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1.
Int J Stroke ; : 1747493019884526, 2019 Oct 25.
Artigo em Inglês | MEDLINE | ID: mdl-31653178

RESUMO

BACKGROUND: Limited national-level information on temporal trends in comprehensive stroke center capabilities and their effects on acute ischemic stroke patients exists. AIMS: To examine trends in in-hospital outcomes of acute ischemic stroke patients and the prognostic influence of temporal changes in comprehensive stroke center capabilities in Japan. METHODS: This retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 acute ischemic stroke patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy usage were examined. Facility comprehensive stroke center capabilities were assessed using a validated scoring system (comprehensive stroke center score: 1-25 points) in 2010 and 2014. The prognostic influence of temporal comprehensive stroke center score changes on in-hospital mortality and poor outcomes (modified Rankin Scale: 3-6) at discharge were examined using hierarchical logistic regression models. RESULTS: Over time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. The median comprehensive stroke center score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility comprehensive stroke center score, proportion of in-hospital mortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding comprehensive stroke center score increase (in 2010-2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and mechanical thrombectomy use (odds ratio (95% confidence interval): 0.97 (0.95-0.99), 0.97 (0.95-0.998), 1.07 (1.04-1.10), and 1.21 (1.14-1.28), respectively). CONCLUSIONS: This nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and mechanical thrombectomy in acute ischemic stroke. In addition to lesser stroke severity, preceding improvement of comprehensive stroke center capabilities was an independent factor associated with such trends, suggesting importance of comprehensive stroke center capabilities as a prognostic indicator of acute stroke care.

2.
Heart Vessels ; 2019 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-31641888

RESUMO

Despite a higher risk of ischemic stroke in hospitalized patients with acute heart failure (HF), little is known about the risk of ischemic stroke during the post-discharge phases of HF. Here we investigated (1) the ischemic stroke incidence rate during the post-discharge phases among HF patients receiving standard treatments; (2) the association between ischemic stroke incidence and clinical background, including cardiac structure and function. Among 950 patients who required hospitalization for HF (median duration: 19 days) at our institution, where they received standard treatments, we investigated stroke occurrences during the 2-year period following their discharge and retrospectively evaluated their clinical data. Relative wall thickness (RWT) and left ventricular (LV) mass were determined based on echocardiographic measurements and then used to determine LV geometric patterns. During the follow-up period, ischemic stroke occurred in 25 patients (2.6%) after hospital discharge (1.4 per 100 patient-years). The incidence rate of IS tended to be higher in patients with AF than those without AF (1.8 vs. 1.0 per 100 patient-years, respectively). Notably, multivariate analysis revealed a significant association between RWT and ischemic stroke risk (p < 0.05). RWT was associated with ischemic stroke risk in patients with AF or left atrial enlargement, but not in patients without them. These findings suggest that even with standard HF treatments, the risk of ischemic stroke is high in patients with HF. Moreover, LV concentric geometry is a significant risk factor for ischemic stroke in patients with HF, especially in those with left atrial remodeling and/or AF.

3.
J Matern Fetal Neonatal Med ; : 1-8, 2019 Oct 09.
Artigo em Inglês | MEDLINE | ID: mdl-31575321

RESUMO

Background: Stroke is one of the major causes of maternal death. This study aimed to analyze the maternal and fetal outcomes of stroke occurred during pregnancy and puerperium. Methods: We conducted a retrospective analysis of patients admitted to our perinatology center between 1982 and 2012 with a diagnosis of acute cerebral stroke during pregnancy or within 6 weeks postpartum. Results: Thirty-four patients were registered and all the patients had never been diagnosed as stroke nor detected cerebrovascular abnormalities before the current pregnancies. They were divided into 8 ischemic strokes (ISs) and 26 intracranial hemorrhage group. In the hemorrhage group, there was a spontaneous abortion and two patients chose artificial abortions to avoid rehemorrhage, and there were another three intrauterine fetal deaths (IUFDs) in the acute stage of maternal stroke. More patients in hemorrhage group delivered in preterm than in IS group for the treatment of stroke, 10/23 (43%) versus 0/8 (0%), p < .05. More patients in hemorrhage group had low Glasgow Coma Scale (GCS) (3-8) than in IS group at the onset of the stroke, 12/26 (46%) versus 0/8 (0%), p < .05. There were three maternal deaths and 6/23 (26%) were neurologically dependent in hemorrhage group in the chronic stage, whereas 87% were independent in IS group, p < .05. Conclusions: Hemorrhagic stroke was more common etiology of stroke related to pregnancy than IS in this study. Intensive and multidisciplinary care was needed especially in hemorrhagic stroke related to pregnancy as in the hemorrhagic stroke the fetal survival rate was lower, and maternal conscious levels at the onset of the stroke and neurological outcomes in the chronic stage were worse than IS.

