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1. Potential missed opportunities to prevent ischaemic stroke: prospective multicentre cohort study of atrial fibrillation-associated ischaemic stroke and TIA

Author

Gregory Y H Lip, Michael Power, Martin M Brown, Matthew Smith, Christopher Price, Tarek Yousry, Gargi Banerjee, David J Werring, Gareth Ambler, Michelle Davis, Chris Patterson, Keith Muir, Krishna Dani, Julie Staals, Jon Scott, Pankaj Sharma, Duncan Wilson, Clare Shakeshaft, Hannah Cohen, Kirsty Harkness, Louise Shaw, Jane Sword, Roland Veltkamp, Deborah Kelly, Frances Harrington, Marc Randall, Karim Mahawish, Abduelbaset Elmarim, Bernard Esisi, Claire Cullen, Arumug Nallasivam, Adrian Barry, Christine Roffe, John Coyle, Ahamad Hassan, Caroline Lovelock, Jonathan Birns, David Cohen, L Sekaran, Adrian Parry-Jones, Anthea Parry, David Hargroves, Harald Proschel, Prabel Datta, Khaled Darawil, Aravindakshan Manoj, Mathew Burn, Elio GialloMbardo, Nigel Smyth, Syed Mansoor, Ijaz Anwar, Rachel Marsh, Sissi Ispoglou, Dinesh Chadha, Mathuri Prabhakaran, Sanjeevikumar Meenakishundaram, Vinodh Krishnamurthy, Prasanna Aghoram, Michael McCormick, Nikola Sprigg Paul O’Mahony, Peter Wilkinson, Simon Leach, Sarah Caine, Ilse Burger, Gunaratam Gunathilagan, Paul Guyler, Hedley Emsley, Dulka Manawadu, Kath Pasco, Maam Mamun, Robert Luder, Mahmud Sajid, James Okwera, Elizabeth Warburton, Kari Saastamoinen, Timothy England, Janet Putterill, Enrico Flossman, David Mangion, Appu Suman, John Corrigan, Enas Lawrence, Djamil Vahidassr, Janice O’Connell, Mark White, Martin Cooper, Lillian Choy, David Seiffge, Andreas Charidimou, H R Jäger, Azlisham Mohd Nor, and Al-Shahi Salman Rustam

Subjects
Medicine
Abstract

Objective We report on: (1) the proportion of patients with known atrial fibrillation (AF); and (2) demographic, clinical or radiological differences between patients with known AF (and not treated) and patients with newly diagnosed AF, in a cohort of patients who presented with ischaemic stroke or transient ischaemic attack (TIA) not previously treated with anticoagulation.Design We reviewed cross-sectional baseline demographic and clinical data from a prospective observational cohort study, (CROMIS-2).Setting Patients were recruited from 79 hospital stroke centres throughout the UK and one centre in the Netherlands.Participants Patients were eligible if they were adults who presented with ischaemic stroke or TIA and AF and had not been previously treated with oral anticoagulation.Main outcome measures Proportion of patients with known AF before index ischaemic stroke or TIA from a cohort of patients who have not been previously treated with oral anticoagulation. Secondary analysis includes the comparison of CHA2DS2-VASc and HAS-BLED scores and other demographics and risk factors between those with newly diagnosed AF and those with previously known AF.Results Of 1470 patients included in the analysis (mean age 76 years (SD 10)), 622 (42%) were female; 999 (68%) patients had newly diagnosed AF and 471 (32%) patients had known AF. Of the 471 patients with known AF, 68% had a strong indication for anticoagulation and 89% should have been considered for anticoagulation based upon CHA2DS2-VASc score. Patients with known AF were more likely to have a prior history of dementia (4% vs 2%, p=0.02) and had higher HAS-BLED scores (median 3 vs 2). CHA2DS2-VASc, other risk factors and demographics were similar.Conclusions About 1/3 of patients who present with stroke and have AF who have not been treated with oral anticoagulation have previously known AF. Of these patients, at least 68% were not adequately treated with oral anticoagulation.Trial registration number NCT02513316.

Published
2019
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2. Practical '1-2-3-4-Day' Rule for Starting Direct Oral Anticoagulants After Ischemic Stroke With Atrial Fibrillation: Combined Hospital-Based Cohort Study

Author

Shunsuke Kimura, Kazunori Toyoda, Sohei Yoshimura, Kazuo Minematsu, Masahiro Yasaka, Maurizio Paciaroni, David J. Werring, Hiroshi Yamagami, Takehiko Nagao, Shinichi Yoshimura, Alexandros Polymeris, Annaelle Zietz, Stefan T. Engelter, Bernd Kallmünzer, Manuel Cappellari, Tetsuya Chiba, Takeshi Yoshimoto, Masayuki Shiozawa, Takanari Kitazono, Masatoshi Koga, Kenichi Todo, Kazumi Kimura, Yoshiki Yagita, Eisuke Furui, Ryo Itabashi, Tadashi Terasaki, Yoshiaki Shiokawa, Teruyuki Hirano, Kenji Kamiyama, Jyoji Nakagawara, Shunya Takizawa, Kazunari Homma, Satoshi Okuda, Yasushi Okada, Keisuke Tokunaga, Tomoaki Kameda, Kazuomi Kario, Yoshinari Nagakane, Yasuhiro Hasegawa, Hisanao Akiyama, Satoshi Shibuya, Hiroshi Mochizuki, Yasuhiro Ito, Takahiro Nakashima, Hideki Matsuoka, Kazuhiro Takamatsu, Kazutoshi Nishiyama, Shoichiro Sato, Shoji Arihiro, Manabu Inoue, Masahito Takagi, Kanta Tanaka, Kazuyuki Nagatsuka, Takenori Yamaguchi, Yoichiro Hashimoto, Kiyohiro Houkin, Kazuo Kitagawa, Masayasu Matsumoto, Norio Tanahashi, Yasuo Terayama, Shinichiro Uchiyama, Etsuro Mori, Yutaka Furukawa, Takeshi Kimura, Yoshiaki Kumon, Ken Nagata, Shigeru Nogawa, Tomohiro Sakamoto, Toshinori Hirai, Kohsuke Kudo, Makoto Sasaki, Shotai Kobayashi, Toshimitsu Hamasaki, Michela Giustozzi, Monica Acciarresi, Giancarlo Agnelli, Valeria Caso, Fabio Bandini, Georgios Tsivgoulis, Shadi Yaghi, Karen L. Furie, Prasanna Tadi, Cecilia Becattini, Marialuisa Zedde, Azmil H Abdul-Rahim, Kennedy R Lees, Andrea Alberti, Michele Venti, Cataldo D’Amore, Maria Giulia Mosconi, Ludovica Anna Cimini, Paolo Bovi, Monica Carletti, Alberto Rigatelli, Jukka Putaala, Liisa Tomppo, Turgut Tatlisumak, Simona Marcheselli, Alessandro Pezzini, Loris Poli, Alessandro Padovani, Vieri Vannucchi, Sung-Il Sohn, Gianni Lorenzini, Rossana Tassi, Francesca Guideri, Maurizio Acampa, Giuseppe Martini, George Ntaios, George Athanasakis, Konstantinos Makaritsis, Efstathia Karagkiozi, Konstantinos Vadikolias, Chrissoula Liantinioti, Maria Chondrogianni, Nicola Mumoli, Franco Galati, Simona Sacco, Cindy Tiseo, Francesco Corea, Walter Ageno, Marta Bellesini, Giovanna Colombo, Giorgio Silvestrelli, Alfonso Ciccone, Alessia Lanari, Umberto Scoditti, Licia Denti, Michelangelo Mancuso, Miriam Maccarrone, Leonardo Ulivi, Giovanni Orlandi, Nicola Giannini, Tiziana Tassinari, Maria Luisa De Lodovici, Christina Rueckert, Antonio Baldi, Danilo Toni, Federica Letteri, Martina Giuntini, Enrico Maria Lotti, Yuriy Flomin, Alessio Pieroni, Odysseas Kargiotis, Theodore Karapanayiotides, Serena Monaco, Mario Maimone Baronello, Laszló Csiba, Lilla Szabó, Alberto Chiti, Elisa Giorli, Massimo Del Sette, Davide Imberti, Dorjan Zabzuni, Boris Doronin, Vera Volodina, Patrik Michel, Peter Vanacker, Kristian Barlinn, Lars-Peder Pallesen, Jessica Barlinn, Dirk Deleu, Gayane Melikyan, Faisal Ibrahim, Naveed Akhtar, Vanessa Gourbali, Luca Masotti, Adrian Parry-Jones, Chris Patterson, Christopher Price, Abduelbaset Elmarimi, Anthea Parry, Arumug Nallasivam, Azlisham Mohd Nor, Bernard Esis, David Bruce, Christine Roffe, Clare Holmes, David Cohen, David Hargroves, David Mangion, Dinesh Chadha, Djamil Vahidassr, Dulka Manawadu, Elio Giallombardo, Elizabeth Warburton, Enrico Flossman, Gunaratam Gunathilagan, Harald Proschel, Hedley Emsley, Ijaz Anwar, James Okwera, Janet Putterill, Janice O’Connell, John Bamford, John Corrigan, Jon Scott, Jonathan Birns, Karen Kee, Kari Saastamoinen, Kath Pasco, Krishna Dani, Lakshmanan Sekaran, Lillian Choy, Liz Iveson, Maam Mamun, Mahmud Sajid, Martin Cooper, Matthew Burn, Matthew Smith, Michael Power, Michelle Davis, Nigel Smyth, Roland Veltkamp, Pankaj Sharma, Paul Guyler, Paul O’Mahony, Peter Wilkinson, Prabel Datta, Prasanna Aghoram, Rachel Marsh, Robert Luder, Sanjeevikumar Meenakishundaram, Santhosh Subramonian, Simon Leach, Sissi Ispoglou, Sreeman Andole, Timothy England, Aravindakshan Manoj, Frances Harrington, Habib Rehman, Jane Sword, Julie Staals, Karim Mahawish, Kirsty Harkness, Louise Shaw, Michael McCormich, Nikola Sprigg, Syed Mansoor, Vinodh Krishnamurthy, Philippe A Lyrer, Leo H Bonati, David J Seiffge, Christopher Traenka, Nils Peters, Gian Marco De Marchis, Sebastian Thilemann, Nikolaos S Avramiotis, Henrik Gensicke, Lisa Hert, Benjamin Wagner, Fabian Schaub, Louisa Meya, Joachim Fladt, Tolga Dittrich, Urs Fisch, Bruno Bonetti, Giampaolo Tomelleri, Nicola Micheletti, Cecilia Zivelonghi, Andrea Emiliani, Kosmas Macha, Gabriela Siedler, Svenja Stoll, Ruihao Wang, Bastian Volbers, Stefan Schwab, David Haupenthal, and Luise Gaßmann

