How do anticoagulated atrial fibrillation patients who suffer ischemic stroke or spontaneous intracerebral hemorrhage differ?

Object The well-known predictors for increased early deaths after spontaneous intracerebral hemorrhage (ICH) include the clinical and radiological severity of bleeding as well as being on a warfarin regimen at the onset of stroke. Ischemic heart disease and atrial fibrillation may also increase early deaths. In the present study the authors aimed to elucidate the role of the last 2 factors. Methods The authors assessed the 3-month mortality rate in patients with spontaneous ICH (453 individuals) who were admitted to the stroke unit of Oulu University Hospital within a period of 11 years (1993–2004). Results The 3-month mortality rate for the 453 patients was 28%. The corresponding mortality rates were 42% for the patients who had ischemic heart disease and 61% for those with atrial fibrillation on admission. The following independent predictors of death emerged after adjustment for sex and the use of warfarin or aspirin at the onset of ICH: 1) ischemic heart disease (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.12–2.48, p < 0.02); 2) atrial fibrillation on admission (HR 1.79, 95% CI 1.12–2.86, p < 0.02); 3) the Glasgow Coma Scale score on admission (HR 0.82 per unit, 95% CI 0.79–0.87, p < 0.01); 4) size of hematoma (HR 1.11 per 10 ml, 95% CI 1.07–1.16, p < 0.01); 5) intraventricular hemorrhage (HR 2.62, 95% CI 1.71–4.02, p < 0.01); 6) age (HR 1.04 per year, 95% CI 1.02–1.06, p < 0.01); and 7) infratentorial location of the hematoma (HR 1.93, 95% CI 1.26–2.97, p < 0.01). Conclusions Both ischemic heart disease and atrial fibrillation independently and significantly impaired the 3-month survival of patients with ICH.

Download Full-text

Abstract TP351: Microembolic Signals Monitoring in Acute Intracerebral Hemorrhage

Stroke ◽

10.1161/str.51.suppl_1.tp351 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Eva Rocha Ramos ◽

Izadora Deliberalli ◽

Joao Brainer ◽

Aneesh B Singhal ◽

Gisele S Silva

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Intracranial Hypertension ◽

Transcranial Doppler ◽

Large Artery ◽

Hematoma Volume ◽

Ethanol Abuse ◽

Acute Intracerebral Hemorrhage ◽

The Mean

Background: The etiology of remote DWI lesions in acute intracerebral hemorrhage (ICH) is still unknown. Postulated mechanisms include intracranial or extracranial emboli, small vessel abnormalities and ischemia following acute intracranial hypertension. Our aim is to evaluate the presence of spontaneous microembolic signals (MES) using transcranial Doppler (TCD) in acute ICH patients. Methods: Twenty patients with acute ICH were prospectively enrolled and monitored with TCD for 1 hour on admission days 1, 3 and 7. TCD monitoring was performed using 2MHz probes. Results: Of the 20 patients evaluated, 40% were females and mean age was 55.6±14.1. Eight patients (40%) had dyslipidemia, 15 (75%) hypertension, 5 (20%) diabetes, 2 (10%) ethanol abuse, 6 (30%) smoking and 1 (10%) had prior ischemic stroke. Most frequent location was lobar (9 patients). The mean hematoma volume was 13,5±17,9 ml. Of six patients who underwent MRI, 2 (20%) had remote DWI lesions. Embolic sources were found in 3 patients (1 with atrial fibrillation and 2 with large artery atherosclerosis). Microembolic signals were detected in seven patients (35%). Conclusion: The high occurrence of microemboli in patients admitted with acute ICH indicates a possible embolic mechanism for DWI lesions in these patients.

Download Full-text

Spontaneous Intracerebral Hemorrhage during Acute and Chronic Hypertension in Mice

Journal of Cerebral Blood Flow & Metabolism ◽

10.1038/jcbfm.2009.183 ◽

2009 ◽

Vol 30 (1) ◽

pp. 56-69 ◽

Cited By ~ 71

Author(s):

Yoshinobu Wakisaka ◽

Yi Chu ◽

Jordan D Miller ◽

Gary A Rosenberg ◽

Donald D Heistad

Keyword(s):

Oxidative Stress ◽

Nitric Oxide ◽

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Hemorrhagic Transformation ◽