5.
J Am Heart Assoc ; 8(16): e013306, 2019 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-31390925
6.
J Cardiol ; 74(6): 539-542, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31337525

RESUMO

BACKGROUND: Catheter ablation (CA) has been reported to reduce risk of stroke in patients with nonvalvular atrial fibrillation (NVAF) in retrospective studies. However, the risks and benefits of CA have not been well elucidated in patients with NVAF and who have suffered a recent ischemic stroke in prospective randomized trials. Thus, the aim of the STABLED clinical trial is to investigate the efficacy and safety of CA with anticoagulant therapy using edoxaban in patients with NVAF and a history of recent ischemic stroke. METHODS AND DESIGN: The STABLED trial is a multicenter, prospective, randomized, open-label, standard medication-controlled study in Japan. The target patient number is 250, comprising 125 patients receiving standard medication and 125 receiving CA. For patients allocated to the CA group, ablation is to be performed between 1 to 6 months from the onset of index stroke. The observation period will be 3 years from the day of random allocation of the final patient to any of the groups. The primary outcome measure is the composite of recurrence of ischemic stroke, systemic embolism, all-cause death, and hospitalization for heart failure. CONCLUSION: This study will investigate the effectiveness and safety of CA and basic anticoagulation treatment with edoxaban for patients with NVAF who have suffered a recent ischemic stroke. The aim is to determine the best evidence for an optimal treatment strategy for patients with NVAF and recent stroke. TRIAL REGISTRATION: UMIN000031424/NCT03777631.

7.
J Neurol Sci ; 404: 11-15, 2019 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-31323516

RESUMO

Robot-assisted gait training following acute stroke could allow patients with severe disability to receive a high dosage and intensity of gait training compared with conventional physical therapy (CP). However, given the limited data on gauging the efficacy of Hybrid Assistive Limb (HAL) on gait training in patients with acute stroke, we aimed to evaluate several outcome measures following gait training with HAL. Patients with first-ever stroke, who required a walking aid and were able to start gait training within 1 week of stroke onset were included in the current study. Patients were assigned to either the CP or HAL group. Outcome measures were collected at baseline, and at the 2nd (at 2-6 weeks), and 3rd (at 3-5 months) assessments. All patients underwent physical therapy until the 3rd assessment; patients in the HAL group underwent gait training using HAL until the 2nd assessment. Thirty-seven patients (19 from CP and 18 from HAL, median age = 69 years) completed the study. At the 2nd assessment, the total Functional Independence Measure (FIM) score was higher in the HAL group than in the CP group (90.1 vs. 79.0, p = 0.042). In conclusion, the FIM scale could be used to identify responsiveness to acute stroke rehabilitation using HAL.

8.
BMC Neurol ; 19(1): 152, 2019 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-31277605

RESUMO

BACKGROUND: Simultaneous cerebral and myocardial infarction is called cardiocerebral infarction (CCI), and is rarely encountered. Because of the narrow time window and complex pathophysiology, CCI is challenging to immediately diagnose and treat. CASE PRESENTATION: A 73-year-old woman suddenly developed right hemiplegia and severe aphasia. Twelve-lead electrocardiography showed tachycardic atrial fibrillation without any significant ST-T change. Magnetic resonance imaging revealed a proximal middle cerebral artery occlusion. She was immediately treated with alteplase at the dosage approved for ischemic stroke followed by mechanical thrombectomy as bridging therapy, and complete recanalization was achieved. Aphasia improved and she began to complain of chest pain, and reported that she had experienced chest discomfort just prior to right limb weakness. Coronary angiography showed a partial filling defect in the right coronary artery with rapid and adequate distal flow, for which percutaneous coronary intervention was not required. Alteplase was suggested to have effectively resolved the coronary emboli. The occlusions of the cerebral and coronary arteries were assumed to have occurred nearly simultaneously and cardiogenic embolism due to atrial fibrillation was considered as the most likely etiology. CONCLUSIONS: As seen in the present case, CCI may benefit from immediate treatment with intravenous tissue plasminogen activator (IV-tPA). Although which of percutaneous coronary intervention or cerebral thrombectomy should be performed first remains unclear, we must decide whether to rescue the brain or heart first in each patient within a limited window of time. This dilemma has recently become evident in this era with mechanical thrombectomy strongly established as an effective intervention for acute ischemic stroke. Close cooperation between stroke physicians and cardiologists is becoming more important.

