Clinical Neuroscience

[The importance of anticoagulant therapy in patients with artial fibrillation in stroke prevention – summary of international data and novel therapeutic modalities]

MIROLOVICS Ágnes1, PAPP Csaba2, ZSUGA Judit2, BERECZKI Dániel3

MARCH 30, 2016

Clinical Neuroscience - 2016;69(03-04)

DOI: https://doi.org/10.18071/isz.69.0076

[The most common cardiogenic cause of ischaemic stroke is atrial fibrillation which increases the probability of stroke five-fold and doubles case fatality. Based on international data the incidence of atrial fibrillation is approx. 2% however this rapidly increases with age. The necessity of using oral anticoagulants in the prevention of non-valvular atrial fibrillation related stroke is decided based on estimated stroke risk. The CHADS2 and the more predictive CHA2DS2-VASc scales are used for this purpose while the bleeding risk of patients treated with anticoagulant may be estimated by the HAS-BLED scoring scale. For decades oral anticoagulation meant using vitamin-K antagonists. Based on international data we can see that rate of anticoagulation is unacceptably low, furthermore most of the anticoagulated patients aren’t within the therapeutic range of INR (INR: 2-3). A lot of disadvantages of vitamin-K antagonists are known (e.g. food-drug interaction, need for regular coagulation monitoring, increased risk of bleeding), therefore compounds with new therapeutic target have been developed. The novel oral anticoagulants (NOAC) can be divided in two major subgroups: direct thrombin inhibitors (dabigatran etexilate) and Xa-factor inhibitors (rivaroxaban, apixaban, edoxaban). These products are administered in fix doses, they less frequently interact with other medications or food, and regular coagulation monitoring is not needed when using these drugs. Moreover several studies have shown that they are at least as effective in the prevention of ischaemic stroke than the vitamin-K antagonists, with no more haemorrhagic complications.]

AFFILIATIONS

  1. Nyírô Gyula Kórház-OPAI, Neurológiai Osztály, Budapest
  2. Debreceni Egyetem, Egészségügyi Menedzsment és Minôségirányítási Tanszék, Debrecen
  3. Semmelweis Egyetem, Neurológiai Klinika, Budapest

COMMENTS

0 comments

Further articles in this publication

Clinical Neuroscience

Cerebral amyloid angiopathy related inflammation: is susceptibility weighted imaging the clue for diagnosis?

CSÉCSEI Péter, KOMOLY Sámuel, SZAPÁRY László, BARSI Péter

Background - Cerebral amyloid angiopathy-related inflammation (CAA-ri) is characterized by various neurological symptoms such as gradually developing confusion, progressive cognitive decline, seizure or headaches; T2 hyperintensities on magnetic resonance imaging (MRI); and neuropathological evidence of cerebral amyloid angiopathy (CAA) and associated vascular or perivascular inflammation. Although histological confirmation is necessary for accurate diagnosis, in case of typical clinical features and neuroimaging, the diagnosis can be established without biopsy. Case summary - We present the case of a 57-year-old man with a history of hypertension who presented to the emer¬gency department 3-week history of progressive headache and a gradually developing altered mental status. On examination, he was found to have left sided weakness and decreased pscyhomotility. Routine clinical work-up (lab investigations, CT, cerebrospinal fluid analysis) did not show obvious diagnosis, so we performed an MRI. It raised the suspicion of CAA-ri which diagnosis was verified by neuroradiological evaluation. High dose steroid treatment was initiated. The patient rapidly responded to treatment, his focal neurological signs resolved. Control MRI after 1.5 months showed multiple haemorrhagic laesions in the field of previous inflammation which posteriorly supported the previous supposed work-diagnosis. Conclusions - Although histopathology is the gold standard for the diagnosis of cerebral amyloid angiopathy, the typical clinical presentation, good response to steroids and accurate neuroradiological criteria make biopsy unnecessary to diagnose CAA-ri.

Clinical Neuroscience

[The therapeutic use of transcranial magnetic stimulation in major depression]

NÉMETH Viola Luca, CSIFCSÁK Gábor, KINCSES Zsigmond Tamás, JANKA Zoltán, MUST Anita

[The antidepressive effect of repetitive transcranial magnetic stimulation (rTMS) has been investigated for almost 20 years now. Several studies have been published aiming to identify the exact and reliable parameters leading to the desired therapeutic effect. However, the related literature shows great variability. The current overview aims to provide a comprehensive overview of factors associated with the therapeutic effect of rTMS in major depression. High frequency stimulation of the left dorsolateral prefrontal cortex (DLPFC) for 3-6 weeks leads to mood improvement comparable to the effect of antidepressive medications in 35-40% of patients. Pharmacotherapy resistant patients treated with rTMS reach remission for 3 months on average. Low frequency stimulation of the right DLPFC appears to be similarly effective, though much less investigated so far. In addition to the exact delineation of the stimulation area, treatment outcome is also related to stimulation intensity as well as the number of sessions and impulses. Considering the safety and tolerability aspects of rTMS, it might be a significant therapeutic support for therapy resistant patients. Above this, patients diagnosed with major depression might benefit from the additional positive influence of rTMS improving the effect of antidepressive medication. Based on converging research evidence, the Food and Drug Administration (FDA) agency approved the use of rTMS as a treatment option for therapy resistant major depression in 2008. So far, in Hungary rTMS is primarily considered as a promising tool in research settings only. Hopefully, patients suffering from major depression will increasingly benefit from the positive therapeutic effect of this intervention.]

