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1.
Acta Neurol Taiwan ; 31(4): 84-89, 2022 Dec 30.
Artigo em Inglês | MEDLINE | ID: mdl-35470409

RESUMO

PURPOSE: Perihematomal edema of intracerebral hemorrhage (ICH) is caused by a hematoma-induced inflammatory reaction, which usually contributes to delayed deterioration of neurological function and poor outcomes. Celecoxib is a commonly used nonsteroidal anti-inflammatory drug that selectively inhibits cyclooxygenase-2. High-dose celecoxib (400 mg twice daily) for 14 days has been shown to reduce perihematomal edema and hematoma enlargement in patients with ICH, but without improvement in long-term functional outcome, which may be confounded by the heterogeneity of hematoma location. Low-dose celecoxib may be an effective management for symptoms caused by perihematomal edema in patients with ICH, particularly those involving the thalamus. CASE REPORT: We reported two patients with acute thalamic ICH; a common symptom between the two was delayed onset of drowsiness caused by perihematomal edema involving the thalamus. Their consciousness improved after low-dose celecoxib (200 mg once daily) administration for 3 and 2 days in case A and B, respectively. Furthermore, other symptoms that concomitantly improved included poor appetite caused by perihematomal edema involving the left hypothalamus in case A, and limb weakness caused by perihematomal edema of the internal capsule in case B. CONCLUSION: These cases revealed that low-dose celecoxib may be an effective management for symptoms caused by perihematomal edema in patients with ICH, particularly those involving the thalamus.


Assuntos
Edema Encefálico , Celecoxib/uso terapêutico , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/complicações , Hemorragia Cerebral/tratamento farmacológico , Edema/complicações , Hematoma/complicações , Humanos
2.
Medicine (Baltimore) ; 101(7): e25836, 2022 Feb 18.
Artigo em Inglês | MEDLINE | ID: mdl-35363159

RESUMO

ABSTRACT: Anticoagulant treatment increases the risk of intracerebral hemorrhage (ICH), but whether the treatment, more specifically non-vitamin K oral anticoagulants (NOACs), increases the risk of cerebral microbleeds (CMBs) remains uncertain. We performed this study to investigate the development of new CMBs due to NOACs or warfarin treatment in patients with atrial fibrillation (AF).We prospectively recruited AF patients before anticoagulation from June 2016 to June 2018. We performed susceptibility-weighted imaging (SWI) examinations on all enrolled AF patients and re-examined SWI 1 year later. We compared demographic features and new CMBs between the NOACs group and the warfarin group. Univariate analysis of clinical factors was performed according to the development of new CMBs; and age, a HAS-B(L)ED score, warfarin use, and the presence of baseline CMBs were then selected for inclusion in the multivariate logistic regression model.A total of 72 AF patients were recruited, 29 of whom were assigned to the NOACs group and 43 to the warfarin group. Finally, 1 patient in the NOACs group (3.4%) and 9 patients (20.9%) in the warfarin group developed new CMBs after 1 year follow-up (P = .08). Univariate analysis showed that age, a HAS-B(L)ED score ≥4, the presence of baseline CMBs were associated with the development of new CMBs (P < .05). And multivariate regression analysis showed baseline CMBs (P = .03, odds ratio = 6.37, 95% confidence interval 1.15-35.36) was independently related to the increase in new CMBs.AF patients treated with NOACs may have a decreased trend in the development of new CMBs compared with those treated with warfarin. Baseline CMBs increased the frequency of new CMBs during anticoagulant treatment. The development of new CMBs in AF patients with anticoagulation requires further longitudinal studies with longer follow-up in larger samples.


Assuntos
Fibrilação Atrial , Varfarina , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/epidemiologia , Seguimentos , Humanos , Vitamina K/uso terapêutico , Varfarina/efeitos adversos
3.
Curr Neurol Neurosci Rep ; 22(2): 143-150, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-35332513

RESUMO

PURPOSE OF REVIEW: Hypertension is common in patients presenting with stroke and is independently associated with unfavorable outcomes. This article reviews current guidelines for early management of blood pressure (BP) and highlights the findings of recent investigative works. RECENT FINDINGS: Intensive blood pressure reduction after receiving alteplase has not been shown to improve outcomes. Patients with large vessel occlusions may benefit from lower blood pressure targets post-intervention. Retrospective analyses of large intracerebral hemorrhage trials suggest that specific subgroups of patients may disproportionately benefit from or be harmed by intensive BP reduction. Robust data for management of blood pressure in subarachnoid hemorrhage patients is lacking and expert consensus continues to guide decision-making. Despite the impact of hypertension on outcomes, most prospective trials assessing efficacy of blood pressure reduction have yielded neutral or inconclusive results. Further trials are necessary to determine which patient populations are most likely to benefit from blood pressure control.


