ORCID Profile
0000-0002-8495-4578
Current Organisation
Radboud Universitair Medisch Centrum
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Publisher: BMJ
Date: 13-08-2015
Abstract: Case-control studies have reported multiple genetic loci to be associated with sporadic brain arteriovenous malformations (AVMs) but most of these have not been replicated in independent populations. The aim of this study was to find additional evidence for these reported associations and perform a meta-analysis including all previously published results. We included 167 Dutch patients and 1038 Dutch controls. Case genotyping was performed by KASPar assays. Controls had been previously genotyped with a genome wide single nucleotide polymorphisms (SNP) array. Differences in genotype frequencies between cases and controls were estimated by χ(2) testing in Plink V.1.07. Meta-analysis was performed in RevMan V.5.3. In our case-control study we found no significant association with brain AVM (BAVM) for previously discovered SNPs near ANGPTL4, IL-1β, GPR124, VEGFA and MMP-3. The meta-analysis revealed a statistically significant association with BAVMs for the polymorphism rs11672433 near ANGPTL4 (OR 1.39 95% CI 1.10 to 1.75, p value 0.005). The results of this study support a role for the previously identified SNP near ANGPTL4 in the pathogenesis of AVMs. Previously found associations with SNPs near IL-1β, GPR124, VEGFA and MMP-3 genes could not be substantiated in our replication cohort or in the meta-analysis.
Publisher: BMJ
Date: 21-06-2022
Abstract: Antithrombotic therapy is a key element of secondary prevention in patients who have had an ischaemic stroke or transient ischaemic attack. However, its use in clinical practice is not always straightforward. This review provides an update on certain difficult scenarios in antithrombotic management, with a focus on recent clinical trials and large observational studies. We discuss the approach to patients with an indication for antithrombotic treatment who also have clinical or radiological evidence of previous intracranial bleeding, patients with indications for both anticoagulant and antiplatelet treatment, and patients in whom antithrombotic treatment fails to prevent stroke. We also review the timing of anticoagulation initiation after cardioembolic stroke, and the use of antithrombotics in patients with asymptomatic cerebrovascular disease. Despite a wealth of new evidence, numerous uncertainties remain and we highlight ongoing trials addressing these.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2002
Abstract: Background and Purpose — Chronic ocular ischemia is a rare form of ischemia of the eye in patients with carotid artery occlusion (CAO). The early and often asymptomatic stage of chronic ocular ischemia is referred to as venous stasis retinopathy (VSR). The aim of this study was to gain insight into the prevalence, cause, and outcome of VSR in patients with symptomatic CAO. Methods — In 110 patients with symptomatic CAO, we prospectively investigated the frequency of VSR, the association between the presence of VSR and impaired cerebral blood flow, and the proportion of patients who developed clinically manifest chronic ocular ischemia with ischemia of the anterior eye segment or blindness. Results — At study entry, VSR was found in 32 patients (29% 95% CI, 21 to 38), particularly in those with symptoms classically associated with a hemodynamic cause, such as limb shaking (relative risk, 2.4 95% CI, 1.0 to 5.9). Patients with VSR had lower pulsatility indexes in the ophthalmic artery in case of reversed flow, lower cerebral CO 2 reactivity, and lower cerebropetal blood flow than patients without VSR. On follow-up (mean, 29 months), clinically manifest chronic ocular ischemia developed in 4 patients (annual rate, 1.5% 95% CI, 0.4 to 3.8) it tended to occur more often in patients in whom VSR was present at study entry (relative risk, 7.3 95% CI, 0.8 to 68). Conclusions — One third of patients with symptomatic CAO has VSR on ophthalmoscopy. VSR is associated with an impaired flow state of the brain. Development of clinically manifest chronic ocular ischemia is rare.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2022
DOI: 10.1161/STROKEAHA.121.036233
Abstract: Whether certain activities can trigger spontaneous intracerebral hemorrhage (ICH) remains unknown. Insights into factors that trigger vessel rupture resulting in ICH improves knowledge on the pathophysiology of ICH. We assessed potential trigger factors and their risk for ICH onset. We included consecutive patients diagnosed with ICH between July 1, 2013, and December 31, 2019. We interviewed patients on their exposure to 12 potential trigger factors (eg, Valsalva maneuvers) in the (hazard) period soon before onset of ICH and their normal exposure to these trigger factors in the year before the ICH. We used the case-crossover design to calculate relative risks (RR) for potential trigger factors. We interviewed 149 patients (mean age 64, 66% male) with ICH. Sixty-seven (45%) had a lobar hemorrhage, 60 (40%) had a deep hemorrhage, 19 (13%) had a cerebellar hemorrhage, and 3 (2%) had an intraventricular hemorrhage. For ICH in general, there was an increased risk within an hour after caffeine consumption (RR=2.5 [95% CI=1.8–3.6]), within an hour after coffee consumption alone (RR=4.8 [95% CI=3.3–6.9]), within an hour after lifting kg (RR=6.6 [95% CI=2.2–19.9]), within an hour after minor head trauma (RR=10.1 [95% CI=1.7–60.2]), within an hour after sexual activity (RR=30.4 [95% CI=16.8–55.0]), within an hour after straining for defecation (RR=37.6 [95% CI=22.4–63.4]), and within an hour after vigorous exercise (RR=21.8 [95% CI=12.6–37.8]). Within 24 hours after flu-like disease or fever, the risk for ICH was also increased (RR=50.7 [95% CI=27.1–95.1]). Within an hour after Valsalva maneuvers, the RR for deep ICH was 3.5 (95% CI=1.7–6.9) and for lobar ICH the RR was 2.0 (95% CI=0.9–4.2). We identified one infection and several blood pressure related trigger factors for ICH onset, providing new insights into the pathophysiology of vessel rupture resulting in ICH.
Publisher: Elsevier BV
Date: 06-2000
Publisher: Elsevier BV
Date: 2018
DOI: 10.1016/J.JSTROKECEREBROVASDIS.2017.08.031
Abstract: Nonagenarians are under-represented in thrombolytic trials for acute ischemic stroke (AIS). The effectiveness of intravenous thrombolytics in nonagenarians in terms of safety and outcome is not well established. We used a multinational registry to identify patients aged 90 years or older with good baseline functional status who presented with AIS. Differences in outcomes-disability level at 90 days, frequency of symptomatic intracerebral hemorrhage (sICH), and mortality-between patients who did and did not receive thrombolytics were assessed using multivariable logistic regression, adjusted for prespecified prognostic factors. Coarsened exact matching (CEM) was utilized before evaluating outcome by balancing both groups in the sensitivity analysis. We identified 227 previously independent nonagenarians with AIS 122 received intravenous thrombolytics and 105 did not. In the unmatched cohort, ordinal analysis showed a significant treatment effect (adjusted common odds ratio [OR]: .61, 95% confidence interval [CI]: .39-.96). There was an absolute difference of 8.1% in the rate of excellent outcome in favor of thrombolysis (17.4% versus 9.3% adjusted ratio: .30, 95% CI: .12-.77). Rates of sICH and in-hospital mortality were not different. Similarly, in the matched cohort, CEM analysis showed a shift in the primary outcome distribution in favor of thrombolysis (adjusted common OR: .45, 95% CI: .26-.76). Nonagenarians treated with thrombolytics showed lower stroke-related disability at 90 days than those not treated, without significant difference in sICH and in-hospital mortality rates. These observations cannot exclude a residual confounding effect, but provide evidence that thrombolytics should not be withheld from nonagenarians because of age alone.
Publisher: BMJ
Date: 27-01-2016
Publisher: SAGE Publications
Date: 23-04-2014
Abstract: In patients with spontaneous intracerebral hemorrhage (ICH) coexisting abnormalities on brain imaging can provide clues on the etiology of the underlying small vessel disease. We examined cortical cerebral microinfarcts as a novel marker of coexistent vascular damage in ICH. Twelve patients with spontaneous ICH and 15 controls underwent 7Tesla magnetic resonance imaging (MRI). Microinfarcts were present in 9 of 12 patients with spontaneous ICH, and in 5 of 15 controls. This explorative study shows, for the first time, that microinfarcts appear to be a very common vascular comorbidity in spontaneous ICH. Future larger studies should further assess the etiological significance of these lesions.
Publisher: American Medical Association (AMA)
Date: 2017
DOI: 10.1001/JAMANEUROL.2016.3482
Abstract: The incidence of stroke is higher in men than in women. The influence of sex-specific risk factors on stroke incidence and mortality is largely unknown. To conduct a systematic review and meta-analysis of female- and male-specific risk factors for stroke. PubMed, EMBASE, and the bibliographies of articles were searched for studies published between January 1, 1985, and January 26, 2015, reporting on the association between female- and male-specific characteristics and stroke. Observational studies reporting associations between sex-specific risk factors and stroke were selected. Two authors performed data extraction independently. Estimates were pooled with a generic variance-based, random-effects method. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. In addition, our study adhered to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Ischemic stroke, hemorrhagic stroke, any stroke, and stroke mortality. This systematic review and meta-analysis included 78 studies (70 longitudinal and 8 case-control) comprising 10 187 540 persons. In women, the pooled relative risks of ischemic stroke were 1.80 (95% CI, 1.49-2.18) after any hypertensive disorder in pregnancy (HDP) (gestational hypertension [GH], preecl sia, or ecl sia) and 1.81 (95% CI, 1.44-2.27) after GH vs no HDP. The pooled relative risks of hemorrhagic stroke were 2.24 (95% CI, 1.19-4.21) in women with menopause at the age of at least 55 years vs 50 to 54 years and 5.08 (95% CI, 1.80-14.34) after GH vs no GH. The pooled relative risks of any stroke were 1.42 (95% CI, 1.34-1.50) after oophorectomy vs no oophorectomy, 0.88 (95% CI, 0.85-0.90) after hysterectomy vs no hysterectomy, 1.63 (95% CI, 1.52-1.75) after any vs no HDP, 1.54 (95% CI, 1.39-1.70) after preecl sia or ecl sia, 1.51 (95% CI, 1.27-1.80) after GH vs no HDP, 1.62 (95% CI, 1.46-1.79) after preterm delivery, and 1.86 (95% CI, 1.15-3.02) after stillbirth vs no pregnancy complications. The pooled relative risk of stroke mortality was 1.57 (95% CI, 1.04-2.39) after GH vs no GH. In men, the pooled relative risks of ischemic stroke were 1.19 (95% CI, 1.05-1.34) after androgen deprivation therapy (ADT) vs no ADT and 1.21 (95% CI, 1.00-1.46) after orchiectomy vs no orchiectomy. The pooled relative risks of any stroke were 1.21 (95% CI, 1.06-1.37) for ADT vs no ADT and 1.35 (95% CI, 1.18-1.53) for erectile dysfunction vs no dysfunction. Female-specific characteristics increasing stroke risk include HDP for ischemic stroke, late menopause and gestational hypertension for hemorrhagic stroke, and oophorectomy, HDP, preterm delivery, and stillbirth for any stroke. Hysterectomy is possibly protective against any stroke. Male-specific characteristics increasing stroke risk include medical androgen deprivation therapy for ischemic and any stroke and erectile dysfunction for any stroke. Consideration of sex-specific risk factors can improve in idualized stroke risk assessment.
Publisher: Wiley
Date: 08-1998
Abstract: The objective of this study was to evaluate the role of collateral blood flow via the anterior and posterior communicating arteries (ACoA and PCoA) and via the ophthalmic artery (OphA) on cerebral hemodynamics, metabolism, and border zone infarcts in 57 patients with unilateral symptomatic occlusions of the internal carotid artery. Collateral flow via the ACoA and PCoA was determined with magnetic resonance angiography (MRA) and collateral flow via the OphA with transcranial Doppler (TCD). Volume flow was studied with MRA, metabolism with 1H MR spectroscopy, CO2 reactivity with TCD, and the incidence of border zone infarcts with MRI. Compared with controls, patients had deteriorated volume flow, metabolism, and CO2 reactivity. No differences were found between patients with and patients without collateral flow through the ACoA and/or PCoA, or between patients with or without collateral flow via the OphA. Patients without collateral flow via any of these collaterals had decreased volume flow in the middle cerebral artery, decreased N-acetylaspartate/choline, and increased lactate/N-acetylaspartate, compared with the other patients. Patients with symptomatic internal carotid artery occlusion have deteriorated cerebral hemodynamics and metabolism. Different collateral flow patterns via the ACoA, PCoA, or OphA have no effect on the hemodynamic and metabolic parameters, as long as one of these pathways is present.
Publisher: Wiley
Date: 14-05-2015
DOI: 10.1002/ANA.24416
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2010
DOI: 10.1161/STROKEAHA.110.589291
Abstract: Background and Purpose— Intracerebral hematomas (ICHs) often increase in size in the initial hours. It is unknown whether expansion of ICHs after aneurysmal rupture in the acute phase is always a sign of rerupture of the original aneurysm. Methods— We included patients with an ICH from a ruptured aneurysm who underwent computed tomography imaging within 24 hours of symptom onset and a repeat computed tomography within 48 hours. Hematoma growth was considered present when there was a 33% increase in hematoma volume, as assessed by the ABC/2 method. Clinical and radiologic characteristics were compared between patients with ICH growth, with and without clinical signs of rerupture. Rerupture was defined as a sudden deterioration in the level of consciousness in the absence of ventricular enlargement or a systemic cause. Results— Hematoma expansion within 48 hours after onset occurred in 12 of the 49 included patients and was preceded by clinical evidence of rerupture in 6 of these 12 patients. Of the 6 patients without an evident rerupture, 3 had no clinical deterioration, 1 had respiratory failure due to pneumonia, another had temporal brain herniation, and the last had acute hydrocephalus. Conclusion— Only half of the patients with early ICH expansion after aneurysmal rupture had clinical signs of rerupture of the aneurysm. Early ICH expansion after aneurysmal rupture can be caused by other mechanisms, which are possibly comparable to those responsible for hematoma expansion in spontaneous ICH.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-02-2022
DOI: 10.1212/WNL.0000000000013195
Abstract: There is a worldwide increase in the incidence of stroke in young adults, with major regional and ethnic differences. Advancing knowledge of ethnic and regional variation in causes and outcomes will be beneficial in implementation of regional health care services. We studied the global distribution of risk factors, causes, and 3-month mortality of young patients with ischemic stroke, by performing a patient data meta-analysis from different cohorts worldwide. We performed a pooled analysis of in idual patient data from cohort studies that included consecutive patients with ischemic stroke aged 18–50 years. We studied differences in prevalence of risk factors and causes of ischemic stroke between different ethnic and racial groups, geographic regions, and countries with different income levels. We investigated differences in 3-month mortality by mixed-effects multivariable logistic regression. We included 17,663 patients from 32 cohorts in 29 countries. Hypertension and diabetes were most prevalent in Black (hypertension, 52.1% diabetes, 20.7%) and Asian patients (hypertension 46.1%, diabetes, 20.9%). Large vessel atherosclerosis and small vessel disease were more often the cause of stroke in high-income countries (HICs both p 0.001), whereas “other determined stroke” and “undetermined stroke” were higher in low and middle-income countries (LMICs both p 0.001). Patients in LMICs were younger, had less vascular risk factors, and despite this, more often died within 3 months than those from HICs (odds ratio 2.49 95% confidence interval 1.42–4.36). Ethnoracial and regional differences in risk factors and causes of stroke at young age provide an understanding of ethnic and racial and regional differences in incidence of ischemic stroke. Our results also highlight the dissimilarities in outcome after stroke in young adults that exist between LMICs and HICs, which should serve as call to action to improve health care facilities in LMICs.
Publisher: Elsevier BV
Date: 10-2010
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-09-2012
Publisher: Elsevier BV
Date: 02-2014
Publisher: Elsevier BV
Date: 09-2002
Abstract: Quantitative perfusion MRI is a promising new technique capable of offering information on cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT). However, it is still unclear how these perfusion parameters relate to the underlying physiological indicators and how they compare to conventional techniques. The purpose of this study was to investigate how quantitative perfusion MRI is related to the cerebrovascular reactivity as measured by transcranial Doppler ultrasonography (TCD) in combination with a CO2 stimulus in patients with a symptomatic occlusion of the internal carotid artery (ICA). Thirty-nine patients with transient or minor disabling retinal or hemispheric ischemic symptoms and an occlusion of the ICA underwent quantitative perfusion MRI and CO2 reactivity measurements by TCD. Perfusion parameters were correlated with cerebrovascular reactivity measurements and compared with measurements of control subjects. The results of this study show a negative correlation between the cerebrovascular reactivity and the time to bolus peak (TBP) both for gray (r = -0.26, P = 0.035) and white matter (r = -0.28, P = 0.026). No correlation between resting CBV, CBF, or MTT and cerebrovascular reactivity was found. Our results indicate that an increase in TBP reflects a poor development of collateral flow, which is supported by a relatively low CO2 reactivity in these patients.
Publisher: SAGE Publications
Date: 27-02-2017
Abstract: It is unclear whether the risk of bleeding from brain arteriovenous malformations is higher during pregnancy, delivery, or puerperium. We compared occurrence of brain arteriovenous malformation hemorrhage in women during this period with occurrence of hemorrhage outside this period during their fertile years. We included all women with ruptured brain arteriovenous malformations (16–41 years) from a retrospective database of patients with brain arteriovenous malformations in four Dutch university hospitals (n = 95) and from the population-based Scottish Audit of Intracranial Vascular Malformations (n = 44). We estimated the relative rate of brain arteriovenous malformation rupture (before any treatment) during exposed time (pregnancy, delivery, puerperium) versus non-exposed time during fertile years, using the case-crossover design as primary analysis, and the self-controlled case-series design as secondary analysis. In 17 of 95 Dutch women and in 3 of 44 Scottish women, hemorrhages occurred while pregnant none occurred during delivery or puerperium. In Dutch women, the relative rate of brain arteriovenous malformation rupture during pregnancy, delivery, or puerperium was 6.8 (95% confidence interval 3.6–13) according to the case-crossover method and 7.1 (95% confidence interval 3.4–13) using the self-controlled case-series method. In Scottish women, the relative rate was 1.3 (95% confidence interval 0.39–4.1) using the case-crossover method and 1.7 (95% confidence interval 0.0–4.4) according to the self-controlled case-series method. Because of limited overlap of confidence intervals, we refrained from pooling the cohorts. Case-crossover and self-controlled case series analyses reveal an increase in relative rate of brain arteriovenous malformation rupture during pregnancy in the Dutch cohort but not in the Scottish cohort. Since point estimates varied between both cohorts and numbers are relatively small, the clinical implications of our findings are uncertain.
Publisher: SAGE Publications
Date: 24-08-2014
DOI: 10.1111/IJS.12309
Abstract: Intracerebral hemorrhage (ICH) accounted for 9% to 27% of all strokes worldwide in the last decade, with high early case fatality and poor functional outcome. In view of recent randomized controlled trials (RCTs) of the management of ICH, the European Stroke Organisation (ESO) has updated its evidence-based guidelines for the management of ICH. A multidisciplinary writing committee of 24 researchers from 11 European countries identified 20 questions relating to ICH management and created recommendations based on the evidence in RCTs using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We found moderate- to high-quality evidence to support strong recommendations for managing patients with acute ICH on an acute stroke unit, avoiding hemostatic therapy for acute ICH not associated with antithrombotic drug use, avoiding graduated compression stockings, using intermittent pneumatic compression in immobile patients, and using blood pressure lowering for secondary prevention. We found moderate-quality evidence to support weak recommendations for intensive lowering of systolic blood pressure to mmHg within six-hours of ICH onset, early surgery for patients with a Glasgow Coma Scale score 9–12, and avoidance of corticosteroids. These guidelines inform the management of ICH based on evidence for the effects of treatments in RCTs. Outcome after ICH remains poor, prioritizing further RCTs of interventions to improve outcome.
Publisher: SAGE Publications
Date: 09-07-2016
Publisher: American Medical Association (AMA)
Date: 04-2019
Publisher: American Medical Association (AMA)
Date: 09-11-2011
Abstract: Outcomes following treatment of brain arteriovenous malformations (AVMs) with microsurgery, embolization, stereotactic radiosurgery (SRS), or combinations vary greatly between studies. To assess rates of case fatality, long-term risk of hemorrhage, complications, and successful obliteration of brain AVMs after interventional treatment and to assess determinants of these outcomes. We searched PubMed and EMBASE to March 1, 2011, and hand-searched 6 journals from January 2000 until March 2011. We identified studies fulfilling predefined inclusion criteria. We used Poisson regression analyses to explore associations of patient and study characteristics with case fatality, complications, long-term risk of hemorrhage, and successful brain AVM obliteration. We identified 137 observational studies including 142 cohorts, totaling 13,698 patients and 46,314 patient-years of follow-up. Case fatality was 0.68 (95% CI, 0.61-0.76) per 100 person-years overall, 1.1 (95% CI, 0.87-1.3 n = 2549) after microsurgery, 0.50 (95% CI, 0.43-0.58 n = 9436) after SRS, and 0.96 (95% CI, 0.67-1.4 n = 1019) after embolization. Intracranial hemorrhage rates were 1.4 (95% CI, 1.3-1.5) per 100 person-years overall, 0.18 (95% CI, 0.10-0.30) after microsurgery, 1.7 (95% CI, 1.5-1.8) after SRS, and 1.7 (95% CI, 1.3-2.3) after embolization. More recent studies were associated with lower case-fatality rates (rate ratio [RR], 0.972 95% CI, 0.955-0.989) but increased rates of hemorrhage (RR, 1.02 95% CI, 1.00-1.03). Male sex (RR, 0.964 95% CI, 0.945-0.984), small brain AVMs (RR, 0.988 95% CI, 0.981-0.995), and those with strictly deep venous drainage (RR, 0.975 95% CI, 0.960-0.990) were associated with lower case fatality. Lower hemorrhage rates were associated with male sex (RR, 0.976, 95% CI, 0.964-0.988), small brain AVMs (RR, 0.988, 95% CI, 0.980-0.996), and brain AVMs with deep venous drainage (0.982, 95% CI, 0.969-0.996). Complications leading to permanent neurological deficits or death occurred in a median 7.4% (range, 0%-40%) of patients after microsurgery, 5.1% (range, 0%-21%) after SRS, and 6.6% (range, 0%-28%) after embolization. Successful brain AVM obliteration was achieved in 96% (range, 0%-100%) of patients after microsurgery, 38% (range, 0%-75%) after SRS, and 13% (range, 0%-94%) after embolization. Although case fatality after treatment has decreased over time, treatment of brain AVM remains associated with considerable risks and incomplete efficacy. Randomized controlled trials comparing different treatment modalities appear justified.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-1999
Abstract: Background and Purpose —We sought to investigate the relation between collateral flow via different pathways and hemodynamic parameters measured by dynamic susceptibility contrast–enhanced MRI in patients with severe carotid artery disease. Methods —Dynamic susceptibility contrast–enhanced MRI was performed in 66 patients and 33 control subjects. Patients had severe stenosis ( %, n=12), unilateral occlusion (n=38), or bilateral occlusion (n=16) of the internal carotid artery (ICA). Cerebripetal flow and collateral flow via the circle of Willis were investigated with MR angiography. Collateral flow via the ophthalmic artery was investigated with transcranial Doppler sonography. Results —Patients with ICA stenosis had well-preserved cerebral perfusion and were in general not dependent on collateral supply. Patients with unilateral ICA occlusion had impaired cerebral perfusion. However, appearance time, peak time, and mean transit time in white matter were less increased in patients with than in patients without collateral flow via the circle of Willis ( P .05). Furthermore, patients with collateral flow via both anterior and posterior communicating arteries had less increased regional cerebral blood volume than patients with collateral flow via the posterior communicating artery only ( P .05). Patients with bilateral ICA occlusion had severely compromised hemodynamic status despite recruitment of collateral supply. Conclusions —In patients with unilateral ICA occlusion, the pattern of collateral supply has significant influence on hemodynamic status. Collateral flow via the anterior communicating artery is a sign of well-preserved hemodynamic status, whereas no collateral flow via the circle of Willis or flow via only the posterior communicating artery is a sign of deteriorated cerebral perfusion.