Clinical Neuroscience

[Computed tomographic examination of cranial lesions, a paleoradiological approach]

ZÁDORI Péter, BAJZIK Gábor, BÍRÓ Gergely, LELOVICS Zsuzsanna, BALASSA Tímea, BERNERT Zsolt, ÉVINGER Sándor, HAJDU Tamás, MARCSIK Antónia, MOLNÁR Erika, ŐSZ Brigitta, PÁLFI György, WOLFF Katalin, REPA Imre

[Background and purpose - Introducing the multidisciplinary paleoradiology research at the Institute of Diagnostic Imaging and Radiation Oncology of the Kaposvár University, highlighting the cases with potential central nervous system involvement - from the scanning methods to the 3D printing - in order to draw attention to the historical background and clinical aspects of certain pathological conditions. Methods - The authors developed the examination protocols for three different CT scanners. Among the examined archaeological remains cranial lesions were identified in 26 cases, from which 4 cases with potential central nervous system involvement are demonstrated. The scanning parameters and the advantages of secondary image reconstructions (multiplanar reconstruction, maximum intensity projection, three-dimensional volume rendering technique) are presented with the cases. Results - The authors demonstrate a case with destructive skull lesions due to syphilis from the 15th century AD, a condition rarely seen or even unknown nowadays in the modern world. With the CT images of the skull base fracture from the Iron Age, signs of healing could be verified. Using the CT images a non-invasive approach is presented in the case of the craniofacial osteosarcoma in order to visualize the local status and the direct intracranial propagation. Advantages of the 3D VRT reconstructions are shown in the case of unilateral coronal suture synostosis. Conclusion - Paleoradiological CT examinations serve as a non-invasive, non-destructive tool for studying archaeological remains and artifacts. The special applications provided by the imaging modality contribute to the conventional paleopathological investigations. Keywords: paleoradiology, computed tomography, 3D reconstruction, skull lesions, paleopathology]

Clinical Neuroscience

[Endoscopic removal of tuberculum sellae meningeoma through endonasal transsphenoidal approach]

FÜLÖP Béla, BELLA Zsolt, PALÁGYI Péter, BARZÓ Pál

[Experiences acquired in our department with endoscope assisted microsurgical transsphenoidal pituitary surgery encouraged us to expanded the endoscopic approach to skull base lesions. The endoscopic endonasal transsphenoidal approach proved to be less traumatic to the traditional microsurgical approaches, yet very effective. The endoscopic transsphenoidal technique was applied in a patient havin anterior skull base tumor. The patient was a 49-year-old woman with several months history of left visual defect. The magnetic resonance (MR) scans of the skull revealed a midline anterior fossa space-occupying lesion measuring 21×16×22 mm located on planum sphenoidale, tuberculum sellae and intrasellar. The tumor compressed both optic nerves and optic chiasm. Total resection of the tumor was achieved by use of endoscopic transnasal, transsphenoidal technique. This is the first reported case of an anterior fossa meningeoma being treated by an endoscopic transsphenoidal technique in Hungary.]

Clinical Neuroscience

[Hungarian adaptation of a short eating disorder questionnaire (SCOFF)]

DUKAY-SZABÓ Szilvia, SIMON Dávid, VARGA Márta, SZABÓ Pál, TÚRY Ferenc, RATHNER Günther

[Aim - Eating disorders are becoming an increasingly relevant health issue, therefore the fast and accurate screening of people at risk is of great practical importance. The aim of SCOFF questionnaire is to assess this risk and the extent to which a person is affected, by using five simple yes or no questions. The objective of our study was to assess the validity of the Hungarian version of the test Methods - 777 medical students (210 men, 567 women, mean age 22.3±2.33 years) participated in the survey. The online questionnaire contained anthropometric data, the Eating Behaviour Severity Scale and, beside the SCOFF, the Eating Disorder Inventory (EDI). Results - The SCOFF is excellent at screening clinical eating disorders. Its sensitivity was 100% and specificity 85.1%. It is less efficient at detecting subclinical cases, but it does not show worse results than EDI. According to the data SCOFF is better at identifying more serious cases. Applying on the same sample SCOFF had higher sensitivity and lower specificity than EDI. Discussion - SCOFF is suitable for primary screening of eating disorders with a non-diagnostic purpose, taken two “yes” answers out of five as the critical margin, specified by the authors.]

