2937-2940. [DOI: 10.1161/strokeaha.119.026573] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Stroke mimics (SM) pose a common clinical challenge, but the burden of SM in patients with previous ischemic stroke (IS) or transient ischemic attack is unknown. The objective of this study was to calculate the incidence of SM in IS survivors, compare it with the incidence of recurrent stroke in the same population, and explore the time-dependent patterns of SM etiologies.
Methods—
This prospective cohort study registered SM events and etiologies among 1872 IS and transient ischemic attack survivors diagnosed with index stroke at Haukeland University Hospital stroke unit from 2007 to 2013 by review of medical records. Cumulative incidences of SM were estimated with a competing risks Cox model and compared with incidence of recurrent stroke in the same population.
Results—
During 8172 person-years of follow-up, 339 patients had 480 SM events. The cumulative incidence rate of SM during follow-up was 58.7 per 1.000 person-years (95% CI, 53.7–64.2) compared with 34.0 per 1.000 person-years (95% CI, 30.2–38.2) for recurrent stroke in the same time period. The risks of SM and recurrent stroke were highest the first year after index IS or transient ischemic attack. The most frequent SM diagnoses were sequelae of cerebral infarction (19.8%), medical observation, and evaluation for suspected cerebrovascular disease (15.6%) and infections (14.0%). The 2 most frequent and unspecific diagnoses (sequelae of cerebral infarction and medical observation) were clustered in the first months after index stroke.
Conclusions—
SM after IS or transient ischemic attack are more frequent than recurrent stroke and the risk is especially high in the early period. SMs are multietiological and unspecific diagnoses are most frequent early after index stroke.
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Affiliation(s)
- Andrej Netland Khanevski
- From the Department of Clinical Medicine, University of Bergen, Norway (A.N.K., C.E.K., V.N., H.N., L.T., N.L., A.T.B.)
- Department of Neurology (A.N.K., C.E.K., V.N., H.N., L.T., A.T.B.), Haukeland University Hospital, Bergen, Norway
| | - Christopher E. Kvistad
- From the Department of Clinical Medicine, University of Bergen, Norway (A.N.K., C.E.K., V.N., H.N., L.T., N.L., A.T.B.)
- Department of Neurology (A.N.K., C.E.K., V.N., H.N., L.T., A.T.B.), Haukeland University Hospital, Bergen, Norway
| | - Vojtech Novotny
- From the Department of Clinical Medicine, University of Bergen, Norway (A.N.K., C.E.K., V.N., H.N., L.T., N.L., A.T.B.)
- Department of Neurology (A.N.K., C.E.K., V.N., H.N., L.T., A.T.B.), Haukeland University Hospital, Bergen, Norway
| | - Halvor Næss
- From the Department of Clinical Medicine, University of Bergen, Norway (A.N.K., C.E.K., V.N., H.N., L.T., N.L., A.T.B.)
- Department of Neurology (A.N.K., C.E.K., V.N., H.N., L.T., A.T.B.), Haukeland University Hospital, Bergen, Norway
| | - Lars Thomassen
- From the Department of Clinical Medicine, University of Bergen, Norway (A.N.K., C.E.K., V.N., H.N., L.T., N.L., A.T.B.)
- Department of Neurology (A.N.K., C.E.K., V.N., H.N., L.T., A.T.B.), Haukeland University Hospital, Bergen, Norway
| | - Nicola Logallo
- From the Department of Clinical Medicine, University of Bergen, Norway (A.N.K., C.E.K., V.N., H.N., L.T., N.L., A.T.B.)
- Department of Neurosurgery (N.L.), Haukeland University Hospital, Bergen, Norway
| | - Anna Therese Bjerkreim
- From the Department of Clinical Medicine, University of Bergen, Norway (A.N.K., C.E.K., V.N., H.N., L.T., N.L., A.T.B.)
- Department of Neurology (A.N.K., C.E.K., V.N., H.N., L.T., A.T.B.), Haukeland University Hospital, Bergen, Norway
- Norwegian Health Association, Oslo, Norway (A.N.K.)
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Bjerkreim AT, Khanevski AN, Thomassen L, Selvik HA, Waje-Andreassen U, Naess H, Logallo N. Five-year readmission and mortality differ by ischemic stroke subtype. J Neurol Sci 2019; 403:31-37. [DOI: 10.1016/j.jns.2019.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 05/15/2019] [Accepted: 06/04/2019] [Indexed: 01/25/2023]
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Naess H, Logallo N, Waje‐Andreassen U, Thomassen L, Kvistad CE. U-shaped relationship between hemoglobin level and severity of ischemic stroke. Acta Neurol Scand 2019; 140:56-61. [PMID: 30972738 DOI: 10.1111/ane.13100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/16/2019] [Accepted: 03/29/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM We aimed to explore the relation between hemoglobin level and ischemic stroke severity and short-term improvement in patients admitted to hospital within 3 hours of stroke onset. METHODS The relation between stroke severity and hemoglobin was explored by locally weighted scatterplot smoothing (lowess smoother) curves. The effect of hemoglobin on short-term outcome was determined by means of linear regression analyses with NIHSS score day 7 as dependent variable after adjusting for confounders including NIHSS score on admission. Analyses were performed to disclose clinical factor associated with hemoglobin level. RESULTS This study includes 905 ischemic stroke patients admitted within 3 hours of stroke onset. Lowess smoother curves showed a U-shaped relation between NIHSS score on admission and mRS score day 7 and hemoglobin level. Regression analysis showed low hemoglobin to be independently associated with females, high age, severe stroke, low systolic blood pressure, prior cerebral infarction, not smoking, not atrial fibrillation, and unknown etiology (all P < 0.05). Another regression analysis showed that high NIHSS score day 7 was independently associated with low hemoglobin after adjusting for confounders including NIHSS score on admission. CONCLUSIONS We found a U-shaped relationship between hemoglobin level on admission and stroke severity. There was no U-shaped relationship between improvement and hemoglobin level. Poor short-term improvement was associated with low hemoglobin levels.
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Affiliation(s)
- Halvor Naess
- Department of Neurology Haukeland University Hospital Bergen Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
- Centre for age‐related medicine Stavanger University Hospital Stavanger Norway
| | - Nicola Logallo
- Department of Neurology Haukeland University Hospital Bergen Norway
| | - Ulrike Waje‐Andreassen
- Department of Neurology Haukeland University Hospital Bergen Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
| | - Lars Thomassen
- Department of Neurology Haukeland University Hospital Bergen Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
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Khanevski AN, Bjerkreim AT, Novotny V, Næss H, Thomassen L, Logallo N, Kvistad CE. Recurrent ischemic stroke: Incidence, predictors, and impact on mortality. Acta Neurol Scand 2019; 140:3-8. [PMID: 30929256 PMCID: PMC6594196 DOI: 10.1111/ane.13093] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [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: 02/20/2019] [Revised: 03/13/2019] [Accepted: 03/19/2019] [Indexed: 11/29/2022]
Abstract
Background and purpose Recurrent ischemic stroke (IS) or TIA is frequent with a considerable variation in incidence and mortality across populations. Current data on stroke recurrence and mortality are useful to examine trends, risk factors, and treatment effects. In this study, we calculated the incidence of recurrent IS or TIA in a hospital‐based stroke population in Western Norway, investigated recurrence factors, and estimated the effect of recurrence on all‐cause mortality. Methods This prospective cohort study registered recurrence and mortality among 1872 IS and TIA survivors admitted to the stroke unit at Haukeland University Hospital between July 2007 and December 2013. Recurrence and death until September 1, 2016, were identified by medical chart review. Cumulative incidences of recurrence were estimated with a competing risks Cox model. Multivariate Cox models were used to examine recurrence factors and mortality. Results During follow‐up, 220 patients had 277 recurrent IS or TIAs. The cumulative recurrence rate was 5.4% at 1 year, 11.3% at 5 years, and 14.2% at the end of follow‐up. Hypertension (HR = 1.65, 95% CI 1.21‐2.25), prior symptomatic stroke (HR = 1.63, 95% CI 1.18‐2.24), chronic infarcts on MRI (HR = 1.48, 95% CI 1.10‐1.99), and age (HR 1.02/year, 95% CI 1.00‐1.03) were independently associated with recurrence. A total of 668 (35.7%) patients died during follow‐up. Recurrence significantly increased the all‐cause mortality (HR = 2.55, 95% CI 2.04‐3.18). Conclusions The risk of recurrent IS stroke or TIA was modest in our population and was associated with previously established risk factors. Recurrence more than doubled the all‐cause mortality.
