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Kuo DP, Chen YC, Cheng SJ, Hsieh KLC, Ou CY, Li YT, Chen CY. Ischemia-reperfusion injury in a salvaged penumbra: Longitudinal high-tesla perfusion magnetic resonance imaging in a rat model. Magn Reson Imaging 2024; 112:47-53. [PMID: 38909765 DOI: 10.1016/j.mri.2024.06.003] [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: 04/18/2024] [Revised: 05/23/2024] [Accepted: 06/20/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Although ischemia-reperfusion (I/R) injury varies between cortical and subcortical regions, its effects on specific regions remain unclear. In this study, we used various magnetic resonance imaging (MRI) techniques to examine the spatiotemporal dynamics of I/R injury within the salvaged ischemic penumbra (IP) and reperfused ischemic core (IC) of a rodent model, with the aim of enhancing therapeutic strategies by elucidating these dynamics. MATERIALS AND METHODS A total of 17 Sprague-Dawley rats were subjected to 1 h of transient middle cerebral artery occlusion with a suture model. MRI, including diffusion tensor imaging (DTI), T2-weighted imaging, perfusion-weighted imaging, and T1 mapping, was conducted at multiple time points for up to 5 days during the I/R phases. The spatiotemporal dynamics of blood-brain barrier (BBB) modifications were characterized through changes in T1 within the IP and IC regions and compared with mean diffusivity (MD), T2, and cerebral blood flow. RESULTS During the I/R phases, the MD of the IC initially decreased, normalized after recanalization, decreased again at 24 h, and peaked on day 5. By contrast, the IP remained relatively stable. Both the IP and IC exhibited hyperperfusion, with the IP reaching its peak at 24 h, followed by resolution, whereas hyperperfusion was maintained in the IC until day 5. Despite hyperperfusion, the IP maintained an intact BBB, whereas the IC experienced persistent BBB leakage. At 24 h, the IC exhibited an increase in the T2 signal, corresponding to regions exhibiting BBB disruption at 5 days. CONCLUSIONS Hyperperfusion and BBB impairment have distinct patterns in the IP and IC. Quantitative T1 mapping may serve as a supplementary tool for the early detection of malignant hyperemia accompanied by BBB leakage, aiding in precise interventions after recanalization. These findings underscore the value of MRI markers in monitoring ischemia-specific regions and customizing therapeutic strategies to improve patient outcomes.
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Affiliation(s)
- Duen-Pang Kuo
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei, Taiwan; Translational Imaging Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yung-Chieh Chen
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei, Taiwan; Translational Imaging Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sho-Jen Cheng
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei, Taiwan; Translational Imaging Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kevin Li-Chun Hsieh
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei, Taiwan; Translational Imaging Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chen-Yin Ou
- Translational Imaging Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yi-Tien Li
- Translational Imaging Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Research Center for Neuroscience, Taipei Medical University, Taipei, Taiwan; Ph.D. Program in Medical Neuroscience, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.
| | - Cheng-Yu Chen
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei, Taiwan; Translational Imaging Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Research Center for Artificial Intelligence in Medicine, Taipei Medical University, Taipei, Taiwan; Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Radiology, National Defense Medical Center, Taipei, Taiwan
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Jung YH, Lee HY, Lee BK, Choi BK, Kim TH, Kim JW, Kim HC, Kim HJ, Jeung KW. Feasibility of Magnetic Resonance-Based Conductivity Imaging as a Tool to Estimate the Severity of Hypoxic-Ischemic Brain Injury in the First Hours After Cardiac Arrest. Neurocrit Care 2024; 40:538-550. [PMID: 37353670 DOI: 10.1007/s12028-023-01776-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/05/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Early identification of the severity of hypoxic-ischemic brain injury (HIBI) after cardiac arrest can be used to help plan appropriate subsequent therapy. We evaluated whether conductivity of cerebral tissue measured using magnetic resonance-based conductivity imaging (MRCI), which provides contrast derived from the concentration and mobility of ions within the imaged tissue, can reflect the severity of HIBI in the early hours after cardiac arrest. METHODS Fourteen minipigs were resuscitated after 5 min or 12 min of untreated cardiac arrest. MRCI was performed at baseline and at 1 h and 3.5 h after return of spontaneous circulation (ROSC). RESULTS In both groups, the conductivity of cerebral tissue significantly increased at 1 h after ROSC compared with that at baseline (P = 0.031 and 0.016 in the 5-min and 12-min groups, respectively). The increase was greater in the 12-min group, resulting in significantly higher conductivity values in the 12-min group (P = 0.030). At 3.5 h after ROSC, the conductivity of cerebral tissue in the 12-min group remained increased (P = 0.022), whereas that in the 5-min group returned to its baseline level. CONCLUSIONS The conductivity of cerebral tissue was increased in the first hours after ROSC, and the increase was more prominent and lasted longer in the 12-min group than in the 5-min group. Our findings suggest the promising potential of MRCI as a tool to estimate the severity of HIBI in the early hours after cardiac arrest.
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Affiliation(s)
- Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hyoung Youn Lee
- Trauma Center, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Bup Kyung Choi
- Medical Science Research Institute, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Medical Convergence Research Center, Wonkwang University, Iksan, Republic of Korea
| | - Jin Woong Kim
- Department of Radiology, Chosun University Hospital, Gwangju, Republic of Korea
| | - Hyun Chul Kim
- Department of Radiology, Chosun University Hospital, Gwangju, Republic of Korea
| | - Hyung Joong Kim
- Medical Science Research Institute, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea.
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea.
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Li Y, Cao W, Xu X, Li T, Chen Y, Wang Y, Chen J, Gao P, Yang B, Dmytriw AA, Regenhardt RW, Chen F, Ma Q, Lu J, Liu Y, Wang C, Bai X, Jiao L. Early venous filling after mechanical thrombectomy in acute ischemic stroke due to large vessel occlusion in anterior circulation. J Neurointerv Surg 2024; 16:248-252. [PMID: 37197935 DOI: 10.1136/jnis-2023-020336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/28/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND The significance of early venous filling (EVF) after mechanical thrombectomy (MT) in acute ischemic stroke (AIS) is not fully understood. In this study, we aimed to investigate the impact of EVF after MT. METHODS From January 2019 to May 2022, AIS patients with successful recanalization (modified Thrombolysis in Cerebral Infarction score (mTICI) ≥2b) after MT were retrospectively reviewed. EVF was evaluated on final digital subtraction angiography runs after successful recanalization and was categorized into phase subgroups (arterial phase and capillary phase) and pathway subgroups (cortical veins subgroup and thalamostriate veins subgroup), respectively. The impact of EVF subgroups on functional outcomes after successful recanalization were both investigated. RESULTS A total of 349 patients achieving successful recanalization after MT were included, including 45 patients in the EVF group and 304 patients in the non-EVF group. Multivariable logistic regression analysis showed the EVF group had a higher rate of intracranial hemorrhage (ICH; 66.7% vs 22%, adjusted odds ratio (aOR) 6.805, 95% CI 3.389 to 13.662, P<0.001), symptomatic ICH (sICH; 28.9% vs 4.9%, aOR 6.011, 95% CI 2.493 to 14.494, P<0.001) and malignant cerebral edema (MCE; 20% vs 6.9%, aOR 2.682, 95% CI 1.086 to 6.624, P=0.032) than the non-EVF group. Furthermore, the cortical veins subgroup of EVF had a higher rate of mortality than the thalamostriate veins subgroup (37.5% vs 10.3%, P=0.029). CONCLUSIONS EVF is independently associated with ICH, sICH and MCE after successful recanalization of MT, but not with favorable outcome and mortality.
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Affiliation(s)
- Yi Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurology, Guangzhou Red Cross Hospital, Guangzhou, China
| | - Wenbo Cao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Xin Xu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Tianhua Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Yanfei Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Yabing Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Peng Gao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Bin Yang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Adam A Dmytriw
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fei Chen
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jie Lu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Radiology and Nuclear Medicine, Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Yuqi Liu
- Department of Neurological Sciences, Escope Innovation Academy, Beijing, China
| | - Chunliang Wang
- Department of Neurological Sciences, Escope Innovation Academy, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
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van der Knaap N, Franx BAA, Majoie CBLM, van der Lugt A, Dijkhuizen RM. Implications of Post-recanalization Perfusion Deficit After Acute Ischemic Stroke: a Scoping Review of Clinical and Preclinical Imaging Studies. Transl Stroke Res 2024; 15:179-194. [PMID: 36653525 PMCID: PMC10796479 DOI: 10.1007/s12975-022-01120-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 01/20/2023]
Abstract
The goal of reperfusion therapy for acute ischemic stroke (AIS) is to restore cerebral blood flow through recanalization of the occluded vessel. Unfortunately, successful recanalization does not always result in favorable clinical outcome. Post-recanalization perfusion deficits (PRPDs), constituted by cerebral hypo- or hyperperfusion, may contribute to lagging patient recovery rates, but its clinical significance remains unclear. This scoping review provides an overview of clinical and preclinical findings on post-ischemic reperfusion, aiming to elucidate the pattern and consequences of PRPD from a translational perspective. The MEDLINE database was searched for quantitative clinical and preclinical studies of AIS reporting PRPD based on cerebral circulation parameters acquired by translational tomographic imaging methods. PRPD and stroke outcome were mapped on a charting table, creating an overview of PRPD after AIS. Twenty-two clinical and twenty-two preclinical studies were included. Post-recanalization hypoperfusion is rarely reported in clinical studies (4/22) but unequivocally associated with detrimental outcome. Post-recanalization hyperperfusion is more commonly reported (18/22 clinical studies) and may be associated with positive or negative outcome. PRPD has been replicated in animal studies, offering mechanistic insights into causes and consequences of PRPD and allowing delineation of possible courses of PRPD. Complex relationships exist between PRPD and stroke outcome. Diversity in methods and lack of standardized definitions in reperfusion studies complicate the characterization of reperfusion patterns. Recommendations are made to advance the understanding of PRPD mechanisms and to further disentangle the relation between PRPD and disease outcome.
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Affiliation(s)
- Noa van der Knaap
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Bart A A Franx
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands.
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rick M Dijkhuizen
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands.
