1,721,126 research outputs found
Characteristics and outcomes of intracerebral hemorrhage in a population-based stroke registry
Full text linkBackground. Intracerebral hemorrhage (ICH) is the most severe stroke type. Understanding the epidemiology and pathogenesis of ICH is key to design adequate prevention and treatment strategies to improve the dismal prognosis of ICH.
Methods. We performed a prospective population-based study in the district of L’Aquila covering the years 2011-2019. ICH incidence, 30-day and 1-year and case-fatality rates (CFRs) were computed in patients residing in the district and suffering a first-ever ICH over the 2011-2017 period (incidence dataset). All the other assessments were performed in residents of the district reporting either a first-ever ICH or an ICH after a stroke during the 2011-2019 period (full dataset). Cases were actively monitored from multiple sources.
We classified ICH according to the SMASH-U system. ICH volumes were calculated using the ABC/2 method. The presence of radiological Edinburgh criteria, including associated subarachnoid hemorrhage (aSAH) and finger-like projections (FLPs) was assessed on the first available brain CT of patients with lobar ICH.
Crude incidence rates were calculated assuming a Poisson distribution. Incidence rates were also standardized to the European population using the direct method. Univariate comparisons were performed using the chi-square test, t test, ANOVA, Mann-Whitney or Kruskal-Wallis tests, as appropriate. Logistic regression or Cox regression models were used to perform multivariate analyses.
Results. We identified 645 patients with ICH (full dataset; 58.6% men; mean age 75.3±13.4 years). The incidence dataset included 514 patients. The crude ICH incidence rate was 24.6 per 100,000 person-years (95% confidence interval [CI] 22.5-26.8); the corresponding rate was 19.4 per 100,000 person-years (95% CI 17.9-20.9) after standardization to the European population. Case-fatality rates were 36.0% at 30 days and 44.6% at 1-year.
Compared with the 567 patients with a first-ever ICH, the 78 patients with ICH after a stroke had a higher pre-stroke disability (median modified Rankin Scale score 2, interquartile range [IQR] 1-3, vs 1, IQR 0-2; P<0.001) and higher ICH volume at onset (median 20 cm3, IQR 3-53, vs 8, IQR 2-25; P=0.004), but not higher case-fatality rate. The 34 patients with ICH after hemorrhagic stroke had a higher proportion of lobar location compared with the 44 patients with ICH after ischemic stroke (79.4% vs 40.9%; P=0.009).
According to the SMASH-U classification, 39 patients (6.0%) had an ICH attributable to structural lesions, 74 (11.5%) to medication, 41 (6.4%) to systemic or other disease, 217 (33.6%) to amyloid angiopathy, 235 (36.4%) to hypertensive angiopathy, and 39 (6.0%) to undetermined cause. ICH attributable to medication was the only category which independently predicted 30-day (hazard ratio 1.78, 95% CI 1.18-2.67; P=0.006) and 1-year case-fatality (hazard ratio 1.50, 95% CI 1.02-2.19; P=0.038).
We included 259 patients with lobar ICH; 87 (33.6%) had both the Edinburgh CT criteria for the classification of probable amyloid angiopathy, i.e. aSAH+FLPs, while 77 (29.7%) had only one and 95 (25.6%) none of the criteria. Patients with aSAH+FLPs also had more severe ICH at onset, higher 30-day (log rank test P=0.009) and 1-year case-fatality (log rank test P=0.003), and higher mRS scores at discharge (P<0.001) as compared to those fulfilling one or none of the Edinburgh criteria. However, the Edinburgh criteria were not independent predictors of case-fatality.