Publisher: SAGE Publications
Date: 07-10-2009
Abstract: Arterial spin labeling (ASL) perfusion magnetic resonance imaging (MRI) with image acquisition at multiple inversion times is a noninvasive ASL technique able to compensate for spatial heterogeneities in transit times caused by collateral blood flow in patients with severe stenosis of the cerebropetal blood vessels. Our aim was to compare ASL-MRI and H 2 15 O positron emission tomography (PET), the gold standard for cerebral blood flow (CBF) assessment, in patients with a symptomatic internal carotid artery (ICA) occlusion. Fourteen patients (63±14 years) with a symptomatic ICA occlusion underwent both ASL-MRI and H 2 15 O PET. The ASL-MRI was performed using a pulsed STAR labeling technique at multiple inversion times within 7 days of the PET. The CBF was measured in the gray-matter of the anterior, middle and posterior cerebral artery, and white-matter. Both PET and ASL-MRI showed a significantly decreased CBF in the gray-matter of the middle cerebral artery in the hemisphere ipsilateral to the ICA occlusion. The average gray-matter CBF measured with ASL-MRI (71.8±4.3 mL/min/100 g) was higher ( P .01) than measured with H 2 15 O PET (43.1±1.0 mL/min/100 g). In conclusion, ASL-MRI at multiple TIs is capable of depicting areas of regions with low CBF in patients with an occlusion of the ICA, although a systematic overestimation of CBF relative to H 2 15 O PET was noted.
Publisher: Elsevier BV
Date: 12-2018
DOI: 10.1016/J.RESUSCITATION.2018.09.012
Abstract: Hypoxic-ischemic brain injury is the main cause of death and disability of comatose patients after cardiac arrest. Early and reliable prognostication is challenging. Common prognostic tools include clinical neurological examination and electrophysiological measures. Brain imaging is well established for diagnosis of focal cerebral ischemia but has so far not found worldwide application in this patient group. To review the value of Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET) for early prediction of neurological outcome of comatose survivors of cardiac arrest. A literature search was performed to identify publications on CT, MRI or PET in comatose patients after cardiac arrest. We included evidence from 51 articles, 21 on CT, 27 on MRI, 1 on CT and MRI, and 2 on PET imaging. Studies varied regarding timing of measurements, choice of determinants, and cut-off values predicting poor outcome. Most studies were small (n = 6-398) and retrospective (60%). In general, cytotoxic oedema, defined by a grey-white matter ratio <1.10, derived from CT, or MRI-diffusion weighted imaging <650 × 10 CT derived grey-white matter ratio and MRI based measures of diffusivity and connectivity hold promise to improve outcome prediction after cardiac arrest. Prospective validation studies in a multivariable approach are needed to determine the additional value for the in idual patient.
Publisher: BMJ
Date: 25-03-2014
Abstract: The reported effects of treating cerebral cavernous malformations (CCMs) by neurosurgical excision or stereotactic radiosurgery are imprecise and vary between studies. We searched Ovid Medline, EMBASE and The Cochrane Library for peer-reviewed publications of cohort studies describing outcomes of treating 20 or more patients with CCM with at least 80% completeness of follow-up. Two reviewers extracted data to quantify the incidence of a composite outcome (death, non-fatal intracranial haemorrhage, or new/worse persistent focal neurological deficit) after CCM treatment. We explored associations between summary measures of study characteristics and outcome using Poisson meta-regression analyses. We included 63 cohorts, involving 3424 patients. The incidence of the composite outcome was 6.6 (95% CI 5.7 to 7.5) per 100 person-years after neurosurgical excision (median follow-up 3.3 years) and 5.4 (95% CI 4.5 to 6.4) after stereotactic radiosurgery (median follow-up 4.1 years). After neurosurgical excision the incidence of the composite outcome increased with every per cent point increase in patients with brainstem CCM (rate ratio (RR) 1.03, 95% CI 1.01 to 1.05), and decreased with each more recent study midyear (RR 0.91, 95% CI 0.85 to 0.98) and each per cent point increase in patients presenting with haemorrhage (RR 0.98, 95% CI 0.96 to 1.00). We did not find significant associations in studies of stereotactic radiosurgery. The reported risks of CCM treatment (and the lower risks of neurosurgical excision over time, from recently bled CCMs, and for CCMs outside the brainstem) compare favourably with the risks of recurrent haemorrhage from CCM. Long-term effects, especially important for stereotactic radiosurgery, are unknown.
Publisher: Springer Science and Business Media LLC
Date: 27-02-2015
DOI: 10.1007/S00381-015-2665-Y
Abstract: Moyamoya vasculopathy progressively compromises cerebral blood flow resulting in chronic hypoperfusion. The middle cerebral artery (MCA) territory and the bifrontal areas are the regions most frequently affected. Although most techniques aim to only revascularize the MCA territory, augmentation of blood flow of the bifrontal areas is of importance in the pediatric moyamoya population since these regions play an important role in cognition, intellectual development, and in lower extremity and sphincter function. We recently described a one-staged surgical procedure combining revascularization of three regions, the MCA territory unilaterally and the frontal areas bilaterally. The purpose of this article is to report our surgical experience in eight children and to emphasize the rational for bifrontal revascularization. We report a case series consisting of eight children where the following surgical strategy was applied: (1) a direct superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass with encephalo-duro-myo-synangiosis (EDMS) for unilateral MCA revascularization in combination with (2) a bifrontal encephalo-duro-periosteal-synangiosis (EDPS) for bifrontal revascularization. Patients' characteristics and 30-day follow-up data are reported. The patient group consisted of six girls and two boys (mean age 10.0, range 4.2-17.5 years): six children presented with moyamoya disease, two with moyamoya syndrome. We performed a one-staged revascularization of one MCA territory and both frontal areas in all patients. No significant complications occurred. Two patients experienced postoperative focal seizures, successfully treated with anti-epileptic medication. The single-staged STA-MCA bypass with EDMS combined with bifrontal EDPS allowed revascularization of three regions (the MCA territory unilaterally and the frontal areas bilaterally) and may serve as an alternative and safe treatment option for pediatric moyamoya patients.
Publisher: BMJ
Date: 31-05-2018
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2013
DOI: 10.1161/STROKEAHA.113.002386
Abstract: We aimed to validate externally in a setting outside the United States the secondary intracerebral hemorrhage (ICH) score that was developed to predict the probability of macrovascular causes in patients with nontraumatic ICH. Patients with nontraumatic ICH admitted to the University Medical Center Utrecht, the Netherlands, between 2003 and 2011 were included if an angiographic examination, neurosurgical inspection, or pathological examination had been performed. Secondary ICH score performance was assessed by calibration (agreement between predicted and observed outcomes) and discrimination (separation of those with and without macrovascular cause). Forty-eight of 204 patients (23.5%) had a macrovascular cause. The secondary ICH score showed modest calibration ( P =0.06) and modest discriminative ability ( c -statistic 0.73 95% confidence interval, 0.65–0.80). Discrimination improved slightly using only noncontrast computed tomography categorization ( c -statistic 0.79 95% confidence interval, 0.72–0.86). The discriminative ability and calibration of the secondary ICH score are moderate in a university hospital setting outside the United States. Clues on noncontrast computed tomography are the strongest predictor of a macrovascular cause in patients with ICH.
Publisher: Elsevier BV
Date: 11-2018
DOI: 10.1016/J.JNS.2018.09.006
Abstract: Patients with complete occlusion of the internal carotid artery (CAO) are vulnerable to cerebral hypoperfusion. Since cerebral hypoperfusion is associated with accelerated cognitive decline, patients with CAO may have an increased risk of cognitive impairment. We aimed to assess the prevalence and profile of cognitive impairment in patients with CAO and to explore the relation between hemodynamic impairment and cognitive functioning. We systematically searched Medline and EMBASE for studies including patients with symptomatic or asymptomatic CAO subjected to cognitive testing that were published between 1980 and 2017. We did not include patients with carotid stenosis. We obtained data on type of study, patient characteristics, cerebral imaging and neuropsychological testing. In addition, we extracted data on potential causes of systemic hemodynamic impairment and the presence and stage of cerebral hemodynamic impairment. We assessed methodological quality of included studies with the Newcastle-Ottawa Scale. We found eight studies comprising 244 patients (mean age 61 years, 76% male, 93% symptomatic CAO). The proportion of patients with cognitive impairment ranged from 54 to 71% in four studies in the other four studies patients with CAO performed worse on cognitive testing than controls, but results were not quantified. Impairment was reported in all cognitive domains. We found no data on the association between systemic hemodynamic impairment and cognitive functioning. Studies that assessed whether cerebral hemodynamic impairment was associated with cognitive functioning showed conflicting results. In patients with CAO, cognitive impairment is present in about half to two-thirds of patients and is not restricted to specific cognitive domains. The effect of systemic and cerebral hemodynamic impairment on cognitive functioning in patients with CAO deserves further study.
Publisher: BMJ
Date: 05-06-2013
Publisher: Informa UK Limited
Date: 2002
Abstract: The annual risk of stroke in patients with symptomatic carotid artery occlusion (CAO) and impaired cerebral blood flow (CBF) is approximately 10%. Increased oxygen extraction fraction measured by positron emission tomography (PET) and low cerebrovascular reactivity assessed by transcranial Doppler is associated with an increased risk of recurrent ischemic stroke in these patients. Recently, other risk factors have been identified: (1) symptoms of purported hemodynamic origin (2) ongoing symptoms in the presence of documented symptomatic CAO (3) leptomeningeal collaterals visible on angiography and (4) low NAA/choline ratio on magnetic resonance (MR) spectroscopy. Evidence is growing that a second extracranial-intracranial (EC-IC) bypass trial might be worthwhile in patients with symptomatic CAO. Probably, only patients with ongoing symptoms and compromised CBF should be included in such a trial. Current evidence based therapeutic options for patients with symptomatic CAO include antithrombotic medication and control of vascular risk factors. For stenosis of the contralateral internal or ipsilateral external carotid artery endarterectomy may be considered. Ongoing symptoms may cease after tapering of antihypertensive medication.
Publisher: S. Karger AG
Date: 12-2009
DOI: 10.1159/000262309
Abstract: i Background: /i A structured interview improves the reliability of the modified Rankin Scale (mRS), a commonly used functional outcome scale in stroke trials. Telephone interview is a fast and convenient way to assess the mRS grade, but its validity is unknown. We assessed the validity of a telephone interview in patients who had had an aneurysmal subarachnoid haemorrhage (SAH) by comparing it with a face-to-face assessment. i Methods: /i Eighty-three SAH patients were interviewed twice, once face-to-face and once by telephone, by 2 of 5 observers who used a structured interview to assess the mRS grade. Intermodality agreement was measured using weighted kappa statistics. To check for systematic differences between face-to-face and telephone assessment the Wilcoxon test for matched pairs was used. i Results: /i Agreement between telephone and face-to-face assessment was perfect in 47 (57%) patients. A difference of 1 level occurred in 31 (37%) patients and this was almost equally distributed over the grades of the mRS. Weighted kappa was 0.71 (95% CI 0.59–0.82). Telephone assessment did not result in a consistently more or less favourable grade than face-to-face assessment (Wilcoxon test for matched pairs, p = 0.33). i Conclusions: /i Telephone assessment of the mRS with a structured interview has a good agreement with face-to-face assessment and can thus be used reliably in the setting of a clinical trial.
Publisher: Springer Science and Business Media LLC
Date: 11-08-2010
Publisher: Wiley
Date: 19-10-2016
DOI: 10.1002/ANA.24780
Abstract: In observational epidemiologic studies, higher plasma high‐density lipoprotein cholesterol (HDL‐C) has been associated with increased risk of intracerebral hemorrhage (ICH). DNA sequence variants that decrease cholesteryl ester transfer protein ( CETP ) gene activity increase plasma HDL‐C as such, medicines that inhibit CETP and raise HDL‐C are in clinical development. Here, we test the hypothesis that CETP DNA sequence variants associated with higher HDL‐C also increase risk for ICH. We performed 2 candidate‐gene analyses of CETP . First, we tested in idual CETP variants in a discovery cohort of 1,149 ICH cases and 1,238 controls from 3 studies, followed by replication in 1,625 cases and 1,845 controls from 5 studies. Second, we constructed a genetic risk score comprised of 7 independent variants at the CETP locus and tested this score for association with HDL‐C as well as ICH risk. Twelve variants within CETP demonstrated nominal association with ICH, with the strongest association at the rs173539 locus (odds ratio [OR] = 1.25, standard error [SE] = 0.06, p = 6.0 × 10 −4 ) with no heterogeneity across studies ( I 2 = 0%). This association was replicated in patients of European ancestry ( p = 0.03). A genetic score of CETP variants found to increase HDL‐C by ∼2.85mg/dl in the Global Lipids Genetics Consortium was strongly associated with ICH risk (OR = 1.86, SE = 0.13, p = 1.39 × 10 −6 ). Genetic variants in CETP associated with increased HDL‐C raise the risk of ICH. Given ongoing therapeutic development in CETP inhibition and other HDL‐raising strategies, further exploration of potential adverse cerebrovascular outcomes may be warranted. Ann Neurol 2016 :730–740
Publisher: SAGE Publications
Date: 07-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2022
DOI: 10.1161/STROKEAHA.121.035019
Abstract: Although evidence accumulates that the cerebellum is involved in cerebral amyloid angiopathy (CAA), cerebellar superficial siderosis is not considered to be a disease marker. The objective of this study is to investigate cerebellar superficial siderosis frequency and its relation to hemorrhagic magnetic resonance imaging markers in patients with sporadic and Dutch-type hereditary CAA and patients with deep perforating arteriopathy–related intracerebral hemorrhage. We recruited patients from 3 prospective 3 Tesla magnetic resonance imaging studies and scored siderosis and hemorrhages. Cerebellar siderosis was identified as hypointense linear signal loss (black) on susceptibility-weighted or T2*-weighted magnetic resonance imaging which follows at least one folia of the cerebellar cortex (including the vermis). We included 50 subjects with Dutch-type hereditary CAA, (mean age 50 years), 45 with sporadic CAA (mean age 72 years), and 43 patients with deep perforating arteriopathy–related intracerebral hemorrhage (mean age 54 years). Cerebellar superficial siderosis was present in 5 out of 50 (10% [95% CI, 2–18]) patients with Dutch-type hereditary CAA, 4/45 (9% [95% CI, 1–17]) patients with sporadic CAA, and 0 out of 43 (0% [95% CI, 0–8]) patients with deep perforating arteriopathy–related intracerebral hemorrhage. Patients with cerebellar superficial siderosis had more supratentorial lobar (median number 9 versus 2, relative risk, 2.9 [95% CI, 2.5–3.4]) and superficial cerebellar macrobleeds (median number 2 versus 0, relative risk, 20.3 [95% CI, 8.6–47.6]) compared with patients without the marker. The frequency of cortical superficial siderosis and superficial cerebellar microbleeds was comparable. We conclude that cerebellar superficial siderosis might be a novel marker for CAA.
Publisher: Springer Science and Business Media LLC
Date: 11-2003
DOI: 10.1007/S00415-003-0222-1
Abstract: Although transient ischemic attacks (TIAs) by definition do not cause lasting neurological deficits, cognitive impairment has been suggested in patients with carotid artery disease who have suffered from a TIA. The purpose of our study was to assess whether patients with carotid artery disease and TIAs are cognitively impaired, to describe the frequency, nature and severity of this impairment, and to search for associated patient characteristics.Thirty-nine consecutive patients with carotid occlusion and ipsilateral cerebral or retinal TIAs, and 46 healthy controls underwent extensive neuropsychological assessment. Performances were compared group-wise with analysis of variance. In addition, the presence of cognitive impairment in the in idual patient was determined. Associations between illness characteristics and cognitive impairment were explored with regression analysis.Fifty-four percent of patients were cognitively impaired. Cognitive deficits were non-specific in nature and mild in severity. Impairment occurred also in patients with isolated retinal symptoms and in those without visible ischemic brain lesions on MRI. Neither the presence of any vascular risk factor, the side of the symptomatic carotid occlusion, the uni- or bilaterality of carotid occlusion, nor the number of cerebral ischemic lesions were predictors of cognitive impairment. We conclude that about half of the patients with carotid artery occlusion and ipsilateral TIAs are cognitively impaired. The presence of cognitive deficits in patients with isolated retinal symptoms and in those without cerebral ischemic lesions on MRI argues against an exclusive role for structural brain damage in the pathogenesis of these deficits.
Publisher: Elsevier BV
Date: 02-2010
Publisher: Oxford University Press (OUP)
Date: 2009
DOI: 10.1016/J.EJCTS.2008.10.004
Abstract: Coronary artery bypass grafting (CABG) is associated with significant cerebral morbidity, usually manifested as cognitive decline or stroke. The underlying mechanism leading to cognitive decline is still unclear. Presence of coronary collateral arteries, which may reflect an overall better cardiovascular condition, recently appeared to relate to a better cardiac outcome after CABG. In this study, we investigated the hypothesis that presence of coronary collaterals is associated with less cognitive decline after coronary artery bypass grafting. Data from 281 patients undergoing first-time coronary artery bypass grafting were used. Presence of coronary collaterals was determined on the preoperative angiogram. Cognitive function was evaluated before the operation, at 3 and 12 months and 5 years thereafter by standardised neuropsychological assessment. Cognitive decline in in iduals was determined by calculating the reliable change score, a cognitive change score corrected for natural testing variability and practice effects. Cognitive decline was found in 19 (8%) patients at 3 months, in 31 (12%) patients at 12 months and in 82 (34%) at 5 years follow-up. Presence of coronary collaterals was independently associated with a better cognitive outcome at both 3 months (odds ratio (OR) 0.30 95% confidence interval (CI) 0.09-0.95 p=0.04) and 12 months (OR 0.42 95% CI 0.18-0.97 p=0.04) after coronary artery bypass grafting. At 5 years, the OR was 0.57 (95% CI 0.31-1.05 p=0.07). In patients undergoing first-time coronary artery bypass grafting, presence of coronary collaterals is associated with a decreased risk of cognitive decline at both 3 and 12 months of follow-up. This trend persists at 5-year follow-up. Preoperative differences in the cardiac vascular condition may therefore predict cognitive outcome in patients undergoing coronary artery bypass grafting.
Publisher: Springer Science and Business Media LLC
Date: 2013
Publisher: Elsevier BV
Date: 03-2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 13-05-2003
DOI: 10.1212/01.WNL.0000061616.96745.90
Abstract: To investigate the association between ischemic brain lesions and intracranial collateral blood flow in patients with unilateral occlusion of the internal carotid artery (ICA). Sixty-eight consecutive patients were included. Ischemic lesions on MRI were identified on hard copies, and volume measurements of the lesions were performed on an MR workstation. Intracranial collateral pathways were studied with MR angiography, digital subtraction angiography, and transcranial Doppler sonography. The presence of collateral flow via the anterior communicating artery (ACoA) was associated with a reduction in prevalence (p = 0.01) and volume (p = 0.008) of internal border zone infarcts in the hemisphere ipsilateral to the occluded ICA. Absence of collateral blood flow via the circle of Willis was associated with an increase in prevalence (p = 0.007) and volume (p = 0.005) of internal border zone infarcts. No association between any collateral flow pattern in the circle of Willis and periventricular lesions or lacunar, territorial, or external border zone infarcts was found. No association between collateral flow via the ophthalmic artery or leptomeningeal vessels with any type of ischemic lesion was found. Collateral flow via the ACoA is associated with a reduction of the prevalence and volume of internal border zone lesions but not with any other type of ischemic lesion. The presence of a functional posterior communicating artery or secondary collateral pathways is not associated with the prevalence of any type of ischemic lesion.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2003
DOI: 10.1161/01.STR.0000069725.09499.14
Abstract: Background and Purpose— Patients with carotid artery occlusion (CAO) and ipsilateral transient ischemic attack (TIA) can have lasting cognitive impairment, despite the recovery of focal neurological deficits. We sought to assess whether cognitive impairment in these patients is associated with hemodynamic compromise and/or impaired cerebral metabolism. Methods— In 39 consecutive patients with a TIA associated with an angiographically proven occlusion of the carotid artery, we examined (1) cognitive functioning, (2) cerebrovascular reserve capacity of the middle cerebral artery ipsilateral to the CAO as measured by transcranial Doppler ultrasound, and (3) metabolic ratios as measured by 1 H-MR spectroscopy in the centrum semiovale ipsilateral to the symptomatic CAO. Findings were compared with those in healthy control subjects. Results— As a group, patients were cognitively impaired. Mean CO 2 reactivity and the mean ratio of N -acetyl aspartate to creatine were decreased. In approximately one third of patients, lactate was present in noninfarcted regions. The presence of lactate proved to be a stronger correlate of cognitive impairment than MRI-detected lesions (β=0.41 versus β=0.15). Cognitive impairment did not correlate with CO 2 reactivity or the ratio of N -acetyl aspartate to creatine. Conclusions— This exploratory study in patients with CAO and ipsilateral TIA showed that 1 H-MR spectroscopy–detected lactate in noninfarcted regions is a better indicator of cognitive impairment than MRI-detected lesions. Cognitive impairment did not correlate with CO 2 reactivity.
