Rate Of Cerebral Hemorrhage Research Articles

Observation of the Therapeutic Effect of Dual Antiplatelet Therapy with Aspirin and Clopidogrel on the Incidence, Characteristics, and Outcome in Acute Ischemic Stroke Patients with Cerebral Microbleeds at a Teaching Hospital, China.

Cerebral microbleeds (CMBs) are an important risk factor for stroke recurrence and prognosis. However, there is no consensus on the safety of antiplatelet therapy in patients with ischemic stroke and CMBs. This study aimed to observe the effects of dual antiplatelet therapy with aspirin and clopidogrel on bleeding conversion in patients with different degrees of CMBs. An observational retrospective study was conducted on 160 patients with acute mild ischemic stroke admitted to the Stroke Center, Affiliated Hospital of Beihua University between March 2021 and December 2022. Patients were divided into the CMBs and non-CMB groups. The CMB group was then divided into the low, medium and high-risk groups. In two groups, all patients were administered dual antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg orally once a day for 21 days according to the Chinese Stroke Guidelines of 2018), and no other anticoagulant or antiplatelet drugs were administered during the treatment period. Head CT, National Institutes of Health Stroke Scale(NIHSS) and modified Rankin Scale (mRS) score were re-checked, and the number of bleeding conversions was calculated at 21 days. Five patients in the CMB group had intracranial hemorrhage (5/116, 4.3%), while no intracranial hemorrhage was observed in the non-CMB group. There were no differences in the conversion rate of cerebral hemorrhage, NIHSS score, or mRS score between two groups after dual antiplatelet therapy (p>0.05). The conversion rate of cerebral hemorrhage in the high-risk group was higher than that in the non-CMB group (p<0.05), but the NIHSS and mRS score showed no difference between the high-risk and non-CMB groups (p>0.05). Dual antiplatelet therapy with aspirin and clopidogrel does not significantly increase the risk of bleeding transformation; however, it improves neurological recovery or long-term prognosis in patients with acute ischemic cerebral stroke complicated by low-risk and middle-risk CMBs.

Time‑dependent changes in blood cells, NIHSS and mRS according to reperfusion treatment type in stroke patients who developed hemorrhagic complication.

Hemorrhagic complications may be seen following reperfusion therapy with rtPA and/or thrombectomy after acute ischemic stroke (AIS). Neutrophils, lymphocytes, and platelets have important roles in the inflammatory and immune responses that develop in these patients. We investigated time‑dependent changes in blood cells, NIHSS and mRS values according to type of reperfusion therapy in AIS patients who developed cerebral hemorrhage. In AIS patients who underwent rtPA and/or thrombectomy and developed cerebral hemorrhage within the first 24 hours after treatment, leukocyte, neutrophil, lymphocyte, platelet counts and their ratios were recorded on admission, 1st, 3rd, and 7th days. NIHSS values on admission, 3rd days and mRS values on admission, discharge, and the 3rd month were recorded. These values were compared according to the type of reperfusion therapy. Out of 436 AIS patients, rtPA was applied in 50.5%, thrombectomy in 28.2%, and rtPA+thrombectomy in 21.3%. Hemorrhage developed in 25.5% of the patients. Patients treated with thrombectomy had a greater rate of cerebral hemorrhage. Pre‑stroke mRS values were lower in all therapy types than mRS scores at discharge and the 3rd month. The NIHSS scores did not differ significantly in 3 days. Depending on the type of reperfusion treatment, there are a few time‑dependent significant changes observed in the blood cell counts and ratios. In conclusion, there is a relation between the type of reperfusion therapy and the time‑dependent changes in blood cells and ratios as well as mRS scores among AIS patients who have undergone rtPA and/or thrombectomy and developed cerebral hemorrhage.

Characteristics and outcomes of elderly patients undergoing carotid stenting: Experience of a high-volume interventional cardiology center.

