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Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2018; 49:e46-e110. [PMID: 29367334 DOI: 10.1161/str.0000000000000158] [Citation(s) in RCA: 3461] [Impact Index Per Article: 576.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 guidelines and subsequent updates. METHODS Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft guideline was performed by 4 expert peer reviewers and by the members of the Stroke Council's Scientific Statements Oversight Committee and Stroke Council Leadership Committee. These guidelines use the American College of Cardiology/American Heart Association 2015 Class of Recommendations and Levels of Evidence and the new American Heart Association guidelines format. RESULTS These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. CONCLUSIONS These guidelines are based on the best evidence currently available. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
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Maingard J, Churilov L, Mitchell P, Dowling R, Yan B. Selection criteria for endovascular therapy for acute ischaemic stroke: Are patients missing out? J Med Imaging Radiat Oncol 2018; 62:345-354. [PMID: 29316375 DOI: 10.1111/1754-9485.12700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 11/29/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Endovascular clot retrieval (ECR) following intravenous thrombolysis is superior to intravenous thrombolysis alone for acute stroke with large vessel occlusion. However, trial selection criteria may exclude potentially salvageable patients. We investigated the impact of published selection criteria on the different proportions of patients excluded and clinical outcome. METHODS We included patients with anterior circulation stroke treated with ECR from a single centre. Selection criteria from five trials (REVASCAT, EXTEND IA, MR CLEAN, SWIFT PRIME, ESCAPE) and American Stroke Association (ASA) guidelines were applied. We calculated the proportion of patient's ineligible for ECR according to different selection criteria. Clinical benefit and harm were quantified as the number of patients benefiting per 1 patient harmed (NB1H) for each of the 6 applied selection criteria. RESULTS One hundred and seventy-eight patients were included. Mean age was 74 (SD 14) years, 60.1% were male, median baseline NIHSS was 17 (IQR 13-21). Patients were hypothetically excluded from ECR: REVASCAT 35.4%, EXTENDA IA 86%, SWIFT PRIME 86%, MR CLEAN 2.3%, ESCAPE 93.3% and ASA 29.2%. The NB1H for included and excluded patients respectively in decreasing order of magnitude: EXTEND IA >100 vs 3, ESCAPE >100 vs 3.4, SWIFT PRIME 10 vs 3.3, REVASCAT 4.4 vs 2.9, MR CLEAN 3.7 vs >100, and ASA 3.7 vs 3.9. CONCLUSION We found that criteria from MR CLEAN, ASA and REVASCAT excluded the lowest proportion of patients with comparable NB1H. We believe that these criteria would be reasonable to be utilised for ECR selection.
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Affiliation(s)
- Julian Maingard
- Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Leonid Churilov
- Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,Department of Mathematics and Statistics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter Mitchell
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Richard Dowling
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Bernard Yan
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Dong MX, Li CM, Shen P, Hu QC, Wei YD, Ren YF, Yu J, Gui SW, Liu YY, Pan JX, Xie P. Recombinant tissue plasminogen activator induces long-term anxiety-like behaviors via the ERK1/2-GAD1-GABA cascade in the hippocampus of a rat model. Neuropharmacology 2018; 128:119-131. [DOI: 10.1016/j.neuropharm.2017.09.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 09/26/2017] [Accepted: 09/30/2017] [Indexed: 01/04/2023]
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104
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Madelung CF, Ovesen C, Trampedach C, Christensen A, Havsteen I, Hansen CK, Christensen H. Leptomeningeal collateral status predicts outcome after middle cerebral artery occlusion. Acta Neurol Scand 2018; 137:125-132. [PMID: 28905995 DOI: 10.1111/ane.12834] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Perfusion through leptomeningeal collateral vessels is a likely pivotal factor in the outcome of stroke patients. We aimed to investigate the effect of collateral status on outcome in a cohort of unselected, consecutive stroke patients with middle cerebral artery occlusion undergoing reperfusion therapy. MATERIALS AND METHODS This retrospectively planned analysis was passed on prospectively collected data from 187 consecutive patients with middle cerebral artery occlusion admitted within 4.5 hours to one center and treated with intravenous thrombolysis alone (N = 126), mechanical thrombectomy alone (N = 5), or both (N = 56) from May 2009 to April 2014. Non-contrast CT (NCCT) and computed tomography angiography (CTA) were provided on admission and NCCT repeated at 24 hours. Collateral status was assessed based on the initial CTA. Hemorrhagic transformation was evaluated on the 24-hour NCCT and according to European Cooperative Acute Stroke Study (ECASS) criteria. Modified Rankin Scale score was assessed at 90 days, and mortality at 1 year. RESULTS At 90 days, median (IQR) modified Rankin Scale score in patients with poor collateral status was 4 (3-6) compared to 2 (1-4) in patients with good collateral status (P < .0001). Patients with poor collateral status were less likely to achieve a good 90-day outcome (modified Rankin Scale score 0-2) (Adjusted odds ratio 0.27, 95% CI: 0.09-0.86). During the first year, 40.9% of patients with poor collateral status died vs 18.2% of the remaining population (P = .001). CONCLUSIONS Leptomeningeal collateral status predicts functional outcome, mortality, and hemorrhagic transformation following middle cerebral artery occlusion.