Conclusions. In our population-based study, the incidence and outcomes of first-ever ICH were comparable to those reported in similar studies. Applying a classification tool to patients with ICH identified patient categories with different prognosis; however, only ICH attributable to anticoagulant medication was an independent predictor of ICH case-fatality. Besides, the available classification tools are limited by the coexistence of several etiologic factors in the same patient
Antithrombotic treatment of cervical arterial dissection: Big data needed to inform long-term management
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Migraine Prevention with Erenumab: Focus on Patient Selection, Perspectives and Outcomes
Full text link: Erenumab is a monoclonal antibody targeting the calcitonin gene-related peptide (CGRP) receptor suitable for episodic and chronic migraine prevention. Randomized clinical trials proved the superiority of erenumab to placebo in a strictly selected population, while real-world studies confirmed treatment efficacy in more severe forms of disease - most patients suffered from chronic migraine with medication overuse headache, had prior treatment failures, and long disease duration. According to guidelines, anti-CGRP pathway monoclonal antibodies should be reserved to patients who failed or have contraindication to several classes of preventive treatments. However, their ease of use, tolerability and efficacy make these monoclonal antibodies ideally suitable for most patients with migraine; cost-effectiveness needs to be considered when looking at expanding current prescription criteria. Also, data from open label extensions of randomized control trials confirmed sustained benefits of prolonged treatment up to 5 consecutive years without significant risk of adverse events. Further studies will provide insights on optimal treatment duration to achieve migraine remission and predictors of treatment response. In the present work, we aimed at reviewing design and results of the main studies on erenumab and discussing treatment use in the current migraine prevention scenario; we also summarized the main ongoing research projects and provided clinical perspectives for the future
The paradigm shift in long‐term treatments for migraine prevention
No full textMonoclonal antibodies targeting calcitonin gene-related peptide (CGRP) or its receptor are a key achievement in the field of migraine prevention, being the first migraine-specific preventatives.1 Several characteristics distinguish monoclonal antibodies targeting the CGRP pathway from the previously available drug classes for migraine prevention, including their specificity, their monthly or quarterly subcutaneous administration, and their rapid onset of action
Menstrually associated migraine
No full text: Menstrually related migraine is a disabling condition affecting 35% to 54% females with migraine during their fertile years. The International Headache Classification distinguishes menstrually related migraine from pure menstrual migraine based on the occurrence of the attacks even outside the perimenstrual periods. Hormonal fluctuations are the main driver for the disease in subjects with genetic susceptibility and alterations of brain structures and connectivity. Menstrually related attacks are often particularly severe and disabling requiring proper management. Acute treatment mainly consists of nonsteroidal anti-inflammatory drugs (NSAIDs), recommended in patients also suffering from dysmenorrhea, and triptans. Prevention is specifically indicated in women with high monthly headache frequency or burdensome attacks during perimenstrual periods. Trials proved the efficacy of short-term prevention with triptans and NSAIDs but did not evaluate possible long-term effectiveness and tolerability. Evidence of prevention using hormonal treatments is poor, but extended-cycle treatments might be suitable for women requiring hormonal replacement for concomitant conditions. Few data are available on treatments targeting CGRP, among whom gepants are the most promising because of their utility both in migraine acute and preventive treatment. A greater recognition of disease and a deep knowledge of patients' comorbidities are essential to its proper management
Patterns of Migraine in Postmenopausal Women: A Systematic Review
Full text linkIntroduction: Migraine prevalence is higher in fertile than in postmenopausal women. However, few literature data are available on the prevalence and characteristics of migraine after the menopause and on the effect of hormones in postmenopausal women with migraine.Methods: We performed a systematic literature review of studies available on Scopus and Web of Science from the beginning off indexing until October 18th, 2020. We included both randomized trials and observational studies.Results: We included 12 papers, six of which assessed the prevalence and characteristics of migraine in postmenopausal women, while the other six assessed the effect of hormones on migraine after the menopause. One of the studies was a randomized trial, while the remaining 11 were observational studies. Ten studies were clinic-based, while the remaining two were population-based. Studies assessing the prevalence and characteristics of migraine after the menopause reported inconsistent findings; in studies performed in headache clinics, likely affected by selection bias towards the most severe cases, a relevant proportion of women reported migraine worsening after the menopause. Studies assessing the effect of hormones on migraine after the menopause showed that postmenopausal hormone replacement therapy was invariably associated with migraine worsening, if containing estrogen.Conclusion: Our systematic review showed that migraine could be a relevant health problem in postmenopausal women, mostly in headache clinics. However, the available studies allow a limited assessment of the prevalence and characteristics of postmenopausal migraine. Further large studies are needed to better determine the burden of migraine after the menopause according to migraine characteristics and the impact of hormonal treatments
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