10.
Int J Stroke ; 14(7): 670-677, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31226919

RESUMO

OBJECTIVE: To investigate the comparative efficacy and safety of the low-dose versus standard-dose alteplase using real-world acute stroke registry data from Asian countries. METHODS: Individual participant data were obtained from nine acute stroke registries from China, Japan, Philippines, Singapore, South Korea, and Taiwan between 2005 and 2018. Inverse probability of treatment weight was used to remove baseline imbalances between those receiving low-dose versus standard-dose alteplase. The primary outcome was death or disability defined by modified Rankin Scale scores of 2 to 6 at 90 days. Secondary outcomes were symptomatic intracerebral hemorrhage and death. Generalized linear mixed models with the individual registry as a random intercept were performed to determine associations of treatment with low-dose alteplase and outcomes. RESULTS: Of the 6250 patients (mean age 66 years, 36% women) included in these analyses, 1610 (24%) were treated with low-dose intravenous alteplase. Clinical outcomes for low-dose alteplase were not significantly different to those for standard-dose alteplase, adjusted odds ratios for death or disability: 1.00 (0.85-1.19) and symptomatic intracerebral hemorrhage 0.87 (0.63-1.19), except for lower death with borderline significance, 0.77 (0.59-1.01). CONCLUSIONS: The present analyses of real-world Asian acute stroke registry data suggest that low-dose intravenous alteplase has overall comparable efficacy for functional recovery and greater potential safety in terms of reduced mortality, to standard-dose alteplase for the treatment of acute ischemic stroke.

11.
Circ J ; 83(7): 1538-1545, 2019 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-31168044

RESUMO

BACKGROUND: Despite the well-established benefits in patients with nonvalvular atrial fibrillation (NVAF), anticoagulants have been underused in elderly patients. The All Nippon AF In the Elderly (ANAFIE) Registry is a multicenter, prospective, observational study with 2-year follow-up of Japanese patients aged ≥75 years with a definitive diagnosis of NVAF, aiming to collect detailed information on clinical status and therapeutic challenges in this patient population.Methods and Results:Patients were enrolled from October 2016 to January 2018. A total of 32,726 patients (57.2% male) were included. The average age, CHADS2score, and creatinine clearance were 81.5±4.8 years (26.2% of patients were aged ≥85 years), 2.9±1.2, and 48.4±21.8 mL/min, respectively. Paroxysmal AF was the most common clinical AF type (42.0%), and most patients (97.2%) had comorbidities. Most patients (91.9%) were receiving anticoagulant therapy; of these, 27.8% and 72.2% were treated with warfarin and direct oral anticoagulants, respectively. The average number of concomitant drugs used was 6.6±3.2, including anticoagulants. CONCLUSIONS: The ANAFIE Registry is the largest prospective registry study of elderly Japanese patients with NVAF to date. Baseline data indicate that patients in this age group are treated in a manner similar to their younger counterparts.

12.
Stroke ; 50(7): 1751-1757, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31233392

RESUMO

Background and Purpose- We aimed to evaluate the effect of chronic hypertension on acute leptomeningeal collateral flow in patients with large-vessel ischemic stroke using digital subtraction angiography, which is the gold standard for the assessment of collateral circulation. Methods- Of the consecutive ischemic stroke patients from October 2011 to December 2017 seen in our institution, patients with acute occlusion of the M1 segment of the middle cerebral artery confirmed on initial digital subtraction angiography were enrolled. Chronic hypertension was defined as its documentation before the index stroke or as the administration of antihypertensive medications before onset. Angiographic leptomeningeal collateral flow was evaluated according to the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology Collateral Flow Grading System and dichotomized the findings into excellent (grade 3-4) or poor (grade 0-2) collateral status for analysis. Results- Of the 3759 consecutive ischemic stroke patients, 100 patients were analyzed. Thirty-nine patients (39%) had poor collateral status. Patients with poor collateral status were older, more frequently male, and had chronic hypertension more frequently, shorter time from onset to angiography, and higher admission systolic blood pressure than those with excellent collateral status. Multivariable logistic analysis with prespecified covariates showed a significantly positive association between chronic hypertension and poor collateral status (odds ratio, 2.80; 95% CI, 1.08-7.70; P=0.034). This association was independent of admission systolic blood pressure. The proportion of patients with poor collateral status increased in a stepwise manner in patients without chronic hypertension, hypertensive patients with premorbid antihypertensive medications, and hypertensive patients without antihypertensive medications ( P for trend <0.001). Conclusions- Our data suggest that chronic hypertension has a detrimental effect on acute leptomeningeal collateral flow in patients with cerebral large-vessel occlusion. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02251665.