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Affiliation(s)
- C. F. Madelung
- Department of Neurology; Bispebjerg Hospital; Copenhagen Denmark
| | - C. Ovesen
- Department of Neurology; Bispebjerg Hospital; Copenhagen Denmark
| | - C. Trampedach
- Department of Radiology; Bispebjerg Hospital; Copenhagen Denmark
| | - A. Christensen
- Department of Radiology; Bispebjerg Hospital; Copenhagen Denmark
| | - I. Havsteen
- Department of Radiology; Bispebjerg Hospital; Copenhagen Denmark
| | - C. K. Hansen
- Department of Neurology; Bispebjerg Hospital; Copenhagen Denmark
| | - H. Christensen
- Department of Neurology; Bispebjerg Hospital; Copenhagen Denmark
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105
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Use of a mechanical thrombectomy device to treat early hepatic artery thrombosis after orthotopic liver transplant. Radiol Case Rep 2017; 13:522-526. [PMID: 29904504 PMCID: PMC6000183 DOI: 10.1016/j.radcr.2017.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 12/11/2017] [Indexed: 12/14/2022] Open
Abstract
Hepatic artery thrombosis (HAT) is a major cause of morbidity and mortality after orthotopic liver transplantation, occurring in 5% of cases (Piardi et al, 2016). HAT is the second main cause of graft loss after primary nonfunction, the leading cause of graft failure in the immediate postoperative period (<1 month), and is associated with a mortality rate of up to 60% without intervention (Piardi et al, 2016; Pareja et al., 2010; Crossin et al., 2003). Although retransplantation is the preferred therapy, the limited availability of donor organs can necessitate urgent, alternative treatment. These patients present physicians with an often-severe clinical picture, which requires consideration of endovascular approaches as opposed to the more traditional, invasive surgical interventions. The following case study presents a novel mechanical therapy that uses an endovascular approach for revascularization—a stent retriever device.
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106
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Mazya MV, Cooray C, Lees KR, Toni D, Ford GA, Bar M, Frol S, Moreira T, Sekaran L, Švigelj V, Wahlgren N, Ahmed N. Minor stroke due to large artery occlusion. When is intravenous thrombolysis not enough? Results from the SITS International Stroke Thrombolysis Register. Eur Stroke J 2017; 3:29-38. [PMID: 31008335 DOI: 10.1177/2396987317746003] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 11/07/2017] [Indexed: 11/17/2022] Open
Abstract
Purpose Beyond intravenous thrombolysis, evidence is lacking on acute treatment of minor stroke caused by large artery occlusion. To identify candidates for additional endovascular therapy, we aimed to determine the frequency of non-haemorrhagic early neurological deterioration in patients with intravenous thrombolysis-treated minor stroke caused by occlusion of large proximal and distal cerebral arteries. Secondary aims were to establish risk factors for non-haemorrhagic early neurological deterioration and report three-month outcomes in patients with and without non-haemorrhagic early neurological deterioration. Method We analysed data from the SITS International Stroke Thrombolysis Register on 2553 patients with intravenous thrombolysis-treated minor stroke (NIH Stroke Scale scores 0-5) and available arterial occlusion data. Non-haemorrhagic early neurological deterioration was defined as an increase in NIH Stroke Scale score ≥4 at 24 h, without parenchymal hematoma on follow-up imaging within 22-36 h. Findings The highest frequency of non-haemorrhagic early neurological deterioration was seen in 30% of patients with terminal internal carotid artery or tandem occlusions (internal carotid artery + middle cerebral artery) (adjusted odds ratio: 10.3 (95% CI 4.3-24.9), p < 0.001) and 17% in extracranial carotid occlusions (adjusted odds ratio 4.3 (2.5-7.7), p < 0.001) versus 3.1% in those with no occlusion. Proximal middle cerebral artery-M1 occlusions had non-haemorrhagic early neurological deterioration in 9% (adjusted odds ratio 2.1 (0.97-4.4), p = 0.06). Among patients with any occlusion and non-haemorrhagic early neurological deterioration, 77% were dead or dependent at three months. Conclusions Patients with minor stroke caused by internal carotid artery occlusion, with or without tandem middle cerebral artery involvement, are at high risk of disabling deterioration, despite intravenous thrombolysis treatment. Acute vessel imaging contributes usefully even in minor stroke to identify and consider endovascular treatment, or intensive monitoring at a comprehensive stroke centre, for patients at high risk of neurological deterioration.
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Affiliation(s)
- Michael V Mazya
- 1Department of Neurology, Karolinska University Hospital, Solna, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Charith Cooray
- 1Department of Neurology, Karolinska University Hospital, Solna, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kennedy R Lees
- 3Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Danilo Toni
- Department of Neurology and Psychiatry, University of Rome - 'La Sapienza', Rome, Italy
| | - Gary A Ford
- Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michal Bar
- 6Department of Neurology, University Hospital and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Senta Frol
- Department of Vascular Neurology and Neurological Intensive Care, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Tiago Moreira
- 1Department of Neurology, Karolinska University Hospital, Solna, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Viktor Švigelj
- Department of Vascular Neurology and Neurological Intensive Care, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Nils Wahlgren
- 1Department of Neurology, Karolinska University Hospital, Solna, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Niaz Ahmed
- 1Department of Neurology, Karolinska University Hospital, Solna, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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The organisation of the acute ischemic stroke management: key notes of the Italian Neurological Society and of the Italian Stroke Organization. Neurol Sci 2017; 39:415-422. [DOI: 10.1007/s10072-017-3200-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 11/17/2017] [Indexed: 01/19/2023]
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108
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Mackay MT, Monagle P, Babl FE. Improving diagnosis of childhood arterial ischaemic stroke. Expert Rev Neurother 2017; 17:1157-1165. [DOI: 10.1080/14737175.2017.1395699] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mark T. Mackay
- Department of Neurology, Royal Children’s Hospital, Parkville, Australia
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Florey Institute of Neurosciences and Mental Health, Parkville, Australia
| | - Paul Monagle
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Department of Haematology, Royal Children’s Hospital, Parkville, Australia
| | - Franz E. Babl
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Emergency Department, Royal Children’s Hospital Melbourne, Parkville, Australia
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109
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Raghib MF, Mutzenbach JS, Rösler C, Otto F, Coy MM, Müller-Thies-Broussalis E, Pikija S. Acute treatment of stroke due to spontaneous calcified cerebral emboli causing large vessel occlusion. J Clin Neurosci 2017; 47:56-61. [PMID: 29102234 DOI: 10.1016/j.jocn.2017.10.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 10/11/2017] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Calcified cerebral emboli (CCE) are rarely responsible for large vessel occlusion (LVO) in acute anterior stroke, and therefore therapeutic experience is scarce. We sought to expand current knowledge upon therapeutic options with three new cases and a review of current literature. METHODS Systematic search of patients with acute anterior stroke due to LVO in one comprehensive stroke center throughout a 4 year period. Literature search for reported cases of CCE. RESULTS In total, 21 cases (19 found in literature and 3 from our institution) are reported with a median age of 72 years (interquartile range [IQR] 63-80). Eleven patients were treated acutely, 4 of them with endovascular thrombectomy (EVT). Middle cerebral artery (MCA) M1 was the most affected segment and large artery atherosclerosis (LAA) and cardioembolism (CE) was causative in 41% of cases. EVT was significantly superior to intravenous recombinant tissue plasminogen activator (rtPA) at p = .048 (Fisher's exact test, chi square 6.7). CONCLUSIONS Given the small sample reported in literature and no reported randomised studies, definitive recommendations could not be reached. However, considering thrombus composition, thrombolysis is most probably not sufficient and priority should be given to EVT.
