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Comment Cerebral amyloid angiopathy and implications for atrial fibrillation management
Atrial fibrillation, the most common arrhythmia in adults, will increase in prevalence as the population ages.1 The risk of embolic stroke in atrial fibrillation also increases with age. Treatments for the prevention of embolic stroke include warfarin, direct oral anticoagulant agents, and non-anticoagulation strategies such as left atrial appendage occlusion.1 Current scores to estimate the risk of ischaemic stroke (CHA2DS2-VaSc score) or haemorrhage (HAS-BLED score) help guide intervention, but do not account for cerebral amyloid angiopathy (CAA), a prevalent, but overlooked condition.
Source: LANCET - June 29, 2017 Category: General Medicine Authors: Christopher V DeSimone, Jonathan Graff-Radford, Majd A El-Harasis, Alejandro A Rabinstein, Samuel J Asirvatham, David R Holmes Tags: Comment Source Type: research

Correspondence Risk of mortality and stroke after atrial fibrillation – Authors' reply
On behalf our colleagues, we would like to thank Zitian Huo and Constantinos Mihas and colleagues for their interest in our Article and for their questions. We agree with Mihas and colleagues that it would be informative to examine regional differences in haemorrhagic stroke. However, given the large size of our study,1 we needed to minimise the burden of data collection to keep costs affordable. As a result, we did not collect any data on stroke subtypes. The decision not to collect these data was also influenced by the fact that not all participating regions in this study had equal access to advanced neurological imaging...
Source: LANCET - March 3, 2017 Category: Journals (General) Authors: Jeff S Healey, Jonas Oldgren, RE-LY Atrial Fibrillation and Cohort Study Investigators Tags: Correspondence Source Type: research

Seminar Spontaneous subarachnoid haemorrhage
Subarachnoid haemorrhage is an uncommon and severe subtype of stroke affecting patients at a mean age of 55 years, leading to loss of many years of productive life. The rupture of an intracranial aneurysm is the underlining cause in 85% of cases. Survival from aneurysmal subarachnoid haemorrhage has increased by 17% in the past few decades, probably because of better diagnosis, early aneurysm repair, prescription of nimodipine, and advanced intensive care support. Nevertheless, survivors commonly have cognitive impairments, which in turn affect patients' daily functionality, working capacity, and quality of life.
Source: LANCET - September 12, 2016 Category: Journals (General) Authors: R Loch Macdonald, Tom A Schweizer Tags: Seminar Source Type: research

Comment Stroke is largely preventable across the globe: where to next?
Despite the ever-increasing disease burden of stroke in the world,1 accurate data on stroke risk factors are still scarce. In the first phase of the INTERSTROKE study,2 more than 90% of strokes (ischaemic stroke and intracerebral haemorrhage) were attributed to just ten risk factors. However, the study was restricted to developing countries only, and was not powered to explore age, sex, ethnicity, and regional variations in the effect of risk factors or pathological type of stroke, such as ischaemic stroke and intracerebral haemorrhage.
Source: LANCET - July 14, 2016 Category: Journals (General) Authors: Valery L Feigin, Rita Krishnamurthi Tags: Comment Source Type: research

Comment Platelets after intracerebral haemorrhage: more is not better
Spontaneous intracerebral haemorrhage has a disproportionally high burden of mortality and disability compared with other subtypes of stroke.1,2 As a clinician, when faced with a condition as devastating as intracerebral haemorrhage, one feels compelled to use any and all therapies available, even though at times evidence of effectiveness of those therapies is not yet established.1 This is particularly the case for many health-care providers on the front lines of emergency diagnosis and treatment for patients who have had an intracerebral haemorrhage while taking antiplatelet therapy.
Source: LANCET - May 9, 2016 Category: Journals (General) Authors: Calin I Prodan Tags: Comment Source Type: research

Articles Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial
Platelet transfusion seems inferior to standard care for people taking antiplatelet therapy before intracerebral haemorrhage. Platelet transfusion cannot be recommended for this indication in clinical practice.
Source: LANCET - May 9, 2016 Category: Journals (General) Authors: M Irem Baharoglu, Charlotte Cordonnier, Rustam Al-Shahi Salman, Koen de Gans, Maria M Koopman, Anneke Brand, Charles B Majoie, Ludo F Beenen, Henk A Marquering, Marinus Vermeulen, Paul J Nederkoorn, Rob J de Haan, Yvo B Roos, PATCH Investigators Tags: Articles Source Type: research

Correspondence Intracerebral haemorrhage, atrial fibrillation, and anticoagulation
The Review by Freek Verheugt and colleagues (July 18, p 303)1 provides an excellent overview of non-vitamin K antagonist oral anticoagulants (NOACs) and stroke prevention in atrial fibrillation. However, we emphasise another factor that was omitted: survivors of intracranial haemorrhage who also have atrial fibrillation. Observational studies show up to 37% of patients with an intracerebral haemorrhage have concurrent atrial fibrillation,2 with absolute numbers of patients who have anticoagulant-related intracranial haemorrhage expected to increase because of the increased use of oral anticoagulation and an ageing population.
Source: LANCET - October 30, 2015 Category: Journals (General) Authors: Duncan Wilson, Rustam Al-Shahi Salman, Catharina J M Klijn, Gregory Y H Lip, David J Werring Tags: Correspondence Source Type: research