Carotid artery stenting (CAS) is an attractive option in order to treat carotid artery stenosis. However, its safety in elderly patients is questioned. Aim of this single-center retrospective study was to assess data of elderly patients undergoing CAS, and to compare them with those of the younger (< 75 years). We collected data of 580 consecutive patients undergoing CAS between December 2007 and June 2020 and compared clinical and procedural characteristics as well as in-hospital major adverse events (MACCE) and long-term mortality between patients < 75 years and patients ≥ 75 years old. There were 272 patients (46.9%) with age ≥ 75 years and 308 patients (53.1%) with age < 75 years. The median follow-up was 48 months (range 2-144). There was no significant difference about in-hospital MACCE between the two groups (4.7% in the older vs. 3.5% in the younger group, p=0.9), but a higher rate of cerebral hemorrhage occurred in the older group (1.8% vs. = 0.3%, p=0.07), even if not significant. Long-term mortality was significantly higher in the older group (27.9 vs. 20.1%, p=0.027). Multivariate predictors of 12-months mortality were neurologic symptoms within 6months (OR: 4.83; 95% CI: 2.04-11.42; p ≤ 0.001), smoking status (OR: 2.84; 95% CI: 1.17-6.86; p=0.02) and age ≥ 75 years (OR: 2.78; 95% CI: 1.14-6.76; p=0.024). In elderly patients, CAS can be carried out efficaciously with acceptable procedural risks, if performed by expert operators and after a correct selection by a multidisciplinary team.

Abstract TP422: Comparison of Natural History and Effect of Intracranial Stent Placement Between Patients With Intra-Dural and Those With Sub-Arachnoid Intracranial Arterial Stenosis

Background: Intracranial stenosis can be located in intradural or subarachnoid space. It is unclear whether there are any differences in ipsilateral ischemic stroke risk, cerebral hemorrhage and death in response to stent placement in these two locations. Methods: We analyzed Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis (SAMMPRIS) data. We divided the patients based on location of arterial stenosis: intradural [petrous internal carotid artery (ICA), pre-cavernous ICA, cavernous ICA or pre-posterior inferior cerebellar artery (PICA) vertebral artery] and subarachnoid [post-cavernous ICA, middle cerebral artery, vertebral artery at the level of or distal to origin of PICA, or basilar artery]. Cox proportional hazards analyses were used to determine the effect of intradural versus subarachnoid location on risk of ipsilateral ischemic stroke, cerebral hemorrhage or death during the follow-up period. Results: A total of 451 patients with stenosis located in intradural (n=74, 16.4%) or subarachnoid (n=377, 83.5 %) spaces were followed for a mean (SD) period of 29.06 (15.22) months after randomization. The rate of ischemic stroke seen in intradural and subarachnoid spaces was 11.86% and 14.58%, respectively. The rate of cerebral hemorrhage in the intradural and subarachnoid spaces was 1.35% and 2.92 %, respectively. The rate of death in the intradural and subarachnoid spaces was 10.81% and 1.59%, respectively. In Cox proportional hazards analyses, the risk of ipsilateral ischemic stroke (HR 1.08, P = 0.46), cerebral hemorrhage (HR 1.05, P = 0.59) and death (HR 0.9, P = 0.9) was not significantly different between patients with intradural arterial stenosis and those with subarachnoid arterial stenosis. The interaction between location of stenosis and treatment (intracranial stent versus best medical treatment) was not significant for the either ipsilateral ischemic stroke (p= 0.21), cerebral hemorrhage (p= 0.18) or death (p=0.15). Conclusion: We did not find any evidence to suggest that there was any difference in natural history or response to intracranial stent placement in patients with intradural location of stenosis compared with those with subarachnoid location.