Assuntos
Isquemia Encefálica , Hipertensão , Acidente Vascular Cerebral , Pressão Sanguínea , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/complicações , Hemorragia Cerebral/prevenção & controle , Fibrinolíticos/farmacologia , Humanos , Hipertensão/complicações , Estudos Prospectivos , Estudos Retrospectivos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/prevenção & controle , Ativador de Plasminogênio Tecidual , Resultado do Tratamento
4.
J Am Heart Assoc ; 11(6): e022849, 2022 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-35243876

RESUMO

Background To investigate the effectiveness and safety of withholding or restarting antithrombotic agents, and different antithrombotic therapies among patients with atrial fibrillation post-intracranial hemorrhage. Methods and Results This is a nationwide retrospective cohort study involving patients with atrial fibrillation receiving antithrombotic therapies who subsequently developed intracranial hemorrhage between January 1, 2011 and December 31, 2017. The risk of ischemic stroke (IS), recurrent intracerebral hemorrhage (ICH), and all-cause mortality were investigated between patients receiving no treatment versus patients reinitiating oral anticoagulants (OACs) or antiplatelet agents, and warfarin versus non-vitamin K antagonist OACs. We applied inverse probability of treatment weighting to balance the baseline characteristics and Cox proportional hazards model to estimate the hazard ratios (HRs) of different outcomes of interest. Compared with no treatment, OACs reduced the risk of IS (HR, 0.61; 0.42-0.89), without increase in the risk of ICH (1.15, 0.66-2.02); antiplatelet agent users showed a similar risk of IS (1.13, 0.81-1.56) and increased risk of ICH (1.81, 1.07-3.04). Use of OACs or antiplatelet agents did not reduce the risk of all-cause mortality (0.85, 0.72-1.01; and 0.88, 0.75-1.03, respectively). Compared with warfarin, non-vitamin K antagonist OAC users showed a similar risk of IS (0.92, 0.50-1.70), non-significantly reduced risk of ICH (0.53, 0.22-1.30), and significantly reduced all-cause mortality (0.60, 0.43-0.84). Conclusions OACs are recommended in patients with atrial fibrillation and intracranial hemorrhage because they reduced the risk of IS with no increase in the risk of subsequent ICH. Non-vitamin K antagonist OACs are recommended over warfarin owing to their survival benefits.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/epidemiologia , Fibrinolíticos/efeitos adversos , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/complicações , Hemorragias Intracranianas/epidemiologia , Inibidores da Agregação Plaquetária/efeitos adversos , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Varfarina/efeitos adversos
5.
J Am Heart Assoc ; 11(6): e024749, 2022 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-35253443

RESUMO

Background The aim of this study was to determine the associations of cerebral small vessel disease (SVD) burden with renal dysfunction and albuminuria in patients taking oral antithrombotic agents. Methods and Results Patients who newly started or continued taking oral antiplatelets or anticoagulants were enrolled in a prospective, multicenter, observational study. Obligatorily acquired multimodal magnetic resonance imaging at registration with prespecified imaging conditions was assessed for cerebral microbleeds, white matter hyperintensities, enlarged basal ganglia perivascular spaces, or lacunes, and an ordinal SVD score was calculated (range, 0-4). Multivariable adjusting covariates were age, sex, hypertension, diabetes, dyslipidemia, current smoking, drinking, and estimated glomerular filtration rate (eGFR). Of 5324 patients (1762 women; median age, 73 years), 4797 (90.1%) patients were taking oral antithrombotic agents for secondary stroke prevention. Cerebral microbleeds were present in 32.7%, confluent white matter hyperintensities in 51.8%, extensive basal ganglia perivascular spaces in 38.9%, and lacunes in 59.4%. Median SVD score was 2. Compared with eGFR category G1 (eGFR ≥90 mL/min per 1.73 m2), adjusted odds ratios for SVD score increment were 1.63 (95% CI, 1.11-2.39) at category G4 (eGFR 15-<30 mL/min per 1.73 m2) and 2.05 (95% CI, 1.33-3.16) at G5 (eGFR <15 mL/min per 1.73 m2). Corresponding odds ratios relative to urinary albumin-to-creatinine ratio (ACR) category A1 (ACR <30 mg/g) were 1.29 (95% CI, 1.12-1.49) for category A2 (ACR 30-<300 mg/g) and 1.37 (95% CI, 1.05-1.77) for A3 (ACR ≥300 mg/g). When combined eGFR and ACR categories were assessed, risks for SVD score increment generally increased as eGFR decreased and ACR increased. Conclusions Both reduced eGFR and albuminuria were independently associated with increased cerebral SVD burden in patients requiring oral antithrombotic medication mainly for secondary stroke prevention. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01581502; URL: https://www.umin.ac.jp/ctr; Unique identifier: UMIN000023669.


