Effect of anticoagulant and antiplatelet therapy on the occurrence of primary intracerebral hemorrhage

Introduction. The incidence of intracerebral hemorrhage related to oral anticoagulant and antiplatelet therapy has an increasing trend, thus it may be a potential indicator of unvaforable outcome of primary intracerebral hemorrhage. The aim of the study was to determine the effect of these therapies on the occurrence, localization and outcome of primary intracerebral hemorrhage. Material and Methods. A retrospective study included 246 patients with first time diagnosed primary intracerebral hemorrhage. Patients were divided into three groups, according to the drugs they have used. The incidence, anatomical distribution of primary intracerebral hemorrhage and survival/mortality rates were observed in all groups. Results. Antiplatelet therapy was used by 20.3% of patients, 8.2% received antocoagulant therapy, while the rest of 71.5% didn not take these drugs in the premorbid period. The most common risk factor was arterial hypertension (97.2%). In all groups, patients had a tendency for supratentorial hematomas. Only alcohol consumption had a significant impact on the localization of hemorrhage (p < 0,05). There was no statistically significant difference between groups in National Institutes of Health Stroke Scale score on admission and a modified Rankin Scale Score at discharge. Oral anticoagulant users presented with the highest mortality rate in the first 24 hours (odds ratio - 2.5). Patients in other two groups showed a significantly higher survival rate (odds ratio - 1.5). Conclusion. Oral anticoagulant users had significantly higher National Institutes of Health Stroke Scale score on admission with an increased risk for early death. A significantly higher percentage of survival was noted in other two groups. Approximately 2/3 of all patients had poor functional recovery.

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Thrombectomy in Extensive Stroke May Not Be Beneficial and Is Associated With Increased Risk for Hemorrhage

Stroke ◽

10.1161/strokeaha.120.033101 ◽

2021 ◽

Author(s):

Lukas Meyer ◽

Matthias Bechstein ◽

Maxim Bester ◽

Uta Hanning ◽

Caspar Brekenfeld ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Cerebral Infarction ◽

Medical Treatment ◽

Scale Score ◽

Odds Ratio ◽

Modified Rankin Scale ◽

Anterior Circulation ◽

Symptomatic Intracerebral Hemorrhage ◽

Best Medical Treatment ◽

Increased Risk

Background and Purpose: This study evaluates the benefit of endovascular treatment (EVT) for patients with extensive baseline stroke compared with best medical treatment. Methods: This retrospective, multicenter study compares EVT and best medical treatment for computed tomography (CT)–based selection of patients with extensive baseline infarcts (Alberta Stroke Program Early CT Score ≤5) attributed to anterior circulation stroke. Patients were selected from the German Stroke Registry and 3 tertiary stroke centers. Primary functional end points were rates of good (modified Rankin Scale score of ≤3) and very poor outcome (modified Rankin Scale score of ≥5) at 90 days. Secondary safety end point was the occurrence of symptomatic intracerebral hemorrhage. Angiographic outcome was evaluated with the modified Thrombolysis in Cerebral Infarction Scale. Results: After 1:1 pair matching, a total of 248 patients were compared by treatment arm. Good functional outcome was observed in 27.4% in the EVT group, and in 25% in the best medical treatment group ( P =0.665). Advanced age (adjusted odds ratio, 1.08 [95% CI, 1.05–1.10], P <0.001) and symptomatic intracerebral hemorrhage (adjusted odds ratio, 6.35 [95% CI, 2.08–19.35], P <0.001) were independently associated with very poor outcome. Mortality (43.5% versus 28.9%, P =0.025) and symptomatic intracerebral hemorrhage (16.1% versus 5.6%, P =0.008) were significantly higher in the EVT group. The lowest rates of good functional outcome (≈15%) were observed in groups of failed and partial recanalization (modified Thrombolysis in Cerebral Infarction Scale score of 0/1–2a), whereas patients with complete recanalization (modified Thrombolysis in Cerebral Infarction Scale score of 3) with recanalization attempts ≤2 benefitted the most (modified Rankin Scale score of ≤3:42.3%, P =0.074) compared with best medical treatment. Conclusions: In daily clinical practice, EVT for CT–based selected patients with low Alberta Stroke Program Early CT Score anterior circulation stroke may not be beneficial and is associated with increased risk for hemorrhage and mortality, especially in the elderly. However, first- or second-pass complete recanalization seems to reveal a clinical benefit of EVT highlighting the vulnerability of the low Alberta Stroke Program Early CT Score subgroup. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03356392.

