Worse Stroke Outcome in Atrial Fibrillation is Explained by More Severe Hypoperfusion, Infarct Growth, and Hemorrhagic Transformation

Tu, Hans; Campbell, Bruce; Christensen, Søren; Desmond, Patricia; Silva, Deidre Anne De; Parsons, Mark; Чурилов, Леонид; Lansberg, Maarten G.; Mlynash, Michael; Olivot, Jean‐Marc; Straka, Matús; Bammer, Roland; Albers, Gregory W.; Donnan, Geoffrey A.; Davis, Stephen M.

doi:10.1111/ijs.12007

Cited by 140 publications

(117 citation statements)

References 37 publications

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“…4,8 Large registries and trials have shown that AF-related strokes constitute the most severe ischemic stroke subtype. 3,5,6,9 Yet, the majority of studies compared patients with AF-related strokes to patients with strokes deemed unrelated to cardioembolic sources; i.e., those with small or large vessel disease related strokes. 5,6,9 An important remaining question is whether the risk for a unfavorable post stroke outcome after CES differs based on the underlying pathomechanism.…”

Section: Introductionmentioning

confidence: 99%

“…3,5,6,9 Yet, the majority of studies compared patients with AF-related strokes to patients with strokes deemed unrelated to cardioembolic sources; i.e., those with small or large vessel disease related strokes. 5,6,9 An important remaining question is whether the risk for a unfavorable post stroke outcome after CES differs based on the underlying pathomechanism. Specifically, do patients with AF-related CES have a greater ischemic stroke severity and worse outcomes than patients with non-AF related CES?…”

Section: Introductionmentioning

confidence: 99%

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Atrial Fibrillation Is Associated With a Worse 90-Day Outcome Than Other Cardioembolic Stroke Subtypes

Henninger

Goddeau

Karmarkar

et al. 2016

Stroke

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Background and Purpose Patients with a cardioembolic stroke (CES) have worse outcomes than stroke patients with other causes of stroke. Among patients with CES, atrial fibrillation (AF) is a common comorbidity. Mounting data indicates that AF may relate to stroke pathogenesis beyond acute cerebral thromboembolism. We sought to determine whether AF represents an independent risk factor for stroke severity and outcome among patients with CES. Methods We retrospectively analyzed patients with acute hemispheric CES included in an academic medical center’s stroke registry. CES was determined using the Causative Classification System of ischemic stroke. Multivariable logistic regression was used to determine whether AF was associated with 90-day outcome functional status. Results Our cohort included 140 patients. Of these, 52 had prevalent AF and 28 had incident AF diagnosed during their index hospitalization or within 90-days of hospital discharge. After adjustment for potential confounders or mediators, any AF (OR 2.51; 95%-CI 1.03–6.33; p=0.049), infarct volume (OR 1.03; 95%-CI 1.01–1.06; p=0.005), pre-admission mRS (OR 2.58; 95%-CI 1.66–4.01; p<0.001), and admission National Institutes of Health Stroke Scale score (OR 1.17; 95%-CI 1.08–1.28; p<0.001) remained associated with an unfavorable 90-day outcome (modified Rankin Scale 2–6). Conclusions AF is associated with an unfavorable 90-day outcome among patients with a CES independent of established risk factors and initial stroke severity. This suggests that AF-specific mechanisms impact CES severity and functional status after CES. If confirmed in future studies, further investigation into the underlying pathophysiological mechanisms may provide novel avenues to AF detection and treatment.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Atrial Fibrillation Is Associated With a Worse 90-Day Outcome Than Other Cardioembolic Stroke Subtypes

Henninger

Goddeau

Karmarkar

et al. 2016

Stroke

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“…Presence of atrial fibrillation in stroke patients most likely via poorer collateral blood supply is associated with more severe hypoperfusion and hence with increased infarct growth and volume, more frequent and more severe HT and worse stroke outcome [96].…”