Assuntos
Doenças de Pequenos Vasos Cerebrais , Nefropatias , Acidente Vascular Cerebral , Idoso , Albuminúria/complicações , Albuminúria/epidemiologia , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/epidemiologia , Doenças de Pequenos Vasos Cerebrais/complicações , Doenças de Pequenos Vasos Cerebrais/diagnóstico por imagem , Doenças de Pequenos Vasos Cerebrais/epidemiologia , Feminino , Fibrinolíticos/efeitos adversos , Taxa de Filtração Glomerular , Humanos , Nefropatias/complicações , Imageamento por Ressonância Magnética , Estudos Prospectivos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle
7.
Neurologia (Engl Ed) ; 37(2): 130-135, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-35279226

RESUMO

INTRODUCTION: The use of low doses of recombinant tissue plasminogen activator (rt-PA) was initially proposed in Asian countries in response to racial peculiarities related to the functionality of fibrinogen and coagulation factors that potentially increased the risk of intracerebral haemorrhage, and with a view to saving costs. In view of the controversy over the use of rt-PA below the standard dose, we conducted a literature review of studies promoting the use of low doses or comparing different doses of rt-PA. DEVELOPMENT: We reviewed 198 abstracts related to the search terms and the full texts of 52 studies published in the last 30 years. We finally included 13 randomised clinical trials aiming to determine the efficacy and safety of the use of rt-PA at different doses in acute stroke, 14 observational cohort studies, 5 meta-analyses, and 3 systematic reviews. CONCLUSIONS: There is insufficient evidence to classify low doses of rt-PA as superior or at least not inferior to the standard treatment in the management of acute stroke in western populations. More clinical trials are required to determine whether the use of low doses is beneficial in patients with relative contraindications for thrombolytic therapy or other particular circumstances that may increase the risk of intracerebral haemorrhage.


Assuntos
Acidente Vascular Cerebral , Ativador de Plasminogênio Tecidual , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/tratamento farmacológico , Humanos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/efeitos adversos
8.
Medicine (Baltimore) ; 101(6): e28756, 2022 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-35147099

RESUMO

RATIONALE: The new vaccines are emergently authorized and currently approved for use to protect against the coronavirus disease 2019 (COVID-19) pandemic and serious adverse events are uncommon. Moyamoya disease (MMD) with autoimmune disease is a rare entity and usually presents with intracranial hemorrhage in adults. PATIENT CONCERNS: We reported a 40-year-old female patient with Sjogren disease and autoimmune thyroiditis, who had received the second dose of Moderna (mRNA-1273) vaccination. Three days later, she presented with left intraventricular and intracerebral hemorrhage as a complication. DIAGNOSIS: After a series of diagnostic workups, left intracranial hemorrhage was associated with MMD. INTERVENTIONS: Emergent external ventricular drainage and subsequent stereotactic evacuation of hematoma with insertion of intracranial pressure monitoring were performed. OUTCOMES: Under the care of the neurocritical care team, her physical condition improved gradually. The neurological sequelae was noted by defects of cognitive function, apraxia, agnosia, and impaired executive function. She was discharged after eight weeks with a follow-up in the vascular neurology clinic planning for performing revascularization. LESSONS: To the best of our knowledge, no similar case has been reported before, and this is the first case of MMD complicated with intracerebral and intraventricular hemorrhage after mRNA-1273 vaccination. It is noticeable to assess the vaccine safety surveillance and raise the alertness about moyamoya in patients with autoimmune diseases during the COVID-19 pandemic. Further studies for risk evaluation of COVID-19 vaccines in patients with autoimmune diseases might be required in the future.


