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Liu WS, Zhu SF, Guo YL, Huang R, Yang X. Effect of microbubbles on transcranial doppler ultrasound-assisted intracranial recombinant tissue-type plasminogen activator thrombolysis. Vascular 2023; 31:1194-1200. [PMID: 35799413 DOI: 10.1177/17085381221079109] [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: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the effect of microbubbles on the efficacy of transcranial doppler (TCD) ultrasound-assisted thrombolytic therapy of recombinant tissue-type plasminogen activator (rt-PA). METHODS Male New Zealand white rabbits (n = 36) were randomly divided into an rt-PA group (n = 18) and an rt-PA plus microbubble group (n = 18). After the cerebral infarction model was constructed with autologous blood clots, rt-PA and rt-PA plus microbubble intervention were performed, respectively. The hemodynamic changes and infarct size of the two groups were recorded. In addition, the ELISA method was used to detect the level of nitric oxide (NO), superoxide dismutase (SOD), and malondialdehyde (MDA) in the brain tissue of the two-group graph model and high-sensitivity C-reactive protein (hs-CRP) in the serum. RESULTS In the rt-PA group, the recanalization rate was 38.9% and the average infarct size was 11.8%. In the rt-PA plus microbubble group, the recanalization rate was 66.7% and the average infarct size was 8.2%. In addition, the average values for NO, SOD, MDA, and hs-CRP were 16.48 ± 5.39 μmol/L, 730.2 ± 9.86 U/mg, 0.92 ± 0.43 nmol/mg, and 8.56 ± 1.64 mg/L in the rt-PA group, respectively, and the average values were 9.18 ± 3.37 μmol/L, 426.2 ± 6.39 U/mg, 0.73 ± 0.44 nmol/mg, and 5.23 ± 0.94 mg/L in the rt-PA plus microbubble group, respectively. CONCLUSIONS The addition of microbubbles enhanced the effects of TCD-assisted rrt-PA thrombolysis.
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Affiliation(s)
- Wei-Song Liu
- Department of Internal Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Shao-Fen Zhu
- Department of Internal Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yuan-Ling Guo
- Department of Internal Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Rong Huang
- Department of Internal Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xue Yang
- Department of Internal Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
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2
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Chen R, Du W, Zhang X, Xu R, Jiang W, Zhang C, Yang Y, Zhang H, Xie X, Song D, Yuan Y, Zhang X. Protective effects of low-intensity pulsed ultrasound (LIPUS) against cerebral ischemic stroke in mice by promoting brain vascular remodeling via the inhibition of ROCK1/p-MLC2 signaling pathway. Cereb Cortex 2023; 33:10984-10996. [PMID: 37771006 DOI: 10.1093/cercor/bhad330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/30/2023] Open
Abstract
Vascular remodeling is essential for patients with cerebral ischemic stroke (CIS). Our previous study proved that low-intensity pulsed ultrasound (LIPUS) could increase cortical hemodynamics. However, the effects and mechanisms of LIPUS on cerebral vascular remodeling after CIS are still unknown. In this study, we applied LIPUS to the mouse brain at 0.5 h after distal middle cerebral artery occlusion (dMCAO) and subsequently daily for a stimulation time of 30 min. Results showed that compared with the dMCAO group, LIPUS markedly increased cerebral blood flow (CBF), reduced brain swelling, and improved functional recovery at day 3 after CIS. LIPUS promoted leptomeningeal vasculature remodeling, enlarged vascular diameter, and increased the average vessel length and density at day 3 after CIS. Proteomic analysis highlighted that LIPUS mainly participated in the regulation of actin cytoskeleton pathway. Rho kinase 1 (ROCK1) was downregulated by LIPUS and participated in regulation of actin cytoskeleton. Subsequently, we verified that ROCK1 was mainly expressed in pericytes. Furthermore, we demonstrated that LIPUS inhibited ROCK1/p-MLC2 signaling pathway after CIS, which had positive effects on vascular remodeling and cerebral blood circulation. In conclusion, our preliminary study revealed the vascular remodeling effects and mechanism of LIPUS in CIS, provided evidence for potential clinical application of LIPUS.