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Huang X, Chen C, Wang H, Cai Q, Li Z, Xu J, Yuan L, Xu X, Yang Q, Zhou Z, Liu X. The ACORNS grading scale: a novel tool for the prediction of malignant brain edema after endovascular thrombectomy. J Neurointerv Surg 2023; 15:e190-e197. [PMID: 36207112 PMCID: PMC10646923 DOI: 10.1136/jnis-2022-019404] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/22/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND To develop and validate a novel tool for predicting the development of malignant brain edema (MBE) in large vessel occlusion stroke patients after endovascular thrombectomy (EVT). METHODS We used a prospectively registered population of EVT patients from three comprehensive stroke centers. The population was randomly divided into two subsets (7:3): a training cohort and an internal validation cohort. External validation was performed using the Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke Registry in China (ACTUAL) database. MBE was defined as (1) hypodense parenchyma in at least 50% of the middle cerebral artery and signs of local brain swelling, and (2) a midline shift of ≥5 mm at the septum pellucidum or pineal gland with obliteration of the basal cisterns. The model was constructed using logistic regression analysis. The performance of the model was examined in terms of discrimination and calibration. RESULTS After adjusting for other confounders, baseline National Institutes of Health Stroke Scale (NIHSS) and Alberta Stroke Program Early CT (ASPECT) scores, a clinical history of hypertension, collateral status, intravenous thrombolysis before thrombectomy, fasting blood glucose, reperfusion status, and occlusion site were found to be independent predictors of MBE. These variables were combined to create the ACORNS grading scale. The areas under the curve in receiver operating curve analysis were 0.850 (95% CI 0.816 to 0.884), 0.874 (95% CI 0.821 to 0.926), and 0.785 (95% CI 0.740 to 0.829) for the training, internal validation, and external validation cohorts, respectively, indicating good discriminative performance in the validation cohorts. CONCLUSIONS The ACORNS grading scale is an accurate and easily applicable model for the prediction of the development of MBE after EVT.
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Affiliation(s)
- Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Chu Chen
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Huaiming Wang
- Department of Neurology, The 80th Group Army Hospital of the People's Liberation Army, Weifang, Shandong Province, China
- Department of Neurology, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Qiankun Cai
- Department of Neurology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Zibao Li
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Junfeng Xu
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Lili Yuan
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Xiangjun Xu
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Qian Yang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Xinfeng Liu
- Department of Neurology, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
- Stroke Center & Department of Neurology, University of Science and Technology of China, Hefei, Anhui Province, China
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Kondziella D. Neuroprognostication after cardiac arrest: what the cardiologist should know. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:550-558. [PMID: 36866627 DOI: 10.1093/ehjacc/zuad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/04/2023]
Abstract
Two aspects are a key to mastering prognostication of comatose cardiac arrest survivors: a detailed knowledge about the clinical trajectories of consciousness recovery (or lack thereof) and the ability to correctly interpret the results of multimodal investigations, which include clinical examination, electroencephalography, neuroimaging, evoked potentials, and blood biomarkers. While the very good and the very poor ends of the clinical spectrum typically do not pose diagnostic challenges, the intermediate 'grey zone' of post-cardiac arrest encephalopathy requires cautious interpretation of the available information and sufficiently long clinical observation. Late recovery of coma patients with initially ambiguous diagnostic results is increasingly reported, as are unresponsive patients with various forms of residual consciousness, including so-called cognitive motor dissociation, rendering prognostication of post-anoxic coma highly complex. The aim of this paper is to provide busy clinicians with a high-yield, concise overview of neuroprognostication after cardiac arrest, emphasizing notable developments in the field since 2020.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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Nagy SA, Ivic I, Tóth P, Komoly S, Kiss T, Pénzes M, Málnási-Csizmadia A, Dóczi T, Perlaki G, Orsi G. Post-reperfusion acute MR diffusion in stroke is a potential predictor for clinical outcome in rats. Sci Rep 2023; 13:5598. [PMID: 37019923 PMCID: PMC10076321 DOI: 10.1038/s41598-023-32679-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 03/31/2023] [Indexed: 04/07/2023] Open
Abstract
Middle cerebral artery occlusion (MCAO) models show substantial variability in outcome, introducing uncertainties in the evaluation of treatment effects. Early outcome predictors would be essential for prognostic purposes and variability control. We aimed to compare apparent diffusion coefficient (ADC) MRI data obtained during MCAO and shortly after reperfusion for their potentials in acute-phase outcome prediction. Fifty-nine male rats underwent a 45-min MCAO. Outcome was defined in three ways: 21-day survival; 24 h midline-shift and neurological scores. Animals were divided into two groups: rats surviving 21 days after MCAO (survival group, n = 46) and rats dying prematurely (non-survival/NS group, n = 13). At reperfusion, NS group showed considerably larger lesion volume and lower mean ADC of the initial lesion site (p < 0.0001), while during occlusion there were no significant group differences. At reperfusion, each survival animal showed decreased lesion volume and increased mean ADC of the initial lesion site compared to those during occlusion (p < 10-6), while NS group showed a mixed pattern. At reperfusion, lesion volume and mean ADC of the initial lesion site were significantly associated with 24 h midline-shift and neurological scores. Diffusion MRI performed soon after reperfusion has a great impact in early-phase outcome prediction, and it works better than the measurement during occlusion.
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Affiliation(s)
- Szilvia Anett Nagy
- ELKH-PTE Clinical Neuroscience MR Research Group, Ret Str. 2, 7623, Pecs, Hungary.
- Pecs Diagnostic Centre, Rét Street 2, 7623, Pecs, Hungary.
- Structural Neurobiology Research Group, Szentágothai Research Centre, University of Pecs, Ifjúság Street 20, 7624, Pecs, Hungary.
- Department of Neurology, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary.
| | - Ivan Ivic
- Pecs Diagnostic Centre, Rét Street 2, 7623, Pecs, Hungary
- Selvita d.o.o., Prilaz Baruna Filipovića 29, 10000, Zagreb, Croatia
| | - Péter Tóth
- ELKH-PTE Clinical Neuroscience MR Research Group, Ret Str. 2, 7623, Pecs, Hungary
- Department of Neurosurgery, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
| | - Sámuel Komoly
- Department of Neurology, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
| | - Tamás Kiss
- Szentágothai Research Centre, University of Pecs, Ifjúság Street 20, Pecs, Hungary
| | - Máté Pénzes
- Department of Biochemistry, Eötvös Loránd University, Pázmány Péter Sétány 1/C, 1117, Budapest, Hungary
- Motorpharma Ltd., Szilágyi E. Fasor 27, 1026, Budapest, Hungary
| | - András Málnási-Csizmadia
- Motorpharma Ltd., Szilágyi E. Fasor 27, 1026, Budapest, Hungary
- ELKH-ELTE Motor Pharmacology Research Group, Department of Biochemistry, Eötvös Loránd University, Pázmány Péter Sétány 1/C, 1117, Budapest, Hungary
| | - Tamás Dóczi
- Pecs Diagnostic Centre, Rét Street 2, 7623, Pecs, Hungary
- Department of Neurosurgery, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
| | - Gábor Perlaki
- ELKH-PTE Clinical Neuroscience MR Research Group, Ret Str. 2, 7623, Pecs, Hungary
- Pecs Diagnostic Centre, Rét Street 2, 7623, Pecs, Hungary
- Department of Neurology, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
- Department of Neurosurgery, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
| | - Gergely Orsi
- ELKH-PTE Clinical Neuroscience MR Research Group, Ret Str. 2, 7623, Pecs, Hungary
- Pecs Diagnostic Centre, Rét Street 2, 7623, Pecs, Hungary
- Department of Neurology, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
- Department of Neurosurgery, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
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Zhou Y, He Y, Yan S, Chen L, Zhang R, Xu J, Hu H, Liebeskind DS, Lou M. Reperfusion Injury Is Associated With Poor Outcome in Patients With Recanalization After Thrombectomy. Stroke 2023; 54:96-104. [PMID: 36367100 DOI: 10.1161/strokeaha.122.039337] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The existence of cerebral reperfusion injury in human beings remains controversial. Thus, we aimed to explore the presence of reperfusion injury in acute ischemic stroke patients with recanalization after mechanical thrombectomy and analyzed its impact on neurological outcome. METHODS We reviewed our prospectively collected database CIPPIS (Comparison Influence to Prognosis of CTP and MRP in AIS Patients, NCT03367286), and enrolled anterior circulation large artery occlusion patients with recanalization after mechanical thrombectomy who underwent (1) computed tomography (CT) perfusion on admission and immediately after recanalization to determine reperfusion region, and (2) CT and/or magnetic resonance imaging (MRI) immediately and 24 hours after recanalization to determine lesion areas. The expansion of lesion between recanalization and 24 hours within reperfusion region was potentially caused by reperfusion, thus termed as radiological observed reperfusion injury (RORI). Based on the imaging modality immediately after recanalization, RORI was further divided into RORICT and RORIMRI. We first included a small cohort who had performed both CT and MRI immediately after recanalization to validate the consistency between RORICT and RORIMRI (Study 1). Then the association with RORICT and poor outcome, defined as 3-month modified Rankin Scale score of 3 to 6, was explored in a larger cohort (Study 2). RESULTS Study 1 included 23 patients and good consistency was found between RORICT and RORIMRI (intraclass correlation=0.97, P<0.001). Among 226 patients included in Study 2, a total of 106 (46.9%) were identified with RORI. The ratio of RORI to reperfusion region was 30.1 (16.2, 51.0)% and was independently associated with poor outcome (odds ratio=1.55 per 10% [95% CI' 1.30-1.84]; P<0.001). CONCLUSIONS Our findings suggested that RORI was relatively frequent in stroke patients with recanalization after mechanical thrombectomy and associated with poor outcome despite successful recanalization. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03367286.
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Affiliation(s)
- Ying Zhou
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (Y.Z., Y.H., S.Y., L.C., R.Z., J.X., H.H., M.L.)
| | - Yaode He
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (Y.Z., Y.H., S.Y., L.C., R.Z., J.X., H.H., M.L.)
| | - Shenqiang Yan
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (Y.Z., Y.H., S.Y., L.C., R.Z., J.X., H.H., M.L.)
| | - Lin Chen
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (Y.Z., Y.H., S.Y., L.C., R.Z., J.X., H.H., M.L.)
| | - Ruoxia Zhang
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (Y.Z., Y.H., S.Y., L.C., R.Z., J.X., H.H., M.L.)
| | - Jinjin Xu
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (Y.Z., Y.H., S.Y., L.C., R.Z., J.X., H.H., M.L.)
| | - Haitao Hu
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (Y.Z., Y.H., S.Y., L.C., R.Z., J.X., H.H., M.L.)
| | | | - Min Lou
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China (Y.Z., Y.H., S.Y., L.C., R.Z., J.X., H.H., M.L.)