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Affiliation(s)
| | - Johannes Sebastian Mutzenbach
- Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Cornelia Rösler
- Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Ferdinand Otto
- Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Mark Mc Coy
- Department of Neuroradiology, Christian Doppler Medical Centre, Paracelsus Medical University Salzburg, Salzburg, Austria
| | | | - Slaven Pikija
- Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University Salzburg, Salzburg, Austria.
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110
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Li JG, Wang LQ, Yang XY, Chen Z, Lai LYW, Xu H, Liu JP. Chinese herbal medicine Dengzhan Xixin injection for acute ischemic stroke: A systematic review and meta-analysis of randomised controlled trials. Complement Ther Med 2017; 34:74-85. [PMID: 28917378 DOI: 10.1016/j.ctim.2017.08.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 06/19/2017] [Accepted: 08/04/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To evaluate the effectiveness and safety of Chinese herbal medicine Dengzhan Xixin (Erigeron breviscapus) injection for acute ischemic stroke. DESIGN Systematic review and meta-analysis (CRD42016038413, http://www.crd.york.ac.uk/PROSPERO). METHODS Six electronic databases were searched from inception to March 2016 for randomised controlled trials (RCTs) of Dengzhan Xixin (DZXX) injection for acute ischemic stroke. The methodological quality of RCTs was assessed by the Cochrane risk of bias tool. DATA SYNTHESIS was performed using RevMan 5.3 and was presented with mean difference (MD) or relative risk (RR) and their 95% confidence interval (CI). A summary of finding table was generated by GRADEpro (version 3.6). RESULTS Twenty-five RCTs with 2498 participants were included and all trials adopted conventional therapy (CT) in both arms. Most of the studies had high risk of bias. The addition of DZXX to CT showed no significant benefit on death (RR 0.27, 95% CI 0.05-1.63) within the treatment period (14-35 d), but showed higher Barthel index score (MD 10.20, 95% CI 8.16-12.25), lower neurological function deficit score (MD -3.99, 95% CI -5.68 to -2.30, by NFDS; MD -1.67, 95% CI -2.59 to -0.76, by NIHSS), and lower treatment failure (RR 0.40, 95% CI 0.31-0.52). Thirteen trials (52%) reported the outcome of adverse events, but no serious adverse events were reported. CONCLUSION Low quality evidence implied that DZXX injection appeared to improve neurological function in patients with acute ischemic stroke. However, this potential benefit should be further studied in large, rigorous trials.
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Affiliation(s)
- Jin-Gen Li
- Graduate School, Beijing University of Chinese Medicine, Beijing 100029, China
| | - Li-Qiong Wang
- Center for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing 100029, China
| | - Xiao-Ying Yang
- Center for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing 100029, China
| | - Zhuo Chen
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 10091, China
| | - Lily Y W Lai
- Complementary and Integrated Medicine Research Unit, Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Hao Xu
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 10091, China.
| | - Jian-Ping Liu
- Center for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing 100029, China; The National Research Center in Complementary and Alternative Medicine (NAFKAM), Department of Community Medicine, Faculty of Health Science, the Arctic University of Norway, 9037 Tromsø, Norway.
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111
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Gao S, Zhu Q, Guo M, Gao Y, Dong X, Chen Z, Liu Z, Xie F. Ultrasound and Intra-Clot Microbubbles Enhanced Catheter-Directed Thrombolysis in Vitro and in Vivo. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:1671-1678. [PMID: 28479088 DOI: 10.1016/j.ultrasmedbio.2017.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/03/2017] [Accepted: 03/27/2017] [Indexed: 06/07/2023]
Abstract
Insufficient penetration of microbubbles (MBs) into the vessel-obstructing thrombi significantly reduces the effectiveness of ultrasound thrombolysis (UT). The widely performed catheter-directed therapy (CDT) makes it possible to increase the local concentration of MBs in the clot. In an occluded vessel with a bypass, treatment of fresh human whole blood clots with CDT-based UT (intra-clot injection of MBs and urokinase, with ultrasound exposure) resulted in a significantly higher percentage of weight loss (35.32 ± 15.42%), compared with CDT alone (19.64 ± 4.71%), non-CDT-based UT (systemic administration of urokinase and MBs, with ultrasound exposure, 8.79 ± 3.02%) and systemic thrombolysis (7.90 ± 2.14). Ultrasound and intra-clot MB enhancement of CDT was further confirmed by a rabbit IVC thrombolysis study, where CDT-based UT resulted in significantly more effective thrombolysis compared with CDT alone. In summary, combining CDT with intra-clot MB-induced acoustic cavitation can improve thrombolysis.
