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Koukalova L, Chmelova M, Amlerova Z, Vargova L. Out of the core: the impact of focal ischemia in regions beyond the penumbra. Front Cell Neurosci 2024; 18:1336886. [PMID: 38504666 PMCID: PMC10948541 DOI: 10.3389/fncel.2024.1336886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/08/2024] [Indexed: 03/21/2024] Open
Abstract
The changes in the necrotic core and the penumbra following induction of focal ischemia have been the focus of attention for some time. However, evidence shows, that ischemic injury is not confined to the primarily affected structures and may influence the remote areas as well. Yet many studies fail to probe into the structures beyond the penumbra, and possibly do not even find any significant results due to their short-term design, as secondary damage occurs later. This slower reaction can be perceived as a therapeutic opportunity, in contrast to the ischemic core defined as irreversibly damaged tissue, where the window for salvation is comparatively short. The pathologies in remote structures occur relatively frequently and are clearly linked to the post-stroke neurological outcome. In order to develop efficient therapies, a deeper understanding of what exactly happens in the exo-focal regions is necessary. The mechanisms of glia contribution to the ischemic damage in core/penumbra are relatively well described and include impaired ion homeostasis, excessive cell swelling, glutamate excitotoxic mechanism, release of pro-inflammatory cytokines and phagocytosis or damage propagation via astrocytic syncytia. However, little is known about glia involvement in post-ischemic processes in remote areas. In this literature review, we discuss the definitions of the terms "ischemic core", "penumbra" and "remote areas." Furthermore, we present evidence showing the array of structural and functional changes in the more remote regions from the primary site of focal ischemia, with a special focus on glia and the extracellular matrix. The collected information is compared with the processes commonly occurring in the ischemic core or in the penumbra. Moreover, the possible causes of this phenomenon and the approaches for investigation are described, and finally, we evaluate the efficacy of therapies, which have been studied for their anti-ischemic effect in remote areas in recent years.
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Affiliation(s)
- Ludmila Koukalova
- Department of Neuroscience, Second Faculty of Medicine, Charles University, Prague, Czechia
| | - Martina Chmelova
- Department of Neuroscience, Second Faculty of Medicine, Charles University, Prague, Czechia
- Department of Cellular Neurophysiology, Institute of Experimental Medicine of the Czech Academy of Sciences, Prague, Czechia
| | - Zuzana Amlerova
- Department of Neuroscience, Second Faculty of Medicine, Charles University, Prague, Czechia
| | - Lydia Vargova
- Department of Neuroscience, Second Faculty of Medicine, Charles University, Prague, Czechia
- Department of Cellular Neurophysiology, Institute of Experimental Medicine of the Czech Academy of Sciences, Prague, Czechia
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2
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Abstract
The discovery that brain tissue could potentially be salvaged from ischaemia due to stroke, has led to major advances in the development of therapies for ischemic stroke. In this review, we detail the advances in the understanding of this area termed the ischaemic penumbra, from its discovery to the evolution of imaging techniques, and finally some of the treatments developed. Evolving from animal studies from the 70s and 80s and translated to clinical practice, the field of ischemic reperfusion therapy has largely been guided by an array of imaging techniques developed to positively identify the ischemic penumbra, including positron emission tomography, computed tomography and magnetic resonance imaging. More recently, numerous penumbral identification imaging studies have allowed for a better understanding of the progression of the ischaemic core at the expense of the penumbra, and identification of patients than can benefit from reperfusion therapies in the acute phase. Importantly, 40 years of critical imaging research on the ischaemic penumbra have allowed for considerable extension of the treatment time window and better patient selection for reperfusion therapy. The translation of the penumbra concept into routine clinical practice has shown that "tissue is at least as important as time."