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Affiliation(s)
- Andrej Netland Khanevski
- Department of Clinical Medicine University of Bergen Bergen Norway
- Department of Neurology Haukeland University Hospital Bergen Norway
- Norwegian Health Association Oslo Norway
| | - Anna Therese Bjerkreim
- Department of Clinical Medicine University of Bergen Bergen Norway
- Department of Neurology Haukeland University Hospital Bergen Norway
| | - Vojtech Novotny
- Department of Clinical Medicine University of Bergen Bergen Norway
- Department of Neurology Haukeland University Hospital Bergen Norway
| | - Halvor Næss
- Department of Clinical Medicine University of Bergen Bergen Norway
- Department of Neurology Haukeland University Hospital Bergen Norway
- Centre for Age‐Related Medicine Stavanger University Hospital Stavanger Norway
| | - Lars Thomassen
- Department of Clinical Medicine University of Bergen Bergen Norway
- Department of Neurology Haukeland University Hospital Bergen Norway
| | - Nicola Logallo
- Department of Clinical Medicine University of Bergen Bergen Norway
- Department of Neurosurgery Haukeland University Hospital Bergen Norway
| | - Christopher E. Kvistad
- Department of Clinical Medicine University of Bergen Bergen Norway
- Department of Neurology Haukeland University Hospital Bergen Norway
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Kvistad CE, Novotny V, Kurz MW, Rønning OM, Thommessen B, Carlsson M, Waje-Andreassen U, Næss H, Thomassen L, Logallo N. Safety and Outcomes of Tenecteplase in Moderate and Severe Ischemic Stroke. Stroke 2019; 50:1279-1281. [DOI: 10.1161/strokeaha.119.025041] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christopher Elnan Kvistad
- From the Department of Neurology, Center for Neurovascular Diseases (C.E.K., V.N., U.W.-A., H.N., L.T., N.L.), Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway (C.E.K., V.N., M.W.K., L.T., N.L.)
| | - Vojtech Novotny
- From the Department of Neurology, Center for Neurovascular Diseases (C.E.K., V.N., U.W.-A., H.N., L.T., N.L.), Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway (C.E.K., V.N., M.W.K., L.T., N.L.)
| | - Martin Wilhelm Kurz
- Department of Clinical Medicine, University of Bergen, Norway (C.E.K., V.N., M.W.K., L.T., N.L.)
- Department of Neurology and Neuroscience Research Group (M.W.K.), Stavanger University Hospital, Norway
| | - Ole Morten Rønning
- Division of Medicine, Department of Neurology, Akershus University Hospital, Lorenskog, Norway (O.M.R., B.T.)
- Institute of Clinical Medicine, University of Oslo, Norway (O.M.R., B.T.)
| | - Bente Thommessen
- Division of Medicine, Department of Neurology, Akershus University Hospital, Lorenskog, Norway (O.M.R., B.T.)
- Institute of Clinical Medicine, University of Oslo, Norway (O.M.R., B.T.)
| | - Maria Carlsson
- Department of Neurology, Nordlandssykehuset, Bodø, Norway (M.C.)
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø (M.C.)
| | - Ulrike Waje-Andreassen
- From the Department of Neurology, Center for Neurovascular Diseases (C.E.K., V.N., U.W.-A., H.N., L.T., N.L.), Haukeland University Hospital, Bergen, Norway
| | - Halvor Næss
- From the Department of Neurology, Center for Neurovascular Diseases (C.E.K., V.N., U.W.-A., H.N., L.T., N.L.), Haukeland University Hospital, Bergen, Norway
- Centre for Age-Related Medicine (H.N.), Stavanger University Hospital, Norway
| | - Lars Thomassen
- Department of Clinical Medicine, University of Bergen, Norway (C.E.K., V.N., M.W.K., L.T., N.L.)
| | - Nicola Logallo
- Department of Neurosurgery (N.L.), Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway (C.E.K., V.N., M.W.K., L.T., N.L.)
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Naess H, Thomassen L, Waje-Andreassen U, Glad S, Kvistad CE. High risk of early neurological worsening of lacunar infarction. Acta Neurol Scand 2019; 139:143-149. [PMID: 30229856 DOI: 10.1111/ane.13029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/27/2018] [Accepted: 09/12/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to evaluate factors associated with neurological worsening among patients with lacunar or non-lacunar infarction admitted within 3 hours and between 3 and 24 hours after stroke onset. METHODS All patients admitted to Haukeland university hospital between 2006 and 2016 with acute cerebral infarction on MRI and admission within 24 hours were included. Repeated National Institute of Health Stroke Scale (NIHSS) scoring was performed in all patients whenever possible. Neurological worsening during the hospital stay was defined as NIHSS score increase ≥3 compared to NIHSS score on admission. RESULTS In patients with lacunar infarction admitted within 3 hours of onset, neurological worsening was associated with low NIHSS score on admission, low body temperature, and leukoaraiosis, whereas only internal carotid artery stenosis or occlusion was associated with neurological worsening in non-lacunar infraction. For patients admitted 3-24 hours after onset, neurological worsening was associated with low body temperature, high systolic blood pressure, and short time from onset to admission in patients with lacunar infarction, whereas high systolic blood pressure, high NIHSS score on admission, middle cerebral artery occlusion, and high blood glucose were associated with neurological worsening in patients with non-lacunar infarction (all P < 0.05). CONCLUSIONS Lacunar infarctions with minor neurological deficits within 3 hours of stroke onset are at high risk of neurological worsening especially if concomitant low body temperature and leukoaraiosis.
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Affiliation(s)
- Halvor Naess
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Centre for age-related medicine; Stavanger University Hospital; Stavanger Norway
| | - Lars Thomassen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Ulrike Waje-Andreassen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Solveig Glad
- Department of Neurology; Haukeland University Hospital; Bergen Norway
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Nzwalo H, Félix C, Nogueira J, Guilherme P, Ferreira F, Salero T, Ramalhete S, Martinez J, Mouzinho M, Marreiros A, Thomassen L, Logallo N. Predictors of long-term survival after spontaneous intracerebral hemorrhage in southern Portugal: A retrospective study of a community representative population. J Neurol Sci 2018; 394:122-126. [PMID: 30248570 DOI: 10.1016/j.jns.2018.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 09/12/2018] [Accepted: 09/14/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Hipólito Nzwalo
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal.
| | - Catarina Félix
- Neurology Department, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Jerina Nogueira
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Patrícia Guilherme
- Neurology Department, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Fátima Ferreira
- Neurology Department, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Teresa Salero
- Department of Internal Medicine, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Sara Ramalhete
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Joana Martinez
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Maria Mouzinho
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Ana Marreiros
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal; Algarve Biomedical Center, Algarve, Portugal
| | - Lars Thomassen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
| | - Nicola Logallo
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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Aamodt AH, Kurz M, Jacobsen EA, Totland JA, Rønning OM, Thomassen L, Lund CG, Næss H. Indications for thrombectomy. Tidsskr Nor Laegeforen 2018; 138:18-0771. [PMID: 30378416 DOI: 10.4045/tidsskr.18.0771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Pristipino C, Sievert H, D’Ascenzo F, Louis Mas J, Meier B, Scacciatella P, Hildick-Smith D, Gaita F, Toni D, Kyrle P, Thomson J, Derumeaux G, Onorato E, Sibbing D, Germonpré P, Berti S, Chessa M, Bedogni F, Dudek D, Hornung M, Zamorano J, D’Ascenzo F, Omedè P, Ballocca F, Barbero U, Giordana F, Gili S, Iannaccone M, Capodanno D, Valgimigli M, Byrne R, Akagi T, Carroll J, Dalvi B, Ge J, Kasner S, Michel-Behnke I, Pedra C, Rhodes J, Søndergaard L, Thomassen L, Biondi-Zoccai GGL. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. Eur Heart J 2018; 40:3182-3195. [PMID: 30358849 DOI: 10.1093/eurheartj/ehy649] [Citation(s) in RCA: 165] [Impact Index Per Article: 27.5] [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] [Received: 09/24/2018] [Accepted: 09/28/2018] [Indexed: 02/05/2023] Open
Abstract
Abstract
The presence of a patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions; however, the subject remains controversial and no official statements have been published. This interdisciplinary paper, prepared with involvement of eight European scientific societies, aims to review the available trial evidence and to define the principles needed to guide decision making in patients with PFO. In order to guarantee a strict process, position statements were developed with the use of a modified grading of recommendations assessment, development, and evaluation (GRADE) methodology. A critical qualitative and quantitative evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk/benefit ratio. The level of evidence and the strength of the position statements of particular management options were weighed and graded according to predefined scales. Despite being based often on limited and non-randomised data, while waiting for more conclusive evidence, it was possible to conclude on a number of position statements regarding a rational general approach to PFO management and to specific considerations regarding left circulation thromboembolism. For some therapeutic aspects, it was possible to express stricter position statements based on randomised trials. This position paper provides the first largely shared, interdisciplinary approach for a rational PFO management based on the best available evidence.