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Affiliation(s)
- Shunji Gao
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Qiong Zhu
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - MengJiao Guo
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Yuan Gao
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Xiaoxiao Dong
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Zhong Chen
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Zheng Liu
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
| | - Feng Xie
- Internal Medicine Cardiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
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112
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Stenumgård PS, Rakotondranaivo MJ, Sletvold O, Follestad T, Ellekjær H. Stroke in a resource-constrained hospital in Madagascar. BMC Res Notes 2017; 10:307. [PMID: 28738901 PMCID: PMC5525216 DOI: 10.1186/s13104-017-2627-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 07/13/2017] [Indexed: 11/11/2022] Open
Abstract
Background Stroke is reported as the most frequent cause of in-hospital death in Madagascar. However, no descriptive data on hospitalized stroke patients in the country have been published. In the present study, we sought to investigate the feasibility of collecting data on stroke patients in a resource-constrained hospital in Madagascar. We also aimed to characterize patients hospitalized with stroke. Methods We registered socio-demographics, clinical characteristics, and early outcomes of patients admitted for stroke between 23 September 2014 and 3 December 2014. We used several validated scales for the evaluation. Stroke severity was measured by the National Institutes of Health Stroke Scale (NIHSS), disability by the modified Rankin Scale (mRS), and function by the Barthel Index (BI). Results We studied 30 patients. Sixteen were males. The median age was 62.5 years (IQR 58–67). The NIHSS and mRS were completed for all of the patients, and BI was used for the survivors. Three patients received a computed tomography (CT) brain scan. The access to laboratory investigations was limited. Electrocardiographs (ECGs) were not performed. The median NIHSS score was 16.5 (IQR 10–35). The in-hospital stroke mortality was 30%. At discharge, the median mRS score was 5 (IQR 4–6), and the median BI score was 45 (IQR 0–72.5). Conclusions Although the access to brain imaging and supporting investigations was deficient, this small-scale study suggests that it is feasible to collect essential data on stroke patients in a resource-constrained hospital in Madagascar. Such data should be useful for improving stroke services and planning further research. The hospitalized stroke patients had severe symptoms. The in-hospital stroke mortality was high. At discharge, the disability category was high, and functional status low.
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Affiliation(s)
- Pål Sigurd Stenumgård
- Department of Geriatrics, St. Olavs Hospital, Postbox 3250, Sluppen, 7006, Trondheim, Norway. .,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Postbox 8905, 7491, Trondheim, Norway.
| | | | - Olav Sletvold
- Department of Geriatrics, St. Olavs Hospital, Postbox 3250, Sluppen, 7006, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Postbox 8905, 7491, Trondheim, Norway
| | - Turid Follestad
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Postbox 8905, 7491, Trondheim, Norway
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Postbox 8905, 7491, Trondheim, Norway.,Stroke Unit, St. Olavs Hospital, Postbox 3250, Sluppen, 7006, Trondheim, Norway
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113
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Hameed A, Zafar H, Mylotte D, Sharif F. Recent Trends in Clot Retrieval Devices: A Review. Cardiol Ther 2017; 6:193-202. [PMID: 28702878 PMCID: PMC5688975 DOI: 10.1007/s40119-017-0098-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Indexed: 11/27/2022] Open
Abstract
Stroke is the second leading cause of death worldwide and in Europe. Even with gold standard medical management of acute ischemic stroke, which is intravenous (IV) thrombolysis by administration of recombinant tissue plasminogen activator (rt-PA), the mortality rate remains the same. Intra-arterial (IA) thrombolysis therapy also did not achieve significant results and was not approved by the US Food and Drug Administration (FDA) because of limited sample size. This encouraged scientists and engineers to develop endovascular clot retrieval devices for the mechanical recanalization of the occluded arteries in stroke patients. Although the initial designs of clot retrieval devices failed, efforts to improve these devices continue. Recently clot retrieval devices were approved by the FDA as first-line treatment along with IV rt-PA. This article gives an in-depth review of different clot retrieval devices which includes MERCI (the first), the Penumbra Aspiration System, EmboTrap®II, stent retrievers, and the way forward with the new FDA clearance of the devices as first-line treatment for acute ischemic stroke along with IV rt-PA. The review also includes a comparison of clot retrieval devices to gold standard treatment.
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Affiliation(s)
- Aamir Hameed
- Cardiovascular Research Centre Galway, School of Medicine, National University of Ireland Galway, Galway, Ireland
- CÚRAM, SFI Centre for Research in Medical Devices, Galway, Ireland
| | - Haroon Zafar
- Cardiovascular Research Centre Galway, School of Medicine, National University of Ireland Galway, Galway, Ireland.
- Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland.
| | - Darren Mylotte
- Cardiovascular Research Centre Galway, School of Medicine, National University of Ireland Galway, Galway, Ireland
- Department of Cardiology, University Hospital Galway, Galway, Ireland
| | - Faisal Sharif
- Cardiovascular Research Centre Galway, School of Medicine, National University of Ireland Galway, Galway, Ireland
- CÚRAM, SFI Centre for Research in Medical Devices, Galway, Ireland
- Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland
- Department of Cardiology, University Hospital Galway, Galway, Ireland
- BioInnovate, Galway, Ireland
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Daoud AN, Francois B, Chesneau P, Senekian VP, Duong K, Keita M, Chiv S, Tsafehi M, Mimeau E. Thrombolyse intraveineuse dans les infarctus cérébraux aigus dans un centre sans unité neurovasculaire : expérience du centre hospitalier de Cayenne. ANNALES FRANCAISES DE MEDECINE D URGENCE 2017. [DOI: 10.1007/s13341-017-0763-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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115
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Evans MRB, White P, Cowley P, Werring DJ. Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy. Pract Neurol 2017. [PMID: 28647705 PMCID: PMC5537551 DOI: 10.1136/practneurol-2017-001685] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Rapid, safe and effective arterial recanalisation to restore blood flow and improve functional outcome remains the primary goal of hyperacute ischaemic stroke management. The benefit of intravenous thrombolysis with recombinant tissue-type plasminogen activator for patients with severe stroke due to large artery occlusion is limited; early recanalisation is generally less than 30% for carotid, proximal middle cerebral artery or basilar artery occlusion. Since November 2014, nine positive randomised controlled trials of mechanical thrombectomy for large vessel occlusion in the anterior circulation have led to a revolution in the care of patients with acute ischaemic stroke. Its efficacy is unmatched by any previous therapy in stroke medicine, with a number needed to treat of less than 3 for improved functional outcome. With effectiveness shown beyond any reasonable doubt, the key challenge now is how to implement accessible, safe and effective mechanical thrombectomy services. This review aims to provide neurologists and other stroke physicians with a summary of the evidence base, a discussion of practical aspects of delivering the treatment and future challenges. We aim to give guidance on some of the areas not clearly described in the clinical trials (based on evidence where available, but if not, on our own experience and practice) and highlight areas of uncertainty requiring further research.