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Ramadan Fasting and Intracerebral Hematoma: Incidence and Outcomes

International Neuropsychiatric Disease Journal ◽

10.9734/indj/2021/v15i330155 ◽

2021 ◽

pp. 6-10

Author(s):

Khaled Eltoukhy ◽

Wessam Mustafa ◽

Nadia Elgendy ◽

Hossam Egila

Keyword(s):

Intracerebral Hemorrhage ◽

Religious Tradition ◽

National Institutes Of Health ◽

University Hospital ◽

Hematoma Expansion ◽

Intracerebral Hematoma ◽

Ramadan Fasting ◽

Significant Difference ◽

Ct Brain ◽

First Time

Background and Objectives: Fasting over a prescribed period of time is a common religious tradition practiced by several prominent faiths in the world. It is also currently regaining interest as a medical practice, both as preventive and as therapy and/or simple choice of lifestyle. For the first time, we evaluate how Ramadan (an Islamic month) fasting can influence the incidence of intracerebral hematoma and its outcome. Methods: 69 patients with primary intracerebral hemorrhage enrolled in this study, 32 patients were enrolled during Ramadan (18 patients were fasting, 14 patients were not fasting) and 37 patients were enrolled one month later (Shawal) which is not a mandatory fasting month among Muslims. All patients were admitted to Neurology department, Mansoura university hospital. The clinical characteristics and mortality during hospital admission were noticed. They were all assessed using routine lab, CT brain, “National Institutes of Health Stroke Scale” (NIHSS) and “Modified Rankin Scale” (mRS). Results: About 22 percentage of fasting patients with intracerebral hematoma died, 28.6% non-fasting patients died and 20.5% of patients died in the month after Ramadan without significant difference among the three groups (ρ>0.05). Also regarding NIHSS, hematoma expansion and mRS, there was no statistically significant difference among the three groups (ρ>0.05). Conclusion: Ramadan fasting showed neither protective effect nor worsening as regard incidence or bad impact on patients with spontaneous intracerebral hemorrhage.

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Dual Antiplatelet Therapy Improves Functional Outcome in Patients With Progressive Lacunar Strokes

Stroke ◽

10.1161/strokeaha.118.023789 ◽

2019 ◽

Vol 50 (4) ◽

pp. 1007-1009 ◽

Cited By ~ 10

Author(s):

Anne Berberich ◽

Christine Schneider ◽

Tilman Reiff ◽

Christoph Gumbinger ◽

Peter Arthur Ringleb

Keyword(s):

Functional Outcome ◽

Antiplatelet Therapy ◽

Scale Score ◽

Dual Antiplatelet Therapy ◽

Treatment Strategies ◽

National Institutes Of Health ◽

Bleeding Complications ◽

Positive Effects ◽

End Point ◽

Early Neurological Deterioration

Background and Purpose— In 20% to 30% of patients with lacunar strokes, early neurological deterioration (END) occurs within the first days after stroke onset. However, effective treatment strategies are still missing for these patients. The purpose of this study was to analyze efficacy of dual antiplatelet therapy (DAPT) in patients presenting with END. Methods— Four hundred fifty-eight patients with lacunar strokes and corresponding neuroimaging evidence of lacunar ischemia were retrospectively screened for END, which was defined by deterioration of ≥3 total National Institutes of Health Stroke Scale points, ≥2 National Institutes of Health Stroke Scale points for limb paresis, or documented clinical deterioration within 5 days after admission. Patients with END were treated with DAPT according to in-house standards. Primary efficacy end point was fulfilled if National Institutes of Health Stroke Scale score at discharge improved at least to the score at admission. Secondary end points were Rankin Scale score, further clinical fluctuation, and symptomatic bleeding complications. Results— END occurred in 130 (28%) of 458 patients with lacunar strokes. Ninety-seven (75%) of these patients were treated with DAPT after END, mostly for 5 days. DAPT was associated with improved functional outcome. The primary end point was met in 68% (66) of patients with DAPT compared with 36% (12) of patients with standard treatment ( P =0.0019). Further clinical fluctuations were absent in 79% (77) of patients with DAPT versus 33% (11) of patients without DAPT ( P <0.001). Symptomatic bleeding complications were not observed in any patient. Conclusions— The results demonstrated potential positive effects of DAPT in patients with progressive lacunar strokes.