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Affiliation(s)
| | - Horst Sievert
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany
- Anglia Ruskin University, Chelmsford, United Kingdom, and University of California San Francisco (UCSF), San Francisco, USA
| | - Fabrizio D’Ascenzo
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Jean Louis Mas
- Hôpital Sainte-Anne, Université Paris Descartes, Paris, France
| | | | - Paolo Scacciatella
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Fiorenzo Gaita
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Danilo Toni
- Hospital Policlinico Umberto I, Sapienza University, Rome, Italy
| | | | | | | | | | - Dirk Sibbing
- Campus Großhadern, Ludwig-Maximilians-Universität (LMU), Munich, Germany
| | | | | | - Massimo Chessa
- Policlinico, San Donato, University Hospital, San Donato Milanese, Milan, Italy
| | - Francesco Bedogni
- Policlinico, San Donato, University Hospital, San Donato Milanese, Milan, Italy
| | | | - Marius Hornung
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany
| | | | - Fabrizio D’Ascenzo
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Pierluigi Omedè
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Flavia Ballocca
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Umberto Barbero
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Francesca Giordana
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Sebastiano Gili
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Mario Iannaccone
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy
| | | | - Robert Byrne
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | | | - John Carroll
- University of Colorado Hospital, Denver, CO, USA
| | | | - Junbo Ge
- Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Scott Kasner
- University of Pennsylvania, Philadelphia, PA, USA
| | | | - Carlos Pedra
- Dante Pazzanese Instituto de Cardiologia, Sao Paulo, Brazil
| | - John Rhodes
- Nicklaus Children’s Hospital, Miami, USA, FL
| | | | | | - Giuseppe G L Biondi-Zoccai
- Sapienza University of Rome, Latina, Italy
- Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy
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Khanevski AN, Bjerkreim AT, Novotny V, Naess H, Thomassen L, Logallo N, Kvistad CE. Thirty-day recurrence after ischemic stroke or TIA. Brain Behav 2018; 8:e01108. [PMID: 30222913 PMCID: PMC6192402 DOI: 10.1002/brb3.1108] [Citation(s) in RCA: 12] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 07/31/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Incidence of recurrent stroke is highest within 30 days after the initial ischemic stroke (IS) or TIA, but knowledge about early recurrence is lacking. We aimed to identify etiological groups with highest risk of early recurrence and assess how the TOAST classification identified index stroke etiology. METHODS Medical records of 1874 IS and TIA patients in the Bergen NORSTROKE registry were retrospectively reviewed for identification of recurrent IS or TIA within 30 days after index IS or TIA. Stroke etiology was determined by review of electronical medical journals. Logistic regression was used to calculate odds ratios (OR) for 30-day recurrence. RESULTS Thirty-three patients (1.8%) were readmitted with recurrent IS or TIA within 30 days after index stroke. By using TOAST, 12 patients were initially classified with stroke of unknown etiology (SUE). Etiologies behind recurrent IS or TIA were after the recurrent episode identified as extracranial large artery atherosclerosis (LAA) in 14 patients (42.4%), intracranial arterial pathology in seven patients (21.2%), active malignancy in six patients (18.2%), and cardio embolism in four patients (12.1%). Small vessel occlusion and SUE were the causes in one patient each. Logistic regression showed that patients with stroke of other determined etiology (SOE) and LAA had increased risk of 30-day recurrence (OR = 9.72, 95% CI 1.84-51.3, p < 0.01 and OR = 4.36, 95% CI 2.01-9.47, p < 0.01, respectively). CONCLUSION Patients with LAA and SOE had increased risk of recurrent IS or TIA within 30 days. TOAST was inadequate at identifying exact etiologies behind recurrent stroke at index event.
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Affiliation(s)
- Andrej Netland Khanevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Norwegian Health Association, Oslo, Norway
| | - Anna Therese Bjerkreim
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Vojtech Novotny
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Halvor Naess
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Centre for Age-related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Lars Thomassen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Nicola Logallo
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Christopher E Kvistad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Kvistad CE, Novotny V, Næss H, Hagberg G, Ihle-Hansen H, Waje-Andreassen U, Thomassen L, Logallo N. Safety and predictors of stroke mimics in The Norwegian Tenecteplase Stroke Trial (NOR-TEST). Int J Stroke 2018; 14:508-516. [DOI: 10.1177/1747493018790015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Stroke mimics are frequently treated with thrombolysis in clinical practice and thrombolytic trials. Although alteplase in stroke mimics has proven to be safe, safety of tenecteplase in stroke mimics has not been assessed in an ischemic stroke study setting. We aimed to assess clinical characteristics and safety of stroke mimics treated with thrombolysis in the Norwegian Tenecteplase Stroke Trial. We also aimed to identify possible predictors of stroke mimics as compared to patients with acute cerebral ischemia. Methods Norwegian Tenecteplase Stroke Trial was a phase-3 trial investigating safety and efficacy of tenecteplase vs. alteplase in patients with suspected acute cerebral ischemia. Two groups were defined based on diagnose at discharge: patients with a different diagnose than ischemic stroke or transient ischemic attack (stroke mimics group) and patients diagnosed with ischemic stroke or transient ischemic attack (acute cerebral ischemia group). Logistic regression analyses were performed with stroke mimics vs. acute cerebral ischemia as dependent variable to identify predictors of stroke mimics. Results Of 1091 randomized patients, 181 (16.6%) were stroke mimics. Migraine (22.2%) and peripheral vertigo (11.4%) were the two most frequent stroke mimic-diagnoses. There was no symptomatic intracerebral hemorrhage in the stroke mimics group. Stroke mimics were independently associated with age ≤60 years (OR 2.75, p < 0.001), female sex (OR 1.48, p = 0.026), no history of myocardial infarction (OR 2.03, p = 0.045), systolic BP ≤ 150 mmHg (OR 2.33, p < 0.001), NIHSS ≤ 6 points (OR 1.83, p = 0.011), sensory loss (OR 1.55, p = 0.015), and no facial paresis (OR 2.41, p < 0.001) on admission. Conclusion Thrombolysis with tenecteplase seems to be as safe as with alteplase in stroke mimics. Predictors were identified for stroke mimics which may contribute to differentiate stroke mimics from acute cerebral ischemia in future stroke trials.
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Affiliation(s)
- Christopher Elnan Kvistad
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Vojtech Novotny
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Halvor Næss
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
- Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Guri Hagberg
- Department of Medicine, Vestre Viken HT, Bærum Hospital, Drammen, Norway
| | - Hege Ihle-Hansen
- Department of Medicine, Vestre Viken HT, Bærum Hospital, Drammen, Norway
| | - Ulrike Waje-Andreassen
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Thomassen
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Nicola Logallo
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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Nzwalo H, Nogueira J, Guilherme P, Abreu P, Félix C, Ferreira F, Ramalhete S, Marreiros A, Tatlisumak T, Thomassen L, Logallo N. Hospital readmissions after spontaneous intracerebral hemorrhage in Southern Portugal. Clin Neurol Neurosurg 2018; 169:144-148. [PMID: 29665499 DOI: 10.1016/j.clineuro.2018.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/09/2018] [Accepted: 04/11/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Spontaneous intracerebral hemorrhage (SICH) survivors are at risk of hospital readmissions. Data on readmissions after SICH is scarce. We aimed to study the frequency and predictors of readmissions after SICH in Algarve, Portugal. PATIENTS AND METHODS Retrospective study of a community representative cohort of SICH survivors (2009-2015). The first unplanned readmission in the first year after discharge was the outcome. Cox regression analysis was performed to identify predictors of 1-year readmission. RESULTS Of the 357 SICH survivors followed, 116 (32.5%) were readmitted within the first-year. Sixty-seven (18.8%) of the survivors were early readmitted (<90 days), corresponding to 57.8% or all readmissions. Common causes were pneumonia, endocrine/nutritional/metabolic and cardiovascular complications. The risk of readmission was increased by prior to index SICH history of ≥ 3 previous emergency department visits (hazards ratio (HR) = 2.663 (1.770-4.007); P < 0.001), pneumonia during index hospitalization (HR = 2.910 (1.844-4.592); P < 0.001) and reduced in patients discharge home (HR = 0.681 (0.366-0.976); P = 0.048). CONCLUSIONS The rate of readmissions after SICH is high, predictors are identifiable and causes are potentially preventable. Improvement of care can potentially reduce this burden.