Chronic Hypertension ◽

Spontaneous Intracerebral Hemorrhage ◽

Acute Hypertension ◽

Oxide Synthase ◽

The Brain

Oxidative stress and matrix metalloproteinases (MMPs) contribute to hemorrhagic transformation after ischemic stroke and brain injury after intracerebral hemorrhage (ICH). The goal of this study was to develop a new model of spontaneous ICH, based on the hypothesis that acute, superimposed on chronic, hypertension produces ICH. We hypothesized that increases in angiotensin II (AngII)-mediated oxidative stress and activation of MMPs are associated with, and may precede, spontaneous ICH during hypertension. In C57BL/6 mice, chronic hypertension was produced with AngII infusion and an inhibitor of nitric oxide synthase. During chronic hypertension, mice with acute hypertension from injections of AngII developed ICH. Oxidative stress and MMP levels increased in the brain even before developing ICH. Active MMPs colocalized with a marker of oxidative stress, especially on cerebral vessels that appeared to lead toward regions with ICH. Incidence of ICH and levels of oxidative stress and MMP-9 were greater in mice with acute hypertension produced by AngII than by norepinephrine. In summary, we have developed an experimental model of ICH during hypertension that may facilitate studies in genetically altered mice. We speculate that acute hypertension, especially when induced by AngII, may be critical in spontaneous ICH during chronic hypertension, possibly through oxidative stress and MMP-9.

Download Full-text

Development and Validation of a Prognostic Tool for Direct Enteral Tube Insertion After Acute Stroke

Stroke ◽

10.1161/strokeaha.120.028949 ◽

2020 ◽

Vol 51 (6) ◽

pp. 1720-1726

Author(s):

Raed A. Joundi ◽

Gustavo Saposnik ◽

Rosemary Martino ◽

Jiming Fang ◽

Moira K. Kapral

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Validation Cohort ◽

Favorable Outcome ◽

Tube Placement ◽

Stroke Severity ◽

Modified Rankin Scale ◽

Tube Insertion ◽

Poor Outcome

Background and Purpose— We aimed to create a novel prognostic risk score to estimate outcomes after direct enteral tube placement in acute stroke. Methods— We used the Ontario Stroke Registry and linked databases to obtain clinical information on all patients with direct enteral tube insertion after ischemic stroke or intracerebral hemorrhage from July 1, 2003 to June 30, 2010 (derivation cohort) and July 1, 2010 to March 31, 2013 (validation cohort). We used multivariable regression to assign scores to predictor variables for 3 outcomes after tube placement: favorable outcome (discharge modified Rankin Scale score 0–3 and alive at 90 days), poor outcome (discharge modified Rankin Scale score 5 or death at 90 days), and 30-day mortality. Results— Variables associated with a favorable outcome were younger age, preadmission independence, ischemic stroke rather than intracerebral hemorrhage, lower stroke severity, and a shorter time between stroke and tube placement. Variables associated with a poor outcome were older age, preadmission dependence, atrial fibrillation, greater stroke severity, and tracheostomy. Age, preadmission dependence, atrial fibrillation, cancer, chronic obstructive pulmonary disease, and shorter time to tube placement were associated with increased 30-day mortality. Using these variables, we created an online calculator to facilitate estimation of individual patient risk of favorable and poor outcomes. C -statistic in the validation cohort was 0.82 for favorable outcome, 0.65 for poor outcome, and 0.62 for 30-day mortality, and calibration was adequate. Conclusions— We developed risk scores to estimate outcomes after direct enteral tube insertion for acute dysphagic stroke. This information may be useful in discussions with patients and families when there is prognostic uncertainty surrounding outcomes with direct enteral tube placement after stroke.

Download Full-text

Genetically Predicted Cardiac Troponin I Concentrations and Risk of Stroke and Atrial Fibrillation

10.21203/rs.3.rs-699688/v1 ◽

2021 ◽

Author(s):

Dandan Liu ◽

Yue Deng ◽

Jiao Wang ◽

Yanan Chen ◽

Jian Yu ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Cardiac Troponin ◽

Troponin I ◽

Mendelian Randomization ◽

Cardiac Troponin I ◽

Cardioembolic Stroke ◽

Large Artery ◽

Increased Risk

Abstract Background: Observational studies have shown that elevated circulating cardiac troponin I (cTnI) concentrations were associated with higher risk of stroke and atrial fibrillation, but the causality remains unclear. Therefore, we conducted a two-sample mendelian randomization study to evaluate the causal effects of cTnI concentrations on the risk of stroke subtypes and atrial fibrillation.Methods: The instrumental variables for circulating cTnI concentrations were selected from a genome-wide association study meta-analysis of 48,115 European individuals. Applying a 2-sample mendelian randomization approach, we examined the associations of circulating cTnI concentrations with stroke (40,585 cases and 406,111 controls), ischemic stroke (34,217 cases and 406,111 controls), ischemic stroke subtypes (cardioembolic, large artery, small vessel stroke), intracerebral hemorrhage (1,545 cases and 1,481 controls) and atrial fibrillation (60,620 cases and 970,216 controls). Results: Genetically predicted elevated circulating cTnI concentrations were associated with increased risk of cardioembolic stroke (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.20-2.68; P = 0.004). However, no significant association was observed for cTnI concentrations with large artery stroke, small vessel stroke, total stroke, ischemic stroke and intracerebral hemorrhage. Additionally, we also found that elevated cTnI concentrations were associated with higher risk of atrial fibrillation (OR, 1.30; 95% CI, 1.10-1.53; P = 0.003).Conclusions: This study provides evidence that genetically predicted circulating cTnI concentrations are causally associated with increased risk of cardioembolic stroke and atrial fibrillation.