Assuntos
/efeitos adversos , COVID-19/prevenção & controle , Hemorragia Cerebral/induzido quimicamente , Hemorragias Intracranianas/induzido quimicamente , Doença de Moyamoya/complicações , Tireoidite Autoimune/complicações , /administração & dosagem , Adulto , Feminino , Humanos , Pandemias , RNA Mensageiro/genética , SARS-CoV-2 , Síndrome de Sjogren
9.
Sci Rep ; 12(1): 1814, 2022 02 02.
Artigo em Inglês | MEDLINE | ID: mdl-35110612

RESUMO

Data on the use of activated prothrombin complex concentrate (aPCC) for the management of warfarin associated major bleeding is sparse. The objective of the study was to assess the achievement of effective clinical hemostasis using aPCC in patients presenting with major bleeding while on warfarin. We also assessed the safety of the drug. This retrospective study was conducted at a tertiary care teaching center in the USA where patients with major bleeding while receiving warfarin, and received aPCC were included. Efficacy of aPCC in achieving effective hemostasis was assessed according to the International Society of Thrombosis and Hemostasis Scientific and Standardization Subcommittee criteria. Efficacy was also assessed by achieving INR < 1.5 after treatment. The primary safety endpoint was the occurrence of any thromboembolic complications. A total of 67 patients were included in the study. The most common site for bleeding was intracerebral hemorrhage (n = 37, 55.2%), followed by gastrointestinal bleed (n = 26, 38.8%). Clinical hemostasis was achieved in 46 (68.7%) patients and of the 21 (31.3%) patients who did not achieve clinical hemostasis, 16 died. Thirty nine (58.2%) patients achieved INR < 1.5. Five (7.5%) patients developed thromboembolic complications. This study suggests that the use of aPCCs is effective in achieving effective hemostasis in patients on warfarin presenting with major bleeding.


Assuntos
Anticoagulantes/efeitos adversos , Fatores de Coagulação Sanguínea/uso terapêutico , Hemorragia Cerebral/tratamento farmacológico , Coagulantes/uso terapêutico , Hemorragia Gastrointestinal/tratamento farmacológico , Vitamina K/antagonistas & inibidores , Varfarina/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Fatores de Coagulação Sanguínea/efeitos adversos , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/mortalidade , Coagulantes/efeitos adversos , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/mortalidade , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tromboembolia/etiologia , Fatores de Tempo , Resultado do Tratamento
10.
J Thromb Thrombolysis ; 53(3): 722-730, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35028829

RESUMO

The clinical symptoms of perforating arteries differ, and responses to intravenous thrombolytic therapy are heterogeneous. Here, we investigated the effect of intravenous thrombolytic therapy and the related factors influencing acute perforating and non-perforating middle cerebral artery infarctions. We analyzed 320 patients with acute middle cerebral artery infarction who received alteplase thrombolysis within 4.5 h of onset at two stroke centers from January 2016 to December 2019. Outcome measures included rates of a favorable functional outcome (modified Rankin Scale scores of 0-2), distribution of modified Rankin Scale scores, intracranial hemorrhage, and symptomatic cerebral hemorrhage at 14 days, with comparisons between perforating artery and non-perforating artery cerebral infarction groups. In the perforating vessel disease group, 12 cases (17.4%) of intracranial hemorrhage occurred, with symptomatic cerebral hemorrhage in three cases (4.3%); there were no significant differences between the perforating and non-perforating vessel disease groups (all P > 0.05). In the perforating vessel disease group, the only significant prognostic factor was the National Institutes of Health Stroke Scale score before thrombolysis (Exp(B) = 1.365; 95% confidence interval [CI] 1.124-1.659; P = 0.002), and the only significant risk factor for hemorrhagic transformation was previous perforator disease (Exp(B) = 0.078; P = 0.038). Regardless of whether an acute infarction is perforating or non-perforating, intravenous thrombolytic therapy can yield a favorable outcome. Therefore, intravenous thrombolysis should be actively administered to treat perforating artery infarctions with a high risk of disability.


Assuntos
Isquemia Encefálica , Infarto da Artéria Cerebral Média , Isquemia Encefálica/tratamento farmacológico , Hemorragia Cerebral/induzido quimicamente , Fibrinolíticos/efeitos adversos , Humanos , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/tratamento farmacológico , Hemorragias Intracranianas/etiologia , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
11.
BMC Neurosci ; 23(1): 6, 2022 01 29.
Artigo em Inglês | MEDLINE | ID: mdl-35093027