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9
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Henson T, Rawanduzy C, Salazar M, Sebastian A, Weber H, Al-Mufti F, Mayer SA. Outcome and prognostication after cardiac arrest. Ann N Y Acad Sci 2021; 1508:23-34. [PMID: 34580886 DOI: 10.1111/nyas.14699] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/17/2021] [Accepted: 08/29/2021] [Indexed: 11/27/2022]
Abstract
The outcome after out-of-hospital cardiac arrest has historically been grim at best. The current overall survival rate of patients admitted to a hospital is approximately 10%, making cardiac arrest one of the leading causes of death in the United States. The situation is improving with the incorporation of therapeutic temperature modulation, aggressive prevention of secondary brain injury, and improved access to advanced cardiovascular support, all of which have decreased mortality and allowed for better outcomes. Mortality after cardiac arrest is often the direct result of active withdrawal of life-sustaining therapy based on the perception that neurological recovery is not possible. This reality highlights the importance of providing accurate estimates of neurological prognosis to decision makers when discussing goals of care. The current standard of care for assessing neurological status in patients with hypoxic-ischemic encephalopathy emphasizes a multimodal approach that includes five elements: (1) neurological examination off sedation, (2) continuous electroencephalography, (3) serum neuron-specific enolase levels, (4) magnetic resonance brain imaging, and (5) somatosensory-evoked potential testing. Sophisticated decision support systems that can integrate these clinical, imaging, and biomarker and neurophysiologic data and translate it into meaningful projections of neurological outcome are urgently needed.
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Affiliation(s)
| | | | | | | | - Harli Weber
- New York Medical College, Valhalla, New York
| | - Fawaz Al-Mufti
- Westchester Medical Center, Valhalla, New York.,New York Medical College, Valhalla, New York
| | - Stephan A Mayer
- Westchester Medical Center, Valhalla, New York.,New York Medical College, Valhalla, New York
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10
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Tukhovskaya EA, Ismailova AM, Shaykhutdinova ER, Slashcheva GA, Prudchenko IA, Mikhaleva II, Khokhlova ON, Murashev AN, Ivanov VT. Delta Sleep-Inducing Peptide Recovers Motor Function in SD Rats after Focal Stroke. Molecules 2021; 26:5173. [PMID: 34500605 PMCID: PMC8434407 DOI: 10.3390/molecules26175173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/12/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives: Mutual effect of the preliminary and therapeutic intranasal treatment of SD rats with DSIP (8 days) on the outcome of focal stroke, induced with intraluminal middle cerebral occlusion (MCAO), was investigated. Materials and Methods: The groups were the following: MCAO + vehicle, MCAO + DSIP, and SHAM-operated. DSIP or vehicle was applied nasally 60 (±15) minutes prior to the occlusion and for 7 days after reperfusion at dose 120 µg/kg. The battery of behavioral tests was performed on 1, 3, 7, 14, and 21 days after MCAO. Motor coordination and balance and bilateral asymmetry were tested. At the end of the study, animals were euthanized, and their brains were perfused, serial cryoslices were made, and infarction volume in them was calculated. Results: Although brain infarction in DSIP-treated animals was smaller than in vehicle-treated animals, the difference was not significant. However, motor performance in the rotarod test significantly recovered in DSIP-treated animals. Conclusions: Intranasal administration of DSIP in the course of 8 days leads to accelerated recovery of motor functions.
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Affiliation(s)
- Elena A. Tukhovskaya
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov, Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, Prospekt Nauki, 6, 142290 Moscow, Russia; (A.M.I.); (E.R.S.); (G.A.S.); (O.N.K.); (A.N.M.)
| | - Alina M. Ismailova
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov, Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, Prospekt Nauki, 6, 142290 Moscow, Russia; (A.M.I.); (E.R.S.); (G.A.S.); (O.N.K.); (A.N.M.)
| | - Elvira R. Shaykhutdinova
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov, Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, Prospekt Nauki, 6, 142290 Moscow, Russia; (A.M.I.); (E.R.S.); (G.A.S.); (O.N.K.); (A.N.M.)
| | - Gulsara A. Slashcheva
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov, Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, Prospekt Nauki, 6, 142290 Moscow, Russia; (A.M.I.); (E.R.S.); (G.A.S.); (O.N.K.); (A.N.M.)
| | - Igor A. Prudchenko
- Laboratory of Peptide Chemistry, Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya Street, 16/10, 117997 Moscow, Russia; (I.A.P.); (I.I.M.); (V.T.I.)
| | - Inessa I. Mikhaleva
- Laboratory of Peptide Chemistry, Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya Street, 16/10, 117997 Moscow, Russia; (I.A.P.); (I.I.M.); (V.T.I.)
| | - Oksana N. Khokhlova
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov, Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, Prospekt Nauki, 6, 142290 Moscow, Russia; (A.M.I.); (E.R.S.); (G.A.S.); (O.N.K.); (A.N.M.)
| | - Arkady N. Murashev
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov, Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, Prospekt Nauki, 6, 142290 Moscow, Russia; (A.M.I.); (E.R.S.); (G.A.S.); (O.N.K.); (A.N.M.)
| | - Vadim T. Ivanov
- Laboratory of Peptide Chemistry, Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya Street, 16/10, 117997 Moscow, Russia; (I.A.P.); (I.I.M.); (V.T.I.)
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11
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Abstract
Diffusion magnetic resonance imaging (MRI) offers a wealth of information regarding the neonatal brain. Diffusion anisotropy values reflect changes in the microstructure that accompany early maturation of white and gray matter. In term neonates with neonatal encephalopathy, diffusion imaging provides a useful means of assessing brain injury during the first week of life. In preterm neonates, measures of white matter anisotropy provide information on the nature and extent of white matter disruption. Subsequently, diffusion MRI plays an important role in illuminating fundamental elements of brain development and fulfilling the clinical need to develop prognostic indicators for term and preterm infants.
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Affiliation(s)
- Jeffrey J Neil
- Department of Neurology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8111, St Louis, MO 63110-1093, USA; Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8116, St Louis, MO 63110-1093, USA; Department of Radiology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8131, St Louis, MO 63110-1093, USA
| | - Christopher D Smyser
- Department of Neurology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8111, St Louis, MO 63110-1093, USA; Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8116, St Louis, MO 63110-1093, USA; Department of Radiology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8131, St Louis, MO 63110-1093, USA.
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12
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Nagaraja N, Forder JR, Warach S, Merino JG. Reversible diffusion-weighted imaging lesions in acute ischemic stroke: A systematic review. Neurology 2020; 94:571-587. [PMID: 32132175 DOI: 10.1212/wnl.0000000000009173] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 01/27/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To systematically review the literature for reversible diffusion-weighted imaging (DWIR) lesions and to describe its prevalence, predictors, and clinical significance. METHODS Studies were included if the first DWI MRI was performed within 24 hours of stroke onset and follow-up DWI or fluid-attenuated inversion recovery (FLAIR)/T2 was performed within 7 or 90 days, respectively, to measure DWIR. We abstracted clinical, imaging, and outcomes data. RESULTS Twenty-three studies met the study criteria. The prevalence of DWIR was 26.5% in DWI-based studies and 6% in FLAIR/T2-based studies. DWIR was associated with recanalization or reperfusion of the ischemic tissue with or without the use of tissue plasminogen activator (t-PA) or endovascular therapy, earlier treatment with t-PA, shorter time to endovascular therapy after MRI, and absent or less severe perfusion deficit within the DWI lesion. DWIR was associated with early neurologic improvement in 5 of 6 studies (defined as improvement in the NIH Stroke Scale (NIHSS) score by 4 or 8 points from baseline or NIHSS score 0 to 2 at 24 hours after treatment or at discharge or median NIHSS score at 7 days) and long-term outcome in 6 of 7 studies (defined as NIHSS score ≤1, improvement in the NIHSS score ≥8 points, or modified Rankin Scale score up to ≤2 at 30 or 90 days) likely due to reperfusion. CONCLUSIONS DWIR is seen in up to a quarter of patients with acute ischemic stroke, and it is associated with good clinical outcome following reperfusion. Our findings highlight the pitfalls of DWI to define ischemic core in the early hours of stroke.
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Affiliation(s)
- Nandakumar Nagaraja
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC.
| | - John R Forder
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC
| | - Steven Warach
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC
| | - Jośe G Merino
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC
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13
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Du M, Huang X, Li S, Xu L, Yan B, Zhang Y, Wang H, Liu X. A Nomogram Model to Predict Malignant Cerebral Edema in Ischemic Stroke Patients Treated with Endovascular Thrombectomy: An Observational Study. Neuropsychiatr Dis Treat 2020; 16:2913-2920. [PMID: 33293816 PMCID: PMC7719319 DOI: 10.2147/ndt.s279303] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Malignant cerebral edema (MCE) in patients undergoing endovascular thrombectomy (EVT) is not uncommon and can reduce the benefit of EVT. We aimed to develop a nomogram model to predict the risk of MCE in ischemic stroke patients after EVT. PATIENTS AND METHODS We retrospectively collected patients treated with EVT caused by anterior circulation large vessel occlusion stroke at two comprehensive stroke centers. MCE was defined as midline shift >5 mm at the septum pellucidum or pineal gland with obliteration of the basal cisterns or the need for early decompressive hemicraniectomy. A multivariate logistic model was utilized to construct the best-fit nomogram model. The discrimination and calibration of the nomogram were estimated using the area under the receiver operating characteristic curve (AUC-ROC) and Hosmer-Lemeshow test. RESULTS A total of 370 patients (mean age, 67.2±11.9 years; male, 56.8%) were enrolled in the final analysis. Among them, 71 (19.2%) patients experienced MCE after EVT treatment. After adjustment for potential confounders, age, baseline National Institutes of Health Stroke Scale score, collateral circulation, fast blood glucose level and recanalization were independent predictors of MCE and were incorporated into the nomogram. The AUC-ROC value of the nomogram was 0.805 (95% confidence interval [CI]: 0.750-0.860). The Hosmer-Lemeshow goodness-of-fit test showed good calibration of the nomogram (P = 0.681). CONCLUSION The nomogram composed of age, baseline National Institutes of Health Stroke Scale score, blood glucose level, collateral circulation and recanalization may predict the probability of MCE in anterior circulation large vessel occlusion stroke patients treated with EVT.