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Affiliation(s)
- Charlotte M Ermine
- Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - Andrew Bivard
- Department of Medicine, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Australia.,Department of Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Australia
| | - Mark W Parsons
- Department of Medicine, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Australia.,Department of Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Australia
| | - Jean-Claude Baron
- Institute of Psychiatry and Neuroscience of Paris (IPNP), Université de Paris, Paris, France.,GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte Anne, Paris, France
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3
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Endovascular stroke treatment using balloon guide catheters may reduce penumbral tissue damage and improve long-term outcome. Eur Radiol 2020; 31:2191-2198. [PMID: 33037911 PMCID: PMC7979594 DOI: 10.1007/s00330-020-07260-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/01/2020] [Accepted: 09/04/2020] [Indexed: 12/27/2022]
Abstract
Objectives During mechanical recanalization of large vessel occlusions (LVO), the use of proximal flow arrest with balloon guide catheters (BGC) was shown to be associated with better angiographic and even clinical outcome. The aim of the study was to analyze the impact of BGC use on microstructural alterations in the salvaged penumbra. Methods All patients who underwent mechanical recanalization of LVO of the anterior circulation were reviewed within a prospective stroke registry of a single comprehensive stroke center. Fifty-two patients received an admission CT perfusion together with post-interventional diffusion tensor imaging. Technical details such as BGC usage were correlated with microstructural integrity changes of the salvaged gray matter through the mean diffusivity (MD) index. Moderation analysis was performed to test the interaction of BGC on the correlation between angiographic and clinical outcomes. Results For all patients with complete reperfusion, microstructural integrity changes with lowered MD index were found within the salvaged penumbra for cases of non-BGC usage (mean − 0.02) compared to cases with BGC usage (0.01, p = 0.04). The importance of complete reperfusion for good clinical outcome is predominantly based on patients treated with BGC (effect 2.78, p = 0.01 vs. for non-BGC: 0.3, p = 0.71). Conclusions The lowered MD index early after mechanical recanalization without BGC usage can be interpreted as microstructural ischemic damage of the salvaged penumbra. It was shown that achieving complete reperfusion in a setting of BGC usage with proximal flow arrest minimizes penumbral damage and improves long-term outcomes. Key Points • Microstructural ischemic damage can be reduced by using proximal flow arrest during endovascular treatment with balloon guide catheter. • Complete reperfusion in a setting of balloon guide catheter minimizes penumbral damage and improves long-term outcome. Electronic supplementary material The online version of this article (10.1007/s00330-020-07260-3) contains supplementary material, which is available to authorized users.
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Mulder IA, Holswilder G, van Walderveen MAA, van der Schaaf IC, Bennink E, Horsch AD, Kappelle LJ, Velthuis BK, Dankbaar JW, Terwindt GM, Schonewille WJ, Visser MC, Ferrari MD, Algra A, Wermer MJH. Stroke progression and clinical outcome in ischemic stroke patients with a history of migraine. Int J Stroke 2019; 14:946-955. [DOI: 10.1177/1747493019851288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Patients with migraine might be more susceptible of spreading depolarizations, which are known to affect vascular and neuronal function and penumbra recovery after stroke. We investigated whether these patients have more severe stroke progression and less favorable outcomes after recanalization therapy. Methods We included patients from a prospective multicenter ischemic stroke cohort. Lifetime migraine history was based on the International Classification of Headache Disorders II criteria. Patients without confirmed migraine diagnosis were excluded. Patients underwent CT angiography and CT perfusion <9 h of onset and follow-up CT after three days. On admission, presence of a perfusion deficit, infarct core and penumbra volume, and blood brain barrier permeability (BBBP) were assessed. At follow-up we assessed malignant edema, hemorrhagic transformation, and final infarct volume. Outcome at three months was evaluated with the modified Rankin Scale (mRS). We calculated adjusted relative risks (aRR) or difference of means (aB) with regression analyses. Results We included 600 patients of whom 43 had migraine. There were no differences between patients with or without migraine in presence of a perfusion deficit on admission (aRR: 0.98, 95%CI: 0.77–1.25), infarct core volume (aB: -10.8, 95%CI: -27.04–5.51), penumbra volume (aB: -11.6, 95%CI: -26.52–3.38), mean blood brain barrier permeability (aB: 0.08, 95%CI: -3.11–2.96), malignant edema (0% vs. 5%), hemorrhagic transformation (aRR: 0.26, 95%CI: 0.04–1.73), final infarct volume (aB: -14.8, 95%CI: 29.9–0.2) or outcome after recanalization therapy (mRS > 2, aRR: 0.50, 95%CI: 0.21–1.22). Conclusion Elderly patients with a history of migraine do not seem to have more severe stroke progression and have similar treatment outcomes compared with patients without migraine.