RESUMO

BACKGROUND: In the horizon of therapeutic restrictions in intracerebral hemorrhage (ICH), recently, non-invasive transcranial electrical stimulation (tES) has achieved considerable prosperities. Translational studies have postulated that transcranial direct current stimulation (tDCS) and the other types of tES remain potentially a novel therapeutic option to reverse or stabilize cognitive and motor impairments. OBJECTIVE: The aim of this study was to comparatively evaluate the effects of the four main paradigms of tES, including tDCS, transcranial alternating (tACS), pulsed (tPCS), and random noise (tRNS) stimulations on collagenase-induced sensorimotor impairments and striatum tissue damage in male rats. METHODS: To induce ICH, 0.5 µl of collagenase was injected into the right striatum of male Sprague Dawley rats. One day after surgery, tES, was applied to the animals for seven consecutive days. Motor functions were appraised by neurological deficit score, rotarod, and wire hanging tests on the day before surgery and postoperative days 3, 7, and 14. After behavioral tests, brain tissue was prepared appropriately to perform the stereological evaluations. RESULTS: The results indicated that the application of the four tES paradigms (tDCS, tACS, tRNS, and tPCS) significantly reversed motor disorders in collagenase-induced ICH groups. Further, the motor function improvement of tACS and tRNS receiving rats in wire-hanging and rotarod tests were higher than the other two tES receiving groups. Structural changes and stereological assessments also confirmed the results of behavioral functions. CONCLUSION: Our findings suggest that in addition to tDCS application in the treatment of ICH, other tES paradigms, especially tACS and tRNS may be considered as add-on therapeutic strategies in stroke.


Assuntos
Estimulação Transcraniana por Corrente Contínua , Animais , Encéfalo/fisiologia , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/terapia , Colagenases , Masculino , Ratos , Ratos Sprague-Dawley , Estimulação Transcraniana por Corrente Contínua/métodos
13.
Neurol Res ; 44(4): 291-298, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34581662

RESUMO

OBJECTIVE: To precisely prevent stroke, we evaluated three platelet function tests and their associations with clinical outcomes in ischemic stroke patients. METHODS: On-treatment platelet reactivity of acute minor stroke patients taking aspirin plus clopidogrel was tested by light transmittance aggregometry (LTA), thromboelastography (TEG) and platelet function analyzer (PFA). Mann-Whitney U tests and receiver operating characteristic (ROC) curve analysis were used to assess their associations with recurrent events and clinical outcome prediction. RESULTS: 127 acute minor stroke patients were stringently selected and followed for 13 months. Eight patients (6.3%) self-reported the recurrence and 13 (10.2%) patients self-reported bleeding. Recurrent patients displayed significantly higher on-treatment platelet reactivity when measured with LTA (p = 0.030) and PFA (p < 0.001). Further ROC analysis demonstrated that LTA and PFA had modest-to-fair ability to predict stroke recurrence (LTA: area under the curve [AUC], 0.765; 95% CI, 0.584-0.945, PFA: AUC, 0.832; 95% CI, 0.658-1.000). However, TEG (measured by the platelet inhibition rate) could not detect the difference between recurrent patients and non-recurrent patients (p = 0.515) and predict recurrent events (AUC, 0.569; 95% CI, 0.368-0.770). None of the tests were associated with bleeding except for PFA (p < 0.001), with AUC of PFA reaching 0.772 (0.726-0.818). CONCLUSIONS: Of the three tests assessed, the predictive accuracies of PFA and LTA were satisfying for aspirin secondary prevention, while TEG's performance was poor. Only PFA could provide accurate prognostic information for bleeding.


Assuntos
Aspirina/farmacologia , Plaquetas/efeitos dos fármacos , Hemorragia Cerebral/induzido quimicamente , AVC Isquêmico/prevenção & controle , Inibidores da Agregação Plaquetária/farmacologia , Prevenção Secundária , Idoso , Idoso de 80 Anos ou mais , Aspirina/efeitos adversos , Clopidogrel/farmacologia , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Inibidores da Agregação Plaquetária/efeitos adversos , Testes de Função Plaquetária
14.
Ann Intern Med ; 175(1): 20-28, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34871048

RESUMO

BACKGROUND: Apixaban and rivaroxaban are replacing vitamin K antagonists for the treatment of venous thromboembolism (VTE) in adults; however, head-to-head comparisons remain limited. OBJECTIVE: To assess the effectiveness and safety of apixaban compared with rivaroxaban in patients with VTE. DESIGN: Retrospective new-user cohort study. SETTING: U.S.-based commercial health care insurance database from 1 January 2015 to 30 June 2020. PARTICIPANTS: Adults with VTE who were newly prescribed apixaban or rivaroxaban. MEASUREMENTS: The primary effectiveness outcome was recurrent VTE, a composite of deep venous thrombosis and pulmonary embolism. The primary safety outcome was a composite of gastrointestinal and intracranial bleeding. RESULTS: Of 49 900 eligible patients with VTE, 18 618 were new users of apixaban and 18 618 were new users of rivaroxaban. Median follow-up was 102 days (25th, 75th percentiles: 30, 128 days) among apixaban and 105 days (25th, 75th percentiles: 30, 140 days) among rivaroxaban users. After propensity score matching, apixaban (vs. rivaroxaban) was associated with a lower rate for recurrent VTE (hazard ratio, 0.77 [95% CI, 0.69 to 0.87]) and bleeding (hazard ratio, 0.60 [CI, 0.53 to 0.69]). The absolute reduction in the probability of recurrent VTE with apixaban versus rivaroxaban was 0.006 (CI, 0.005 to 0.011) within 2 months and 0.011 (CI, 0.011 to 0.013) within 6 months of initiation. The absolute reduction in the probability of gastrointestinal and intracranial bleeding with apixaban versus rivaroxaban was 0.011 (CI, 0.010 to 0.011) within 2 months and 0.015 (CI, 0.013 to 0.015) within 6 months of initiation. LIMITATION: Short follow-up. CONCLUSION: In this population-based cohort study, patients with VTE who were new users of apixaban had lower rates for recurrent VTE and bleeding than new users of rivaroxaban. PRIMARY FUNDING SOURCE: None.