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Affiliation(s)
- Hipólito Nzwalo
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal.
| | - Jerina Nogueira
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Patrícia Guilherme
- Neurology Department, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Pedro Abreu
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Catarina Félix
- Neurology Department, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Fátima Ferreira
- Neurology Department, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Sara Ramalhete
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Ana Marreiros
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Thomassen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
| | - Nicola Logallo
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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Abstract
OBJECTIVES We aimed to investigate the impact of visual field defects (VFD) on mortality in ischemic stroke patients. MATERIALS AND METHODS All patients with acute infarction and a clinically detected VFD from February 2006 to December 2013 in the NORSTROKE Registry (n = 506) were included and compared with ischemic stroke patients with normal visual fields (n = 2041). A record of patients who had died per ultimo April 2015 was obtained from the central registry at Haukeland University Hospital. RESULTS Patients with VFD were significantly older (75.0 vs 69.8, P < .001) than patients with normal visual fields. The majority of patients with VFD was male, had higher cardiovascular morbidity prestroke, and were more likely to have shorter median time from symptom onset to admission (1.7 hours vs 2.7 hours, P < .001). Baseline National Institute of Health Stroke Scale (NIHSS) score was higher (12.7 vs 3.5, P < .001) as was modified Rankin Scale (mRS) score (3.5 vs 1.9, P < .001) and Barthel Index was lower (51.9 vs 84.8, P < .001) day 7. VFD was associated with increased mortality on Kaplan-Meier plots. Hazard ratio was significantly higher for patients with VFD after adjusting for age, sex, employment prior to infarction, married prior to infarction, institutionalization prior to infarction, prior myocardial infarction, atrial fibrillation, smoking, Barthel Index score and i.v. thrombolysis with Cox regression (hazard ratios [HR] 1.30, CI 1.07-1.56, P = .007). CONCLUSIONS Having a visual field defect after ischemic stroke is independently associated with increased mortality. This should be addressed when selecting candidates for thrombolysis and in the rehabilitation process.
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Affiliation(s)
- K. M. Sand
- Department of Neurology; Institute for Clinical Medicine; University of Bergen; Bergen Norway
| | - H. Naess
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Centre for Age-Related Medicine; Stavanger University Hospital; Stavanger Norway
| | - L. Thomassen
- Department of Neurology; Institute for Clinical Medicine; University of Bergen; Bergen Norway
- Department of Neurology; Haukeland University Hospital; Bergen Norway
| | - J. M. Hoff
- Department of Neurology; Haukeland University Hospital; Bergen Norway
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Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is the most severe form of stroke, but data on readmission after ICH are sparse. We aimed to determine frequency, causes, and predictors of 30-day readmission after ICH. MATERIALS AND METHODS This retrospective cohort study includes all spontaneous ICH survivors admitted to the stroke unit at Haukeland University Hospital in Bergen in Norway from July 2007 to December 2013. Patients were followed by review of electronic medical charts, and the first unplanned readmission within 30 days after discharge was used as final outcome. Cox regression analysis was performed to identify predictors of 30-day readmission. RESULTS We identified 226 patients with spontaneous ICH, 70 (31.0%) of whom died before discharge or were discharged to palliative care. Of the remaining 156 ICH survivors, 28 (18.0%) were readmitted within 30 days. Median time to readmission was 12 days (IQR 4.5 - 18.5). Most patients were readmitted due to infections (N = 13). None of the patients were readmitted with recurrent stroke. Pneumonia and enteral feeding during the index hospitalization were associated with readmission for infections (both p < .01). Age was the only independent predictor of readmission (HR 1.06, 95% CI 1.02 - 1.11, p = .006). CONCLUSIONS Almost one in five of our spontaneous ICH survivors was readmitted within 30 days, and most readmissions were caused by infections.
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Affiliation(s)
- Anna Therese Bjerkreim
- Department of Clinical Medicine University of Bergen Bergen Norway.,Department of Neurology Haukeland University Hospital Bergen Norway
| | - Andrej Netland Khanevski
- Department of Neurology Haukeland University Hospital Bergen Norway.,Norwegian Health Association Oslo Norway
| | | | - Lars Thomassen
- Department of Clinical Medicine University of Bergen Bergen Norway.,Department of Neurology Haukeland University Hospital Bergen Norway
| | - Halvor Naess
- Department of Clinical Medicine University of Bergen Bergen Norway.,Department of Neurology Haukeland University Hospital Bergen Norway.,Centre for age-related medicine Stavanger University Hospital Stavanger Norway
| | - Nicola Logallo
- Department of Clinical Medicine University of Bergen Bergen Norway.,Department of Neurology Haukeland University Hospital Bergen Norway.,Department of Neurosurgery Haukeland University Hospital Bergen Norway
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Kvistad CE, Nacu A, Novotny V, Logallo N, Waje‐Andreassen U, Naess H, Thomassen L. Contrast-enhanced sonothrombolysis in acute ischemic stroke patients without intracranial large-vessel occlusion. Acta Neurol Scand 2018; 137:256-261. [PMID: 29068044 DOI: 10.1111/ane.12861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Contrast-enhanced sonothrombolysis (CEST) leads to a more rapid recanalization in acute ischemic stroke caused by intracranial large-vessel occlusion (LVO). Animal studies have shown that CEST also may be safe and efficient in treating the ischemic microcirculation in the absence of LVO. The exact mechanism behind this treatment effect is not known. We aimed to assess safety and efficacy of CEST in acute ischemic stroke patients included in the Norwegian Sonothrombolysis in Acute Stroke Study (NOR-SASS) without LVO on admission CT angiography (CTA). METHODS NOR-SASS was a randomized controlled trial of CEST in ischemic stroke patients treated with intravenous thrombolysis within 4.5 hours after stroke onset. Patients were randomized to either CEST or sham CEST. In this study, patients were excluded if they had partial or total occlusion on admission CTA, ultrasound-resistant bone window, had received CEST with incorrect insonation as compared to stroke location on Magnetic resonance imaging (MRI), or were stroke mimics. RESULTS Of the 183 patients included in NOR-SASS, a total of 83 (45.4%) patients matched the inclusion criteria, of which 40 received CEST and 43 sham CEST. There were no patients with symptomatic intracranial hemorrhage (sICH) in the CEST group. Rates of asymptomatic ICH, microbleeds, and mortality were not increased in the CEST group. Neurological improvement at 24 hours and functional outcome at 90 days were similar in both groups. CONCLUSION CEST is safe in ischemic stroke patients without intracranial LVO. There were no differences in clinical outcomes between the treatment groups.
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Affiliation(s)
- C. E. Kvistad
- Department of Neurology Haukeland University Hospital Bergen Norway
| | - A. Nacu
- Department of Neurology Haukeland University Hospital Bergen Norway
| | - V. Novotny
- Department of Neurology Haukeland University Hospital Bergen Norway
| | - N. Logallo
- Department of Neurology Haukeland University Hospital Bergen Norway
| | | | - H. Naess
- Department of Neurology Haukeland University Hospital Bergen Norway
| | - L. Thomassen
- Department of Neurology Haukeland University Hospital Bergen Norway
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Kasner SE, Sondergaard L, Rhodes JF, Anderson G, Iversen HK, Nielsen-Kudsk JE, Settergren M, Sjostrand C, Roine RO, Hildick-Smith D, Spence JD, Thomassen L. Abstract 102: Consistency of Efficacy of PFO Closure in the Gore Reduce Trial. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.102] [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 Gore REDUCE Clinical Study (REDUCE) demonstrated superiority of PFO closure in conjunction with antiplatelet therapy over antiplatelet therapy alone in reducing the risk of recurrent clinical ischemic stroke or new silent brain infarct in patients with cryptogenic stroke.