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Affiliation(s)
- Mingyang Du
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China.,Department of Cerebrovascular Disease Treatment Center, Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui Province, People's Republic of China.,Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
| | - Shun Li
- Department of Cerebrovascular Disease Treatment Center, Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
| | - Lili Xu
- Department of Cerebrovascular Disease Treatment Center, Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
| | - Bin Yan
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
| | - Yi Zhang
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
| | - Huaiming Wang
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China.,Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, Jiangsu Province, People's Republic of China.,Department of Neurology, The 80th Group Army Hospital of People's Liberation Army, Weifang, Shandong Province, People's Republic of China
| | - Xinfeng Liu
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China.,Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing 210002, Jiangsu Province, People's Republic of China
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14
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Sah RG, Nobakht S, Rajashekar D, Mouches P, Forkert ND, Sitaram A, Tsang A, Hill MD, Demchuk AM, d'Esterre CD, Barber PA. Temporal evolution and spatial distribution of quantitative T2 MRI following acute ischemia reperfusion injury. Int J Stroke 2019; 15:495-506. [DOI: 10.1177/1747493019895673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Determining mechanisms of secondary stroke injury related to cerebral blood flow and the severity of microvascular injury contributing to edema and blood-brain barrier breakdown will be critical for the development of adjuvant therapies for revascularization treatment. Aim To characterize the heterogeneity of the ischemic lesion using quantitative T2 imaging along with diffusion-weighted magnetic resonance imaging (DWI) within five hours of treatment. Methods Quantitative T2 magnetic resonance imaging was acquired within 5 h (baseline) and at 24 h (follow-up) of stroke treatment in 29 patients. Dynamic contrast enhanced permeability imaging was performed at baseline in a subgroup of patients. Absolute volume change and lesion percent change was determined for the quantitative T2, DWI, and absolute volume change sequences. A Gaussian process with RRELIEFF feature selection algorithm was used for prediction of relative quantitative T2 and DWI lesion growth, baseline and follow-up quantitative T2/DWI lesion ratios, and also NIHSS at 24 h and change in NIHSS from admission to 24 h. Results In n = 27 patients, median (interquartile range) lesion percent change was 114.8% (48.9%, 259.1%) for quantitative T2, 48.2% (−12.6%, 179.6%) for absolute volume change, and 62.7% (26.3%, 230.9%) for DWI, respectively. Our model, consisting of baseline NIHSS, CT ASPECTS, and systolic blood pressure, showed a strong correlation with quantitative T2 percent change (cross correlation R2 = 0.80). There was a strong predictive ability for quantitative T2/DWI lesion ratio at 24 h using baseline NIHSS and last seen normal to 24 h magnetic resonance imaging time (cross correlation R2 = 0.93). Baseline dynamic contrast enhanced permeability was moderately correlated to the baseline quantitative T2 values (rho = 0.38). Conclusion Quantitative T2 imaging provides critical information for development of therapeutic approaches that could ameliorate microvascular damage during ischemia reperfusion.
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Affiliation(s)
- Rani Gupta Sah
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Seaman Family Centre, Foothills Medical Centre, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
| | | | - Deepthi Rajashekar
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, Canada
| | - Pauline Mouches
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, Canada
| | - Nils D Forkert
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Amith Sitaram
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
| | - Adrian Tsang
- Seaman Family Centre, Foothills Medical Centre, Calgary, Canada
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Seaman Family Centre, Foothills Medical Centre, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
| | - Andrew M Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Seaman Family Centre, Foothills Medical Centre, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
| | - Christopher D d'Esterre
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Seaman Family Centre, Foothills Medical Centre, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
| | - Philip A Barber
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Seaman Family Centre, Foothills Medical Centre, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
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15
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Huang X, Yang Q, Shi X, Xu X, Ge L, Ding X, Zhou Z. Predictors of malignant brain edema after mechanical thrombectomy for acute ischemic stroke. J Neurointerv Surg 2019; 11:994-998. [PMID: 30798266 DOI: 10.1136/neurintsurg-2018-014650] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/31/2019] [Accepted: 02/01/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Malignant brain edema (MBE) is a devastating complication in ischemic stroke. Data on MBE in patients who have had mechanical thrombectomy (MT) are relatively scarce. OBJECTIVE To investigate the incidence, predictors, and clinical outcomes of MBE in patients after MT. METHODS We included 130 consecutive patients after MT caused by anterior circulation large vessel occlusion stroke, treated with MT. MBE was defined as a midline shift of ≥5 mm on the follow-up imaging within 72 hours after MT. Characteristics of patients at admission and details of treatment were collected. The 90-day modified Rankin scale score was used as a measure of functional outcomes. RESULTS Of the 130 patients (age, 68.6±10.9 years; male, 50%), 35 (26.9%) patients developed MBE. The patients with MBE had a lower rate of functional independence (OR=7.831; 95% CI 1.731 to 35.427; p=0.008) and significantly higher mortality at 90 days (OR=7.958; 95% CI 2.274 to 27.848; p=0.001) than patients without MBE. In 104 (80%) patients with successful recanalization (modified Thrombolysis in Cerebral Infarction score of 2b-3), 24 (23.1%) patients exhibited MBE. After adjustment for confounding, ICA occlusion (OR=3.746; 95% CI 1.169 to 12.006; p=0.026) and worse collateral score (grade 1 vs grade 0: OR=0.727; 95% CI 0.192 to 2.753; p=0.638; grade 2 vs grade 0: OR=0.130; 95% CI 0.021 to 0.819; p=0.030) were significantly associated with the development of MBE, despite successful recanalization. CONCLUSIONS MBE after MT is not uncommon and was related to poor functional outcomes. Localization of a vessel occlusion and collateral status may play a role in the development of MBE.
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Affiliation(s)
- Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Qian Yang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Xiaolei Shi
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Xiangjun Xu
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Liang Ge
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Xianhui Ding
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
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16
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Irvine HJ, Ostwaldt AC, Bevers MB, Dixon S, Battey TW, Campbell BC, Davis SM, Donnan GA, Sheth KN, Jahan R, Saver JL, Kidwell CS, Kimberly WT. Reperfusion after ischemic stroke is associated with reduced brain edema. J Cereb Blood Flow Metab 2018; 38:1807-1817. [PMID: 28731381 PMCID: PMC6168909 DOI: 10.1177/0271678x17720559] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rapid revascularization is highly effective for acute stroke, but animal studies suggest that reperfusion edema may attenuate its beneficial effects. We investigated the relationship between reperfusion and edema in patients from the Echoplanar Imaging Thrombolysis Evaluation Trial (EPITHET) and Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) cohorts. Reperfusion percentage was measured as the difference in perfusion-weighted imaging lesion volume between baseline and follow-up (day 3-5 for EPITHET; day 6-8 for MR RESCUE). Midline shift (MLS) and swelling volume were quantified on follow-up MRI. We found that reperfusion was associated with less MLS (EPITHET: Spearman ρ = -0.46; P < 0.001, and MR RESCUE: Spearman ρ = -0.49; P < 0.001) and lower swelling volume (EPITHET: Spearman ρ = -0.56; P < 0.001, and MR RESCUE: Spearman ρ = -0.27; P = 0.026). Multivariable analyses performed in EPITHET and MR RESCUE demonstrated that reperfusion independently predicted both less MLS (ß coefficient = -0.056; P = 0.025, and ß coefficient = -0.38; P = 0.028, respectively) and lower swelling volumes (ß coefficient = -4.7; P = 0.007, and ß coefficient = -10.7; P = 0.009, respectively), after adjusting for age, sex, NIHSS, admission glucose and follow-up lesion size. Taken together, our data suggest that even modest improvement in perfusion is associated with less brain edema in EPITHET and MR RESCUE.
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Affiliation(s)
- Hannah J Irvine
- 1 Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.,2 Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Ann-Christin Ostwaldt
- 1 Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.,2 Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew B Bevers
- 3 Divisions of Stroke, Cerebrovascular and Critical Care Neurology, Brigham & Women's Hospital, Boston, MA, USA
| | - Simone Dixon
- 4 Department of Neurology, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Thomas Wk Battey
- 1 Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.,2 Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce Cv Campbell
- 5 Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,6 Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M Davis
- 5 Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Geoffrey A Donnan
- 6 Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Kevin N Sheth
- 7 Division of Neurocritical Care and Emergency Neurology, Yale New Haven Hospital, New Haven, USA
| | - Reza Jahan
- 8 Department of Radiology, Ronald Reagan - UCLA Medical Center, Los Angeles, CA, USA
| | - Jeffrey L Saver
- 9 Comprehensive Stroke Center and Department of Neurology, Ronald Reagan - UCLA Medical Center, Los Angeles, CA, USA
| | - Chelsea S Kidwell
- 4 Department of Neurology, University of Arizona College of Medicine, Tucson, AZ, USA
| | - W Taylor Kimberly
- 1 Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.,2 Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
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17
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Wang S, Li Y, Paudyal R, Ford BD, Zhang X. Evaluation of neuregulin-1's neuroprotection against ischemic injury in rats using diffusion tensor imaging. Magn Reson Imaging 2018; 53:63-70. [PMID: 30021123 DOI: 10.1016/j.mri.2018.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 07/11/2018] [Accepted: 07/14/2018] [Indexed: 12/11/2022]
Abstract
Stroke is a devastating neurovascular disorder that results in damage to neurons and white matter tracts. It has been previously demonstrated that neuregulin-1 (NRG-1) protects neurons from ischemic injury following stroke. Here, diffusion tensor imaging (DTI) was utilized to characterize the effects of NRG-1 treatment on cererbral infarction and integrity of white matter after ischemic insult using a permanent middle celebral artery occlusion (pMCAo) rat model. In the present study, sixteen Sprague-Dawley rats underwent pMCAo surgery and received either a single intra-arterial bolus (20 μg/kg) dose of NRG-1 or saline immediately prior to pMCAo. MRI including T2-weighted imaging and DTI was performed in the first 3 h post stroke, and repeated 48 h later. It is found that the stroke infarction was significantly reduced in the NRG-1 treated group. Also, NRG-1 prevented the reduction of fractional anisotropy (FA) in white matter tracts of fornix and corpus callosum (CC), indicating its protection of CC and fornix white matter bundles from ischemia insult. As a conclusion, the present DTI results demonstrate that NRG-1 has significantly neuroprotective effects in both cerebral cortex and white matter including corpus callosum and fornix during acute stroke. In particular, NRG-1 is more effective on stroke lesion with mild ischemia. As CC and fornix white matter bundles play critical roles in transcallosal connectivity and hippocampal projections respectively in the central nervous system, the findings could provide complementary information for better understanding the biological mechanism of NRG-1's neuroprotection in ischemic tissues and neurobehavioral effects.
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Affiliation(s)
- Silun Wang
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, 954 Gatewood Road NE, Atlanta, GA 30329, USA
| | - Yonggang Li
- Division of Biomedical Sciences, University of California-Riverside School of Medicine, Riverside, CA 92521, USA
| | - Ramesh Paudyal
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, 954 Gatewood Road NE, Atlanta, GA 30329, USA
| | - Byron D Ford
- Division of Biomedical Sciences, University of California-Riverside School of Medicine, Riverside, CA 92521, USA.
| | - Xiaodong Zhang
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, 954 Gatewood Road NE, Atlanta, GA 30329, USA; Division of Neuropharmacology and Neurologic Diseases, Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA.