Subjects
Advanced and Specialized Nursing, acute ischemic stroke, Time Factors, Administration, Oral, Anticoagulants, Hemorrhage, cardioembolism, Hospitals, United States, Brain Ischemia, anticoagulation, atrial fibrillation, stroke prevention, Cohort Studies, Stroke, Treatment Outcome, Ischemic Attack, Transient, Atrial Fibrillation, Humans, Prospective Studies, Neurology (clinical), Cardiology and Cardiovascular Medicine, Ischemic Stroke
Abstract

Background: The “1-3-6-12-day rule” for starting direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation after acute ischemic stroke or transient ischemic attack recommends timings that may be later than used in clinical practice. We investigated more practical optimal timing of DOAC initiation according to stroke severity. Methods: The combined data of prospective registries in Japan, Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-nonvalvular atrial fibrillation (September 2011 to March 2014) and RELAXED (February 2014 to April 2016) were used. Patients were divided into transient ischemic attack and 3 stroke subgroups by the National Institutes of Health Stroke Scale score: mild (0–7), moderate (8–15), and severe (≥16). The early treatment group was defined as patients starting DOACs earlier than the median initiation day in each subgroup. Outcomes included a composite of recurrent stroke or systemic embolism, ischemic stroke, and severe bleeding within 90 days. Six European prospective registries were used for validation. Results: In the 1797 derivation cohort patients, DOACs were started at median 2 days after transient ischemic attack and 3, 4, and 5 days after mild, moderate, and severe strokes, respectively. Stroke or systemic embolism was less common in Early Group (n=785)—initiating DOACS within 1, 2, 3, and 4 days, respectively—than Late Group (n=1012) (1.9% versus 3.9%; adjusted hazard ratio, 0.50 [95% CI, 0.27–0.89]), as was ischemic stroke (1.7% versus 3.2%, 0.54 [0.27–0.999]). Major bleeding was similarly common in the 2 groups (0.8% versus 1.0%). On validation, both ischemic stroke (2.4% versus 2.2%) and intracranial hemorrhage (0.2% versus 0.6%) were similarly common in Early (n=547) and Late (n=1483) Groups defined using derivation data. Conclusions: In Japanese and European populations, early DOAC initiation within 1, 2, 3, or 4 days according to stroke severity seemed to be feasible to decrease the risk of recurrent stroke or systemic embolism and no increase in major bleeding. These findings support ongoing randomized trials to better establish the optimal timing of DOAC initiation.

Published
2022
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3. Development of imaging-based risk scores for prediction of intracranial haemorrhage and ischaemic stroke in patients taking antithrombotic therapy after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies

Author

Henry Ma, Eleni Sakka, Hugues Chabriat, Duncan Wilson, Appu Suman, Peter J. Kelly, SL Ho, Charlotte Zerna, Eric Jouvent, Lawrence K.S. Wong, Anthea Parry, Frances Harrington, Jan Stam, Christopher Patterson, Rustam Al-Shahi Salman, Shigeru Inamura, Krishna A Dani, Henry Houlden, Sebastian Thilemann, Kotaro Iida, Chao Xu, Eunbin Ko, Daniel Guisado-Alonso, Urs Fischer, Caroline E. Lovelock, Man Yu Tse, Wing Chi Fong, Azlisham Mohd Nor, Clare Shakeshaft, Philippe Maeder, Henrik Gensicke, Stefan T. Engelter, James Okwera, Christopher Chen, Dulka Manawadu, John F. Corrigan, Efrat Kliper, Shelagh B. Coutts, Alexander P. Leff, Kam Tat Leung, Chathuri Yatawara, Leopold Hertzberger, M. Eline Kooi, Kazuhisa Yoshifuji, Hing Lung Ip, Keon-Joo Lee, Sanjeevikumar Meenakishundaram, Hiroyuki Irie, Marc Randall, Hatice Ozkan, Hideo Hara, Jill Abrigo, Raquel Delgado-Mederos, Shaloo Singhal, Enrico Flossmann, Beatriz Gómez-Ansón, Paul O'Mahony, Carmen Barbato, Ahamad Hassan, Francesca M Chappell, Harald Proschel, Vincent Mok, Masashi Nishihara, Lakshmanan Sekaran, Derya Selcuk Demirelli, Chu Peng Hoi, Hakan Ay, Joan Martí-Fàbregas, Rebeca Marín, Anne Cristine Guevarra, Martin Cooper, Einor Ben Assayag, Anne-Marie Mendyk, Christine Roffe, Myung Suk Jang, Maarten van Gemert, Hannah Cohen, Jae-Sung Lim, YK Wong, Bonnie Y.K. Lam, Janet Putterill, Wouter Schoonewille, Nick S. Ward, Nikola Sprigg, Kui Kai Lau, Bernard Esisi, Peter M. Rothwell, Henk Verbiest, Kirsty Harkness, Elisa Merino, Gareth Ambler, Arumug Nallasivam, Nigel Smyth, Paul A. Armitage, Heinrich Mattle, Pol Camps-Renom, Martin M. Brown, David Cohen, Min Lou, Pankaj Sharma, Sarah Gunkel, Elles Douven, Andreas Charidimou, Djamil Vahidassr, Cathy Soufan, Alexandros A Polymeris, Michael G. Hennerici, Chris Moran, Rachel Marsh, Mahmud Sajid, Kyohei Fujita, David J. Werring, Joanna M. Wardlaw, Derek Hayden, Joseph Kwan, Timothy J. England, Jaap van der Sande, Luis Prats-Sánchez, Paul Guyler, Ryan Hoi Kit Cheung, Koon-Ho Chan, Frank-Erik de Leeuw, Simone Browning, Jon Scott, Adrian Barry, Alejandro Martínez-Domeño, Luc Bracoub, Dinesh Chadha, Ijaz Anwar, Deborah Kelly, Moon-Ku Han, Anil M. Tuladhar, Thomas Gattringer, Fiona Carty, Abduelbaset Elmarim, Syed Mansoor, Enrico Flossman, Dilek Necioglu Orken, Jane Sword, Velandai Srikanth, Ping Wing Ng, Thomas W. Leung, Richard Shek-kwan Chang, Hans Rolf Jäger, Marwan El-Koussy, Jeroen Hendrikse, Khaled Darawil, Kazunori Toyoda, Mathuri Prabhakaran, Karim Mahawish, Ethem Murat Arsava, Jihoon Kang, Kwok Kui Wong, Michael Power, Felix Fluri, Enas Lawrence, Maam Mamun, Sissi Ispoglou, Mathew Burn, Siu Hung Li, Henry K.F. Mak, Kaori Miwa, Els De Schryver, Franz Fazekas, Jonathan G. Best, Louise Shaw, Hen Hallevi, Keith W. Muir, Ilse Burger, Adrian Wong, Nils Peters, Susana Muñoz-Maniega, Yusuke Yakushiji, David Calvet, Mark White, Michael McCormick, Vinodh Krishnamurthy, David Hargroves, Jan C. Purrucker, Tae Jin Song, Masayuki Shiozawa, Noortje A.M. Maaijwee, Prasanna Aghoram, Nicolas Christ, Lino Ramos, Yannie Soo, Thanh G. Phan, Parashkev Nachev, David J. Seiffge, Kim Wiegertjes, Leo H. Bonati, Chahin Pachai, Oi Ling Chan, Yvo B.W.E.M. Roos, Santiago Medrano-Martorell, Natan M. Bornstein, Elizabeth A. Warburton, Richard Li, Prabel Datta, Pascal P. Gratz, Edmund Ka Ming Wong, Hedley C. A. Emsley, Marie-Yvonne Douste-Blazy, Gunaratam Gunathilagan, Nagaendran Kandiah, Masatoshi Koga, Roland Veltkamp, Lee-Anne Slater, Suk Fung Tsang, Beom Joon Kim, Simon Jung, Zeynep Tanriverdi, Sarah Caine, Peter J. Koudstaal, Laurence Legrand, Kari Saastamoinen, Ale Algra, Jean-Louis Mas, Christine Delmaire, Fidel Nuñez, Robert J. van Oostenbrugge, Sebastian Eppinger, Lillian Choy, Robert Luder, Vincent I.H. Kwa, Aad van der Lugt, Marie Dominique Fratacci, Stephen Makin, Layan Akijian, Régis Bordet, Mi Hwa Yang, Ying Zhou, Elio Giallombardo, Adrian R Parry-Jones, John S. Thornton, Amos D. Korczyn, Narayanaswamy Venketasubramanian, David J. Williams, Aravindakshan Manoj, Julie Staals, Solveig Horstmann, Dianne H.K. van Dam-Nolen, Claire Cullen, Benjamin Wagner, Jun Tanaka, Martin Dennis, Stef Bakker, Gregory Y.H. Lip, L. Jaap Kappelle, Robin Lemmens, Achim Gass, David Mangion, Matthew Smith, Toshio Imaizumi, Wenyan Liu, Jeremy Molad, Christopher Price, Paul J. Nederkoorn, P. J. A. M. Brouwers, Vincent Thijs, Sze Ho Ma, Mark Schembri, Peter Wilkinson, Janice E. O’Connell, Karen Ma, John Ly, Leonidas Panos, Chung Yan Chan, Toshihiro Ide, Christopher Traenka, Joost Jöbsis, Gargi Banerjee, Paul Berntsen, Michael J. Thrippleton, Raymond T.F. Cheung, Christopher Karayiannis, Werner H. Mess, Robert Simister, Jayesh Modi Medanta, Syuhei Ikeda, John Mitchell, Linxin Li, Mauro S.B. Silva, Eric Vicaut, John Coyle, Shoichiro Sato, Michelle Davis, Jonathan Birns, Richard J. Perry, Sean M. Murphy, KC Teo, Maria del C. Valdés Hernández, Bibek Gyanwali, Tarek A. Yousry, Kath Pasco, Sebastian Köhler, Joachim Fladt, Edward S. Hui, Philippe Lyrer, Young Dae Kim, Anna K. Heye, Eric E. Smith, Saima Hilal, Ender Uysal, Ji Hoe Heo, Ysoline Beigneux, Cisca Linn, Hee-Joon Bae, Simon Leach, Winnie C.W. Chu, Ronil V. Chandra, Neurology, ACS - Atherosclerosis & ischemic syndromes, ANS - Neurovascular Disorders, MUMC+: HZC Med Staf Spec Klinische Neurofys (9), RS: Carim - B06 Imaging, MUMC+: HZC Klinische Neurofysiologie (5), Klinische Neurowetenschappen, Psychiatrie & Neuropsychologie, RS: MHeNs - R1 - Cognitive Neuropsychiatry and Clinical Neuroscience, MUMC+: MA Neurologie (3), RS: Carim - B05 Cerebral small vessel disease, MUMC+: Hersen en Zenuw Centrum (3), MUMC+: MA Med Staf Spec Neurologie (9), RS: NUTRIM - R1 - Obesity, diabetes and cardiovascular health, Beeldvorming, and MUMC+: DA BV Klinisch Fysicus (9)