13.
Rinsho Shinkeigaku ; 59(7): 399-404, 2019 Jul 31.
Artigo em Japonês | MEDLINE | ID: mdl-31243252

RESUMO

Modified Rankin Scale (mRS) is widely used as an indicator of physical disability after the onset of stroke and a main evaluation scale in clinical stroke trials but sometimes has discrepancies among raters. We designed a Japanese version of simplified mRS questionnaire (J-RASQ) to evaluate mRS using closed question to assess the difference from the original. Currently there are no Japanese version of mRS questionnaire and its validity and reliability assessment has been warranted. Patients with planned visit to our hospital between 60 and 120 days after the onset of cerebral hemorrhage or infarction between August 2017 and March 2018 were recruited. J-RASQ was distributed before the outpatient visit to stroke patients, families or caregivers, and response was obtained. Thereafter, outpatient attending physicians qualified as stroke or neurological specialists evaluated mRS according to the Japanese version of guidance scheme for mRS. Subsequently, 130 patients (mean age, 72 ± 12 years old) were enrolled, and the difference between the two scale scores (mRS vs. J-RASQ) were statistically examined by the κ statistic and the weighted κ statistic. The κ statistic was 0.42 (95% CI, 0.31-0.52), and the weighted κ statistic calculated taking into account the extent of disagreement was 0.78 (95% CI, 0.70-0.86). We conclude that the J-RASQ appears to have decent reliability and is similar to the existing mRS.


Assuntos
Atividades Cotidianas , Linguagem , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/psicologia , Inquéritos e Questionários , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Fatores Sexuais , Fatores de Tempo
14.
Stroke ; 50(6): 1586-1589, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31035902

RESUMO

Background and Purpose- As a prespecified post hoc analysis of the J-STARS (Japan Statin Treatment Against Recurrent Stroke) Echo Study, the 5-year stroke recurrence rate according to the baseline mean carotid intima-media thickness (IMT) with and without pravastatin treatment was investigated. Methods- Patients were randomly assigned to receive pravastatin 10 mg/day (pravastatin group) or control group (nonstatin treatment; 1:1) for 5 years. Baseline mean IMT of the common carotid artery was measured by ultrasonography. Cox proportional hazards models were used to investigate whether the stroke (any ischemic stroke, atherothrombotic brain infarction, or lacunar infarction) recurrence rate was different according to tertiles of baseline mean IMT. Results- A total of 793 patients, including 388 in the pravastatin group and 405 in the control group, were investigated. In the control group, Cox proportional hazards models showed that participants in the highest tertile IMT group (≥0.931 mm) had a higher rate of atherothrombotic brain infarction than those in the lowest tertile IMT group (<0.812 mm; [hazard ratio, 9.08; 95% CI, 1.15-71.43]). Patients in the pravastatin group had a lower risk of atherothrombotic brain infarction than those in the control group only in the highest tertile IMT group by the log-rank test ( P value=0.045). Conclusions- Long-term pravastatin administration may prevent the occurrence of atherothrombotic brain infarction in noncardioembolic infarction patients with the highest tertile IMT. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT00361530.