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Methylene Blue Ameliorates Ischemia/Reperfusion-Induced Cerebral Edema: An MRI and Transmission Electron Microscope Study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2016; 121:227-36. [PMID: 26463954 DOI: 10.1007/978-3-319-18497-5_41] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The neuroprotective effect of methylene blue (MB) has been identified against various brain disorders, including ischemic stroke. In the present study, we evaluated the effects of MB on postischemic brain edema using magnetic resonance imaging (MRI) and transmission electron microscopy (TEM). Adult male rats were subjected to transient focal cerebral ischemia induced by 1 h middle cerebral artery occlusion (MCAO), followed by reperfusion. MB was infused intravenously immediately after reperfusion (3 mg/kg) and again at 3 h post-occlusion (1.5 mg/kg). Normal saline was administered as vehicle control. Sequential MRIs, including apparent diffusion coefficient (ADC) and T2-weighted imaging (T2WI), were obtained at 0.5, 2.5, and 48 h after the onset of stroke. Separated groups of animals were sacrificed at 2.5 and 48 h after stroke for ultrastructural analysis by TEM. In addition, final lesion volumes were analyzed by triphenyltetrazolium chloride (TTC) staining at 48 h after stroke. Ischemic stroke induced ADC lesion volume at 0.5 h during MCAOs that were temporally recovered at 1.5 h after reperfusion. No significant difference in ADC-defined lesion was observed between vehicle and MB treatment groups. At 48 h after stroke, MB significantly reduced ADC lesion and T2WI lesion volume and attenuated cerebral swelling. Consistently, MB treatment significantly decreased TTC-defined lesion volume at 48 h after stroke. TEM revealed remarkable swollen astrocytes, astrocytic perivascular end-feet, and concurrent shrunken neurons in the penumbra at 2.5 and 48 h after MCAO. MB treatment attenuated astrocyte swelling, the perivascular astrocytic foot process, and endothelium and also alleviated neuron degeneration. This study demonstrated that MB could decrease postischemic brain edema and provided additional evidence that future clinical investigation of MB for the treatment of ischemic stroke is warrented.
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Gonzales NR, Grotta JC. Pharmacologic Modification of Acute Cerebral Ischemia. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00055-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Youn CS, Park KN, Kim JY, Callaway CW, Choi SP, Rittenberger JC, Kim SH, Oh SH, Kim YM. Repeated diffusion weighted imaging in comatose cardiac arrest patients with therapeutic hypothermia. Resuscitation 2015. [PMID: 26206595 DOI: 10.1016/j.resuscitation.2015.06.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the changing pattern and prognostic values of diffusion-weighted imaging (DWI) at two time points in cardiac arrest patients treated with therapeutic hypothermia. METHODS Twenty two patients with cardiac arrest who underwent two DWI studies were enrolled in the retrospective study. The first DWI was performed after the induction of therapeutic hypothermia (median 6.0h) and was repeated between 48h and 168h (second DWI, median 74h). Apparent diffusion coefficient (ADC) values were measured in the predefined brain regions, and qualitative analysis was also performed. Good neurologic outcomes were defined as Cerebral Performance Category (CPC) scores of 1 and 2. RESULTS The ADC value tended to increase over time except the cortical regions of the poor outcome group (N=10). In the comparisons of receiver operating characteristic (ROC) curve to predict poor outcome using ADC value, postcentral cortex in the second DWI has a better association with neurological outcome (p=0.001, area under the curve (AUC)=0.996 for second DWI, AUC=0.571 for first DWI). In the same analysis using qualitative score, precentral cortex, postcentral cortex, parietal lobe, occipital lobe, caudate and putamen in the second DWI have a better association with neurological outcome. CONCLUSIONS The changing pattern of ADC values after cardiac arrest is different according to anatomic region and neurologic status. The DWI after 48h has a better association with neurological outcome of cardiac arrest patients in both quantitative and qualitative analysis.
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Affiliation(s)
- Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Republic of Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Republic of Korea.
| | - Jee Young Kim
- Department of Radiology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Republic of Korea
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Iroquois Building, Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA 15261, United States
| | - Seung Pill Choi
- Department of Emergency Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Republic of Korea
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Iroquois Building, Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA 15261, United States
| | - Soo Hyun Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Republic of Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Republic of Korea
| | - Young Min Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Republic of Korea
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Chodobski A, Ghersi-Egea JF, Nicholson C, Nagaraja TN, Szmydynger-Chodobska J. The quest for a better insight into physiology of fluids and barriers of the brain: the exemplary career of Joseph D. Fenstermacher. Fluids Barriers CNS 2015; 12:1. [PMID: 25745556 PMCID: PMC4350980 DOI: 10.1186/2045-8118-12-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 12/18/2014] [Indexed: 12/27/2022] Open
Abstract
In June 2014 Dr. Joseph D. Fenstermacher celebrated his 80th birthday, which was honored by the symposium held in New London, NH, USA. This review discusses Fenstermacher's contribution to the field of fluids and barriers of the CNS. Specifically, his fundamental work on diffusion of molecules within the brain extracellular space and the research on properties of the blood-brain barrier in health and disease are described. Fenstermacher's early research on cerebrospinal fluid dynamics and the regulation of cerebral blood flow is also reviewed, followed by the discussion of his more recent work involving the use of magnetic resonance imaging.
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Affiliation(s)
- Adam Chodobski
- Department of Emergency Medicine, Neurotrauma and Brain Barriers Research Laboratory, The Warren Alpert Medical School of Brown University, Coro Center West, Room 112, 1 Hoppin Street, Providence, RI 02903 USA
| | - Jean-François Ghersi-Egea
- Blood-Brain Interface Group, Oncoflam Team and BIP Platform INSERM U 1028, CNRS UMR5292 Lyon Neuroscience Research Center, Faculté de Médecine RTH Laennec, Rue Guillaume Paradin, Cedex 08, 69372 Lyon, France
| | - Charles Nicholson
- Department of Neuroscience and Physiology, NYU School of Medicine, MSB 460, 550 First Avenue, New York, NY 10016 USA
| | - Tavarekere N Nagaraja
- Department of Anesthesiology, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202-2689 USA
| | - Joanna Szmydynger-Chodobska
- Department of Emergency Medicine, Neurotrauma and Brain Barriers Research Laboratory, The Warren Alpert Medical School of Brown University, Coro Center West, Room 112, 1 Hoppin Street, Providence, RI 02903 USA
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Abstract
The ability to image the ischemic penumbra during hyper-acute stroke promises to identify patients who may benefit from treatment intervention beyond population-defined therapeutic time windows. MR blood oxygenation level dependent (BOLD) contrast imaging has been explored in ischemic stroke. This review provides an overview of several BOLD-based methods, including susceptibility weighted imaging (SWI), R2, R2*, R2', R2* under oxygen challenge, MR_OEF and MROMI approaches to assess cerebral oxygen metabolism in ischemic stroke. We will review the underlying pathophysiological basis of the imaging approaches, followed by a brief introduction of BOLD contrast. Finally, we will discuss the applications of the BOLD approaches in patients with ischemic stroke. BOLD-based methods hold promise for imaging tissue oxygenation during acute ischemia. Further technical refinement and validation studies in stroke patients against positron emission tomography (PET) measurements are needed.
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23
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Freeman JW, Luby M, Merino JG, Latour LL, Auh S, Song SS, Magadán A, Lynch JK, Warach S, Hsia AW. Negative diffusion-weighted imaging after intravenous tissue-type plasminogen activator is rare and unlikely to indicate averted infarction. Stroke 2013; 44:1629-34. [PMID: 23572476 DOI: 10.1161/strokeaha.111.000486] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Some patients treated with intravenous (IV) tissue-type plasminogen activator (tPA) have negative diffusion-weighted imaging (DWI) on follow-up imaging. Without a visible infarct, there may be uncertainty as to whether the patient was having a stroke that was averted by tPA or whether the symptoms had not been cerebrovascular in origin. We evaluated patients presenting with suspected acute stroke with a positive DWI lesion before IV tPA to determine the probability of finding a negative DWI up to 48 hours after treatment. METHODS We included patients from the Lesion Evolution in Stroke and Ischemia On Neuroimaging (LESION) project who had acute MRI screening with a positive DWI lesion before IV tPA treatment and had follow-up MRI up to 48 hours later. Experienced readers interpreted all acute and follow-up MRIs looking for ischemic lesions on DWI. RESULTS There were 231 patients who met study inclusion criteria, of which 225 patients (97.4%) had a persistent positive DWI corresponding to the acute stroke lesion on all follow-up imaging. Four patients (1.7%) had transient DWI lesion reversal with positive DWI on subsequent follow-up imaging. There were only 2 cases (0.9%) of complete DWI lesion reversal on all follow-up imaging. CONCLUSIONS Averted infarction after IV tPA is rare, occurring in 0.9% of patients with pretreatment positive DWI evidence of acute ischemia. For IV tPA-treated patients who have a negative DWI on follow-up imaging, a cause other than acute stroke should be explored.
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Affiliation(s)
- Jason W Freeman
- Section on Stroke Diagnostics and Therapeutics, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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Connell BJ, Di Iorio P, Sayeed I, Ballerini P, Saleh MC, Giuliani P, Saleh TM, Rathbone MP, Su C, Jiang S. Guanosine protects against reperfusion injury in rat brains after ischemic stroke. J Neurosci Res 2012; 91:262-72. [PMID: 23151946 DOI: 10.1002/jnr.23156] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 09/10/2012] [Accepted: 09/12/2012] [Indexed: 12/27/2022]
Abstract
After ischemic stroke, early thrombolytic therapy to reestablish tissue perfusion improves outcome but triggers a cascade of deleterious cellular and molecular events. Using a collaborative approach, our groups examined the effects of guanosine (Guo) in response to ischemic reperfusion injury in vitro and in vivo. In a transient middle cerebral artery occlusion (MCAO) in rats, Guo significantly reduced infarct volume in a dose-dependent manner when given systemically either immediately before or 30 min, but not 60 min, after the onset of the 5.5-hr reperfusion period. In a separate experiment, Guo significantly reduced infarct volume after 24 hr of reperfusion when administered 5 min before reperfusion. Western blot analysis did not reveal any significant changes either in endoplasmic reticulum (ER) stress proteins (GRP 78 and 94) or HSP 70 or in levels of m-calpain. In vitro oxygen and glucose deprivation (OGD) significantly increased production of both reactive oxygen species (ROS) and interleukin-8 (IL-8) in the primary astrocytes. Guo did not alter ROS or IL-8 production when given to the astrocytes before OGD. However, Guo when added to the cells prior to or 30 min after reperfusion significantly reduced IL-8 release but not ROS formation. Our study revealed a dose- and time-dependent protective effect of Guo on reperfusion injury in vitro and vivo. The mechanisms by which Guo exerts its effect are independent of unfolded proteins in ER or the level of intracellular calcium or ROS formation. However, the effect may be induced, at least partially, by inhibiting IL-8, a marker of reperfusion-triggered proinflammatory events.
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Affiliation(s)
- Barry J Connell
- Department of Biomedical Science, Atlantic Veterinary College, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
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Kidwell CS. MRI biomarkers in acute ischemic stroke: a conceptual framework and historical analysis. Stroke 2012; 44:570-8. [PMID: 23132783 DOI: 10.1161/strokeaha.111.626093] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Chelsea S Kidwell
- Department of Neurology and Stroke Center, Georgetown University, Building D, Suite 150, 4000 Reservoir Road, NW Washington, DC 20007, USA.