Download Full-text

Developmental Venous Anomaly Presenting with Spontaneous Intracerebral Hemorrhage, Acute Ischemic Stroke, and Seizure

Cureus ◽

10.7759/cureus.5412 ◽

2019 ◽

Author(s):

Naresh Mullaguri ◽

Anusha Battineni ◽

Balaji Krishnaiah ◽

Ibrahim Migdady ◽

Christopher R Newey

Keyword(s):

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Acute Ischemic Stroke ◽

Developmental Venous Anomaly ◽

Venous Anomaly ◽

Spontaneous Intracerebral Hemorrhage

Download Full-text

Non-vitamin K oral anticoagulants (NOACs) in patients with stroke and atrial fibrillation

Arhiv za farmaciju ◽

10.5937/arhfarm2005269j ◽

2020 ◽

Vol 70 (5) ◽

pp. 269-283

Author(s):

Dejana Jovanović

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Vitamin K ◽

Hemorrhagic Stroke ◽

Small Vessel Disease ◽

Oral Anticoagulants ◽

Stroke Recurrence ◽

Ischemic Attack

Patients with atrial fibrillation who had a previous transient ischemic attack or ischemic stroke had a significantly high risk of stroke recurrence and the introduction of oral anticoagulants should be mandatory. However, the long-term use of oral anticoagulants increases the risk of developing all types of intracranial hemorrhages. The advantages of non-vitamin K oral anticoagulants (NOACs) compared to warfarin are that they have a significantly lower risk for hemorrhagic stroke. They are preferred in elderly patients, those with small vessel disease, or those with previous intracerebral hemorrhage. The time of NOACs introduction after an ischemic stroke depends on its severity and the rule "1-3-6-12" days should be applied. The reintroduction of NOACs in patients with atrial fibrillation and previous intracerebral hemorrhage depends on its etiology and should be after about 4-8 weeks if the cardioembolic risk is high and the risk for intracranial hemorrhage small.

Download Full-text

Atrial Fibrillation in Spontaneous Intracerebral Hemorrhage, Dijon Stroke Registry (2006–2017)

Journal of the American Heart Association ◽

10.1161/jaha.120.020040 ◽

2021 ◽

Author(s):

Amélie Gabet ◽

Valérie Olié ◽

Yannick Béjot

Keyword(s):

Atrial Fibrillation ◽

Intracerebral Hemorrhage ◽

Scale Score ◽

Oral Anticoagulants ◽

Temporal Trends ◽

Population Based ◽

Modified Rankin Scale ◽

Newly Diagnosed ◽

Spontaneous Intracerebral Hemorrhage ◽

Stroke Registry

Background Atrial fibrillation (AF) represents a major indication for oral anticoagulants (OAC) that contribute to spontaneous intracerebral hemorrhage (ICH). This study evaluated AF prevalence among patients with ICH, temporal trends, and early functional outcomes and death of patients. Methods and Results Patients with first‐ever ICH were prospectively recorded in the population‐based stroke registry of Dijon, France, (2006–2017). Association between AF and early outcome of patients with ICH (ordinal modified Rankin Scale score and death at discharge) were analyzed using ordinal and logistic regressions. Among 444 patients with ICH, 97 (21.9%) had AF, including 65 (14.6%) with previously known AF treated with OAC, and 13 (2.9%) with newly diagnosed AF. AF prevalence rose from 17.2% (2006–2011) to 25.8% (2012–2017) ( P ‐trend=0.05). An increase in the proportion of AF treated with OAC (11.3% to 17.5%, P ‐trend=0.09) and newly diagnosed AF (1.5% to 4.2%, P ‐trend=0.11) was observed. In multivariable analyses, after adjustment for premorbid OAC, AF was not significantly associated with ordinal modified Rankin Scale score (odds ratio [OR], 1.29; 95% CI, 0.69–2.42) or death (OR, 0.89; 95% CI, 0.40–1.96) in patients with ICH. Nevertheless, adjusted premorbid OAC use remained highly associated with a higher probability of death (OR, 2.53; 95% CI, 1.11–5.78). Conclusions AF prevalence and use of OAC among patients with ICH increased over time. Premorbid use of OAC was associated with poor outcome after ICH, thus suggesting a need to better identify ICH risk before initiating or pursuing OAC therapy in patients with AF, and to develop acute treatment and secondary prevention strategies after ICH in patients with AF.