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Affiliation(s)
- Rong Chen
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, China
- Hebei Key Laboratory of Vascular Homeostasis and Hebei Collaborative Innovation Center for Cardio-Cerebrovascular Disease, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neurology (Hebei Medical University), Ministry of Education, Shijiazhuang, Hebei 050000, China
| | - Wei Du
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, China
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Xiao Zhang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, China
- Hebei Key Laboratory of Vascular Homeostasis and Hebei Collaborative Innovation Center for Cardio-Cerebrovascular Disease, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neurology (Hebei Medical University), Ministry of Education, Shijiazhuang, Hebei 050000, China
| | - Renhao Xu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, China
- Hebei Key Laboratory of Vascular Homeostasis and Hebei Collaborative Innovation Center for Cardio-Cerebrovascular Disease, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neurology (Hebei Medical University), Ministry of Education, Shijiazhuang, Hebei 050000, China
| | - Wei Jiang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, China
- Hebei Key Laboratory of Vascular Homeostasis and Hebei Collaborative Innovation Center for Cardio-Cerebrovascular Disease, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neurology (Hebei Medical University), Ministry of Education, Shijiazhuang, Hebei 050000, China
| | - Cong Zhang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, China
- Hebei Key Laboratory of Vascular Homeostasis and Hebei Collaborative Innovation Center for Cardio-Cerebrovascular Disease, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neurology (Hebei Medical University), Ministry of Education, Shijiazhuang, Hebei 050000, China
| | - Yi Yang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, China
- Hebei Key Laboratory of Vascular Homeostasis and Hebei Collaborative Innovation Center for Cardio-Cerebrovascular Disease, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neurology (Hebei Medical University), Ministry of Education, Shijiazhuang, Hebei 050000, China
| | - Huiran Zhang
- Department of Biological Pharmacy, Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Xiaoli Xie
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, China
| | - Degang Song
- Department of Neurology, First Hospital of Qinhuangdao, Hebei Medical University, No. 258, Wenhua Road, Qinhuangdao, Hebei 066000, China
| | - Yi Yuan
- School of Electrical Engineering, Key Laboratory of Intelligent Rehabilitation and Neuromodulation of Hebei Province, Yanshan University, Qinhuangdao, Hebei 066004, China
| | - Xiangjian Zhang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, China
- Hebei Key Laboratory of Vascular Homeostasis and Hebei Collaborative Innovation Center for Cardio-Cerebrovascular Disease, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neurology (Hebei Medical University), Ministry of Education, Shijiazhuang, Hebei 050000, China
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Davis CM, Ammi AY, Zhu W, Methner C, Cao Z, Giraud D, Alkayed NJ, Woltjer RL, Kaul S. Low-Intensity Ultrasound Reduces Brain Infarct Size by Upregulating Phosphorylated Endothelial Nitric Oxide in Mouse Model of Middle Cerebral Artery Occlusion. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:1091-1101. [PMID: 36739244 PMCID: PMC10050145 DOI: 10.1016/j.ultrasmedbio.2022.12.008] [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: 09/27/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 05/11/2023]
Abstract
OBJECTIVE There have been attempts to use therapeutic ultrasound (US) for the treatment of both experimental and clinical stroke. We hypothesized that low-intensity US has direct beneficial effects on the brain independent of cerebral blood flow (CBF) during middle cerebral artery occlusion (MCAO). METHODS Three groups of mice were studied. Group I included 84 mice with MCAO undergoing US treatment/no treatment at two US frequencies (0.25 and 1.05 MHz) with three different acoustic pressures at each frequency in which infarct size (IS) was measured 24 h later. Group II included 11 mice undergoing treatment based on best US results from group I animals in which the IS/risk area (RA) ratio was measured 24 h later. Group III included 38 normal mice undergoing US treatment/no treatment for assessment of CBF, tissue metabolite and protein expression and histopathology. DISCUSSION Ultrasound at both frequencies and most acoustic pressures resulted in reduction in IS in group I animals, with the best results obtained with 0.25 MHz at 2.0 MPa: IS was reduced 4-fold in the cerebral cortex, 1.5-fold in the caudate putamen and 3.5-fold in the cerebral hemisphere compared with control. US application in group III animals elicited only a marginal increase in CBF despite a 2.6-fold increase in phosphorylated endothelial nitric oxide synthase (p-eNOS)-S1177 and a corresponding decrease in p-eNOS-T494. Histopathology revealed no evidence of hemorrhage, inflammation or necrosis. CONCLUSION Low-intensity US at specific frequencies and acoustic pressures results in marked neuroprotection in a mouse model of stroke by modulation of p-eNOS independent of its effect on CBF.