Publisher: BMJ
Date: 27-04-2017
Publisher: Springer Science and Business Media LLC
Date: 02-06-2009
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2008
DOI: 10.1161/STROKEAHA.108.514265
Abstract: Background and Purpose— The purpose of this study was to prospectively investigate the contribution of the ipsilateral external carotid artery (ECA) to cerebral perfusion in patients with internal carotid artery occlusion. Methods— Institutional Review Board approval and informed consent were obtained. Thirty functionally independent patients (24 men, 6 women mean age, 63 years) with an angiographically proven unilateral internal carotid artery occlusion and transient or minor disabling ischemic attacks ipsilateral to the side of the internal carotid artery occlusion were included. Grading of ECA collateral flow was performed with intraarterial digital subtraction angiography. The contribution of the ECA to regional cerebral blood flow was assessed with selective arterial spin labeling MRI. Differences in regional cerebral blood flow were analyzed with Student t test. Results— Twenty percent of the patients had ECA Grade 0 collateral flow (no filling of ophthalmic artery), 20% Grade 1 (filling of carotid siphon), and 60% Grade 2 (filling of anterior and/or middle cerebral artery) as demonstrated on digital subtraction angiography. Although in the Grade 1 group, the ECA supplied a smaller region of the brain compared with the Grade 2 group, the mean regional cerebral blood flow of the perfusion territory supplied by the ECA is similar ( P =0.70) in the Grade 1 group (mean±SD 57±16 mL/min/100 g) and the Grade 2 group (60±12 mL/min/100g). Conclusion— In patients with symptomatic internal carotid artery occlusion, focal brain regions may strongly depend on the contribution to cerebral perfusion of the ECA ipsilateral to the side of the internal carotid artery occlusion, even in patients with limited ECA collateral supply as demonstrated on digital subtraction angiography.
Publisher: BMJ
Date: 16-07-2009
Abstract: Treatment of patients with aneurysmal subarachnoid haemorrhage not only involves securing the aneurysm by endovascular coiling or surgical clipping but also prevention and treatment of the medical and neurological complications of the bleed. These acutely ill patients should be looked after in specialised centres by a multidisciplinary team that is available 24 h a day, 7 days a week. No medical intervention is known to improve outcome by reducing the risk of rebleeding but oral nimodipine should be standard care to prevent delayed cerebral ischaemia. For patients who develop delayed ischaemia, there is no evidence that hypervolaemia, haemodilution, hypertension, balloon angioplasty or intra-arterial vasodilating agents improve outcome. Lumbar puncture is a safe and reasonably effective way of treating those forms of acute hydrocephalus that are not caused by intraventricular obstruction.
Publisher: Springer Science and Business Media LLC
Date: 18-03-2010
Publisher: Journal of Neurosurgery Publishing Group (JNSPG)
Date: 11-2002
DOI: 10.3171/JNS.2002.97.5.1029
Abstract: Object. If clip application or coil placement for treatment of intracranial aneurysms is not feasible, the parent vessel can be occluded to induce thrombosis of the aneurysm. The Excimer laser—assisted anastomosis technique allows the construction of a high-flow bypass in patients who cannot tolerate such an occlusion. The authors assessed the complications of this procedure and clinical outcomes after the construction of high-flow bypasses in patients with intracranial aneurysms. Methods. Data were retrospectively collected on patient and aneurysm characteristics, procedural complications, and functional outcomes in 77 patients in whom a high-flow bypass was constructed. Logistic regression analysis was used to quantify the relationships between patient and aneurysm characteristics on the one hand and outcome measures on the other. Fifty-one patients harbored a giant aneurysm, 24 patients suffered from a ruptured aneurysm, and 35 patients from an unruptured symptomatic aneurysm. In 22 patients (29% 95% confidence interval [CI] 19–40%) a permanent deficit developed from an operative complication. At a median follow-up period of 2.5 months, 25 patients (32% 95% CI 22–44%) were dependent or had died in 10 of these patients (13% of all patients 95% CI 6–23%) operative complications were the single cause of this poor outcome. Univariate analysis demonstrated that a poor clinical condition before treatment (odds ratio [OR] 4.7 95% CI 1.7–13.3) and a history of cardiovascular disease (OR 4.1 95% CI 1–16.2) increased the risk of poor outcome. Multivariate analysis demonstrated that only the clinical condition before treatment was significantly related to outcome (OR 4 95% CI 1.3–11.9). Conclusions. In patients with an intracranial aneurysm that cannot be treated by clip application or coil placement, and in whom occlusion of the parent artery cannot be tolerated, the construction of a high-flow bypass should be considered. This procedure carries a considerable risk of complications, but this should be weighed against the disabling or life-threatening effects of compression, the high risk of rupture, and the substantial chance of poor outcome after the rupture of such aneurysms.
Publisher: Springer Science and Business Media LLC
Date: 23-11-2011
Publisher: BMJ
Date: 06-08-2021
Abstract: Inflammatory responses to intracerebral haemorrhage (ICH) are potential therapeutic targets. We aimed to quantify molecular markers of inflammation in human brain tissue after ICH compared with controls using meta-analysis. We searched OVID MEDLINE (1946–) and Embase (1974–) in June 2020 for studies that reported any measure of a molecular marker of inflammation in brain tissue from five or more adults after ICH. We assessed risk of bias using a modified Newcastle-Ottawa Scale (mNOS mNOS score 0–9 9 indicates low bias), extracted aggregate data, and used random effects meta-analysis to pool associations of molecules where more than two independent case–control studies reported the same outcome and Gene Ontology enrichment analysis to identify over-represented biological processes in pooled sets of differentially expressed molecules (International Prospective Register of Systematic Reviews ID: CRD42018110204). Of 7501 studies identified, 44 were included: 6 were case series and 38 were case–control studies (median mNOS score 4, IQR 3–5). We extracted data from 21 491 analyses of 20 951 molecules reported by 38 case–control studies. Only one molecule (interleukin-1β protein) was quantified in three case–control studies (127 ICH cases vs 41 ICH-free controls), which found increased abundance of interleukin-1β protein after ICH (corrected standardised mean difference 1.74, 95% CI 0.28 to 3.21, p=0.036, I 2 =46%). Processes associated with interleukin-1β signalling were enriched in sets of molecules that were more abundant after ICH. Interleukin-1β abundance is increased after ICH, but analyses of other inflammatory molecules after ICH lack replication. Interleukin-1β pathway modulators may optimise inflammatory responses to ICH and merit testing in clinical trials.
Publisher: SAGE Publications
Date: 09-05-2018
Abstract: Neuroimaging in older adults commonly reveals signs of cerebral small vessel disease (SVD). SVD is believed to be caused by chronic hypoperfusion based on animal models and longitudinal studies with inter-scan intervals of years. Recent imaging evidence, however, suggests a role for acute ischaemia, as indicated by incidental diffusion-weighted imaging lesions (DWI+ lesions), in the origin of SVD. Furthermore, it becomes increasingly recognised that focal SVD lesions likely affect the structure and function of brain areas remote from the original SVD lesion. However, the temporal dynamics of these events are largely unknown. (1) To investigate the monthly incidence of DWI+ lesions in subjects with SVD (2) to assess to which extent these lesions explain progression of SVD imaging markers (3) to investigate their effects on cortical thickness, structural and functional connectivity and cognitive and motor performance and (4) to investigate the potential role of the innate immune system in the pathophysiology of SVD. The RUN DMC – InTENse study is a longitudinal observational study among 54 non-demented RUN DMC survivors with mild to severe SVD and no other presumed cause of ischaemia. We performed MRI assessments monthly during 10 consecutive months (totalling up to 10 scans per subject), complemented with clinical, motor and cognitive examinations. Our study will provide a better understanding of the role of DWI+ lesions in the pathophysiology of SVD and will further unravel the structural and functional consequences and clinical importance of these lesions, with an unprecedented temporal resolution. Understanding the role of acute, potentially ischaemic, processes in SVD may provide new strategies for therapies.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2014
DOI: 10.1161/STROKEAHA.114.005442
Abstract: It is uncertain whether familial occurrence of brain arteriovenous malformations (BAVMs) represents coincidental aggregation or a shared familial risk factor. We aimed to compare the prevalence of BAVMs in first-degree relatives (FDRs) of patients with BAVM and the prevalence in the general population. We sent a postal questionnaire to 682 patients diagnosed with a BAVM in 1 of 4 university hospitals to retrieve information about the occurrence of BAVMs among their FDRs. We calculated a prevalence ratio using the BAVM prevalence among FDRs and the prevalence from a Scottish population-based study (93 per 628 788 adults). A prevalence ratio of ≥9 with a lower limit of the 95% confidence interval of 3 was considered indicative of a shared familial risk factor. Informed consent was given by 460 (67%) patients, who had 2992 FDRs. We identified 3 patients with a FDR with a BAVM, yielding a prevalence ratio of 6.8 (95% CI, 2.2–21). The prevalence of BAVMs in FDRs of patients with a BAVM was increased but did not meet our prespecified criterion for a shared familial risk factor. In combination with the low absolute risk of a BAVM in FDRs, our results do not support screening of FDRs for BAVMs.
Publisher: Springer Science and Business Media LLC
Date: 11-04-2018
DOI: 10.1038/S41598-018-22952-Z
Abstract: A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has not been fixed in the paper.
Publisher: Wiley
Date: 20-02-2023
DOI: 10.1002/ANA.26610
Abstract: Vascular amyloid β (Aβ) accumulation is the hallmark of cerebral amyloid angiopathy (CAA). The composition of cerebrospinal fluid (CSF) of CAA patients may serve as a diagnostic biomarker of CAA. We studied the diagnostic potential of the peptides Aβ38, Aβ40, Aβ42, and Aβ43 in patients with sporadic CAA (sCAA), hereditary Dutch‐type CAA (D‐CAA), and Alzheimer disease (AD). Aβ peptides were quantified by immunoassays in a discovery group (26 patients with sCAA and 40 controls), a validation group (40 patients with sCAA, 40 patients with AD, and 37 controls), and a group of 22 patients with D‐CAA and 54 controls. To determine the diagnostic accuracy, the area under the curve (AUC) was calculated using a receiver operating characteristic curve with 95% confidence interval (CI). We found decreased levels of all Aβ peptides in sCAA patients and D‐CAA patients compared to controls. The difference was most prominent for Aβ42 (AUC of sCAA vs controls for discovery: 0.90, 95% CI = 0.82–0.99 for validation: 0.94, 95% CI = 0.89–0.99) and Aβ43 (AUC of sCAA vs controls for discovery: 0.95, 95% CI = 0.88–1.00 for validation: 0.91, 95% CI = 0.83–1.0). All Aβ peptides except Aβ43 were also decreased in sCAA compared to AD (CSF Aβ38: AUC = 0.82, 95% CI = 0.71–0.93 CSF Aβ40: AUC = 0.88, 95% CI = 0.80–0.96 CSF Aβ42: AUC = 0.79, 95% CI = 0.66–0.92). A combined biomarker panel of CSF Aβ38, Aβ40, Aβ42, and Aβ43 has potential to differentiate sCAA from AD and controls, and D‐CAA from controls. ANN NEUROL 2023 :1173–1186
Publisher: S. Karger AG
Date: 2011
DOI: 10.1159/000332087
Abstract: i Background: /i Assessment of outcome after childhood stroke is important both for clinical practice and for research purposes. The objective of this study was to compare two frequently used outcome measures. i Methods: /i In 40 children with arterial ischemic stroke (AIS), dichotomized outcome obtained from the Pediatric Stroke Outcome Measure (PSOM) was compared with a dichotomized modified Rankin Scale (mRS) combined with information on type of school attendance. In addition, we compared dichotomized outcome, obtained from the PSOM and the mRS combined with school attendance, with the results of pediatric quality of life (PedsQL) questionnaires and the impressions of the child’s general functioning on a visual analogue scale (VAS) that was filled out by parents and investigators. i Results: /i In 35 children (88%), outcome classification was concordant between the two outcome measures. Five children had a poor outcome according to the PSOM and good outcome with the mRS including school performance. In these patients, mRS outcome classification agreed better with the impression of the investigators, as reflected by VAS scores ≧7.5. For both the PSOM and mRS in combination with school performance, patients with a good outcome had significantly higher PedsQL and VAS scores than those with a poor outcome (p values .01 for all comparisons). VAS scores of investigators and parents correlated significantly with PedsQL. i Conclusions: /i In children with AIS, both PSOM and mRS combined with school type correlated significantly with quality of life and VAS scores of general functioning. The mRS combined with school type is easier to obtain than the PSOM, reflects function rather than deficits, includes an important measure of cognitive outcome, and corresponds better with the doctor’s impression of outcome.
Publisher: BMJ
Date: 03-2001
Abstract: The aetiology of clinical symptoms in patients with severe internal carotid artery (ICA) lesions may be thromboembolic or haemodynamic. The purpose was to assess whether changes in cerebropetal blood flow caused by an ICA occlusion have an effect on clinical symptoms and cerebral metabolism. Forty three patients with an ICA occlusion who had hemispheric ischaemia (transient ischaemic attack or stroke), retinal ischaemia, or without symptoms, and 34 patients without significant ICA lesions with either hemispheric ischaemia or no symptoms were studied. Magnetic resonance angiography (MRA) was used to investigate total cerebropetal flow (flow in the ICAs plus basilar artery) and the flow in the middle cerebral arteries. Cerebral metabolic changes in the flow territory of the middle cerebral artery were determined with proton MR spectroscopy. Low total cerebropetal flow (r=-0.15, p<0.05) and low middle cerebral artery flow (r=-0.31, p<0.001) were found in patients with an ICA occlusion, but did not correlate with the clinical syndrome. By contrast, patients with prior symptoms of hemispheric ischaemia had decreased cerebral N-acetylaspartate/choline ratios (r=-0.35, p<0.001). However, the presence of an ICA occlusion (and subsequent low flow) did not correlate with low N-acetylaspartate/choline ratios. Neurological deficit caused by (transient) hemispheric ischaemia is associated with low N-acetylaspartate/choline ratios, whereas prior clinical features are not associated with low cerebropetal blood flow, as measured with MR angiography. As a result, differences in cerebropetal flow cannot explain why patients with similar carotid artery disease experience different neurological features.
Publisher: S. Karger AG
Date: 2001
DOI: 10.1159/000047708
Abstract: i Objectives: /i We performed a systematic review of the literature to assess the impact of potential risk factors of recurrent stroke other than a compromised cerebral blood flow in patients with carotid occlusion or intracranial arterial lesions. In addition, we investigated the effect of treatment with aspirin or oral anticoagulation on recurrent stroke rate and assessed whether the incidence of recurrent stroke has decreased over the years. i Methods: /i We searched Medline (1966 and onwards) and reference lists of identified articles for papers reporting on the recurrent stroke risk in patients with carotid occlusion or intracranial arterial lesions. Two authors independently extracted information from all papers. The influence of study characteristics on the risk of the endpoints ‘recurrent stroke’, ‘ipsilateral stroke’ and ‘vascular death’ was determined by Poisson regression analysis. Rate ratios were calculated per 10 percentage points increase of a characteristic. i Results and Conclusions: /i Patients with intracranial carotid stenosis or occlusion had a higher rate of recurrent stroke (rate ratio 1.09 95% CI 1.05–1.14) than patients with extracranial carotid occlusion or middle cerebral artery stenosis or occlusion. In patients with bilateral carotid occlusion the rate was lower (rate ratio 0.82 95% CI 0.68–0.98). No other vascular risk factors than hypertension (rate ratio 1.23 95% CI 1.07–1.41) could be shown to increase the rate of recurrent stroke. Oral anticoagulation but not aspirin had a protective effect on the incidence of recurrent stroke (rate ratio 0.86 95% CI 0.79–0.93). The reported rates of recurrent stroke in patients with symptomatic occlusion of the internal carotid artery or intracranial arterial lesions have not decreased over the years.
Publisher: Springer Science and Business Media LLC
Date: 25-05-2018
DOI: 10.1038/S41582-018-0014-Y
Abstract: Cerebral small vessel disease (SVD) is commonly observed on neuroimaging among elderly in iduals and is recognized as a major vascular contributor to dementia, cognitive decline, gait impairment, mood disturbance and stroke. However, clinical symptoms are often highly inconsistent in nature and severity among patients with similar degrees of SVD on brain imaging. Here, we provide a new framework based on new advances in structural and functional neuroimaging that aims to explain the remarkable clinical variation in SVD. First, we discuss the heterogeneous pathology present in SVD lesions despite an identical appearance on imaging and the perilesional and remote effects of these lesions. We review effects of SVD on structural and functional connectivity in the brain, and we discuss how network disruption by SVD can lead to clinical deficits. We address reserve and compensatory mechanisms in SVD and discuss the part played by other age-related pathologies. Finally, we conclude that SVD should be considered a global rather than a focal disease, as the classically recognized focal lesions affect remote brain structures and structural and functional network connections. The large variability in clinical symptoms among patients with SVD can probably be understood by taking into account the heterogeneity of SVD lesions, the effects of SVD beyond the focal lesions, the contribution of neurodegenerative pathologies other than SVD, and the interaction with reserve mechanisms and compensatory mechanisms.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-09-2017
DOI: 10.1212/WNL.0000000000004490
Abstract: To investigate the temporal dynamics of cerebral small vessel disease (SVD) by 3 consecutive assessments over a period of 9 years, distinguishing progression from regression. Changes in SVD markers of 276 participants of the Radboud University Nijmegen Diffusion Tensor and Magnetic Resonance Imaging Cohort (RUN DMC) cohort were assessed at 3 time points over 9 years. We assessed white matter hyperintensities (WMH) volume by semiautomatic segmentation and rated lacunes and microbleeds manually. We categorized baseline WMH severity as mild, moderate, or severe according to the modified Fazekas scale. We performed mixed-effects regression analysis including a quadratic term for increasing age. Mean WMH progression over 9 years was 4.7 mL (0.54 mL/y interquartile range 0.95–5.5 mL), 20.3% of patients had incident lacunes (2.3%/y), and 18.9% had incident microbleeds (2.2%/y). WMH volume declined in 9.4% of the participants during the first follow-up interval, but only for 1 participant (0.4%) throughout the whole follow-up. Lacunes disappeared in 3.6% and microbleeds in 5.7% of the participants. WMH progression accelerated over time: including a quadratic term for increasing age during follow-up significantly improved the model ( p 0.001). SVD progression was predominantly seen in participants with moderate to severe WMH at baseline compared to those with mild WMH (odds ratio [OR] 35.5, 95% confidence interval [CI] 15.8–80.0, p 0.001 for WMH progression OR 5.7, 95% CI 2.8–11.2, p 0.001 for incident lacunes and OR 2.9, 95% CI 1.4–5.9, p = 0.003 for incident microbleeds). SVD progression is nonlinear, accelerating over time, and a highly dynamic process, with progression interrupted by reduction in some, in a population that on average shows progression.
Publisher: Wiley
Date: 03-2000
DOI: 10.1002/(SICI)1522-2586(200003)11:3<279::AID-JMRI6>3.0.CO;2-0
Abstract: The objective of this 1H magnetic resonance spectroscopy study was to investigate the time course of the brain metabolites N-acetyl-aspartate (NAA), choline, and lactate in patients with transient or minor disabling neurological deficits associated with an occlusion of the internal carotid artery (ICA). Fifty patients had had symptoms of hemispheric ischemia, and 16 had suffered symptoms of retinal ischemia. Single-voxel proton spectra were obtained from uninfarcted cerebral regions on three occasions: 0-6, 6-12, and 12-18 months after symptoms. Reference values were obtained from 29 control subjects. In the 0-6 month period, patients with hemispheric ischemia showed a significantly lower NAA/creatine ratio in the hemisphere ipsilateral to the ICA occlusion, compared with control subjects and patients with retinal ischemia, and a significantly higher choline/creatine ratio, compared with control subjects. The prevalence of lactate did not differ significantly between patient groups. In the following time periods, the NAA/creatine ratio in patients with hemispheric ischemia tended to return to control values and no longer differed from that in patients with retinal ischemia the choline/creatine ratio decreased significantly and returned to control values. These results demonstrate that cerebral metabolism is altered in patients with an ICA occlusion who have had a hemispheric ischemic event, but returns (choline) or tends to return (NAA) to control values over time. The metabolic changes occur primarily in the hemisphere ipsilateral to the symptomatic ICA occlusion and are related to the occurrence of the hemispheric ischemic event.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2005
DOI: 10.1161/01.STR.0000150494.91762.70
Abstract: Background and Purpose— Epidemiological and laboratory studies suggest that increasing concentrations of plasma homocysteine (total homocysteine [tHcy]) accelerate cardiovascular disease by promoting vascular inflammation, endothelial dysfunction, and hypercoagulability. Methods— We conducted a randomized controlled trial in 285 patients with recent transient ischemic attack or stroke to examine the effect of lowering tHcy with folic acid 2 mg, vitamin B 12 0.5 mg, and vitamin B 6 25 mg compared with placebo on laboratory markers of vascular inflammation, endothelial dysfunction, and hypercoagulability. Results— At 6 months after randomization, there was no significant difference in blood concentrations of markers of vascular inflammation (high-sensitivity C-reactive protein [ P =0.32] soluble CD40L [ P =0.33] IL-6 [ P =0.77]), endothelial dysfunction (vascular cell adhesion molecule-1 [ P =0.27] intercellular adhesion molecule-1 [ P =0.08] von Willebrand factor [ P =0.92]), and hypercoagulability (P-selectin [ P =0.33] prothrombin fragment 1 and 2 [ P =0.81] D-dimer [ P =0.88]) among patients assigned vitamin therapy compared with placebo despite a 3.7-μmol/L (95% CI, 2.7 to 4.7) reduction in total homocysteine (tHcy). Conclusions— Lowering tHcy by 3.7 μmol/L with folic acid-based multivitamin therapy does not significantly reduce blood concentrations of the biomarkers of inflammation, endothelial dysfunction, or hypercoagulability measured in our study. The possible explanations for our findings are: (1) these biomarkers are not sensitive to the effects of lowering tHcy (eg, multiple risk factor interventions may be required) (2) elevated tHcy causes cardiovascular disease by mechanisms other than the biomarkers measured or (3) elevated tHcy is a noncausal marker of increased vascular risk.