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Affiliation(s)
- Inge A Mulder
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ghislaine Holswilder
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Edwin Bennink
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Alexander D Horsch
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - L Jaap Kappelle
- Department of Neurology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jan Willem Dankbaar
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Marieke C Visser
- Department of Neurology, VU Medical Center, Amsterdam, the Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ale Algra
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Neurology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marieke JH Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
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Docosanoids Promote Neurogenesis and Angiogenesis, Blood-Brain Barrier Integrity, Penumbra Protection, and Neurobehavioral Recovery After Experimental Ischemic Stroke. Mol Neurobiol 2018; 55:7090-7106. [PMID: 29858774 DOI: 10.1007/s12035-018-1136-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 05/18/2018] [Indexed: 02/07/2023]
Abstract
Docosahexaenoic acid (DHA) and neuroprotectin D1 (NPD1) are neuroprotective after experimental ischemic stroke. To explore underlying mechanisms, SD rats underwent 2 h of middle cerebral artery occlusion (MCAo) and treated with DHA (5 mg/kg, IV) or NPD1 (5 μg/per rat, ICV) and vehicles 1 h after. Neuro-behavioral assessments was conducted on days 1, 2, and 3, and on week 1, 2, 3, or 4. BrdU was injected on days 4, 5, and 6, immunohistochemistry was performed on week 2 or 4, MRI on day 7, and lipidomic analysis at 4 and 5 h after onset of stroke. DHA improved short- and long-term behavioral functions and reduced cortical, subcortical, and total infarct volumes (by 42, 47, and 31%, respectively) after 2 weeks and reduced tissue loss by 50% after 4 weeks. DHA increased the number of BrdU+/Ki-67+, BrdU+/DCX+, and BrdU+/NeuN+ cells in the cortex, subventricular zone, and dentate gyrus and potentiated NPD1 synthesis in the penumbra at 5 h after MCAo. NPD1 improved behavior, reduced lesion volumes, protected ischemic penumbra, increased NeuN, GFAP, SMI-71-positive cells and vessels, axonal regeneration in the penumbra, and attenuated blood-brain barrier (BBB) after MCAo. We conclude that docosanoid administration increases neurogenesis and angiogenesis, activates NPD1 synthesis in the penumbra, and diminishes BBB permeability, which correlates to long-term neurobehavioral recovery after experimental ischemic stroke.
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Efrati S, Hadanny A, Daphna-Tekoah S, Bechor Y, Tiberg K, Pik N, Suzin G, Lev-Wiesel R. Recovery of Repressed Memories in Fibromyalgia Patients Treated With Hyperbaric Oxygen - Case Series Presentation and Suggested Bio-Psycho-Social Mechanism. Front Psychol 2018; 9:848. [PMID: 29896150 PMCID: PMC5987035 DOI: 10.3389/fpsyg.2018.00848] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 05/11/2018] [Indexed: 12/15/2022] Open
Abstract
Fibromyalgia Syndrome (FMS) is a condition considered to represent a prototype of central sensitization syndrome, characterized by chronic widespread pain and along with symptoms of fatigue, non-restorative sleep and cognitive difficulties. FMS can be induced by trauma, infection or emotional stress with cumulative evidence that dissociation is relatively frequent in FMS patients. Two randomized controlled trials have shown that hyperbaric oxygen therapy (HBOT) can induce neuroplasticity and be effective in patients suffering from FMS. In this paper we present, for the first time, case series of female fibromyalgia patients who, in the course of HBOT, suddenly recalled repressed traumatic memories of childhood sexual abuse (CSA). The surfacing of the repressed (dissociative) memories decades after the sexual abuse events was sudden and utterly surprising. No psychological intervention was involved. As the memories surfaced, the physical pain related to FMS subsided. In one patient who had brain single photon emission CT (SPECT) before and after HBOT, the prefrontal cortex appeared suppressed before and reactivated after. The 3 cases reported in this article are representative of a total of nine fibromyalgia patients who experienced a retrieval of repressed memory during HBOT. These cases provide insights on dissociative amnesia and suggested mechanism hypothesis that is further discussed in the article. Obviously, prospective studies cannot be planned since patients are not aware of their repressed memories. However, it is very important to keep in mind the possibility of surfacing memories when treating fibromyalgia patients with HBOT or other interventions capable of awakening dormant brain regions.
