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Pérez-Mato M, López-Arias E, Bugallo-Casal A, Correa-Paz C, Arias S, Rodríguez-Yáñez M, Santamaría-Cadavid M, Campos F. New Perspectives in Neuroprotection for Ischemic Stroke. Neuroscience 2024; 550:30-42. [PMID: 38387732 DOI: 10.1016/j.neuroscience.2024.02.017] [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: 11/01/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 02/24/2024]
Abstract
The constant failure of new neuroprotective therapies for ischemic stroke has partially halted the search for new therapies in recent years, mainly because of the high investment risk required to develop a new treatment for a complex pathology, such as stroke, with a narrow intervention window and associated comorbidities. However, owing to recent progress in understanding the stroke pathophysiology, improvement in patient care in stroke units, development of new imaging techniques, search for new biomarkers for early diagnosis, and increasingly widespread use of mechanical recanalization therapies, new opportunities have opened for the study of neuroprotection. This review summarizes the main protective agents currently in use, some of which are already in the clinical evaluation phase. It also includes an analysis of how recanalization therapies, new imaging techniques, and biomarkers have improved their efficacy.
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Affiliation(s)
- María Pérez-Mato
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Esteban López-Arias
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Ana Bugallo-Casal
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Clara Correa-Paz
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Susana Arias
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - Manuel Rodríguez-Yáñez
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - María Santamaría-Cadavid
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - Francisco Campos
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain.
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Vints WAJ, Valatkevičienė K, Levin O, Weerasekera A, Jesmanas S, Kušleikienė S, Česnaitienė VJ, Himmelreich U, Verbunt JA, Ratai EM, Gleiznienė R, Masiulis N. Hippocampal neurometabolic and structural changes from pre-to post-COVID-19: A case-series study. Magn Reson Imaging 2024; 109:249-255. [PMID: 38521366 DOI: 10.1016/j.mri.2024.03.032] [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: 01/19/2024] [Revised: 03/19/2024] [Accepted: 03/20/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Neurological complications of the COVID-19 infection may be caused in part by local neurochemical and structural abnormalities that could not be detected during routine medical examinations. We examined within subject neurometabolic and structural brain alterations from pre-to post-COVID-19 in the hippocampal region of three elderly individuals (aged 63-68 years) who had a COVID-19 infection with mild symptoms. Patients were participating in an interventional study in which they were closely monitored at the time they were diagnosed with COVID-19. Patients 1 and 2 just completed 18-20 resistance training sessions prior to their diagnosis. Patient 3 was assigned to a non-training condition in the same study. METHODS Whole brain magnetic resonance imaging (MRI) images and proton magnetic resonance spectroscopy (1H-MRS) of the left hippocampus were collected before and after infection. Structural and spectroscopic imaging measures post-COVID-19 were contrasted to the pre-COVID-19 measures and were compared with values for Minimal Detectable Change at 95% (MDC95) and 90% (MDC90) confidence from a group of six elderly (aged 60-79 years) without COVID-19 that participated in the same study. RESULTS After SARS-COV-2 infection, we observed a reduction of glutamate-glutamine (Glx) in Patients 1 and 2 (≥ 42.0%) and elevation of myo-inositol (mIns) and N-acetyl-aspartate (NAA) in Patient 3 (≥ 36.4%); all > MDC90. MRI findings showed increased (Patients 1 and 2) or unchanged (Patient 3) hippocampal volume. CONCLUSIONS Overall, findings from this exploratory study suggest that mild COVID-19 infection could be associated with development of local neuroinflammation and reduced glutamate levels in the hippocampus. Our 1H-MRS findings may have clinical value for explaining chronic neurological and psychological complaints in COVID-19 long-haulers.
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Affiliation(s)
- Wouter A J Vints
- Department of Health Promotion and Rehabilitation, Lithuanian Sports University, LT-44221 Kaunas, Lithuania; Department of Rehabilitation Medicine Research School CAPHRI, Maastricht University, P.O. Box 616, 6200 MD Maastricht, the Netherlands; Adelante Zorggroep, P.O. Box 88, 6430 AB, Hoensbroek, the Netherlands.