Assuntos
Hemorragia Cerebral/induzido quimicamente , Inibidores do Fator Xa/uso terapêutico , Hemorragia Gastrointestinal/induzido quimicamente , Pirazóis/uso terapêutico , Piridonas/uso terapêutico , Rivaroxabana/uso terapêutico , Tromboembolia Venosa/tratamento farmacológico , Idoso , Bases de Dados Factuais , Feminino , Humanos , Masculino , Recidiva , Estudos Retrospectivos , Fatores de Risco , Estados Unidos
15.
Stroke Vasc Neurol ; 7(2): 158-165, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34848566

RESUMO

RATIONALE: Haematoma growth is common early after intracerebral haemorrhage (ICH), and is a key determinant of outcome. Tranexamic acid, a widely available antifibrinolytic agent with an excellent safety profile, may reduce haematoma growth. METHODS AND DESIGN: Stopping intracerebral haemorrhage with tranexamic acid for hyperacute onset presentation including mobile stroke units (STOP-MSU) is a phase II double-blind, randomised, placebo-controlled, multicentre, international investigator-led clinical trial, conducted within the estimand statistical framework. HYPOTHESIS: In patients with spontaneous ICH, treatment with tranexamic acid within 2 hours of onset will reduce haematoma expansion compared with placebo. SAMPLE SIZE ESTIMATES: A sample size of 180 patients (90 in each arm) would be required to detect an absolute difference in the primary outcome of 20% (placebo 39% vs treatment 19%) under a two-tailed significance level of 0.05. An adaptive sample size re-estimation based on the outcomes of 144 patients will allow a possible increase to a prespecified maximum of 326 patients. INTERVENTION: Participants will receive 1 g intravenous tranexamic acid over 10 min, followed by 1 g intravenous tranexamic acid over 8 hours; or matching placebo. PRIMARY EFFICACY MEASURE: The primary efficacy measure is the proportion of patients with haematoma growth by 24±6 hours, defined as either ≥33% relative increase or ≥6 mL absolute increase in haematoma volume between baseline and follow-up CT scan. DISCUSSION: We describe the rationale and protocol of STOP-MSU, a phase II trial of tranexamic acid in patients with ICH within 2 hours from onset, based in participating mobile stroke units and emergency departments.


Assuntos
Antifibrinolíticos , Acidente Vascular Cerebral , Ácido Tranexâmico , Antifibrinolíticos/efeitos adversos , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/tratamento farmacológico , Ensaios Clínicos Fase II como Assunto , Hematoma/induzido quimicamente , Hematoma/tratamento farmacológico , Humanos , Estudos Multicêntricos como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/terapia , Ácido Tranexâmico/efeitos adversos
16.
Int J Stroke ; 17(3): 354-361, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33724081

RESUMO

BACKGROUND: Recent studies have shown that tPA can be safely administered past the standard 4.5 h window with good outcomes when selected with multi-model imaging, which is often lacking outside of comprehensive stroke centers. AIM: We aim to analyze the safety and outcomes of wake up/unknown onset (WUS/UNK) patients treated based on non-contrast head CT (NCCT) at our institution and in the literature. METHODS: Suspected stroke patients from January 2015 to December 2018 receiving tPA within 4.5 h (standard window-SW) and with WUS/UNK based on NCCT and clinical-imaging mismatch were identified. We compared baseline characteristics, tPA metrics, and outcome data, with primary outcome as symptomatic intracerebral hemorrhage (sICH). A meta-analysis was performed evaluating NCCT-based treatment of WUS/UNK patients. RESULTS: Of 1827 patients treated at our hub or through telestroke, 93 underwent WUS/UNK-based treatment. There was no statistical difference in sICH between WUS/UNK and SW: 1% vs. 4% (OR 0.3; 95% confidence interval 0.0-1.9). 90-day modified Rankin scale outcomes were similar between SW and WUS/UNK-treated patients. Seven studies encompassing 485 WUS/UNK patients were included in a pooled analysis with a 2.1% incidence of sICH. In our meta-analysis, three studies compared NCCT-based treated WUS/UNK patients with SW patients with no difference in rate of hemorrhage: 2.1% vs 3.4% (OR 1.01; 95% confidence interval 0.45-2.28). INTERPRETATION: Our single-center analysis and meta-analysis suggest that tPA can be safely administered based on NCCT with comparable rates of sICH for select WUS/UNK stroke patients.