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Affiliation(s)
- Shai Efrati
- Sagol Center for Hyperbaric Medicine and Research, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Amir Hadanny
- Sagol Center for Hyperbaric Medicine and Research, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shir Daphna-Tekoah
- Ashkelon Academic College, Ashkelon, Israel.,Social Work Department, Kaplan Medical Center, Rehovot, Israel
| | - Yair Bechor
- Sagol Center for Hyperbaric Medicine and Research, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Kobi Tiberg
- Department of Psychology, Loewenstein Hospital Rehabilitation Center, Raanana, Israel
| | - Nimrod Pik
- Psychiatric Services, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Gil Suzin
- Sagol Center for Hyperbaric Medicine and Research, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Rachel Lev-Wiesel
- The Emili Sagol CAT Research Center, Graduate School of Creative Arts Therapies, University of Haifa, Haifa, Israel
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7
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Sommer CJ. Ischemic stroke: experimental models and reality. Acta Neuropathol 2017; 133:245-261. [PMID: 28064357 PMCID: PMC5250659 DOI: 10.1007/s00401-017-1667-0] [Citation(s) in RCA: 344] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/31/2016] [Accepted: 01/01/2017] [Indexed: 12/11/2022]
Abstract
The vast majority of cerebral stroke cases are caused by transient or permanent occlusion of a cerebral blood vessel (“ischemic stroke”) eventually leading to brain infarction. The final infarct size and the neurological outcome depend on a multitude of factors such as the duration and severity of ischemia, the existence of collateral systems and an adequate systemic blood pressure, etiology and localization of the infarct, but also on age, sex, comorbidities with the respective multimedication and genetic background. Thus, ischemic stroke is a highly complex and heterogeneous disorder. It is immediately obvious that experimental models of stroke can cover only individual specific aspects of this multifaceted disease. A basic understanding of the principal molecular pathways induced by ischemia-like conditions comes already from in vitro studies. One of the most frequently used in vivo models in stroke research is the endovascular suture or filament model in rodents with occlusion of the middle cerebral artery (MCA), which causes reproducible infarcts in the MCA territory. It does not require craniectomy and allows reperfusion by withdrawal of the occluding filament. Although promptly restored blood flow is far from the pathophysiology of spontaneous human stroke, it more closely mimics the therapeutic situation of mechanical thrombectomy which is expected to be increasingly applied to stroke patients. Direct transient or permanent occlusion of cerebral arteries represents an alternative approach but requires craniectomy. Application of endothelin-1, a potent vasoconstrictor, allows induction of transient focal ischemia in nearly any brain region and is frequently used to model lacunar stroke. Circumscribed and highly reproducible cortical lesions are characteristic of photothrombotic stroke where infarcts are induced by photoactivation of a systemically given dye through the intact skull. The major shortcoming of this model is near complete lack of a penumbra. The two models mimicking human stroke most closely are various embolic stroke models and spontaneous stroke models. Closeness to reality has its price and goes along with higher variability of infarct size and location as well as unpredictable stroke onset in spontaneous models versus unpredictable reperfusion in embolic clot models.
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Affiliation(s)
- Clemens J Sommer
- Institute of Neuropathology, University Medical Center of the Johannes Gutenberg-University Mainz; Focus Program Translational Neuroscience (FTN) and Rhine Main Neuroscience Network (rmn2), Langenbeckstrasse 1, 55131, Mainz, Germany.
