Maurizio Paciaroni1, Giancarlo Agnelli2, Valeria Caso2, Georgios Tsivgoulis2, Karen L Furie2, Prasanna Tadi2, Cecilia Becattini2, Nicola Falocci2, Marialuisa Zedde2, Azmil H Abdul-Rahim2, Kennedy R Lees2, Andrea Alberti2, Michele Venti2, Monica Acciarresi2, Cataldo D'Amore2, Maria Giulia Mosconi2, Ludovica Anna Cimini2, Antonio Procopio2, Paolo Bovi2, Monica Carletti2, Alberto Rigatelli2, Manuel Cappellari2, Jukka Putaala2, Liisa Tomppo2, Turgut Tatlisumak2, Fabio Bandini2, Simona Marcheselli2, Alessandro Pezzini2, Loris Poli2, Alessandro Padovani2, Luca Masotti2, Vieri Vannucchi2, Sung-Il Sohn2, Gianni Lorenzini2, Rossana Tassi2, Francesca Guideri2, Maurizio Acampa2, Giuseppe Martini2, George Ntaios2, Efstathia Karagkiozi2, George Athanasakis2, Kostantinos Makaritsis2, Kostantinos Vadikolias2, Chrysoula Liantinioti2, Maria Chondrogianni2, Nicola Mumoli2, Domenico Consoli2, Franco Galati2, Simona Sacco2, Antonio Carolei2, Cindy Tiseo2, Francesco Corea2, Walter Ageno2, Marta Bellesini2, Giovanna Colombo2, Giorgio Silvestrelli2, Alfonso Ciccone2, Umberto Scoditti2, Licia Denti2, Michelangelo Mancuso2, Miriam Maccarrone2, Giovanni Orlandi2, Nicola Giannini2, Gino Gialdini2, Tiziana Tassinari2, Maria Luisa De Lodovici2, Giorgio Bono2, Christina Rueckert2, Antonio Baldi2, Sebastiano D'Anna2, Danilo Toni2, Federica Letteri2, Martina Giuntini2, Enrico Maria Lotti2, Yuriy Flomin2, Alessio Pieroni2, Odysseas Kargiotis2, Theodore Karapanayiotides2, Serena Monaco2, Mario Maimone Baronello2, Laszló Csiba2, Lilla Szabó2, Alberto Chiti2, Elisa Giorli2, Massimo Del Sette2, Davide Imberti2, Dorjan Zabzuni2, Boris Doronin2, Vera Volodina2, Patrik Michel2, Peter Vanacker2, Kristian Barlinn2, Lars-Peder Pallesen2, Jessica Kepplinger2, Ulf Bodechtel2, Johannes Gerber2, Dirk Deleu2, Gayane Melikyan2, Faisal Ibrahim2, Naveed Akhtar2, Vanessa Gourbali2, Shadi Yaghi2. 1. From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M.P., G. Agnelli, V.C., C.B., N.F., A.A., M.V., M. Acciarresi, C.D., M.G.M., L.A.C., A. Procopio); Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece (G.T., K.V.); International Clinic Research Center, St Anne's University Hospital Brno, Czech Republic (G.T.); Second Department of Neurology, "Attikon" Hospital, University of Athens, School of Medicine, Greece (G.T., C.L., M. Chondrogianni); Division of Stroke and Cerebrovascular Diseases, Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (K.L.F., P.T., S.Y.); Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy (M.Z.); Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., K.R.L.); Unità Semplice Dipartimentale (USD) Stroke Unit, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, A.R., M. Cappellari); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., L.T., T. Tatlisumak); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Sweden (T. Tatlisumak); Department of Neurology, Ospedale San Paolo, Savona, Italy (F.B.); Neurologia d'urgenza e Stroke Unit, Istituto Clinico Humanitas, Rozzano, Milano, Italy (S. Marcheselli); Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A. Pezzini, L.P., A. Padovani); Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy (L.M., V. Vannucchi); Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea (S.