Stroke risk among adult patients with third, fourth or sixth cranial nerve palsy: a Nationwide Cohort Study

Stroke, risk, adult, third, fourth or sixth cranial nerve palsy, Cohort Study

2017 Aug 3. doi: 10.1111/aos.13488. [Epub ahead of print]

Stroke risk among adult patients with third, fourth or sixth cranial nerve palsy: a Nationwide Cohort Study.

Abstract

PURPOSE:

This study sought to determine whether isolated third, fourth and sixth cranial nerve palsies (NPs) are associated with increased short- and long-term risk of a subsequent stroke.

METHODS:

This was a nationwide retrospective propensity score-matched cohort study. A cohort of patients with NP (n = 466) and a randomly selected, propensity-matched control cohort (n = 2281) were extracted from the Korean national insurance claim database. Subjects were tracked for 5 years total, subdivided into periods of 0-1 years, 1-3 years and 3-5 years. We assessed the risk of stroke using hazard ratios (HRs) and confidence intervals (CIs) after adjustments using Cox regression at different time intervals.

RESULTS:

The median follow-up was 3.1 years. Stroke developed in 18.9% of the NP cohort and 7.5% of the control cohort. Stroke risk after NP was highest in the first year [14.7 per 100 person-year at 0-1 years (HR = 6.6), 3.1 per 100 person-year at 1-3 years (HR = 1.6) and 4.3 per 100 person-year at 3-5 years (HR = 2.8)]. Each type of NP was also associated with stroke risk: within 0-1 years, stroke risk was increased in third (HR = 7.6), fourth (HR = 6.0) and sixth (HR = 5. 84) NPs. In the 3- to 5-year period, risk was increased in sixth (HR = 4.7) and fourth (HR = 3.3) NPs, but not third (HR = 0.6) NPs.

CONCLUSION:

Patients in the NP cohort were more likely to have a stroke than those in the matched control cohort; the increased risk was both time- and cranial nerve-dependent.

Stroke, risk, adult, third, fourth or sixth cranial nerve palsy, Cohort Study

KEYWORDS:

cranial nerve palsy; fourth nerve palsy; sixth nerve palsy; stroke; third nerve palsy

Risk of Intraocular Bleeding With Novel Oral Anticoagulants Compared With Warfarin

Risk, Intraocular Bleeding, Anticoagulant, Warfarin

2017 Jul 6. doi: 10.1001/jamaophthalmol.2017.2199. [Epub ahead of print]

Risk of Intraocular Bleeding With Novel Oral Anticoagulants Compared With Warfarin: A Systematic Review and Meta-analysis.

Abstract

IMPORTANCE:

It is unclear if the risk of intraocular bleeding with novel oral anticoagulants differs compared with warfarin.

OBJECTIVE:

To characterize the risk of intraocular bleeding with novel oral anticoagulants compared with warfarin.

DATA SOURCES:

A systematic review and meta-analysis was undertaken in an academic medical setting. MEDLINE and ClinicalTrials.gov were searched for randomized clinical trials published up until August 2016. This search was supplemented by manual bibliography searches of identified trials and other review articles.

STUDY SELECTION:

Studies were eligible for inclusion if they were phase 3 randomized clinical trials, enrolled patients with atrial fibrillation or venous thromboembolism, compared a novel oral anticoagulant (dabigatran, rivaroxaban, apixaban, or edoxaban) with warfarin, and recorded event data on intraocular bleeding. Data on intraocular bleeding were pooled using inverse-variance, weighted, fixed-effects meta-analysis.

DATA EXTRACTION AND SYNTHESIS:

The PRISMA guidelines were used for abstracting data and assessing quality. Independent extraction was performed by 2 investigators.

MAIN OUTCOMES AND MEASURES:

Intraocular bleeding events and associated risk ratio for novel oral anticoagulants compared with warfarin.

RESULTS:

Twelve trials investigating 102 627 patients were included. Randomization to novel oral anticoagulants was associated with a 22% relative reduction in intraocular bleeding compared with warfarin (risk ratio, 0.78; 95% CI, 0.61-0.99). There was no significant heterogeneity observed (I2 = 4.8%, P = .40). Comparably lower risks of intraocular bleeding with novel oral anticoagulants were seen in subgroup analyses, with no significant difference according to the indication for anticoagulation (P for heterogeneity = .49) or the novel oral anticoagulant type (P for heterogeneity = .15). Summary estimates did not differ materially when random-effects meta-analytic techniques were used.

CONCLUSIONS AND RELEVANCE:

These results suggest that novel oral anticoagulants reduce the risk of intraocular bleeding by approximately one-fifth compared with warfarin. Similar benefits were seen in both patients with atrial fibrillation and venous thromboembolism. Our data have particular relevance for patients at higher risk of spontaneous retinal and subretinal bleeding. These findings may also have important implications in the perioperative period, in which the use of novel oral anticoagulants may be superior. Future studies are required to better characterize the optimal management of patients with both ophthalmic disease and cardiovascular comorbidities requiring anticoagulation.

PMID:
28687831
DOI:
10.1001/jamaophthalmol.2017.2199