| | - Kristina Valatkevičienė
- Department of Radiology, Kauno Klinikos, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Oron Levin
- Department of Health Promotion and Rehabilitation, Lithuanian Sports University, LT-44221 Kaunas, Lithuania; Movement Control & Neuroplasticity Research Group, Group Biomedical Sciences, KU Leuven, Heverlee 3001, Belgium
| | - Akila Weerasekera
- A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School (MGH/HMS), Boston 02129, MA, USA
| | - Simonas Jesmanas
- Department of Radiology, Kauno Klinikos, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Simona Kušleikienė
- Department of Health Promotion and Rehabilitation, Lithuanian Sports University, LT-44221 Kaunas, Lithuania
| | - Vida J Česnaitienė
- Department of Health Promotion and Rehabilitation, Lithuanian Sports University, LT-44221 Kaunas, Lithuania
| | - Uwe Himmelreich
- Biomedical MRI Unit, Department of Imaging and Pathology, Group Biomedical Sciences, KU Leuven, Leuven 3000, Belgium
| | - Jeanine A Verbunt
- Department of Rehabilitation Medicine Research School CAPHRI, Maastricht University, P.O. Box 616, 6200 MD Maastricht, the Netherlands; Adelante Zorggroep, P.O. Box 88, 6430 AB, Hoensbroek, the Netherlands
| | - Eva-Maria Ratai
- A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School (MGH/HMS), Boston 02129, MA, USA
| | - Rymantė Gleiznienė
- Department of Radiology, Kauno Klinikos, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Nerijus Masiulis
- Department of Health Promotion and Rehabilitation, Lithuanian Sports University, LT-44221 Kaunas, Lithuania; Department of Rehabilitation, Physical and Sports Medicine, Institute of Health Science, Faculty of Medicine, Vilnius University, M. K. Čiurlionio Str. 21, LT-03101 Vilnius, Lithuania
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Gory B, Finitsis S, Olivot JM, Richard S, Marnat G, Sibon I, Viguier A, Cognard C, Mazighi M, Chamorro A, Lapergue B, Maïer B. Intravenous Thrombolysis before Complete Angiographic Reperfusion: Beyond Angiographic Assessment to Target Microvascular Obstruction? Ann Neurol 2024; 95:762-773. [PMID: 38148607 DOI: 10.1002/ana.26867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVE Recent data have suggested that ineffective tissue reperfusion despite successful angiographic reperfusion was partly responsible for unfavorable outcomes after endovascular therapy (EVT) and might be modulated by intravenous thrombolysis (IVT) use before EVT. To specifically decipher the effect played by IVT before EVT, we compared the clinical and safety outcomes of patients who experienced a complete reperfusion at the end of EVT according to IVT use before EVT. METHODS The Endovascular Treatment in Ischemic Stroke (ETIS) registry is an ongoing, prospective, observational study at 21 centers that perform EVT in France. Patients were included if they had an anterior large vessel occlusion of the intracranial internal carotid artery or middle cerebral artery (M1/M2 segments) and complete reperfusion (expanded Thrombolysis in Cerebral Infarction score = 3) with EVT within 6 hours, between January 2015 and December 2021. The cohort was divided into two groups according to IVT use before EVT, and propensity score matching (PSM) was used to balance the two groups. Primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included favorable outcome (mRS 0-2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. Outcomes were estimated with multivariate logistic models adjusted for age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and time from symptom onset to puncture. RESULTS Among 5,429 patients included in the ETIS registry, 1,093 were included in the study, including 651 patients with complete recanalization treated with IVT before EVT. After PSM, 488 patients treated with IVT before EVT were compared to 337 patients without IVT. In the matched cohort analysis, the IVT+EVT group had a favorable shift in the overall mRS score distribution (adjusted odds ratio [aOR] = 1.41, 95% confidence interval [CI] = 1.04-1.91, p = 0.023) and higher rates of favorable outcome (61.1% vs 48.7%, aOR = 1.49, 95% CI = 1.02-2.20, p = 0.041) at 90 days compared with the EVT alone group. Rates of symptomatic intracerebral hemorrhage were comparable between both groups (6.0% vs 4.3%, aOR = 1.16, 95% CI = 0.53-2.54, p = 0.709). INTERPRETATION In clinical practice, even after complete angiographic reperfusion by EVT, prior IVT use improves clinical outcomes of patients without increasing bleeding risk. ANN NEUROL 2024;95:762-773.
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Affiliation(s)
- Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France
- INSERM U1254, IADI, Université de Lorraine, 54511, Vandoeuvre-les-Nancy, France
| | - Stephanos Finitsis
- Aristotle University of Thessaloniki, Ahepa Hospital, Thessaloniki, Greece
| | - Jean-Marc Olivot
- Department of Vascular Neurology, University Hospital of Toulouse, Toulouse, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, Nancy, France
- CIC-P 1433, INSERM U1116, CHRU-Nancy, Nancy, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Neurology Department, University Hospital of Bordeaux, Bordeaux, France
| | - Alain Viguier
- Department of Vascular Neurology, University Hospital of Toulouse, Toulouse, France
| | | | - Mikael Mazighi
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
- Department of Neurology, Hôpital Lariboisière, Paris, France
- Université Paris-Cité, Paris, France
- Université Paris-Cité and Université Sorbonne Paris Nord, Paris, France
| | - Angel Chamorro
- Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Benjamin Maïer
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
- Université Paris-Cité, Paris, France
- Université Paris-Cité and Université Sorbonne Paris Nord, Paris, France
- Department of Neurology, Hôpital Saint-Joseph, Paris, France
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Correa-Paz C, Pérez-Mato M, Bellemain-Sagnard M, González-Domínguez M, Marie P, Pérez-Gayol L, López-Arias E, Del Pozo-Filíu L, López-Amoedo S, Bugallo-Casal A, Alonso-Alonso ML, Candamo-Lourido M, Santamaría-Cadavid M, Arias-Rivas S, Rodríguez-Yañez M, Iglesias-Rey R, Castillo J, Vivien D, Rubio M, Campos F. Pharmacological preclinical comparison of tenecteplase and alteplase for the treatment of acute stroke. J Cereb Blood Flow Metab 2024:271678X241237427. [PMID: 38436292 DOI: 10.1177/0271678x241237427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Alteplase (rtPA) remains the standard thrombolytic drug for acute ischemic stroke. However, new rtPA-derived molecules, such as tenecteplase (TNK), with prolonged half-lives following a single bolus administration, have been developed. Although TNK is currently under clinical evaluation, the limited preclinical data highlight the need for additional studies to elucidate its benefits. The toxicities of rtPA and TNK were evaluated in endothelial cells, astrocytes, and neuronal cells. In addition, their in vivo efficacy was independently assessed at two research centers using an ischemic thromboembolic mouse model. Both therapies were tested via early (20 and 30 min) and late administration (4 and 4.5 h) after stroke. rtPA, but not TNK, caused cell death only in neuronal cultures. Mice were less sensitive to thrombolytic therapies than humans, requiring doses 10-fold higher than the established clinical dose. A single bolus dose of 2.5 mg/kg TNK led to an infarct reduction similar to perfusion with 10 mg/kg of rtPA. Early administration of TNK decreased the hemorrhagic transformations compared to that by the early administration of rtPA; however, this result was not obtained following late administration. These two independent preclinical studies support the use of TNK as a promising reperfusion alternative to rtPA.
