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Rehman S, Nadeem A, Akram U, Sarwar A, Quraishi A, Siddiqui H, Malik MAJ, Nabi M, Ul Haq I, Cho A, Mazumdar I, Kim M, Chen K, Sepehri S, Wang R, Balar AB, Lakhani DA, Yedavalli VS. Molecular Mechanisms of Ischemic Stroke: A Review Integrating Clinical Imaging and Therapeutic Perspectives. Biomedicines 2024; 12:812. [PMID: 38672167 PMCID: PMC11048412 DOI: 10.3390/biomedicines12040812] [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: 02/29/2024] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/28/2024] Open
Abstract
Ischemic stroke poses a significant global health challenge, necessitating ongoing exploration of its pathophysiology and treatment strategies. This comprehensive review integrates various aspects of ischemic stroke research, emphasizing crucial mechanisms, therapeutic approaches, and the role of clinical imaging in disease management. It discusses the multifaceted role of Netrin-1, highlighting its potential in promoting neurovascular repair and mitigating post-stroke neurological decline. It also examines the impact of blood-brain barrier permeability on stroke outcomes and explores alternative therapeutic targets such as statins and sphingosine-1-phosphate signaling. Neurocardiology investigations underscore the contribution of cardiac factors to post-stroke mortality, emphasizing the importance of understanding the brain-heart axis for targeted interventions. Additionally, the review advocates for early reperfusion and neuroprotective agents to counter-time-dependent excitotoxicity and inflammation, aiming to preserve tissue viability. Advanced imaging techniques, including DWI, PI, and MR angiography, are discussed for their role in evaluating ischemic penumbra evolution and guiding therapeutic decisions. By integrating molecular insights with imaging modalities, this interdisciplinary approach enhances our understanding of ischemic stroke and offers promising avenues for future research and clinical interventions to improve patient outcomes.
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Affiliation(s)
- Sana Rehman
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Arsalan Nadeem
- Department of Medicine, Allama Iqbal Medical College, Lahore 54700, Pakistan;
| | - Umar Akram
- Department of Medicine, Allama Iqbal Medical College, Lahore 54700, Pakistan;
| | - Abeer Sarwar
- Department of Medicine, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore 54000, Pakistan; (A.S.); (H.S.)
| | - Ammara Quraishi
- Department of Medicine, Dow University of Health Sciences, Karachi 74200, Pakistan;
| | - Hina Siddiqui
- Department of Medicine, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore 54000, Pakistan; (A.S.); (H.S.)
| | | | - Mehreen Nabi
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Ihtisham Ul Haq
- Department of Medicine, Amna Inayat Medical College, Sheikhupura 54300, Pakistan;
| | - Andrew Cho
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Ishan Mazumdar
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Minsoo Kim
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Kevin Chen
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Sadra Sepehri
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Richard Wang
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Aneri B. Balar
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Dhairya A. Lakhani
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
| | - Vivek S. Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; (M.N.); (A.C.); (I.M.); (M.K.); (K.C.); (S.S.); (R.W.); (A.B.B.); (D.A.L.); (V.S.Y.)
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Idiopathic atrial fibrillation patients rapidly outgrow their low thromboembolic risk: a 10-year follow-up study. Neth Heart J 2019; 27:487-497. [PMID: 30953281 PMCID: PMC6773787 DOI: 10.1007/s12471-019-1272-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background Healthy atrial fibrillation (AF) patients will eventually outgrow their low thromboembolic risk. The purpose of this study is to compare the development of cardiovascular disease in healthy AF patients as compared to healthy sinus rhythm patients and to assess appropriate anticoagulation treatment. Methods Forty-one idiopathic paroxysmal AF patients (56 ± 10 years, 66% male) were compared with 45 healthy sinus rhythm patients. Patients were free of hypertension, antihypertensive and antiarrhythmic drugs, diabetes, congestive heart failure, coronary artery or peripheral vascular disease, previous stroke, thyroid, pulmonary and renal disease, and structural abnormalities on echocardiography. Results Baseline characteristics and echocardiographic parameters were the same in both groups. During 10.7 ± 1.6 years, cardiovascular disease and all-cause death developed significantly more often in AF patients as compared to controls (63% vs 31%, log rank p < 0.001). Even after the initial 5 years of follow-up, survival curves show divergent patterns (log rank p = 0.006). Mean duration to reach a CHA2DS2-VASc score > 1 among AF patients was 5.1 ± 3.0 years. Five of 24 (21%) patients with CHA2DS2-VASc > 1 did not receive oral anticoagulation therapy at follow-up. Mean duration of over- or undertreatment with oral anticoagulation in patients with CHA2DS2-VASc > 1 was 5 ± 3.0 years. Conclusion The majority of recently diagnosed healthy AF patients develop cardiovascular diseases with a consequent change in thromboembolic risk profile within a short time frame. A comprehensive follow-up of this patient category is necessary to avoid over- and undertreatment with anticoagulants.