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Increased risk of intracerebral hemorrhage among patients with chronic osteomyelitis

Journal of Neurosurgery ◽

10.3171/2014.11.jns141269 ◽

2015 ◽

Vol 123 (6) ◽

pp. 1528-1533 ◽

Cited By ~ 4

Author(s):

Chun-Hung Tseng ◽

Wei-Shih Huang ◽

Chih-Hsin Muo ◽

Yen-Jung Chang ◽

Fung-Chang Sung

Keyword(s):

Intracerebral Hemorrhage ◽

Chronic Osteomyelitis ◽

Cox Model ◽

The Elderly ◽

Inflammatory Disorder ◽

Inflammatory Factor ◽

Specific Analysis ◽

Increased Risk ◽

Comparison Cohort ◽

First Time

OBJECT Inflammation may provoke cerebral arteriolar ectasia, inducing microaneurysm formation and further promoting intracerebral hemorrhage (ICH). Chronic osteomyelitis (COM) is an inflammatory disorder for which study of its role in ICH is lacking. This study explored whether COM increases the risk of ICH. METHODS From Taiwan national insurance inpatient claims, 22,052 patients who were newly diagnosed with COM between 1997 and 2010 were identified; 88, 207 age and sex frequency-matched subjects without COM were selected at random for comparison. Risks of ICH associated with COM and comorbidities, including hypertension, diabetes, hyperlipidemia, chronic kidney disease, and drug abuse, were assessed by the end of 2010. RESULTS The incidence of ICH was 1.68 times higher in the COM cohort than in the comparison cohort, with an adjusted hazard ratio (HR) of 1.50 (95% CI 1.29–1.74) estimated in the multivariable Cox model. Age-specific analysis showed that the HR of ICH for COM patients decreased with age, with an adjusted HR of 3.28 (95% CI 1.88–5.75) in the < 40-year age group, which declined to 1.11 (95% CI 0.88–1.40) in the elderly. The incidence of ICH increased with the severity of COM; for those with severe COM the adjusted HR was 4.42 (95% CI 3.31–5.89). For subjects without comorbidities, the incidence of ICH was 1.20-fold (95% CI 1.00–1.45) higher in the COM cohort than in the comparison cohort. CONCLUSIONS This study suggests for the first time that COM is an inflammatory factor associated with increased risk of ICH, especially in younger patients.

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Treatment and Outcome in Stroke Patients With Acute M2 Occlusion and Minor Neurological Deficits

Stroke ◽

10.1161/strokeaha.120.031672 ◽

2021 ◽

Author(s):

Tomas Dobrocky ◽

Eike I. Piechowiak ◽

Bastian Volbers ◽

Nedelina Slavova ◽

Johannes Kaesmacher ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Scale Score ◽

