Background and Purpose—The relationship between elevated lipoprotein (a) levels(Lp(a)) and stroke... more Background and Purpose—The relationship between elevated lipoprotein (a) levels(Lp(a)) and stroke is controversial. We systematically reviewed the literature to determine whether Lp(a) is a risk factor for stroke. Methods—We searched MEDLINE (1966 to 2006), EMBASE (1974 to 2006), and Google scholar for articles on Lp(a) and cerebrovascular disease. From potentially relevant references retrieved, we excluded uncontrolled studies, studies of children
Background and Purpose—We sought to assess whether the volume of the ischemic penumbra can be est... more Background and Purpose—We sought to assess whether the volume of the ischemic penumbra can be estimated more accurately by altering the threshold selected for defining perfusion-weighting imaging (PWI) lesions. Methods—DEFUSE is a multicenter study in which consecutive acute stroke patients were treated with intravenous tissue-type plasminogen activator 3 to 6 hours after stroke onset. Magnetic resonance imaging scans were obtained
BACKGROUND AND PURPOSE: Identifying tissue at risk for infarction is an important goal of stroke ... more BACKGROUND AND PURPOSE: Identifying tissue at risk for infarction is an important goal of stroke imaging. This study was performed to determine whether pixel-based apparent diffusion coefficient (ADC) and signal intensity ratio are helpful diffusion-weighted (DW) imaging metrics to predict tissue at risk for infarction. METHODS: Twelve patients presenting with acute hemispheric strokes underwent DW imaging within 7 hours of
Background—Studies evaluating predictors of tPA-associated symptomatic intracerebral hemorrhage (... more Background—Studies evaluating predictors of tPA-associated symptomatic intracerebral hemorrhage (SICH) have typically focused on clinical and CT-based variables. MRI-based variables have generally not been included in predictive models, and little is known about the influence of reperfusion on SICH risk. Methods—Seventy-four patients were prospectively enrolled in an open-label study of intravenous tPA administered between 3 and 6 hours after symptom onset.
Background and Purpose—The arterial input function (AIF) is critical in determining hemodynamic p... more Background and Purpose—The arterial input function (AIF) is critical in determining hemodynamic parameters quantitatively with bolus-tracking MRI. We studied the effect of varying the location of measurement of AIF on the volume of hypoperfusion. We compared the volumes of hypoperfusion obtained with different AIFs with the final ischemic lesion volume. Methods—We included 13 patients with acute cerebral ischemia in the
The perfusion-/diffusion-weighted imaging (PWI/DWI) mismatch and the diffusion/fluid attenuated i... more The perfusion-/diffusion-weighted imaging (PWI/DWI) mismatch and the diffusion/fluid attenuated inversion recovery (DWI/FLAIR) mismatch are magnetic resonance imaging (MRI) markers of evolving brain ischemia. We examined whether the DWI/FLAIR mismatch was independently associated with the PWI/DWI mismatch. Furthermore, we determined whether the presence of the DWI/FLAIR mismatch in patients with the PWI/DWI mismatch would provide additional information regarding last seen normal time (LTM). We used data from the 'AX200 for ischemic stroke' trial (AXIS 2 study NCT00927836). We studied the association between the presence of the DWI/FLAIR and PWI/DWI mismatch, baseline National Institute of Health Stroke Scale (NIHSS), age, ischemic-core volume, gender, intravenous (IV) tissue plasminogen activator (tPA), and perfusion-mismatch volume in univariate analysis. Significant variables (P<0.05) were added into the final multivariate model. We analyzed 197 patients. Seventy-two (37%) had both the PWI/DWI and the DWI/FLAIR mismatch. Patients with the double mismatch pattern had a shorter LTM than patients with the PWI/DWI mismatch alone (Median difference 90 minutes, P<0.01). Multivariate analysis confirmed the independent association between the two mismatch patterns (odds ratio (OR) 2.6, 95% confidence interval (CI) 1.2 to 5.4). Our study implies that the DWI/FLAIR mismatch and PWI/DWI mismatch are strongly associated, independent from LTM. Furthermore, in the presence of the PWI/DWI mismatch, the DWI/FLAIR pattern indicates a shorter LTM. This could have implications in selecting patients for reperfusion therapy.Journal of Cerebral Blood Flow & Metabolism advance online publication, 3 June 2015; doi:10.1038/jcbfm.2015.108.