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Affiliation(s)
- Clara Correa-Paz
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - María Pérez-Mato
- Neuroscience and Cerebrovascular Research Laboratory, Department of Neurology and Stroke Center, La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mathys Bellemain-Sagnard
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
| | - Marco González-Domínguez
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - Pauline Marie
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
| | - Lara Pérez-Gayol
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - Esteban López-Arias
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - Lucia Del Pozo-Filíu
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - Sonia López-Amoedo
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - Ana Bugallo-Casal
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - María Luz Alonso-Alonso
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
| | - María Candamo-Lourido
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
| | - María Santamaría-Cadavid
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, A Coruña, Spain
| | - Susana Arias-Rivas
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, A Coruña, Spain
| | - Manuel Rodríguez-Yañez
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, A Coruña, Spain
| | - Ramón Iglesias-Rey
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - José Castillo
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
| | - Denis Vivien
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
- Department of Clinical Research, Caen Normandie University Hospital, Caen, France
| | - Marina Rubio
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
| | - Francisco Campos
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), A Coruña, Spain
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Chen G, Wang A, Zhang X, Li Y, Xia X, Tian X, Li J, Miao Z, Yue W. Systemic Immune-Inflammation Response is Associated with Futile Recanalization After Endovascular Treatment. Neurocrit Care 2024:10.1007/s12028-023-01930-y. [PMID: 38316736 DOI: 10.1007/s12028-023-01930-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/15/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Frequent incidence of futile recanalization decreases the benefit of endovascular treatment (EVT) in acute ischemic stroke. We hypothesized that the inflammation and immune response after ischemic are associated with futile recanalization. We aimed to investigate the correlation of admission systemic immune-inflammation index (SII) with futile recanalization post EVT. METHODS Patients with successful recanalization (modified Thrombolysis in Cerebral Ischemia angiographic score 2b-3) and maintained artery recanalized after 24 h of EVT were chosen from a prospective nationwide registry study. Futile recanalization was defined as a poor functional outcome (modified Rankin Scale score 3-6) at 90 days, irrespective of a successful recanalization. At admission, SII was calculated as (platelet count × neutrophil count)/lymphocyte count/100. Logistic regression analysis helped to test the relationship of SII with futile recanalization. RESULTS Among the 1,002 patients included, futile recanalization occurred in 508 (50.70%). No matter whether tested as quartiles or continuous variables, SII was significantly associated with futile recanalization (P < 0.05), and for every one standard deviation increase of SII, the risk of futile recanalization elevated by 22.3% (odds ratio 1.223, 95% confidence interval 1.053-1.444, P = 0.0093). Moreover, no significant interactions could be observed between SII or SII quartiles and age, baseline National Institutes of Health Stroke Scale scores, onset-to-recanalization time, and modified Thrombolysis in Cerebral Ischemia angiographic scores (all P for interaction > 0.05). CONCLUSIONS Early SII elevation was associated with an increased risk of futile recanalization among patients with EVT. Our results indicated that therapeutic drug targeting hyperreactive immune-inflammation response might be helpful for reducing the incidence of futile recanalization.
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Affiliation(s)
- Guojuan Chen
- Department of Neurology, Clinical College of Neurology, Neurosurgery, and Neurorehabilitation, Tianjin Medical University, Tianjin Huanhu Hospital, No.6 Jizhao Road, Shuanggang Town, Jinnan District, Tianjin, 300350, China
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaoli Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuhao Li
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Xue Xia
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xue Tian
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Jing Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Wei Yue
- Department of Neurology, Clinical College of Neurology, Neurosurgery, and Neurorehabilitation, Tianjin Medical University, Tianjin Huanhu Hospital, No.6 Jizhao Road, Shuanggang Town, Jinnan District, Tianjin, 300350, China.