Subjects
Adult, Male, Risk, EXTERNAL VALIDATION, medicine.medical_specialty, Neurology, MODELS, Clinical Neurology, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Fibrinolytic Agents, Recurrence, Internal medicine, Antithrombotic, Humans, Medicine, Prospective cohort study, 610 Medicine & health, Stroke, METAANALYSIS, Aged, Ischemic Stroke, Science & Technology, medicine.diagnostic_test, business.industry, Proportional hazards model, Magnetic resonance imaging, Middle Aged, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], medicine.disease, Magnetic Resonance Imaging, Ischemic Attack, Transient, ATRIAL-FIBRILLATION, Cardiology, Female, Neurology (clinical), Neurosciences & Neurology, business, Intracranial Hemorrhages, Life Sciences & Biomedicine, 030217 neurology & neurosurgery, Fibrinolytic agent, Cohort study
Abstract

Contains fulltext : 235277.pdf (Publisher’s version ) (Closed access) BACKGROUND: Balancing the risks of recurrent ischaemic stroke and intracranial haemorrhage is important for patients treated with antithrombotic therapy after ischaemic stroke or transient ischaemic attack. However, existing predictive models offer insufficient performance, particularly for assessing the risk of intracranial haemorrhage. We aimed to develop new risk scores incorporating clinical variables and cerebral microbleeds, an MRI biomarker of intracranial haemorrhage and ischaemic stroke risk. METHODS: We did a pooled analysis of individual-patient data from the Microbleeds International Collaborative Network (MICON), which includes 38 hospital-based prospective cohort studies from 18 countries. All studies recruited participants with previous ischaemic stroke or transient ischaemic attack, acquired baseline MRI allowing quantification of cerebral microbleeds, and followed-up participants for ischaemic stroke and intracranial haemorrhage. Participants not taking antithrombotic drugs were excluded. We developed Cox regression models to predict the 5-year risks of intracranial haemorrhage and ischaemic stroke, selecting candidate predictors on biological relevance and simplifying models using backward elimination. We derived integer risk scores for clinical use. We assessed model performance in internal validation, adjusted for optimism using bootstrapping. The study is registered on PROSPERO, CRD42016036602. FINDINGS: The included studies recruited participants between Aug 28, 2001, and Feb 4, 2018. 15 766 participants had follow-up for intracranial haemorrhage, and 15 784 for ischaemic stroke. Over a median follow-up of 2 years, 184 intracranial haemorrhages and 1048 ischaemic strokes were reported. The risk models we developed included cerebral microbleed burden and simple clinical variables. Optimism-adjusted c indices were 0·73 (95% CI 0·69-0·77) with a calibration slope of 0·94 (0·81-1·06) for the intracranial haemorrhage model and 0·63 (0·62-0·65) with a calibration slope of 0·97 (0·87-1·07) for the ischaemic stroke model. There was good agreement between predicted and observed risk for both models. INTERPRETATION: The MICON risk scores, incorporating clinical variables and cerebral microbleeds, offer predictive value for the long-term risks of intracranial haemorrhage and ischaemic stroke in patients prescribed antithrombotic therapy for secondary stroke prevention; external validation is warranted. FUNDING: British Heart Foundation and Stroke Association.

Published
2021
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4. Small Vessel Disease and Ischemic Stroke Risk During Anticoagulation for Atrial Fibrillation After Cerebral Ischemia

Author

Houwei Du, Duncan Wilson, Gareth Ambler, Gargi Banerjee, Clare Shakeshaft, Hannah Cohen, Tarek Yousry, Rustam Al-Shahi Salman, Gregory Y.H. Lip, Henry Houlden, Martin M. Brown, Keith W. Muir, Hans Rolf Jäger, David J. Werring, Adrian Parry-Jones, Chris Patterson, Christopher Price, Abduelbaset Elmarimi, Anthea Parry, Arumug Nallasivam, Azlisham Mohd Nor, Bernard Esisi, David Bruce, Biju Bhaskaran, Christine Roffe, Claire Cullen, Clare Holmes, David Cohen, David Hargroves, David Mangion, Dinesh Chadha, Djamil Vahidassr, Dulka Manawadu, Elio Giallombardo, Elizabeth Warburton, Enrico Flossman, Gunaratam Gunathilagan, Harald Proschel, Hedley Emsley, Ijaz Anwar, Ilse Burger, James Okwera, Janet Putterill, Janice O’Connell, John Bamford, John Corrigan, Jon Scott, Jonathan Birns, Karen Kee, Kari Saastamoinen, Kath Pasco, Krishna Dani, Lakshmanan Sekaran, Lillian Choy, Liz Iveson, Maam Mamun, Mahmud Sajid, Martin Cooper, Mathew Burn, Matthew Smith, Michael Power, Michelle Davis, Nigel Smyth, Roland Veltkamp, Pankaj Sharma, Paul Guyler, Paul O’Mahony, Peter Wilkinson, Prabel Datta, Prasanna Aghoram, Rachel Marsh, Robert Luder, Sanjeevikumar Meenakishundaram, Santhosh Subramonian, Simon Leach, Sissi Ispoglou, Sreeman Andole, Timothy England, Aravindakshan Manoj, Harrington Frances, Habib Rehman, Jane Sword, Julie Staals, Karim Mahawish, Kirsty Harkness, Louise Shaw, Michael McCormick, Nikola Sprigg, Syed Mansoor, and Vinodh Krishnamurthy

Subjects
Male, medicine.medical_specialty, brain, Small vessel occlusion, Ischemia, Disease, Brain Ischemia, White matter, Recurrence, Internal medicine, Atrial Fibrillation, medicine, Humans, ischemic attack, transient, atrial fibrillation, anticoagulation, Aged, Ischemic Stroke, Aged, 80 and over, Advanced and Specialized Nursing, business.industry, Atrial fibrillation, Middle Aged, medicine.disease, medicine.anatomical_structure, Cerebral Small Vessel Diseases, Ischemic stroke, Cardiology, Female, Neurology (clinical), Small vessel, Cardiology and Cardiovascular Medicine, business, white matter
Abstract

Background and Purpose: The causes of recurrent ischemic stroke despite anticoagulation for atrial fibrillation are uncertain but might include small vessel occlusion. We investigated whether magnetic resonance imaging markers of cerebral small vessel disease (SVD) are associated with ischemic stroke risk during follow-up in patients anticoagulated for atrial fibrillation after recent ischemic stroke or transient ischemic attack. Methods: We analyzed data from a prospective multicenter inception cohort study of ischemic stroke or transient ischemic attack anticoagulated for atrial fibrillation (CROMIS-2 [Clinical Relevance of Microbleeds in Stroke Study]). We rated markers of SVD on baseline brain magnetic resonance imaging: basal ganglia perivascular spaces (number ≥11); cerebral microbleeds (number ≥1); lacunes (number ≥1); and white matter hyperintensities (periventricular Fazekas grade 3 or deep white matter Fazekas grade ≥2). We investigated the associations of SVD presence (defined as presence of ≥1 SVD marker) and severity (composite SVD score) with the risk of ischemic stroke during follow-up using a Cox proportional hazards model adjusted for congestive heart failure, hypertension, age >75, diabetes, stroke, vascular disease, age 65–74, female score. Results: We included 1419 patients (mean age: 75.8 years [SD, 10.4]; 42.1% female). The ischemic stroke rate during follow-up in patients with any SVD was 2.20 per 100-patient years (95% CI, 1.60–3.02), compared with 0.98 per 100 patient-years (95% CI, 0.59–1.62) in those without SVD ( P =0.008). After adjusting for congestive heart failure, hypertension, age >75, diabetes, stroke, vascular disease, age 65–74, female score, SVD presence remained significantly associated with ischemic stroke during follow-up (hazard ratio, 1.89 [95% CI, 1.01–3.53]; P =0.046); the risk of recurrent ischemic stroke increased with SVD score (hazard ratio per point increase, 1.33 [95% CI, 1.04–1.70]; P =0.023). Conclusions: In patients anticoagulated for atrial fibrillation after ischemic stroke or transient ischemic attack, magnetic resonance imaging markers of SVD are associated with an increased risk of ischemic stroke during follow-up; improved stroke prevention treatments are required in this population. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02513316.