Spontaneous intracranial artery dissection is an uncommon and probably underdiagnosed cause of st... more Spontaneous intracranial artery dissection is an uncommon and probably underdiagnosed cause of stroke that is defi ned by the occurrence of a haematoma in the wall of an intracranial artery. Patients can present with headache, ischaemic stroke, subarachnoid haemorrhage, or symptoms associated with mass eff ect, mostly on the brainstem. Although intracranial artery dissection is less common than cervical artery dissection in adults of European ethnic origin, intracranial artery dissection is reportedly more common in children and in Asian populations. Risk factors and mechanisms are poorly understood, and diagnosis is challenging because characteristic imaging features can be diffi cult to detect in view of the small size of intracranial arteries. Therefore, multimodal follow-up imaging is often needed to confi rm the diagnosis. Treatment of intracranial artery dissections is empirical in the absence of data from randomised controlled trials. Most patients with subarachnoid haemorrhage undergo surgical or endovascular treatment to prevent rebleeding, whereas patients with intracranial artery dissection and cerebral ischaemia are treated with antithrombotics. Prognosis seems worse in patients with subarachnoid haemorrhage than in those without.
Stroke; a journal of cerebral circulation, Jan 7, 2015
The most common monogenic cause of cerebral small-vessel disease is cerebral autosomal dominant a... more The most common monogenic cause of cerebral small-vessel disease is cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, caused by NOTCH3 gene mutations. It has been hypothesized that more common variants in NOTCH3 may also contribute to the risk of sporadic small-vessel disease. Previously, 4 common variants (rs10404382, rs1043994, rs10423702, and rs1043997) were found to be associated with the presence of white matter hyperintensity in hypertensive community-dwelling elderly. We investigated the association of common single nucleotide polymorphisms (SNPs) in NOTCH3 in 1350 patients with MRI-confirmed lacunar stroke and 7397 controls, by meta-analysis of genome-wide association study data sets. In addition, we investigated the association of common SNPs in NOTCH3 with MRI white matter hyperintensity volumes in 3670 white patients with ischemic stroke. In each analysis, we considered all SNPs within the NOTCH3 gene, and within 50-kb upstream an...
... 22'23 Trials that have attempted to expand the time window of treatment with IV tPA ... more ... 22'23 Trials that have attempted to expand the time window of treatment with IV tPA to five or 6 hours 207 Page 232. 208 Vincent N. Thijs and Gregory W. Albers have not been successful. ... Page 234. 210 Vincent N. Thijs and Gregory W. Albers Fig. 16.1. ...
Rivaroxaban is one of the new oral anticoagulants (NOACs). It has many potential advantages in co... more Rivaroxaban is one of the new oral anticoagulants (NOACs). It has many potential advantages in comparison with Vitamin K Antagonists (VKA). It has a predictable anticoagulant effect and does not theoretically require biological monitoring. It is also characterized by less food and drug interactions. However, due to major risks associated with over- and under-dosage, its optimal use in patients should be carefully followed by health care professionals. The aim of this article is to provide recommendations for pharmacists on the practical use of Xarelto in its different approved indications. This document is adapted from the practical user guide of rivaroxaban which was developed by an independent group of Belgian experts in the field of thrombosis and haemostasis.
There is only scarce information on the incidence and costs of stroke in Belgium. Knowledge of th... more There is only scarce information on the incidence and costs of stroke in Belgium. Knowledge of these figures permits targeted allocation of resources and aids cost efficacy estimates. We analysed a nationwide administrative database used for reimbursement of hospitals in Belgium. This database allows analysis of the rate of all hospital admissions for TIA, acute ischemic stroke, intracranial hemorrhage and carotid surgery or angioplasty. We compared the costs of hospitalization for stroke and related disorders with the costs of hospitalization for coronary artery disease. There were 32970 admissions for stroke related disorders in 2007 at a cost of 191.6 million EUROS. There was a decline of 4.7% of the rate of hospitalization for stroke and associated disorders over the period 2002-2007. Despite this decline the total costs did not diminish substantially. In 2007 stroke and related disorders accounted for 2.0% of all Belgian hospitalizations, whereas coronary artery disease hospita...