Abstract P451: Cerebrovasuclular Events in Patients With Primary Aldosteronism: Results of the PA Sendai Study Registry

Background: Hyperaldosteronism is associated with the risk of cardio-and cerebrovascular events (CVE) that is independent of blood pressure levels and Primary aldosteronism (PA) display a higher risk of CVE compared with essential hypertension (EH). Objective: Our objective was to elucidate the prevalence of symptomatic stroke in PA patients and to characterize their clinical features. Design and Setting: This was a retrospective cross-sectional single center study (PA Sendai Study registry) between 2007 and 2016 in Japan. Patient: 807 patients with PA were registered and analyzed. The all patients were performed adrenal venous sampling(AVS) to make the diagnosis of PA subtypes. Results: Of 807 patients (male/female:395/412, age:53.3±11.8), 357 patients (44.2%) with alsosterone producing adenoma underwent adrenalectomy. The other patients were treated by medical therapy mostly administrating MR antagonists. Around the same time performed AVS, 698 patients were also performed MRI brain scans. Unruptured cerebral aneurysms were detected in about 4%, and Silent Brain Infarction were detected mainly around subcortical and basal ganglia region in about 30%. 27 patients (3.35%) suffered symptomatic stroke before the confirmed diagnosis of PA. The ratio of elderly and male was significantly high in stroke patients with PA. These patients had a higher rate of cerebral hemorrhage (thalamus or putaminal hemorrhage) rather than cerebellar infarction (63% vs 37%, p&lt; 0.05). 457/807 patients (56.65%) were follow-up continually (period of observation: mean 1907 days) in our medical center. During this follow-up period, 6 patients died (malignant disease: 1, advanced heart failure: 2, cerebellar infarction: 1, unknown: 1). Eventually, the only 6 patients had new onset of cerebrovascular events (cerebral infarction: 4, cerebellar hemorrhage: 2). Over all, the prevalence of new-onset CVE was 1.8% in the patients treated for PA subtypes specific. Conclusion: This study suggests that the aldosterone excess in untreated PA patients particularly damages cerebral small vessels around subcortical and basal ganglia region. By extension, PA subtypes specific treatment and early diagnosis are useful in preventing CVE.

Efficacy comparison of three vascular recanalization in patients with acute vertebrobasilar occlusion

Objectives: To investigate the therapeutic effects of intravenous thrombolysis, intra-artery thrombolysis, mechanical thrombectomy on patients with acute vertebrobasilar occlusion. Methods: Retrospective analysis of clinical data of patients with acute vertebrobasilar occlusion, admitted to Huai'an First People's Hospital and Bingtuan Qishi Hospital from January 2014 to January 2016, was performed. According to different vascular recanalization, these patients were divided into intravenous thrombolysis group, intra-artery thrombolysis group and mechanical thrombectomy group. Clinical outcomes were compared among the three groups such as recanalization rates( modified thrombolysis in cerebral infarction[mTICI]≥2b), changes of NIHSS scores after 24 hours(scores decreased at least 4 points or complete resolution of symptoms), symptomatic cerebral hemorrhage rate(European Cooperative Acute Stroke Study Ⅱ standard) and modified Rankin scale(mRS) score improvement 3 months after treatment. Results: Among patients from mechanical thrombectomy group, the recanalization rate was 87.5%(28/32), 22 patients(68.8%)got good outcome according to the significant decrease of NIHSS scores, symptomatic intracranial hemorrhage occurred in 3 patient (9.4%), the rate of good prognosis(mRS≤2) at 3 months was 50.0% (16/32). In patients from intravenous thrombolysis group, the rate of recanalization was 34.8% (16/46), 12 patients(26.1%)got apparent decrease of NIHSS scores, symptomatic cerebral hemorrhage occurred in 14 patients(30.4%), the rate of good clinical outcome(mRS ≤2) at 3 months was 17.4%(8/46). Among patients from intra-arterial thrombolysis group, the recanalization rate was 53.3%(16/30), 12 patients(40.0%) got good outcome according to the significant decrease in NIHSS score, symptomatic intracranial hemorrhage occurred in 6 patients(20.0%), the rate of good prognosis(mRS≤2) at 3 months was 26.7%(8/30). The rate of complete recanalization and NIHSS score improvement at 24 hours were significantly higher in the mechanical thrombectomy group than the intravenous or intra-arterial thrombolysis group(χ(2)=21.324, P<0.001; χ(2)=14.162, P=0.001). The good outcome(mRS≤2) at 3 months was more frequent in the mechanical thrombectomy group than the intravenous or intra-arterial thrombolysis group (χ(2)=9.799, P=0.007). The differences of symptomatic intracranial hemorrhage rate among the three treatment groups were not statistically significant(χ(2)=5.035, P=0.081). Conclusion: As compared with the intravenous or intra-arterial thrombolysis, the mechanical thrombectomy has better efficiency and safety in the treatment of acute vertebrobasilar occlusion.