Published
2021
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5. Cognitive Impairment Before Atrial Fibrillation-Related Ischemic Events:Neuroimaging and Prognostic Associations

Author

Gargi Banerjee, Edgar Chan, Gareth Ambler, Duncan Wilson, Lisa Cipolotti, Clare Shakeshaft, Hannah Cohen, Tarek Yousry, Rustam Al‐Shahi Salman, Gregory Y. H. Lip, Keith W. Muir, Martin M. Brown, Hans Rolf Jäger, David J. Werring, Louise Shaw, Kirsty Harkness, Jane Sword, Azlisham Mohd Nor, Pankaj Sharma, Deborah Kelly, Frances Harrington, Marc Randall, Matthew Smith, Karim Mahawish, Abduelbaset Elmarim, Bernard Esisi, Claire Cullen, Arumug Nallasivam, Christopher Price, Adrian Barry, Christine Roffe, John Coyle, Ahamad Hassan, Caroline Lovelock, Jonathan Birns, David Cohen, L. Sekaran, Adrian Parry‐Jones, Anthea Parry, David Hargroves, Harald Proschel, Prabel Datta, Khaled Darawil, Aravindakshan Manoj, Mathew Burn, Chris Patterson, Elio Giallombardo, Nigel Smyth, Syed Mansoor, Ijaz Anwar, Rachel Marsh, Sissi Ispoglou, Dinesh Chadha, Mathuri Prabhakaran, Sanjeevikumar Meenakishundaram, Janice O'Connell, Jon Scott, Vinodh Krishnamurthy, Prasanna Aghoram, Michael McCormick, Paul O'Mahony, Martin Cooper, Lillian Choy, Peter Wilkinson, Simon Leach, Sarah Caine, Ilse Burger, Gunaratam Gunathilagan, Paul Guyler, Hedley Emsley, Michelle Davis, Dulka Manawadu, Kath Pasco, Maam Mamun, Robert Luder, Mahmud Sajid, James Okwera, Julie Staals, Elizabeth Warburton, Kari Saastamoinen, Timothy England, Janet Putterill, Enrico Flossman, Michael Power, Krishna Dani, David Mangion, Appu Suman, John Corrigan, Enas Lawrence, and Djamil Vahidassr

Subjects
medicine.medical_specialty, Neuroimaging, Neuropsychological Tests, Brain ischemia, Disability Evaluation, Cognition, Leukoencephalopathies, Predictive Value of Tests, Modified Rankin Scale, Internal medicine, Atrial Fibrillation, Prevalence, medicine, Humans, Cognitive Dysfunction, atrial fibrillation, Prospective Studies, Cognitive decline, Vascular dementia, Stroke, Original Research, Ischemic Stroke, cognitive impairment, business.industry, cerebral small vessel disease, Transient Ischemic Attack (TIA), Atrial fibrillation, vascular dementia, Odds ratio, Prognosis, medicine.disease, United Kingdom, Hyperintensity, brain ischemia, Functional Status, Ischemic Attack, Transient, Cerebral Small Vessel Diseases, Cardiology, Cardiology and Cardiovascular Medicine, business
Abstract

Background It is likely that a proportion of poststroke cognitive impairment is sometimes attributable to unidentified prestroke decline; prestroke cognitive function is also clinically relevant because it is associated with poor functional outcomes, including death. We investigated the radiological and prognostic associations of preexisting cognitive impairment in patients with ischemic stroke or transient ischemic attack associated with atrial fibrillation. Methods and Results We included 1102 patients from the prospective multicenter observational CROMIS ‐2 (Clinical Relevance of Microbleeds in Stroke 2) atrial fibrillation study. Preexisting cognitive impairment was identified using the 16‐item Informant Questionnaire for Cognitive Decline in the Elderly. Functional outcome was measured using the modified Rankin scale. Preexisting cognitive impairment was common (n=271; 24.6%). The presence of lacunes (odds ratio [OR], 1.50; 95% CI , 1.03–1.05; P =0.034), increasing periventricular white matter hyperintensity grade (per grade increase, OR , 1.38; 95% CI , 1.17–1.63; P OR , 1.26; 95% CI , 1.05–1.51; P =0.011), and medial temporal atrophy grade (per grade increase, OR , 1.61; 95% CI , 1.34–1.95; P mRS >2; adjusted OR , 2.43; 95% CI , 1.42–4.20; P =0.001). Conclusions Preexisting cognitive impairment in patients with atrial fibrillation–associated ischemic stroke or transient ischemic attack is common, and associated with imaging markers of cerebral small vessel disease and neurodegeneration, as well as with longer‐term functional outcome. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02513316.

Published
2020
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6. Cerebral microbleeds and stroke risk after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies

Author

Christopher Price, P. J. A. M. Brouwers, Vincent Thijs, Sze Ho Ma, Mark Schembri, Raymond T.F. Cheung, Christopher Karayiannis, Werner H. Mess, Robert Simister, Peter Wilkinson, Jayesh Modi Medanta, Janice E. O’Connell, Karen Ma, Martin Dennis, Sean C. Murphy, John Ly, Velandai Srikanth, Hing Lung Ip, Mathew Burn, Saima Hilal, Ijaz Anwar, Richard Shek-kwan Chang, Christopher Chen, Carmen Barbato, Hatice Ozkan, Achim Gass, Louise Shaw, Hen Hallevi, Aravindakshan Manoj, Julie Staals, Frances Harrington, Henry Houlden, Hideo Hara, Kam Tat Leung, Christopher Traenka, Jeroen Hendrikse, Keon-Joo Lee, Elio Giallombardo, Ender Uysal, Edmund Ka Ming Wong, Joost Jöbsis, Gargi Banerjee, Dulka Manawadu, Rebeca Marín, John S. Thornton, Nick S. Ward, Vinodh Krishnamurthy, Thomas W. Leung, Ji Hoe Heo, Philippe Maeder, Masatoshi Koga, Michael Power, Marc Randall, Amos D. Korczyn, Narayanaswamy Venketasubramanian, Derya Selcuk Demirelli, Richard Li, Prabel Datta, Christine Guevarra, YK Wong, Ysoline Beigneux, Cisca Linn, Solveig Horstmann, Henk Verbiest, Kirsty Harkness, Eric Vicaut, John Coyle, Shoichiro Sato, Anne Marie Mendyk, Chathuri Yatawara, Alexandros A Polymeris, Lisa Hert, Joan Martí-Fàbregas, Felix Fluri, Cathy Soufan, Djamil Vahidassr, Lakshmanan Sekaran, Chu Peng Hoi, Maarten van Gemert, Andreas Charidimou, Robert Luder, Lillian Choy, Jaap van der Sande, Hannah Cohen, Jae-Sung Lim, Maam Mamun, Vincent I.H. Kwa, Kyohei Fujita, Joseph Kwan, Syuhei Ikeda, John Mitchell, Paul Berntsen, Michael J. Thrippleton, Shelagh B. Coutts, Simone Browning, Paul Guyler, Heinrich Mattle, Elles Douven, Jonathan Birns, M. Eline Kooi, Jan Stam, Hedley C. A. Emsley, David Mangion, David Calvet, Min Lou, Yannie Soo, Santiago Medrano-Martorell, Michael G. Hennerici, Chris Moran, Thomas Gattringer, Bernard Esisi, Kazuhisa Yoshifuji, Hakan Ay, Rustam Al-Shahi Salman, Joanna M. Wardlaw, Derek Hayden, Richard J. Perry, Gunaratam Gunathilagan, Hans Rolf Jäger, Frank-Erik de Leeuw, Luis Prats-Sánchez, Pankaj Sharma, Mi Hwa Yang, Marie Yvonne Douste-Blazy, Enas Lawrence, Nils Peters, Elisa Merino, KC Teo, Ethem Murat Arsava, Luc Bracoub, Dinesh Chadha, Linxin Li, Nikola Sprigg, Adrian R Parry-Jones, Pascal P. Gratz, Siu Hung Li, Stephen Makin, Arumug Nallasivam, Jane Sword, Mauro S.B. Silva, Ping Wing Ng, Layan Akijian, Krishna A Dani, Sebastian Thilemann, Marie Dominique Fratacci, Gareth Ambler, Nagaendran Kandiah, Lee-Anne Slater, Ilse Burger, Kath Pasco, Paul J. Nederkoorn, Suk Fung Tsang, Tae Jin Song, Henry Ma, Kaori Miwa, Keith W. Muir, Susana Muñoz-Maniega, Jihoon Kang, Nicolas Christ, Beom Joon Kim, Noortje A.M. Maaijwee, Kwok Kui Wong, Jon Scott, Leonidas Panos, Oi Ling Chan, Shigeru Inamura, Prasanna Aghoram, David Hargroves, Lino Ramos, Ying Zhou, Chung Yan Chan, Masayuki Shiozawa, Eleni Sakka, Michelle Davis, Matthew Smith, Leo H. Bonati, Dilek Necioglu Orken, Toshihiro Ide, Jaap Kappelle, Ale Algra, Charlotte Zerna, Laurence Legrand, Eric Jouvent, Roland Veltkamp, Simon Jung, Zeynep Tanriverdi, Shahoo Singhal, Sarah Caine, Natan M. Bornstein, Régis Bordet, Anil M. Tuladhar, Maarten Schrooten, John F. Corrigan, Alexander P. Leff, Kazunori Toyoda, Mathuri Prabhakaran, Kim Wiegertjes, Eunbin Ko, Wouter Schoonewille, Sebastian Köhler, Yvo B.W.E.M. Roos, Wing Chi Fong, Jun Tanaka, Abduelbaset Elmarim, Syed Mansoor, Peter J. Koudstaal, Kari Saastamoinen, Eric E. Smith, Paul O'Mahony, Hugues Chabriat, Duncan Wilson, Appu Suman, Dianne H.K. van Dam-Nolen, Parashkev Nachev, Ahamad Hassan, Maria del C. Valdés Hernández, Clare Shakeshaft, Stefan T. Engelter, James Okwera, Aad van der Lugt, Els De Schryver, Stef Bakker, Azlisham Mohd Nor, Yusuke Yakushiji, Robert J. van Oostenbrugge, Claire Cullen, Man Yu Tse, Sebastian Eppinger, Gregory Y.H. Lip, Kotaro Iida, Efrat Kliper, Bibek Gyanwali, Elizabeth A. Warburton, Hee-Joon Bae, Thanh G. Phan, Tarek A. Yousry, Henrik Gensicke, Christine Delmaire, Jean-Louis Mas, Jill Abrigo, Fiona Carty, Jan C. Purrucker, Masashi Nishihara, Leopold Hertzberger, Joachim Fladt, Einor Ben Assayag, Simon Leach, Winnie C.W. Chu, Edward S. Hui, Bonnie Y.K. Lam, Moon Ku Han, Francesca M Chappell, David Williams, Robin Lemmens, Philippe Lyrer, Hiroyuki Irie, Raquel Delgado-Mederos, Ronil V. Chandra, Nigel Smyth, Henry K.F. Mak, Young Dae Kim, Ryan Hoi Kit Cheung, Beatriz Gómez-Ansón, Fidel Nuñez, Anna K. Heye, Adrian Barry, Janet Putterill, Mark White, Alejandro Martínez-Domeño, Vincent Mok, Rachel Marsh, Mahmud Sajid, Timothy J. England, SL Ho, Christopher Patterson, Daniel Guisado-Alonso, Peter J. Kelly, Lawrence K.S. Wong, Anthea Parry, Enrico Flossman, Chao Xu, Marwan El-Koussy, Karim Mahawish, Sissi Ispoglou, Franz Fazekas, Toshio Imaizumi, David J. Seiffge, Wenyan Liu, Chahin Pachai, Adrian Wong, Khaled Darawil, Jeremy Molad, Sanjeevikumar Meenakishundaram, Enrico Flossmann, Harald Proschel, Caroline E. Lovelock, Christine Roffe, Kui Kai Lau, Michael McCormick, Peter M. Rothwell, Paul A. Armitage, Sarah Gunkel, Myung Suk Jang, Martin Cooper, Pol Camps-Renom, Martin M. Brown, David Cohen, David J. Werring, Koon-Ho Chan, Deborah Kelly, Neurology, ACS - Atherosclerosis & ischemic syndromes, ANS - Neurovascular Disorders, Division 2, Radiology & Nuclear Medicine, RS: Carim - B06 Imaging, Beeldvorming, MUMC+: DA BV Klinisch Fysicus (9), RS: NUTRIM - R1 - Obesity, diabetes and cardiovascular health, RS: CARIM - R3.11 - Imaging, MUMC+: MA Neurologie (3), Klinische Neurowetenschappen, RS: Carim - B05 Cerebral small vessel disease, RS: CARIM - R3.03 - Cerebral small vessel disease, and MUMC+: MA Med Staf Spec Neurologie (9)