-I.S.); Stroke Unit, AOU Senese, Siena, Italy (G.L.); SC Medicina e Chirurgia d'Accettazione e d'Urgenza, Pontedera o Volterra, Azienda USL Toscana Nord Ovest, Italy (R.T., F. Guideri, M. Acampa, G. Martini); Department of Medicine, University of Thessaly, Larissa, Greece (G.N., E.K., G. Athanasakis, K.M.); Department of Internal Medicine, Ospedale Civile di Livorno, Italy (N.M.); Stroke Unit, Jazzolino Hospital, Vibo Valentia, Italy (D.C., F. Galati); Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy (S.S., A. Carolei, C.T.); UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno (F.C.); Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy (W.A., M.B., G.C.); S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy (G.S., A. Ciccone); Stroke Unit, Neuroscience Department, University of Parma, Italy (U.S.); Stroke Unit, Dipartimento Geriatrico Riabilitativo, University of Parma, Italy (L.D.); Clinica Neurologica, Azienda Ospedaliero-Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, G.O., N.G., G.G., A. Chiti); Neurologia, Ospedale Apuano, Massa Carrara, Italy (G.O., M.G.); Stroke Unit, Department of Neurology, Santa Corona Hospital, Pietra Ligure (Savona), Italy (T. Tassinari); Stroke Unit, Department of Neurology, Insubria University, Varese, Italy (M.L. D.L., G.B.); Abteilung für Neurologie, Oberschwabenklinik gGmbH, Ravensburg, Germany (C.R.); Stroke Unit, Ospedale di Portogruaro, Portogruaro (Venice), Italy (A.B., S.D.); Department of Neurology and Psychiatry, Sapienza University of Rome, Italy (D.T., F.L., A. Pieroni); U.O. Neurologia Stroke Unit, Ospedale SM delle Croci, Ravenna, Italy (E.M.L.); Stroke and Neurorehabilitation Unit, MC 'Universal Clinic 'Oberig' Kyiv, Ukraine (Y.F.); Stroke Unit, Metropolitan Hospital, Piraeus, Greece (O.K.); 2nd Department of Neurology, AHEPA University Hospital, Thessaloniki, Greece (T.K.); Stroke Unit, Ospedale Civico, Palermo, Italy (S. Monaco, M.M.B.); Stroke Unit, University of Debrecen, Hungary (L.C., L.S.); Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy (A. Chiti, E.G., M.D.S.); Divisione di Neurologia, Ospedale Galliera, Genoa, Italy (M.D.S.); Department of Internal Medicine, Ospedale Civile di Piacenza, Italy (D.I., D.Z.); City Hospital No. 1, Novosibirsk State Medical University, Russia (B.D., V. Volodina); Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois, Lausanne (Switzerland) (P.M.); Department of Neurology, Born Bunge Institute, Antwerp University Hospital, Antwerp, Belgium (P.V.); Department of Neurology, Dresden University Stroke Center, Germany (K.B., L.-P.P., J.K., U.B., J.G.); Neurology, Hamad Medical Corporation, Doha, Qatar (D.D., G. Melikyan, F.I., N.A.); and Department of Neurology, Evangelismos Hospital, Athens (V.G.). maurizio.paciaroni@unipg.it. 2. From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M.P., G. Agnelli, V.C., C.B., N.F., A.A., M.V., M. Acciarresi, C.D., M.G.M., L.A.C., A. Procopio); Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece (G.T., K.V.); International Clinic Research Center, St Anne's University Hospital Brno, Czech Republic (G.T.); Second Department of Neurology, "Attikon" Hospital, University of Athens, School of Medicine, Greece (G.T., C.L., M. Chondrogianni); Division of Stroke and Cerebrovascular Diseases, Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (K.L.F., P.T., S.Y.); Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy (M.Z.); Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., K.R.L.); Unità Semplice Dipartimentale (USD) Stroke Unit, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, A.R., M. Cappellari); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., L.T., T. Tatlisumak); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Sweden (T. Tatlisumak); Department of Neurology, Ospedale San Paolo, Savona, Italy (F.B.); Neurologia d'urgenza e Stroke Unit, Istituto Clinico Humanitas, Rozzano, Milano, Italy (S. Marcheselli); Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A. Pezzini, L.P., A. Padovani); Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy (L.M., V. Vannucchi); Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea (S.-I.S.); Stroke Unit, AOU Senese, Siena, Italy (G.L.); SC Medicina e Chirurgia d'Accettazione e d'Urgenza, Pontedera o Volterra, Azienda USL Toscana Nord Ovest, Italy (R.T., F. Guideri, M. Acampa, G. Martini); Department of Medicine, University of Thessaly, Larissa, Greece (G.N., E.K., G. Athanasakis, K.M.); Department of Internal Medicine, Ospedale Civile di Livorno, Italy (N.M.); Stroke Unit, Jazzolino Hospital, Vibo Valentia, Italy (D.C., F. Galati); Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy (S.S., A. Carolei, C.T.); UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno (F.C.); Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy (W.A., M.B., G.C.); S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy (G.S., A. Ciccone); Stroke Unit, Neuroscience Department, University of Parma, Italy (U.S.); Stroke Unit, Dipartimento Geriatrico Riabilitativo, University of Parma, Italy (L.D.); Clinica Neurologica, Azienda Ospedaliero-Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, G.O., N.G., G.G., A. Chiti); Neurologia, Ospedale Apuano, Massa Carrara, Italy (G.O., M.G.); Stroke Unit, Department of Neurology, Santa Corona Hospital, Pietra Ligure (Savona), Italy (T. Tassinari); Stroke Unit, Department of Neurology, Insubria University, Varese, Italy (M.L. D.L., G.B.); Abteilung für Neurologie, Oberschwabenklinik gGmbH, Ravensburg, Germany (C.R.); Stroke Unit, Ospedale di Portogruaro, Portogruaro (Venice), Italy (A.B., S.D.); Department of Neurology and Psychiatry, Sapienza University of Rome, Italy (D.T., F.L., A. Pieroni); U.O. Neurologia Stroke Unit, Ospedale SM delle Croci, Ravenna, Italy (E.M.L.); Stroke and Neurorehabilitation Unit, MC 'Universal Clinic 'Oberig' Kyiv, Ukraine (Y.F.); Stroke Unit, Metropolitan Hospital, Piraeus, Greece (O.K.); 2nd Department of Neurology, AHEPA University Hospital, Thessaloniki, Greece (T.K.); Stroke Unit, Ospedale Civico, Palermo, Italy (S. Monaco, M.M.B.); Stroke Unit, University of Debrecen, Hungary (L.C., L.S.); Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy (A. Chiti, E.G., M.D.S.); Divisione di Neurologia, Ospedale Galliera, Genoa, Italy (M.D.S.); Department of Internal Medicine, Ospedale Civile di Piacenza, Italy (D.I., D.Z.); City Hospital No. 1, Novosibirsk State Medical University, Russia (B.D., V. Volodina); Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois, Lausanne (Switzerland) (P.M.); Department of Neurology, Born Bunge Institute, Antwerp University Hospital, Antwerp, Belgium (P.V.); Department of Neurology, Dresden University Stroke Center, Germany (K.B., L.-P.P., J.K., U.B., J.G.); Neurology, Hamad Medical Corporation, Doha, Qatar (D.D., G. Melikyan, F.I., N.A.); and Department of Neurology, Evangelismos Hospital, Athens (V.G.).