Publisher: MDPI AG
Date: 27-04-2021
DOI: 10.3390/JCM10091898
Abstract: Information on presentation and outcome of moyamoya vasculopathy (MMV) in European countries is limited. We investigated patient characteristics, treatment and outcome of patients with MMV. We retrieved patient characteristics and treatment information and determined functional outcome (modified Rankin Score (mRS) type of school/work) by structured telephone interviews. We performed uni- and multivariable logistic regression analysis to determine predictors of poor outcome. We included 64 patients with bilateral MMV. In children (31 patients), median age was 5 years (interquartile range (IQR) 2–11) and in adults (33 patients), it was 33 years (IQR 28–41). Predominant mode of presentation was ischemia (children 84% adults 88%). Modified Rankin Scale (mRS) at presentation was ≤2 in 74%. Revascularization was performed in 42 patients (23 children). Median follow-up time was 46 months (IQR 26–90). During this period, 16 patients had recurrent stroke(s) and four patients died. In 73% of the patients (83% surgical group 55% medically treated group), mRS was ≤2 46% were able to return to regular school or work, of whom only 41% were on the same level. Univariable analysis revealed that surgical treatment was associated with lower odds of poor outcome ((mRS ≥ 3), OR 0.24 p = 0.017). This association was no longer statistically significant (OR 3.47 p = 0.067) in the multivariable model, including age and diagnosis (moyamoya disease or moyamoya syndrome). In this cohort of patients with MMV who presented in a single European center, a large proportion had good functional outcome. Nevertheless, less than half were able to attend regular school or were able to work at their previous level, indicating a large impact of the disease on their life.
Publisher: Public Library of Science (PLoS)
Date: 05-11-2015
Publisher: S. Karger AG
Date: 16-12-2015
DOI: 10.1159/000442532
Abstract: b i Background: /i /b This study aimed at identifying the determinants and prognostic significance of a sedimentation level (fluid-blood level) in the hematoma among patients with acute intracerebral hemorrhage (ICH) who participated in the main Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). b i Methods: /i /b Post-hoc analysis of the INTERACT2 dataset, a randomized controlled trial of patients with acute ICH with elevated systolic blood pressure (SBP), randomly assigned to intensive (target SBP mm Hg) or guideline-based ( mm Hg) BP management. Patients with a sedimentation level at baseline assessment on CT, and modified Rankin Scale score at 90-day, were included in these analyses. Factors associated with a sedimentation level and its significance in relation to 90-day clinical outcomes were assessed in univariable and multivariable logistic regression models. b i Results: /i /b Of 2,065 participants, 19 (1%) had sedimentation level on baseline CT, which was independently associated with warfarin use (p = 0.006) and lobar ICH (p = 0.025). Sedimentation level was also associated with death or major disability at 90-day in both crude (84 vs. 53% p = 0.014) and multivariable analyses adjusted for age, gender, Chinese region, warfarin use, baseline National Institutes of Health Stroke Scale score, onset to CT time, volume and location of ICH, intraventricular extension, and randomized intensive BP lowering (OR 3.94, 95% CI 1.01-15.37 p = 0.049). b i Conclusions: /i /b The presence of hematoma sedimentation level on baseline CT is associated with warfarin use and lobar location of ICH, and predicts a worse outcome. Although uncommon, sedimentation level is an easily detectable prognostic factor in acute ICH.
Publisher: Elsevier BV
Date: 05-2019
DOI: 10.1016/J.WNEU.2019.01.140
Abstract: Arterial spin labeling (ASL) perfusion magnetic resonance imaging (MRI) may be used to determine brain regions at risk for ischemia in patients with moyamoya vasculopathy and to identify patients who may benefit from surgical revascularization. We aimed to investigate whether 1) the severity of moyamoya is related to the presence of leptomeningeal collaterals and cerebrovascular reactivity (CVR), 2) the presence of collaterals and ivy sign reflects disturbed CVR, and 3) arterial transit artefacts (ATAs) and ivy sign reflect the presence of collaterals. We determined severity of moyamoya on digital subtraction angiography (DSA) according to the modified Suzuki classification in 20 brain regions and scored regional tissue revascularization using a 4-point scale. Regional CVR and ATAs were assessed on ASL perfusion MRI, ivy sign on fluid attenuation inversion recovery MRI. In 11 patients (median age 36 years 91% female), we studied 203 regions. ATAs were associated with the presence of collaterals on DSA (P < 0.01). Of all regions with clearly visible collateral vessels on DSA, however, only 24% had ATAs. Ivy sign was not related to the presence or absence of collaterals nor to CVR. In 10% of regions with good vascularization on DSA, CVR was poor or showed steal. ATAs were associated with the presence of collaterals on DSA. Although DSA vascularization scores correlated with CVR, 10% of regions with good vascularization on DSA had absent CVR or steal on ASL-MRI. DSA and ivy sign did not provide adequate information on the hemodynamic status of brain tissue in patients with moyamoya vasculopathy.
Publisher: Springer Science and Business Media LLC
Date: 13-01-2019
Publisher: Springer Science and Business Media LLC
Date: 06-12-2013
DOI: 10.1007/S11910-013-0423-7
Abstract: Moyamoya disease is a progressive intracranial arteriopathy characterized by bilateral stenosis of the distal portion of the internal carotid artery and the proximal anterior and middle cerebral arteries, resulting in transient ischemic attacks or strokes. The pathogenesis of moyamoya disease remains unresolved, but recent advances have suggested exciting new insights into a genetic contribution as well as into other pathophysiological mechanisms. Treatment that may halt progression of the disease or even reverse the intracranial arteriopathy is yet to be found. There are strong indications that neurosurgical intervention, through direct, indirect, or combined revascularization surgery, can reduce the risk of ischemic stroke and possibly also cognitive dysfunction by improving cerebral perfusion, although randomized clinical trials have not been performed. Many questions regarding the indication for and timing of surgery remain unanswered. In this review, we discuss recent developments in the pathogenesis and treatment of moyamoya disease.
Publisher: Elsevier BV
Date: 12-2000
Publisher: Springer Science and Business Media LLC
Date: 28-11-2019
DOI: 10.1038/S41598-019-54491-6
Abstract: A 3-dimensional (3D) convolutional neural network is presented for the segmentation and quantification of spontaneous intracerebral haemorrhage (ICH) in non-contrast computed tomography (NCCT). The method utilises a combination of contextual information on multiple scales for fast and fully automatic dense predictions. To handle a large class imbalance present in the data, a weight map is introduced during training. The method was evaluated on two datasets of 25 and 50 patients respectively. The reference standard consisted of manual annotations for each ICH in the dataset. Quantitative analysis showed a median Dice similarity coefficient of 0.91 [0.87–0.94] and 0.90 [0.85–0.92] for the two test datasets in comparison to the reference standards. Evaluation of a separate dataset of 5 patients for the assessment of the observer variability produced a mean Dice similarity coefficient of 0.95 ± 0.02 for the inter-observer variability and 0.97 ± 0.01 for the intra-observer variability. The average prediction time for an entire volume was 104 ± 15 seconds. The results demonstrate that the method is accurate and approaches the performance of expert manual annotation.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2000
DOI: 10.1161/01.STR.31.12.3001
Abstract: Background and Purpose —We sought to assess whether MRI, MR angiography, or 1 H MR spectroscopy can be used to identify patients with symptomatic carotid artery occlusion (CAO) who are at high risk of recurrent ipsilateral cerebral ischemic events. Methods —In 115 consecutive patients with transient or moderately disabling symptoms of cerebral or retinal ischemia and ipsilateral CAO, we studied the prognostic value of (1) presence of a border-zone infarct (2) quantitative flow in the middle cerebral artery (MCA) ipsilateral to the CAO and (3) metabolic ratios in the centrum semiovale ipsilateral to the CAO. Results —Presence of a border-zone infarct and the rate of flow in the MCA did not have a significant relationship with recurrence of cerebral ischemic events. Patients with a low N -acetyl aspartate (NAA)/choline ratio had an annual risk of recurrent, ipsilateral, cerebral ischemic events of 16.0% (95% CI, 9.5 to 27.0), whereas this risk was 4.2% (95% CI, 2.2 to 8.0) in those with a normal NAA/choline ratio (hazard ratio, 0.43 95% CI, 0.19 to 1.00). Patients who on entry had had only retinal symptoms had on average a higher NAA/choline ratio (mean difference, 0.25 95% CI, 0.13 to 0.37) and a lower risk of recurrent cerebral ischemic events (odds ratio, 0.0 95% CI, 0.0 to 0.6) than those with cerebral ischemic symptoms. Conclusions —NAA/choline ratio measured by 1 H MRS, but not the presence of a border-zone infarct or the amount of flow in the MCA, can identify patients with symptomatic CAO who are at risk of future ipsilateral cerebral ischemic events.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2013
DOI: 10.1161/STROKEAHA.111.000586
Abstract: Many patients with aneurysmal subarachnoid hemorrhage (SAH) with intraparenchymal extension develop early hematoma expansion, which is not explained by aneurysmal rerupture in half of cases. In patients with primary intracerebral hemorrhage, the computed tomography angiography (CTA) spot sign predicts hematoma expansion and poor outcome. We conducted a 2-center prospective cohort study to evaluate whether CTA spot sign predicts case fatality in aneurysmal subarachnoid hemorrhage with intraparenchymal extension. We studied consecutive patients with aneurysmal subarachnoid hemorrhage with intraparenchymal extension. Two experienced readers, blinded to clinical data, analyzed CTAs for spot sign presence. We assessed the proportion of patients with the CTA spot sign and tested its association with in-hospital and 90-day case fatality, using univariable and multivariable logistic regression. In 32 of 236 patients (14%), we found at least 1 spot sign. Acute surgical hematoma evacuation with aneurysm occlusion occurred in 120 patients (51%). The overall in-hospital case fatality rate was 37%. The CTA spot sign was not associated with in-hospital (multivariable odds ratio, 0.51 [95% confidence interval, 0.06–3.26]) or 90-day (multivariable odds ratio, 0.59 [0.21–1.65]) case fatality. The found frequency of CTA spot signs is lower after aneurysmal than primary intracerebral hemorrhage and is not associated with in-hospital or 90-day case fatality in patients with aneurysmal subarachnoid hemorrhage with intraparenchymal extension.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-05-2017
Abstract: Ischemic and hemorrhagic stroke are increasingly recognized as heterogeneous diseases with distinct subtypes and etiologies. Information on variation in distribution of vascular risk factors according to age in stroke subtypes is limited. We investigated the prevalence of vascular risk factors in stroke subtypes in relation to age. We studied a prospective multicenter university hospital–based cohort of 4033 patients. For patients with ischemic stroke caused by large artery atherosclerosis, small vessel disease, or cardioembolism and for patients with spontaneous intracerebral hemorrhage or aneurysmal subarachnoid hemorrhage, we calculated prevalences of vascular risk factors in 4 age groups: , 55 to 65, 65 to 75, and ≥75 years, and mean differences with 95% CIs in relation to the reference age group. Patients aged years were significantly more often of non‐white origin (in particular in spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage patients) and most often smoked (most prominent for aneurysmal subarachnoid hemorrhage patients). Patients aged years with ischemic stroke caused by large artery atherosclerosis or small vessel disease more often had hypertension, hyperlipidemia, and diabetes mellitus than patients with ischemic stroke of cardiac origin. Overall, the frequency of hypertension, hyperlipidemia, and diabetes mellitus increased with age among all stroke subtypes, whereas smoking decreased with age. Regardless of age, accumulation of potentially modifiable risk factors was most pronounced in patients with ischemic stroke caused by large artery atherosclerosis or small vessel disease. The prevalence of common cardiovascular risk factors shows different age‐specific patterns among various stroke subtypes. Recognition of these patterns may guide tailored stroke prevention efforts aimed at specific risk groups.
Publisher: Elsevier BV
Date: 11-2003
DOI: 10.1016/S1474-4422(03)00558-1
Abstract: Ischaemic stroke is an important cause of death and dependency in industrialised countries it has a high incidence (affecting up to 0.2% of the population each year) and is commonly lethal or disabling. One in six patients die in the first month after ischaemic stroke, and half of survivors are permanently disabled despite best efforts to rehabilitate them and to prevent complications, recurrent stroke, and other serious vascular events. Optimisation of the early, and ongoing, management of patients with acute ischaemic stroke is pivotal to the reduction of both case fatality and long-term disability. Guidelines for the early management of patients with ischaemic stroke have recently been published by the Stroke Council of the American Stroke Association (ASA Adams and co-workers, Stroke 2003 34: 1056-83) and the European Stroke Initiative (EUSI European Stroke Initiative Executive Committee and Writing Committee, Cerebrovasc Dis 2003 16: 311-38). Although transatlantic differences might create different interpretations, priorities, and views, the guidelines are remarkably similar, even regarding controversial issues. We believe this is not only because both groups have had the opportunity to discuss many of the controversial issues at international meetings, but also because both groups have endorsed the concept of evidence-based medicine and have based their recommendations on similar classifications of the levels of evidence for the effectiveness of interventions. This is a triumph for evidence-based medicine and a major step towards unification of acute stroke management worldwide. WHERE NEXT?: There are three main challenges in stroke management. To increase the body of reliable evidence from large randomised controlled trials (RCTs) of the safety, effectiveness, and cost of promising treatments (eg, thrombolysis, antithrombotic therapy, neuroprotection, and interventional recanalisation, alone and in combination) in a wide range of patients around the world. To facilitate the widespread development of stroke units, delivery of organised stroke care, and emergency transport of patients with stroke to appropriate stroke centres. And finally, to improve the uptake of effective therapies into clinical practice (eg, by widely disseminating the ASA and EUSI guidelines).
Publisher: American Medical Association (AMA)
Date: 25-12-2013
Publisher: Elsevier BV
Date: 10-2017
DOI: 10.1016/J.JCRC.2017.06.002
Abstract: Hypoalbuminemia and systemic inflammatory response syndrome (SIRS) are reported in critically-ill patients, but their relationship is unclear. We sought to determine the association of admission serum albumin and SIRS with outcomes in patients with intracerebral hemorrhage (ICH). We used a multicenter, multinational registry of ICH patients to select patients in whom SIRS parameters and serum albumin levels had been determined on admission. Hypoalbuminemia was defined as the lowest standardized quartile of albumin SIRS according to standard criteria. Primary outcomes were modified Rankin Scale (mRS) at discharge and in-hospital mortality. Regression models were used to assess for the association of hypoalbuminemia and SIRS with discharge mRS and in-hospital mortality. Of 761 ICH patients included in the registry 518 met inclusion criteria 129 (25%) met SIRS criteria on admission. Hypoalbuminemia was more frequent in patients with SIRS (42% versus 19% p<0.001). SIRS was associated with worse outcomes (OR: 4.68, 95%CI, 2.52-8.76) and in-hospital all-cause mortality (OR: 2.18, 95% CI, 1.60-2.97), while hypoalbuminemia was not associated with all-cause mortality. In patients with ICH, hypoalbuminemia is strongly associated with SIRS. SIRS, but not hypoalbuminemia, predicts poor outcome at discharge. Recognizing and managing SIRS early may prevent death or disability in ICH patients.
Publisher: BMJ
Date: 11-2007
Publisher: SAGE Publications
Date: 09-06-2014
DOI: 10.1111/IJS.12283
Publisher: S. Karger AG
Date: 2001
DOI: 10.1159/000047688
Abstract: i Objective: /i To assess whether patients with carotid artery occlusion (CAO) who have clinical features suggesting a haemodynamic origin have a poor haemodynamic or metabolic state of the brain. i Methods: /i In 117 patients with ischaemic symptoms of the eye or brain that were transient or at most moderately disabling and associated with a CAO, we compared CO sub /sub reactivity, quantitative flow measurement by magnetic resonance (MR) angiography, metabolic ratios measured by sup /sup H-MR spectroscopy, collateral blood flow patterns and the presence of infarcts of the borderzone type between patients grouped by the following clinical features: (1) presence or absence of at least one of the ‘classical’ haemodynamic symptoms: limb shaking, retinal claudication, precipitation of symptoms by exercise, by rising from a sitting or lying position, by transition from a cold to a warm environment, or by documented hypotension, and (2) symptoms having occurred after demonstration of the CAO or only before the occlusion was documented. i Results: /i Patients with (n = 16) and without (n = 101) one of the ‘classical’ haemodynamic symptoms did not differ in any of the measured indices. Patients with recurrent symptoms after documentation of the CAO (n = 56) had lower CO sub /sub reactivity (difference 8.3%, 95% confidence interval 0.1–16.5) than those with symptoms only before documentation of the occlusion (n = 61), whereas no significant differences were found in any of the other measured indices. The difference in CO sub /sub reactivity was no longer significant after adjustment for the interval between the patients’ last symptoms and the CO sub /sub reactivity measurement. i Conclusion: /i In patients with CAO we could not find an association between symptoms that have been associated with hypoperfusion and a poor haemodynamic or metabolic state of the brain.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-12-2022
DOI: 10.1212/WNL.0000000000201160
Abstract: The ULTRA trial showed that ultra-early and short-term tranexamic acid treatment after subarachnoid hemorrhage did not improve clinical outcome at 6 months. An expected proportion of the included patients experienced nonaneurysmal subarachnoid hemorrhage. In this post hoc study, we will investigate whether ultra-early and short-term tranexamic acid treatment in patients with aneurysmal subarachnoid hemorrhage improves clinical outcome at 6 months. The ULTRA trial is a multicenter, prospective, randomized, controlled, open-label trial with blinded outcome assessment, conducted between July 24, 2013, and January 20, 2020. After confirmation of subarachnoid hemorrhage on noncontrast CT, patients were allocated to either ultra-early and short-term tranexamic acid treatment with usual care or usual care only. In this post hoc analysis, we included all ULTRA participants with a confirmed aneurysm on CT angiography and/or digital subtraction angiography. The primary endpoint was clinical outcome at 6 months, assessed by the modified Rankin scale (mRS), dichotomized into good (0–3) and poor (4–6) outcomes. Of the 813 ULTRA trial patients who experienced an aneurysmal subarachnoid hemorrhage, 409 (50%) were assigned to the tranexamic acid group and 404 (50%) to the control group. In the intention-to-treat analysis, 233 of 405 (58%) patients in the tranexamic acid group and 238 of 399 (60%) patients in the control group had a good clinical outcome (adjusted odds ratio [aOR] 0.92 95% CI 0.69–1.24). None of the secondary outcomes showed significant differences between the treatment groups: excellent clinical outcome (mRS 0–2) (aOR 0.76 95% CI 0.57–1.03), all-cause mortality at 30 days (aOR 0.91 95% CI 0.65–1.28), and all-cause mortality at 6 months (aOR 1.10 95% CI 0.80–1.52). Ultra-early and short-term tranexamic acid treatment did not improve clinical outcomes at 6 months in patients with aneurysmal subarachnoid hemorrhage and therefore cannot be recommended. ClinicalTrials.gov (NCT02684812 submission date February 18, 2016, first patient enrollment on July 24, 2013). This study provides Class II evidence that tranexamic acid does not improve outcomes in patients presenting with aneurysmal subarachnoid hemorrhage.
Publisher: Springer Science and Business Media LLC
Date: 26-09-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2003
DOI: 10.1161/01.STR.0000076012.19397.4B
Abstract: Background and Purpose— In patients with severe obstruction of the internal carotid artery (ICA), it is recognized that the preoperative failure to visualize collaterals of the circle of Willis increases the risk of hemispheric ischemia before, during, and after carotid endarterectomy (CEA). The purpose of the present study was to assess the effect of CEA on the anatomy and function of the circle of Willis. Methods— Time-of-flight and phase-contrast MR angiography were used to study changes in vessel diameter and collateral flow of the circle of Willis in 48 patients with 70% to 99% ICA stenosis before and after CEA. Results— In patients with unilateral ICA stenosis, all preoperative vessel diameters on both sides of the circle of Willis were larger than in control subjects. All demonstrated a significant diameter decrease to reach normal values after CEA. Furthermore, preoperative collateral flow patterns normalized after CEA ( P =0.03). In patients with stenosis and contralateral ICA occlusion, CEA resulted in a significant increase in the prevalence of collateral flow via the anterior communicating artery (33% to 83%, P .01) and a significant increase in diameter of both A1 segments ( P .05) in patients in whom collateral flow developed after CEA. Conclusions— CEA reduces the caliber of compensatory collateral channels to normal levels by MR angiography measurements in the presence of severe unilateral stenosis when the opposite side is occluded and the stenosis is removed ipsilaterally, a greater amount of compensatory collateral circulation can be measured on both the occluded side and the fully opened side.