Subjects
INTRACEREBRAL HEMORRHAGE, 030204 cardiovascular system & hematology, AMYLOID ANGIOPATHY, PREDICT, Brain Ischemia, 0302 clinical medicine, SMALL VESSEL DISEASE, Medicine, CHINESE PATIENTS, 10. No inequality, Stroke, medicine.diagnostic_test, DEMENTIA, Hazard ratio, Absolute risk reduction, Brain, Atrial fibrillation, ASSOCIATION, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], Magnetic Resonance Imaging, 3. Good health, Ischemic Attack, Transient, Cardiology, Life Sciences & Biomedicine, Intracranial Hemorrhages, medicine.drug, Cohort study, medicine.medical_specialty, RECURRENT STROKE, Clinical Neurology, 610 Medicine & health, Neuroimaging, Article, WARFARIN, 03 medical and health sciences, Internal medicine, Journal Article, Humans, Intracerebral hemorrhage, Science & Technology, business.industry, Warfarin, Magnetic resonance imaging, T2-ASTERISK-WEIGHTED MR-IMAGES, medicine.disease, ATRIAL-FIBRILLATION, Neurosciences & Neurology, Neurology (clinical), business, 030217 neurology & neurosurgery
Abstract

Contains fulltext : 208975.pdf (Publisher’s version ) (Open Access) BACKGROUND: Cerebral microbleeds are a neuroimaging biomarker of stroke risk. A crucial clinical question is whether cerebral microbleeds indicate patients with recent ischaemic stroke or transient ischaemic attack in whom the rate of future intracranial haemorrhage is likely to exceed that of recurrent ischaemic stroke when treated with antithrombotic drugs. We therefore aimed to establish whether a large burden of cerebral microbleeds or particular anatomical patterns of cerebral microbleeds can identify ischaemic stroke or transient ischaemic attack patients at higher absolute risk of intracranial haemorrhage than ischaemic stroke. METHODS: We did a pooled analysis of individual patient data from cohort studies in adults with recent ischaemic stroke or transient ischaemic attack. Cohorts were eligible for inclusion if they prospectively recruited adult participants with ischaemic stroke or transient ischaemic attack; included at least 50 participants; collected data on stroke events over at least 3 months follow-up; used an appropriate MRI sequence that is sensitive to magnetic susceptibility; and documented the number and anatomical distribution of cerebral microbleeds reliably using consensus criteria and validated scales. Our prespecified primary outcomes were a composite of any symptomatic intracranial haemorrhage or ischaemic stroke, symptomatic intracranial haemorrhage, and symptomatic ischaemic stroke. We registered this study with the PROSPERO international prospective register of systematic reviews, number CRD42016036602. FINDINGS: Between Jan 1, 1996, and Dec 1, 2018, we identified 344 studies. After exclusions for ineligibility or declined requests for inclusion, 20 322 patients from 38 cohorts (over 35 225 patient-years of follow-up; median 1.34 years [IQR 0.19-2.44]) were included in our analyses. The adjusted hazard ratio [aHR] comparing patients with cerebral microbleeds to those without was 1.35 (95% CI 1.20-1.50) for the composite outcome of intracranial haemorrhage and ischaemic stroke; 2.45 (1.82-3.29) for intracranial haemorrhage and 1.23 (1.08-1.40) for ischaemic stroke. The aHR increased with increasing cerebral microbleed burden for intracranial haemorrhage but this effect was less marked for ischaemic stroke (for five or more cerebral microbleeds, aHR 4.55 [95% CI 3.08-6.72] for intracranial haemorrhage vs 1.47 [1.19-1.80] for ischaemic stroke; for ten or more cerebral microbleeds, aHR 5.52 [3.36-9.05] vs 1.43 [1.07-1.91]; and for >/=20 cerebral microbleeds, aHR 8.61 [4.69-15.81] vs 1.86 [1.23-1.82]). However, irrespective of cerebral microbleed anatomical distribution or burden, the rate of ischaemic stroke exceeded that of intracranial haemorrhage (for ten or more cerebral microbleeds, 64 ischaemic strokes [95% CI 48-84] per 1000 patient-years vs 27 intracranial haemorrhages [17-41] per 1000 patient-years; and for >/=20 cerebral microbleeds, 73 ischaemic strokes [46-108] per 1000 patient-years vs 39 intracranial haemorrhages [21-67] per 1000 patient-years). INTERPRETATION: In patients with recent ischaemic stroke or transient ischaemic attack, cerebral microbleeds are associated with a greater relative hazard (aHR) for subsequent intracranial haemorrhage than for ischaemic stroke, but the absolute risk of ischaemic stroke is higher than that of intracranial haemorrhage, regardless of cerebral microbleed presence, antomical distribution, or burden. FUNDING: British Heart Foundation and UK Stroke Association.

Published
2019
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7. Impact of evidence-based stroke care on patient outcomes : A multilevel analysis of an international study