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Affiliation(s)
- Catherine M Davis
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA; Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Azzdine Y Ammi
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Wenbin Zhu
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Carmen Methner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Zhiping Cao
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA; Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - David Giraud
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Nabil J Alkayed
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA; Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Randy L Woltjer
- Department of Pathology, Oregon Health & Science University, Portland, OR, USA
| | - Sanjiv Kaul
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
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4
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The Role of Ultrasound as a Diagnostic and Therapeutic Tool in Experimental Animal Models of Stroke: A Review. Biomedicines 2021; 9:biomedicines9111609. [PMID: 34829837 PMCID: PMC8615437 DOI: 10.3390/biomedicines9111609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/25/2021] [Accepted: 11/01/2021] [Indexed: 11/18/2022] Open
Abstract
Ultrasound is a noninvasive technique that provides real-time imaging with excellent resolution, and several studies demonstrated the potential of ultrasound in acute ischemic stroke monitoring. However, only a few studies were performed using animal models, of which many showed ultrasound to be a safe and effective tool also in therapeutic applications. The full potential of ultrasound application in experimental stroke is yet to be explored to further determine the limitations of this technique and to ensure the accuracy of translational research. This review covers the current status of ultrasound applied to monitoring and treatment in experimental animal models of stroke and examines the safety, limitations, and future perspectives.
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5
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Bonow RH, Silber JR, Enzmann DR, Beauchamp NJ, Ellenbogen RG, Mourad PD. Towards use of MRI-guided ultrasound for treating cerebral vasospasm. J Ther Ultrasound 2016; 4:6. [PMID: 26929821 PMCID: PMC4770693 DOI: 10.1186/s40349-016-0050-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 02/19/2016] [Indexed: 12/23/2022] Open
Abstract
Cerebral vasospasm is a major cause of morbidity and mortality in patients with subarachnoid hemorrhage (SAH), causing delayed neurological deficits in as many as one third of cases. Existing therapy targets induction of cerebral vasodilation through use of various drugs and mechanical means, with a range of observed efficacy. Here, we perform a literature review supporting our hypothesis that transcranially delivered ultrasound may have the ability to induce therapeutic cerebral vasodilation and, thus, may one day be used therapeutically in the context of SAH. Prior studies demonstrate that ultrasound can induce vasodilation in both normal and vasoconstricted blood vessels in peripheral tissues, leading to reduced ischemia and cell damage. Among the proposed mechanisms is alteration of several nitric oxide (NO) pathways, where NO is a known vasodilator. While in vivo studies do not point to a specific physical mechanism, results of in vitro studies favor cavitation induction by ultrasound, where the associated shear stresses likely induce NO production. Two papers discussed the effects of ultrasound on the cerebral vasculature. One study applied clinical transcranial Doppler ultrasound to a rodent complete middle cerebral artery occlusion model and found reduced infarct size. A second involved the application of pulsed ultrasound in vitro to murine brain endothelial cells and showed production of a variety of vasodilatory chemicals, including by-products of arachidonic acid metabolism. In sum, nine reviewed studies demonstrated evidence of either cerebrovascular dilation or elaboration of vasodilatory compounds. Of particular interest, all of the reviewed studies used ultrasound capable of transcranial application: pulsed ultrasound, with carrier frequencies ranging between 0.5 and 2.0 MHz, and intensities not substantially above FDA-approved intensity values. We close by discussing potential specific treatment paradigms of SAH and other cerebral ischemic disorders based on MRI-guided transcranial ultrasound.