The aim of this study was to supplement the few data that exist regarding the potential effect of... more The aim of this study was to supplement the few data that exist regarding the potential effect of the referring medical specialty on the proposed treatment for asymptomatic carotid stenosis. In a web survey, we presented Belgian cardiologists, neurologists and vascular surgeons with two fairly uncomplicated case vignettes on asymptomatic carotid stenosis differing only in the degree of stenosis (70-80% in case 1 and >80% in case 2). In both cases the suggested therapies were different per medical specialty (P<0.000002 and P<0.00002, respectively). Cardiologists were more conservative and vascular surgeons were more aggressive. Preferred therapies for both cases differed statistically significantly (odds ratio 8.63; 95% confidence interval 5.11-14.58). Suggesting a different therapy or not for case 1 and case 2 was also different per medical specialty (P<0.035). Cardiologists were most inclined to suggest a different therapy and vascular surgeons the least. Nobody switche...
We report the Belgian results of the Safe Implementation of Thrombolysis in Stroke - Internationa... more We report the Belgian results of the Safe Implementation of Thrombolysis in Stroke - International Stroke Thrombolysis Register (SITS-ISTR). This prospective observational register evaluates the safety and efficacy of intravenous thrombolysis with rtPA (recombinant tissue Plasminogen Activator) for ischemic stroke in routine clinical practice. We compared the baseline characteristics, treatment delay, rate of symptomatic intracerebral hemorrhage and functional outcome at 90 days after treatment between patients enrolled in centres in Belgium and the non-Belgian SITS-registry population. We performed a multivariate analysis to adjust for differences in demographic and baseline characteristics. 743 patients were enrolled in 42 centers in Belgium between December 2002 and December 2007. These patients were older, had more severe stroke were more frequently female and more frequently had hyperlipidemia and atrial fibrillation. The median stroke onset-to-treatment delay was 140 min vs. 1...
There is ample evidence from randomized trials that for patients with stroke, stroke unit care is... more There is ample evidence from randomized trials that for patients with stroke, stroke unit care is superior to care in general medical or neurological wards. This evidence, which has been adopted by international guidelines has to be implemented into daily stroke care. This consensus document prepared by the Belgian Stroke Council provides a set of minimum criteria to meet international standards for stroke care. It is intended to provide help in the creation of stroke units in centers who do not currently have one and to provide a benchmark for centres already having organised stroke care.
The aim of this study was to compare the clinical and ultrasound outcome of carotid artery stenti... more The aim of this study was to compare the clinical and ultrasound outcome of carotid artery stenting at 2-year follow-up in patients treated with open-cell nitinol stents versus patients treated with closed cell stainless steel stents. This was a non-randomized, retrospective study including 123 patients in whom 132 carotid stent-procedures were performed. Nine patients were treated bilaterally. All patients presented with severe asymptomatic (80%) or symptomatic (>70%) carotid artery stenosis and were treated by carotid angioplasty and stent placement with or without filter embolic protection system. Follow-up consisted of physical evaluation at 1, 6, 12 and 24 months and assessment of the stent patency by ultrasound examination at 6, 12 and 24 months after the stent procedure. In 72 procedures a closed cell stainless steel stent was implanted, in the remaining 60 procedures an open cell nitinol stent was placed. In 8 patients with a stainless steel stent (11%) and in 6 patients ...
Recently we reported that percutaneous atrial septal defect (ASD) closure had no influence on the... more Recently we reported that percutaneous atrial septal defect (ASD) closure had no influence on the prevalence of migraine during a short followup period. 12 % of patients however developed a new-onset migraine after the ASD closure. As it has been suggested that the closing device might induce or maintain migraine temporarily, we were interested in the prevalence of migraine at longer follow-up. All 75 patients included in the previous study, received the same structured headache questionnaire. A neurologist, blinded to previous data, diagnosed migraine with or without aura (MA+ or MA-) according to the International Headache Criteria. McNemar paired X2 test was used to evaluate changes in the occurrence of migraine. Seventy-one patients (94.7%) answer the questionnaire (55 women, mean age at closure 51 +/- 18 years). Mean follow-up time was 52 +/- 13 months. The overall migraine prevalence decreased from 30.7% before to 22.5% after closure (P=0.21). A significant reduction was noted...