Correspondence Intracerebral haemorrhage, atrial fibrillation, and anticoagulation – Authors' reply
We thank Duncan Wilson and colleagues for their comments about our Review.1 These authors discuss an important issue and suggest that non-vitamin K antagonist oral anticoagulants might provide a strong option to reduce ischaemic stroke in patients who have atrial fibrillation and have suffered an intracranial haemorrhage. A fundamental advantage of non-vitamin K antagonist oral anticoagulants over warfarin is the substantially lower risk of intracranial haemorrhage,2 and this feature might be particularly important for patients at high risk of intracranial haemorrhage, including those with previous history of this disorder.
Source: LANCET - October 30, 2015 Category: Journals (General) Authors: Freek W A Verheugt, Christopher B Granger Tags: Correspondence Source Type: research

Correspondence Thrombolysis in acute stroke
In their meta-analysis of intravenous thrombolysis with alteplase for acute ischaemic stroke, Jonathan Emberson and colleagues (Nov 29, p 1929)1 concluded that the increased risk of early death from intracranial haemorrhage in patients taking alteplase was offset by an increase in disability-free survival. This interpretation gives the impression that the high level of mortality in the acute phase tends to diminish with time, but that is not the case. In the latest Cochrane analysis of thrombolysis for acute ischaemic stroke,2 thrombolysis gave no survival advantage between 7 days after thrombolysis and the end of follow-up.
Source: LANCET - April 10, 2015 Category: Journals (General) Authors: Peter Appelros, Andreas Terént Tags: Correspondence Source Type: research

Editorial Thrombolysis for stroke: clinical judgment at its apogee
In the Correspondence section of today's Lancet, we publish a selection of letters challenging the report by Jonathan Emberson and colleagues on the effect of treatment delay, age, and stroke severity on the effects of thrombolysis with alteplase for acute ischaemic stroke. Emberson and colleagues concluded from their meta-analysis of 6756 patients that despite early increases in fatal intracranial haemorrhage, alteplase improves the overall likelihood of a good stroke outcome at 3–6 months when delivered within 4·5 h of the initial stroke symptoms, with earlier treatment increasing proportional benefit, irrespective of...
Source: LANCET - April 10, 2015 Category: Journals (General) Authors: The Lancet Tags: Editorial Source Type: research

Series Oral anticoagulants for stroke prevention in atrial fibrillation: current status, special situations, and unmet needs
In patients with non-valvular atrial fibrillation, oral anticoagulation with vitamin K antagonists reduces the risk of stroke by more than 60%. But vitamin K antagonists have limitations, including causing serious bleeding such as intracranial haemorrhage and the need for anticoagulation monitoring. In part related to these limitations, they are used in only about half of patients who should be treated according to guideline recommendations. In the past decade, oral agents have been developed that directly block the activity of thrombin (factor IIa), as well as drugs that directly inhibit activated factor X (Xa), which is ...
Source: LANCET - March 14, 2015 Category: Journals (General) Authors: Freek W A Verheugt, Christopher B Granger Tags: Series Source Type: research

Articles Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials
Irrespective of age or stroke severity, and despite an increased risk of fatal intracranial haemorrhage during the first few days after treatment, alteplase significantly improves the overall odds of a good stroke outcome when delivered within 4·5 h of stroke onset, with earlier treatment associated with bigger proportional benefits.
Source: LANCET - November 28, 2014 Category: Journals (General) Authors: Jonathan Emberson, Kennedy R Lees, Patrick Lyden, Lisa Blackwell, Gregory Albers, Erich Bluhmki, Thomas Brott, Geoff Cohen, Stephen Davis, Geoffrey Donnan, James Grotta, George Howard, Markku Kaste, Masatoshi Koga, Ruediger von Kummer, Maarten Lansberg, R Tags: Articles Source Type: research

Correspondence Questions about authorisation of alteplase for ischaemic stroke
Stroke thrombolysis can cause potentially fatal intracerebral haemorrhage, but advocates claim the potential reduction in disability justifies this risk. Alteplase was authorised following the National Institute of Neurological Disorders and Stroke (NINDS) trial. A 2004 review raised concerns over the trial data. Outcomes across the centres differed considerably. Bias could explain the observation that the plot of outcome (modified Rankin score 0–1) against number of patients recruited does not resemble the expected symmetrical funnel ().
Source: LANCET - August 23, 2014 Category: Journals (General) Authors: Roger Shinton Tags: Correspondence Source Type: research

Articles Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials
This meta-analysis is the first to include data for all four new oral anticoagulants studied in the pivotal phase 3 clinical trials for stroke prevention or systemic embolic events in patients with atrial fibrillation. New oral anticoagulants had a favourable risk–benefit profile, with significant reductions in stroke, intracranial haemorrhage, and mortality, and with similar major bleeding as for warfarin, but increased gastrointestinal bleeding. The relative efficacy and safety of new oral anticoagulants was consistent across a wide range of patients.
Source: LANCET - March 14, 2014 Category: Journals (General) Authors: Christian T Ruff, Robert P Giugliano, Eugene Braunwald, Elaine B Hoffman, Naveen Deenadayalu, Michael D Ezekowitz, A John Camm, Jeffrey I Weitz, Basil S Lewis, Alexander Parkhomenko, Takeshi Yamashita, Elliott M Antman Tags: Articles Source Type: research

Comment Genetics of warfarin dosing—one polymorphism at a time
Few drugs define a narrow therapeutic index better than warfarin. With a typical therapeutic international normalised ratio (INR) of 2·0–3·0 for most indications (2·5–3·5 for mechanical heart valves), clinicians are challenged to define and implement dosing regimens that achieve therapeutic anticoagulation. The stakes could hardly be higher: too low a dose places the patient at an increased risk of a life-altering ischaemic event (ie, stroke or pulmonary embolism); and too high a dose can lead to a fatal cerebral or gastrointestinal haemorrhage.
Source: LANCET - August 30, 2013 Category: Journals (General) Authors: Mark J Alberts Tags: Comment Source Type: research