Methods:
We randomized 664 subjects with cryptogenic stroke at 63 multinational sites in a 2:1 ratio to either antiplatelet therapy plus PFO closure (with Gore HELEX Septal Occluder or Gore CARDIOFORM Septal Occluder) or antiplatelet therapy alone. Co-primary endpoints were freedom from recurrent clinical ischemic stroke through ≥2 years and incidence of new brain infarct (defined as the composite of clinical ischemic stroke and silent brain infarct) at 2 years. Primary analyses were performed on the intention-to-treat (ITT) population. Per-protocol (PP) analysis included only subjects randomized and treated according to critical protocol requirements (excluding those who violated key eligibility criteria, did not receive the therapy to which they were randomized, or did not comply with protocol-required medical regimen). As-treated (AT) analysis assessed all subjects based on treatment received, regardless of study assignment.
Results:
PFO closure was associated with a highly consistent reduction in risk compared to medical therapy alone in all three analytic cohorts (Table).
Conclusions:
Among selected patients with cryptogenic stroke and PFO, closure of the PFO plus antiplatelet therapy was superior to antiplatelet therapy alone for reducing the risk of subsequent ischemic stroke.
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Affiliation(s)
| | | | | | - Grethe Anderson
- Neurology, Aarhus Univ Hosp and Faculty of Heath, Aarhus Univ, Aarhus, Denmark
| | - Helle K Iversen
- Neurology, Rigshospitalet, Univ of Copenhagen, Copenhagen, Denmark
| | | | - Magnus Settergren
- Cardiology, Karolinska Institutet and Karolinska Univ Hosp, Stockholm, Sweden
| | - Christina Sjostrand
- Neurology, Karolinska Institutet, and Karolinska Univ Hosp, Stockholm, Sweden
| | - Risto O Roine
- Clinical Neuroscience, Turku Univ Hosp and Univ of Turku, Turku, Finland
| | - David Hildick-Smith
- Cardiology, Sussex Cardiac Cntr, Brighton & Sussex Univ Hosps, Sussex, United Kingdom
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Bjerkreim AT, Khanevski A, Selvik HA, Thomassen L, Waje-Andreassen U, Naess H, Logallo N. Abstract TP198: Risk of 30-day Hospital Readmission: Does Ischemic Stroke Subtype Matter? Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tp198] [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:
Stroke patients are at high risk of new diseases. However, as there are differences in risk factors, outcome and treatment for the various ischemic stroke (IS) and transient ischemic attack (TIA) etiologies, there may also be differences in their risk and causes of readmission. We aimed to investigate frequency and causes for 30-day readmission for the different IS subtypes, and estimate each subtypes risk of cause-specific 30-day readmission.
Methods:
All surviving IS or TIA patients admitted to a large Norwegian Hospital between July 2007 and January 2014 were followed by review of medical records. Main outcome of interest was the first unplanned readmission within 30 days after discharge. Stroke etiology was classified according to the TOAST criteria as large-artery atherosclerosis (LAA), cardioembolism (CE), small vessel occlusion (SVO), stroke of other demonstrated cause (SOC), or stroke of undetermined cause (SUC). Cox regression was performed to assess 30-day readmission risk of all-cause and cause-specific readmission for the different IS subtypes.
Results:
Of 1890 patients, 10.6 % were readmitted within 30 days (43/245 (17.6%) LAA, 75/614 (12.2%) CE, 12/205 (5.9%) SVO, 6/33 (18.2%) SOC, 65/793 (8.2%) SUC). Most frequent causes were stroke-related events (sequela, progressive stroke and neurological symptoms), infections, recurrent stroke and heart disease, but causes of readmission were unevenly distributed among the different stroke subtypes. Patients with LAA or SOC had significant higher risk of all-cause readmission and recurrent stroke, and patients with SUC had significant lower risk of all-cause readmission.
Conclusion:
We found significant variations in frequency and causes of 30-day readmission for the different IS subtypes. This approach supports the concept of IS as an polyetiologic disease, with unevenly distributed risk factors and comorbidity between the different etiologies. At the conference, we will also present and discuss predictors for 30-day all-cause readmission.
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Affiliation(s)
| | | | | | | | | | - Halvor Naess
- Dept of Neurology, Haukeland Univ Hosp, Bergen, Norway
| | - Nicola Logallo
- Dept of Neurosurgery, Haukeland Univ Hosp, Bergen, Norway
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Selvik HA, Bjerkreim AT, Thomassen L, Waje-Andreassen U, Naess H, Kvistad CE. When to Screen Ischaemic Stroke Patients for Cancer. Cerebrovasc Dis 2018; 45:42-47. [PMID: 29402826 DOI: 10.1159/000484668] [Citation(s) in RCA: 29] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/25/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND PURPOSE Ischemic stroke can be the first manifestation of cancer and it is therefore important to ascertain which stroke patients should be considered for cancer-diagnostic investigations. We aimed to determine the frequency of active cancer in patients with acute ischemic stroke and to compare clinical findings in stroke patients with active cancer to ischemic stroke patients with no history of cancer. Finally, we aimed to develop a predictive and feasible score for clinical use to uncover underlying malignancy. METHODS All ischemic stroke patients admitted to the stroke unit in the Department of Neurology, Haukeland University Hospital were consecutively included in the Norwegian Stroke Research Registry (NORSTROKE). Stroke etiology was determined by the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Data on cancer diagnoses was obtained from patients' medical records and the Cancer Registry of Norway. Active cancer was defined as cancer diagnosis, metastasis of known cancer, recurrent cancer or receiving cancer treatment, all within 12 months before or after the index stroke. Based on variables independently associated with active cancer, a predictive score was developed using the area under the receiver operating characteristic (AUC-ROC) curves. Bayes' theorem was used to calculate post-test probabilities of active cancer. RESULTS Of the 1,646 ischemic stroke patients included, 82 (5.0%) had active cancer. Increased D-dimer (OR = 1.1, 95% CI: 1.1-1.2, p = <0.001), lower Hb (OR = 0.6, 95% CI: 0.5-0.7, p = <0.001), smoking (OR = 2.2, 95% CI: 1.2-4.3, p = 0.02) and suffering a stroke of undetermined etiology (OR = 1.9, 95% CI: 1.1-3.3, p = 0.03) were factors independently associated with active cancer. These were included in the final predictive score which gave an AUC of 0.73 (95% CI: 0.65-0.81) in patients younger than 75 years of age. Assuming the prevalence of cancer to be 5%, the score shows that if a patient fulfills all 3 score points, the probability of active cancer is 53%. CONCLUSIONS Active cancer was found in 5% of our ischemic stroke patients. We found that a clinical score comprising elevated D-dimer ≥3 mg/L, lower Hb ≤12.0 g/dL and previous or current smoking is feasible for predicting active cancer in ischemic stroke patients.
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Affiliation(s)
- Henriette Aurora Selvik
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Anna Therese Bjerkreim
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Thomassen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Ulrike Waje-Andreassen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - Halvor Naess
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
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Kvistad CE, Thomassen L, Aamodt AH, Logallo N. Tenecteplase ved akutt hjerneinfarkt. Tidsskriftet 2018; 138:17-0992. [DOI: 10.4045/tidsskr.17.0992] [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: 11/02/2022] Open
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Nzwalo H, Nogueira J, Félix AC, Guilherme P, Abreu P, Figueiredo T, Ferreira F, Marreiros A, Thomassen L, Logallo N. Short-Term Outcome of Spontaneous Intracerebral Hemorrhage in Algarve, Portugal: Retrospective Hospital-Based Study. J Stroke Cerebrovasc Dis 2017; 27:346-351. [PMID: 29102391 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 08/24/2017] [Accepted: 09/07/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The short-term outcome from spontaneous intracerebral hemorrhage (SICH) is influenced by local quality of care and population specificities. There are no studies about the SICH mortality in southern Portugal. The objective of this study was to describe the predictors of 30-day in-hospital SICH mortality in Algarve, the southernmost region of Portugal. METHODS Logistic regression was used to identify predictors of in-hospital death. Kaplan-Meier analysis was used to estimate survival over time based on SICH severity. RESULTS Of the 549 cases, 349 (63.6%) were men; the mean age was 71.4 years. Two hundred seventeen patients (39.5%) did not receive stroke unit (SU) care. The 30-day mortality was 34.4%. Independent predictors of death were older age (odds ratio [OR] = 1.096, 95% confidence interval [CI] = 1.031-2.062, P = .022) per additional year, vitamin K antagonists use (OR = 5.464, 95% CI = 2.088-25.714, P = .043), admission Glasgow Coma Scale (GCS) score of 8 or lower (OR = 20.511, 95% CI = 7.862-62.168, P < .0001) or GCS score of 9-12 (OR = 12.709, 95% CI = 3.078-44.113, P < .0001), hematoma volume (OR = 1.037, 95% CI = 1.004-1.071, P = .028) per additional milliliter, intraventricular dissection (OR = 1.916, 95% CI = 1.105-4.566, P = .046), and pneumonia (OR 12.918, 95% CI = 4.603-24.683, P < .0001). SU care was independently associated with reduction of death (OR .395, 95% CI = .126-.635, P = .004). Severity correlated with short time to death (P < .0001). Sixty-five of the patients (39.2%) died after the seventh day of SICH ("non-neurological deaths"). CONCLUSIONS The in-hospital 30-day mortality is high in the region. Admitting more patients to the SU and implementation of preventive strategies of complications can reduce mortality.