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Affiliation(s)
- Robert H Bonow
- Department of Neurological Surgery, University of Washington, 325 9th Ave, Box 359924, Seattle, WA 98104 USA
| | - John R Silber
- Department of Neurological Surgery, University of Washington, 325 9th Ave, Box 359924, Seattle, WA 98104 USA
| | - Dieter R Enzmann
- Department of Radiology, University of California Los Angeles, 924 Westwood Blvd. Suite 805, Los Angeles, CA 90024 USA
| | - Norman J Beauchamp
- Department of Radiology, University of Washington, RR-218 Health Science Building, 1959 NE Pacific St, Seattle, WA 98195 USA
| | - Richard G Ellenbogen
- Department of Neurological Surgery, University of Washington, 325 9th Ave, Box 359924, Seattle, WA 98104 USA
| | - Pierre D Mourad
- Department of Neurological Surgery, University of Washington, 325 9th Ave, Box 359924, Seattle, WA 98104 USA ; Department of Radiology, University of Washington, RR-218 Health Science Building, 1959 NE Pacific St, Seattle, WA 98195 USA ; Division of Engineering, University of Washington, 18115 Campus Way NE, Bothell, WA 98011 USA
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6
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Abstract
Stroke is the second leading cause of global mortality after coronary heart disease, and a major cause of neurological disability. About 17 million strokes occur worldwide each year. Patients with stroke often require long-term rehabilitation following the acute phase, with ongoing support from the community and nursing home care. Thus, stroke is a devastating disease and a major economic burden on society. In this overview, we discuss current strategies for specific treatment of stroke in the acute phase, focusing on intravenous thrombolysis and mechanical thrombectomy. We will consider two important issues related to intravenous thrombolysis treatments: (i) how to shorten the delay between stroke onset and treatment and (ii) how to reduce the risk of symptomatic intracerebral haemorrhage. Intravenous thrombolysis has been approved treatment for acute ischaemic stroke in most countries for more than 10 years, with rapid development towards new treatment strategies during that time. Mechanical thrombectomy using a new generation of endovascular tools, stent retrievers, is found to improve functional outcome in combination with pharmacological thrombolysis when indicated. There is an urgent need to increase public awareness of how to recognize a stroke and seek immediate attention from the healthcare system, as well as shorten delays in prehospital and within-hospital settings.
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Affiliation(s)
- R Mikulik
- International Clinical Research Center, Department of Neurology, St. Anne's University Hospital in Brno, Brno, Czech Republic.,Masaryk University, Brno, Czech Republic
| | - N Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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Schellinger PD, Alexandrov AV, Barreto AD, Demchuk AM, Tsivgoulis G, Kohrmann M, Alleman J, Howard V, Howard G, Alexandrov AW, Brandt G, Molina CA. Combined Lysis of Thrombus with Ultrasound and Systemic Tissue Plasminogen Activator for Emergent Revascularization in Acute Ischemic Stroke (Clotbust-ER): Design and Methodology of a Multinational Phase 3 Trial. Int J Stroke 2015; 10:1141-8. [DOI: 10.1111/ijs.12536] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 04/22/2015] [Indexed: 11/26/2022]
Abstract
Background We designed a Phase 3 clinical trial to determine the safety and efficacy of adding transcranial ultrasound using an operator-independent headframe to recombinant tissue-plasminogen-activator for the treatment of acute ischemic stroke. Methods Combined lysis of thrombus with ultrasound and systemic tissue-plasminogen-activator for emergent revascularization in acute ischemic stroke is a randomized, double-blind, placebo-controlled clinical trial that will enroll subjects with the following main inclusion criteria: less than 4·5 hours from symptom onset (three-hours in US and Canada), age 18–80 years, baseline National Institutes of Health Stroke Scale score ≥ 10, and premorbid modified-Rankin-score of 0–1, eligibility for full dose recombinant tissue-plasminogen-activator. Subjects will receive two-hours of 2-MHz pulsed wave transcranial ultrasound (target group) or sham ultrasound (control group). The projected sample size is approximately 824 subjects. Results The primary endpoint, based on intention-to-treat criteria of patients enrolled within three-hours of symptom onset is the comparison between target and control groups of modified-Rankin-score scores at day 90 poststroke assessed using the proportional odds method. The study will have two planned interim analyses after approximately one-third and two-thirds of subjects have reached the 90-day modified-Rankin-score evaluation. Safety outcomes are symptomatic intracranial hemorrhage within 24 h and an overall analysis of adverse events. Conclusions Since intravenous recombinant tissue-plasminogen-activator remains the only medical therapy to reverse ischemic stroke applicable in the emergency department, our trial will determine if the additional use of transcranial ultrasound improves functional outcomes in patients with severe acute ischemic stroke (NCT#01098981).