Publisher: Springer Science and Business Media LLC
Date: 04-06-2013
Publisher: SAGE Publications
Date: 25-02-2015
Abstract: The purpose of this study was to assess whether calibrated magnetic resonance imaging (MRI) can identify regional variances in cerebral hemodynamics caused by vascular disease. For this, arterial spin labeling (ASL)/blood oxygen level-dependent (BOLD) MRI was performed in 11 patients (65±7 years) and 14 controls (66±4 years). Cerebral blood flow (CBF), ASL cerebrovascular reactivity (CVR), BOLD CVR, oxygen extraction fraction (OEF), and cerebral metabolic rate of oxygen (CMRO 2 ) were evaluated. The CBF was 34±5 and 36±11 mL/100 g per minute in the ipsilateral middle cerebral artery (MCA) territory of the patients and the controls. Arterial spin labeling CVR was 44±20 and 53±10% per 10 mm Hg ΔEtCO 2 in patients and controls. The BOLD CVR was lower in the patients compared with the controls (1.3±0.8 versus 2.2±0.4% per 10 mm Hg ΔEtCO 2 , P 0.01). The OEF was 41±8% and 38±6%, and the CMRO 2 was 116±39 and 111±40 μmol/100 g per minute in the patients and the controls. The BOLD CVR was lower in the ipsilateral than in the contralateral MCA territory of the patients (1.2±0.6 versus 1.6±0.5% per 10 mmHg ΔEtCO 2 , P 0.01). Analysis was h ered in three patients due to delayed arrival time. Thus, regional hemodynamic impairment was identified with calibrated MRI. Delayed arrival artifacts limited the interpretation of the images in some patients.
Publisher: Springer Science and Business Media LLC
Date: 04-09-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2000
Abstract: Background and Purpose —The purpose of the present study was to assess whether the direction of flow via the circle of Willis and the ophthalmic artery (OphA) changed over time in patients with a symptomatic occlusion of the internal carotid artery (ICA) who did not experience recurrent cerebral ischemic symptoms. Methods —Sixty-two patients with a symptomatic ICA occlusion were investigated within 6 months after symptoms occurred. The investigations were repeated after 6 and 12 months. The directions of flow in the A1 segment and the posterior communicating artery (PCoA), both on the side of the symptomatic ICA occlusion, were assessed with the use of magnetic resonance angiography. The pattern of collateral flow via the circle of Willis was categorized as via the A1 segment only, via the PCoA only, via the A1 segment plus the PCoA, or no collateral flow via the circle of Willis. The direction of flow in the OphA was investigated with transcranial Doppler sonography. CO 2 reactivity was determined with transcranial Doppler sonography to investigate whether changes in flow patterns were accompanied by changes in cerebrovascular reactivity. Results —There were no statistically significant changes over time in the direction of blood flow in the A1 segment and the PCoA or in the pattern of collateral flow via the circle of Willis. On average, 72% of patients with a unilateral ICA occlusion (n=41) had willisian collateral flow compared with 37% of patients with a bilateral ICA occlusion (n=21 P .05). Patients with a unilateral ICA occlusion tended to a lower prevalence of reversed flow via the OphA over time. CO 2 reactivity did not change significantly in any patient group. In patients with a unilateral ICA occlusion, decreased CO 2 reactivity was associated with a higher prevalence of absent willisian collateral flow and a lower prevalence of collateral flow via the A1 segment plus the PCoA. Conclusions —The absence of recurrent cerebral ischemic symptoms in patients with a symptomatic ICA occlusion is not associated with an improvement in collateral flow via the circle of Willis or the OphA during 1.5-year follow-up.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2004
DOI: 10.1161/01.STR.0000128697.52150.75
Abstract: Background and Purpose— To investigate whether the risk of recurrent ipsilateral ischemic stroke in patients with symptomatic carotid artery occlusion (CAO) is related to (1) volume flow in the contralateral internal carotid artery (ICA), basilar artery (BA), and middle cerebral arteries (MCAs), and (2) intracranial collateral flow to the symptomatic side, measured in the first 6 months after the qualifying symptoms occurred. Methods— We prospectively studied 112 patients with symptomatic CAO. Quantitative volume flow was measured with magnetic resonance angiography (MRA) and collateral flow via the circle of Willis with MRA, via the ophthalmic artery (OA) with transcranial Doppler sonography, and via leptomeningeal anastomoses with conventional angiography. Results— During 49±14 months of follow-up (mean±SD), 7 patients had recurrent ipsilateral ischemic stroke. Compared with patients without recurrent stroke, these patients had significantly higher total flow to the brain, ie, ICA+BA flow (mean 536 mL/min versus 410 mL/min P .05), and significantly higher contralateral ICA flow (355 mL/min versus 209 mL/min P .001), whereas BA and MCA flow showed no significant differences. Also, they more often had Willisian collateral flow ( P .05), mainly caused by increased collateral flow via the posterior communicating artery (PCoA 71% versus 28% P .05), whereas collateral flow via the OA and leptomeningeal anastomoses did not differ significantly. Conclusions— Recurrent ipsilateral ischemic stroke in patients with symptomatic CAO is associated with high volume flow to the brain and increased collateral PCoA flow.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2014
DOI: 10.1161/STROKEAHA.114.005505
Abstract: Low socioeconomic status has been linked to high incidence of stroke in industrialized countries therefore, reducing socioeconomic disparities is an important goal of health policy. The evidence on migrant groups is, however, limited and inconsistent. We assessed socioeconomic inequalities in relation to stroke incidence among major ethnic groups in the Netherlands. A nationwide register-based cohort study was conducted (n=2 397 446) between January 1, 1998, and December 31, 2010, among ethnic Dutch and ethnic minority groups. Standardized disposable household income was used as a measure of socioeconomic position. Among ethnic Dutch, the incidence of stroke was higher in the low-income group than in the high-income group (adjusted hazard ratio, 1.18 95% confidence interval, 1.16–1.20). Similar socioeconomic inequalities in stroke incidence were found among Surinamese (1.36 1.17–1.58), Indonesians (1.15 1.03–1.28), Moroccans (1.54 0.97–2.43), Turkish (1.19 0.97–1.46), and to a lesser extent among Antilleans (1.24 0.84–1.84). When compared with ethnic Dutch, the incidence of stroke was lower in Moroccans, similar in Turkish, but higher in Surinamese among all income groups. The incidence of stroke was higher in Indonesian low- and high-income groups than in their ethnic Dutch counterparts. Among Antilleans, the risk of stroke was higher than ethnic Dutch but only in the low-income group. Our findings reveal socioeconomic inequalities in stroke incidence among all ethnic groups. Reduction of socioeconomic inequalities in stroke incidence among all ethnic groups may lead to a major public health improvement for all. Policy measures tackling socioeconomic inequalities should take into account the increased risk of stroke among ethnic minority populations.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 16-09-2015
Publisher: BMJ
Date: 09-11-2015
DOI: 10.1136/BMJ.H5762
Abstract: What are the diagnostic yield and accuracy of early computed tomography (CT) angiography followed by magnetic resonance imaging/angiography (MRI/MRA) and digital subtraction angiography (DSA) in patients with non-traumatic intracerebral haemorrhage? This prospective diagnostic study enrolled 298 adults (18-70 years) treated in 22 hospitals in the Netherlands over six years. CT angiography was performed within seven days of haemorrhage. If the result was negative, MRI/MRA was performed four to eight weeks later. DSA was performed when the CT angiography or MRI/MRA results were inconclusive or negative. The main outcome was a macrovascular cause, including arteriovenous malformation, aneurysm, dural arteriovenous fistula, and cavernoma. Three blinded neuroradiologists independently evaluated the images for macrovascular causes of haemorrhage. The reference standard was the best available evidence from all findings during one year's follow-up. A macrovascular cause was identified in 69 patients (23%). 291 patients (98%) underwent CT angiography 214 with a negative result underwent additional MRI/MRA and 97 with a negative result for both CT angiography and MRI/MRA underwent DSA. Early CT angiography detected 51 macrovascular causes (yield 17%, 95% confidence interval 13% to 22%). CT angiography with MRI/MRA identified two additional macrovascular causes (18%, 14% to 23%) and these modalities combined with DSA another 15 (23%, 18% to 28%). This last extensive strategy failed to detect a cavernoma, which was identified on MRI during follow-up (reference strategy). The positive predictive value of CT angiography was 72% (60% to 82%), of additional MRI/MRA was 35% (14% to 62%), and of additional DSA was 100% (75% to 100%). None of the patients experienced complications with CT angiography or MRI/MRA 0.6% of patients who underwent DSA experienced permanent sequelae. Not all patients with negative CT angiography and MRI/MRA results underwent DSA. Although the previous probability of finding a macrovascular cause was lower in patients who did not undergo DSA, some small arteriovenous malformations or dural arteriovenous fistulas may have been missed. CT angiography is an appropriate initial investigation to detect macrovascular causes of non-traumatic intracerebral haemorrhage, but accuracy is modest. Additional MRI/MRA may find cavernomas or alternative diagnoses, but DSA is needed to diagnose macrovascular causes undetected by CT angiography or MRI/MRA. Dutch Heart Foundation and The Netherlands Organisation for Health Research and Development, ZonMw. The authors have no competing interests. Direct requests for additional data to the corresponding author.
Publisher: Springer Science and Business Media LLC
Date: 22-09-2017
DOI: 10.1038/S41598-017-07404-4
Abstract: We aimed to replicate reported associations of 10 SNPs at eight distinct loci with overall ischemic stroke (IS) and its subtypes in an independent cohort of Dutch IS patients. We included 1,375 IS patients enrolled in a prospective multicenter hospital-based cohort in the Netherlands, and 1,533 population-level controls of Dutch descent. We tested these SNPs for association with overall IS and its subtypes (large artery atherosclerosis, small vessel disease and cardioembolic stroke (CE), as classified by TOAST) using an additive multivariable logistic regression model, adjusting for age and sex. We obtained odds ratios (OR) with 95% confidence intervals (95% CI) for the risk allele of each SNP analyzed and exact p-values by permutation. We confirmed the association at 4q25 ( PITX2 ) (OR 1.43 95% CI, 1.13–1.81, p = 0.029) and 16q22 ( ZFHX3 ) (OR 1.62 95% CI, 1.26–2.07, p = 0.001) as risk loci for CE. Locus 16q22 was also associated with overall IS (OR 1.24 95% CI, 1.08–1.42, p = 0.016). Other loci previously associated with IS and/or its subtypes were not confirmed. In conclusion, we validated two loci (4q25, 16q22) associated with CE. In addition, our study may suggest that the association of locus 16q22 may not be limited to CE, but also includes overall IS.
Publisher: Journal of Neurosurgery Publishing Group (JNSPG)
Date: 05-2009
Abstract: Excimer laser–assisted nonocclusive anastomosis (ELANA) is a technique that can be used for extracranial-to-intracranial (EC-IC) bypasses, without the necessity of temporary occlusion of the donor or recipient artery. Information on predictors of patency of EC-IC bypasses in general and the ELANA bypass in particular is sparse. The authors studied 159 ELANA EC-IC bypasses to find predictors of patency. From a prospective database of patients who underwent EC-IC bypass surgery, 143 consecutive patients who underwent a total of 159 ELANA bypasses were studied. The associations of patient characteristics, surgical aspects, and technical aspects specific to the ELANA technique with intraoperative and postoperative bypass patency were studied using logistic regression analysis. At the end of the operation, 146 (92%) of the 159 bypasses were patent. A first attempt to create a bypass was almost 8 times more likely (OR 7.6, 95% CI 2.1–27.5 p = 0.02) to result in a patent bypass than a second attempt. Administration of a small amount of heparin during the operation was also associated with bypass patency (OR 5.2, 95% CI 1.1–24.9 p = 0.04). One hundred twenty-three (77%) of the 159 bypasses were functional at patency assessments during the 1st month after the operation. Older age (OR 1.043 for every year of increase in age, 95% CI 1.010–1.076 p = 0.01), male sex (OR 2.9, 95% CI 1.3–6.5 p = 0.01), and high intraoperative bypass flow (OR 1.017 for every milliliter per minute increase in flow, 95% CI 1.004–1.030 p = 0.01) were associated with postoperative bypass patency. Attempts to create a second EC-IC ELANA bypass after the first one are more likely to fail, whereas administration of heparin to the patient during the procedure increases the intraoperative bypass patency rate. Postoperative patency results are better in male and in older patients. Intraoperative bypass flow measurements are essential because high bypass flow is an important determinant of postoperative patency.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-08-2014
Publisher: Oxford University Press (OUP)
Date: 15-02-2010
DOI: 10.1093/BRAIN/AWQ009
Abstract: Limb-shaking is a specific clinical feature of transient ischaemic attacks that has been associated with a high-grade stenosis or occlusion of the internal carotid artery. The aim of this study was to describe the clinical characteristics of limb-shaking in patients with internal carotid artery occlusion and to investigate whether patients with limb-shaking have a worse haemodynamic state of the brain than patients with internal carotid artery occlusion without limb-shaking. We included 34 patients (mean age 62 + or - 7 years, 82% male) with limb-shaking associated with internal carotid artery occlusion and 68 sex- and age-matched controls with cerebral transient ischaemic attack or minor disabling ischaemic stroke associated with internal carotid artery occlusion, but without limb-shaking. We investigated clinical characteristics, collateral pathways on contrast angiograms and carbon dioxide-reactivity measured by transcranial Doppler. The results showed that limb-shaking usually lasted less than 5 min and was often accompanied by paresis of the involved limb. Compared with controls, patients with limb-shaking more frequently had symptoms precipitated by rising or exercise (odds ratio 14.2, 95% confidence interval 4.2-47.9), more frequently had recurrent ischaemic deficits after documented internal carotid artery occlusion (but before inclusion in the study) (odds ratio 8.2, 95% confidence interval 2.3-29.3), more often had leptomeningeal collaterals (odds ratio 6.8, 95% confidence interval 2.0-22.7), and tended to have a lower carbon dioxide-reactivity (mean 5% + or - 16 versus 12% + or - 17 odds ratio 0.97 per 1% increase in carbon dioxide-reactivity, 95% confidence interval 0.94-1.00). In conclusion, limb-shaking transient ischaemic attacks in patients with internal carotid artery occlusion can be recognized by their short duration, are often accompanied by paresis and precipitated by rising or exercise and are indicative of an impaired haemodynamic state of the brain.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-01-2022
DOI: 10.1212/WNL.0000000000201341
Abstract: Causes of stroke in young adults differ from those in the elderly in iduals, and in a larger percentage, no cause can be determined. To gain more insight into the etiology of (cryptogenic) stroke in the young population, we investigated whether trigger factors, such as short-lasting exposure to toxins or infection, may play a role. Patients aged 18–49 years with a first-ever ischemic stroke or intracerebral hemorrhage (ICH) in 17 participating centers in the Netherlands completed a questionnaire about exposure to 9 potential trigger factors in hazard periods and on a regular yearly basis. A case-crossover design was used to assess relative risks (RRs) with 95% confidence intervals (95% CIs) by the Mantel-Haenszel case-crossover method, for any stroke (ischemic stroke and ICH combined) and for different etiologic subgroups of ischemic stroke. One thousand one hundred forty-six patients completed the questionnaire (1,043 patients with an ischemic stroke and 103 with an ICH, median age 44.0 years, 52.6% men). For any stroke, an increased risk emerged within 1 hour of cola consumption (RR 2.0, 95% CI 1.5–2.8) and vigorous physical exercise (RR 2.6, 95% CI 2.2–3.0), within 2 hours after sexual activity (RR 2.4, 95% CI 1.6–3.5), within 4 hours after illicit drug use (RR 2.8, 95% CI 1.7–4.9), and within 24 hours after fever or flu-like disease (RR 14.1, 95% CI 10.5–31.2 RR 13.9, 95% CI 8.9–21.9). Four trigger factors increased the risk of other determined and cryptogenic ischemic stroke, 3 that of cardioembolic stroke, 2 that of large vessel atherosclerosis and likely atherothrombotic stroke combined and stroke with multiple causes, and none that of stroke due to small vessel disease. We identified cola consumption, vigorous physical exercise, sexual activity, illicit drug use, fever, and flu-like disease as potential trigger factors for stroke in the young population and found differences in the type and number of trigger factors associated with different etiologic subgroups of ischemic stroke. These findings might help in better understanding the pathophysiologic mechanisms of (cryptogenic) stroke in the young population.
Publisher: Elsevier BV
Date: 06-2016
Publisher: BMJ
Date: 16-05-2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 21-06-2004
Abstract: Little is known about long-term cognitive functioning and quality of life (QoL) in patients with symptomatic carotid artery occlusion who do not undergo revascularization surgery. To assess the course of cognitive impairment and changes in QoL in these patients and whether impaired cerebral metabolism predicts the course of cognitive functioning. In 73 consecutive patients with TIA or a minor stroke associated with an occlusion of the internal carotid artery (ICA), cognition and health-related QoL in a 1-year follow-up study were examined. The presence of cerebral ischemic lesions was examined by MRI the metabolic N-acetyl aspartate/creatine ratio and the presence of lactate were measured by 1H-MR spectroscopy in the centrum semiovale ipsilateral to the symptomatic ICA occlusion. Seventy percent of patients with a stroke and 40% of patients with a TIA were cognitively impaired. In patients with recurrent TIAs during follow-up, cognitive functioning remained at the same (impaired) level (mean impairment score: at baseline 0.7, at 1-year follow-up 0.6 p = 0.646). In patients without lactate at baseline and without recurrent symptoms during follow-up, cognitive functioning improved (mean impairment score: at baseline 1.1, at 1-year follow-up 0.7 p < 0.001). Self-perceived QoL remained affected at 12 months' follow-up, although not to a large extent (mean SD from norm scores <1). In patients with a symptomatic ICA occlusion, cognitive functioning improved within 1.5 years after the ischemic event, if no further symptoms occurred and patients had no lactate at baseline. Self-perceived QoL remained slightly affected.
Publisher: Elsevier BV
Date: 10-2015
Publisher: Springer Science and Business Media LLC
Date: 2012
Publisher: Springer Science and Business Media LLC
Date: 22-12-2020
Publisher: BMJ
Date: 16-11-2017
Abstract: The global burden of intracerebral haemorrhage (ICH) is enormous. Developing evidence-based management strategies for ICH has been h ered by its erse aetiology, high case fatality and variable cooperative organisation of medical and surgical care. Progress is being made through the conduct of collaborative multicentre studies with the large s le sizes necessary to evaluate therapies with realistically modest treatment effects. This narrative review describes the major consequences of ICH and provides evidence-based recommendations to support decision-making in medical management.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2011
Publisher: Elsevier BV
Date: 06-2013
Publisher: Elsevier BV
Date: 07-2013
DOI: 10.1016/J.JVS.2012.12.059
Abstract: Selective endarterectomy of external carotid artery (ECA) stenosis has been considered a therapeutic option for patients presenting with symptomatic ipsilateral internal carotid artery (ICA) occlusion to correct cerebral hypoperfusion or eliminate a source of emboli. However, data are scarce, and the long-term benefit of ECA revascularization remains unclear. Our objective was to study the operative results and durability of selective ECA endarterectomy in patients presenting with cerebrovascular symptoms in association with nonacute ipsilateral ICA occlusion. This was a retrospective analysis of 27 consecutive patients who underwent selective ECA endarterectomy in a single center between 2000 and 2010. All patients presented with neurologic symptoms (<6 months of surgery, 78% repeat events) referable to an ipsilateral occlusion of the ICA and concomitant stenosis of the ECA. We assessed the perioperative clinical outcome <30 days and at midterm follow-up (mean, 31.6 months). Patency was defined as freedom of duplex ultrasound detected ≥ 50% restenosis. Endarterectomy of the ECA was successful in 26 patients (96.3%) with one ECA found occluded at surgery. No perioperative deaths occurred. In the 30 days after surgery, one patient developed an ipsilateral disabling ischemic stroke (3.7%), and one patient (3.7%) had a myocardial infarction. At follow-up, nine patients had died: one of a fatal ischemic stroke, six of non-vascular-related causes, and two of unknown causes. At 3 years, 83% (standard error, 8%) of patients were free from stroke or death, and 80% (standard error, 8%) of the operated-on arteries were patent. Five patients developed restenosis ≥ 50% (n = 2, asymptomatic) or occlusion (n = 3, one symptomatic) ≤ 3 months, and two other patients developed late asymptomatic restenosis. Selective endarterectomy of the ECA in symptomatic patients with an ipsilateral occlusion of the ICA is a feasible procedure with an acceptable perioperative risk. Most patients remain stroke-free during follow-up and have a low rate of symptomatic restenosis.