15.
Stroke ; 50(6): 1561-1563, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31060437

RESUMO

Background and Purpose- The ring finger protein 213 gene ( RNF213) is a susceptibility gene for moyamoya disease and large-artery ischemic stroke in East Asia. We examined the prevalence and correlates of the RNF213 p.R4810K variant in patients with early-onset ischemic stroke in a Japanese single-center cohort. Methods- We analyzed 70 early-onset stroke patients with intracranial arterial stenosis who developed a noncardioembolic stroke or transient ischemic attack from 20 to 60 years of age. Patients with moyamoya disease were excluded. Results- The RNF213 p.R4810K variant was found in 17 patients (24%), and more often in women than men (38% versus 16%, odds ratio 3.3; 95% CI, 1.1-10.2, P=0.04). The variant was identified in 35% of patients with stenosis in the M1 segment of the middle cerebral artery or the A1 segment of the anterior cerebral artery (odds ratio, 25.0; 95% CI, 1.4-438; P<0.01) but in only one patient (9%) with intracranial posterior circulation stenosis. Conventional atherosclerotic risk factors did not differ between variant carriers and noncarriers. Conclusions- The RNF213 p.R4810K variant is common in early-onset ischemic stroke with anterior circulation stenosis in Japan. Further investigation of the RNF213 gene will provide new insights into pathogenetic mechanisms of early-onset stroke.

16.
N Engl J Med ; 380(20): 1906-1917, 2019 05 16.
Artigo em Inglês | MEDLINE | ID: mdl-31091372

RESUMO

BACKGROUND: Cryptogenic strokes constitute 20 to 30% of ischemic strokes, and most cryptogenic strokes are considered to be embolic and of undetermined source. An earlier randomized trial showed that rivaroxaban is no more effective than aspirin in preventing recurrent stroke after a presumed embolic stroke from an undetermined source. Whether dabigatran would be effective in preventing recurrent strokes after this type of stroke was unclear. METHODS: We conducted a multicenter, randomized, double-blind trial of dabigatran at a dose of 150 mg or 110 mg twice daily as compared with aspirin at a dose of 100 mg once daily in patients who had had an embolic stroke of undetermined source. The primary outcome was recurrent stroke. The primary safety outcome was major bleeding. RESULTS: A total of 5390 patients were enrolled at 564 sites and were randomly assigned to receive dabigatran (2695 patients) or aspirin (2695 patients). During a median follow-up of 19 months, recurrent strokes occurred in 177 patients (6.6%) in the dabigatran group (4.1% per year) and in 207 patients (7.7%) in the aspirin group (4.8% per year) (hazard ratio, 0.85; 95% confidence interval [CI], 0.69 to 1.03; P = 0.10). Ischemic strokes occurred in 172 patients (4.0% per year) and 203 patients (4.7% per year), respectively (hazard ratio, 0.84; 95% CI, 0.68 to 1.03). Major bleeding occurred in 77 patients (1.7% per year) in the dabigatran group and in 64 patients (1.4% per year) in the aspirin group (hazard ratio, 1.19; 95% CI, 0.85 to 1.66). Clinically relevant nonmajor bleeding occurred in 70 patients (1.6% per year) and 41 patients (0.9% per year), respectively. CONCLUSIONS: In patients with a recent history of embolic stroke of undetermined source, dabigatran was not superior to aspirin in preventing recurrent stroke. The incidence of major bleeding was not greater in the dabigatran group than in the aspirin group, but there were more clinically relevant nonmajor bleeding events in the dabigatran group. (Funded by Boehringer Ingelheim; RE-SPECT ESUS ClinicalTrials.gov number, NCT02239120.).


Assuntos
Antitrombinas/administração & dosagem , Dabigatrana/administração & dosagem , Acidente Vascular Cerebral/prevenção & controle , Idoso , Antitrombinas/efeitos adversos , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Dabigatrana/efeitos adversos , Método Duplo-Cego , Feminino , Hemorragia/induzido quimicamente , Humanos , Incidência , Embolia Intracraniana/tratamento farmacológico , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/efeitos adversos , Recidiva , Prevenção Secundária , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade
17.
Lancet Neurol ; 18(6): 539-548, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31122494