Section: Atrial Fibrillationmentioning

confidence: 99%

Hemorrhagic transformation of ischemic stroke

J¹,

Hortobágyi²

2017

Vascul Dis Ther

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The better understanding of the diverse mechanisms leading to the hemorrhagic transformation of an ischemic stroke is the crucial point in the prevention of this altogether common phenomenon. The different individual risk factors include the anatomical variability of collateral blood supply, age, genetics, body weight, etiology of the occlusion, side of the occluded vessel, renal status, stroke severity, history of high serum glucose or hypertension and hypertension or hyperglycemia at the onset of the stroke, ferritin level, INR, antiplatelet usage or the platelet count etc. All these might contribute to the process of hemorrhagic transformation. These risk factors have been identified by retrospective epidemiological studies and are useful to identify patients who are at high risk for hemorrhagic conversion and help the decision between conservative, thrombolytic or more advanced treatments such as thrombectomy. The modulations of potential molecular targets participating in the process seem to be promising in animal models, but human trials are lacking the breakthrough success so far, both in extending the time frame of the thrombolysis and in replacing the recombinant tissue plasminogen activator (rtPA) as thrombolytic agent.So far, the careful preselection of patients eligible for thrombolytic therapy is the best way to prevent hemorrhagic transformation. The intensive research in the field revealing small but important molecular details are continuously contributing to the better understanding of hemorrhagic transformation with the intention of finding new agents that co-administrated to the rtPA or completely replacing that could decrease the risk of secondary bleeding.The aim of this review is to give comprehensive insight into the process of hemorrhagic transformation of ischemic stroke, starting with basic overview of the penumbra concept and the collateral supply followed by discussion of the recanalisation-reperfusion-hemorrhagic transformation process after vessel occlusion also highlighting the importance of timing and ratio of recanalisation spontaneously and in case of thrombolytic agent administration. We overview the risk factors of hemorrhagic transformation, which may be helpful to physicians to identify high risk patients before rtPA administration. The last part of the work is dealing with future therapeutic possibilities based on the so far revealed molecular mechanisms of hemorrhagic transformation. With the aim to assess the rate and influencing factors on the recanalisation and reperfusion rate 381 patients with large-vessel occlusion was investigated. The patient group involved ones treated with rtPA or treated conservatively. Partial or complete recanalisation was achieved in 121 out of 210 (58%) patients after intravenous rtPA administration. The recanalisation success was more likely if the patient had atrial fibrillation [4] -maybe because cardioembolic clots consists more fibrin and are more likely to reopen by plasmin proteolysis than thrombosis of an atherosclerotic plaq...

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“…58 The risk of hemorrhagic transformation is also increased by pre-existing patient factors such hyperglycemia, 59 poor collateral flow, 60 anticoagulant therapy, and atrial fibrillation/cardioembolic stroke. 61,62 Certain imaging parameters may also signal an increased risk of hemorrhagic transformation following thrombolytic therapy. With regard to treated anterior circulation infarcts within 6 hours, a retrospective study by the MR Stroke Study Group Investigators found a 5.8-fold increased risk of symptomatic Intracerebral hemorrhage (ICH) with large (>100 mL) compared with small (<10 mL) pretreatment DWI volume infarct cores, and a 2.8-fold increased risk compared with moderate (10 to 100 mL) core volumes.…”

Section: Complications Of Acute Infarction and Reperfusion Therapymentioning

confidence: 99%

Magnetic Resonance Imaging in Ischemic Stroke and Cerebral Venous Thrombosis

Krieger

Dehkharghani

2015

Topics in Magnetic Resonance Imaging

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Imaging is indispensable in the evaluation of patients presenting with central nervous system emergencies. Although computed tomography (CT) is the mainstay of initial assessment and triage, magnetic resonance imaging (MRI) has become vital in expanding diagnostic capabilities, refining management strategies, and developing our understanding of disease processes. Ischemic stroke and cerebral venous thrombosis are 2 areas wherein MRI is actively revolutionizing patient care. Familiarity with the imaging manifestations of these 2 disease processes is crucial for any radiologist reading brain MR studies. In this review, the fundamentals of image interpretation will be addressed in-depth. Furthermore, advanced imaging techniques which are redefining the role of emergency MRI will be outlined, with a focus on the pathophysiological mechanisms that underlie image interpretation. In particular, emerging data surrounding the use of MR perfusion imaging in acute stroke management portend dramatic shifts in neurointerventional management. To this end, a review of the recent stroke literature will hopefully enhance the radiologist's role in both meaningful reporting and multidisciplinary teamwork.

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Worse Stroke Outcome in Atrial Fibrillation is Explained by More Severe Hypoperfusion, Infarct Growth, and Hemorrhagic Transformation

Cited by 140 publications

References 37 publications

Atrial Fibrillation Is Associated With a Worse 90-Day Outcome Than Other Cardioembolic Stroke Subtypes

Atrial Fibrillation Is Associated With a Worse 90-Day Outcome Than Other Cardioembolic Stroke Subtypes

Hemorrhagic transformation of ischemic stroke

Magnetic Resonance Imaging in Ischemic Stroke and Cerebral Venous Thrombosis

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