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26
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Sakamoto Y, Kimura K, Shibazaki K, Inoue T, Uemura J, Aoki J, Sakai K, Iguchi Y. Early Ischaemic Diffusion Lesion Reduction in Patients Treated with Intravenous Tissue Plasminogen Activator: Infrequent, but Significantly Associated with Recanalization. Int J Stroke 2012; 8:321-6. [DOI: 10.1111/j.1747-4949.2012.00902.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background and purpose Recent studies have shown that thrombolysis could decrease or eliminate ischaemic diffusion-weighted imaging lesions. However, the features of such diffusion-weighted imaging lesion reduction are not well known. Aims To clarify, the frequency of and factors associated with lesion reduction were investigated. Methods Patients given intravenous tissue plasminogen activator therapy within three-hours of onset were prospectively enrolled. Magnetic resonance imaging including diffusion-weighted imaging and magnetic resonance angiography was performed four times: on admission, just after intravenous tissue plasminogen activator, 24 h from intravenous tissue plasminogen activator, and seven-days after intravenous tissue plasminogen activator. The diffusion-weighted imaging lesion volume was measured by manual trace using National Institutes of Health imaging software. All patients were divided into three groups according to the early diffusion-weighted imaging lesion volume change from admission to just after intravenous tissue plasminogen activator: the lesion reduction group (>20% decrease); the lesion growth group (>20% increase); and the lesion unchanged group. Results In total, 105 patients [56 males, median age 77 (interquartile range 70–83) years, and National Institutes of Health Stroke Scale score 16 ( 10 – 22 )] were enrolled. Early diffusion-weighted imaging lesion reduction was observed in seven (7%) patients. The decreased lesion increased subsequently. On multivariate analysis, the glucose level on admission (odds ratio 0·95, 95% confidence interval 0·91 to 0·99, P = 0·045) and early recanalization (odds ratio 15·7, 95% confidence interval 1·61 to 153, P = 0·018) were independently related to early lesion reduction. Conclusion Early diffusion-weighted imaging lesion reduction was observed in 7% of patients treated with intravenous tissue plasminogen activator. The decreased lesion increased subsequently. Initial glucose level and early recanalization were independently associated with early diffusion-weighted imaging lesion reduction.
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Affiliation(s)
- Yuki Sakamoto
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Kazumi Kimura
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Kensaku Shibazaki
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Takeshi Inoue
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Jyunichi Uemura
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Junya Aoki
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Kenichiro Sakai
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Yasuyuki Iguchi
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
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Prieto-Arribas R, Pascual-Garvi JM, González-Llanos F, Roda JM. How to repair an ischemic brain injury? Value of experimental models in search of answers. Neurologia 2012; 26:65-73. [PMID: 21163184 DOI: 10.1016/j.nrl.2010.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 05/21/2010] [Indexed: 12/28/2022] Open
Abstract
The major aim of experimental models of cerebral ischemia is to study the cerebral ischemic damage under controlled and reproducible conditions. Experimental studies have been fundamental in the establishment of new concepts regarding the mechanisms underlying the ischemic brain injury, such as the ischemic penumbra, the reperfusion injury, the cell death or the importance of the damage induced on mitochondria, glial cells and white matter. Disagreement between experimental and clinical studies regarding the benefit of drugs to reduce or restore the cerebral ischemic damage has created a growing controversy about the clinical value of the experimental models of cerebral ischemia. One of the major explanations for the failure of the clinical trials is the reductionist approach of most therapies, which are focused on the known effect of a single molecule within a specific pathway of ischemic damage. This philosophy contrasts to the complex morphological design of the cerebral tissue and the complex cellular and molecular physiopathology underlying the ischemic brain injury. We believe that the main objective of studies carried out in experimental models of cerebral ischemic injury must be a better understanding of the fundamental mechanisms underlying progression of the ischemic injury. Clinical trials should not be considered if the benefit obtained in experimental studies is limited or weak.
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Zille M, Farr TD, Przesdzing I, Müller J, Sommer C, Dirnagl U, Wunder A. Visualizing cell death in experimental focal cerebral ischemia: promises, problems, and perspectives. J Cereb Blood Flow Metab 2012; 32:213-31. [PMID: 22086195 PMCID: PMC3272608 DOI: 10.1038/jcbfm.2011.150] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
One of the hallmarks of stroke pathophysiology is the widespread death of many different types of brain cells. As our understanding of the complex disease that is stroke has grown, it is now generally accepted that various different mechanisms can result in cell damage and eventual death. A plethora of techniques is available to identify various pathological features of cell death in stroke; each has its own drawbacks and pitfalls, and most are unable to distinguish between different types of cell death, which partially explains the widespread misuse of many terms. The purpose of this review is to summarize the standard histopathological and immunohistochemical techniques used to identify various pathological features of stroke. We then discuss how these methods should be properly interpreted on the basis of what they are showing, as well as advantages and disadvantages that require consideration. As there is much interest in the visualization of stroke using noninvasive imaging strategies, we also specifically discuss how these techniques can be interpreted within the context of cell death.
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Affiliation(s)
- Marietta Zille
- Department of Experimental Neurology, Center for Stroke Research Berlin, Charité-University Medicine Berlin, Berlin, Germany
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An H, Liu Q, Chen Y, Vo KD, Ford AL, Lee JM, Lin W. Oxygen metabolism in ischemic stroke using magnetic resonance imaging. Transl Stroke Res 2011; 3:65-75. [PMID: 24323755 DOI: 10.1007/s12975-011-0141-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 12/01/2011] [Accepted: 12/05/2011] [Indexed: 12/22/2022]
Abstract
Detecting "at-risk" but potentially salvageable brain tissue, known as the ischemic penumbra, is of importance for identifying patients who may benefit from thrombolytic or other treatments beyond the currently FDA-approved short therapeutic window for tissue plasminogen activator. Since the magnetic resonance blood oxygenation level-dependent (BOLD) contrast may provide information concerning tissue oxygen metabolism, its utilization in ischemic stroke has been explored. The focus of this review is to provide an introduction of several BOLD-based methods, including susceptibility-weighted imaging, R2 BOLD, R2*, R2', MR_OEF, and MR_OMI approaches to assess cerebral oxygenation changes induced by ischemia. Specifically, we will review the underlying pathophysiological basis of the imaging approaches, followed by a brief introduction of BOLD contrast, and finally the applications of BOLD approaches in ischemic stroke. The advantages and disadvantages of each method are addressed. In summary, the BOLD-based methods are promising for imaging oxygenation in ischemic tissue. Future steps would include technical refinement and vigorous validation against another independent method, such as positron emission tomography.
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Affiliation(s)
- Hongyu An
- Department of Radiology and Biomedical Research Imaging Center, CB#7513, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA,
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Abstract
Stroke is a leading cause of death and adult morbidity worldwide. By defining stroke symptom onset by the time the patient was last known to be well, many patients whose onsets are unwitnessed are automatically ineligible for thrombolytic therapy. Advanced brain imaging may serve as a substitute witness to estimate stroke onset and duration in those patients who do not have a human witness. This article reviews and compares some of these imaging-based approaches to thrombolysis eligibility, which can potentially expand the use of thrombolytic therapy to a broader population of acute stroke patients.
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Affiliation(s)
- Ona Wu
- Department of Radiology, MGH/MIT/HMS Athinoula A. Martinos Center for Biomedical Imaging, MGH, 149 Thirteenth Street Suite 2301, Charlestown, MA 02129, USA.
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How to repair an ischemic brain injury? Value of experimental models in search of answers. NEUROLOGÍA (ENGLISH EDITION) 2011. [DOI: 10.1016/s2173-5808(11)70016-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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32
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Gonzales NR, Grotta JC. Pharmacologic Modification of Acute Cerebral Ischemia. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10053-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tortora F, Cirillo M, Ferrara M, Manto A, Briganti F, Cirillo S. DWI Reversibility after Intra-Arterial Thrombolysis. A Case Report and Literature Review. Neuroradiol J 2010; 23:752-62. [PMID: 24148733 DOI: 10.1177/197140091002300618] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 11/05/2010] [Indexed: 11/16/2022] Open
Abstract
We report our case and review the literature on reversal DWI lesions, ADC thresholds and correlation between DWI lesion and outcome measured with clinical scales. A 30-years old woman was admitted to our hospital 18 hours after stroke onset. Considering the absence of alterations on CT and the worsening of symptomatology, the patient underwent MRI, which showed a slightly hyperintense signal in FLAIR images in the left portion of the pons and midbrain and a more evident bilateral DWI hyperintensity of the pons. The patient was treated with mechanical and pharmacological intra-arterial thrombolysis. The patient showed a rapid improvement of symptoms. Two weeks after the treatment her clinical conditions were characterized by a residual right hemiparesis and complete recovery of right motility, respiratory and swallowing difficulties. MR examination demonstrated a slight signal alteration of the pons left hemiportion and a disappearance of the mesencephalic signal alteration and of the right portion of the pons. DWI lesions represent irreversibly damaged tissue but new evidence suggests that DWI lesions may be reversible, especially with reperfusion, by now well demonstrated in animal models. Therefore acute DWI lesions probably contain not only irreversibly injured tissue but also parts of the penumbra. The debate on the capability of ADC maps to discriminate irreversibly from reversibly damaged tissue is a matter of controversy. ADC values in human stoke are not an independent indicator of tissue viability. The use of thresholds may improve reproducibility but not validity.
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Affiliation(s)
- F Tortora
- Department of Neuroradiology, II University School of Medicine; Naples, Italy -
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Abstract
All prior drug development programs of neuroprotective agents were unsuccessful for a variety of reasons related to both preclinical assessment and the design/implementation of clinical trials. The neuroprotection hypothesis of improving functional outcome related to salvaging ischemic brain tissue is strongly supported by robust preclinical data for many agents. In the future, monotherapy neuroprotection trials will be difficult but could be performed in underused centers with drugs that have very promising and complete preclinical results. Additional approaches for the testing and use of neuroprotective agents should be considered. Novel approaches would include extending penumbral survival for the later use of reperfusion therapy, reducing reperfusion injury after successful reperfusion, and using drugs with both neuroprotective and recovery enhancing effects, as exemplified by granulocyte colony-stimulating factor and citicoline. To maximize outcome after stroke, the combined use or reperfusion and neuroprotection is likely to be needed, so we must begin to perform carefully designed trials with this combination.
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Affiliation(s)
- Marc Fisher
- Department of Neurology, UMASS/Memorial Healthcare, Worcester, MA 01545, USA.