The short time window is frequently cited as the main reason for exclusion of intravenous tissue ... more The short time window is frequently cited as the main reason for exclusion of intravenous tissue plasminogen activator (tPA) in acute stroke. Identifying and circumventing barriers to thrombolysis other than time could increase the frequency of treatment. The goal of this study was to identify whether the rate of treatment with tPA would increase if time window was not an obstacle to treatment. In four hospitals we prospectively recorded the rate of tPA use in consecutive patients admitted with acute ischemic stroke and in those admitted within 3 hours, the reasons why thrombolysis was not given, and the potential gain in the rate of tPA use if all patients had been admitted within 3 hours considering all exclusion criteria other than time. We recruited 486 patients (258 men; mean age, 70.4 +/- 13.5 years), of whom 154 (31.7%) were admitted within 3 hours. The time of stroke onset was unknown in 28 (5.8%). The rate of tPA use was 11.1% in the whole study population and 35.1% in thos...
The perfusion-diffusion mismatch (PDM) model has been proposed as a tool to select acute stroke p... more The perfusion-diffusion mismatch (PDM) model has been proposed as a tool to select acute stroke patients who are most likely to benefit from reperfusion therapy. The clinical-diffusion mismatch (CDM) model is an alternative method that is technically less challenging because it does not require perfusion-weighted imaging. This study is an evaluation of these 2 models in the DEFUSE dataset. DEFUSE is an open-label multicenter study in which acute stroke patients were treated with intravenous tPA between 3 and 6 hours after symptoms onset and an MRI was obtained before and 3 to 6 hours after treatment. Presence of PDM and CDM was determined for each patient. Based on conventional predefined mismatch criteria, PDM was present in 54% of the DEFUSE population and CDM in 62%. There was no agreement beyond chance between the 2 mismatch models (kappa 0.07). The presence of PDM was associated with an increased chance of favorable clinical response after reperfusion (OR, 5.4; P=0.039). Reperf...
Although it is indisputable that high blood pressure should be treated to prevent a first or a re... more Although it is indisputable that high blood pressure should be treated to prevent a first or a recurrent stroke, the management of high blood pressure in the first hours and days after stroke remains controversial. There is no high-quality evidence from randomized controlled trials to guide treatment in the 80% of patients who have elevated blood pressure during the first days after stroke. Theoretically, there are pros and cons for manipulating blood pressure after onset of stroke. Most treatment guidelines suggest leaving blood pressure untouched based on pathophysiologic principles. Post-hoc analyses from randomized trials, however, suggest that elevated blood pressure is associated with recurrent stroke and higher mortality, even after adjustment for potential confounders. On the other hand, preliminary studies have suggested that voluntarily increasing blood pressure might be beneficial in a selected subgroup of patients. In this overview, we present a summary of recent studies...
Patients, who wake up with an ischemic stroke, account for a large number of the total stroke pop... more Patients, who wake up with an ischemic stroke, account for a large number of the total stroke population, due to circadian morning predominance of stroke. Currently, this subset of patients is excluded from revascularization-therapy since no exact time of onset is known. A large group of these patients might be eligible for therapy. In this review, we assessed the current literature about the hypothesis that wake-up-strokes occur just prior on awakening and if this subgroup differs in characteristics compared to the overall stroke population. We looked at the safety and efficacy of thrombolysis and interventional techniques in the group of patients with unknown stroke-onset. We performed a meta-analysis of the diagnostic accuracy of the diffusion-FLAIR mismatch in identifying stroke within 3 and 4.5 h. The different imaging-selection criteria that can be used to treat these patients are discussed. Additional research on imaging findings associated with recent stroke and penumbral imaging will eventually lead to a shift from a rigid time-frame based therapy to a tissue-based individualized treatment approach.