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Affiliation(s)
- Matthew R B Evans
- Stroke Research Centre, Department of Brain repair and Rehabilitation, University College London Institute of Neurology, London, UK
| | - Phil White
- Stroke Research Centre, Institute of Neuroscience and Newcastle University Institute for Ageing, Newcastle Upon Tyne, UK
| | - Peter Cowley
- Stroke Research Centre, Department of Brain repair and Rehabilitation, University College London Institute of Neurology, London, UK.,Neuroradiological Academic Unit, University College London Institute of Neurology, London, UK
| | - David J Werring
- Stroke Research Centre, Department of Brain repair and Rehabilitation, University College London Institute of Neurology, London, UK
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116
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Dong Q, Dong Y, Liu L, Xu A, Zhang Y, Zheng H, Wang Y. The Chinese Stroke Association scientific statement: intravenous thrombolysis in acute ischaemic stroke. Stroke Vasc Neurol 2017; 2:147-159. [PMID: 28989804 PMCID: PMC5628383 DOI: 10.1136/svn-2017-000074] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/20/2017] [Accepted: 03/22/2017] [Indexed: 12/30/2022] Open
Abstract
The most effective medical treatment for acute ischaemic stroke (AIS) is to offer intravenous thrombolysis during the ultra-early period of time after the onset. Even based on the Consensus of Chinese Experts on Intravenous Thrombolysis for AIS in 2012 and 2014 Chinese Guidelines on the Diagnosis and Treatment of AIS, the rate of thrombolysis for AIS in China remained around 2.4%, and the rate of intravenous tissue plasminogen activator usage was only about 1.6% in real world. The indication of thrombolysis for AIS has been expanded, and contraindications have been reduced with recently published studies. In order to facilitate the standardisation of treating AIS, improve the rate of thrombolysis and benefit patients who had a stroke, Chinese Stroke Association has organised and developed this scientific statement.
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Affiliation(s)
- Qiang Dong
- Department of Neurology, Huashan Hospital affiliated to Fudan University, Shanghai Shi, China
| | - Yi Dong
- Department of Neurology, Huashan Hospital affiliated to Fudan University, Shanghai Shi, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
| | - Anding Xu
- Department of Neurology and Stroke Center, First Affiliated Hospital, Jinan University, Guangzhou Shi, China
| | - Yusheng Zhang
- Department of Neurology and Stroke Center, First Affiliated Hospital, Jinan University, Guangzhou Shi, China
| | - Huaguang Zheng
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
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117
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Fu VWY, Weatherall M, McNaughton H. The Taking Charge After Stroke (TaCAS) study protocol: a multicentre, investigator-blinded, randomised controlled trial comparing the effect of a single Take Charge session, two Take Charge sessions and control intervention on health-related quality of life 12 months after stroke for non-Māori, non-Pacific adult New Zealanders discharged to community living. BMJ Open 2017; 7:e016512. [PMID: 28576903 PMCID: PMC5726100 DOI: 10.1136/bmjopen-2017-016512] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Stroke is one of the leading causes of disability worldwide. Recent data support the possibility that person-centred, self-management interventions can reduce dependence after stroke. However, there is limited information on the generalisability and optimum dose of these interventions. METHODS The Taking Charge After Stroke (TaCAS) study is a multicentre, investigator-blinded, randomised controlled trial recruiting 400 participants following acute stroke from seven hospitals in New Zealand. All patients discharged to community living who have ongoing symptoms at time of discharge (modified Rankin scale>0) will be eligible. Participants will be randomly assigned to one Take Charge session, two Take Charge sessions 6 weeks apart or control. OUTCOMES The primary outcome will be the Physical Component Summary score of the Short-Form 36 at 12 months post stroke. Secondary outcomes will include dependence (modified Rankin scale), performance in activities of daily living (Barthel Index) and carer strain (Caregiver Strain Index), at 6 and 12 months post stroke. All analyses will be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION The TaCAS study is funded by a Health Research Council of New Zealand grant. It has been approved by the Central Health and Disability Ethics Committee (15/CEN/115). Results will be published and presented at relevant stroke meetings within New Zealand and internationally, informing the use of a self-management intervention after stroke. TRIAL REGISTRATION Australia and New Zealand Clinical Trials Registry ACTRN12615001163594. Date registered 02-11-2015. Medical Research Institute of New Zealand Registry TCS01. Universal trial number U1111-1171-4127.
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Affiliation(s)
| | | | - Harry McNaughton
- Medical Research Institute of New Zealand, Wellington, New Zealand
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118
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Wee CK, McAuliffe W, Phatouros CC, Phillips TJ, Blacker D, Singh TP, Baker E, Hankey GJ. Outcomes of Endovascular Thrombectomy with and without Thrombolysis for Acute Large Artery Ischaemic Stroke at a Tertiary Stroke Centre. Cerebrovasc Dis Extra 2017; 7:95-102. [PMID: 28463832 PMCID: PMC6685497 DOI: 10.1159/000470855] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 02/28/2017] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Endovascular thrombectomy (EVT) improves the functional outcome when added to best medical therapy, including alteplase, in patients with acute ischaemic stroke secondary to large vessel occlusion (LVO) in the anterior circulation. However, the evidence for EVT in alteplase-ineligible patients is less compelling. It is also uncertain whether alteplase is necessary in patients with successful recanalization by EVT, as the treatment effect of EVT may be so powerful that bridging alteplase may not add to efficacy and may compromise safety by increasing bleeding risks. We aimed to survey the proportion of patients suitable for EVT who are alteplase-ineligible and to compare the safety and effectiveness of standard care of acute large artery ischaemic stroke by EVT plus thrombolysis with that of EVT alone in a tertiary hospital clinical stroke service. METHODS We performed a retrospective analysis of acute ischaemic stroke patients treated with EVT at our centre between October 2013 and April 2016, based on a registry with prospective and consecutive patient collection. Individual patient records were retrieved for review. Significant early neurological improvement was defined as a NIHSS score of 0-1, or a decrease from baseline of ≤8, at 24 h after stroke onset. RESULTS Fifty patients with acute ischaemic stroke secondary to LVO in the anterior circulation received EVT in this period, of whom 21 (42%) received concurrent alteplase and 29 (58%) EVT alone. The 2 groups had similar baseline characteristics and similar outcomes. Significant neurological improvement at 24 h occurred in 47.6% of the patients with EVT and bridging alteplase and in 51.7% of the patients with EVT alone (p = 0.774). Mortality during acute hospitalization was 20% for the bridging alteplase group versus 7.1% for EVT alone (p = 0.184). Intracranial haemorrhage rates were 14.3% for bridging alteplase versus 20.7% for EVT alone (p = 0.716). Local complications, groin haematoma (23.8 vs. 10.3%) and groin pseudoaneurysms (4.8 vs. 0%) (p = 0.170), were not significantly different. CONCLUSION Our study highlights the relatively large proportion of patients suitable for EVT who have a contraindication to alteplase and raises the hypothesis that adding alteplase to successful EVT may not be necessary to optimize functional outcome. The results are consistent with observational data from other endovascular centres and support a randomised controlled trial of EVT versus EVT with bridging alteplase.