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Affiliation(s)
- Hipolito Nzwalo
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal.
| | - Jerina Nogueira
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | | | | | - Pedro Abreu
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Teresa Figueiredo
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Fátima Ferreira
- Neurology Department, Centro Hospitalar do Algarve, Algarve, Portugal
| | - Ana Marreiros
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Lars Thomassen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
| | - Nicola Logallo
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
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Khanevski AN, Naess H, Thomassen L, Waje-Andreassen U, Nacu A, Kvistad CE. Elevated body temperature in ischemic stroke associated with neurological improvement. Acta Neurol Scand 2017; 136:414-418. [PMID: 28251609 DOI: 10.1111/ane.12743] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Some studies suggest that high body temperature within the first few hours of ischemic stroke onset is associated with improved outcome. We hypothesized an association between high body temperature on admission and detectable improvement within 6-9 hours of stroke onset. MATERIALS AND METHODS Consecutive ischemic stroke patients with NIHSS scores obtained within 3 hours and in the interval 6-9 hours after stroke onset were included. Body temperature was measured on admission. RESULTS A total of 315 patients with ischemic stroke were included. Median NIHSS score on admission was 6. Linear regression showed that NIHSS score 6-9 hours after stroke onset was inversely associated with body temperature on admission after adjusting for confounders including NIHSS score <3 hours after stroke onset (P<.001). The same result was found in patients with proximal middle cerebral occlusion on admission. CONCLUSIONS We found an inverse association between admission body temperature and neurological improvement within few hours after admission. This finding may be limited to patients with documented proximal middle cerebral artery occlusion on admission and suggests a beneficial effect of higher body temperature on clot lysis within the first three hours.
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Affiliation(s)
- A. N. Khanevski
- Department of Neurology; Haukeland University Hospital; Bergen Norway
| | - H. Naess
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Centre of Age-Related Medicine; Stavanger University Hospital; Stavanger Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - L. Thomassen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | | | - A. Nacu
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - C. E. Kvistad
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
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44
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Logallo N, Novotny V, Assmus J, Kvistad CE, Alteheld L, Rønning OM, Thommessen B, Amthor KF, Ihle-Hansen H, Kurz M, Tobro H, Kaur K, Stankiewicz M, Carlsson M, Morsund Å, Idicula T, Aamodt AH, Lund C, Næss H, Waje-Andreassen U, Thomassen L. Tenecteplase versus alteplase for management of acute ischaemic stroke (NOR-TEST): a phase 3, randomised, open-label, blinded endpoint trial. Lancet Neurol 2017; 16:781-788. [DOI: 10.1016/s1474-4422(17)30253-3] [Citation(s) in RCA: 205] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 11/24/2022]
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Søndergaard L, Kasner SE, Rhodes JF, Andersen G, Iversen HK, Nielsen-Kudsk JE, Settergren M, Sjöstrand C, Roine RO, Hildick-Smith D, Spence JD, Thomassen L. Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke. N Engl J Med 2017; 377:1033-1042. [PMID: 28902580 DOI: 10.1056/nejmoa1707404] [Citation(s) in RCA: 654] [Impact Index Per Article: 93.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The efficacy of closure of a patent foramen ovale (PFO) in the prevention of recurrent stroke after cryptogenic stroke is uncertain. We investigated the effect of PFO closure combined with antiplatelet therapy versus antiplatelet therapy alone on the risks of recurrent stroke and new brain infarctions. METHODS In this multinational trial involving patients with a PFO who had had a cryptogenic stroke, we randomly assigned patients, in a 2:1 ratio, to undergo PFO closure plus antiplatelet therapy (PFO closure group) or to receive antiplatelet therapy alone (antiplatelet-only group). Imaging of the brain was performed at the baseline screening and at 24 months. The coprimary end points were freedom from clinical evidence of ischemic stroke (reported here as the percentage of patients who had a recurrence of stroke) through at least 24 months after randomization and the 24-month incidence of new brain infarction, which was a composite of clinical ischemic stroke or silent brain infarction detected on imaging. RESULTS We enrolled 664 patients (mean age, 45.2 years), of whom 81% had moderate or large interatrial shunts. During a median follow-up of 3.2 years, clinical ischemic stroke occurred in 6 of 441 patients (1.4%) in the PFO closure group and in 12 of 223 patients (5.4%) in the antiplatelet-only group (hazard ratio, 0.23; 95% confidence interval [CI], 0.09 to 0.62; P=0.002). The incidence of new brain infarctions was significantly lower in the PFO closure group than in the antiplatelet-only group (22 patients [5.7%] vs. 20 patients [11.3%]; relative risk, 0.51; 95% CI, 0.29 to 0.91; P=0.04), but the incidence of silent brain infarction did not differ significantly between the study groups (P=0.97). Serious adverse events occurred in 23.1% of the patients in the PFO closure group and in 27.8% of the patients in the antiplatelet-only group (P=0.22). Serious device-related adverse events occurred in 6 patients (1.4%) in the PFO closure group, and atrial fibrillation occurred in 29 patients (6.6%) after PFO closure. CONCLUSIONS Among patients with a PFO who had had a cryptogenic stroke, the risk of subsequent ischemic stroke was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone; however, PFO closure was associated with higher rates of device complications and atrial fibrillation. (Funded by W.L. Gore and Associates; Gore REDUCE ClinicalTrials.gov number, NCT00738894 .).
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Affiliation(s)
- Lars Søndergaard
- From the Departments of Cardiology (L.S.) and Neurology (H.K.I.) Rigshospitalet, University of Copenhagen, Copenhagen, and the Departments of Neurology (G.A.) and Cardiology (J.E.N.-K.) and the Faculty of Health (G.A.), Aarhus University, Aarhus - both in Denmark; the Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.); the Department of Cardiology, Nicklaus Children's Hospital, Miami (J.F.R.); Heart and Vascular Theme (M.S.) and Department of Neurology (C.S.), Karolinska University Hospital, and Departments of Medicine (M.S.) and Clinical Neuroscience (C.S.), Karolinska Institutet - both in Stockholm; the Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland (R.O.R.); the Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom (D.H.-S.); the Division of Neurology, Western University, London, ON, Canada (J.D.S.); and the Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.)
| | - Scott E Kasner
- From the Departments of Cardiology (L.S.) and Neurology (H.K.I.) Rigshospitalet, University of Copenhagen, Copenhagen, and the Departments of Neurology (G.A.) and Cardiology (J.E.N.-K.) and the Faculty of Health (G.A.), Aarhus University, Aarhus - both in Denmark; the Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.); the Department of Cardiology, Nicklaus Children's Hospital, Miami (J.F.R.); Heart and Vascular Theme (M.S.) and Department of Neurology (C.S.), Karolinska University Hospital, and Departments of Medicine (M.S.) and Clinical Neuroscience (C.S.), Karolinska Institutet - both in Stockholm; the Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland (R.O.R.); the Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom (D.H.-S.); the Division of Neurology, Western University, London, ON, Canada (J.D.S.); and the Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.)
| | - John F Rhodes
- From the Departments of Cardiology (L.S.) and Neurology (H.K.I.) Rigshospitalet, University of Copenhagen, Copenhagen, and the Departments of Neurology (G.A.) and Cardiology (J.E.N.-K.) and the Faculty of Health (G.A.), Aarhus University, Aarhus - both in Denmark; the Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.); the Department of Cardiology, Nicklaus Children's Hospital, Miami (J.F.R.); Heart and Vascular Theme (M.S.) and Department of Neurology (C.S.), Karolinska University Hospital, and Departments of Medicine (M.S.) and Clinical Neuroscience (C.S.), Karolinska Institutet - both in Stockholm; the Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland (R.O.R.); the Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom (D.H.-S.); the Division of Neurology, Western University, London, ON, Canada (J.D.S.); and the Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.)