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Limantoro I, de Vos CB, Delhaas T, Weijs B, Blaauw Y, Schotten U, Kietselaer B, Pisters R, Crijns HJGM. Clinical correlates of echocardiographic tissue velocity imaging abnormalities of the left atrial wall during atrial fibrillation. Europace 2014; 16:1546-53. [DOI: 10.1093/europace/euu047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Folkeringa RJ, Geven LM, Veldhuis T, Hoogendoorn M, Hofma SH, Van Roon E. Practical introduction of novel oral anticoagulants through an anticoagulation nurse. The Leeuwarden model. Neth Heart J 2014; 22:297-300. [PMID: 24590768 PMCID: PMC4031353 DOI: 10.1007/s12471-014-0529-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction This paper describes the implementation of novel oral anticoagulants (NOACs) through an anticoagulation nurse. Logistics and tasks of this new function are described and preliminary data are presented. Methods Indications for NOACs are explained by the treating cardiologists. Thereafter, the patient is referred to the anticoagulation nurse before starting a NOAC. After providing a patient with information and checking the creatinine clearance, co-medication and medical history, a prescription for NOAC is made. Results In 3 months, 51 patients were referred for NOAC therapy. Mean age was 68 years, CHA2DS2-VASc score was 2.9. Renal function was impaired in 28 %. Only 63 % of the patients had an uneventful start-up. NOAC therapy was withheld or prematurely stopped in 22 %. 30 % of patients needed a reduced NOAC dose. In 37 %, the anticoagulation nurse had extended patient contact, mainly because of (presumed) side effects. Conclusion Given the number of interactions that were made using a separate patient contact through the anticoagulation nurse, this seems to be an important improvement in the quality of care and deserves further expansion.
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Affiliation(s)
- R J Folkeringa
- Department of Cardiology, Medical Centre Leeuwarden, Henry Dunantweg 2, 8934 AD, Leeuwarden, the Netherlands,
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Dinh T, Baur LHB, Pisters R, Kamp O, Verheugt FWA, Smeets JLRM, Cheriex EC, Lindeboom JE, Heesen WF, Tieleman RG, Prins MH, Crijns HJGM. Aspirin versus vitamin K antagonist treatment guided by transoesophageal echocardiography in patients with atrial fibrillation: a pilot study. Heart 2014; 100:563-8. [DOI: 10.1136/heartjnl-2013-305017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
In patients with nonvalvular atrial fibrillation, oral anticoagulation with the vitamin K antagonists acenocoumarol, phenprocoumon and warfarin reduces the risk of stroke by more than 60 %, whereas single or double antiplatelet therapy is much less effective and sometimes associated with a similar bleeding risk as vitamin K antagonists. Besides bleeding, and intracranial haemorrhage in particular, INR monitoring remains the largest drawback of vitamin K antagonists. In the last decade oral agents have been developed that directly block the activity of thrombin (factor IIa), as well as drugs that directly inhibit activated factor X (Xa), which is the first compound in the final common pathway to the activation of thrombin. These agents have been approved for stroke prevention in atrial fibrillation and are now reimbursed under a national guideline for their safe use. They have advantages in that they do not need monitoring and have a fast onset and offset of action, but lack an established specific antidote. This survey addresses the role of modern anticoagulation for stroke prevention in atrial fibrillation.
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Smit MD, Van Gelder IC. Risk-benefit ratio assessment for stroke prevention in intermediate risk atrial fibrillation patients: will TEE-based aspirin treatment fill the gap? Neth Heart J 2013; 19:212-3. [PMID: 21487742 PMCID: PMC3087023 DOI: 10.1007/s12471-011-0119-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- M D Smit
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
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Zoppo F, Brandolino G, Berton A, Frigato N, Michieletto M, Zanocco A, Zerbo F, Bacchiega E, Lupo A, Bertaglia E. Predictors of left atrium appendage clot detection despite on-target warfarin prevention for atrial fibrillation. J Interv Card Electrophysiol 2012; 35:151-8. [DOI: 10.1007/s10840-012-9707-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Accepted: 06/20/2012] [Indexed: 11/29/2022]
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Souza MVLD, Duarte MMT, Coeli CM, Vaisman M. Atrial fibrillation and hyperthyroidism: relation between transoesophageal markers of a thrombogenic milieu and clinical risk factors for thromboembolism. Clin Endocrinol (Oxf) 2012; 76:448-53. [PMID: 21950838 DOI: 10.1111/j.1365-2265.2011.04232.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED Hyperthyroidism is a questionable risk factor for thromboembolism among patients with atrial fibrillation. OBJECTIVE To correlate clinical risk factors for thromboembolism from a group of patients with atrial fibrillation related to hyperthyroidism with transoesophageal echocardiography (TOE) markers of a thrombogenic milieu. DESIGN Clinical risk factors for thromboembolism, thyroid hormonal status, time since diagnosis of hyperthyroidism and TOE markers of a thrombogenic milieu were assessed in consecutive patients with atrial fibrillation related to hyperthyroidism. The following TOE parameters were assessed to define the presence of thrombogenic milieu: dense spontaneous echo contrast, thrombi or left atrial appendage blood flow velocities <0·20 m/s. Clinical risk factors for thromboembolism were based on CHADS(2) (Cardiac failure, Hypertension, Age, Diabetes and Stroke) classification. PATIENTS This study included 31 consecutive patients aged between 18 and 65 years with atrial fibrillation related to hyperthyroidism scheduled for TOE. RESULTS Thrombogenic milieu was present in 14 of 31 (45·2%) patients. The thyroid status could not predict the presence of a thrombogenic milieu. Despite low CHADS(2) score of 0/1, 6 of 13 (46·1%) patients had a thrombogenic milieu, whereas 10 of 18 (55·6%) patients with score ≥2 had none. The probability of having a thrombogenic milieu did not correlate with the number of clinical risk factors. CONCLUSION Among patients younger than 65 years of age with atrial fibrillation related to hyperthyroidism, there is no association between clinical risk factors with TOE markers of a thrombogenic milieu. TOE adds useful information that may affect antithrombotic therapy guided by clinical risk classification.
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Affiliation(s)
- Marcus Vinicius Leitão de Souza
- Division of Endocrinology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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