Author

Paula Muñoz Venturelli, Xian Li, Sandy Middleton, Caroline Watkins, Pablo M. Lavados, Verónica V. Olavarría, Alejandro Brunser, Octavio Pontes‐Neto, Taiza E. G. Santos, Hisatomi Arima, Laurent Billot, Maree L. Hackett, Lily Song, Thompson Robinson, Craig S. Anderson, Gillian Mead, H. Asita De Silva, Jeyaraj D. Pandian, Ruey‐Tay Lin, Tsong‐Hai Lee, Liying Cui, Bin Peng, Stephane Heritier, Richard Lindley, Stephen Jan, Elizabeth Boaden, Christopher P. L. H. Chen, Anne Forster, Mark Woodward, Kris Rogers, Anish Scaria, Joyce Y. Lim, Natalie Espinosa, Lucy McEvoy, Lee Blackburn, Sarah S. Richtering, Shoujiang You, Simon Ladwig, Gabrielle P. Merritt, Bryce Thomsen, Kerry Jenson, Penelope Gordon, Dennis Ryan Nguyen, Wei Wei Quan, Tessa Pei‐Yi Lo, Jonathan Lim, Selena Goh, Leibo Liu, Mirza Ahmad Baig, Ravider Singh, Paul Donnelly, Manuela Armenis, Marna Van Zyl, Helen Monaghan, Phillipa Smith, Parisa Glass, Fanli Zhou, Yun Shen, Li Lei, Di Li, Ting Zhang, Xiaoyan Zhang, Yun Peng, Lingling Feng, Zhiping Ye, Philip Gregory, Jeyaraj D. Pandain, Deepti Arora, Francisca Gonzalez, Bernardita Portales, Taiza Santos‐Pontelli, Brunna Rimoli, Monica Braga, Carolina Vidal, Dafna Benadof, Rodrigo J. Rivas, Laura Carvallo, Pamela Carvallo, Rubia Miranda, Brunna Pileggi, H. Asita de Silva, Shalomi Weerawardena, Thanushanthan Jeevarajah, Devaki Dharmawardena, Dumindi Ranasinghe, Matheesha Dharshana, Nilesh Nandadeva, Savithri Nawarathna, Jiu‐Haw Yin, Shoou‐Jeng Yeh, Ruei‐Jen Ma, Caroline L. Watkins, Gemma Whiteley, Denise Forshaw, Catherine Elizabeth Lightbody, Joanna Cox, Jane Fitzgerald, John F. Heney, Helen Byfield, Simone Finley, Hayley E. Tyrer, Carole Bruce, Alison Gibbon, Brett Jones, Emma Siracusa, Koushik Gowda, Shahla Cowans, Briana Forman, Sherin Jacob, Kristine Caprecho, Roshan Khatri, Po Yi Wan, Maria Lopez, Sifiso Vanika, Wilhelmina Bleeker, Marinka Ireland, Sheila Jala, Susan Day, Eric Ha, Martin Krause, Melissa Passer, Sarah Giaccari, Nadia Burkolter, Michael Braithwaite, Kylie Tastula, Darshan Ghia, Tapuwa Musuka, Anthony Alvaro, Gillian Edmonds, Nicole O'Loughin, Rebecca Phair, Joanne Kaoutal, David J. Blacker, Belinda L Saint, Kim Parrey, Michelle Coad, Matthew Kinchington, Nishantha Senanayake, Johanna Alaban, Irma Kuehne, Millene Camilo, Milena Libardi, Sheila Martins, Batista Carlos, Magda Martins, Leonardo Carbonera, Andrea Almeida, Martin Kelin, Carla Pauli, Mariana Lunardi, Luciane Silveira, Olga Chagas, Daily Souza, Gabriel Braga, Priscila Ribeiro, Gustavo Luvizutto, Marcia Polin, Fernanda Winckler, Jinfeng Liu, Zhenjiang Wang, Huibing Wang, Suying Lin, Jing Dong, Junshan Zhou, Suping Qin, Hui Zhan, Yongquan Xue, Dong Tian, Dan Yang, Yan Yin, He Li, Changming Geng, Jieyi Liu, Xiaolin Jiang, Yujun Wu, Wei Sun, Bingqi Yu, Yanmei Guan, Qin Wang, Bo Wei, Huirong Wang, Yan Wang, Liwen Tai, Wenchao Zhang, Weili Zhao, Xueying Wang, Guoli Li, Zhiming Ni, Fudong Guo, Lan Cen, Jun Lu, Zheng Chen, Guoming Yin, Yingchun Wang, Jiping Zheng, Zhimin Zhou, Hongquan Wang, Renlin Zou, Bin Xue, Airu Li, Jing Guo, Ying Guo, Xingguo Jiang, Xiuge Tan, Chunpeng Zhang, Bei Shao, Xiaoting Niu, Chunfeng Liu, Dongqin Chen, Ping Liang, Xia Zhang, Chunqing Zhang, Wenjie Gong, Zhichao Huang, Huihui Liu, Junying Huang, Rongfang Shi, Cuilan Wang, Ying Liu, Jinchao Wang, Guojun Wu, Zhihong Gao, Qunli Lin, Cong Xu, Huile Zheng, Xinghai Ye, Xiaoqiong Jin, Junyan Liu, Xiaoyun Cao, Yan Zhang, Jinyang Wang, Yuzhu Xu, Yan Li, Xin Ma, Qi Kong, Yanlei Hao, Baojun Qiao, Hui Yan, Zhiyong Huang, Baoqiang Chang, Jinjin Yan, Pinjun Liao, Wei Zhang, Ling Liu, Tingting Zhu, Xuehui Liu, Yongping Li, Ruifang Dong, Miao Chen, Xiaoli Ge, Hairong Wang, Lihua Dai, Jiafu Liu, Shixia Wang, Jihui Du, Aixiu Song, Yunhai Li, Jie Feng, Cheng Yu, Honglin Feng, Xiaojia Sun, Ruihong Sun, Weisong Liu, Jianfeng Liu, Xuesheng Lu, Enzhuo Chen, Wei Gao, Hui Liu, Heping Wang, Yanxia Wang, Juan Song, Dongqi Liu, Wenhui Du, Guixia Li, Cuiling Li, Yanling Liang, Xuekun Cai, Jinli Zhang, Xiaowei Tao, Pingshun An, Ranran Tang, Xu Qin, Yingling Wang, Wenjun Zhang, Rong Ma, Xiaoqiong Huang, Yonglin Liu, Yazhi Wang, Ping Fan, Hailan Yang, Lianyuan Feng, Jianxia Zhi, Jiewen Zhang, Yao Zhou, Danhong Wu, Haiyan He, Xiaohong Chen, Yongge Hou, Xiaohui Su, Siyuan Fan, Luis Suárez, Juan de Dios Polanco, Patricio Sotomayor, Ricardo Urzúa, Daniela Urrutia, Nathalie Conejan, Arturo Escobar, Monica Gonzalez, Danisa Vargas, Angel Constante, Erika Vásquez, Elizabeth Godoy, Christian Figueroa, Vanesa San Martin, Nataly Vidal, Madeleyn Muñoz, María Spencer, Juan Almeida, Ignacio Acosta, Rodrigo Guerrero, Prudencio Lozano, Camila Aguayo, Jimena Pizarro, Alvaro Soto, Flor Bonilla, Pía García, Carolina Del Castillo, Marcela Grandjean, Alexis Von Johnn, Ignacio Gutierrez, Francisca Rivero, Ignacio López, Federico Silva, Marlen Pachón, José Mendoza, Alexander Pabón, Mahesh Kate, Naushad Akhtar, Gibbsdeep S. Narang, Ashish Deepak, Vikram Huded, Romnesh De Sowza, Alben Sigamani, Karthikeyan Rajendran, Anisha Vishwanath, Anusha K, Somasundaram Kumaravelu, Syed Rahamath, Sandeep Kannneganti, Dheeraj Khurana, Cheena Katoch, Taranpreet Kaur, Ummer Karadan, Anu Kuriakose, Jaison John, Mumthaz Basheer, Harsha Hemal Gunasekara, Gamlath Chandima Udeni De Silva, Peetagam Harshi Lakmali Ubeywickrama, Kavisha Chathumali Silva, Eshani Anuradha De Silva, Udaya Ranawaka, Chamila Mettananda, Yamuna Nanayakkara, Tharini Mendis, Gayathri Fernando, Ahamed Imthikab, Kandula Pieris, Saman B. Gunatilake, Pamuditha M. W. Madanayake, Shiran A. Paranavitane, Bimsara Senanayake, Vaidhehi Vishwanathan, Maathury Sivapalan, Ruwangi U. Murage, Uthpala Chandradeva, Yao‐Hua Liu, Chih‐Lung Lin, Hsiu‐Fen Lin, Kuan‐Ting Liu, Chien‐Fu Chen, Meng‐Ni Wu, Su‐Hua Tsai, Chi‐Ching Chen, Lan‐Yi Chen, Chien‐Hung Chang, Yeu‐Jhy Chang, Kuo‐Lun Huang, Ting‐Yu Chang, Chi‐Hung Liu, Chen‐June Seak, Yu‐Li Lin, Jia‐Yi Luo, Hsiao‐Ying Yang, Ching‐Yi Wang, Lung Chan, Chaur‐Jong Hu, Nai‐Fang Chi, Dean Wu, Yao‐Hsien Huang, Yi‐Chun Kuan, Chien‐Tai Hong, Yi‐Chun Chen, Yu Sun, Cheng‐Huai Lin, Chien‐Jung Lu, Hai‐Jui Chu, Yi‐Chia Lo, Wen‐Hui Chang, Wan‐Jung Lin, Hui‐Chen Su, Tien‐Yu Lin, Chi‐Hsuan Cho, Shu‐Lan