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Affiliation(s)
- Chee-Keong Wee
- Department of Neurology, Sir Charles Gairdner Hospital, Perth, Washington, Australia
| | - William McAuliffe
- Neurological Intervention and Imaging Service of Western Australia (NIISWA), Perth, Washington, Australia
| | - Constantine C Phatouros
- Neurological Intervention and Imaging Service of Western Australia (NIISWA), Perth, Washington, Australia
| | - Timothy J Phillips
- Neurological Intervention and Imaging Service of Western Australia (NIISWA), Perth, Washington, Australia
| | - David Blacker
- Department of Neurology, Sir Charles Gairdner Hospital, Perth, Washington, Australia
| | - Tejinder P Singh
- Neurological Intervention and Imaging Service of Western Australia (NIISWA), Perth, Washington, Australia
| | - Ellen Baker
- Department of Neurology, Sir Charles Gairdner Hospital, Perth, Washington, Australia
| | - Graeme J Hankey
- Department of Neurology, Sir Charles Gairdner Hospital, Perth, Washington, Australia.,School of Medicine and Pharmacology, The University of Western Australia, Perth, Washington, Australia
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119
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Kang DW, Jeong HG, Kim DY, Yang W, Lee SH. Prediction of Stroke Subtype and Recanalization Using Susceptibility Vessel Sign on Susceptibility-Weighted Magnetic Resonance Imaging. Stroke 2017; 48:1554-1559. [PMID: 28432264 PMCID: PMC5436734 DOI: 10.1161/strokeaha.116.016217] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 02/20/2017] [Accepted: 03/14/2017] [Indexed: 12/20/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— The susceptibility vessel sign (SVS) is a hypointense signal visualized because of the susceptibility effect of thrombi, sensitively detected on susceptibility-weighted magnetic resonance imaging. The relationship of SVS parameters with the stroke subtype and recanalization status after endovascular treatment remains uncertain. Methods— The data from 89 patients with acute stroke caused by anterior circulation infarcts who underwent susceptibility-weighted magnetic resonance imaging before endovascular treatment were examined. Independent reviewers, blinded to the stroke subtype and recanalization status, measured the SVS diameter, length, and estimated volume. The intra- and interrater agreements of the SVS parameters were assessed. Results— The SVS was identified in 78% of the patients. SVS was more commonly associated with cardioembolism than with noncardioembolism (P=0.01). The SVS diameter (P<0.01) and length (P=0.01) were larger in the cardioembolism group. The SVS diameter was larger in the recanalization group (thrombolysis in cerebral infarction ≥2b) than in the nonrecanalization group (P=0.04). Multivariable analysis revealed that the SVS diameter was an independent predictor of cardioembolism (adjusted odds ratio, 1.97; 95% confidence interval, 1.34–2.90; P<0.01). There was no significant association between the SVS volume and the recanalization status (adjusted odds ratio, 1.003; 95% confidence interval, 0.999–1.006; P=0.12). The optimal cutoff value of the SVS diameter for the cardioembolism was 5.5 mm (sensitivity, 45.6%; specificity, 93.8%). Conclusions— Increased SVS diameter on susceptibility-weighted magnetic resonance imaging may predict cardioembolism. No clear association was found between SVS volume and endovascular recanalization.
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Affiliation(s)
- Dong-Wan Kang
- From the Department of Neurology, Seoul National University Hospital, Republic of Korea
| | - Han-Gil Jeong
- From the Department of Neurology, Seoul National University Hospital, Republic of Korea
| | - Do Yeon Kim
- From the Department of Neurology, Seoul National University Hospital, Republic of Korea
| | - Wookjin Yang
- From the Department of Neurology, Seoul National University Hospital, Republic of Korea
| | - Seung-Hoon Lee
- From the Department of Neurology, Seoul National University Hospital, Republic of Korea.
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120
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le Feber J, Erkamp N, van Putten MJAM, Hofmeijer J. Loss and recovery of functional connectivity in cultured cortical networks exposed to hypoxia. J Neurophysiol 2017; 118:394-403. [PMID: 28424292 DOI: 10.1152/jn.00098.2017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/18/2017] [Accepted: 04/18/2017] [Indexed: 01/13/2023] Open
Abstract
In the core of a brain infarct, loss of neuronal function is followed by neuronal death within minutes. In an area surrounding the core (penumbra), some perfusion remains. Here, neurons initially remain structurally intact, but massive synaptic failure strongly reduces neural activity. Activity in the penumbra may eventually recover or further deteriorate toward massive cell death. Besides activity recovery, return of brain functioning requires restoration of connectivity. However, low activity has been shown to initiate compensatory mechanisms that affect network connectivity. We investigated the effect of transient hypoxia and compensatory mechanisms on activity and functional connectivity using cultured cortical networks on multielectrode arrays. Networks were exposed to hypoxia of controlled depth (10-90% of normoxia) and duration (6-48 h). First, we determined how hypoxic depth and duration govern activity recovery. Then, we investigated connectivity changes during and after hypoxic incidents, mild enough for activity to recover. Shortly after hypoxia onset, activity and connectivity decreased. Following 4-6 h of ongoing hypoxia, we observed partial recovery. Only if the hypoxic burden was limited did connectivity show further recovery upon return to normoxia. Partial recovery during hypoxia was dominated by restored baseline connections, rather than newly formed ones. Baseline strengths of surviving (persisting or recovered) and lost connections did not differ nor did baseline activity at their "presynaptic" electrodes. However, "postsynaptic" electrodes of surviving connections were significantly more active during baseline than those of lost connections. This implies that recovery during hypoxia reflects an effective mechanism to restore network activity, which does not necessarily conserve prehypoxia connectivity.NEW & NOTEWORTHY Hypoxia reduced the firing rates of cultured neurons. Depending on hypoxic depth and duration, activity recovered during hypoxia and upon return to normoxia. Recovery (partial) during hypoxia was associated with restored baseline connections rather than newly formed ones. Predominantly, baseline connections with most active postsynaptic electrodes recovered, supporting the notion of effective activity homeostasis. This compensatory mechanism remained effective during ~20 h of hypoxia. Beyond 20 h of compensation, loss of activity and connectivity became irreversible.