Background and Purpose—The relationship between elevated lipoprotein (a) levels(Lp(a)) and stroke... more Background and Purpose—The relationship between elevated lipoprotein (a) levels(Lp(a)) and stroke is controversial. We systematically reviewed the literature to determine whether Lp(a) is a risk factor for stroke. Methods—We searched MEDLINE (1966 to 2006), EMBASE (1974 to 2006), and Google scholar for articles on Lp(a) and cerebrovascular disease. From potentially relevant references retrieved, we excluded uncontrolled studies, studies of children
Background and Purpose—We sought to assess whether the volume of the ischemic penumbra can be est... more Background and Purpose—We sought to assess whether the volume of the ischemic penumbra can be estimated more accurately by altering the threshold selected for defining perfusion-weighting imaging (PWI) lesions. Methods—DEFUSE is a multicenter study in which consecutive acute stroke patients were treated with intravenous tissue-type plasminogen activator 3 to 6 hours after stroke onset. Magnetic resonance imaging scans were obtained
BACKGROUND AND PURPOSE: Identifying tissue at risk for infarction is an important goal of stroke ... more BACKGROUND AND PURPOSE: Identifying tissue at risk for infarction is an important goal of stroke imaging. This study was performed to determine whether pixel-based apparent diffusion coefficient (ADC) and signal intensity ratio are helpful diffusion-weighted (DW) imaging metrics to predict tissue at risk for infarction. METHODS: Twelve patients presenting with acute hemispheric strokes underwent DW imaging within 7 hours of
Background—Studies evaluating predictors of tPA-associated symptomatic intracerebral hemorrhage (... more Background—Studies evaluating predictors of tPA-associated symptomatic intracerebral hemorrhage (SICH) have typically focused on clinical and CT-based variables. MRI-based variables have generally not been included in predictive models, and little is known about the influence of reperfusion on SICH risk. Methods—Seventy-four patients were prospectively enrolled in an open-label study of intravenous tPA administered between 3 and 6 hours after symptom onset.
Background and Purpose—The arterial input function (AIF) is critical in determining hemodynamic p... more Background and Purpose—The arterial input function (AIF) is critical in determining hemodynamic parameters quantitatively with bolus-tracking MRI. We studied the effect of varying the location of measurement of AIF on the volume of hypoperfusion. We compared the volumes of hypoperfusion obtained with different AIFs with the final ischemic lesion volume. Methods—We included 13 patients with acute cerebral ischemia in the
The perfusion-/diffusion-weighted imaging (PWI/DWI) mismatch and the diffusion/fluid attenuated i... more The perfusion-/diffusion-weighted imaging (PWI/DWI) mismatch and the diffusion/fluid attenuated inversion recovery (DWI/FLAIR) mismatch are magnetic resonance imaging (MRI) markers of evolving brain ischemia. We examined whether the DWI/FLAIR mismatch was independently associated with the PWI/DWI mismatch. Furthermore, we determined whether the presence of the DWI/FLAIR mismatch in patients with the PWI/DWI mismatch would provide additional information regarding last seen normal time (LTM). We used data from the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;AX200 for ischemic stroke&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; trial (AXIS 2 study NCT00927836). We studied the association between the presence of the DWI/FLAIR and PWI/DWI mismatch, baseline National Institute of Health Stroke Scale (NIHSS), age, ischemic-core volume, gender, intravenous (IV) tissue plasminogen activator (tPA), and perfusion-mismatch volume in univariate analysis. Significant variables (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05) were added into the final multivariate model. We analyzed 197 patients. Seventy-two (37%) had both the PWI/DWI and the DWI/FLAIR mismatch. Patients with the double mismatch pattern had a shorter LTM than patients with the PWI/DWI mismatch alone (Median difference 90 minutes, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01). Multivariate analysis confirmed the independent association between the two mismatch patterns (odds ratio (OR) 2.6, 95% confidence interval (CI) 1.2 to 5.4). Our study implies that the DWI/FLAIR mismatch and PWI/DWI mismatch are strongly associated, independent from LTM. Furthermore, in the presence of the PWI/DWI mismatch, the DWI/FLAIR pattern indicates a shorter LTM. This could have implications in selecting patients for reperfusion therapy.Journal of Cerebral Blood Flow &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Metabolism advance online publication, 3 June 2015; doi:10.1038/jcbfm.2015.108.