Thrombolysis Is Not Associated with a Higher Rate of Cerebral Hemorrhage in Patients with Severe Ischemic Stroke

Thrombolysis Is Not Associated with a Higher Rate of Cerebral Hemorrhage in Patients with Severe Ischemic Stroke

Effects of Surgery and Antiplatelet Therapy in Ten-Year Follow-Up from the Registry Study of Research Committee on Moyamoya Disease in Japan

Despite the common practice of surgery and antiplatelet therapy for the prevention of recurrent stroke in patients with moyamoya disease, the benefit of these treatments is controversial. We analyzed the stroke recurrence rate in the Registry Study of Research Committee on Moyamoya Disease in Japan funded by the Health, Labor and Welfare Ministry of Japan. An annual follow-up study of the registered cases was continued for 10 years. The rate of recurrent stroke, including cerebral infarction and hemorrhage but not transient ischemic attack and seizure, was evaluated with Kaplan-Meier analysis. The proportion of childhood-onset cases decreased in recently registered cases (within 10 years, n = 541) compared to remote cases (> 10 years, n = 735). Among types at disease onset in adult-onset cases, intracerebral hemorrhage decreased recently. In recent cases, the rate of subsequent cerebral hemorrhage was much higher in the hemorrhagic group (10.9 ± 3.3%/5 years) than in the ischemic group (2.0 ± .9%/5 years). The recurrence rate of cerebral infarction was lower in the surgery group (1.8 ± .9%/5 years) than in the nonsurgery group (3.8 ± 2.2%/5 years). In the adult-onset ischemic group, the proportion of surgically treated patients increased and their recurrence rate was lower than that of nonsurgery patients. In the ischemic group, the rate of cerebral infarction was not significantly different between the antiplatelet subgroup and the non-antiplatelet subgroup, whereas the rate of cerebral hemorrhage was higher in the non-antiplatelet subgroup than in the antiplatelet subgroup. Our results suggest revascularization surgery may suppress recurrent ischemic attacks in patients with moyamoya disease.

326: Pulmonary embolysm and thrombolysis

To determine the value, limitations and complications of thrombolysis in pulmonary embolism. This is a descriptive study of all patients admitted to the cardiology department of CHU Ibn Rushd from 2009 to 2011 with pulmonary embolism confirmed by echocardiography and chest CT angiography. These 68 patients with a mean age of 49 months or over 19 years with a female. The styles of pulmonary embolism vary widely with the management is different. 5% of patients with pulmonary embolism occurs in cardiac arrest and fibrinolysis offers better benefits and has no indication cons. 10 to 20% of pulmonary embolism with hemodynamic instability occurs PAS ≤ 90 mmHg or respiratory distress Quick Installation fibrinolysis in these patients provides better clinical improvement and ultrasound. Pulmonary embolism at low risk and intermediate risk shows no indication for fibrinolysis using simple anticoagulation. The rate of cerebral hemorrhage is zero, 5 cases of gastrointestinal bleeding under control, intra-hospital overall mortality is about 7%. This series demonstrates the value of thrombolysis on the dissolution of stones in the pulmonary arteries and hemodynamic parameters as well as the reduction in mortality despite the slight increased risk of bleeding.