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Affiliation(s)
- Joost le Feber
- Clinical Neurophysiology, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands;
| | - Niels Erkamp
- Clinical Neurophysiology, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Michel J A M van Putten
- Clinical Neurophysiology, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands.,Department of Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, the Netherlands; and
| | - Jeannette Hofmeijer
- Clinical Neurophysiology, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands.,Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
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121
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Karsy M, Brock A, Guan J, Taussky P, Kalani MYS, Park MS. Neuroprotective strategies and the underlying molecular basis of cerebrovascular stroke. Neurosurg Focus 2017; 42:E3. [DOI: 10.3171/2017.1.focus16522] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Stroke is a leading cause of disability in the US. Although there has been significant progress in the area of medical and surgical thrombolytic technologies, neuroprotective agents to prevent secondary cerebral injury and to minimize disability remain limited. Only limited success has been reported in preclinical and clinical trials evaluating a variety of compounds. In this review, the authors discuss the most up-to-date information regarding the underlying molecular biology of stroke as well as strategies that aim to mitigate this complex signaling cascade. Results of historical research trials involving N-methyl-d-aspartate and α-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptor antagonists, clomethiazole, antioxidants, citicoline, nitric oxide, and immune regulators have laid the groundwork for current progress. In addition, more recent studies involving therapeutic hypothermia, magnesium, albumin, glyburide, uric acid, and a variety of other treatments have provided more options. The use of neuroprotective agents in combination or with existing thrombolytic treatments may be one of many exciting areas of further development. Although past trials of neuroprotective agents in ischemic stroke have been limited, significant insights into mechanisms of stroke, animal models, and trial design have incrementally improved approaches for future therapies.
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122
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Vidale S, Agostoni E. Endovascular Treatment of Ischemic Stroke: An Updated Meta-Analysis of Efficacy and Safety. Vasc Endovascular Surg 2017; 51:215-219. [DOI: 10.1177/1538574417698905] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Recent randomized trials demonstrated the superiority of the mechanical thrombectomy over the best medical treatment in patients with acute ischemic stroke due to an occlusion of arteries of proximal anterior circulation. In this updated meta-analysis, we aimed to summarize the total clinical effects of the treatment, including the last trials. Methods: We performed literature search of Randomized Crontrolled Trials (RCTs) published between 2010 and October 2016, comparing endovenous thrombolysis plus mechanical thrombectomy (intervention group) with best medical care alone (control group). We identified 8 trials. Primary outcomes were reduced disability at 90 days from the event and symptomatic intracranial hemorrhage. Statistical analysis was performed pooling data into the 2 groups, evaluating outcome heterogeneity. The Mantel-Haenszel method was used to calculate odds ratios (ORs). Results: We analyzed data for 1845 patients (interventional group: 911; control group: 934). Mechanical thrombectomy contributed to a significant reduction in disability rate compared to the best medical treatment alone (OR: 2.087; 95% confidence interval [CI]: 1.718-2.535; P < .001). We calculated that for every 100 treated patients, 16 more participants have a good outcome as a result of mechanical treatment. No significant differences between groups were observed concerning the occurrence of symptomatic hemorrhage (OR: 1.021; 95% CI: 0.641-1.629; P = .739). Conclusion: Mechanical thrombectomy contributes to significantly increase the functional benefit of endovenous thrombolysis in patients with acute ischemic stroke caused by arterial occlusion of proximal anterior circulation, without reduction in safety. These findings are relevant for the optimization of the acute stroke management, including the implementation of networks between stroke centers.
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Affiliation(s)
- Simone Vidale
- Department of Neurology and Stroke Unit, Sant’Anna Hospital, Como, Italy
| | - Elio Agostoni
- Department of Neurology and Stroke Unit, Niguarda Ca’ Granda Hospital, Milan, Italy
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123
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Boyle K, Joundi RA, Aviv RI. An historical and contemporary review of endovascular therapy for acute ischemic stroke. ACTA ACUST UNITED AC 2017. [DOI: 10.1186/s40809-016-0025-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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124
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Chang H, Wang X, Yang X, Song H, Qiao Y, Liu J. Digestive and urologic hemorrhage after intravenous thrombolysis for acute ischemic stroke: Data from a Chinese stroke center. J Int Med Res 2017; 45:352-360. [PMID: 28222621 PMCID: PMC5536590 DOI: 10.1177/0300060516686515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objective Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) is considered the most effective treatment method for AIS; however, it is associated with a risk of hemorrhage. We analyzed the risk factors for digestive and urologic hemorrhage during rt-PA therapy. Methods We retrospectively analyzed patients with AIS who underwent intravenous thrombolysis with rt-PA during a 5-year period in a Chinese stroke center. Data on the demographics, medical history, laboratory test results, and clinical outcomes were collected. Results 338 patients with AIS were eligible and included. Logistic regression multivariate analysis showed that gastric catheter was significantly correlated with digestive hemorrhage, while age and urinary catheter were significantly correlated with urologic hemorrhage. Most hemorrhagic events were associated with catheterization after 1 to 24 hours of rt-PA therapy. Conclusions In summary, gastric and urinary catheters were correlated with digestive and urologic hemorrhage in patients with AIS undergoing rt-PA therapy. Well-designed controlled studies with large samples are required to confirm our findings.
