Microbleed Status and 3-Month Outcome After Intravenous Thrombolysis in 717 Patients With Acute Ischemic Stroke

Turc, Guillaume; Sallem, Asmaa; Moulin, Solène; Tisserand, Marie; Machet, A.; Edjlali, Myriam; Baron, Jean‐Claude; Leclerc, Xavier; Leys, Didier; Mas, Jean‐Louis; Cordonnier, Charlotte; Oppenheim, Catherine

doi:10.1161/strokeaha.115.009290

Cited by 50 publications

(35 citation statements)

References 31 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…8,17,[24][25][26][27] Individual patient data were not available from the BRASIL (Bleeding Risk Analysis in Stroke Imaging Before Thrombolysis) multicenter study (n=570) 28,29 with similar quality and characteristics to studies included. 7 We excluded 1 study of mainly intravenous and intra-arterial treatments.…”

Section: Resultsmentioning

confidence: 99%

Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Stroke Thrombolysis

Charidimou

Turc

Oppenheim

et al. 2017

Stroke

Self Cite

115

View full text Add to dashboard Cite

Background and Purpose-We assessed whether the presence, number, and distribution of cerebral microbleeds (CMBs) on pre-intravenous thrombolysis MRI scans of acute ischemic stroke patients are associated with an increased risk of intracerebral hemorrhage (ICH) or poor functional outcome. Methods-We performed an individual patient data meta-analysis, including prospective and retrospective studies of acute ischemic stroke treated with intravenous tissue-type plasminogen activator. Using multilevel mixed-effects logistic regression, we investigated associations of pre-treatment CMB presence, burden (1, 2-4, ≥5, and >10), and presumed pathogenesis (cerebral amyloid angiopathy defined as strictly lobar CMBs and noncerebral amyloid angiopathy) with symptomatic ICH, parenchymal hematoma (within [parenchymal hemorrhage, PH] and remote from the ischemic area [remote parenchymal hemorrhage, PHr]), and poor 3-to 6-month functional outcome (modified Rankin score >2). We performed a large-scale pooled individual patient data meta-analysis of quality observational studies to test the following hypotheses: (1) there is a relationship between increasing CMB burden and ICH risk 8,9 ; (2) strictly lobar CMBs (reflecting possible or probable cerebral amyloid angiopathy [CAA]) and mixed or strictly deep CMBs (likely associated with hypertensive arteriopathy) have different effects on ICH risk; (3) CMBs are associated more strongly with the risk of remote ICH than other ICH types 10 ; and (4) CMBs are associated with worse functional outcome. Results-In Methods Study Design and Inclusion CriteriaWe identified prospective or retrospective studies that assessed pretreatment MRI-defined CMBs, ICH, and 3-to 6-month functional outcome after acute ischemic stroke, treated solely with intravenous tPA from a systematic review prepared according to Preferred Reporting Items for Systematic Review and Meta-Analyses 7,11 (updated August 1, 2015). We searched PubMed for micro(-)bleed*, or micro(-)h(a) emorrhag*, or gradient-echo, or susceptibility-weighted in association with thromboly* or tPA, or tissue plasminogen activator 7 ; reference lists; and authors' own files. Figure I in the online-only Data Supplement shows a flow diagram.We collected anonymized individual patient detailed clinical data and CMB counts in lobar, deep, and infratentorial regions according to standardized definitions 6,12,13 using standardized report forms. A prespecified protocol was circulated to collaborators but not published. OutcomesWe defined ICH according to ECASS-2 (European Cooperative Acute Stroke Study II), 14,15 including hemorrhagic infarction, parenchymal hemorrhage (PH), and sICH 16 (acute intracerebral blood and associated increase in National Institutes of Health Stroke Scale ≥4 points, except 1 study 17 that used the definition in the PROACT-II trial [Prolyse in Acute Cerebral Thromboembolism]).18 Remote parenchymal hemorrhage (PHr) was defined as ICH remote from the symptomatic ischemic area. 10 We defined poor outcome at 3 to 6 months as modified...

show abstract

Section: Resultsmentioning

confidence: 99%

Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Stroke Thrombolysis

Charidimou

Turc

Oppenheim

et al. 2017

Stroke

Self Cite

115

View full text Add to dashboard Cite

show abstract

“…Finally, another metaanalysis showed that bleeding risk rises 1.9 times per CMH (47). However, it was shown that the risk did not rise in relation with the number of CMHs in some studies (42).…”

Section: Question: Can IV Tpa Be Administered To Patients With Cerebrmentioning

confidence: 91%

“…Balancing potential risks and benefits is required, but there is no measurement that can be used for this. CMH is found in 15-35% of patients in whom IV tPA will be administered, which means it is not rare (42). Having CMH causes 2.5 times more symptomatic intracerebral hemorrhage risk following IV tPA (43).…”

Section: Question: Can IV Tpa Be Administered To Patients With Cerebrmentioning

confidence: 99%

“…Although CMH causes a mild increase in bleeding rates, to make general and clear decisions, the efficacy of IV tPA in patients with CMH should be evaluated in randomized and controlled studies. There is an important point: the presence of CMH decreases the rate of good outcomes in patients both with and without bleeding following IV tPA (42,44,45). This could be related with small vessel dysfunction and insufficient control of risk factors.…”