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6
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Marei O, Podlasek A, Soo E, Butt W, Gory B, Nguyen TN, Appleton JP, Richard S, Rice H, de Villiers L, Carraro do Nascimento V, Domitrovic L, McConachie N, Lenthall R, Nair S, Malik L, Panesar J, Krishnan K, Bhogal P, Dineen RA, England TJ, Campbell BCV, Dhillon PS. Safety and efficacy of adjunctive intra-arterial antithrombotic therapy during endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis. J Neurointerv Surg 2024:jnis-2023-021244. [PMID: 38253378 DOI: 10.1136/jnis-2023-021244] [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: 11/09/2023] [Accepted: 01/06/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Half of patients who achieve successful recanalization following endovascular thrombectomy (EVT) for acute ischemic stroke experience poor functional outcome. We aim to investigate whether the use of adjunctive intra-arterial antithrombotic therapy (AAT) during EVT is safe and efficacious compared with standard therapy (ST) of EVT with or without prior intravenous thrombolysis. METHODS Electronic databases were searched (PubMed/MEDLINE, Embase, Cochrane Library) from 2010 until October 2023. Data were pooled using a random-effects model and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of bias was assessed using ROBINS-I and ROB-2. The primary outcome was functional independence (modified Rankin Scale (mRS) 0-2) at 3 months. Secondary outcomes were successful recanalization (modified Thrombolysis In Cerebral Infarction (TICI) 2b-3), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS 41 randomized and non-randomized studies met the eligibility criteria. Overall, 15 316 patients were included; 3296 patients were treated with AAT during EVT and 12 020 were treated with ST alone. Compared with ST, patients treated with AAT demonstrated higher odds of functional independence (46.5% AAT vs 42.6% ST; OR 1.22, 95% CI 1.07 to 1.40, P=0.004, I2=48%) and a lower likelihood of 90-day mortality (OR 0.71, 95% CI 0.61 to 0.83, P<0.0001, I2=20%). The rates of sICH (OR 1.00, 95% CI 0.82 to 1.22,P=0.97, I2=13%) and successful recanalization (OR 1.09, 95% CI 0.84 to 1.42, P=0.52, I2=76%) were not significantly different. CONCLUSION The use of AAT during EVT may improve functional outcomes and reduce mortality rates compared with ST alone, without an increased risk of sICH. These findings should be interpreted with caution pending the results from ongoing phase III trials to establish the efficacy and safety of AAT during EVT.
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Affiliation(s)
- Omar Marei
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Anna Podlasek
- Tayside Innovation Medtech Ecosystem (TIME), University of Dundee, Dundee, UK
| | - Emma Soo
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Waleed Butt
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
| | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
- Radiology, Boston Medical Center Department of Radiology, Boston, Massachusetts, USA
| | - Jason P Appleton
- Stroke Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | | | - Hal Rice
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Laetitia de Villiers
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | | | - Luis Domitrovic
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Norman McConachie
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jasmin Panesar
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kailash Krishnan
- Stroke Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Pervinder Bhogal
- Interventional Neuroradiology, Royal London Hospital, London, UK
| | - Robert A Dineen
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Bruce C V Campbell
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Permesh Singh Dhillon
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
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Migliavacca M, Correa-Paz C, Pérez-Mato M, Bielawski PB, Zhang I, Marie P, Hervella P, Rubio M, Maysinger D, Vivien D, Del Pino P, Pelaz B, Polo E, Campos F. Thrombolytic therapy based on lyophilized platelet-derived nanocarriers for ischemic stroke. J Nanobiotechnology 2024; 22:10. [PMID: 38166940 PMCID: PMC10763438 DOI: 10.1186/s12951-023-02206-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/07/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Intravenous administration of fibrinolytic drugs, such as recombinant tissue plasminogen activator (rtPA) is the standard treatment of acute thrombotic diseases. However, current fibrinolytics exhibit limited clinical efficacy because of their short plasma half-lives and risk of hemorrhagic transformations. Platelet membrane-based nanocarriers have received increasing attention for ischemic stroke therapies, as they have natural thrombus-targeting activity, can prolong half-life of the fibrinolytic therapy, and reduce side effects. In this study we have gone further in developing platelet-derived nanocarriers (defined as cellsomes) to encapsulate and protect rtPA from degradation. Following lyophilization and characterization, their formulation properties, biocompatibility, therapeutic effect, and risk of hemorrhages were later investigated in a thromboembolic model of stroke in mice. RESULTS Cellsomes of 200 nm size and loaded with rtPA were generated from membrane fragments of human platelets. The lyophilization process did not influence the nanocarrier size distribution, morphology, and colloidal stability conferring particle preservation and long-term storage. Encapsulated rtPA in cellsomes and administered as a single bolus showed to be as effective as a continuous clinical perfusion of free rtPA at equal concentration, without increasing the risk of hemorrhagic transformations or provoking an inflammatory response. CONCLUSIONS This study provides evidence for the safe and effective use of lyophilized biomimetic platelet-derived nanomedicine for precise thrombolytic treatment of acute ischemic stroke. In addition, this new nanoformulation could simplify the clinical use of rtPA as a single bolus, being easier and less time-consuming in an emergency setting than a treatment perfusion, particularly in stroke patients. We have successfully addressed one of the main barriers to drug application and commercialization, the long-term storage of nanomedicines, overcoming the potential chemical and physical instabilities of nanomedicines when stored in an aqueous buffer.
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Affiliation(s)
- Martina Migliavacca
- Center for Research in Biological Chemistry and Molecular Materials (CiQUS), University of Santiago de Compostela, 15705, Santiago de Compostela, Spain
| | - Clara Correa-Paz
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706, Santiago de Compostela, Spain
| | - María Pérez-Mato
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706, Santiago de Compostela, Spain
| | - Patrick-Brian Bielawski
- Department of Pharmacology and Therapeutics, McGill University, Montreal, QC, H3G 1Y6, Canada
| | - Issan Zhang
- Department of Pharmacology and Therapeutics, McGill University, Montreal, QC, H3G 1Y6, Canada
| | - Pauline Marie
- UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Normandie University, UNICAEN, INSERM, GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), 14000, Caen, France
| | - Pablo Hervella
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706, Santiago de Compostela, Spain
| | - Marina Rubio
- UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Normandie University, UNICAEN, INSERM, GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), 14000, Caen, France
| | - Dusica Maysinger
- Department of Pharmacology and Therapeutics, McGill University, Montreal, QC, H3G 1Y6, Canada
| | - Denis Vivien
- UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Normandie University, UNICAEN, INSERM, GIP Cyceron, Institute Blood and Brain @ Caen-Normandie (BB@C), 14000, Caen, France
- Department of Clinical Research, Caen Normandie University Hospital, Caen, France
| | - Pablo Del Pino
- Center for Research in Biological Chemistry and Molecular Materials (CiQUS), University of Santiago de Compostela, 15705, Santiago de Compostela, Spain
| | - Beatriz Pelaz
- Center for Research in Biological Chemistry and Molecular Materials (CiQUS), University of Santiago de Compostela, 15705, Santiago de Compostela, Spain.
| | - Ester Polo
- Center for Research in Biological Chemistry and Molecular Materials (CiQUS), University of Santiago de Compostela, 15705, Santiago de Compostela, Spain.
| | - Francisco Campos
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706, Santiago de Compostela, Spain.