Download Full-text

Clinical Outcomes and Prognostic Factors for Spontaneous Intracerebral Hemorrhage in Pediatric ICU: A 12-Year Experience

Journal of Intensive Care Medicine ◽

10.1177/0885066617726049 ◽

2017 ◽

Vol 34 (11-12) ◽

pp. 1003-1009

Author(s):

Marco Piastra ◽

Daniele De Luca ◽

Orazio Genovese ◽

Federica Tosi ◽

Francesca Caliandro ◽

...

Keyword(s):

Ischemic Stroke ◽

Prognostic Factors ◽

Intracerebral Hemorrhage ◽

Clinical Outcomes ◽

Pediatric Population ◽

Vegetative State ◽

Adult Population ◽

Spontaneous Intracerebral Hemorrhage ◽

Midline Shift ◽

Mortality And Morbidity

Background: In the pediatric population, spontaneous intracerebral hemorrhage (sICH) is as common as ischemic stroke and accounts for significant mortality and morbidity. Differently from the ischemic stroke, there are few guidelines for directing management of sICH. This article aims to analyze both clinical outcomes and prognostic factors in order to produce tools for the design of prospective randomized studies addressed to implement treatment of pediatric sICH. Methods: Twelve-year retrospective review of a single-center consecutivesICH pediatric cases admitted to the pediatric intensive care unit (PICU). Selected end points were survival, PICU stay, and dichotomized Glasgow Outcome Score (GOS), with recovery and moderate disability (GOS 4-5) classified as favorable outcome and vegetative state or severe disability (GOS 2-3) classified as unfavorable. Results: Data of 107 children younger than 14 years admitted to our PICU due to sICH were analyzed. Overall PICU mortality was 24.2%. On multivariate analysis, the single factor markedly influencing survival was the presence of midline shift ( P = .002). In PICU survivors, there were 42 GOS 2-3 and 39 GOS 4-5. A low Glasgow Coma Scale (GCS) on PICU admission was predictive of severe neurological impairment in survivors ( P = .003). Intraventricular hemorrhage and infratentorial origin did not influence outcome in this series. Conclusion: The severity of presentation of sICH expressed by the midline shift and the GCS at PICU admission are significant prognostic factors for survival and neurological outcome. Some prognostic factors of the adult population have not been confirmed.

Download Full-text

Abstract TP331: Right Insular Damage is Associated With New Onset Atrial Fibrillation in Patients With Acute Intracerebral Hemorrhage

Stroke ◽

10.1161/str.48.suppl_1.tp331 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Luis Prats-Sánchez ◽

Elba Pascual-Goñi ◽

Fernando Fayos ◽

Celia Painous ◽

Raquel Delgado-Mederos ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Insular Cortex ◽

Brain Atlas ◽

Cardiac Monitoring ◽

Acute Intracerebral Hemorrhage ◽

Onset Atrial Fibrillation ◽

New Onset

Introduction: The frequency and risk factors for new-onset atrial fibrillation (nAF) after acute intracerebral hemorrhage (ICH) are uncertain. Hypothesis: By analogy with ischemic stroke, we hypothesized that insular cortex damage may be a risk factor for nAF. Methods: This is an observational study of consecutive patients with spontaneous ICH. All patients underwent continuous bedside cardiac monitoring for at least 24 hours. We excluded patients with previous history of AF, recent myocardial infarction and ischemic stroke. We prospectively collected the following variables: Demographic data (age and sex), traditional vascular risk factors, neurological severity (assessed with the Glasgow scale coma score), vital signs, laboratory and radiological data (localization and volume of the hematoma, concomitant intraventricular or subarachnoid hemorrhage), and detection of nAF. A blind evaluator using an interactive brain atlas assessed the insular cortex damage. Bivariate and multivariate regression analyses were performed to describe nAF risk factors. Results: We included 167 patients who fulfilled the inclusion/exclusion criteria. Mean age was 70.5±14.7 years and 56.8% were men. Cardiac monitoring was initiated after a median of 240 minutes (interquartile range 67-720) of the onset of ICH symptoms. We detected nAF in 9 patients (5.3%). Patients with nAF were older (75.6±13.1 vs 70.5±14.7 years, p=0.30) and most of them were men (8/9 vs 87/158, p=0.07) but these differences did not reach the statistical significance. We observed that right insular cortex damage (3/9 vs 9/158, p=0.019) and any insular cortex damage (5/9 vs 25/158, p=0.010) were more frequent in nAF patients. In the logistic regression analysis right insular cortex damage (OR 8.2; 95% CI 1.7-38.4, p=0.007) was associated with nAF. Conclusion: The frequency of nAF in patients with spontaneous ICH is 5.3%. Insular cortex lesions, probably due to the central autonomous nervous system dysregulation, are associated with nAF. This finding may have important implications in the hemodynamic and antithrombotic management.

Download Full-text