Cerebral Artery ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

National Institutes Of Health ◽

Neurological Deficits ◽

Minor Stroke ◽

Modified Rankin Scale ◽

Stroke Patients

Background and Purpose: Treatment in stroke patients with M2 segment occlusion of the middle cerebral artery presenting with mild neurological deficits is a matter of debate. The main purpose was to compare the outcome in patients with a minor stroke and a M2 occlusion. Methods: Consecutive intravenous thrombolysis (IVT) eligible patients admitted to the Bernese stroke center between January 2005 and January 2020 with acute occlusion of the M2 segment and National Institutes of Health Stroke Scale score ≤5 were included. Outcome was compared between IVT only versus endovascular therapy (EVT) including intra-arterial thrombolysis and mechanical thrombectomy (MT; ±IVT) and between IVT only versus MT only. Results: Among 169 patients (38.5% women, median age 70.2 years), 84 (49.7%) received IVT only and 85 (50.3%) EVT (±IVT), the latter including 39 (45.9%) treated with MT only. Groups were similar in sex, age, vascular risk factors, event cause, or preevent independency. Compared with IVT only, there was no difference in favorable outcome (modified Rankin Scale score, 0−2) for EVT (adjusted odds ratio, 0.96; adjusted P =0.935) or for MT only (adjusted odds ratio, 1.12; adjusted P =0.547) groups. Considering only patients treated after 2015, there was a significantly better 3-month modified Rankin Scale shift (adjusted P =0.032) in the EVT compared with the IVT only group. Conclusions: Our study demonstrates similar effectiveness of IVT only versus EVT (±IVT), and of IVT only versus MT only in patients with peripheral middle cerebral artery occlusions and minor neurological deficits and indicates a possible benefit of EVT considering only patients treated after 2015. There is an unmet need for randomized controlled trials in this stroke field, including imaging parameters, and more sophisticated evaluation of National Institutes of Health Stroke Scale score subitems, neurocognition, and quality of life neglected by the standard outcome scales such as modified Rankin Scale and National Institutes of Health Stroke Scale score.

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Spontaneous Intracerebral Hemorrhage: Patient’s Activities before the Onset of Stroke and Localization of Intracerebral Hemorrhage in Black Africans

Research in Health Science ◽

10.22158/rhs.v4n2p101 ◽

2019 ◽

Vol 4 (2) ◽

pp. p101

Author(s):

Serge Malenga Mpaka ◽

Blaise Ngizulu Mazuka ◽

Didier Ndabahweje Ndyanabo ◽

Benjamin Longo-Mbenza ◽

Michel Lelo Tshikwela

Keyword(s):

Physical Activity ◽

Intracerebral Hemorrhage ◽

Hemorrhagic Stroke ◽

P Value ◽

Spontaneous Intracerebral Hemorrhage ◽

Logistic Regression Models ◽

Emotional Factors ◽

Increased Risk ◽

Significant Difference ◽

Republic Of The Congo

Background: Some published studies on the patient’s activity before the stroke occurrence indicate that thereis an increased risk of the onset of acute stroke during these activities. In our community, these data are not yet assessed. The purpose of this pilot study was to examine whether intracerebral hemorrhage may be linked to patient’s physical activity before the onset and to carry out any relationship with location of the hemorrhage.Methods: The patient’s activity before the onset of stroke and location of hemorrhage in 58 patients (40 men and 18 women, aged 39 to 81years) admitted with spontaneous intracerebral hemorrhage seen by CT in Kinshasa, Democratic Republic of the Congo, from 2012 to 2015, were recorded and analyzed using logistic regression models. Results: In 31% of the case, the onset developed after emotional factors, in 24% in the lavatory, in 15% during housework and in 12% during sexual activity (X-squared = 8.319, p-value = 0.081). There was no significant difference between those activities and the site of intracerebral hemorrhage (p?0.05).Conclusion: Most patients in this series seemed to be stricken by the hemorrhagic stroke during some physical activity. It is less certain that location of intracerebral hemorrhage was linked with these activities.

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Acute Ischemic Stroke in Patients With COVID-19

Stroke ◽

10.1161/strokeaha.121.034301 ◽

2021 ◽

Vol 52 (5) ◽

pp. 1826-1829

Author(s):

Pratyaksh K. Srivastava ◽

Shuaiqi Zhang ◽

Ying Xian ◽

Hanzhang Xu ◽

Christine Rutan ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Odds Ratio ◽