Publisher: Wiley
Date: 16-11-2022
DOI: 10.1002/ANA.26519
Abstract: Determining the underlying causes of intracerebral hemorrhage (ICH) is of major importance, because risk factors, prognosis, and management differ by ICH subtype. We developed a new causal CLASsification system for ICH Subtypes, termed CLAS‐ICH, based on recent advances in neuroimaging. CLAS‐ICH defines 5 ICH subtypes: arteriolosclerosis, cerebral amyloid angiopathy, mixed small vessel disease (SVD), other rare forms of SVD (genetic SVD and others), and secondary causes (macrovascular causes, tumor, and other rare causes). Every patient is scored in each category according to the level of diagnostic evidence: (1) well‐defined ICH subtype (2) possible underlying disease and (0) no evidence of the disease. We evaluated CLAS‐ICH in a derivation cohort of 113 patients with ICH from Massachusetts General Hospital, Boston, USA, and in a derivation cohort of 203 patients from Inselspital, Bern, Switzerland. In the derivation cohort, a well‐defined ICH subtype could be identified in 74 (65.5%) patients, including 24 (21.2%) with arteriolosclerosis, 23 (20.4%) with cerebral amyloid angiopathy, 18 (15.9%) with mixed SVD, and 9 (8.0%) with a secondary cause. One or more possible causes were identified in 42 (37.2%) patients. Interobserver agreement was excellent for each category (kappa value ranging from 0.86 to 1.00). Despite substantial differences in imaging modalities, we obtained similar results in the validation cohort. CLAS‐ICH is a simple and reliable classification system for ICH subtyping, that captures overlap between causes and the level of diagnostic evidence. CLAS‐ICH may guide clinicians to identify ICH causes, and improve ICH classification in multicenter studies. ANN NEUROL 2023 :16–28
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2019
DOI: 10.1161/STROKEAHA.118.022516
Abstract: Cerebral small vessel disease (SVD) is a major cause of stroke and dementia, but underlying disease mechanisms are still largely unknown, partly because of the difficulty in assessing small vessel function in vivo. We developed a method to measure blood flow velocity pulsatility in perforating arteries in the basal ganglia and semioval center. We aimed to determine whether this novel method could detect functional abnormalities at the level of the small vessels in patients with stroke attributable to SVD. We investigated 10 patients with lacunar infarction (mean age 61 years, 80% men), 11 patients with deep intracerebral hemorrhage (ICH) considered to be caused by SVD (ICH, mean age 58 years, 82% men) and 18 healthy controls that were age- and sex-matched. We performed 2-dimensional phase contrast magnetic resonance imaging at 7 T to measure time-resolved blood flow velocity in cerebral perforating arteries of the semioval center and the basal ganglia. We compared the number of detected arteries, pulsatility index and mean velocity between the patient groups and controls. In the basal ganglia, the number of detected perforators was lower in lacunar infarction (26±9, P =0.01) and deep ICH patients (28±6, P =0.02) than in controls (35±7). The pulsatility index in the basal ganglia was higher in lacunar infarction (1.07±0.13, P =0.03), and deep ICH patients (1.02±0.11, P =0.11), than in controls (0.94±0.10). Observations in the semioval center were similar. Number of detected perforators was lower in lacunar infarction (32±18, P =0.06), and deep ICH patients (28±18, P =0.02), than in controls (45±16). The pulsatility index was higher in lacunar infarction (1.18±0.15, P =0.02), and deep ICH patients (1.17±0.14, P =0.045) than in controls (1.08±0.07). No velocity differences were detected. This exploratory study shows that SVD can be expressed in terms of functional measures, such as pulsatility index, which are derived directly from the small vessels themselves. Future studies may use this technique to further unravel the mechanisms underlying SVD.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2009
DOI: 10.1161/STROKEAHA.108.539700
Abstract: Background and Purpose— It is unclear whether the risk of aneurysmal subarachnoid hemorrhage (aSAH) is increased during pregnancy, labor, and the puerperium. We compared the risk of aSAH during this period with the risk outside this period. Methods— We included women with aSAH between 18 and 42 years of age (n=244) from our prospectively collected database of patients with subarachnoid hemorrhage treated in the University Medical Center Utrecht, the provincial referral center, between January 1987 and April 2006. We estimated the relative risk of aSAH during pregnancy, delivery, or the puerperium by a case-crossover design and calculated a standardized incidence ratio, iding the observed number of patients with aSAH during pregnancy, delivery, or puerperium by the expected number based on the incidence in the general population of women of the same age during the study period. Results— Of the 244 women, 4 were pregnant, 3 in the puerperium and none in labor. The relative risk of aSAH during pregnancy, delivery, or the puerperium was 0.4 (95% CI, 0.2 to 0.9). Based on the number of women aged 18 to 42 years within the catchment area of our hospital and the number of pregnancies within the study period, the expected number of patients with aSAH during pregnancy, delivery, or the puerperium was 12, resulting in a standardized incidence ratio of 0.6 (95% CI, 0.2 to 1.1). Conclusions— The risk of aSAH is not increased during pregnancy, labor, and the puerperium. There is no need to advise against pregnancy in women with an increased risk of subarachnoid hemorrhage and no evidence to advise against vaginal delivery in such women.
Publisher: BMJ
Date: 21-07-2014
Publisher: BMJ
Date: 18-01-2018
Abstract: A substantial part of non-traumatic intracerebral haemorrhages (ICH) arises from a macrovascular cause, but there is little guidance on selection of patients for additional diagnostic work-up. We aimed to develop and externally validate a model for predicting the probability of a macrovascular cause in patients with non-traumatic ICH. The DIagnostic AngioGRAphy to find vascular Malformations (DIAGRAM) study (n=298 69 macrovascular cause 23%) is a prospective, multicentre study assessing yield and accuracy of CT angiography (CTA), MRI/ magnetic resonance angiography (MRA) and intra-arterial catheter angiography in diagnosing macrovascular causes in patients with non-traumatic ICH. We considered prespecified patient and ICH characteristics in multivariable logistic regression analyses as predictors for a macrovascular cause. We combined independent predictors in a model, which we validated in an external cohort of 173 patients with ICH (78 macrovascular cause, 45%). Independent predictors were younger age, lobar or posterior fossa (vs deep) location of ICH, and absence of small vessel disease (SVD). A model that combined these predictors showed good performance in the development data (c-statistic 0.83 95% CI 0.78 to 0.88) and moderate performance in external validation (c-statistic 0.66 95% CI 0.58 to 0.74). When CTA results were added, the c-statistic was excellent (0.91 95% CI 0.88 to 0.94) and good after external validation (0.88 95% CI 0.83 to 0.94). Predicted probabilities varied from 1% in patients aged 51–70 years with deep ICH and SVD, to more than 50% in patients aged 18–50 years with lobar or posterior fossa ICH without SVD. The DIAGRAM scores help to predict the probability of a macrovascular cause in patients with non-traumatic ICH based on age, ICH location, SVD and CTA.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2014
DOI: 10.1161/STROKEAHA.114.006202
Abstract: Whether intracerebral hemorrhage (ICH) survivors should restart antithrombotic drugs is unknown. We analyzed the frequency of restarting antithrombotic drugs in ICH survivors who had taken prophylactic antithrombotic drugs in atrial fibrillation or after thromboembolic disease in 5 cohorts and explored factors associated with doing so. We compared the characteristics and proportions of patients taking antithrombotic drugs at ICH onset and discharge in 4 hospital-based cohorts (Lille, France, n=542 Utrecht, The Netherlands, n=389 multicenter Clinical Relevance of Microbleeds in Stroke-2 (CROMIS-2) ICH, United Kingdom, n=667 and Amsterdam, The Netherlands, n=403) and 1 community-based study (Lothian, Scotland, n=137), using bivariate analyses. We sought characteristics associated with restarting using bivariate and multivariable logistic regression analyses. A total of 942 (44%) patients with ICH took antithrombotic drugs at hospital admission (no difference between cohorts). Antithrombotic drugs were restarted in 96 (20%) of the 469 survivors who had taken antithrombotic drugs for secondary prevention or atrial fibrillation, but this proportion differed when stratified by the cohort of origin (Lille, 18% Utrecht, 45% Lothian, 15% CROMIS-2 ICH, 11% Amsterdam, 20% P .001) and by type of antithrombotic drug pre-ICH (14% in patients with previous antiplatelet drugs versus 26% in patients with previous vitamin K antagonists and 41% in patients with both drugs P .001). We did not find other consistent, independent associations with restarting antithrombotic drugs. The variation in clinical practice and lack of consistent associations with restarting antithrombotic drugs after ICH reflect current knowledge and support the need for randomized controlled trials to resolve this dilemma.
Publisher: Elsevier BV
Date: 09-2010
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2021
DOI: 10.1161/STROKEAHA.120.033297
Abstract: The computed tomography angiography spot sign is associated with hematoma expansion, case fatality, and poor functional outcome in spontaneous supratentorial intracerebral hemorrhage (ICH). However, no data are available on the spot sign in spontaneous cerebellar ICH. We investigated consecutive patients with spontaneous cerebellar ICH at 3 academic hospitals between 2002 and 2017. We determined patient characteristics, hematoma expansion ( % or 6 mL), rate of expansion, discharge and 90-day case fatality, and functional outcome. Poor functional outcome was defined as a modified Rankin Scale score of 4 to 6. Associations were tested using univariable and multivariable logistic regression. Three hundred fifty-eight patients presented with cerebellar ICH, of whom 181 (51%) underwent a computed tomography angiography. Of these 181 patients, 121 (67%) were treated conservatively of which 15 (12%) had a spot sign. Patients with a spot sign treated conservatively presented with larger hematoma volumes (median [interquartile range]: 26 [7–41] versus 6 [2–13], P =0.001) and higher speed of expansion (median [interquartile range]: 15 [24–3] mL/h versus 1 [5–0] mL/h, P =0.034). In multivariable analysis, presence of the spot sign was independently associated with death at 90 days (odds ratio, 7.6 [95% CI, 1.6–88], P =0.037). With respect to surgically treated patients (n=60, [33%]), 14 (23%) patients who underwent hematoma evacuation had a spot sign. In these 60 patients, patients with a spot sign were older (73.5 [9.2] versus 66.6 [15.4], P =0.047) and more likely to be female (71% versus 37%, P =0.033). In a multivariable analysis, the spot sign was independently associated with death at 90 days (odds ratio, 2.1 [95% CI, 1.1–4.3], P =0.033). In patients with spontaneous cerebellar ICH treated conservatively, the spot sign is associated with speed of hematoma expansion, case fatality, and poor functional outcome. In surgically treated patients, the spot sign is associated with 90-day case fatality.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2002
DOI: 10.1161/01.STR.0000030319.78212.51
Abstract: Background and Purpose— The goal of this study was to determine safety and long-term outcome of the excimer laser–assisted high-flow extracranial/intracranial (EC/IC) bypass in patients with symptomatic carotid artery occlusion (CAO) at high risk of recurrent stroke. Methods— In a prospectively collected cohort of 103 patients with symptomatic CAO, 15 patients were selected for excimer laser–assisted EC/IC bypass surgery on the basis of predefined selection criteria: (1) transient or moderately disabling symptoms of focal cerebral ischemia, not symptoms of the retina only (2) continuing symptoms after documentation of the CAO (3) evidence of a possible hemodynamic origin of symptoms and (4) informed consent of the patient. Results— Eleven patients underwent the operation without complications One patient had a severely disabling stroke (Rankin grade 4) 11 days after the operation the bypass was found occluded on reoperation. Two other patients had a moderately disabling stroke (Rankin grade 3) immediately after the operation. One patient died of myocardial infarction 1 day after surgery. Median follow-up time was 27 months. Of the 11 patients who underwent the operation without complications, 1 died 17 months after the operation of a brainstem stroke, and another patient had a new stroke ipsilateral to his CAO 10 months after the operation but without a change in Rankin grade. Conclusions— The excimer laser–assisted high-flow EC/IC bypass operation is a potentially promising procedure in patients with symptomatic CAO and a presumably high risk of recurrent stroke, but the procedure carries a definite risk. This risk is probably related not only to the procedure itself but also to the selection of patients.
Publisher: S. Karger AG
Date: 2008
DOI: 10.1159/000121344
Abstract: i Objective: /i With routine use of non-invasive methods to assess the internal carotid artery, it becomes increasingly important to clarify the diagnostic accuracy of transcranial Doppler (TCD) ultrasound and magnetic resonance angiography (MRA) compared with intra-arterial digital subtraction angiography (iaDSA) for the detection of collateral flow via the major intracerebral collateral branches. i Subjects and Methods: /i In a prospective study, we compared TCD via a temporal bone window and MRA (flow direction sensitive phase contrast and time of flight) examinations of the intracranial collateral flow with iaDSA in a cohort of 97 consecutive patients with recent transient or minor disabling cerebral ischaemia associated with an occlusion of the carotid artery (38 contralateral stenosis %). i Results: /i iaDSA allowed the evaluation of collateral flow via the anterior and posterior circle of Willis in 97 and 67 patients, respectively, TCD in 76 of 97 and 66 of 67 patients, MRA in 95 of 97 and 66 of 67 patients. MRA and TCD collateral flow measurements via the anterior part of the circle of Willis yielded a sensitivity of 83 and 82%, a specificity of 77 and 79% and a similar accuracy of 80%. MRA and TCD collateral flow measurements via the posterior communicating artery yielded a sensitivity of 33 and 76%, a specificity of 88 and 47% and an accuracy of 47 and 68%. i Conclusion: /i As compared with iaDSA, combined MRA and TCD has a moderate to good diagnostic value for the examination of intracranial collateral flow in patients with symptomatic carotid occlusion.
Publisher: Elsevier BV
Date: 06-2017
DOI: 10.1016/J.JSTROKECEREBROVASDIS.2017.01.010
Abstract: Intracerebral hemorrhage (ICH) volume, particularly if ≥30 mL, is a major determinant of poor outcome. We used a multinational ICH data registry to study the characteristics, course, and outcomes of supratentorial hematomas with volumes <30 mL. Basic characteristics, clinical and radiological course, and 30-day outcomes of these patients were recorded. Outcomes were categorized as early neurological deterioration (END), hematoma expansion, Glasgow Outcome Scale (GOS), and in-hospital death. Poor outcome was defined as composite of in-hospital death and severe disability (GOS ≤ 3). Comparison was conducted based on hemorrhage location. Logistic regression using dichotomized outcome scales was applied to determine predictors of poor outcome. Among 375 cases of supratentorial ICH with volumes <30 mL, expansion and END rates were 19.2% and 7.5%, respectively. Hemorrhage growth was independently associated with END (odds ratio: 28.7, 95% confidence interval [CI]: 8.51-96.5 P < .0001). Expansion rates did not differ according to ICH location. Overall, 13.9% (exact binomial 95% CI: 10.5-17.8) died in the hospital and 29.1% (CI: 24.5-34.0) had severe disability at 30 days there was a cumulative poor outcome rate of 42.9% (CI: 37.9-48.1). Age, admission Glasgow Coma Scale, intraventricular extension, and END were independently associated with poor outcome. There was no difference in poor outcome rates between lobar and deep locations (40.2% versus 43.8%, P = .56). Patients with supratentorial ICH <30 mL have high rates of poor outcome at 30 days, regardless of location. Nearly 1 in 5 hematomas <30 mL expands, leading to END or death.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-08-2022
DOI: 10.1212/WNL.0000000000200808
Abstract: Guidelines recommend antithrombotic medication as secondary prevention for patients with ischemic stroke or transient ischemic attack (TIA) at young age based on results from trials in older patients. We investigated the long-term risk of bleeding and ischemic events in young patients after ischemic stroke or TIA. We included 30-day survivors of first-ever ischemic stroke or TIA aged 18–50 years from the Follow-Up of TIA and Stroke Patients and Unelucidated Risk Factor Evaluation (FUTURE) study, a prospective cohort study of stroke at young age. We obtained information on recurrent ischemia based on structured data collection from 1995 until 2014 as part of the FUTURE study follow-up, complemented with information on any bleeding and ischemic events by retrospective chart review from baseline until last medical consultation or June 2020. Primary outcome was any bleeding secondary outcome any ischemic event during follow-up. Both were stratified for sex, age, etiology, and use of antithrombotic medication at discharge. Bleeding and ischemic events were classified according to location and bleeding events also by severity. We included 544 patients (56.1% women, median age of 42.2 interquartile range [IQR] 36.5–46.7 years) with a median follow-up of 9.6 (IQR 2.5–14.3) years. Ten-year cumulative risk of any bleeding event was 21.8% (95% CI 17.4–26.0) and 33.9% (95% CI 28.3–37.5) of any ischemic event. Risk of bleeding was higher in women with a cumulative risk of 28.2% (95% CI 21.6–34.3) vs 13.7% (95% CI 8.2–18.9) in men ( p 0.01), mainly because of gynecologic bleeds. Female sex ( p 0.001) and age between 40 and 49 years ( p = 0.04) were independent predictors of bleeding. Young patients after ischemic stroke or TIA have a substantial long-term risk of both bleeding (especially women) and ischemic events. Future studies should investigate the effects of long-term antithrombotics in young patients, taking into account the risk of bleeding complications.
Publisher: Springer Science and Business Media LLC
Date: 24-01-2019
Publisher: Elsevier BV
Date: 02-2007
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-1997
Abstract: Background and Purpose Flow measurements in the collateral arteries of patients with internal carotid artery (ICA) occlusions may be important to estimate the risk of future stroke. Quantitative flow measurements in cerebropetal vessels can be reliably assessed by means of magnetic resonance angiography (MRA). Methods Fifty-four patients with transient or minor ischemic neurological deficits and an angiographically proven ICA occlusion and 16 control subjects underwent two-dimensional phase-contrast MRA quantitative flow measurements through the common carotid arteries, basilar artery, ICAs, and middle cerebral arteries (MCA). Results Patients with a unilateral ICA occlusion and a 0% to 69% stenosis of the contralateral ICA had increased flow in the contralateral ICA ( P .005) and in the basilar artery ( P .005) compared with control subjects. Even patients with a 70% to 99% stenosis contralateral to the ICA occlusion had increased flow in the ICA ( P .05) as well as increased flow in the basilar artery ( P .001). Total cerebropetal flow was not significantly different between these patients and control subjects. Patients with bilateral ICA occlusions had an increased flow in the basilar artery ( P .001), while the total cerebropetal flow was less than in control subjects ( P .001). In all patients, flow was decreased in the ipsilateral MCA ( P .001) and in the contralateral MCA ( P .05). Conclusions The contralateral ICA is the main supplying artery in patients with an ICA occlusion. Total cerebropetal flow decreases only when both ICAs are occluded. In patients with symptomatic ICA occlusions, an open contralateral ICA is probably important to retain the cerebral blood flow within normal limits.
Publisher: Korean Stroke Society
Date: 30-09-2018
Publisher: American Medical Association (AMA)
Date: 09-2003
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2004
Publisher: BMJ
Date: 08-06-2021
Abstract: To determine whether the presence of diffusion-weighted imaging-positive (DWI+) lesions is associated with recurrent stroke after intracerebral haemorrhage (ICH). The REstart or STop Antithrombotics Randomised Trial (RESTART) assessed the effect of restarting versus avoiding antiplatelet therapy after ICH on major vascular events for up to 5 years. We rated DWI sequences of MRI done before randomisation for DWI+ lesion presence, masked to outcome and antiplatelet use. Cox proportional hazards regression models were used to quantify associations. Of 537 participants in RESTART, 247 (median (IQR) age 75.7 (69.6-81.1) years 170 men (68.8%) 120 started vs 127 avoided antiplatelet therapy) had DWI sequences on brain MRI at a median of 57 days (IQR 19-103) after ICH, of whom 73 (30%) had one or more DWI+ lesion. During a median follow-up of 2 years (1-3), 18 participants had recurrent ICH and 21 had ischaemic stroke. DWI+ lesion presence was associated with all stroke, (adjusted HR 2.2 (95% CI 1.1 to 4.2)) and recurrent ICH (4.8 (95% CI 1.8 to 13.2)), but not ischaemic stroke (0.9 (95% CI 0.3 to 2.5)). DWI+ lesion presence (0.5 (95% CI 0.2 to 1.3)) vs absence (0.6 (95% CI 0.3 to 1.5), p DWI+ lesion presence in ICH survivors is associated with recurrent ICH, but not with ischaemic stroke. We found no evidence of modification of effects of antiplatelet therapy on recurrent stroke after ICH by DWI+ lesion presence. These findings provide a new perspective on the significance of DWI+ lesions, which may be markers of microvascular mechanisms associated with recurrent ICH. ISRCTN71907627.
Publisher: Radiological Society of North America (RSNA)
Date: 02-2007
DOI: 10.1148/RADIOL.2422060179
Abstract: To prospectively investigate the extent of flow territories of the contralateral internal carotid artery (ICA) and vertebrobasilar arteries in patients with symptomatic ICA occlusion. Ethics committee approval and informed consent were obtained. Flow territory mapping of the ICA contralateral to the occluded ICA and mapping of the vertebrobasilar arteries were performed by using selective arterial spin-labeling magnetic resonance imaging in 23 functionally independent patients (22 men, one woman mean age, 58 years +/- 8 [standard deviation]) with symptomatic ICA occlusion. The control group consisted of 68 subjects (57 men, 11 women mean age, 59 years +/- 9) without hemodynamically significant ICA obstruction. Voxel-based chi(2) testing with Bonferroni correction was performed to analyze significant differences in the extent of the flow territories. Flow territory maps in patients with symptomatic ICA occlusion showed significant differences in the flow territories of the contralateral ICA and vertebrobasilar arteries compared with those in control subjects (P < .05). In functionally independent patients with symptomatic ICA occlusion, the middle cerebral artery flow territory ipsilateral to the occluded ICA is mainly supplied by the vertebrobasilar arteries, whereas the anterior cerebral artery flow territory on the occluded side is mainly supplied by the contralateral ICA.
Publisher: Springer Science and Business Media LLC
Date: 10-2006
DOI: 10.1007/S00415-006-0192-1
Abstract: The aim of the present study was to assess the regional variation in cerebral perfusion, vasomotor reactivity (VMR) and the role of cerebral collaterals in patients with symptomatic internal carotid artery (ICA). Seventeen functionally independent patients (60+/-9 years, mean+/-SD) with a unilateral symptomatic internal carotid artery occlusion and a <30% contralateral ICA stenosis were investigated. (99 m) Tc-hexamethyl propyleneamine oxime (HMPAO) single photon emission computed tomography (SPECT) was performed to study cerebral blood flow in rest and during a CO(2) challenge in the cerebellum, temporal lobe, occipital lobe, basal ganglia, frontal lobe and parietal lobe. Time of flight and phase contrast MRA were used to study collateral flow via circle of Willis. In rest, cerebral perfusion on the side ipsilateral to the ICA occlusion was decreased compared with the contralateral side in the basal ganglia (p<0.05), frontal lobe (p<0.01) and parietal lobe (p<0.01). During a CO(2) challenge only the ipsilateral frontal lobe demonstrated a perfusion decrease compared with the contralateral frontal lobe (p<0.05). Furthermore, in patients without collateral flow via the anterior circle of Willis the perfusion of the ipsilateral frontal lobe was significantly decreased (p<0.01) during the CO(2) challenge and crossed cerebellar diaschisis with a decreased perfusion on the contralateral cerebellar hemisphere was detected (p<0.05). No cerebral blood flow (CBF) differences were found for present/absent collateral flow via the posterior communicating artery. Regional assessment of cerebral perfusion and VMR with SPECT demonstrated the heterogeneity of cerebral hemodynamics and the importance of collateral flow via the anterior circle of Willis.