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Affiliation(s)
- Hong Chang
- 1 Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaojuan Wang
- 1 Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin Yang
- 2 Department of Nursing, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Haiqing Song
- 1 Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchen Qiao
- 1 Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jia Liu
- 1 Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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125
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Hong JM, Lee SE, Lee SJ, Lee JS, Demchuk AM. Distinctive patterns on CT angiography characterize acute internal carotid artery occlusion subtypes. Medicine (Baltimore) 2017; 96:e5722. [PMID: 28151850 PMCID: PMC5293413 DOI: 10.1097/md.0000000000005722] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Noninvasive computed tomography angiography (CTA) is widely used in acute ischemic stroke, even for diagnosing various internal carotid artery (ICA) occlusion sites, which often need cerebral digital subtraction angiography (DSA) confirmation. We evaluated whether clinical outcomes vary depending on the DSA-based occlusion sites and explored correlating features on baseline CTA that predict DSA-based occlusion site.We analyzed consecutive patients with acute ICA occlusion who underwent DSA and CTA. Occlusion site was classified into cervical, cavernous, petrous, and carotid terminus segments by DSA confirmation. Clinical and radiological features associated with poor outcome at 3 months (3-6 of modified Rankin scale) were analyzed. Baseline CTA findings were categorized according to carotid occlusive shape (stump, spearhead, and streak), presence of cervical calcification, Willisian occlusive patterns (T-type, L-type, and I-type), and status of leptomeningeal collaterals (LMC).We identified 49 patients with occlusions in the cervical (n = 17), cavernous (n = 22), and carotid terminus (n = 10) portions: initial NIH Stroke Scale (11.4 ± 4.2 vs 16.1 ± 3.7 vs 18.2 ± 5.1; P < 0.001), stroke volume (27.9 ± 29.6 vs 127.4 ± 112.6 vs 260.3 ± 151.8 mL; P < 0.001), and poor outcome (23.5 vs 77.3 vs 90.0%; P < 0.001). Cervical portion occlusion was characterized as rounded stump (82.4%) with calcification (52.9%) and fair LMC (94.1%); cavernous as spearhead occlusion (68.2%) with fair LMC (86.3%) and no calcification (95.5%); and terminus as streak-like occlusive pattern (60.0%) with poor LMC (60.0%), and no calcification (100%) on CTA.Our study indicates that acute ICA occlusion can be subtyped into cervical, cavernous, and terminus. Distinctive findings on initial CTA can help differentiate ICA-occlusion subtypes with specific characteristics.
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Affiliation(s)
- Ji Man Hong
- Department of Neurology, School of Medicine, Ajou University, Suwon, South Korea
| | - Sung Eun Lee
- Department of Neurology, School of Medicine, Ajou University, Suwon, South Korea
| | - Seong-Joon Lee
- Department of Neurology, School of Medicine, Ajou University, Suwon, South Korea
| | - Jin Soo Lee
- Department of Neurology, School of Medicine, Ajou University, Suwon, South Korea
| | - Andrew M. Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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126
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Mair G, von Kummer R, Adami A, White PM, Adams ME, Yan B, Demchuk AM, Farrall AJ, Sellar RJ, Sakka E, Palmer J, Perry D, Lindley RI, Sandercock PAG, Wardlaw JM. Arterial Obstruction on Computed Tomographic or Magnetic Resonance Angiography and Response to Intravenous Thrombolytics in Ischemic Stroke. Stroke 2016; 48:353-360. [PMID: 28008093 PMCID: PMC5266422 DOI: 10.1161/strokeaha.116.015164] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/01/2016] [Accepted: 11/11/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Computed tomographic angiography and magnetic resonance angiography are used increasingly to assess arterial patency in patients with ischemic stroke. We determined which baseline angiography features predict response to intravenous thrombolytics in ischemic stroke using randomized controlled trial data. METHODS We analyzed angiograms from the IST-3 (Third International Stroke Trial), an international, multicenter, prospective, randomized controlled trial of intravenous alteplase. Readers, masked to clinical, treatment, and outcome data, assessed prerandomization computed tomographic angiography and magnetic resonance angiography for presence, extent, location, and completeness of obstruction and collaterals. We compared angiography findings to 6-month functional outcome (Oxford Handicap Scale) and tested for interactions with alteplase, using ordinal regression in adjusted analyses. We also meta-analyzed all available angiography data from other randomized controlled trials of intravenous thrombolytics. RESULTS In IST-3, 300 patients had prerandomization angiography (computed tomographic angiography=271 and magnetic resonance angiography=29). On multivariable analysis, more extensive angiographic obstruction and poor collaterals independently predicted poor outcome (P<0.01). We identified no significant interaction between angiography findings and alteplase effect on Oxford Handicap Scale (P≥0.075) in IST-3. In meta-analysis (5 trials of alteplase or desmoteplase, including IST-3, n=591), there was a significantly increased benefit of thrombolytics on outcome (odds ratio>1 indicates benefit) in patients with (odds ratio, 2.07; 95% confidence interval, 1.18-3.64; P=0.011) versus without (odds ratio, 0.88; 95% confidence interval, 0.58-1.35; P=0.566) arterial obstruction (P for interaction 0.017). CONCLUSIONS Intravenous thrombolytics provide benefit to stroke patients with computed tomographic angiography or magnetic resonance angiography evidence of arterial obstruction, but the sample was underpowered to demonstrate significant treatment benefit or harm among patients with apparently patent arteries. CLINICAL TRIAL REGISTRATION URL: http://www.isrctn.com. Unique identifier: ISRCTN25765518.
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Affiliation(s)
- Grant Mair
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Rüdiger von Kummer
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Alessandro Adami
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Philip M White
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Matthew E Adams
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Bernard Yan
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Andrew M Demchuk
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Andrew J Farrall
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Robin J Sellar
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Eleni Sakka
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Jeb Palmer
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - David Perry
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Richard I Lindley
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Peter A G Sandercock
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Joanna M Wardlaw
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.).
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Anesthesia on the brain (and spinal cord): progress in neurosurgical anesthesia. Curr Opin Anaesthesiol 2016; 29:537-8. [PMID: 27479716 DOI: 10.1097/aco.0000000000000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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