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Affiliation(s)
- Peter D. Schellinger
- Departments of Neurology and Geriatry, Johannes Wesling Medical Center, Minden, Germany
| | - Andrei V. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew D. Barreto
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Andrew M. Demchuk
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
- Second Department of Neurology, ‘Attikon’ University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Martin Kohrmann
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | | | | | - George Howard
- University of Alabama at Birmingham, Birmingham, AL, UK
| | - Anne W. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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8
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Barlinn K, Tsivgoulis G, Barreto AD, Alleman J, Molina CA, Mikulik R, Saqqur M, Demchuk AM, Schellinger PD, Howard G, Alexandrov AV. Outcomes following sonothrombolysis in severe acute ischemic stroke: subgroup analysis of the CLOTBUST trial. Int J Stroke 2014; 9:1006-10. [PMID: 25079049 PMCID: PMC4227933 DOI: 10.1111/ijs.12340] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 05/20/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sonothrombolysis is safe and may increase the likelihood of early recanalization in acute ischemic stroke patients. AIMS In preparation of a phase III clinical trial, we contrast the likelihood of achieving a sustained recanalization and functional independence in a post hoc subgroup analysis of patients randomized to transcranial Doppler monitoring plus intravenous tissue plasminogen activator (sonothrombolysis) compared with intravenous tissue plasminogen activator alone in the CLOTBUST trial. METHODS We analyzed the data from all randomized acute ischemic stroke patients with pretreatment National Institutes of Health Stroke Scale scores ≥ 10 points and proximal intracranial occlusions in the CLOTBUST trial. We compared sustained complete recanalization rate (Thrombolysis in Brain Ischemia flow grades 4-5) and functional independence (modified Rankin Scale 0-1) at 90 days. Safety was evaluated by the rate of symptomatic intracranial hemorrhage within 72 h of stroke onset. RESULTS Of 126 patients, a total of 85 acute ischemic stroke patients met our inclusion criteria: mean age 71 ± 11years, 56% men, median National Institutes of Health Stroke Scale 17 (interquartile range 14-20). Of these patients, 41 (48%) and 44 (52%) were randomized to intravenous tissue plasminogen activator alone and sonothrombolysis, respectively. More patients achieved sustained complete recanalization in the sonothrombolysis than in the intravenous tissue plasminogen activator alone group (38·6% vs. 17·1%; P = 0·032). Functional independence at 90 days was more frequently achieved in the sonothrombolysis than in the intravenous tissue plasminogen activator alone group (37·2% vs. 15·8%; P = 0·045). Symptomatic intracranial hemorrhage rate was similar in both groups (4·9% vs. 4·6%; P = 1·00). CONCLUSIONS Our results point to a signal of efficacy and provide information to guide the subsequent phase III randomized trial of sonothrombolysis in patients with severe ischemic strokes.