Publisher: Public Library of Science (PLoS)
Date: 09-02-2016
Publisher: Frontiers Media SA
Date: 12-11-2018
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-12-2016
DOI: 10.1212/WNL.0000000000003489
Abstract: To investigate the association between blood pressure (BP) levels and risk of intracerebral hemorrhage (ICH) after ischemic stroke. We performed a post hoc analysis of data from the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial, a randomized clinical trial including 20,332 patients with recent noncardioembolic ischemic stroke. BP measurements were ided into predefined categories. We calculated incidence rates per BP category and performed multivariable Cox regression analysis with systolic blood pressure (SBP) and diastolic blood pressure (DBP) categories as time-dependent covariables. One hundred thirty-three ICHs occurred during 50,778 person-years of follow-up, resulting in an incidence rate of 2.6 per 1,000 person-years. The incidence rate of ICH increased with increasing SBP and DBP categories. Risk of ICH was significantly higher in patients with SBP ≥160 mm Hg (hazard ratio 2.27, 95% confidence interval 1.34–3.86) compared with those with SBP of 130– mm Hg and in patients with DBP ≥100 mm Hg (hazard ratio 3.08, 95% confidence interval 1.78–5.34) compared with those with DBP of 80– mm Hg. The association between SBP or DBP and ICH did not differ by ischemic stroke subtype ( p = 0.55 and 0.93). Among patients with recent noncardioembolic ischemic stroke, the risk of ICH is high. High SBP and DBP are associated with an increased risk of ICH. The association between BP and ICH is not dependent on ischemic stroke subtype.
Publisher: S. Karger AG
Date: 1998
DOI: 10.1159/000015845
Abstract: Since the completion of the international extracranial/intracranial (EC/IC) bypass study in 1985, no treatment of proven value has become available for patients with symptomatic carotid artery occlusion other than treatment with antithrombotic medication. However, in this trial the causal factors of cerebral ischaemia were not part of the inclusion criteria and also patients with single episodes only were included. We report successful Excimer laser-assisted high flow EC/IC bypass surgery in a patient with frequent transient ischaemic attacks associated with a low flow state of the cerebral circulation. In the 1.5 years after the operation the patient has never again experienced any symptoms of cerebral ischaemia. In addition there was improvement in cerebral blood flow, measured by magnetic resonance spectroscopy and hexamethylpropyleneamine oxime single photon emission computed tomography. Certain patients with occlusion of the internal carotid artery may benefit from EC/IC bypass surgery, in particular the Excimer laser-assisted high-flow bypass, that is, if recurrent (transient) ischaemic attacks are associated with compromised cerebral perfusion.
Publisher: S. Karger AG
Date: 2002
DOI: 10.1159/000063719
Abstract: i Background and Purpose: /i In patients with carotid artery occlusion (CAO), collateral flow may reduce the risk of ischemic stroke. Collateral flow via the ophthalmic artery (OphthA) and flow via leptomeningeal vessels have been considered secondary collaterals, which are recruited only if the primary collateral circulation via the circle of Willis is insufficient. The aim of this study was to investigate whether patients with symptomatic CAO who have secondary in addition to primary collaterals have a worse flow state of the brain than those without secondary collaterals, as measured by vascular reactivity testing. i Methods: /i We studied 70 patients with symptomatic CAO who were independent for their daily activities. In all patients, collateral circulation through the circle of Willis was present. Vascular reactivity, measured by means of transcranial Doppler sonography with carbogen inhalation, was compared between patients with and without secondary collaterals. i Results: /i CO sub /sub reactivity was lower in 64 patients with (mean ± standard deviation 8 ± 14%) than in 6 patients without secondary collaterals (33 ± 18%) resulting in a mean difference of 24% (95% confidence interval 12–37% p 0.01). i Conclusions: /i Patients with symptomatic CAO with collateral circulation through the OphthA or through leptomeningeal vessels in addition to collaterals via the circle of Willis have a worse hemodynamic status of the brain than those with Willisian collaterals only. Therefore the presence of these collaterals may indicate insufficiency of collateral blood flow via the circle of Willis.
Publisher: American Society of Neuroradiology (ASNR)
Date: 13-08-2008
DOI: 10.3174/AJNR.A1232
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-1997
DOI: 10.1161/01.STR.28.10.2084
Abstract: Background Over the last several years evidence has accumulated that in addition to embolism, a compromised cerebral blood flow may play an important role in causing transient ischemic attacks and ischemic stroke in patients with occlusion of the internal carotid artery. This evidence is found in both clinical features and ancillary investigations, particularly measurements of cerebral blood flow. Summary of Review On the basis of 20 follow-up studies in patients with transient ischemic attacks or minor ischemic stroke associated with an occluded carotid artery, the annual risk of stroke was 5.5% (95% confidence interval [CI], 5.0% to 6.0%), and that of ipsilateral stroke (distinguished in 11 of the 20 studies) was 2.1% (95% CI, 1.6% to 2.8%). Patients with a compromised cerebral blood flow as measured by positron emission tomography, single-photon emission CT, transcranial Doppler, or stable xenon CT (six studies) have an even higher annual risk of stroke (all strokes: 12.5% 95% CI, 8.9% to 17.6% ipsilateral stroke: 9.5% 95% CI, 6.4% to 14.0%). Conclusions Because a compromised cerebral blood flow may be an important causal factor in patients with symptomatic carotid artery occlusion, medical and surgical options for treatment are reviewed in this light.
Publisher: Springer Science and Business Media LLC
Date: 29-11-2012
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2004
Publisher: SAGE Publications
Date: 03-1996
DOI: 10.1097/00004647-199603000-00018
Abstract: Occlusion or severe stenosis, with a reduction in the diameter of more than 70% of the extracranial arteries may lead to hypoperfusion of the brain with an increased risk of cerebral infarction. The aim of this study was to investigate whether endarterectomy of stenosed internal carotid arteries leads to alterations in cerebral metabolism in regions in which no infarcts were visible with magnetic resonance imaging (MRI). We studied 10 healthy control subjects and 20 patients with transient or nondisabling cerebral ischemia with MRI and 1 H magnetic resonance spectroscopic imaging. All patients underwent carotid endarterectomy. Patients were examined 1 week before and 3–6 months after carotid endarterectomy. The N-acetyl aspartate (NAA)/choline ratio in the symptomatic hemisphere before endarterectomy (2.29 ± 0.42) was significantly ( p 0.001) lower than for control subjects (3.18 ± 0.32). In five of the patients lactate was detected preoperatively in regions that were not infarcted. The NAA/choline ratio in the symptomatic hemisphere of these five patients did not increase significantly after endarterectomy (1.99 ± 0.22 vs. 2.23 ± 0.48). The NAA/choline ratio in patients without lactate preoperatively increased significantly ( p 0.01) after endarterectomy to a normal level (from 2.39 ± 0.42 to 2.92 ± 0.52). These results indicate that the presence of cerebral lactate may predict whether the NAA/choline ratio increases after carotid endarterectomy.
Publisher: S. Karger AG
Date: 2016
DOI: 10.1159/000442298
Abstract: b i Background: /i /b The pathogenesis of moyamoya disease (MMD) is still unknown. The detection of inflammatory molecules such as cytokines, chemokines and growth factors in MMD patients' biological fluids supports the hypothesis that an abnormal angiogenesis is implicated in MMD pathogenesis. However, it is unclear whether these anomalies are the consequences of the disease or rather causal factors as well as these mechanisms remain insufficient to explain the pathophysiology of MMD. The presence of a family history in about 9-15% of Asian patients, the highly variable incidence rate between different ethnic and sex groups and the age of onset support the role of genetic factors in MMD pathogenesis. However, although some genetic loci have been associated with MMD, few of them have been replicated in independent series. Recently, i RNF213 /i gene was shown to be strongly associated with MMD occurrence with a founder effect in East Asian patients. However, the mechanisms leading from i RNF213 /i mutations to MMD clinical features are still unknown. b i Summary: /i /b The research on pathogenic mechanism of MMD is in its infancy. MMD is probably a complex and heterogeneous disorder, including different phenotypes and genotypes, in which more than a single factor is implicated. b i Key Message: /i /b Since the diagnosis of MMD is rapidly increasing worldwide, the development of more efficient stratifying risk systems, including both clinical but also biological drivers became imperative to improve our ability of predict prognosis and to develop mechanism-tailored interventions.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 26-12-2000
Abstract: To identify hemodynamic factors that predict recurrence of ipsilateral cerebral ischemic events in patients with symptomatic carotid artery occlusion (CAO). The authors studied 117 consecutive patients with CAO and corresponding recent (</=6 months) ischemic symptoms of the brain or eye that were transient or at most mildly disabling. They determined, using Cox proportional hazards analysis, the prognostic value for recurrence of ipsilateral cerebral ischemic events of 1) clinical features believed to indicate hemodynamic compromise, 2) collateral blood flow pattern, and 3) transcranial Doppler CO(2)-reactivity. None of the 24 patients with symptoms of retinal ischemia alone had a recurrent cerebral ischemic event. In the 93 patients with cerebral ischemic symptoms on entry, recurrence of these symptoms was independently predicted by 1) the nature of the initial symptoms being of purported hemodynamic origin (limb-shaking, precipitation of symptoms by rising, exercise or low blood pressure, retinal claudication) (hazard ratio [HR] 3.8, 95% CI 1.5 to 9.5), 2) continuing symptoms after the CAO had been documented, but before inclusion in the study (HR 5.9, 95% CI 2.2 to 16.1), and 3) the presence of collateral blood flow via leptomeningeal vessels (HR 4.1, 95% CI 1.3 to 13.1). CO(2)-reactivity did not predict recurrence of cerebral ischemic events. Having cerebral in contrast to retinal ischemia, clinical features suggestive of hemodynamic compromise, continuing symptoms after demonstration of the CAO, and presence of leptomeningeal collaterals may help to identify patients with symptomatic CAO at high risk of future cerebral ischemia.
Publisher: BMJ
Date: 08-03-2011
Abstract: Arterial spin labelling (ASL) is an MRI technique for measuring perfusion at the brain tissue level. The aim of the study was to investigate cerebrovascular reactivity (CVR) at brain-tissue level in patients with an internal carotid artery (ICA) occlusion by combining ASL-MRI with a vascular challenge, and determine whether the CVR varies within the perfusion territory of the brain-feeding arteries. Sixteen patients with a symptomatic ICA occlusion and 16 age-matched healthy control subjects underwent perfusion and perfusion-territory selective ASL-MRI before and after acetazolamide administration. CVR was assessed throughout the brain in the grey matter supplied by the unaffected asymptomatic ICA and the basilar artery. Cerebral blood flow increased (p<0.01) in all perfusion territories after acetazolamide in the patients and controls. In the tissue supplied by the unaffected contralateral ICA, CVR was lower in the tissue supplied by the unaffected contralateral ICA in the patients when compared with the controls (22.8 ± 16.1 vs 54.2 ± 13.1% mean difference, -31.5%, 95% CI -42.1 to -20.8). Within the perfusion territory of the unaffected ICA, the CVR was lower in the brain tissue on the side of the occluded ICA than on the side of the unaffected ICA (13.5 ± 20.4 vs 26.2 ± 16.0% paired mean difference -12.5%, 95% CI -20.3 to -4.7). ASL-MRI can assess impaired cerebrovascular reactivity at the brain-tissue level in patients with a symptomatic ICA occlusion. Assessment of CVR with ASL-MRI may help to identify the tissue most at risk for future stroke and as such may guide medical treatment.
Publisher: S. Karger AG
Date: 17-12-2013
DOI: 10.1159/000355889
Abstract: b i Background: /i /b Little is known about cerebral blood flow (CBF) in young patients with ischemic stroke caused by an intracranial arteriopathy. Arterial spin labeling (ASL) perfusion is a noninvasive technique for measuring CBF. We aimed to investigate whether, in young patients with unilateral intracranial arteriopathy and previous ischemic stroke, CBF is compromised in noninfarcted brain areas of the symptomatic hemisphere and whether this is related to the severity of the arteriopathy. b i Methods: /i /b Patients aged 5-50 years, with previous middle cerebral artery (MCA) territory infarction and a unilateral intracranial arteriopathy, underwent magnetic resonance imaging (MRI), MR angiography and pseudocontinuous ASL perfusion MRI. We assessed the severity of stenosis of arteries that fed the symptomatic MCA territory, quantified CBF in the noninfarcted cortex of both MCA territories and generated CBF maps for visual CBF interpretation. b i Results: /i /b A total of 17 patients were included (median age 29 years, range 5-49, 29% male). We found a similar median quantified CBF in the symptomatic and asymptomatic MCA territories (86 ml·100 g sup -1 /sup ·min sup -1 /sup ). CBF maps showed hypoperfusion in the symptomatic MCA territory in 59% of patients compared to 18% based on quantified CBF. Patients with a severe arteriopathy more often showed hypoperfusion on CBF maps than patients with a mild arteriopathy. In 53% of patients, small foci of increased signal intensity were visible on CBF maps around an area of hypoperfusion, indicating vascular artifacts. In these patients, we found large intrain idual variation in the quantified CBF in the symptomatic hemisphere. In 47% of patients, the visual interpretation of perfusion did not correspond with the quantified CBF. b i Conclusions: /i /b This study shows that more than half of young patients with previous ischemic stroke in the MCA territory and a unilateral intracranial arteriopathy have hypoperfusion in the noninfarcted cortex of the symptomatic hemisphere when CBF is visually assessed using a CBF map, in particular in patients with a severe arteriopathy. In the same patients, quantification of CBF shows hypoperfusion in the symptomatic hemisphere in only 18%. This discrepancy is caused by labeled blood within the arteries that has not yet reached the tissue at the time of imaging. Visual assessment can show hypoperfusion, while the quantified CBF in a similar region appears higher when the intravascular labeled blood is included in the region of interest. Further research should focus on elucidating whether cerebral perfusion deficits in young stroke patients with intracranial arteriopathy might help to identify patients who are at risk of poor outcome or stroke recurrence.
Publisher: American Medical Association (AMA)
Date: 02-2003
DOI: 10.1001/ARCHNEUR.60.2.229
Abstract: Ischemic lesions in patients with internal carotid artery (ICA) steno-occlusive disease can be categorized on the basis of their location and presumed cause: external border zone infarcts, internal border zone infarcts, cortical infarcts, lacunar infarcts, and periventricular lesions. To evaluate the association between the prevalence and size of ischemic lesions and cerebral vasomotor reactivity in patients with unilateral occlusion of the ICA. Cross-sectional study. Referral center. Seventy consecutive patients were included in this study. All patients had a transient or minor disabling retinal or cerebral ischemia that was associated with unilateral occlusion of the ICA. Ischemic lesions on magnetic resonance imaging were identified on hard copies, and volume measurements were obtained by a magnetic resonance workstation. Vasomotor reactivity was assessed with transcranial Doppler ultrasonography with carbon dioxide challenge. Prevalence and size of ischemic lesions. In the hemisphere ipsilateral to the ICA occlusion, we found an increased prevalence of internal border zone infarcts (P =.01), external borders zone infarcts (P<.001), and territorial infarcts (P =.02) compared with the contralateral hemisphere. Hemispheres with a carbon dioxide reactivity less than or equal to 18% demonstrated a significant increase in prevalence (P =.007) and volume (P =.003) of internal border zone infarcts compared with hemispheres with a carbon dioxide reactivity greater than or equal to 19%. No association between carbon dioxide reactivity and any other type of ischemic lesion was found. In patients with an ICA occlusion, only internal border zone infarcts demonstrate a significant association with diminished cerebral hemodynamics.
Publisher: Public Library of Science (PLoS)
Date: 03-10-2013
Publisher: BMJ
Date: 29-02-2012
Abstract: Moyamoya disease (MMD) is a rare cause of stroke, initially described in Japan. In other countries, incidences and presenting symptoms may differ from those in Japan. The literature on regional differences in incidence and patient characteristics of MMD was systematically reviewed. Medline, EMBASE and CINAHL were searched for population based studies on MMD published between January 1969 and January 2011. From studies that met predefined inclusion criteria, information was extracted on incidence and patient characteristics. Incidences with corresponding 95% CIs if possible were calculated and descriptive statistics for patient characteristics were used. 8 studies were included: three from Japan, one each from Taiwan and China and three from the USA. Incidences per 100 000 patient years ranged in Japan from 0.35 to 0.94 (95% CI 0.69 to 1.19), in the USA from 0.05 (-0.04 to 0.12) in Iowa to 0.17 (-0.06 to 0.40) in Hawaii and were 0.41 (0.28 to 0.54) in Nanjing, China and 0.02 (0.003 to 0.04) in Taiwan. Female to male ratio ranged from 1.1 (0.9 to 1.5) in Nanjing to 2.8 (1.2 to 6.1) in Iowa. Proportions with intracerebral haemorrhage as the initial presentation were 56% in China, 52% in Taiwan, 29% in Hawaii, 21% in Japan and 10% in Iowa. Patients with childhood onset presented most often with ischaemia (>75%) in all regions. MMD incidence was higher in Japan and China than in Taiwan and North America and presenting symptoms showed regional differences, which are thus far unexplained. Population based data on MMD in Europe are lacking.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 17-09-2019
DOI: 10.1212/WNL.0000000000008364
Abstract: To investigate the prevalence of asymptomatic diffusion-weighted imaging–positive (DWI+) lesions in in iduals with cerebral small vessel disease (SVD) and identify their role in the origin of SVD markers on MRI. We included 503 in iduals with SVD from the Radboud University Nijmegen Diffusion Tensor and Magnetic Resonance Imaging Cohort (RUN DMC) study (mean age 65.6 years [SD 8.8], 56.5% male) with 1.5T MRI in 2006 and, if available, follow-up MRI in 2011 and 2015. We screened DWI scans (n = 1,152) for DWI+ lesions, assessed lesion evolution on follow-up fluid-attenuated inversion recovery, T1 and T2* images, and examined the association between DWI+ lesions and annual SVD progression (white matter hyperintensities [WMH], lacunes, microbleeds). We found 50 DWI+ lesions in 39 in iduals on 1,152 DWI (3.4%). In iduals with DWI+ lesions were older ( p = 0.025), more frequently had a history of hypertension ( p = 0.021), and had a larger burden of preexisting SVD MRI markers (WMH, lacunes, microbleeds: all p 0.001) compared to in iduals without DWI+ lesions. Of the 23 DWI+ lesions with available follow-up MRI, 14 (61%) evolved into a WMH, 8 (35%) resulted in a cavity, and 1 (4%) was no longer visible. Presence of DWI+ lesions was significantly associated with annual WMH volume increase and yearly incidence of lacunes and microbleeds (all p 0.001). Over 3% of in iduals with SVD have DWI+ lesions. Although DWI+ lesions play a role in the progression of SVD, they may not fully explain progression of SVD markers on MRI, suggesting that other factors than acute ischemia are at play.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-09-2014
Publisher: BMJ
Date: 28-04-2015
DOI: 10.1136/PRACTNEUROL-2015-001104
Abstract: In patients who have intracerebral haemorrhage while on antithrombotic treatment, there is no evidence from randomised clinical trials to support decisions with regard to antithrombotic medication. In the acute phase, we advise stopping all antithrombotic treatment with rapid reversal of antithrombotic effects of oral anticoagulants. After the acute phase, we discourage restarting oral anticoagulants in patients with a lobar haematoma caused by cerebral amyloid angiopathy because of the high risk of recurrent bleeding. In these patients, even treatment with platelet inhibitors needs careful weighing of the risks of bleeding and ischaemic stroke. In patients with non-lobar intracerebral haemorrhage, we suggest considering restarting optimal antithrombotic treatment. This includes treatment with oral anticoagulants for patients with atrial fibrillation and/or mechanical valve prosthesis. After intracerebral haemorrhage during oral anticoagulant therapy in patients with atrial fibrillation, direct anticoagulants may be better than vitamin K antagonists, but we await confirmation of this from ongoing trials.
Publisher: SAGE Publications
Date: 05-2007
DOI: 10.1111/J.1747-4949.2007.00111.X
Abstract: Epidemiological studies suggest that raised plasma concentrations of total homocysteine (tHcy) may be a common, causal and treatable risk factor for atherothromboembolic ischaemic stroke, dementia and depression. Although tHcy can be lowered effectively with small doses of folic acid, vitamin B 12 and vitamin B 6 , it is not known whether lowering tHcy, by means of B vitamin therapy, can prevent stroke and other major atherothromboembolic vascular events. To determine whether the addition of B-vitamin supplements (folic acid 2 mg, B 6 25 mg, B 12 500 μg) to best medical and surgical management will reduce the combined incidence of stroke, myocardial infarction (MI) and vascular death in patients with recent stroke or transient ischaemic attack (TIA) of the brain or eye. A prospective, international, multicentre, randomised, double blind, placebo-controlled clinical trial. One hundred and four medical centres in 20 countries on five continents. Eight thousand (6600 recruited as of 5 January, 2006) patients with recent (7 months) stroke (ischaemic or haemorrhagic) or TIA (brain or eye). Randomisation and data collection are performed by means of a central telephone service or secure internet site. One tablet daily of either placebo or B vitamins (folic acid 2mg, B 6 25 mg, B 12 500 μg). The composite of stroke, MI or death from any vascular cause, whichever occurs first. Outcome and serious adverse events are adjudicated blinded to treatment allocation. TIA, unstable angina, revascularisation procedures, dementia, depression. With 8000 patients followed up for a median of 2 years and an annual incidence of the primary outcome of 8% among patients assigned placebo, the study will have at least 80% power to detect a relative reduction of 15% in the incidence of the primary outcome among patients assigned B vitamins (to 6·8%/year), applying a two-tailed level of significance of 5%. VITATOPS aims to recruit and follow-up 8000 patients between 1998 and 2008, and provide a reliable estimate of the safety and effectiveness of folic acid, vitamin B 12 , and vitamin B 6 supplementation in reducing recurrent serious vascular events among a wide range of patients with TIA and stroke throughout the world.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2010
DOI: 10.1161/STROKEAHA.109.572495
Abstract: Background and Purpose— It is not always clear whether, how, and when to undertake further radiological investigation of spontaneous (nontraumatic) intracerebral hemorrhage (ICH). Methods— We systematically reviewed Ovid MEDLINE and EMBASE databases for studies of the diagnostic utility of radiological investigations of the cause(s) of ICH. We sent a structured survey to neurologists, stroke specialists, neurosurgeons, and neuroradiologists in the United Kingdom, the Netherlands, and France to assess whether, how, and when they would investigate supratentorial ICH. Results— This systematic review detected 20 relevant studies (including 1933 patients), which either quantified the yield of a radiological investigation/imaging strategy (n=15) or compared 2 imaging techniques (n=5). Six hundred ninety-two (49%) physicians responded to the survey. Further investigation would have been undertaken by the following: 99% of respondents, for younger (38 to 43 years), normotensive adults with lobar or deep ICH 76%, for older (age 72 to 83 years), normotensive adults with deep ICH and 31%, for older adults with deep ICH and prestroke hypertension. Younger patient age was the strongest influence on the decision to further investigate ICH (odds ratio=16 95% confidence interval, 13 to 20), followed by the absence of prestroke hypertension (odds ratio=5 95% confidence interval, 4 to 6) and lobar ICH location (odds ratio=2 95% confidence interval, 1 to 2). Conclusions— The paucity of studies on the diagnostic utility of imaging investigations of the cause(s) of ICH may contribute to the variation observed in when and how and which patients are investigated in current clinical practice. Studies comparing different types of diagnostic strategies are required.