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Mlynash M, Campbell DM, Leproust EM, Fischbein NJ, Bammer R, Eyngorn I, Hsia AW, Moseley M, Wijman CAC. Temporal and spatial profile of brain diffusion-weighted MRI after cardiac arrest. Stroke 2010; 41:1665-72. [PMID: 20595666 DOI: 10.1161/strokeaha.110.582452] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Diffusion-weighted magnetic resonance imaging of the brain is a promising technique to help predict functional outcome in comatose survivors of cardiac arrest. We aimed to evaluate prospectively the temporal-spatial profile of brain apparent diffusion coefficient changes in comatose survivors during the first 8 days after cardiac arrest. METHODS Apparent diffusion coefficient values were measured by 2 independent and blinded investigators in predefined brain regions in 18 good- and 15 poor-outcome patients with 38 brain magnetic resonance imaging scans and were compared with those of 14 normal controls. The same brain regions were also assessed qualitatively by 2 other independent and blinded investigators. RESULTS In poor-outcome patients, cortical structures, in particular the occipital and temporal lobes, and the putamen exhibited the most profound apparent diffusion coefficient reductions, which were noted as early as 1.5 days and reached a nadir between 3 and 5 days after the arrest. Conversely, when compared with normal controls, good-outcome patients exhibited increased diffusivity, in particular in the hippocampus, temporal and occipital lobes, and corona radiata. By qualitative magnetic resonance imaging readings, 1 or more cortical gray matter structures were judged to be moderately to severely abnormal in all poor-outcome patients except for the 3 patients imaged within 24 hours after the arrest. CONCLUSIONS Brain diffusion-weighted imaging changes in comatose, postcardiac arrest survivors in the first week after the arrest are region and time dependent and differ between good- and poor-outcome patients. With increasing use of magnetic resonance imaging in this context, it is important to be aware of these relations.
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Affiliation(s)
- Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Palo Alto, Calif 94304, USA
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Use of magnetic resonance imaging to predict outcome after stroke: a review of experimental and clinical evidence. J Cereb Blood Flow Metab 2010; 30:703-17. [PMID: 20087362 PMCID: PMC2949172 DOI: 10.1038/jcbfm.2010.5] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite promising results in preclinical stroke research, translation of experimental data into clinical therapy has been difficult. One reason is the heterogeneity of the disease with outcomes ranging from complete recovery to continued decline. A successful treatment in one situation may be ineffective, or even harmful, in another. To overcome this, treatment must be tailored according to the individual based on identification of the risk of damage and estimation of potential recovery. Neuroimaging, particularly magnetic resonance imaging (MRI), could be the tool for a rapid comprehensive assessment in acute stroke with the potential to guide treatment decisions for a better clinical outcome. This review describes current MRI techniques used to characterize stroke in a preclinical research setting, as well as in the clinic. Furthermore, we will discuss current developments and the future potential of neuroimaging for stroke outcome prediction.
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Abstract
Transient ischemic attacks (TIAs) are brief neurological deficits ofcerebrovascular origin that are followed by complete clinical recovery. Although a plethora of animal models exist for ischemic stroke, a verified TIA model is lacking. We aimed to optimize such a model in mice, investigating the impact of varying durations (from 2.5 to 20 minutes) of intraluminal middle cerebral artery occlusion (MCAo). Three conditions were required to mimic clinical TIA reliably: 1) an objective demonstration of occlusion and reperfusion (assessed by laser Doppler flowmetry); 2) no permanent neurological deficit (assessed by sensorimotor neurological evaluation); and 3) no lesion at 24 hours after reperfusion (assessed by magnetic resonance imaging [MRI]). We observed high incidences of MRI lesions with MCAo durations of 15 minutes or longer. In contrast, no permanent neurological deficits or MRI lesions were observed in animals with MCAo below or equal to 10 minutes. Middle cerebral artery occlusion of 12.5 minutes rarely induced MRI lesions, but histopathologic evaluation using routine and terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling staining revealed minute ischemic changes even after 2.5-minute MCAo. Abundance of necrotic and apoptotic changes gradually increased with the duration of ischemia. These results indicate that 10 minutes or shorter focal cerebral ischemia proves a suitable mouse TIA model; in addition, they indicate that MRI-negative microscopic ischemic damage may occur with even a few minutes of arterial occlusion.
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Bra°tane BT, Bastan B, Fisher M, Bouley J, Henninger N. Ischemic lesion volume determination on diffusion weighted images vs. apparent diffusion coefficient maps. Brain Res 2009; 1279:182-8. [DOI: 10.1016/j.brainres.2009.05.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 05/01/2009] [Accepted: 05/02/2009] [Indexed: 10/20/2022]
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Wijman CAC, Mlynash M, Caulfield AF, Hsia AW, Eyngorn I, Bammer R, Fischbein N, Albers GW, Moseley M. Prognostic value of brain diffusion-weighted imaging after cardiac arrest. Ann Neurol 2009; 65:394-402. [PMID: 19399889 DOI: 10.1002/ana.21632] [Citation(s) in RCA: 191] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Outcome prediction is challenging in comatose postcardiac arrest survivors. We assessed the feasibility and prognostic utility of brain diffusion-weighted magnetic resonance imaging (DWI) during the first week. METHODS Consecutive comatose postcardiac arrest patients were prospectively enrolled. AWI data of patients who met predefined specific prognostic criteria were used to determine distinguishing apparent diffusion coefficient (ADC) thresholds. Group 1 criteria were death at 6 months and absent motor response or absent pupillary reflexes or bilateral absent cortical responses at 72 hours or vegetative at 1 month. Group 2 criterion was survival at 6 months with a Glasgow Outcome Scale score of 4 or 5 (group 2A) or 3 (group 2B). The percentage of voxels below different ADC thresholds was calculated at 50 x 10(-6) mm(2)/sec intervals. RESULTS Overall, 86% of patients underwent DWI. Fifty-one patients with 62 brain DWIs were included. Forty patients met the specific prognostic criteria. The percentage of brain volume with an ADC value less than 650 to 700 x 10(-6)mm(2)/sec best differentiated between Group 1 and Groups 2A and 2B combined (p < 0.001), whereas the 400 to 450 x 10(-6)mm(2)/sec threshold best differentiated between Groups 2A and 2B (p = 0.003). The ideal time window for prognostication using DWI was between 49 and 108 hours after the arrest. When comparing DWI in this time window with the 72-hour neurological examination, DWI improved the sensitivity for predicting poor outcome by 38% while maintaining 100% specificity (p = 0.021). INTERPRETATION Quantitative DWI in comatose postcardiac arrest survivors holds promise as a prognostic adjunct.
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Affiliation(s)
- Christine A C Wijman
- Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA 94304, USA.
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Wu O, Sorensen AG, Benner T, Singhal AB, Furie KL, Greer DM. Comatose patients with cardiac arrest: predicting clinical outcome with diffusion-weighted MR imaging. Radiology 2009; 252:173-81. [PMID: 19420318 DOI: 10.1148/radiol.2521081232] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To examine whether the severity and spatial distribution of reductions in apparent diffusion coefficient (ADC) are associated with clinical outcomes in patients who become comatose after cardiac arrest. MATERIALS AND METHODS This was an institutional review board-approved, HIPAA-compliant retrospective study of 80 comatose patients with cardiac arrest who underwent diffusion-weighted magnetic resonance imaging. The need to obtain informed consent was waived except when follow-up phone calls were required; in those cases, informed consent was obtained from the families. Mean patient age was 57 years +/- 16 (standard deviation); 31 (39%) patients were women. ADC maps were semiautomatically segmented into the following regions: subcortical white matter; cerebellum; insula; frontal, occipital, parietal, and temporal lobes; caudate nucleus; putamen; and thalamus. Median ADCs were measured in these regions and in the whole brain and were compared (with a two-tailed Wilcoxon test) as a function of clinical outcome. Outcome was defined by both early eye opening in the 1st week after arrest (either spontaneously or in response to external stimuli) and 6-month modified Rankin scale score. RESULTS Whole-brain median ADC was a significant predictor of poor outcome as measured by no eye opening (specificity, 100% [95% confidence interval {CI}: 86%, 100%]; sensitivity, 30% [95% CI: 18%, 45%]) or 6-month modified Rankin scale score greater than 3 (specificity, 100% [95% CI: 73%, 100%]; sensitivity, 41% [95% CI: 29%, 54%]), with patients with poor outcomes having significantly lower ADCs for both outcome measures (P <or= .001). Differences in ADC between patients with good and those with poor outcomes varied according to brain region, involving predominantly the occipital and parietal lobes and the putamen, and were dependent on the timing of imaging. CONCLUSION Spatial and temporal differences in ADCs may provide insight into mechanisms of hypoxic-ischemic brain injury and, hence, recovery.
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Affiliation(s)
- Ona Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, 149 13th St, CNY 2301, Charlestown, MA 02129, USA.
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Blondin D, Seitz RJ, Rusch O, Janssen H, Andersen K, Wittsack HJ, Turowski B. Clinical impact of MRI perfusion disturbances and normal diffusion in acute stroke patients. Eur J Radiol 2008; 71:1-10. [PMID: 18490126 DOI: 10.1016/j.ejrad.2008.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Revised: 04/02/2008] [Accepted: 04/02/2008] [Indexed: 10/22/2022]
Abstract
PURPOSE In acute ischemic stroke MR-imaging typically shows diffusion abnormalities surrounded by reduced perfusion signifying the so-called ischemic penumbra. Mismatch between diffusion and perfusion abnormalities gives indication for thrombolysis. But is there an indication for thrombolytic treatment, if there is no diffusion abnormality but pathologic perfusion combined with acute stroke symptoms?. MATERIAL AND METHODS MR-imaging of 1465 patients treated on our Stroke Unit between June 2004 and May 2007 retrospectively are analyzed. 6 patients met the inclusion criteria of severe neurological symptoms, large territorial perfusion disturbances, lack of diffusion abnormalities and complete neurological recovery after treatment. RESULTS In all six patients MTT measurements showed a significantly depressed perfusion in the symptomatic hemisphere (p<0.02). Time-to-peak delay correlated with the mean transit time delay (0.949, p<0.01). Indication for thrombolysis was based on perfusion abnormalities and clinical symptoms. Stroke symptoms could be reversed in all patients without any complication. CONCLUSION Whereas diffusion imaging could not reveal any abnormality, perfusion analysis legitimated therapy with systemic thrombolysis in heavily affected patients. This work underlines the importance of multimodal MR imaging for guiding treatment decisions in acute stroke patients.
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Affiliation(s)
- D Blondin
- Institute of Diagnostic Radiology, University Hospital Duesseldorf, Moorenstr. 5, D-40225 Germany.