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Affiliation(s)
- Kristian Barlinn
- Dresden University Stroke Center,Department of Neurology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Georgios Tsivgoulis
- Department of Neurology,The University of Tennessee Health Science Center, Memphis, TN, USA
- Second Department of Neurology,School of Medicine, Attikon Hospital, University of Athens, Greece
- International Clinical Research Centre,Neurology department, St. Anne's University Hospital in Brno and Masaryk University, Czech Republic
| | | | | | - Carlos A Molina
- Neurovascular Unit, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Robert Mikulik
- International Clinical Research Centre,Neurology department, St. Anne's University Hospital in Brno and Masaryk University, Czech Republic
| | - Maher Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew M Demchuk
- University of Calgary, Department of Clinical Neurosciences, Calgary Stroke Program, Canada
| | | | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, USA
| | - Andrei V. Alexandrov
- Department of Neurology,The University of Tennessee Health Science Center, Memphis, TN, USA
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9
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Abstract
OPINION STATEMENT Acute ischemic stroke remains one of the most devastating diseases when it comes to morbidity and mortality, not to mention the personal and economic burden that occurs in long-term. Intravenous thrombolysis with tissue plasminogen activator (tPA) is the only effective acute stroke therapy that improves outcome if given up to 4.5 hours from symptom onset. However, recanalization rates are meager and the majority of treated patients still have residual disability after stroke, emphasizing the need for further treatment options that may facilitate or even rival the only approved therapy. Sonothrombolysis, the adjuvant continuous ultrasound sonication of an intra-arterial occlusive thrombus during thrombolysis, enhances the clot-dissolving capabilities of intravenous tPA presumably by delivering acoustic pressure to the target brain vessel. Higher recanalization rates produce a trend towards better functional outcomes that could be safely achieved with the combination of high-frequency ultrasound and intravenous tPA. However, data on ultrasound targeting of intracranial proximal occlusive lesions other than those in the middle cerebral arteries are sparse. Moreover, recent sonothrombolysis trials were exclusively conducted with operator-dependent hand-held technology hindering its further testing in clinical sonothrombolysis trials. An operator-independent 2-MHz transcranial Doppler device has been developed allowing health care professionals not formally trained in ultrasound apparatus to provide therapeutic ultrasound as needed. Currently, this operator-independent device covering 12 proximal intracranial segments that most commonly contain thrombo-embolic occlusions enters testing in a pivotal multicenter sonothrombolysis efficacy trial. If this trial demonstrates safety and efficacy, adjuvants, such as gaseous microbubbles that further potentiate the thrombolytic effect of intravenous tPA, could be tested along with this device.
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10
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Alexandrov AV, Barlinn K. Taboos and opportunities in sonothrombolysis for stroke. Int J Hyperthermia 2012; 28:397-404. [PMID: 22621740 DOI: 10.3109/02656736.2012.674621] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Systemic thrombolysis with tissue plasminogen activator (tPA) is the only approved treatment for acute ischaemic stroke that improves functional outcome if given up to 4.5 h from symptom onset. At least half of treated patients have unfavourable outcomes long-term though, emphasising the need to amplify the only approved acute stroke therapy. Ultrasound targeting of an intra-arterial occlusive clot and delivering mechanical pressure to its surrounding fluids (referred to as sonothrombolysis) accelerates the thrombolytic effect of tPA. Higher recanalisation rates produce a trend towards better functional outcomes that could be safely achieved with the combination of 2 MHz frequency ultrasound and systemic tPA. To further accelerate the clot-dissolving effect of ultrasound, a variety of frequencies and intensities as well as other adjuvant treatment elements are being studied. However, literature reports argue efficacy and safety of these novel approaches doubting promptly translation into the clinical practice. This review will summarise our current knowledge about potentially harmful (taboos) directions and what we think are promising avenues for these future stroke therapies. We also give a prospect for novel technologies such as operator-independent devices that aim to further spread the use of sonothrombolysis for stroke.
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Affiliation(s)
- Andrei V Alexandrov
- Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, Alabama, USA.
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