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Qureshi AI, Lodhi A, Akhtar IN, Ma X, Kherani D, Kwok CS, Ford DE, Hanley DF, Hassan AE, Nguyen TN, Spiotta AM, Zaidi SF. Mechanical thrombectomy with intra-arterial thrombolysis versus mechanical thrombectomy alone in patients with acute ischemic stroke: A systematic review and meta-analysis. Int J Stroke 2024; 19:16-28. [PMID: 37306490 DOI: 10.1177/17474930231184369] [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] [Indexed: 06/13/2023]
Abstract
BACKGROUND There is conflicting evidence as to whether intra-arterial thrombolysis (IAT) adds benefit in patients with acute stroke who undergo mechanical thrombectomy (MT). METHODS We conducted a systematic review to identify studies that evaluate IAT in patients with acute stroke who undergo MT. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until February 2023. Statistical pooling with random effects meta-analysis was undertaken to evaluate odds of functional independence, mortality, and near-complete or complete angiographic recanalization with IAT compared to no IAT. RESULTS A total of 18 studies were included (3 matched, 14 unmatched, and 1 randomized). The odds ratio (OR) for functional independence (modified Rankin Scale: 0-2) at 90 days was 1.14 (95% confidence interval (CI): 0.95-1.37, p = 0.17, 16 studies involving 7572 patients) with IAT with moderate between-study heterogeneity (I2 = 38.1%). The OR for functional independence with IAT was 1.28 (95% CI: 0.92-1.78, p = 0.15) in studies that were either matched or randomized and 1.24 (95% CI: 0.97-1.58, p = 0.08) in studies with the highest quality score. IAT was associated with higher odds of near-complete or complete angiographic recanalization (OR: 1.65, 95% CI: 1.03-2.65, p = 0.04) in studies that were either matched or of randomized comparisons. CONCLUSION Although the odds of functional independence appeared to be higher with IAT and MT compared with MT alone, none of the results were statistically significant. A prominent effect of the design and quality of the studies was observed on the association between IAT and functional independence at 90 days.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Abdullah Lodhi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Iqra N Akhtar
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Xiaoyu Ma
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Danish Kherani
- Department of Neurology, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Chun Shing Kwok
- Department of Cardiology, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Daniel E Ford
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel F Hanley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ameer E Hassan
- Department of Neurology, The University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Syed F Zaidi
- Department of Neurology, The University of Toledo Medical Center, Toledo, OH, USA
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9
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ter Schiphorst A, Turc G, Hassen WB, Oppenheim C, Baron JC. Incidence, severity and impact on functional outcome of persistent hypoperfusion despite large-vessel recanalization, a potential marker of impaired microvascular reperfusion: Systematic review of the clinical literature. J Cereb Blood Flow Metab 2024; 44:38-49. [PMID: 37871624 PMCID: PMC10905632 DOI: 10.1177/0271678x231209069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 09/02/2023] [Accepted: 10/02/2023] [Indexed: 10/25/2023]
Abstract
The reported incidence of persistent hypoperfusion despite complete recanalization as surrogate for impaired microvascular reperfusion (IMR) has varied widely among clinical studies, possibly due to differences in i) definition of complete recanalization, with only recent Thrombolysis in Cerebral Infarction (TICI) grading schemes allowing distinction between complete (TICI3) and partial recanalization with distal occlusions (TICI2c); ii) operational definition of IMR; and iii) consideration of potential alternative causes for hypoperfusion, notably carotid stenosis, re-occlusion and post-thrombectomy hemorrhage. We performed a systematic review to identify clinical studies that carried out brain perfusion imaging within 72 hrs post-thrombectomy for anterior circulation stroke and reported hypoperfusion rates separately for TICI3 and TICI2c grades. Authors were contacted if this data was missing. We identified eight eligible articles, altogether reporting 636 patients. The incidence of IMR after complete recanalization (i.e., TICI3) tended to decrease with the number of considered alternative causes of hypoperfusion: range 12.5-42.9%, 0-31.6% and 0-9.1% in articles that considered none, two or all three causes, respectively. No study reported the impact of IMR on functional outcome separately for TICI-3 patients. Based on this systematic review, IMR in true complete recanalization appears relatively rare, and reported incidence highly depends on definition used and consideration of confounding factors.