RESUMO

BACKGROUND: Although dual antiplatelet therapy with aspirin and clopidogrel reduces early recurrence of ischaemic stroke, with long-term use this type of therapy is no longer effective and the risk of bleeding increases. Given that cilostazol prevents stroke recurrence without increasing the incidence of serious bleeding compared with aspirin, we aimed to establish whether dual antiplatelet therapy involving cilostazol is safe and appropriate for long-term use. METHODS: In a multicentre, open-label, randomised controlled trial across 292 hospitals in Japan, patients with high-risk non-cardioembolic ischaemic stroke identified on MRI were randomly assigned to two groups in a 1:1 ratio to receive monotherapy with either oral aspirin (81 or 100 mg, once per day) or clopidogrel (50 or 75 mg, once per day) alone, or a combination of cilostazol (100 mg, twice per day) with aspirin or clopidogrel. Randomisation was done centrally (using block randomisation with a block size of six per each participating hospital) through a web-based registration system and was done by EPS Corporation. The patients were required to have at least 50% stenosis of a major intracranial or extracranial artery or two or more of the vascular risk factors. Trial medication was continued for half a year or longer, for a maximum of 3·5 years. The primary efficacy outcome was the rate of first recurrence of symptomatic ischaemic stroke. Safety outcomes were severe or life-threatening bleeding; any adverse events; serious adverse events; and any bleeding events. Efficacy analyses were done in the intention-to-treat population and safety analyses were done in the as-treated population. This trial was registered with ClinicalTrials.gov (number NCT01995370) and UMIN Clinical Trials Registry (number 000012180). FINDINGS: Participants were recruited from Dec 13, 2013, to March 31, 2017. 932 patients assigned to the dual therapy group and 947 patients assigned to the monotherapy group were included in the intention-to-treat analysis. The trial was stopped after the enrolment of 1884 patients of an anticipated 4000 patients because of the delay in recruitment. Ischaemic stroke recurred in 29 (3%) of 932 patients (annualised rate 2·2%) on dual therapy including cilostazol and 64 (7%) of 947 patients (annualised rate 4·5%) on monotherapy during a median 1·4 years follow-up (hazard ratio [HR] 0·49, 95% CI 0·31-0·76, p=0·0010). Severe or life-threatening bleeding occurred in eight patients (annualised rate 0·6%) on dual therapy and 13 patients (annualised rate 0·9%) on monotherapy (HR 0·66, 95% CI 0·27-1·60, p=0·35). Occurrence of any type of adverse event was similar between the groups (255 [28%] of 910 patients in the dual therapy group vs 219 [24%] of 921 patients in the monotherapy group); as was occurrence of serious adverse events (87 [10%] vs 142 [15%]) and bleeding events (38 [4%] vs 33 [4%]). Gastrointestinal bleeding, which affected nine (<1%) of 910 patients in the monotherapy group and nine (<1%) of 921 patients in the dual therapy group, was the most common type of bleeding. INTERPRETATION: The combination of cilostazol with aspirin or clopidogrel had a reduced incidence of ischaemic stroke recurrence and a similar risk of severe or life-threatening bleeding compared with treatment with aspirin or clopidogrel alone in patients at high risk for recurrent ischaemic stroke. FUNDING: Otsuka Pharmaceutical.

18.
J Stroke Cerebrovasc Dis ; 28(8): 2201-2206, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31122713

RESUMO

BACKGROUND: The purpose of this study was to assess whether carotid ultrasonography indices detect arterial stenosis progression in patients with vertebral artery (VA) dissection. METHODS: This was a retrospective, single-center, observational study that enrolled patients with intracranial VA dissection who were admitted from January 2011 to June 2017. Magnetic resonance angiography (MRA) was done on admission and followed up at a median 20 days after onset (interquartile range [IQR] 9-58 days), and ultrasonography was performed at a median of 22 (interquartile range 7-56) days. Peak systolic velocity (PSV), end-diastolic velocity (EDV), mean velocity (MV), and pulsatility index (PI) were measured by ultrasonography, and the ratio of each follow-up value to the baseline (follow-up/baseline) value was calculated. Two stroke neurologists categorized into 3 groups by morphological changes of the dissected vessel: patients with stenosis progression (progression group: P-group); those with no remarkable change or dilatation improved (stable group: S-group); and those with stenosis regression or dilatation enlargement (enlargement group: E-group). Ultrasonography indices were compared among the groups. RESULTS: Of the 42 patients who were enrolled to this study, 39 patients underwent ultrasonography and MRA on both admission and follow-up. The PI ratio was significantly higher in the P-group than in the S-group (1.96 ± .80 versus .98 ± .44, P = .02) and in the E-group (versus .65 ± .35, P < .01). There were no significant differences in the PSV ratio, EDV ratio, and MV ratio. CONCLUSIONS: In patients with VA dissection, the PI ratio on ultrasonography is a promising index to detect stenosis progression.