Adverse Outcomes ◽

National Institutes Of Health ◽

Stroke Severity ◽

Younger Age ◽

Increased Risk ◽

Scale Scores ◽

Get With The Guidelines

Background and Purpose: Studies suggest an increased risk of adverse outcomes among patients with acute ischemic stroke (AIS) and coronavirus disease 2019 (COVID-19). Methods: Using Get With The Guidelines–Stroke, we identified 41 971 patients (AIS/COVID-19: 1143; AIS/no COVID-19: 40 828) with AIS hospitalized between February 4, 2020 and June 29, 2020, from 458 Get With The Guidelines–Stroke hospitals with at least one COVID-19 case and evaluated clinical characteristics, treatment patterns, and outcomes. Results: Compared with patients with AIS/no COVID-19, those with AIS/COVID-19 were younger, more likely to be non-Hispanic Black, Hispanic, or Asian, more likely to present with higher National Institutes of Health Stroke Scale scores, and had greater proportions of large vessel occlusions. Rates of thrombolysis and thrombectomy were similar between the groups. Door to computed tomography (median 55 [18–207] versus 35 [14–99] minutes, P <0.001), door to needle (59 [40–82] versus 46 [33–64] minutes, P <0.001), and door to endovascular therapy (114 [74–169] versus 90 [54–133] minutes, P =0.002) times were longer in the AIS/COVID-19 cohort. In adjusted models, patients with AIS/COVID-19 had decreased odds of discharge with modified Rankin Scale score of ≤2 (odds ratio, 0.65 [95% CI, 0.52–0.81], P <0.001) and increased odds of in-hospital mortality (odds ratio, 4.34 [95% CI, 3.48–5.40], P <0.001). ConclusionS: This analysis demonstrates younger age, greater stroke severity, longer times to evaluation and treatment, and worse morbidity and mortality in patients with AIS/COVID-19 compared with those with AIS/no COVID-19.

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Obstructive Sleep Apnea as a Risk Factor for Intracerebral Hemorrhage

Stroke ◽

10.1161/strokeaha.120.033342 ◽

2021 ◽

Author(s):

Jacqueline H. Geer ◽

Guido J. Falcone ◽

Kevin N. Vanent ◽

Audrey C. Leasure ◽

Daniel Woo ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Logistic Regression ◽

Risk Factor ◽

Sleep Apnea ◽

Intracerebral Hemorrhage ◽

Odds Ratio ◽

Berlin Questionnaire ◽

Multivariable Logistic Regression Model ◽

Obstructive Sleep ◽

Increased Risk

Background and Purpose: To determine whether obstructive sleep apnea (OSA) is associated with intracerebral hemorrhage (ICH) risk, we assessed premorbid OSA exposure of patients with nontraumatic ICH and matched controls. Methods: Ethnic/Racial Variations of Intracerebral Hemorrhage is a multicenter, case-control study evaluating risk factors for ICH that recruited 3000 cases with ICH and 3000 controls. OSA status was ascertained using the Berlin Questionnaire as a surrogate for premorbid OSA. We performed logistic regression analyses to evaluate the association between OSA and ICH. Results: Two thousand and sixty-four (71%) cases and 1516 (52%) controls were classified as having OSA by the Berlin Questionnaire. Cases with OSA were significantly more likely to be male and have hypertension, heart disease, hyperlipidemia, and higher body mass index compared with those without OSA. OSA was more common among cases compared with controls (71% versus 52%, odds ratio, 2.28 [95% CI, 2.05–2.55]). In a multivariable logistic regression model, OSA was associated with increased risk for ICH (odds ratio, 1.47 [95% CI, 1.29–1.67]). Conclusions: OSA is a risk factor for ICH.

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Adiposity and Outcome After Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.027900 ◽

2021 ◽

Vol 52 (1) ◽

pp. 144-151

Author(s):

Zuolu Liu ◽

Nerses Sanossian ◽

Sidney Starkman ◽

Gilda Avila-Rinek ◽

Marc Eckstein ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Scale Score ◽

Odds Ratio ◽

Functional Outcomes ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Related Quality ◽