Assuntos
Acidente Vascular Cerebral , Ativador de Plasminogênio Tecidual , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Humanos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/etiologia , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/uso terapêutico , Tomografia Computadorizada por Raios X , Resultado do Tratamento
17.
Neurol Sci ; 43(2): 1127-1134, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34212264

RESUMO

PURPOSE: Intracerebral hemorrhage (ICH) can be a fatal complication of intravenous thrombolysis (IVT) for acute ischemic stroke. An early coagulopathy can develop after IVT, in relation to a significant fibrinogen depletion, increasing the risk of ICH. This systematic review and meta-analysis aimed at defining the role of fibrinogen depletion after IVT on the risk of ICH after IVT. METHODS: Protocol was registered with PROSPERO (CRD42020124241) and followed PRISMA and MOOSE guidelines. We systematically searched English studies reporting rates of post-IVT ICH depending on fibrinogen depletion until 7/1/2021. Primary outcome was symptomatic ICH (sICH). Meta-analysis followed random-effects model to account for heterogeneity in design and timing of ascertainments. Biases were assessed via the Newcastle-Ottawa Scale. RESULTS: Overall, among 352 records identified, 5 observational studies were eligible for quantitative synthesis (n = 2142), all of fair quality. Considering sICH within 24-36 h post-IVT, pooling data from 4 studies (n = 1753), fibrinogen depletion consistently increased the risk of sICH (OR 3.67, 95%CI 2.28-5.90, pheterogeneity = 0.55). Pooling adjusted estimated for age, gender, and NIHSS from 3 studies (n = 723), fibrinogen depletion was confirmed to significantly increase the risk of ICH after IVT (OR 5.41, 95%CI 2.96-9.89). CONCLUSIONS: Fibrinogen depletion significantly increases the risk of ICH after IVT for acute ischemic stroke. Routine fibrinogen assessment might be considered to identify people at higher risk of ICH. As fibrinogen repletion is feasible, trials should investigate its efficacy in preventing ICH, potentially increasing the net benefit profile of IVT in acute ischemic stroke.


Assuntos
Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Isquemia Encefálica/complicações , Isquemia Encefálica/tratamento farmacológico , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/tratamento farmacológico , Fibrinogênio , Fibrinolíticos/efeitos adversos , Humanos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
18.
Acad Radiol ; 29(4): 536-542, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-34176729

RESUMO

RATIONALE AND OBJECTIVES: Spontaneous iliopsoas muscle hemorrhage (SIPH) is a rare clinical condition associated with high mortality. In this work we aimed to retrospectively investigate the predictors of mortality in a single-institution cohort of consecutive SIPH patients. MATERIALS AND METHODS: Consecutive patients (n = 61, 30 men, 76 years [range 51-93]) with computed tomography (CT) confirmed diagnosis of SIPH were retrospectively included between January 2010 and April 2020. CT studies were assessed for signs of active bleeding, extramuscular retroperitoneal hematoma, visible sedimentation, and hematoma volume. Medication history, laboratory parameters, comorbidities, and disease management were also recorded. All parameters were subsequently examined with regard to their impact on outcome and survival. Univariate and multivariate Cox regressions were performed to identify variables associated with time to death. RESULTS: The overall mortality was 22.9%. A total of 77% of patients received anticoagulant therapy prior to the onset of SIPH. Active bleeding in contrast enhanced CT (CECT) was the only independent variable associated with shorter survival (p = 0.01, hazard ratio 7.05 [1.45-34.20]). Hematoma volume or extramuscular retroperitoneal hematoma had no significant influence on short-term mortality. CONCLUSION: Only active bleeding but not hematoma volume or extra-muscular bleeding is an independent risk factor for short-term mortality in patients with SIPH.