Low-Molecular-Weight Heparin and Early Neurologic Deterioration in Acute Stroke Caused by Large Artery Occlusive Disease

Patients with acute ischemic stroke and large artery occlusive disease (LAOD) have an increased risk for early neurologic deterioration (END) due to progressive stroke, early recurrent ischemic stroke(ERIS), or symptomatic intracranial cerebral hemorrhage(SICH). Low-molecular-weight heparin (LMWH)has been widely advocated to prevent venous thromboembolism,but its risks and benefits in early ischemic stroke are inadequately defined. To determine the efficacy and safety of LMWH in treating END in patients with acute ischemic stroke and LAOD. Post hoc analysis of randomized, controlled trial. Academic research. Among 603 patients recruited, 353 patients(180 treated with LMWH, 173 with aspirin) had acute ischemic stroke and LAOD. Patients were randomly assigned to receive either subcutaneous LMWH or oral aspirin within 48 hours after stroke onset for 10 days, then all received aspirin once daily for 6 months. We assessed whether LMWH was superior to aspirin for the prevention of END within the first 10 days after index stroke. Early neurologic deterioration was defined as a composite end point of progressive stroke, ERIS, and SICH. Among 353 patients included in the study, END within the first 10 days occurred in 6.7% of LMWH allocated patients (12 of 180 patients) compared with 13.9% of aspirin-allocated patients (24 of 173). Low molecular-weight heparin was significantly associated with the reduction of END(absolute risk reduction, 7.2%; odds ratio [OR], 0.44; 95% CI, 0.21-0.92). When individual components of END were examined, LMWH was significantly associated with a lower frequency of stroke progression within the first 10 days compared with aspirin(5.0% [9 of 180] vs 12.7% [22 of 173]; OR, 0.36; 95%CI, 0.16-0.81). Meanwhile, among those taking LMWH vs aspirin, the frequency rates of ERIS were 1.1% (2 of 180) vs 0 (0); 0.6% (1 of 180) vs 1.2% (2 of 173) for SICH;and 2.2% (4 of 180) vs 2.9% (5 of 173) for symptomatic and asymptomatic cerebral hemorrhage, respectively; they showed nonsignificant trends. Early neurologic deterioration was significantly associated with 6-month disability with both LMWH(OR, 12.75; 95% CI, 3.27-49.79 on Barthel Index and OR, 18.15; 95% CI, 2.09-157.93 on modified Rankin Scale) and aspirin (OR, 6.09; 95% CI,2.44-15.20 on Barthel Index and OR, 7.50; 95% CI, 2.08-27.04 on modified Rankin Scale) groups. For patients with acute ischemic stroke and LAOD, treatment with LMWH within 48 hours of stroke may reduce END during the first 10 days, mainly by preventing stroke progression. The similar rate of cerebral hemorrhage between LMWH and aspirin demonstrated that LMWH may be safely used in acute ischemic stroke. stroke center.org/trials Identifier: FISS -tris

Safety of Tirofiban in Acute Ischemic Stroke

Tirofiban is a highly selective, fast-acting nonpeptide glycoprotein IIb/IIIa platelet receptor antagonist with a short half-life time. Glycoprotein IIb/IIIa antagonists are effective for the treatment of acute coronary syndromes proven in large clinical trials. Safety and efficacy in patients with ischemic stroke are uncertain. This was addressed in the Safety of Tirofiban in acute Ischemic Stroke (SaTIS) trial. Two hundred sixty patients with acute ischemic stroke were randomized in a placebo-controlled, prospective, open-label treatment, blinded outcome reading multicenter trial. Subjects with a National Institutes of Health Stroke Scale between 4 and 18 received intravenously either tirofiban or placebo within 3 to 22 hours after symptom onset for 48 hours. The primary end point was the rate of cerebral bleeding as measured in follow-up CT scans 2 to 7 days after inclusion. The secondary end point was clinical efficacy within 1 week (National Institutes of Health Stroke Scale, modified Rankin Scale) and after 5 months (Barthel Index, modified Rankin Scale). The rate of cerebral hemorrhagic transformation (I/II) and parenchymal hemorrhage (I/II) did not differ between both groups (tirofiban 36 of 120; placebo 33 of 124: OR, 1.18; 95% CI, 0.66 to 2.06). Mortality after 5 months was significantly lower in patients treated with tirofiban (3 of 130 [2.3%] versus 11 of 126 [8.7%]; OR, 4.05; 95% CI, 1.1 to 14.9). No difference in neurological/functional outcome was found after 1 week and after 5 months. We conclude that tirofiban might be safe in acute moderate ischemic stroke even when administered within a large time window after symptom onset and might save lives in the late outcome. Clinical Trial Registration- URL: www.strokecenter.org/trials/. Trial name: SaTIS. Enrollment began before July 1, 2005.