Spontaneous intracranial artery dissection is an uncommon and probably underdiagnosed cause of st... more Spontaneous intracranial artery dissection is an uncommon and probably underdiagnosed cause of stroke that is defi ned by the occurrence of a haematoma in the wall of an intracranial artery. Patients can present with headache, ischaemic stroke, subarachnoid haemorrhage, or symptoms associated with mass eff ect, mostly on the brainstem. Although intracranial artery dissection is less common than cervical artery dissection in adults of European ethnic origin, intracranial artery dissection is reportedly more common in children and in Asian populations. Risk factors and mechanisms are poorly understood, and diagnosis is challenging because characteristic imaging features can be diffi cult to detect in view of the small size of intracranial arteries. Therefore, multimodal follow-up imaging is often needed to confi rm the diagnosis. Treatment of intracranial artery dissections is empirical in the absence of data from randomised controlled trials. Most patients with subarachnoid haemorrhage undergo surgical or endovascular treatment to prevent rebleeding, whereas patients with intracranial artery dissection and cerebral ischaemia are treated with antithrombotics. Prognosis seems worse in patients with subarachnoid haemorrhage than in those without.
Stroke; a journal of cerebral circulation, Jan 7, 2015
The most common monogenic cause of cerebral small-vessel disease is cerebral autosomal dominant a... more The most common monogenic cause of cerebral small-vessel disease is cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, caused by NOTCH3 gene mutations. It has been hypothesized that more common variants in NOTCH3 may also contribute to the risk of sporadic small-vessel disease. Previously, 4 common variants (rs10404382, rs1043994, rs10423702, and rs1043997) were found to be associated with the presence of white matter hyperintensity in hypertensive community-dwelling elderly. We investigated the association of common single nucleotide polymorphisms (SNPs) in NOTCH3 in 1350 patients with MRI-confirmed lacunar stroke and 7397 controls, by meta-analysis of genome-wide association study data sets. In addition, we investigated the association of common SNPs in NOTCH3 with MRI white matter hyperintensity volumes in 3670 white patients with ischemic stroke. In each analysis, we considered all SNPs within the NOTCH3 gene, and within 50-kb upstream an...
... 22&#x27;23 Trials that have attempted to expand the time window of treatment with IV tPA ... more ... 22&#x27;23 Trials that have attempted to expand the time window of treatment with IV tPA to five or 6 hours 207 Page 232. 208 Vincent N. Thijs and Gregory W. Albers have not been successful. ... Page 234. 210 Vincent N. Thijs and Gregory W. Albers Fig. 16.1. ...
Rivaroxaban is one of the new oral anticoagulants (NOACs). It has many potential advantages in co... more Rivaroxaban is one of the new oral anticoagulants (NOACs). It has many potential advantages in comparison with Vitamin K Antagonists (VKA). It has a predictable anticoagulant effect and does not theoretically require biological monitoring. It is also characterized by less food and drug interactions. However, due to major risks associated with over- and under-dosage, its optimal use in patients should be carefully followed by health care professionals. The aim of this article is to provide recommendations for pharmacists on the practical use of Xarelto in its different approved indications. This document is adapted from the practical user guide of rivaroxaban which was developed by an independent group of Belgian experts in the field of thrombosis and haemostasis.
There is only scarce information on the incidence and costs of stroke in Belgium. Knowledge of th... more There is only scarce information on the incidence and costs of stroke in Belgium. Knowledge of these figures permits targeted allocation of resources and aids cost efficacy estimates. We analysed a nationwide administrative database used for reimbursement of hospitals in Belgium. This database allows analysis of the rate of all hospital admissions for TIA, acute ischemic stroke, intracranial hemorrhage and carotid surgery or angioplasty. We compared the costs of hospitalization for stroke and related disorders with the costs of hospitalization for coronary artery disease. There were 32970 admissions for stroke related disorders in 2007 at a cost of 191.6 million EUROS. There was a decline of 4.7% of the rate of hospitalization for stroke and associated disorders over the period 2002-2007. Despite this decline the total costs did not diminish substantially. In 2007 stroke and related disorders accounted for 2.0% of all Belgian hospitalizations, whereas coronary artery disease hospita...