Lu, Ya‐Fang Hsueh, Ching‐Yi Lai, David Jarrett, Claire James, Stacey Valentine, Clare Whistler, Rebecca Butler, Simone Browning, Caroline Watchurst, Renuka Erande, Emma Elliott, Krishna Patel, Maria Brezitski, Caroline Hogan, Asra Banaras, Lucinda Crook, Rashidat Ahmed, Lindsay Potter, Rosie Laird, Natasha Clarke, Alison Loosemore, J. Godber, Sara Gawned, K. A. Hamilton, Rachael Jones, Paul Guyler, Sharon Tysoe, Raji Prabakaran, Sweni Shah, Joanne Calver, Laszlo K. Sztriha, Maria Fitzpatrick, Stephanie Drysdale, John Aeron‐Thomas, Emma McKenzie, Belinda Chitando, Paul Willcoxson, Elizabeth Iveson, Peter Wanklyn, Natasha Dyer, Michael Keeling, Romina Rodriguez, Kerry Elliott, Mia Porteous, Mark O'Neill, Sheridan Orme, Carla Richardson, Janet Tomlinson, Suzanne Hawkins, Delia Bester, Carol Jeffs, Joanne Howard, Pauline Brown, Deborah Ward, Jennifer Turfrey, Leanne Raybould, Allison Bates, Sue O'Connell, Margaret O'Connor, Samantha Williams, Hedley C. A. Emsley, Alison McLoughlin, Sonia Raj, Bindu Gregary, Donna Doyle, G. M. Courtauld, C. Schofield, L. Lucas, A. Lydon, A. James, Kari Saastamoinen, Laura Howaniec, Premchand Daboo, Ali N. Ali, Emma Richards, Joanne Howe, Christine Kamara, Kathy Stocks, Ralf Lindert, Diana J. Day, Sarah Finlay, Joanne McGee, Jennifer Mitchell, Elaine Amis, Rosemary Macey, Suzanne Tauro, Lauren Henry, Sarah Cuddy, Andrew Steele, Kerry Mullen, Sarah Kirker, Murudappa Bhattad, Michael Carpenter, Prabal Datta, Ann Needle, Linda Jackson, Julie Ball, Rosie Beckitt, Nicola Chivers, Angela Bowring, Sara Eddy, Kevin Thorpe, Samantha Keenan, Alison Griffin, Stuart Maguire, Chris Patterson, Hawraman Ramadan, Ruth Bellfield, Michaela Hooley, Kelvin Stewart, Lucy Williams, Cara Gurney, Deborah Oliver, Maria Gardiner, Sarah Grayland, Mohit Bhandari, David M. Collas, Tolu Adesina, Saul Sundayi, Ruth Harvey, Emma Pope, Audrey Lam, Elaine Walker, Colin Merrill, Soma Banerjee, Kirsten Hannah Harvey, Sheila Mashate, Peter Wilding, Linda Johnson, Robert Namushi, Patricia Jacob, Sreeman Andole, Karen Dunne, Naveen Gadapa, Sam King, Sonata Siliuzaite, Sharon Dealing, Karen Attwood, Annette Woods, Banher Sandhu, Maam Mamun, Afzal Mahmood, June Jones, Abimbola Ojo, Denise Carter‐Evans, Royal Liverpool, Aravind Manoj, Glyn Fletcher, Paula Lopez, Jill Greig, Matthew Robinson, Sarah Jones, Lorinda Jones, Claire West, Helen Tench, Rachel Gascoyne, Amanda Whileman, Emily Hall, Stephanie Wright, Julie Toms, Duke Phiri, Sakthivel Sethuraman, Niaz Mohammed, Frances Justin, Margaret Louise Tate, Meena Chauhan, Syed I. Haider, Arumugam Nallasivan, Tim Webster, Sandra Leason, Samantha Seagrave, Peterborough City Hospital, Peter Owksu‐Agyei, Natalie Temple, Nicola Butterworth‐Cowin, Frederick Magezi, Leicester Royal Infirmary, Shagufta Khan, Claire Stephens, Amit Mistri, Aidan Murphy, Manda Lam, Paul Underwood, Catherine Thompson, Clare Buckley, Diane Wood, Sarah Board, Linda Howard, Ashraf Ahmed, Bethany Oates, Sara Leonard, Royal Bournemouth Hospital, Royal Bournemouth, Kamy Thavanesan, Michelle Dharmasiri, Sathyabama Logianathan, Catherine Ovington, Gail Hann, Chantel Cox, Craigavon Area Hospital, Southern Health, Social Care Trust, Catherine Douglas, Michael Goggin, Patricia Fearon, Sara Gilpin, Margaret O'Hagan, Pilgrim Hospital, Anne Hardwick, Kimberley Netherton, Judith Quinn, Tulu Bozkaplan, Josin Jose, Univ New South Wales, Ctr Estudios Clin, Clin Alemana Univ Desarrollo, Peking Univ, Australian Catholic Univ, Univ Cent Lancashire, Univ Chile, Universidade de São Paulo (USP), Fukuoka Univ, Univ Leicester, Univ Edinburgh, George Inst Global Hlth, Univ Desarrollo, St Vincents Hlth Australia Sydney, Univ Kelaniya, Christian Med Coll & Hosp, Kaohsiung Med Univ & Hosp, Linkou Chang Gung Mem Hosp, Peking Union Med Coll Hosp, Monash Univ, Natl Univ Singapore, Bradford Royal Infirm, Christian Med College, RemediumOne Pvt Ltd, Kaohsiung Med Univ, Calvary Publ Hosp Bruce, Royal North Shore Hosp, Royal Prince Alfred Hosp, Concord Repatriat Gen Hosp, Fiona Stanley Hosp, Macquarie Base Hosp, Hosp Governador Celso Ramos, Universidade Estadual Paulista (Unesp), Yangquan Coalmine Grp Gen Hosp, Nanjing Med Univ, 85 Hosp Peoples Liberat Army, Chifeng Univ, Beijing Pinggu Hosp, Wenzhou Med Univ, Soochow Univ, Hebei Med Univ, Capital Med Univ, Jining Med Univ, Third Peoples Hosp Huizhou, Second Cangzhou Cent Hosp, Shanghai Jiao Tong Univ, Baogang Hosp, Harbin Med Univ, Shanghai Jiao Tong Univ Sch, Guangzhou Med Univ, Second Hosp Nanchang, Bethune Int Peace Hosp, Hua Henan Prov Peoples Hosp, Shijiazhuang Cent Hosp, Hosp Base San Jos de Osorno, Unit Narayana Hrudayalaya Ltd, Dr Ramesh Cardiac & Multispecial Hosp Pvt Ltd, Post Grad Inst Med Educ & Res, Baby Mem Hosp Ltd, Sree Chitra Tirunal Inst Med Sci & Technol, Sri Jayawardenepura Gen Hosp, Colombo North Teaching Hosp, Colombo South Coching Hosp, Taipei Med Univ, En Chu Kong Hosp, Natl Cheng Kung Univ Hosp, Queen Alexandra Hosp, Portsmouth Hosp NHS Natl Hlth Serv iTrust, Univ Coll London Hosp NHS Fdn Trust, Univ Hosp Birmingham NHS Fdn Trust, Southend Univ Hosp NHS Fdn Trust, Kings Coll Hosp London, York Teaching Hosp NHS Fdn Trust, Nottingham Univ Hosp NHS Trust, Blackpool Teaching Hosp NHS Fdn Trust, Gloucestershire Hosp NHS Fdn Trust, Teaching Hospi NHS Fdn Trust, Royal Cornwall Hosp NHS Trust, Royal London Hosp, Sheffield Teaching Hosp NHS Fdn Trust, Cambridge Univ Hosp NHS Fdn Trust, Royal Victoria Hosp, Pinderfields Gen Hosp, Royal Devon & Exeter NHS Fdn Trust, Bradford Teaching Hosp NHS Fdn Trust, Great Western Hosp NHS Fdn Trust, Watford Dist Gen Hosp, Imperial Coll Healthcare NHS Trust, Medway NHS Fdn Trust, Royal Liverpool & Broadgreen Univ NHS Trust, Calderdale & Huddersfield NHS Fdn Trust, Hywel Dda Univ Hlth Board, Chesterfield Royal Hosp NHS Fdn Trust, Luton & Dunstable Univ Hosp NHS Fdn Trust, Countess Chester Hosp NHS Fdn Trust, Peterborough City Hosp, Univ Hosp Leicester NHS Trust, Dist Hosp NHS Fdn Trust, Barnsley Hosp NHS Fdn Trust, Dorset Cty Hosp NHS Fdn Trust, Royal Bournemouth & Christchurch Hosp NHS Fdn Tru, Southern Hlth & Social Care Trust, United Lincolnshire Hosp NHS Trust, and Bedford Hosp NHS Trust