Assuntos
Anticoagulantes , Hematoma , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/complicações , Hemorragia Gastrointestinal , Hematoma/induzido quimicamente , Hematoma/diagnóstico por imagem , Humanos , Masculino , Músculos , Estudos Retrospectivos
19.
J Thromb Thrombolysis ; 53(2): 485-494, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34302590

RESUMO

Previous intracerebral hemorrhage (ICH) is labelled as a contraindication for the use of intravenous tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS) based on expert opinion. However, there is a paucity of data available regarding the benefits and risks of IV-tPA in this population. Recent small retrospective cohort studies reporting its off-label use suggest it may be beneficial. This study aims to investigate the safety and efficacy of IV-tPA in AIS patients with previous ICH. We performed a systematic review and meta-analysis of studies reporting on IV-tPA use in AIS patients with and without previous ICH. We searched Embase, PubMed and Cochrane Library from inception to 20 April 2021. Outcomes measured included symptomatic ICH (sICH), 3-month modified Rankin Scale (mRS) score, and 3-month mortality. We included seven retrospective cohort studies comprising 5760 AIS patients who had received IV-tPA, of which 134 had previous ICH. There was no significant difference in the odds of sICH (OR 1.57, 95% CI 0.78-3.15, p = 0.21) and 3-month mRS (mRS 0-1: OR 0.78, 95% CI 0.37-1.65, p = 0.52; mRS 0-2: OR 1.07, 95% CI 0.36-3.15, p = 0.90) between patients with and without previous ICH. There was a trend towards higher 3-month mortality in patients with previous ICH (OR 1.69, 95% CI 0.98-2.91, p = 0.06), although this did not reach statistical significance. The use of IV-tPA in AIS patients with previous ICH was not associated with an increased risk of sICH or disability at 3 months. Further larger studies are needed to establish the safety and efficacy of IV-tPA use in this population.


Assuntos
Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Isquemia Encefálica/complicações , Isquemia Encefálica/tratamento farmacológico , Hemorragia Cerebral/induzido quimicamente , Fibrinolíticos/efeitos adversos , Humanos , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
20.
J Am Heart Assoc ; 11(1): e023345, 2022 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-34935409

RESUMO

Background Data on the relative contribution of clinical and neuroimaging risk factors to acute ischemic stroke (AIS) versus intracerebral hemorrhage (ICH) occurring on oral anticoagulant treatment are scarce. Methods and Results Cross-sectional study was done on consecutive oral anticoagulant-treated patients presenting with AIS, transient ischemic attack (TIA), or ICH from the prospective observational NOACISP (Novel-Oral-Anticoagulants-In-Stroke-Patients)-Acute registry. We compared clinical and neuroimaging characteristics (small vessel disease markers and atherosclerosis) in ICH versus AIS/TIA (reference) using logistic regression. Among 734 patients presenting with stroke on oral anticoagulant treatment (404 [55%] direct oral anticoagulants, 330 [45%] vitamin K antagonists), 605 patients (82%) had AIS/TIA and 129 (18%) had ICH. Prior AIS/TIA, coronary artery disease, dyslipidemia, and worse renal function were associated with AIS/TIA (adjusted odds ratio [aOR] [95% CI] 0.51 [0.32-0.82], 0.48 [0.26-0.86], 0.55 [0.34-0.89], and 0.82 [0.75-0.90] per 10 mL/min). Prior ICH, older age, higher admission blood pressure, and statin treatment were associated with ICH (aOR [95% CI] 6.33 [2.87-14.04], 1.37 [1.04-1.81] per 10 years, 1.19 [1.10-1.29] per 10 mm Hg, and 1.81 [1.09-3.03]). Cerebral microbleeds and moderate-to-severe white matter hyperintensities contributed more to ICH (aOR [95% CI] 2.77 [1.34-6.18], and 2.62 [1.28-5.63]). Aortic arch, common and internal carotid artery atherosclerosis, and internal carotid artery stenosis ≥50% contributed more to AIS/TIA (aOR [95% CI] 0.54 [0.31-0.90], 0.29 [0.05-0.97], 0.48 [0.30-0.76], and 0.32 [0.13-0.67]). Conclusions In patients presenting with stroke on oral anticoagulant, AIS/TIA was 5 times more common than ICH. A high atherosclerotic burden (indicated by cardiovascular comorbidities and extracranial atherosclerosis) and prior AIS/TIA contributed more to AIS/TIA, while small vessel disease markers and prior ICH were stronger determinants for ICH. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02353585.


Assuntos
Aterosclerose , Ataque Isquêmico Transitório , AVC Isquêmico , Acidente Vascular Cerebral , Anticoagulantes/efeitos adversos , Aterosclerose/tratamento farmacológico , Hemorragia Cerebral/induzido quimicamente , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/epidemiologia , Estudos Transversais , Humanos , Ataque Isquêmico Transitório/tratamento farmacológico , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
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