The aim of this study was to supplement the few data that exist regarding the potential effect of... more The aim of this study was to supplement the few data that exist regarding the potential effect of the referring medical specialty on the proposed treatment for asymptomatic carotid stenosis. In a web survey, we presented Belgian cardiologists, neurologists and vascular surgeons with two fairly uncomplicated case vignettes on asymptomatic carotid stenosis differing only in the degree of stenosis (70-80% in case 1 and >80% in case 2). In both cases the suggested therapies were different per medical specialty (P<0.000002 and P<0.00002, respectively). Cardiologists were more conservative and vascular surgeons were more aggressive. Preferred therapies for both cases differed statistically significantly (odds ratio 8.63; 95% confidence interval 5.11-14.58). Suggesting a different therapy or not for case 1 and case 2 was also different per medical specialty (P<0.035). Cardiologists were most inclined to suggest a different therapy and vascular surgeons the least. Nobody switche...
We report the Belgian results of the Safe Implementation of Thrombolysis in Stroke - Internationa... more We report the Belgian results of the Safe Implementation of Thrombolysis in Stroke - International Stroke Thrombolysis Register (SITS-ISTR). This prospective observational register evaluates the safety and efficacy of intravenous thrombolysis with rtPA (recombinant tissue Plasminogen Activator) for ischemic stroke in routine clinical practice. We compared the baseline characteristics, treatment delay, rate of symptomatic intracerebral hemorrhage and functional outcome at 90 days after treatment between patients enrolled in centres in Belgium and the non-Belgian SITS-registry population. We performed a multivariate analysis to adjust for differences in demographic and baseline characteristics. 743 patients were enrolled in 42 centers in Belgium between December 2002 and December 2007. These patients were older, had more severe stroke were more frequently female and more frequently had hyperlipidemia and atrial fibrillation. The median stroke onset-to-treatment delay was 140 min vs. 1...
There is ample evidence from randomized trials that for patients with stroke, stroke unit care is... more There is ample evidence from randomized trials that for patients with stroke, stroke unit care is superior to care in general medical or neurological wards. This evidence, which has been adopted by international guidelines has to be implemented into daily stroke care. This consensus document prepared by the Belgian Stroke Council provides a set of minimum criteria to meet international standards for stroke care. It is intended to provide help in the creation of stroke units in centers who do not currently have one and to provide a benchmark for centres already having organised stroke care.
The aim of this study was to compare the clinical and ultrasound outcome of carotid artery stenti... more The aim of this study was to compare the clinical and ultrasound outcome of carotid artery stenting at 2-year follow-up in patients treated with open-cell nitinol stents versus patients treated with closed cell stainless steel stents. This was a non-randomized, retrospective study including 123 patients in whom 132 carotid stent-procedures were performed. Nine patients were treated bilaterally. All patients presented with severe asymptomatic (80%) or symptomatic (>70%) carotid artery stenosis and were treated by carotid angioplasty and stent placement with or without filter embolic protection system. Follow-up consisted of physical evaluation at 1, 6, 12 and 24 months and assessment of the stent patency by ultrasound examination at 6, 12 and 24 months after the stent procedure. In 72 procedures a closed cell stainless steel stent was implanted, in the remaining 60 procedures an open cell nitinol stent was placed. In 8 patients with a stainless steel stent (11%) and in 6 patients ...
Recently we reported that percutaneous atrial septal defect (ASD) closure had no influence on the... more Recently we reported that percutaneous atrial septal defect (ASD) closure had no influence on the prevalence of migraine during a short followup period. 12 % of patients however developed a new-onset migraine after the ASD closure. As it has been suggested that the closing device might induce or maintain migraine temporarily, we were interested in the prevalence of migraine at longer follow-up. All 75 patients included in the previous study, received the same structured headache questionnaire. A neurologist, blinded to previous data, diagnosed migraine with or without aura (MA+ or MA-) according to the International Headache Criteria. McNemar paired X2 test was used to evaluate changes in the occurrence of migraine. Seventy-one patients (94.7%) answer the questionnaire (55 women, mean age at closure 51 +/- 18 years). Mean follow-up time was 52 +/- 13 months. The overall migraine prevalence decreased from 30.7% before to 22.5% after closure (P=0.21). A significant reduction was noted...