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Affiliation(s)
- Adrien ter Schiphorst
- Department of Neurology, University Hospital of Montpellier, CHU Gui de Chauliac, Montpellier, France
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, FHU NeuroVasc, Paris, France
| | - Wagih Ben Hassen
- Department of Neuroradiology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, Paris, France
| | - Catherine Oppenheim
- Department of Neuroradiology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, Paris, France
| | - Jean-Claude Baron
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, FHU NeuroVasc, Paris, France
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10
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Leira EC, Planas AM, Chauhan AK, Chamorro A. Uric Acid: A Translational Journey in Cerebroprotection That Spanned Preclinical and Human Data. Neurology 2023; 101:1068-1074. [PMID: 37848338 PMCID: PMC10752646 DOI: 10.1212/wnl.0000000000207825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/12/2023] [Indexed: 10/19/2023] Open
Abstract
Uric acid (UA) is a strong endogenous antioxidant that neutralizes the toxicity of peroxynitrite and other reactive species on the neurovascular unit generated during and after acute brain ischemia. The realization that a rapid reduction of UA levels during an acute ischemic stroke was associated with a worse stroke outcome paved the way to investigate the value of exogenous UA supplementation to counteract the progression of redox-mediated ischemic brain damage. The long translational journey for UA supplementation recently reached a critical milestone when the results of the multicenter NIH stroke preclinical assessment network (SPAN) were reported. In a novel preclinical paradigm, 6 treatment candidates including UA supplementation were selected and tested in 6 independent laboratories following predefined criteria and strict methodological rigor. UA supplementation was the only intervention in SPAN that exceeded the prespecified efficacy boundary with male and female animals, young mice, young rats, aging mice, obese mice, and spontaneously hypertensive rats. This unprecedented achievement will allow UA to undergo clinical testing in a pivotal clinical trial through a NIH StrokeNet thrombectomy endovascular platform created to assess new treatment strategies in patients treated with mechanical thrombectomy. UA is a particularly appealing adjuvant intervention for mechanical thrombectomy because it targets the microcirculatory hypoperfusion and oxidative stress that limits the efficacy of this therapy. This descriptive review aims to summarize the translational development of UA supplementation, highlighting those aspects that likely contributed to its success. It includes having a well-defined target and mechanism of action, and an approach that simultaneously integrated rigorous preclinical assessment, with epidemiologic and preliminary human intervention studies. Validation of the clinical value of UA supplementation in a pivotal trial would confirm the translational value of the SPAN paradigm in preclinical research.
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Affiliation(s)
- Enrique C Leira
- From the Department of Neurology (E.L., A.C.), and Departments of Neurosurgery & Epidemiology (E.L.), University of Iowa, Iowa City; Institute of Biomedical Research of Barcelona (IIBB) (A.M.P.), Spanish National Research Council (CSIC); August Pi i Sunyer Biomedical Research Institute (IDIBAPS) (A.M.P., A.C.), Barcelona, Spain; Department of Internal Medicine (A.K.C.), University of Iowa, Iowa City; and Hospital Clinic (A.C.), University of Barcelona, Spain
| | - Anna M Planas
- From the Department of Neurology (E.L., A.C.), and Departments of Neurosurgery & Epidemiology (E.L.), University of Iowa, Iowa City; Institute of Biomedical Research of Barcelona (IIBB) (A.M.P.), Spanish National Research Council (CSIC); August Pi i Sunyer Biomedical Research Institute (IDIBAPS) (A.M.P., A.C.), Barcelona, Spain; Department of Internal Medicine (A.K.C.), University of Iowa, Iowa City; and Hospital Clinic (A.C.), University of Barcelona, Spain
| | - Anil K Chauhan
- From the Department of Neurology (E.L., A.C.), and Departments of Neurosurgery & Epidemiology (E.L.), University of Iowa, Iowa City; Institute of Biomedical Research of Barcelona (IIBB) (A.M.P.), Spanish National Research Council (CSIC); August Pi i Sunyer Biomedical Research Institute (IDIBAPS) (A.M.P., A.C.), Barcelona, Spain; Department of Internal Medicine (A.K.C.), University of Iowa, Iowa City; and Hospital Clinic (A.C.), University of Barcelona, Spain
| | - Angel Chamorro
- From the Department of Neurology (E.L., A.C.), and Departments of Neurosurgery & Epidemiology (E.L.), University of Iowa, Iowa City; Institute of Biomedical Research of Barcelona (IIBB) (A.M.P.), Spanish National Research Council (CSIC); August Pi i Sunyer Biomedical Research Institute (IDIBAPS) (A.M.P., A.C.), Barcelona, Spain; Department of Internal Medicine (A.K.C.), University of Iowa, Iowa City; and Hospital Clinic (A.C.), University of Barcelona, Spain.
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11
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Deng G, Chu YH, Xiao J, Shang K, Zhou LQ, Qin C, Tian DS. Risk Factors, Pathophysiologic Mechanisms, and Potential Treatment Strategies of Futile Recanalization after Endovascular Therapy in Acute Ischemic Stroke. Aging Dis 2023; 14:2096-2112. [PMID: 37199580 PMCID: PMC10676786 DOI: 10.14336/ad.2023.0321-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/22/2023] [Indexed: 05/19/2023] Open
Abstract
Endovascular therapy is the first-line treatment for acute ischemic stroke. However, studies have shown that, even with the timely opening of occluded blood vessels, nearly half of all patients treated with endovascular therapy for acute ischemic stroke still have poor functional recovery, a phenomenon called "futile recanalization.". The pathophysiology of futile recanalization is complex and may include tissue no-reflow (microcirculation reperfusion failure despite recanalization of the occluded large artery), early arterial reocclusion (reocclusion of the recanalized artery 24-48 hours post endovascular therapy), poor collateral circulation, hemorrhagic transformation (cerebral bleeding following primary ischemic stroke), impaired cerebrovascular autoregulation, and large hypoperfusion volume. Therapeutic strategies targeting these mechanisms have been attempted in preclinical research; however, translation to the bedside remains to be explored. This review summarizes the risk factors, pathophysiological mechanisms, and targeted therapy strategies of futile recanalization, focusing on the mechanisms and targeted therapy strategies of no-reflow to deepen the understanding of this phenomenon and provide new translational research ideas and potential intervention targets for improving the efficacy of endovascular therapy for acute ischemic stroke.