Assuntos
Artérias Carótidas/diagnóstico por imagem , Ultrassonografia/métodos , Dissecação da Artéria Vertebral/diagnóstico por imagem , Artéria Vertebral/diagnóstico por imagem , Adulto , Velocidade do Fluxo Sanguíneo , Artérias Carótidas/fisiopatologia , Angiografia Cerebral/métodos , Circulação Cerebrovascular , Constrição Patológica , Progressão da Doença , Feminino , Humanos , Japão , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fluxo Pulsátil , Sistema de Registros , Estudos Retrospectivos , Índice de Gravidade de Doença , Artéria Vertebral/fisiopatologia , Dissecação da Artéria Vertebral/fisiopatologia
19.
Int J Stroke ; : 1747493019852177, 2019 May 27.
Artigo em Inglês | MEDLINE | ID: mdl-31132967

RESUMO

BACKGROUND: Branch atheromatous disease (BAD) is distinctive from large and small arterial diseases, which is single subcortical infarction larger than lacunar stroke in the territories of deep perforators without relevant arterial stenosis. BAD meets the current criteria of embolic stroke of undetermined source. We performed an exploratory analysis of BAD in patients recruited to NAVIGATE embolic stroke of undetermined source, a randomized controlled trial to compare rivaroxaban and aspirin in embolic stroke of undetermined source patients. METHODS AND RESULTS: Among 3972 stroke patients in cerebral hemispheres with intracranial arterial imaging, 502 (12.6%) patients met the criteria for BAD. BAD was associated with younger age (years; OR: 0.97, 95% CI: 0.96-0.98), race (Asian; OR: 1.78, 95% CI: 1.44-2.21), region (Eastern Europe; OR: 2.49, 95% CI: 1.87-3.32), and higher National Institute of Health Stroke Scale (OR: 1.17, 95% CI: 1.12-1.22) at randomization. During follow-up, stroke or systemic embolism (2.5%/year vs. 6.2%/year, p = 0.0022), stroke (2.1%/year vs. 6.2%/year, p = 0.0008), and ischemic stroke (2.1%/year vs. 5.9%/year, p = 0.0013) occurred less frequently in BAD than non-BAD patients. There were no differences in annual rates of stroke or systemic embolism (2.5%/year vs. 2.5%/year, HR: 1.01, 95% CI: 0.33-3.14) or major bleeding (1.3%/year vs. 0.8%/year, HR: 1.51, 95% CI: 0.25-9.05) between rivaroxaban and aspirin groups among BAD patients. CONCLUSIONS: BAD was relatively common, especially in Asian and from Eastern Europe among embolic stroke of undetermined source patients. Stroke severity was higher at randomization but recurrence of stroke was fewer in BAD than non-BAD patients. The efficacy and safety of rivaroxaban and aspirin did not differ among BAD patients.

20.
J Am Heart Assoc ; 8(8): e011302, 2019 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-30977413

RESUMO

Background We aimed to improve the assessment quality of plaque vulnerability with combined use of magnetic resonance imaging and contrast-enhanced ultrasound ( CEUS ). Methods and Results We prospectively enrolled 71 patients with internal carotid artery stenosis who underwent carotid endarterectomy and performed preoperative CEUS and magnetic resonance plaque imaging. We distinguished high-signal-intensity plaques ( HIP s) and non- HIP s based on magnetization-prepared rapid acquisition with gradient echo images. We graded them according to the CEUS contrast effect and compared the CEUS images with the carotid endarterectomy specimens. Among the 70 plaques, except 1 carotid endarterectomy tissue sample failure, 59 were classified as HIP s (43 symptomatic) and 11 were classified as non- HIP s (5 symptomatic). Although the magnetization-prepared rapid acquisition with gradient echo findings alone had no significant correlation with symptoms ( P=0.07), concomitant use of magnetization-prepared rapid acquisition with gradient echo and CEUS findings did show a significant correlation ( P<0.0001). CEUS showed that all 5 symptomatic non- HIP s had a high-contrast effect. These 5 plaques were histopathologically confirmed as vulnerable, with extensive neovascularization but only a small amount of intraplaque hemorrhage. Conclusions Complementary use of magnetic resonance imaging and CEUS to detect intraplaque hemorrhage and neovascularization in plaques can be useful for evaluating plaque vulnerability, consistent with the destabilization process associated with neovessel formation and subsequent intraplaque hemorrhage.

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