| | - Grethe Andersen
- From the Departments of Cardiology (L.S.) and Neurology (H.K.I.) Rigshospitalet, University of Copenhagen, Copenhagen, and the Departments of Neurology (G.A.) and Cardiology (J.E.N.-K.) and the Faculty of Health (G.A.), Aarhus University, Aarhus - both in Denmark; the Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.); the Department of Cardiology, Nicklaus Children's Hospital, Miami (J.F.R.); Heart and Vascular Theme (M.S.) and Department of Neurology (C.S.), Karolinska University Hospital, and Departments of Medicine (M.S.) and Clinical Neuroscience (C.S.), Karolinska Institutet - both in Stockholm; the Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland (R.O.R.); the Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom (D.H.-S.); the Division of Neurology, Western University, London, ON, Canada (J.D.S.); and the Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.)
| | - Helle K Iversen
- From the Departments of Cardiology (L.S.) and Neurology (H.K.I.) Rigshospitalet, University of Copenhagen, Copenhagen, and the Departments of Neurology (G.A.) and Cardiology (J.E.N.-K.) and the Faculty of Health (G.A.), Aarhus University, Aarhus - both in Denmark; the Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.); the Department of Cardiology, Nicklaus Children's Hospital, Miami (J.F.R.); Heart and Vascular Theme (M.S.) and Department of Neurology (C.S.), Karolinska University Hospital, and Departments of Medicine (M.S.) and Clinical Neuroscience (C.S.), Karolinska Institutet - both in Stockholm; the Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland (R.O.R.); the Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom (D.H.-S.); the Division of Neurology, Western University, London, ON, Canada (J.D.S.); and the Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.)
| | - Jens E Nielsen-Kudsk
- From the Departments of Cardiology (L.S.) and Neurology (H.K.I.) Rigshospitalet, University of Copenhagen, Copenhagen, and the Departments of Neurology (G.A.) and Cardiology (J.E.N.-K.) and the Faculty of Health (G.A.), Aarhus University, Aarhus - both in Denmark; the Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.); the Department of Cardiology, Nicklaus Children's Hospital, Miami (J.F.R.); Heart and Vascular Theme (M.S.) and Department of Neurology (C.S.), Karolinska University Hospital, and Departments of Medicine (M.S.) and Clinical Neuroscience (C.S.), Karolinska Institutet - both in Stockholm; the Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland (R.O.R.); the Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom (D.H.-S.); the Division of Neurology, Western University, London, ON, Canada (J.D.S.); and the Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.)
| | - Magnus Settergren
- From the Departments of Cardiology (L.S.) and Neurology (H.K.I.) Rigshospitalet, University of Copenhagen, Copenhagen, and the Departments of Neurology (G.A.) and Cardiology (J.E.N.-K.) and the Faculty of Health (G.A.), Aarhus University, Aarhus - both in Denmark; the Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.); the Department of Cardiology, Nicklaus Children's Hospital, Miami (J.F.R.); Heart and Vascular Theme (M.S.) and Department of Neurology (C.S.), Karolinska University Hospital, and Departments of Medicine (M.S.) and Clinical Neuroscience (C.S.), Karolinska Institutet - both in Stockholm; the Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland (R.O.R.); the Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom (D.H.-S.); the Division of Neurology, Western University, London, ON, Canada (J.D.S.); and the Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.)
| | - Christina Sjöstrand
- From the Departments of Cardiology (L.S.) and Neurology (H.K.I.) Rigshospitalet, University of Copenhagen, Copenhagen, and the Departments of Neurology (G.A.) and Cardiology (J.E.N.-K.) and the Faculty of Health (G.A.), Aarhus University, Aarhus - both in Denmark; the Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.); the Department of Cardiology, Nicklaus Children's Hospital, Miami (J.F.R.); Heart and Vascular Theme (M.S.) and Department of Neurology (C.S.), Karolinska University Hospital, and Departments of Medicine (M.S.) and Clinical Neuroscience (C.S.), Karolinska Institutet - both in Stockholm; the Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland (R.O.R.); the Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom (D.H.-S.); the Division of Neurology, Western University, London, ON, Canada (J.D.S.); and the Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.)
| | - Risto O Roine
- From the Departments of Cardiology (L.S.) and Neurology (H.K.I.) Rigshospitalet, University of Copenhagen, Copenhagen, and the Departments of Neurology (G.A.) and Cardiology (J.E.N.-K.) and the Faculty of Health (G.A.), Aarhus University, Aarhus - both in Denmark; the Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.); the Department of Cardiology, Nicklaus Children's Hospital, Miami (J.F.R.); Heart and Vascular Theme (M.S.) and Department of Neurology (C.S.), Karolinska University Hospital, and Departments of Medicine (M.S.) and Clinical Neuroscience (C.S.), Karolinska Institutet - both in Stockholm; the Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland (R.O.R.); the Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom (D.H.-S.); the Division of Neurology, Western University, London, ON, Canada (J.D.S.); and the Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.)
| | - David Hildick-Smith
- From the Departments of Cardiology (L.S.) and Neurology (H.K.I.) Rigshospitalet, University of Copenhagen, Copenhagen, and the Departments of Neurology (G.A.) and Cardiology (J.E.N.-K.) and the Faculty of Health (G.A.), Aarhus University, Aarhus - both in Denmark; the Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.); the Department of Cardiology, Nicklaus Children's Hospital, Miami (J.F.R.); Heart and Vascular Theme (M.S.) and Department of Neurology (C.S.), Karolinska University Hospital, and Departments of Medicine (M.S.) and Clinical Neuroscience (C.S.), Karolinska Institutet - both in Stockholm; the Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland (R.O.R.); the Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom (D.H.-S.); the Division of Neurology, Western University, London, ON, Canada (J.D.S.); and the Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.)
| | - J David Spence
- From the Departments of Cardiology (L.S.) and Neurology (H.K.I.) Rigshospitalet, University of Copenhagen, Copenhagen, and the Departments of Neurology (G.A.) and Cardiology (J.E.N.-K.) and the Faculty of Health (G.A.), Aarhus University, Aarhus - both in Denmark; the Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.); the Department of Cardiology, Nicklaus Children's Hospital, Miami (J.F.R.); Heart and Vascular Theme (M.S.) and Department of Neurology (C.S.), Karolinska University Hospital, and Departments of Medicine (M.S.) and Clinical Neuroscience (C.S.), Karolinska Institutet - both in Stockholm; the Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland (R.O.R.); the Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom (D.H.-S.); the Division of Neurology, Western University, London, ON, Canada (J.D.S.); and the Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.)
| | - Lars Thomassen
- From the Departments of Cardiology (L.S.) and Neurology (H.K.I.) Rigshospitalet, University of Copenhagen, Copenhagen, and the Departments of Neurology (G.A.) and Cardiology (J.E.N.-K.) and the Faculty of Health (G.A.), Aarhus University, Aarhus - both in Denmark; the Department of Neurology, University of Pennsylvania, Philadelphia (S.E.K.); the Department of Cardiology, Nicklaus Children's Hospital, Miami (J.F.R.); Heart and Vascular Theme (M.S.) and Department of Neurology (C.S.), Karolinska University Hospital, and Departments of Medicine (M.S.) and Clinical Neuroscience (C.S.), Karolinska Institutet - both in Stockholm; the Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland (R.O.R.); the Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom (D.H.-S.); the Division of Neurology, Western University, London, ON, Canada (J.D.S.); and the Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.)