Microplasmin and Tissue Plasminogen Activator: Comparison of Therapeutic Effects in Rat Stroke Model at Multiparametric MR Imaging

To prospectively compare therapeutic and hemorrhagic effects of microplasmin and tissue plasminogen activator (tPA) in stroke therapy by using multiparametric magnetic resonance (MR) imaging in a photothrombotic rat stroke model. The animal experiment complied with institutional regulations for laboratory animals. Stroke was induced in rats with photothrombotic occlusion of middle cerebral artery (MCA). T2-weighted, perfusion-weighted (PW), and diffusion-weighted (DW) MR imaging was performed 1 hour and 24 hours after occlusion. On the basis of PW and DW images at 1 hour, 49 rats with cortex and subcortex involvement and with perfusion-diffusion mismatch were randomly assigned into one of four groups: control group, group treated with 7.5 mg microplasmin, group treated with 10 mg/kg microplasmin, or group treated with 10 mg/kg tPA. Agents were intravenously injected 1.5 hours after occlusion. Infarct size and hemorrhagic transformation were assessed with MR imaging and histomorphologic findings. Neurologic deficit was scored. Measurements were statistically analyzed. There were 13 rats in the control group, 13 in the 7.5 mg/kg microplasmin group, nine in the 10 mg/kg microplasmin group, and 14 in the 10 mg/kg tPA group. Despite similar baseline perfusion-diffusion mismatch, histochemically defined total infarct volume was reduced from 25% +/- 5 (standard deviation) in control group to 21% +/- 2, 20% +/- 4, and 20% +/- 5 in 7.5 mg/kg microplasmin, 10 mg/kg microplasmin, and tPA groups, respectively, as similarly shown on T2-weighted, DW, and PW images at 24 hours (P < .05). Cerebral hemorrhage rate at 24 hours was higher in tPA group than in the other three groups. Bederson score of neurologic deficits was significantly reduced in treated groups compared with that in control group. Perfusion-diffusion mismatch appeared useful in selecting candidates for thrombolytic therapy. Multiparametric MR imaging allowed noninvasive assessment of effects of microplasmin and tPA in rats; microplasmin had a significantly lower hemorrhagic rate.

Predictive Factors for Intracerebral Hemorrhage in Patients with Cavernous Angiomas

Objectives: Prediction of intracerebral hemorrhage (ICH) in patients with cavernous angiomas is not totally elucidated. The aims of our study were to determine the rate of cerebral hemorrhage, its associated factors, and the clinical outcome in patients with cavernous angiomas in a Hispanic population.Methods: We studied 133 patients with cavernous angiomas. The patients were classified into two groups depending on whether they presented an ICH. A comparative analysis of demographics and clinical data, neuroimaging characteristics, and prognosis was carried out in patients with and without hemorrhage. The hemorrhage rate (expressed as the percentage per patient per year) was also estimated.Results: Seventy–eight patients (59%) had hemorrhage. Non–lobar location of angiomas was associated with hemorrhage [OR 4.82 (CI 95% 2.17–10.73; p=<0.001)]. In contrast, factors associated with a decreased risk of hemorrhage were a family history of epilepsy [OR 0.30 (CI 95% 0.10–0.79; p=0.016)] and lobar location of the angiomas [OR 0.21 (CI 95% 0.09–0.46; p=<0.001)]. The hemorrhagic rate of 1.71% per patient per year was influenced by the location. It was only 1.22% per patient per year in lobar angiomas and 2.33, 2.39, and 2.82% per patient per year for brainstem, cerebellum, and deep hemispheric angiomas, respectively.Conclusions: The non–lobar location of cavernous angiomas gives a higher risk of hemorrhage in our Mexican mestizo population, without the hemorrhage being related to either age or sex.