Section: Question: Can IV Tpa Be Administered To Patients With Cerebrmentioning

confidence: 99%

See 1 more Smart Citation

Intravenous Thrombolytic Therapy in Acute Stroke: Problems and Solutions

Topçuoğlu¹,

Arsava²,

Özdemi̇r³

et al. 2017

tnd

View full text Add to dashboard Cite

162Use of intravenous tissue plasminogen activator (tPA) is one of the key elements of acute ischemic stroke management. Its use has not become widespread, and has faced significant problems in our country for more than a quarter of a century most probably due to many unanswered questions about issues related with daily practice. However, recent developments, which adequately focused and found solutions for most of these problems and questions, have led to a major change of point of view and understanding of the hyperacute management of stroke. This article, in the light of the relevant literature, discusses and provides clear recommendations for questions directed by neurologists practicing in Turkey mainly about typical neurologic issues faced in the setting of tPA use for acute stroke.Keywords: Stroke, thrombectomy, contraindication, avoidance, training Akut iskemik inme tedavisinin kritik elementlerinin başında gelen intravenöz doku plazminojen aktivatörü (tPA) kullanımının yirmi yılı aşkın süre içinde ülkemizde yeterince yaygınlaşamamasının başta gelen nedenlerinden biri, kullanımına dair birçok sorunun yanıtsız kalmasıdır. Ancak, son gelişmeler ile bu soruların pek çoğuna yeterli açıklamanın getirilebilmiş olması önemli bir anlayış değişikliğine yol açmaktadır. Bu makalede akut inmede tPA tedavisi ile ilgili uzmanlarımızın yönelttiği birincil olarak nörolojik sorulara ilişkin yanıt ve açıklamalar mevcut literatür ışığında etraflıca ele alınmış ve herbiri için net tavsiyelerde bulunulmuştur.Anahtar Kelimeler: Strok, trombektomi, kontrendikasyon, kaçınma, eğitim Abstract Öz

show abstract

“…Cerebral microbleeds 44 and small-vessel disease 45 are also markers of increased risks for haemorrhagic transformation. However other studies have shown that this effect is modest and should not prevent the administration of rt-PA 46 . Theoretically, patients with pre-stroke cognitive impairment may have a higher sensitivity to the toxic effect of rt-PA and a lower capacity to recover from brain injury 47 .…”

Section: Intravenous Recombinant Tissue Plasminogen Activator (Rt-pa)mentioning

confidence: 94%

Stroke occurring in patients with cognitive impairment or dementia

Moulin

Leys

2017

Arq. Neuro-Psiquiatr.

Self Cite

View full text Add to dashboard Cite

Stroke survivors are at risk for (i) new vascular events such as recurrent stroke 1 , myocardial infarction 2 or vascular death 3 ; (ii) complications of treatments 4 ; and (iii) delayed neurological complications, such as epileptic seizures 5,6 , cognitive impairment 7,8 , depression 9 , and pain 10 . Cognitive impairment is one of the major causes of dependency after stroke 7,8 .It is quite frequent that cognitive impairment, or even dementia, was already present before the stroke 7,8 . Stroke and cognitive impairment are both common, occur in the same age category, and share similar risk factors 11 . Moreover, stroke lesions can lead to cognitive impairment, alone or in association with Alzheimer pathology 11 . Most studies on the relationship between stroke and cognitive impairment have focused on cognitive impairment occurring after stroke, or on patients with cognitive impairment who have "apparently silent" brain lesions of vascular origin. However, although one patient in six admitted for a stroke was already demented before the stroke 7,12,13,14 , and probably many more were cognitively impaired, little is known about the characteristics of stroke occurring in patients with pre-existing cognitive decline, and about the optimal management of stroke in these patients. ABSTRACTOne in six patients admitted for stroke was previously demented. These patients have less access to appropriate stroke care, although little is known about their optimal management. Objective: To determine how pre-stroke cognitive impairment can be detected, its mechanism, and influence on outcome and management. Methods: Literature search. Results: (i) A systematic approach with the Informant Questionnaire of Cognitive Decline in the Elderly is recommended; (ii) Pre-stroke cognitive impairment may be due to brain lesions of vascular, degenerative, or mixed origin; (iii) Patients with pre-stroke dementia, have worse outcomes, more seizures, delirium, and depression, and higher mortality rates; they often need to be institutionalised after their stroke; (iv) Although the safety profile of treatment is not as good as that of cognitively normal patients, the risk:benefit ratio is in favour of treating these patients like others. Conclusion: Patients with cognitive impairment who develop a stroke have worse outcomes, but should be treated like others.Keywords: stroke; cerebral infarction; cerebral hemorrhage; dementia; mild cognitive impairment. RESUMOUm em cada seis pacientes internados em decorrência de acidente vascular cerebral (AVC) apresenta diagnóstico prévio de demência. Estes indivíduos têm menor acesso à assistência recomendada para pacientes com AVC, mas pouco ainda se sabe em relação aos cuidados médicos ideais que devem receber. (ii) O comprometimento cognitivo preexistente pode ser devido a lesões cerebrais de origem vascular, degenerativa ou mista; (iii) Pacientes com demência prévia ao AVC têm pior prognóstico, maior frequência de crises epilépticas, de delirium e depressão, além de taxas de mortalidade mais altas; eles ...

show abstract

Microbleed Status and 3-Month Outcome After Intravenous Thrombolysis in 717 Patients With Acute Ischemic Stroke

Cited by 50 publications

References 31 publications

Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Stroke Thrombolysis

Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Stroke Thrombolysis

Intravenous Thrombolytic Therapy in Acute Stroke: Problems and Solutions

Stroke occurring in patients with cognitive impairment or dementia

Contact Info

Product

Resources

About