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Nzwalo H, Nogueira J, Félix C, Guilherme P, Baptista A, Figueiredo T, Ferreira F, Marreiros A, Thomassen L, Logallo N. Incidence and case-fatality from spontaneous intracerebral hemorrhage in a southern region of Portugal. J Neurol Sci 2017; 380:74-78. [DOI: 10.1016/j.jns.2017.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/15/2017] [Accepted: 07/04/2017] [Indexed: 11/15/2022]
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Abstract
Aim Many patients with ischemic stroke have paroxysmal atrial fibrillation that may be difficult to detect. We sought to identify markers of paroxysmal atrial fibrillation and construct a score that may help the clinician to select patients for anticoagulation even if investigations do not disclose atrial fibrillation. Methods A group of patients with acute ischemic stroke and TIA and documented paroxysmal atrial fibrillation was compared to a group of patients with ischemic stroke and TIA and no known paroxysmal atrial fibrillation and sinus rhythm on Holter monitoring. Clinical features, blood tests, ECG, and MRI findings were compared. Sensitivity and specificity of significant markers for paroxysmal atrial fibrillation were calculated. A simple score based on independent markers for paroxysmal atrial fibrillation was constructed. Results Out of 3480 patients with TIA or ischemic stroke, 237 (19%) had paroxysmal atrial fibrillation and 1002 (81%) had sinus rhythm. On univariate analyses, significant markers for paroxysmal atrial fibrillation included increasing age, females, prior ischemic stroke, myocardial infarction, other heart diseases, pathologic troponin, embolic stroke and stroke in different arterial territories (all P < .01). A score including age dichotomized at 75 years, cardiac disease and troponin was constructed. Conclusion We identified many markers for paroxysmal atrial fibrillation and constructed a score that may help the clinician to select patients for anticoagulation even if investigations do not disclose paroxysmal atrial fibrillation.
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Affiliation(s)
- Halvor Naess
- 1 Department of Neurology, Haukeland University Hospital, Bergen, Norway.,2 Centre for Age-related Medicine, Stavanger University Hospital, Stavanger, Norway.,3 Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ulrike W Andreassen
- 1 Department of Neurology, Haukeland University Hospital, Bergen, Norway.,3 Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Thomassen
- 1 Department of Neurology, Haukeland University Hospital, Bergen, Norway.,3 Institute of Clinical Medicine, University of Bergen, Bergen, Norway
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Sand KM, Naess H, Nilsen RM, Thomassen L, Hoff JM. Less thrombolysis in posterior circulation infarction-a necessary evil? Acta Neurol Scand 2017; 135:546-552. [PMID: 27380826 DOI: 10.1111/ane.12627] [Citation(s) in RCA: 7] [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] [Accepted: 05/26/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Patients with posterior circulation infarction (PCI) have more subtle symptoms than anterior circulation infarction (ACI) and could come too late for acute intervention. This study aimed to describe the clinical presentation, management, and outcome of PCI in the NORSTROKE registry. METHODS All patients with PCI admitted to the Department of Neurology at Haukeland University Hospital and registered in the NORSTROKE database 2006-2013 were included (n=686). Patients with ACI (n=1758) were used for comparison. RESULTS Patients with PCI were younger (68.2 vs 71.8, P<.001), had longer median time from symptom onset to admission (3.8 hours vs 2.2 hours, P<.001), and were less likely to arrive at hospital within 4.5 hours from symptom onset (56.2% vs 72.5%, P<.001, ictus known). Patients with PCI scored lower on baseline National Institute of Health Stroke Scale (NIHSS) total score (3.2 vs 6.3, P<.001), and lower or equally on all items of NIHSS, except for ataxia in two limbs. Patients with PCI were less likely to receive i.v. thrombolytic treatment (9.9% vs 21.5%, OR 0.66, CI 0.47-0.94). On day 7, patients with PCI scored lower on NIHSS (2.8 vs 4.9, P<.001), modified Rankin Scale (2.0 vs 2.3, P<.001), and higher on Barthel Index (84.5 vs 76.0, P<.001). CONCLUSIONS Our study is, to our knowledge, the largest series reporting comprehensively on PCI verified by diffusion-weighted imaging. PCI patients are younger than ACI and have better outcome. PCI and ACI are equally investigated in the acute setting, but thrombolysis rates remain 50% lower in PCI.
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Affiliation(s)
- K. M. Sand
- Department of Neurology; Institute for Clinical Medicine; University of Bergen; Bergen Norway
| | - H. Naess
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Centre for Age-Related Medicine; Stavanger University Hospital; Stavanger Norway
| | - R. M. Nilsen
- Centre for Clinical Research; Haukeland University Hospital; Bergen Norway
| | - L. Thomassen
- Department of Neurology; Institute for Clinical Medicine; University of Bergen; Bergen Norway
- Department of Neurology; Haukeland University Hospital; Bergen Norway
| | - J. M. Hoff
- Department of Neurology; Haukeland University Hospital; Bergen Norway
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Kasner SE, Thomassen L, Søndergaard L, Rhodes JF, Larsen CC, Jacobson J. Patent foramen ovale closure with GORE HELEX or CARDIOFORM Septal Occluder vs. antiplatelet therapy for reduction of recurrent stroke or new brain infarct in patients with prior cryptogenic stroke: Design of the randomized Gore REDUCE Clinical Study. Int J Stroke 2017; 12:998-1004. [PMID: 29090661 DOI: 10.1177/1747493017701152] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rationale The utility of patent foramen ovale (PFO) closure for secondary prevention in patients with prior cryptogenic stroke is uncertain despite multiple randomized trials completed to date. Aims The Gore REDUCE Clinical Study (REDUCE) aims to establish superiority of patent foramen ovale closure in conjunction with antiplatelet therapy over antiplatelet therapy alone in reducing the risk of recurrent clinical ischemic stroke or new silent brain infarct in patients who have had a cryptogenic stroke. Methods and design This controlled, open-label trial randomized 664 subjects with cryptogenic stroke at 63 multinational sites in a 2:1 ratio to either antiplatelet therapy plus patent foramen ovale closure (with GORE® HELEX® Septal Occluder or GORE® CARDIOFORM Septal Occluder) or antiplatelet therapy alone. Subjects will be prospectively followed for up to five years. Neuroimaging is required for all subjects at baseline and at two years or study exit. Study outcomes The two co-primary endpoints for the study are freedom from recurrent clinical ischemic stroke through at least 24 months post-randomization and incidence of new brain infarct (defined as clinical ischemic stroke or silent brain infarct) through 24 months. The primary analyses are an unadjusted log-rank test and a binomial test of subject-based proportions, respectively, both on the intent-to-treat population, with adjustment for testing multiplicity. Discussion The REDUCE trial aims to target a patient population with truly cryptogenic strokes. Medical therapy is limited to antiplatelet agents in both arms thereby reducing confounding. The trial should determine whether patent foramen ovale closure with the Gore septal occluders is safe and more effective than medical therapy alone for the prevention of recurrent clinical ischemic stroke or new silent brain infarct; the neuroimaging data will provide an opportunity to further support the proof of concept. The main results are anticipated in 2017. Registration Clinical trial registration-URL: http://clinicaltrials.gov/show/NCT00738894.
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Affiliation(s)
- Scott E Kasner
- 1 Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Lars Thomassen
- 2 Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - John F Rhodes
- 4 Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
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Novotny V, Thomassen L, Waje-Andreassen U, Naess H. Acute cerebral infarcts in multiple arterial territories associated with cardioembolism. Acta Neurol Scand 2017; 135:346-351. [PMID: 27109593 DOI: 10.1111/ane.12606] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVES It is generally believed that cardioembolism is the main cause of multiple acute cerebral infarcts (MACI). However, there are surprisingly few DWI studies and results are conflicting. Based on a large prospective study we hypothesized that MACI are associated with cardioembolism. MATERIALS AND METHODS We studied 2697 patients with acute cerebral infarcts between February 2006 and October 2013 who were prospectively registered in The Bergen NORSTROKE Registry. Among them, 2220 (82.3%) patients underwent magnetic resonance imaging (MRI) and 2125 (96%) of these 2220 patients had DWI lesions. Only patients with DWI lesions were included. MACI were defined as at least two DWI lesions in at least two different arterial territories. RESULTS MACI were detected in 187/2125 (8.8%) patients with DWI lesions. MACI patients were older and more often females. MACI were associated with cardioembolism (P = 0.042), especially atrial fibrillation (P = 0.002). Other associations were symptomatic internal carotid artery (ICA) stenosis (P = 0.014), asymptomatic ICA stenosis (P = 0.036), and higher NIHSS score on admission (P < 0.001). Among patients with no cardioembolism, 34 (35%) with MACI had symptomatic ICA stenosis versus 268 (25.0%) with non-MACI (P = 0.037); 20 (20%) with MACI had asymptomatic ICA stenosis versus 134 (13%) with non-MACI (P = 0.031). In the logistic regression analysis, cardiac embolism and symptomatic ICA stenosis were independently associated with MACI. CONCLUSIONS Acute cerebral infarcts in more than one arterial territory occur among almost 10% of the patients and are associated with cardioembolism.
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Affiliation(s)
- V. Novotny
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - L. Thomassen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | | | - H. Naess
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Centre for age-related medicine; Stavanger University Hospital; Stavanger Norway
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