The short time window is frequently cited as the main reason for exclusion of intravenous tissue ... more The short time window is frequently cited as the main reason for exclusion of intravenous tissue plasminogen activator (tPA) in acute stroke. Identifying and circumventing barriers to thrombolysis other than time could increase the frequency of treatment. The goal of this study was to identify whether the rate of treatment with tPA would increase if time window was not an obstacle to treatment. In four hospitals we prospectively recorded the rate of tPA use in consecutive patients admitted with acute ischemic stroke and in those admitted within 3 hours, the reasons why thrombolysis was not given, and the potential gain in the rate of tPA use if all patients had been admitted within 3 hours considering all exclusion criteria other than time. We recruited 486 patients (258 men; mean age, 70.4 +/- 13.5 years), of whom 154 (31.7%) were admitted within 3 hours. The time of stroke onset was unknown in 28 (5.8%). The rate of tPA use was 11.1% in the whole study population and 35.1% in thos...
The perfusion-diffusion mismatch (PDM) model has been proposed as a tool to select acute stroke p... more The perfusion-diffusion mismatch (PDM) model has been proposed as a tool to select acute stroke patients who are most likely to benefit from reperfusion therapy. The clinical-diffusion mismatch (CDM) model is an alternative method that is technically less challenging because it does not require perfusion-weighted imaging. This study is an evaluation of these 2 models in the DEFUSE dataset. DEFUSE is an open-label multicenter study in which acute stroke patients were treated with intravenous tPA between 3 and 6 hours after symptoms onset and an MRI was obtained before and 3 to 6 hours after treatment. Presence of PDM and CDM was determined for each patient. Based on conventional predefined mismatch criteria, PDM was present in 54% of the DEFUSE population and CDM in 62%. There was no agreement beyond chance between the 2 mismatch models (kappa 0.07). The presence of PDM was associated with an increased chance of favorable clinical response after reperfusion (OR, 5.4; P=0.039). Reperf...
Although it is indisputable that high blood pressure should be treated to prevent a first or a re... more Although it is indisputable that high blood pressure should be treated to prevent a first or a recurrent stroke, the management of high blood pressure in the first hours and days after stroke remains controversial. There is no high-quality evidence from randomized controlled trials to guide treatment in the 80% of patients who have elevated blood pressure during the first days after stroke. Theoretically, there are pros and cons for manipulating blood pressure after onset of stroke. Most treatment guidelines suggest leaving blood pressure untouched based on pathophysiologic principles. Post-hoc analyses from randomized trials, however, suggest that elevated blood pressure is associated with recurrent stroke and higher mortality, even after adjustment for potential confounders. On the other hand, preliminary studies have suggested that voluntarily increasing blood pressure might be beneficial in a selected subgroup of patients. In this overview, we present a summary of recent studies...
Patients, who wake up with an ischemic stroke, account for a large number of the total stroke pop... more Patients, who wake up with an ischemic stroke, account for a large number of the total stroke population, due to circadian morning predominance of stroke. Currently, this subset of patients is excluded from revascularization-therapy since no exact time of onset is known. A large group of these patients might be eligible for therapy. In this review, we assessed the current literature about the hypothesis that wake-up-strokes occur just prior on awakening and if this subgroup differs in characteristics compared to the overall stroke population. We looked at the safety and efficacy of thrombolysis and interventional techniques in the group of patients with unknown stroke-onset. We performed a meta-analysis of the diagnostic accuracy of the diffusion-FLAIR mismatch in identifying stroke within 3 and 4.5 h. The different imaging-selection criteria that can be used to treat these patients are discussed. Additional research on imaging findings associated with recent stroke and penumbral imaging will eventually lead to a shift from a rigid time-frame based therapy to a tissue-based individualized treatment approach.
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Papers by Vincent Thijs