Abstract
BACKGROUND AND PURPOSES: This study was designed to derive and validate a score to predict early ischemic events and major bleedings after an acute ischemic stroke in patients with atrial fibrillation. METHODS: The derivation cohort consisted of 854 patients with acute ischemic stroke and atrial fibrillation included in prospective series between January 2012 and March 2014. Older age (hazard ratio 1.06 for each additional year; 95% confidence interval, 1.00-1.11) and severe atrial enlargement (hazard ratio, 2.05; 95% confidence interval, 1.08-2.87) were predictors for ischemic outcome events (stroke, transient ischemic attack, and systemic embolism) at 90 days from acute stroke. Small lesions (≤1.5 cm) were inversely correlated with both major bleeding (hazard ratio, 0.39; P=0.03) and ischemic outcome events (hazard ratio, 0.55; 95% confidence interval, 0.30-1.00). We assigned to age ≥80 years 2 points and between 70 and 79 years 1 point; ischemic index lesion >1.5 cm, 1 point; severe atrial enlargement, 1 point (ALESSA score). A logistic regression with the receiver-operating characteristic graph procedure (C statistic) showed an area under the curve of 0.697 (0.632-0.763; P=0.0001) for ischemic outcome events and 0.585 (0.493-0.678; P=0.10) for major bleedings. RESULTS: The validation cohort consisted of 994 patients included in prospective series between April 2014 and June 2016. Logistic regression with the receiver-operating characteristic graph procedure showed an area under the curve of 0.646 (0.529-0.763; P=0.009) for ischemic outcome events and 0.407 (0.275-0.540; P=0.14) for hemorrhagic outcome events. CONCLUSIONS: In acute stroke patients with atrial fibrillation, high ALESSA scores were associated with a high risk of ischemic events but not of major bleedings.
BACKGROUND AND PURPOSES: This study was designed to derive and validate a score to predict early ischemic events and major bleedings after an acute ischemic stroke in patients with atrial fibrillation. METHODS: The derivation cohort consisted of 854 patients with acute ischemic stroke and atrial fibrillation included in prospective series between January 2012 and March 2014. Older age (hazard ratio 1.06 for each additional year; 95% confidence interval, 1.00-1.11) and severe atrial enlargement (hazard ratio, 2.05; 95% confidence interval, 1.08-2.87) were predictors for ischemic outcome events (stroke, transient ischemic attack, and systemic embolism) at 90 days from acute stroke. Small lesions (≤1.5 cm) were inversely correlated with both major bleeding (hazard ratio, 0.39; P=0.03) and ischemic outcome events (hazard ratio, 0.55; 95% confidence interval, 0.30-1.00). We assigned to age ≥80 years 2 points and between 70 and 79 years 1 point; ischemic index lesion >1.5 cm, 1 point; severe atrial enlargement, 1 point (ALESSA score). A logistic regression with the receiver-operating characteristic graph procedure (C statistic) showed an area under the curve of 0.697 (0.632-0.763; P=0.0001) for ischemic outcome events and 0.585 (0.493-0.678; P=0.10) for major bleedings. RESULTS: The validation cohort consisted of 994 patients included in prospective series between April 2014 and June 2016. Logistic regression with the receiver-operating characteristic graph procedure showed an area under the curve of 0.646 (0.529-0.763; P=0.009) for ischemic outcome events and 0.407 (0.275-0.540; P=0.14) for hemorrhagic outcome events. CONCLUSIONS: In acute strokepatients with atrial fibrillation, high ALESSA scores were associated with a high risk of ischemic events but not of major bleedings.
Authors: Shadi Yaghi; Nils Henninger; James A Giles; Christopher Leon Guerrero; Eva Mistry; Ava L Liberman; Daniyal Asad; Angela Liu; Muhammad Nagy; Ashutosh Kaushal; Idrees Azher; Brian Mac Grory; Hiba Fakhri; Kiersten Brown Espaillat; Hemanth Pasupuleti; Heather Martin; Jose Tan; Manivannan Veerasamy; Charles Esenwa; Natalie Cheng; Khadean Moncrieffe; Iman Moeini-Naghani; Mithilesh Siddu; Erica Scher; Tushar Trivedi; Karen L Furie; Salah G Keyrouz; Amre Nouh; Adam de Havenon; Muhib Khan; Eric E Smith; M Edip Gurol Journal: J Neurol Neurosurg Psychiatry Date: 2021-04-26 Impact factor: 13.654