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Affiliation(s)
- Gang Deng
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yun-hui Chu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jun Xiao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Ke Shang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Luo-Qi Zhou
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Chuan Qin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Dai-Shi Tian
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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12
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Favilla CG, Forti RM, Carter S, Kofke WA, Kasner SE, Baker WB, Yodh AG, Messé SR, Cummings S, Kung DK, Burkhardt JK, Choudhri OA, Pukenas B, Srinivasan VM, Hurst RW, Detre JA. Microvascular reperfusion during endovascular therapy: the balance of supply and demand. J Neurointerv Surg 2023:jnis-2023-020834. [PMID: 37898551 PMCID: PMC11055937 DOI: 10.1136/jnis-2023-020834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/03/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Endovascular therapy (EVT) has revolutionized the treatment of acute stroke, but large vessel recanalization does not always result in tissue-level reperfusion. Cerebral blood flow (CBF) is not routinely monitored during EVT. We aimed to leverage diffuse correlation spectroscopy (DCS), a novel transcranial optical imaging technique, to assess the relationship between microvascular CBF and post-EVT outcomes. METHODS Frontal lobe CBF was monitored by DCS in 40 patients undergoing EVT. Baseline CBF deficit was calculated as the percentage of CBF impairment on pre-EVT CT perfusion. Microvascular reperfusion was calculated as the percentage increase in DCS-derived CBF that occurred with recanalization. The adequacy of reperfusion was defined by persistent CBF deficit, calculated as: baseline CBF deficit - microvascular reperfusion. A good functional outcome was defined as 90-day modified Rankin Scale score ≤2. RESULTS Thirty-six of 40 patients achieved successful recanalization, in whom microvascular reperfusion in itself was not associated with infarct volume or functional outcome. However, patients with good functional outcomes had a smaller persistent CBF deficit (median 1% (IQR -11%-16%)) than patients with poor outcomes (median 28% (IQR 2-50%)) (p=0.02). Smaller persistent CBF deficit was also associated with smaller infarct volume (p=0.004). Multivariate models confirmed that persistent CBF deficit was independently associated with infarct volume and functional outcome. CONCLUSIONS CBF augmentation alone does not predict post-EVT outcomes, but when microvascular reperfusion closely matches the baseline CBF deficit, patients experience favorable clinical and radiographic outcomes. By recognizing inadequate reperfusion, bedside CBF monitoring may provide opportunities to personalize post-EVT care aimed at CBF optimization.
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Affiliation(s)
- Christopher G Favilla
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rodrigo M Forti
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarah Carter
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - W Andrew Kofke
- Department of Anesthesia & Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wesley B Baker
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Arjun G Yodh
- Department of Physics & Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven R Messé
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie Cummings
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David K Kung
- Department of Neurosurgery, Robert Wood Johnson Health System, Livingston, New Jersey, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Omar A Choudhri
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bryan Pukenas
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert W Hurst
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John A Detre
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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13
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Mujanovic A, Kurmann CC, Serrallach BL, Dobrocky T, Meinel TR, Windecker D, Grunder L, Beyeler M, Seiffge DJ, Pilgram-Pastor S, Arnold M, Piechowiak EI, Gralla J, Fischer U, Kaesmacher J. Intra-Arterial Thrombolysis is Associated with Delayed Reperfusion of Remaining Vessel Occlusions following Incomplete Thrombectomy. AJNR Am J Neuroradiol 2023; 44:1050-1056. [PMID: 37500281 PMCID: PMC10494949 DOI: 10.3174/ajnr.a7943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/22/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND AND PURPOSE Intra-arterial thrombolytics may be used to treat distal vessel occlusions, which cause incomplete reperfusion following mechanical thrombectomy. Because immediate reperfusion after intra-arterial thrombolytics occurs rarely, the aim of this study was to assess the delayed effect of intra-arterial thrombolytics using follow-up perfusion imaging. MATERIALS AND METHODS We included patients from a prospective stroke registry (February 2015 to September 2022) who had undergone mechanical thrombectomy and had incomplete reperfusion (expanded TICI 2a-2c) and available 24 hour perfusion imaging. Perfusion imaging was rated as delayed reperfusion if time-sensitive perfusion maps did not show wedge-shaped delays suggestive of persisting occlusions corresponding to the post-mechanical thrombectomy angiographic deficit. Patients treated with intra-arterial thrombolytics were compared with controls using multivariable logistic regression and inverse probability of treatment weighting matching for baseline differences and factors associated with delayed reperfusion. RESULTS The median age of the final study population (n = 459) was 74 years (interquartile range, 63-81 years), and delayed reperfusion occurred in 61% of cases. Patients treated with additional intra-arterial thrombolytics (n = 40) were younger and had worse expanded TICI scores. After matching was performed, intra-arterial thrombolytics was associated with higher rates of delayed reperfusion (adjusted OR = 2.7; 95% CI, 1.1-6.4) and lower rates of new infarction in the residually hypoperfused territory after mechanical thrombectomy (adjusted OR = 0.3; 95% CI, 0.1-0.7). No difference was found in the rates of functional independence (90-day mRS, 0-2; adjusted OR = 1.4; 95% CI, 0.4-4.1). CONCLUSIONS Rescue intra-arterial thrombolytics is associated with delayed reperfusion of remaining vessel occlusions following incomplete mechanical thrombectomy. The value of intra-arterial thrombolytics as a potential therapy for incomplete reperfusions after mechanical thrombectomy should be assessed in the setting of randomized controlled trials.