May 13 Highlights

Hill et al. identified an increased risk of hemi-prolingual angioedema after tissue plasminogen activator treatment of acute ischemic stroke associated with angiotensin-converting enzyme inhibitor use and infarction of the frontal and insular cortex. The reaction was usually clinically mild. See page 1525 Thrombolysis—a therapy of proven benefit for stroke—has defined risks, notably a 6% cerebral hemorrhage rate.1 Allergic reactions are rare, but an intriguing syndrome of hemi-orolingual angioedema can occasionally occur contralateral to the treated stroke.2 In the largest case series to date, the Calgary stroke team collected nine patients who experienced hemi-orolingual angioedema after receiving tissue plasminogen activator (t-PA) for stroke for >5 years.3 The team carefully examined 176 consecutively treated stroke patients to find these nine cases. The 5% incidence of hemi-orolingual angioedema in this study is remarkable and is hard to explain; other stroke programs with equal or larger numbers have not seen angioedema as often. Indeed, after many hundreds of t-PA doses administered personally, I have seen it only once, despite looking for it. The mechanism proposed in the article, involving bradykinin metabolism, is plausible and suggests a way to treat the complication. The statistical analysis of Hill et al. provides credence that early ischemic changes (EIC) seen on acute CT brain scans may have related to the incidence of the hemi-orolingual angioedema, although their patient numbers are …

Stroke in renal transplant recipients: epidemiology, predictive risk factors and outcome.

Cerebrovascular and cardiovascular diseases are the most important causes of increased morbidity and mortality in patients with end-stage renal disease. Stroke has been widely reported in chronic dialysis patients, but there is scarce information about stroke in renal transplant recipients (RTR), although cerebrovascular events are the most common and potentially life-threatening neurological complications in them. Our aim is to analyze the prevalence, risk factors, etiopathogenia, clinical aspects and outcome of stroke in RTR. We analyzed 403 patients who received one or more renal grafts between 1979 and 2000: group A = patients who had stroke (n = 19); group B = those who did not (n = 384). Medical records and pertinent data were compiled. The risk of stroke was studied using univariate and multivariate Cox regression models. prevalence of stroke in RTR was 7.97% at 10 yr. Time elapsed between renal transplantation (RT) and stroke: 49.3 months. Possible risk factors based on the univariate analyses were: diabetic nephropathy (DN) (p < 0.001) and autosomal-dominant-polycystic-kidney-disease (p = 0.049) as original nephropathies, peripheral vascular disease (PVD) (p < 0.001), diabetes mellitus prior to RT (p = 0.005), age older than 40 yr (p = 0.037) and hypertension (p = 0.049). Other analysed risk factors such as gender, renal function, cytomegalovirus infection, hyperlipidemia, hyperuricemia, erythrocytosis or hypertensive donor failed to show any significant predictive value for stroke in these patients. When multivariate analyses were carried out, we found that DN (OR = 4.8; p = 0.010), PVD (OR = 8.2; p < 0.001) and age > 40 yr (OR = 3.3; p = 0.019) were predictive risk factors for stroke. For group A, hypertension was present in all patients, 68.4% had hyperlipidemia and 42.1% reported previous stroke. Cerebral hemorrhage occurred in seven of 19 (36.84%) of the stroke patients, but no subarachnoid hemorrhage occurred in them. Seven of 12 ischemic strokes were atherotrombotic. Considering all strokes, basal ganglia was the predominant localization. The outcome was poor, as nearly half of the patients died in the 3 months following stroke. Prevalence of stroke in our RTR population was 7.97%. Cerebral hemorrhage appears to be more prevalent in RTR than in general population. More than that, the cerebral hemorrhage rate we found is higher than that reported elsewhere in RTR. The main predictors of stroke were DN, PVD and age. No patient with interstitial nephropathy suffered stroke. Mortality is high in RTR with stroke.