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Chen F, De Keyzer F, Wang H, Vandecaveye V, Landuyt W, Bosmans H, Hermans R, Marchal G, Ni Y. Diffusion weighted imaging in small rodents using clinical MRI scanners. Methods 2007; 43:12-20. [PMID: 17720559 DOI: 10.1016/j.ymeth.2007.03.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2007] [Revised: 03/26/2007] [Accepted: 03/27/2007] [Indexed: 12/16/2022] Open
Abstract
Diffusion weighted imaging (DWI) has emerged as a unique and powerful non-invasive magnetic resonance imaging (MRI) technique with a major potential impact on imaging-based diagnosis in a variety of clinical applications including oncology and tissue viability assessment. In light of increasing demand for applying this technique in preclinical investigations using small animals, we have explored the potentials of a clinical magnet for acquiring the DWI in rats and mice with either cerebral ischemia or solid tumors. Through technical adaptation and optimization, we have been able to perform a series of clinically relevant animal studies with conclusions based on DWI quantification. Focusing more on practical aspects and cross-referencing with the current literature, this paper is aimed to summarize our ongoing DWI studies on small rodents with stroke and tumors, and to provide protocols for researchers to replicate similar techniques in their own preclinical and clinical studies.
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Affiliation(s)
- Feng Chen
- Biomedical Imaging, Interventional Therapy and Contrast Media Research, Department of Radiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium
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Drobyshevsky A, Derrick M, Prasad PV, Ji X, Englof I, Tan S. Fetal brain magnetic resonance imaging response acutely to hypoxia-ischemia predicts postnatal outcome. Ann Neurol 2007; 61:307-14. [PMID: 17444507 DOI: 10.1002/ana.21095] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebral palsy (CP) is caused by either hypoxia-ischemia (H-I) or long-standing causative factors such as inflammation or genetics. Multiple pathophysiological events over time are thought to contribute eventually to cerebral palsy. Our objective was to examine whether the immediate response of the fetus to an acute H-I event determined the motor deficits associated with cerebral palsy. METHODS Serial diffusion-weighted imaging were performed on 79% gestation New Zealand white rabbits using a 3-Tesla magnetic resonance scanner during 40 minutes of uterine ischemia, 20 minutes of reperfusion, and at 4, 24, and 72 hours. Individual fetuses were tracked to near term, and the delivered kits were divided into hypertonic H-I (n = 18), nonhypertonic H-I (n = 9), stillbirth H-I (n = 4), and control groups (n = 16). RESULTS The hypertonia group had significantly less of a nadir in apparent diffusion coefficient (ADC) during H-I (71.6 +/- 23.8% vs 84.5 +/- 9.3% baseline) and slower and incomplete recovery of ADC during reperfusion compared with the nonhypertonic group. All fetuses in the hypertonic and stillbirth groups had an ADC nadir of less than 0.83 microm(2)/msec (70.3% decrease from baseline), whereas 94% of control animals had an ADC nadir greater than this value. The difference between outcome groups was the largest at 4 hours reperfusion and persisted for 24 hours. INTERPRETATION Serial fetal brain scans indicate that the immediate response of a fetus to H-I is crucial to the development of hypertonia. If the fetal brain can be scanned at the time of insult, ADC changes can predict which fetuses will have an unfavorable outcome.
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Affiliation(s)
- Alexander Drobyshevsky
- Department of Pediatrics, Evanston Northwestern Healthcare and Northwestern University, Evanston, IL 60201, USA.
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Chen F, Suzuki Y, Nagai N, Jin L, Yu J, Wang H, Marchal G, Ni Y. Rodent stroke induced by photochemical occlusion of proximal middle cerebral artery: evolution monitored with MR imaging and histopathology. Eur J Radiol 2007; 63:68-75. [PMID: 17337149 DOI: 10.1016/j.ejrad.2007.01.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2006] [Revised: 01/03/2007] [Accepted: 01/04/2007] [Indexed: 11/20/2022]
Abstract
PURPOSE To longitudinally investigate stroke in rats after photothrombotic occlusion of proximal middle cerebral artery (MCA) with magnetic resonance imaging (MRI) in correlation with histopathology. MATERIALS AND METHODS Forty-two rats were subjected to photochemical MCA occlusion and MRI at 1.5T, and sacrificed in seven groups (n=6 each) at the following time points: 1, 3, 6 and 12h, and at day 1, 3 and 9. T2-weighted (T2WI) and diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) map was performed in all rats. Contrast-enhanced T1-weighted imaging (CE-T1WI) was compared to intravital staining with Evans blue in one group for assessing blood-brain barrier (BBB) integrity. The brain was stained histochemically with triphenyl tetrazolium chloride (TTC) and processed for pathological assessment. The evolutional changes of relative lesion volume, signal intensity (SI), and the BBB integrity on MRI with corresponding histopathology were evaluated. RESULTS The ischemic lesion volume reached a maximum around 12h to day 1 as visualized successively by DWI, ADC map and T2WI, implicating the evolving pathology from cytotoxic edema through vasogenic edema to tissue death. The ADC of brain infarction underwent a significant reversion after 12h, reflecting the colliquative necrosis. On CE-T1WI, BBB leakage peaked at 6h and at day 3 with a transitional partial recovery around 24h. The infarct volume on T2WI, DWI and ADC map matched well with that on TTC staining at 12h and at day 1 (p>0.05). CONCLUSION The evolution of the present photothrombotic stroke model in rats could be characterized by MRI. The obtained information may help longitudinal studies of cerebral ischemia and anti-stroke agents using the same model.
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Affiliation(s)
- Feng Chen
- Department of Radiology, Faculty of Medicine, Catholic University of Leuven, Belgium
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Bardutzky J, Shen Q, Henninger N, Schwab S, Duong TQ, Fisher M. Characterizing tissue fate after transient cerebral ischemia of varying duration using quantitative diffusion and perfusion imaging. Stroke 2007; 38:1336-44. [PMID: 17322082 PMCID: PMC2900771 DOI: 10.1161/01.str.0000259636.26950.3b] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to investigate the effects of reperfusion on ischemic lesion evolution and pixel-by-pixel apparent diffusion coefficient-cerebral blood flow (ADC-CBF) dynamics of core and mismatch tissues after 35, 60, and 95 minutes of transient focal ischemia in rats (n=28). METHODS Serial diffusion-, perfusion-, and T2-weighted imaging were performed up to 24 hours. The evolution of the magnetic resonance image-derived lesion volume was investigated and ADC-CBF scatterplots were performed to prospectively characterize the ADC and CBF dynamics of core and mismatch tissues with different fates. For comparison, similar analysis was performed on a historical 60-minute transient ischemia and permanent ischemia group. RESULTS ADC-derived lesions markedly decreased on reperfusion at 35 minutes to an average of 15+/-5% of prereperfusion lesion size (P<0.00001). At 24 hours, lesion volume as determined by T2 imaging increased again to 51+/-10% of prereperfusion lesion size. In the 95-minute group, ADC lesions only briefly decreased on reperfusion and then secondarily enlarged at 180 minutes, almost reaching prereperfusion lesion volume. Pixel-based analysis demonstrated that >85% of mismatch pixels were salvaged by reperfusion independent of ischemia duration. Recanalization at 35, 60, and 95 minutes resulted in recovery of 46%, 28%, and 9% of core pixels, respectively. Core and mismatch pixels that were ultimately salvaged had persistently higher (P<0.001) CBF values during ischemia in all reperfusion groups, associated with higher (P<0.05) ADC values. CONCLUSIONS This study demonstrated substantial salvage of mismatch tissue after reperfusion independent of ischemia duration and substantial permanent recovery of initial core pixels with early reperfusion. Severity of CBF reduction during ischemia seems to be the main factor determining tissue fate.
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Affiliation(s)
- Juergen Bardutzky
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.
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Affiliation(s)
- Jeffrey J Neil
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA.
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Abstract
The development of acute stroke therapies has yielded only limited success and many failures in multiple clinical trials. The target of acute stroke therapy is that portion of the ischemic region that is still potentially salvageable, i.e. the ischemic penumbra. Neuroprotective drugs have the potential to prevent a portion of the ischemic penumbra from evolving into infracted tissue and designing trials that target neuroprotective drugs at patients with persistent penumbra should enhance the likelihood of a positive outcome. Currently, diffusion and perfusion MRI has the potential to approximate the location and persistence of the ischemic penumbra and can be used in clinical trials to select appropriate patients for inclusion and to evaluate a meaningful treatment effect. Perfusion CT may also have similar capabilities. Use of these imaging modalities in clinical trials and ultimately in clinical practice will likely help in the development and utilization of novel neuroprotective drugs.
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Affiliation(s)
- Marc Fisher
- Department of Neurology, University of Massachusetts Medical School, Worcester, 01605, USA.
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Weber R, Ramos-Cabrer P, Hoehn M. Present status of magnetic resonance imaging and spectroscopy in animal stroke models. J Cereb Blood Flow Metab 2006; 26:591-604. [PMID: 16292254 DOI: 10.1038/sj.jcbfm.9600241] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Magnetic resonance imaging (MRI) is based on a wide variety of physical parameters, which, in principle, can all influence the image contrast conditions. As these diverse variables are validated by independent physiological, metabolic, hemodynamic, and histological techniques, a physiological MRI evolves. This imaging modality has been successfully applied to experimental stroke studies, covering a broad range of raised questions. In the present review, we present an overview of possible physiological criteria to be studied by in vivo MRI and magnetic resonance spectroscopy, and critically analyze the present limits and future potential of the imaging technique for experimental stroke investigations. The documented applications cover the spectrum from morphological-structural details of the lesion to hemodynamic and metabolic alterations, inflammatory reaction, evaluation of thrombolytic treatment, studies on recovery of functional brain activation by functional MRI, and, finally, the most recent applications of exploring stem cells for regenerative therapy.
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Affiliation(s)
- Ralph Weber
- In-vivo-NMR-Laboratory, Max-Planck-Institute for Neurological Research, Cologne, Germany
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Padma V, Fisher M, Moonis M. Thrombolytic therapy for acute ischemic stroke: 3 h and beyond. Expert Rev Neurother 2006; 5:223-33. [PMID: 15853492 DOI: 10.1586/14737175.5.2.223] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The current status of thrombolytic therapy approved by the US Food and Drug Administration is intravenous recombinant plasminogen activator given within 3 h of the onset of ischemic stroke. Intra-arterial therapy is possible for up to 6 h but is not Food and Drug Administration-approved for this purpose. Based on current radiologic methods (i.e., magnetic resonance imaging and perfusion computed tomography scans), it is being increasingly realized that the time window for effective thrombolytic therapy is variable, and salvageable tissue in the form of the ischemic penumbra may exist for longer periods of time and could therefore offer a greater time window based on these imaging studies. Development of an effective neuroprotective drug would greatly enhance the stability of the penumbra and offer further opportunities for extending the time window for reperfusion.
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