All articles in the issue

Related contents

Clinical Neuroscience

[Administration of idarucizumab in spontaneous intracerebral hemorrhage under dabigatran-therapy]

BERECZKI Dániel Jr., SZILÁGYI Géza, KAKUK Ilona, SZAKÁCS ZOLTÁN, MAY Zsolt

[Introduction - Among antidotes in development for reversal of novel oral anticoagulants, dabigatran-specific idarucizumab was the first one to reach the market. Case presentation - We present the first Hungarian case of intracerebral hemorrhage under treatment with dabigatran, where idarucizumab was administered to suspend anticoagulation. Discussion - Our report is concordant with prior publications, confirming the efficacy of the antidote in reversing the effect of dabigatran, and thus, preventing intracerebral hematoma progression in the acute phase. Conclusion - Since there is no proven alternative to idarucizumab, conducting randomized clinical trials would be unethical. Therefore, besides case reports, positive results of prospective studies could help us revise therapeutic guidelines, and thus, improve the prognosis of dabigatran-associated intracerebral hemorrhages.]

Clinical Neuroscience

[Effective, safe stroke prevention with novel oral anticoagulants in patients with atrial fibrillation. Focus on dabigatran]

SZAPÁRY László, FEHÉR Gergely, BOSNYÁK Edit, DELI Gabriella, CSÉCSEI Péter

[Non-valvular AF is the most common cardiac arrhytmia. Its incidence increases with age. AF is an independent risk factor for ischaemic stroke, representing a five times higher risk for it, associated with a high mortality rate. Beside AF, there are several other risk factors which influence the risk of stroke. Stroke risk calculator can be used to assess the risk of patient having a stroke. The most endangered group of patients with AF are those who have already suffered from cerebrovascular event. The only effective medication for prevention of stroke due to AF had been the application of vitamin K antagonists (VKA) which considerably decrease the rate of ischaemic event in a patient with AF providing that the INR is in the therapeutic range. VKA have several limitations of use in clinical practice and the fear of bleeding complications results an underusing of these drugs. Only 50% of all patients treated with VKA reaches the therapeutic range of INR. The breakthrough of prevention of stroke in recent years is undisputedly the coming out of novel oral anticoagulants (NOACs, thrombin and Xa-factor inhibitors). Recent studies suggest that these novel drugs prove the same efficacy as VKA drugs, furthermore dabigatran in a dose of 2×150 mg or apixaban in 2×5mg was statistically superior to warfarin in the prevention of stroke. NOACs have shown a large reduction in intracranial hemorrhage compared with warfarin. They are given as a fixed dose and do not require persistent monitoring making them much more convenient. NOACs at guidelines of European Society of Cardiology act as a preferable drugs in case of ischaemic stroke with AF. Probably the extended use of NOACs in clinical practice will be the mainstream of stroke prevention in the future.]

Clinical Neuroscience

[Current practice of antithrombotic treatment in ischemic stroke: a survey among Hungarian neurologists (in English language)]

SZTRIHA K. László, VÉCSEI László

[Background and purpose - Large multicenter trials have already evaluated the relative benefit of various types of antithrombotic medication in ischemic stroke. However, the application of the trial results still remains uncertain in some clinical situations. We set out to evaluate the various aspects of antithrombotic treatment use among clinical practitioners. Methods - A virtually nationwide survey was performed among Hungarian neurologists involved in stroke care, who responded to a questionnaire concerning the use of antiplatelet agents and anticoagulation in acute ischemic stroke and for secondary prevention. Results - The response rate was 65%. Most (69%) practitioners always wait for brain imaging before initiating antithrombotic treatment in acute stroke. Aspirin (100 mg/ day) is the most frequently prescribed antiplatelet agent after a first ischemic episode. Common reasons for the prescription of alternative agents instead of aspirin after a first attack include high-risk cases and intolerance or allergy to aspirin. The results of in vitro platelet aggregation studies frequently influence drug selection. If an event recurs during a given antiplatelet treatment, most neurologists change the medication. Some participants reported the administration of anticoagulation, or of the combination of aspirin plus clopidogrel in certain situations that are not cardiological indications. Conclusions - This study provides information on the use of antithrombotic treatment in general neurological practice, including everyday clinical situations where no help is available from guidelines.]

Lege Artis Medicinae

[Apixaban: the newest oral anticoagulant in Hungary for the treatment of patients with atrial fibrillation]

BORBÉLY Attila, ÉDES István

[In the past few years a number of articles have been published on the new oral anticoagulants (Xa-factor inhibitors, thrombin inhibitors). These new agents are increasingly used in the daily clinical practice in Hungary. The new oral anticoagulants have been shown to be at least as effective in the prevention of stroke and systemic embolization related to non-valvular atrial fibrillation as K vitamin antagonists. Moreover, their use is safe, can be administered in a daily fixed dose and, even in case of long-term use, they do not require regular laboratory testing. This review aims to summarise the most important theoretical and practical information on the newest direct Xa-factor inhibitor agent apixaban from the perspective of a cardiologist.]

Lege Artis Medicinae

[Dabigatran: a new oral anticoagulant agent for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation]

KANCZ Sándor

[In this article, we summarise the available information on dabigatran, focusing on clinical practice, in particular on the prevention of stroke and systemic embolism, the critical aspects of anticoagulant treatment with dabigatran, potential drug-drug interactions and adverse reactions in nonvalvular atrial fibrillation. The most important molecular characteristics of dabigatran are also described. We highlight the implications of safety issues that have emerged during everyday clinical practice.]