Stroke subtypes among Hispanics living in Guayaquil, Ecuador. Results from the Luis Vernaza Hospital Stroke Registry.

Racial differences in stroke subtypes have been documented. Asians have a higher rate of cerebral hemorrhage than whites; however, there is little information about stroke subtypes among Hispanics. The purpose of this study was to determine the patterns of stroke subtypes in a population of Hispanics. Five hundred consecutive patients with a first stroke were included. Patients were collected from hospital wards, the emergency department, and the outpatient clinic to ensure inclusion of patients with a wide range of stroke severity. Computed tomography was available in all cases. Patients with pure subarachnoid hemorrhage were excluded. There were 313 (62.6%) patients with an infarct and 187 (37.4%) with a hemorrhage. Hypertensive arteriolopathy was the most common cause of both infarcts and hemorrhages. The carotid territory was involved in 70.6% of the 313 patients with infarcts, the vertebrobasilar territory in 17.9%, multiple territories in 6.7%, and a watershed area in 4.8%. Hemorrhages were most often lobar (36.4%), followed by putaminal (30.5%), brain stem (9.1%), cerebellar (8%), thalamic (8%), ventricular (5.3%), and caudate (2.7%). This hospital-based stroke registry suggests that stroke in Hispanics has a pattern different from that in whites but similar to that in Asians. Cerebral hemorrhages occur three times more frequently in Hispanics than in whites.

Comparative safety of thrombolytic agents

Three available thrombolytic agents, streptokinase, alteplase, and anistreplase, have been shown to have similar effects on preservation of left ventricular function and mortality reduction after acute myocardial infarction (AMI). The agents are, however, quite different with respect to their safety profiles. Clinical trials to date suggest that alteplase (tissue plasminogen activator) or anistreplase administration is associated with a high incidence of cerebral hemorrhage. In contrast, streptokinase is associated with a low rate of cerebral hemorrhage. Streptokinase and anistreplase are associated with a higher risk of allergic reaction when compared with alteplase. Hypotension is also more common with streptokinase and anistreplase, but occurs significantly with alteplase as well. Alteplase is associated with a lower reinfarction rate when compared with streptokinase and anistreplase. The Third International Study of Infarct Survival (ISIS-3), a direct comparison of 3 thrombolytic agents (streptokinase, anistreplase, and duteplase), may provide some insight regarding the safety of these agents. Because these agents have been shown to be equally effective, selection of an appropriate agent for an individual patient may depend more on assessment of the likelihood of an adverse event or other factors, such as cost or convenience of administration, rather than assessment of the probability of greater benefit with a particular agent.

Incidence of cerebral hemorrhage after treatment with tissue plasminogen activator or streptokinase following embolic stroke in rabbits [corrected

We studied thrombolysis in an animal model of embolic stroke to determine the safety of tissue plasminogen activator and streptokinase. We occluded the middle cerebral arteries of 137 rabbits with radiolabeled blood clots and administered tissue plasminogen activator (n = 49), streptokinase (n = 40), or saline (n = 48) at various times after embolization. We assessed the rate of thrombolysis and cerebral hemorrhage 24 hours later. Both drugs were very effective in producing thrombolysis. Compared with saline, streptokinase caused a significant increase in the rate of cerebral hemorrhage (p less than 0.05), but tissue plasminogen activator did not. We conclude that thrombolytic therapy for acute stroke should be safer with tissue plasminogen activator than with streptokinase.