Publisher: Wiley
Date: 23-02-2020
DOI: 10.1111/ANS.15756
Publisher: Informa UK Limited
Date: 27-10-2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2023
DOI: 10.1161/STROKEAHA.122.040524
Abstract: Identification of risk factors and causes of stroke is key to optimize treatment and prevent recurrence. Up to one-third of young patients with stroke have a cryptogenic stroke according to current classification systems (Trial of ORG 10172 in Acute Stroke Treatment [TOAST] and atherosclerosis, small vessel disease, cardiac pathology, other causes, dissection [ASCOD]). The aim was to identify risk factors and leads for (new) causes of cryptogenic ischemic stroke in young adults, using the pediatric classification system from the IPSS study (International Pediatric Stroke Study). This is a multicenter prospective cohort study conducted in 17 hospitals in the Netherlands, consisting of 1322 patients aged 18 to 49 years with first-ever, imaging confirmed, ischemic stroke between 2013 and 2021. The main outcome was distribution of risk factors according to IPSS classification in patients with cryptogenic and noncryptogenic stroke according to the TOAST and ASCOD classification. The median age was 44.2 years, and 697 (52.7%) were men. Of these 1322 patients, 333 (25.2%) had a cryptogenic stroke according to the TOAST classification. Additional classification using the ASCOD criteria reduced the number patients with cryptogenic stroke from 333 to 260 (19.7%). When risk factors according to the IPSS were taken into account, the number of patients with no potential cause or risk factor for stroke reduced to 10 (0.8%). Among young adults aged 18 to 49 years with a cryptogenic ischemic stroke according to the TOAST classification, risk factors for stroke are highly prevalent. Using a pediatric classification system provides new leads for the possible causes in cryptogenic stroke, and could potentially lead to more tailored treatment for young in iduals with stroke.
Publisher: Elsevier BV
Date: 06-2012
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2012
DOI: 10.1161/STROKEAHA.112.653212
Abstract: Unilateral intracranial focal nonprogressive arteriopathy is often found in children with arterial ischemic stroke. We aimed to investigate the course of unilateral intracranial arteriopathy in young adults. We searched the Utrecht Stroke Database for patients between 16 and 50 years of age diagnosed with anterior circulation arterial ischemic stroke and a nonatherosclerotic, unilateral intracranial large-artery arteriopathy between 1991 and 2005. We assessed clinical features, potential causes, risk factors, extent of infarction and arteriopathy at presentation, long-term angiographic course, and clinical outcome. Of 356 patients with anterior circulation arterial ischemic stroke, 17 (5%) had a documented unilateral intracranial arteriopathy, of whom 14 could be included for follow-up investigations (median age, 34 years range, 27–49 years). Median duration of follow-up was 8.8 years (range, 1.7–12.8 years). In 11 patients, onset of symptoms was not abrupt. The arteriopathy normalized completely in 5 and improved in 3 patients in none of the patients did the arteriopathy worsen. Two of 14 patients had recurrent symptoms. Ten patients (71%) had a good outcome (modified Rankin Scale score ≤2). In young adults, arterial ischemic stroke is rarely caused by a unilateral intracranial arteriopathy. Similar to children, onset of symptoms in young adults is often not abrupt and the arteriopathy may improve over time. Late recurrences were rare. Possibly, a monophasic inflammatory process, as has been suggested for childhood intracranial focal nonprogressive arteriopathies, also occurs in young adults.
Publisher: Springer Science and Business Media LLC
Date: 16-11-2020
Publisher: BMJ
Date: 30-09-2010
Abstract: Information on outcome of patients with occlusion of the internal carotid artery (ICA) is limited by the short duration of follow-up and lack of haemodynamic studies on the brain. The authors prospectively investigated 117 consecutive patients with transient or moderately disabling cerebral or retinal ischaemia associated with ICA occlusion between September 1995 and July 1998, and followed them until June 2008. The authors determined the risk of recurrent ischaemic stroke and other vascular events and prognostic factors, including collateral pathways and transcranial Doppler CO(2) reactivity. Patients (mean age 61± 9 years 80% male) were followed for a median time of 10.2 years 22 patients underwent endarterectomy for contralateral ICA stenosis and 16 extracranial/intracranial bypass surgery. Recurrent ischaemic stroke occurred in 23 patients, resulting in an annual rate of 2.4% (95% CI 1.5 to 3.6). Risk factors for recurrent ischaemic stroke were age (HR 1.07, 1.02 to 1.13), cerebral rather than retinal symptoms (HR 8.0, 1.1 to 60), recurrent symptoms after documented occlusion (HR 4.4, 1.6 to 12), limb-shaking transient ischaemic attacks at presentation (HR 7.5, 2.6 to 22), history of stroke (HR 2.8, 1.2 to 6.7) and leptomeningeal collaterals (HR 5.2, 1.5 to 17) but not CO(2) reactivity (HR 1.01, 0.99 to 1.02). The composite event of any vascular event occurred in 57 patients, resulting in an annual rate of 6.4% (95% CI 4.9 to 8.2). The prognosis of patients with transient ischaemic attack or minor stroke and ICA occlusion depends on age, several clinical factors and the presence of leptomeningeal collaterals. The long-term risk of recurrent ischaemic stroke is much lower than that of other vascular events.
Publisher: Wiley
Date: 30-04-2020
DOI: 10.1002/ANA.25732
Abstract: The effect of surgical treatment for supratentorial spontaneous intracerebral hemorrhage (ICH) and whether it is modified by key baseline characteristics and timing remains uncertain. We performed a systematic review and meta‐analysis of randomized controlled trials of surgical treatment of supratentorial spontaneous ICH aimed at clot removal. We searched MEDLINE, Embase, and Cochrane databases up to February 21, 2019. Primary outcome was good functional outcome at follow‐up secondary outcomes were death and serious adverse events. We analyzed all types of surgery combined and minimally invasive approaches separately. We pooled risk ratios with 95% confidence intervals and assessed the modifying effect of age, Glasgow Coma Scale, hematoma volume, and timing of surgery with meta‐regression analysis. We included 21 studies with 4,145 patients 4 (19%) were of the highest quality. Risk ratio of good functional outcome after any type of surgery was 1.40 (95% confidence interval [CI] = 1.22–1.60, I 2 = 46%, 20 studies), and after minimally invasive surgery it was 1.47 (95% CI = 1.26–1.72, I 2 = 47%, 12 studies). For death, the risk ratio for any type of surgery was 0.77 (95% CI = 0.68–0.85, I 2 = 23%, 21 studies), and for minimally invasive surgery it was 0.68 (95% CI = 0.56–0.83, I 2 = 14%, 13 studies). Serious adverse events were reported infrequently. Surgery seemed more effective when performed sooner after symptom onset ( p = 0.04, 12 studies). Age, Glasgow Coma Scale, and hematoma volume did not modify the effect of surgery. Surgical treatment of supratentorial spontaneous ICH may be beneficial, in particular with minimally invasive procedures and when performed soon after symptom onset. Further well‐designed randomized trials are needed to demonstrate whether (minimally invasive) surgery improves functional outcome after ICH and to determine the optimal time window of the treatment after symptom onset. ANN NEUROL 2020 :239–250.
Publisher: Springer Science and Business Media LLC
Date: 02-10-2000
Abstract: We present a systematic review of the literature on the prevalence, nature, severity, course, and causes of cognitive deficits in patients with occlusive disease of the carotid artery prior to surgery (if surgery was under discussion). Searches were carried out on Medline and Psychlit from 1980 to 1999 using neurovascular and psychological index terms, and papers and books were checked for further references. Studies describing neuropsychological assessment of groups of patients with carotid obstruction were included. Eighteen studies were found. We extracted from the papers data on study design, demographic characteristics of patients, clinical diagnosis, carotid obstruction, cerebral imaging, time interval between ischemic episode and neuropsychological assessment, neuropsychological assessment procedures, integration and interpretation of test performances, and conclusions of authors. Fourteen studies concluded that there are cognitive deficits both in patients with symptomatic and in those with asymptomatic carotid obstruction four studies denied cognitive impairment. There were no differences in patient characteristics, study design, or neuropsychological assessment procedures between the 14 studies that found deficits and the 4 that did not. There are indications for a mild, diffuse detrimental effect of carotid occlusive disease on cognitive functioning. However, methodological problems prevent a definitive conclusion. Further research is needed to confirm these findings and to ascertain the neurovascular risk factors for and the natural course of cognitive impairment in patients with carotid occlusive disease.
Publisher: F1000 Research Ltd
Date: 12-06-2023
DOI: 10.12688/WELLCOMEOPENRES.19187.1
Abstract: Background : Currently, there are no specific medical treatments for intracerebral haemorrhage (ICH), but the inflammatory response may provide a potential route to treatment. Given the known effects of acute brain injury on peripheral immunity, we hypothesised that inflammatory biomarkers in peripheral blood may be associated with clinical outcome following ICH, as well as perihaematomal oedema (PHO), which is an imaging marker of the neuroinflammatory response. Methods : We searched OVID Medline and EMBASE on 07 April 2021 for studies of humans with ICH measuring an inflammatory biomarker in peripheral blood and PHO or clinical outcome. Risk of bias was assessed using a scale comprising features of the Newcastle-Ottawa Assessment Scale, STROBE-ME and REMARK guidelines. We used random effects meta-analysis to pool standardised mean differences (SMD) if ≥1 study quantified the association between identical biomarkers and measures of PHO or functional outcome. Results : Of 8,615 publications, 16 examined associations between 21 inflammatory biomarkers and PHO (n=1,299 participants), and 93 studies examined associations between ≥1 biomarker and clinical outcome (n=17,702 participants). Overall, 20 studies of nine biomarkers (n=3,199) met criteria for meta-analysis of associations between inflammatory biomarkers and clinical outcome. Death or dependency (modified Rankin Scale (mRS) 3–6) 90 days after ICH was associated with higher levels of C-reactive protein (CRP) (SMD 0.80 95%CI [0.44, 1.17] p .0001), fibrinogen (SMD 0.32 95%CI [0.04, 0.61] p=0.025), white blood cell (WBC) count (SMD 0.27 95%CI [0.11, 0.44] p=0.001) and high mobility group box protein 1 (HMGB1) (SMD 1.67 95%CI [0.05, 3.30] p=0.04). Conclusions : Higher circulating levels of WBC, CRP, fibrinogen and HMGB1 are associated with poorer outcomes after ICH. This study highlights the clinical importance of the inflammatory response to ICH and identifies additional research needs in determining if these associations are mediated via PHO and are potential therapeutic targets. Registration: PROSPERO ( CRD42019132628 28/05/2019).
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-02-2016
Publisher: Wiley
Date: 11-05-2023
DOI: 10.1002/ANA.26666
Publisher: SAGE Publications
Date: 09-07-2016
Abstract: Randomized controlled trials are the most unbiased way to evaluate many types of healthcare interventions. Pharmaceutical and medical technology industries play an important role in developing and testing new interventions that have commercial potential. However, many interventions for the prevention, treatment and rehabilitation of stroke are either not drugs or devices or have no commercial potential. Like many other clinicians who are uncertain about the value of existing or new treatments, we are involved in investigator-led clinical trials to resolve treatment uncertainties. There is common agreement that investigator-led clinical trials are facing increasing difficulties and that as a result clinicians may be deterred from pursuing clinical trials as a research career. In this article, we express our concerns for the future of such trials, balanced with the hope that systems to foster and sustain this important type of research in the future can be developed.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2023
DOI: 10.1161/STROKEAHA.122.041690
Abstract: Prion-like transmission of amyloid-ß through cadaveric dura, decades after neurosurgical procedures, has been hypothesized as an iatrogenic cause of cerebral amyloid angiopathy (CAA). We investigated new and previously described patients to assess the clinical profile, radiological features, and outcome of this presumed iatrogenic CAA-subtype (iCAA). Patients were collected from our prospective lobar hemorrhage and CAA database (n=251) with patients presenting to our hospital between 2008 and 2022. In addition, we identified patients with iCAA from 2 other Dutch CAA-expertise hospitals and performed a systematic literature-search for previously described patients. We classified patients according to the previously proposed diagnostic criteria for iCAA, assessed clinical and radiological disease features, and calculated intracerebral hemorrhage (ICH)-recurrence rates. We evaluated the spatial colocalization of cadaveric dura placement and CAA-associated magnetic resonance imaging markers. We included 49 patients (74% men, mean age 43 years [range, 27–84]) 15 from our database (6% [95% CI, 3%–10%] 45% of patients years), 3 from the 2 other CAA-expertise hospitals, and 31 from the literature. We classified 43% (n=21 1 newly identified patient) as probable and 57% (n=28) as possible iCAA. Patients presented with lobar ICH (57%), transient focal neurological episodes (12%), or seizures (8%). ICH-recurrence rate in the new patients (16/100 person-years [95% CI, 7–32], median follow-up 18 months) was lower than in the previously described patients (77/100 person-years [95% CI, 59–99], median follow-up 18 months). One patient had a 10 year interlude without ICH-recurrence. We identified no clear spatial relationship between dura placement and CAA-associated magnetic resonance imaging markers. During follow-up (median, 18 months), 20% of the patients developed transient focal neurological episodes and 20% cognitively declined. iCAA seems common in patients presenting with nonhereditary CAA under the age of 55. Clinical and radiological features are comparable with sCAA. After diagnosis, multiple ICH-recurrences but also long symptom-free intervals can occur. Harmonized registries are necessary to identify and understand this potentially underrecognized CAA-subtype.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2014
DOI: 10.1161/STROKEAHA.114.006462
Abstract: Data on the incidence of stroke subtypes among ethnic minority groups are limited. We assessed ethnic differences in the incidence of stroke subtypes in the Netherlands. A Dutch nationwide register–based cohort study (n=7 423 174) was conducted between 1998 and 2010. We studied the following stroke subtypes: ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Cox proportional hazard models were used to estimate incidence differences between first-generation ethnic minorities and the Dutch majority population (ethnic Dutch). Compared with ethnic Dutch, Surinamese men and women had higher incidence rates of all stroke subtypes combined (adjusted hazard ratios, 1.43 95% confidence interval, 1.35–1.50 and 1.34 1.28–1.41), ischemic stroke (1.68 1.57–1.81 and 1.57 1.46–1.68), intracerebral hemorrhage (2.08 1.82–2.39 and 1.74 1.50–2.00), and subarachnoid hemorrhage (1.25 0.92–1.69 and 1.26 1.04–1.54). By contrast, Moroccan men and women had lower incidence rates of all stroke subtypes combined (0.42 0.36–0.48 and 0.37 0.30–0.46), ischemic stroke (0.35 0.27–0.45 and 0.34 0.24–0.49), intracerebral hemorrhage (0.61 0.41–0.92 and 0.32 0.16–0.72), and subarachnoid hemorrhage (0.42 0.20–0.88 and 0.34 0.17–0.68) compared with ethnic Dutch counterparts. The results varied by stroke subtype and sex for the other minority groups. For ex le, Turkish women had a reduced incidence of subarachnoid hemorrhage, whereas Turkish men had an increased incidence of ischemic stroke and intracerebral hemorrhage compared with ethnic Dutch. Our findings suggest that Surinamese have an increased risk, whereas Moroccans have a reduced risk for all the various stroke subtypes. Among other ethnic minorities, the risk seems to depend on the stroke subtype and sex. These findings underscore the need to identify the root causes of these ethnic differences to assist primary and secondary prevention efforts.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2001
Abstract: Background and Purpose —We sought to investigate whether in patients with a symptomatic internal carotid artery (ICA) occlusion, endarterectomy of a severe stenosis of the contralateral carotid artery can establish long-term cerebral hemodynamic improvement. Methods —Nineteen patients were studied on average 1 month before and 6 months after contralateral carotid endarterectomy (CEA). Volume flow in the main extracranial and intracranial arteries was measured with MR angiography. Collateral flow via the circle of Willis and the ophthalmic arteries was studied with MR angiography and transcranial Doppler sonography, respectively. Cerebral metabolism and CO 2 vasoreactivity were investigated with MR spectroscopy and transcranial Doppler sonography, respectively. Twelve nonoperated patients with a symptomatic ICA occlusion and contralateral ICA stenosis, who were matched for age and sex, served as control patients. Results —In patients who underwent surgery, flow in the operated ICA increased significantly ( P .05) and flow in the basilar artery decreased significantly ( P .01) after CEA. On the occlusion side, mean flow in the middle cerebral artery increased significantly from 71 to 85 mL/min ( P .05) after CEA. The prevalence of collateral flow via the anterior communicating artery to the occlusion side increased significantly (47% before and 84% after CEA P .05), while the prevalence of reversed ophthalmic artery flow on the operation side decreased significantly (42% before and 5% after CEA P .05). In the hemisphere on the side of the ICA occlusion, lactate was no longer detected after CEA in 80% of operated patients, whereas it was no longer detected over time in 14% of nonoperated patients ( P .05). CO 2 reactivity increased significantly in operated patients in both hemispheres ( P .01). Conclusions —Contralateral CEA in patients with a symptomatic ICA occlusion induces cerebral hemodynamic improvement not only on the side of surgery but also on the side of the ICA occlusion.
Publisher: S. Karger AG
Date: 17-12-2013
DOI: 10.1159/000356349
Abstract: b i Background: /i /b Patients with transient ischaemic attacks (TIAs) or minor disabling ischaemic stroke associated with an internal carotid artery (ICA) occlusion have a high risk of recurrent stroke in case of compromised cerebral blood flow. Recent studies showed that increased oxygen extraction fraction measured by positron emission tomography (PET) is still an independent predictor of subsequent stroke under current medical treatment, but PET facilities are not widely available. Transcranial Doppler (TCD) ultrasonography CO sub /sub reactivity is a cheap and non-invasive alternative to measure haemodynamic compromise. The aim of our study was to investigate whether TCD CO sub /sub reactivity is an independent predictor of recurrent ischaemic stroke in a large cohort of patients with symptomatic ICA occlusion in a time where rigorous control of vascular risk factors has been widely implemented in clinical practice. b i Methods: /i /b Between July 1995 and December 2009, we included consecutive patients with TIAs or minor disabling ischaemic stroke (modified Rankin Scale ≤3) associated with ICA occlusion who were referred to the University Medical Centre Utrecht, The Netherlands. All patients were treated with antiplatelet therapy and received rigorous control of vascular risk factors, including statins, treatment for diabetes and hypertension and lifestyle advices. CO sub /sub reactivity was measured with TCD within 3 months after presentation. We determined the predictive value of TCD CO sub /sub reactivity for recurrent ischaemic stroke using Cox proportional hazard analysis. b i Results: /i /b We included 201 patients with a median follow-up time of 7.1 years. Mean CO sub /sub reactivity was 15% (±20 standard deviation). The annual rate for ipsilateral ischaemic stroke was 2.2% [95% confidence interval (CI) 1.4-3.2] and for any recurrent stroke 3.2% (95% CI 2.3-4.4). We did not find a significant relationship between CO sub /sub reactivity and the risk of ipsilateral [hazard ratio (HR) for every increase in percentage point 1.01, 95% CI 0.99-1.02] or any recurrent ischaemic stroke (HR 1.01, 95% CI 0.998-1.02). Multivariable analysis showed a significant relationship with history of stroke (HR 4.0, 95% CI 1.8-9.0) for ipsilateral recurrent stroke, and age (HR for increase per year 1.05, 95% CI 1.01-1.09) and a history of stroke (HR 3.4, 95% CI 1.7-6.6) for any recurrent stroke. b i Conclusions: /i /b In patients with TIAs or non-disabling stroke associated with occlusion of the carotid artery, the long-term annual risk of stroke is generally low with careful control of vascular risk factors. Impaired CO sub /sub reactivity measured within 3 months after presentation does not identify the subgroup of patients at high risk of recurrent ischaemic stroke.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2018
DOI: 10.1161/STROKEAHA.118.021160
Abstract: Hypertension is an important risk factor for cerebral small vessel disease. We aimed to study the effect of antihypertensive medication (AHM) on the progression of cerebral small vessel disease. We performed a systematic literature search of electronic databases up to January 30, 2017, for randomized controlled trials on the effect of AHM on ≥1 cerebral small vessel disease magnetic resonance imaging markers (ie, white matter hyperintensities, lacunes, microbleeds, enlarged perivascular spaces, acute small subcortical infarcts, and brain atrophy) after ≥1 year. We performed a random-effects meta-analysis using standardized mean difference. We included 4 trials, including patients with stroke, with diabetes mellitus, and people ≥70 years of age. Patients in the AHM group had less progression of white matter hyperintensity during 28 to 47 months (standardized mean difference, −0.19 95% confidence interval, −0.32 to −0.06 I 2 =20% n=1369). Two trials reported on progression of brain atrophy with conflicting results. None of the trials reported on other cerebral small vessel disease markers. AHM has a protective effect on the progression of white matter hyperintensities, but no effect on brain atrophy. There are no trials on the effect of AHM on lacunes, microbleeds, enlarged perivascular spaces, or acute small subcortical infarcts.
Publisher: Springer Science and Business Media LLC
Date: 10-04-2010
No related grants have been discovered for C.J.M. Klijn.