Severely Obese

Background and Purpose: A survival advantage among individuals with higher body mass index (BMI) has been observed for diverse acute illnesses, including stroke, and termed the obesity paradox. However, prior ischemic stroke studies have generally tested only for linear rather than nonlinear relations between body mass and outcome, and few studies have investigated poststroke functional outcomes in addition to mortality. Methods: We analyzed consecutive patients with acute ischemic stroke enrolled in a 60-center acute treatment trial, the NIH FAST-MAG acute stroke trial. Outcomes at 3 months analyzed were (1) death; (2) disability or death (modified Rankin Scale score, 2–6); and (3) low stroke-related quality of life (Stroke Impact Scale<median). Relations with BMI were analyzed univariately and in multivariate models adjusting for 14 additional prognostic variables. Results: Among 1033 patients with acute ischemic stroke, average age was 71 years (±13), 45.1% female, National Institutes of Health Stroke Scale 10.6 (±8.3), and BMI 27.5 (±5.6). In both unadjusted and adjusted analysis, increasing BMI was linearly associated with improved 3-month survival ( P =0.01) odds ratios in adjusted analysis for mortality declined across the BMI categories of underweight (odds ratio, 1.7 [CI, 0.6–4.9]), normal (odds ratio, 1), overweight (0.9 [CI, 0.5–1.4]), obese (0.5, [CI, 0.3–1.0]), and severely obese (0.4 [CI, 0.2–0.9]). In unadjusted analysis, increasing BMI showed a U-shaped relation to poststroke disability or death (modified Rankin Scale score, 2–6), with odds ratios of modified Rankin Scale score, 2 to 6 for underweight, overweight, and obese declined initially when compared with normal weight patients, but then increased again in severely obese patients, suggesting a U-shaped or J-shaped relation. After adjustment, including for baseline National Institutes of Health Stroke Scale, modified Rankin Scale score 2 to 6 was no longer related to adiposity. Conclusions: Mortality and functional outcomes after acute ischemic stroke have disparate relations with patients’ adiposity. Higher BMI is linearly associated with increased survival; and BMI has a U-shaped or J-shaped relation to disability and stroke-related quality of life. Potential mechanisms including nutritional reserve aiding survival during recovery and greater frequency of atherosclerotic than thromboembolic infarcts in individuals with higher BMI.

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ESA use in women with cancer: Consequences of the 2008 FDA clinical alert.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.5040 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 5040-5040

Author(s):

Kimberly M. Dickinson ◽

Bachir Joseph Sakr

Keyword(s):

Blood Transfusion ◽

Blood Transfusions ◽

Entire Study ◽

Time Period ◽

Increased Risk ◽

Significant Difference ◽

Study Population ◽

Time Periods ◽

One Year ◽

First Time

5040 Background: Erythropoietin stimulating agents (ESA) are used clinically as an alternative to blood transfusions in cancer patients suffering from symptoms of anemia. However, more recent randomized controlled trials of ESA usage concluded that its use is associated with an increased risk of tumor progression and death. As a result, in July 2008 the FDA issued a clinical alert restricting the use of ESA. A reduction in the prescribing of ESA was immediately seen but changes in blood transfusion rates have not been examined. Methods: A retrospective chart review was conducted drawing from patients under treatment in the Program in Women’s Oncology at Women and Infant’s Hospital from one year before the clinical alert (August 2007-July 2008) to one year afterward (August 2008-July 2009). The primary outcomes were blood transfusion and ESA administration rates compared across the two time periods. Results: The study population (n=776) included patients with a cancer diagnosis who received chemotherapy during one or both time periods. 165 (21.3%) patients received ESA treatment. The total number of ESA treatments administered in the study period of interest was 1,277, with the majority (60%) given prior to the FDA alert. The mean number of ESA treatments in the first time period was 6.39 per person as compared to 0.61 per person in the second time period. Of the study population, 186 (23.8%) patients received at least one blood transfusion. A total of 463 blood transfusions were administered during the entire study period but a significant difference was not observed in the proportion of those delivered prior to the FDA alert (52%) versus after the FDA alert (48%). The average number of transfusions given in the first time period was 2.34 per person, as compared to 2.17 per person in the second period. Conclusions: Our results indicate that despite a steep decline in the use of ESA for chemotherapy-induced anemia, blood transfusion rates were not significantly different between the two periods. Interestingly, a slight downward trend was observed from before the FDA alert to after the alert. While more work is needed to understand the implications of these findings, it suggests that resource utilization did not increase despite the reduction in ESA use.

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