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Affiliation(s)
- A Mujanovic
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - C C Kurmann
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Diagnostic, Interventional and Pediatric Radiology (C.C.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - B L Serrallach
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - T Dobrocky
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - T R Meinel
- Department of Neurology (T.R.M., M.B., D.J.S., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - D Windecker
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - L Grunder
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - M Beyeler
- Department of Neurology (T.R.M., M.B., D.J.S., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - D J Seiffge
- Department of Neurology (T.R.M., M.B., D.J.S., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - S Pilgram-Pastor
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - M Arnold
- Department of Neurology (T.R.M., M.B., D.J.S., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - E I Piechowiak
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - J Gralla
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - U Fischer
- Department of Neurology (T.R.M., M.B., D.J.S., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology (U.F.), University Hospital Basel, University of Basel, Basel, Switzerland
| | - J Kaesmacher
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
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Elfil M, Ghozy S, Elmashad A, Ghaith HS, Aladawi M, Dicpinigaitis AJ, Mansour OY, Khandelwal P, Asif K, Nour M, Toth G, Al-Mufti F. Effect of intra-arterial thrombolysis following successful endovascular thrombectomy on functional outcomes in patients with large vessel occlusion acute ischemic stroke: A post-CHOICE meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107194. [PMID: 37216750 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107194] [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: 03/24/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/24/2023] Open
Abstract
INTRODUCTION Endovascular thrombectomy (EVT) is the standard treatment of acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Although > 70% of patients in the trials assessing EVT for AIS-LVO had successful recanalization, only a third ultimately achieved favorable outcomes. A "no-reflow" phenomenon due to distal microcirculation disruption might contribute to such suboptimal outcomes. Combining intra-arterial (IA) tissue plasminogen activator (tPA) and EVT to reduce the distal microthrombi burden was investigated in a few studies. We present a pooled-data meta-analysis of the existing evidence of this combinatorial treatment. METHODS We followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) recommendations. We aimed to include all original studies investigating EVT plus IA tPA in AIS-LVO patients. Using R software, we calculated pooled odds ratios (ORs) with corresponding 95% confidence intervals (CI). A fixed-effects model was adopted to evaluate pooled data. RESULTS Five studies satisfied the inclusion criteria. Successful recanalization was comparable between the IA tPA and control groups at 82.9% and 82.32% respectively. The 90-day functional independence was similar between both groups (OR= 1.25; 95% CI= 0.92-1.70; P= 0.154). Symptomatic intracranial hemorrhage (sICH) was also comparable between both groups (OR= 0.66; 95% CI= 0.34-1.26; P= 0.304). CONCLUSION Our current meta-analysis does not show significant differences between EVT alone and EVT plus IA tPA in terms of functional independence or sICH. However, with the limited number of studies and included patients, more randomized controlled trials (RCTs) are needed to further investigate the benefits and safety of combined EVT and IA tPA.
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Affiliation(s)
- Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ahmed Elmashad
- Department of Neurology, University of Connecticut, Farmington, CT, USA
| | | | - Mohammad Aladawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Ossama Yassin Mansour
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Priyank Khandelwal
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Kaiz Asif
- Ascension Health and University of Illinois-Chicago, Chicago, IL, USA
| | - May Nour
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, New York Medical College at Westchester Medical Center, Valhalla, NY, USA.
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15
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Starikova N, Räty S, Strbian D, Kaiser DPO, Gerber JC, Huo X, Qiu Z, Chen HS, Kaesmacher J, Pallesen LP, Barlinn K, Sun D, Abdalkader M, Nguyen TN, Nagel S, Miao Z, Puetz V. Endovascular Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke: An Evolution of Trials. Semin Neurol 2023; 43:397-407. [PMID: 37549693 DOI: 10.1055/s-0043-1771454] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
The last decade's progress in demonstrating the clinical benefit of endovascular thrombectomy (EVT) in patients with large vessel occlusion stroke has transformed the paradigm of care for these patients. This review presents the milestones in implementing EVT as standard of care, demonstrates the current state of evidence, provides guidance for identifying the candidate patient for EVT, and highlights unsolved and controversial issues. Ongoing trials investigate broadening of EVT indications for patients who present with large core infarction, adjunctive intra-arterial thrombolysis, medium vessel occlusion, low NIHSS, and tandem occlusion.
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Affiliation(s)
- Natalia Starikova
- Department of Neurology, University Clinic of Odessa National Medical University, Odessa, Ukraine
- TeleHealth Consulting Service, Medical Center "Expert Health," Odessa, Ukraine
| | - Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | - Daniel P O Kaiser
- Institute of Neuroradiology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Johannes C Gerber
- Institute of Neuroradiology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Xiaochuan Huo
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Johannes Kaesmacher
- Interventional Neuroradiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lars-Peder Pallesen
- Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Department of Neurology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Department of Neurology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Dapeng Sun
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Zhongrong Miao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Volker Puetz
- Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Department of Neurology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
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