Subjects
Male, Stroke care, Brain Ischemia, 0302 clinical medicine, Atrial Fibrillation, Clinical Studies, Thrombolytic Therapy, 030212 general & internal medicine, Acute ischemic stroke, Stroke, Thrombectomy, Original Research, Aged, 80 and over, Evidence-Based Medicine, Quality and Outcomes, Multilevel model, Middle Aged, 16. Peace & justice, 3. Good health, Outcome and Process Assessment, Health Care, quality, outcome, Female, multilevel analysis, Cardiology and Cardiovascular Medicine, China, medicine.medical_specialty, Evidence-based practice, Taiwan, India, Patient Positioning, 03 medical and health sciences, medicine, Humans, Intensive care medicine, Antihypertensive Agents, Physical Therapy Modalities, Aged, Sri Lanka, Ischemic Stroke, business.industry, Australia, Anticoagulants, South America, A300, Process of care, medicine.disease, United Kingdom, Logistic Models, acute stroke care, Cerebrovascular Disease/Stroke, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Deglutition Disorders, business, Platelet Aggregation Inhibitors, 030217 neurology & neurosurgery
Abstract

Made available in DSpace on 2019-10-04T12:41:37Z (GMT). No. of bitstreams: 0 Previous issue date: 2019-07-02 National Health and Medical Research Council of Australia Background-The uptake of proven stroke treatments varies widely. We aimed to determine the association of evidence-based processes of care for acute ischemic stroke (AIS) and clinical outcome of patients who participated in the HEADPOST (Head Positioning in Acute Stroke Trial), a multicenter cluster crossover trial of lying flat versus sitting up, head positioning in acute stroke. Methods and Results-Use of 8 AIS processes of care were considered: reperfusion therapy in eligible patients; acute stroke unit care; antihypertensive, antiplatelet, statin, and anticoagulation for atrial fibrillation; dysphagia assessment; and physiotherapist review. Hierarchical, mixed, logistic regression models were performed to determine associations with good outcome (modified Rankin Scale scores 0-2) at 90 days, adjusted for patient and hospital variables. Among 9485 patients with AIS, implementation of all processes of care in eligible patients, or defect-free care, was associated with improved outcome (odds ratio, 1.40; 95% CI, 1.18-1.65) and better survival (odds ratio, 2.23; 95% CI, 1.62-3.09). Defect-free stroke care was also significantly associated with excellent outcome (modified Rankin Scale score 0-1) (odds ratio, 1.22; 95% CI, 1.04-1.43). No hospital characteristic was independently predictive of outcome. Only 1445 (15%) of eligible patients with AIS received all processes of care, with significant regional variations in overall and individual rates. Conclusions-Use of evidence-based care is associated with improved clinical outcome in AIS. Strategies are required to address regional variation in the use of proven AIS treatments. Univ New South Wales, Fac Med, George Inst Global Hlth, Sydney, NSW, Australia Ctr Estudios Clin, Inst Ciencias & Innovac Med, Santiago, Chile Clin Alemana Univ Desarrollo, Fac Med, Serv Neurol, Dept Neurol & Psiquiatria, Santiago, Chile Peking Univ, Hlth Sci Ctr, George Inst Global Hlth, Beijing, Peoples R China Australian Catholic Univ, Nursing Res Inst, St Vincents Hlth Australia Sydney, Sydney, NSW, Australia Univ Cent Lancashire, Fac Hlth & Wellbeing, Preston, Lancs, England Univ Chile, Fac Med, Dept Ciencias Neurol, Santiago, Chile Univ Sao Paulo, Ribeirao Preto Med Sch, Stroke Serv Neurol Div, Ribeirao Preto, Brazil Fukuoka Univ, Fac Med, Dept Prevent Med & Publ Hlth, Fukuoka, Fukuoka, Japan Univ Leicester, Dept Cardiovasc Sci, Leicester Biomed Res Ctr, Leicester, Leics, England Univ Leicester, Natl Inst Hlth Res, Leicester Biomed Res Ctr, Leicester, Leics, England Univ Edinburgh, Ctr Clin Brain Sci, Edinburgh, Midlothian, Scotland George Inst Global Hlth, Sydney, NSW, Australia Univ Desarrollo, Serv Neurol, Dept Neurol & Psiquiatria Clin Alemana Santiago, Santiago, Chile St Vincents Hlth Australia Sydney, Sydney, NSW, Australia Australian Catholic Univ, Sydney, NSW, Australia Univ Cent Lancashire, Stroke Practice Res Unit, Sch Hlth, Lancashire Clin Trials Unit, Preston, Lancs, England Univ Leicester, Dept Cardiovasc Sci, Cardiovasc Res Ctr, British Heart Fdn, Leicester, Leics, England Univ Kelaniya, Dept Pharmacol, Fac Med, Colombo, Sri Lanka Christian Med Coll & Hosp, Dept Neurol, Ludhiana, India Kaohsiung Med Univ & Hosp, Dept Neurol, Kaohsiung, Taiwan Linkou Chang Gung Mem Hosp, Dept Neurol, Taipei, Taiwan Peking Union Med Coll Hosp, Beijing, Peoples R China Univ Sao Paulo, Ribeirao Preto Sch Med, Ribeirao Preto, Brazil Monash Univ, Dept Epidemiol & Prevent Med, Melbourne, Vic, Australia Univ Cent Lancashire, Sch Hlth Sci, Coll Hlth & Wellbeing, Preston, Lancs, England Univ Desarrollo, Santiago, Chile Univ New South Wales, Neurosci Res Australia, Sydney, NSW, Australia Natl Univ Singapore, Dept Pharmacol, Singapore, Singapore Bradford Royal Infirm, Bradford Inst Hlth Res, Leeds, W Yorkshire, England Christian Med College, Ludhiana, Punjab, India RemediumOne Pvt Ltd, Kandy, Sri Lanka Kaohsiung Med Univ, Chung Ho Mem Hosp, Kaohsiung, Taiwan Calvary Publ Hosp Bruce, Bruce, Australia Royal North Shore Hosp, St Leonards, NSW, Australia Royal Prince Alfred Hosp, Camperdown, NSW, Australia Concord Repatriat Gen Hosp, Camperdown, NSW, Australia Fiona Stanley Hosp, Camperdown, NSW, Australia Macquarie Base Hosp, Melbourne, Vic, Australia Univ Sao Paulo, Fac Med Ribeirao Preto, Hosp Clin, Sao Paulo, Brazil Hosp Governador Celso Ramos, Florianopolis, SC, Brazil Sao Paulo State Univ, Hosp Fac Med Botucatu, UNESP, Sao Paulo, Brazil Yangquan Coalmine Grp Gen Hosp, Yangquan, Peoples R China Nanjing Med Univ, Nanjing Hosp 1, Nanjing, Jiangsu, Peoples R China 85 Hosp Peoples Liberat Army, Beijing, Peoples R China Chifeng Univ, Affiliated Hosp, Chifeng, Peoples R China Beijing Pinggu Hosp, Beijing, Peoples R China Wenzhou Med Univ, Affiliated Hosp 1, Wenzhou, Peoples R China Soochow Univ, Affiliated Hosp 2, Suzhou, Peoples R China Hebei Med Univ, Hosp 3, Shijiazhuang, Hebei, Peoples R China Capital Med Univ, Xuanwu Hosp, Beijing, Peoples R China Jining Med Univ, Affiliated Hosp, Jining, Peoples R China Third Peoples Hosp Huizhou, Huizhou, Peoples R China Second Cangzhou Cent Hosp, Cangzhou, Peoples R China Shanghai Jiao Tong Univ, Hosp Affiliated, Sch Med, Shanghai, Peoples R China Baogang Hosp, Baotou, Peoples R China Harbin Med Univ, Affiliated Hosp 1, Harbin, Heilongjiang, Peoples R China Shanghai Jiao Tong Univ Sch, Tong Ren Hosp, Peoples Hosp Hejian City, Shanghai, Peoples R China Peking Univ, Shougang Hosp, Beijing, Peoples R China Guangzhou Med Univ, Affiliated Hosp 3, Guangzhou, Guangdong, Peoples R China Second Hosp Nanchang, Nanchang, Jiangxi, Peoples R China Bethune Int Peace Hosp, Beijing, Peoples R China Hua Henan Prov Peoples Hosp, Beijing, Peoples R China Hua Henan Prov Peoples Hosp, Zhengzhou, Henan, Peoples R China Shanghai Jiao Tong Univ, Sch Med, Shanghai Ninth Peoples Hosp, Shanghai, Peoples R China Shijiazhuang Cent Hosp, Shijiazhuang, Hebei, Peoples R China Hosp Base San Jos de Osorno, Osorno, Chile Christian Med Coll & Hosp, Ludhiana, Punjab, India Unit Narayana Hrudayalaya Ltd, Mazumdar Shaw Med Ctr, Bangalore, Karnataka, India Dr Ramesh Cardiac & Multispecial Hosp Pvt Ltd, Guntur, India Post Grad Inst Med Educ & Res, Chandigarh, India Baby Mem Hosp Ltd, Calicut, Kerala, India Sree Chitra Tirunal Inst Med Sci & Technol, Thiruvananthapuram, Kerala, India Sri Jayawardenepura Gen Hosp, Sri Jayawardenepura Kott, Sri Lanka Colombo North Teaching Hosp, Colombo, Sri Lanka Colombo South Coching Hosp, Colombo, Sri Lanka Linkou Chang Gung Mem Hosp, Taoyuan, Taiwan Taipei Med Univ, Shuang Ho Hosp, Taipei, Taiwan En Chu Kong Hosp, New Taipei, Taiwan Natl Cheng Kung Univ Hosp, Tainan, Taiwan Queen Alexandra Hosp, Portsmouth, Hants, England Portsmouth Hosp NHS Natl Hlth Serv iTrust, Portsmouth, Hants, England Univ Coll London Hosp NHS Fdn Trust, London, England Univ Hosp Birmingham NHS Fdn Trust, Queen Elizabeth Hosp Birmingham, Birmingham, W Midlands, England Southend Univ Hosp NHS Fdn Trust, Southend On Sea, England Kings Coll Hosp London, London, England York Teaching Hosp NHS Fdn Trust, York, N Yorkshire, England Nottingham Univ Hosp NHS Trust, Nottingham, England Blackpool Teaching Hosp NHS Fdn Trust, Blackpool, England Gloucestershire Hosp NHS Fdn Trust, Gloucestershire Royal Hosp, Gloucester, England Teaching Hospi NHS Fdn Trust, London, England Royal Cornwall Hosp NHS Trust, Truro, England Royal London Hosp, Barts Hlth NHS Trust, London, England Sheffield Teaching Hosp NHS Fdn Trust, Sheffield, S Yorkshire, England Cambridge Univ Hosp NHS Fdn Trust, Addenbrookes Hosp, Cambridge, England Royal Victoria Hosp, Belfast Hlth & Social Care Trust, London, England Pinderfields Gen Hosp, Mid Yorkshire Hosp NHS Trust, Wakefield, England Royal Devon & Exeter NHS Fdn Trust, London, England Bradford Teaching Hosp NHS Fdn Trust, Bradford, W Yorkshire, England Great Western Hosp NHS Fdn Trust, Swindon, Wilts, England Watford Dist Gen Hosp, Watford, England Imperial Coll Healthcare NHS Trust, London, England Medway NHS Fdn Trust, Gillingham, England Royal Liverpool & Broadgreen Univ NHS Trust, Liverpool, Merseyside, England Calderdale & Huddersfield NHS Fdn Trust, Huddersfield, W Yorkshire, England Hywel Dda Univ Hlth Board, Haverfordwest, Wales Chesterfield Royal Hosp NHS Fdn Trust, Calow, England Luton & Dunstable Univ Hosp NHS Fdn Trust, Luton, Beds, England Countess Chester Hosp NHS Fdn Trust, Chester, Cheshire, England Peterborough City Hosp, Peterborough, Cambs, England Univ Hosp Leicester NHS Trust, Leicester Royal Infirm, Leicester, Leics, England Dist Hosp NHS Fdn Trust, London, England Barnsley Hosp NHS Fdn Trust, Barnsley, England Dorset Cty Hosp NHS Fdn Trust, Dorchester, England Royal Bournemouth & Christchurch Hosp NHS Fdn Tru, Royal Bournemouth Hosp, Bournemouth, Dorset, England Southern Hlth & Social Care Trust, Craigavon Area Hosp, Portadown, England United Lincolnshire Hosp NHS Trust, Pilgrim Hosp, Lincoln, England Bedford Hosp NHS Trust, Bedford, England Sao Paulo State Univ, Hosp Fac Med Botucatu, UNESP, Sao Paulo, Brazil National Health and Medical Research Council of Australia: 1066966

Published
2019

8. Acute dural venous thrombosis

Author

Maam Mamun and Joshua P. Harvey

Subjects
medicine.medical_specialty, Neurology, Photophobia, Adolescent, Physical examination, Magnetic resonance angiography, Article, Sinus Thrombosis, Intracranial, medicine, Humans, Medical history, Thrombus, Venous Thrombosis, medicine.diagnostic_test, business.industry, Heparin, Anticoagulants, General Medicine, medicine.disease, Surgery, Venous thrombosis, Vomiting, Female, Radiology, medicine.symptom, business, Tomography, X-Ray Computed, Magnetic Resonance Angiography
Abstract

An 18-year-old female student presented with a 7-day history of worsening frontal headache and 1 day history of vomiting. The patient described marked photophobia, but no fever or history of seizure. She was taking a combined oral contraceptive and had no other medical history. Physical examination showed no focal neurology, but funduscopy revealed bilateral papilloedema. On admission, a non-contrast CT of the head showed a hyperdense thrombus, triangle sign (figure 1) and prominence of the superior sagittal, straight, right transverse and sigmoid …

Published
2015

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