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8
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The emerging role of signal transducer and activator of transcription 3 in cerebral ischemic and hemorrhagic stroke. Prog Neurobiol 2016; 137:1-16. [DOI: 10.1016/j.pneurobio.2015.11.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 10/13/2015] [Accepted: 11/18/2015] [Indexed: 01/05/2023]
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Lindsberg PJ, Pekkola J, Strbian D, Sairanen T, Mattle HP, Schroth G. Time window for recanalization in basilar artery occlusion. Neurology 2015; 85:1806-15. [DOI: 10.1212/wnl.0000000000002129] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Lioutas VA, Alfaro-Martinez F, Bedoya F, Chung CC, Pimentel DA, Novak V. Intranasal Insulin and Insulin-Like Growth Factor 1 as Neuroprotectants in Acute Ischemic Stroke. Transl Stroke Res 2015; 6:264-75. [PMID: 26040423 DOI: 10.1007/s12975-015-0409-7] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 04/16/2015] [Accepted: 05/13/2015] [Indexed: 12/22/2022]
Abstract
Treatment options for stroke remain limited. Neuroprotective therapies, in particular, have invariably failed to yield the expected benefit in stroke patients, despite robust theoretical and mechanistic background and promising animal data. Insulin and insulin-like growth factor 1 (IGF-1) play a pivotal role in critical brain functions, such as energy homeostasis, neuronal growth, and differentiation. They may exhibit neuroprotective properties in acute ischemic stroke based upon their vasodilatory, anti-inflammatory and antithrombotic effects, as well as improvements of functional connectivity, neuronal metabolism, neurotransmitter regulation, and remyelination. Intranasally administered insulin has demonstrated a benefit for prevention of cognitive decline in older people, and IGF-1 has shown potential benefit to improve functional outcomes in animal models of acute ischemic stroke. The intranasal route presents a feasible, tolerable, safe, and particularly effective administration route, bypassing the blood-brain barrier and maximizing distribution to the central nervous system (CNS), without the disadvantages of systemic side effects and first-pass metabolism. This review summarizes the neuroprotective potential of intranasally administered insulin and IGF-1 in stroke patients. We present the theoretical background and pathophysiologic mechanisms, animal and human studies of intranasal insulin and IGF-1, and the safety and feasibility of intranasal route for medication administration to the CNS.
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Affiliation(s)
- Vasileios-Arsenios Lioutas
- Department of Neurology, Division of Cerebrovascular Diseases, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Palmer 127, Boston, MA, 02215, USA,
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Zhang X, Tong F, Li CX, Yan Y, Nair G, Nagaoka T, Tanaka Y, Zola S, Howell L. A fast multiparameter MRI approach for acute stroke assessment on a 3T clinical scanner: preliminary results in a non-human primate model with transient ischemic occlusion. Quant Imaging Med Surg 2014; 4:112-22. [PMID: 24834423 DOI: 10.3978/j.issn.2223-4292.2014.04.06] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 04/21/2014] [Indexed: 11/14/2022]
Abstract
Many MRI parameters have been explored and demonstrated the capability or potential to evaluate acute stroke injury, providing anatomical, microstructural, functional, or neurochemical information for diagnostic purposes and therapeutic development. However, the application of multiparameter MRI approach is hindered in clinic due to the very limited time window after stroke insult. Parallel imaging technique can accelerate MRI data acquisition dramatically and has been incorporated in modern clinical scanners and increasingly applied for various diagnostic purposes. In the present study, a fast multiparameter MRI approach including structural T1-weighted imaging (T1W), T2-weighted imaging (T2W), diffusion tensor imaging (DTI), T2-mapping, proton magnetic resonance spectroscopy, cerebral blood flow (CBF), and magnetization transfer (MT) imaging, was implemented and optimized for assessing acute stroke injury on a 3T clinical scanner. A macaque model of transient ischemic stroke induced by a minimal interventional approach was utilized for evaluating the multiparameter MRI approach. The preliminary results indicate the surgical procedure successfully induced ischemic occlusion in the cortex and/or subcortex in adult macaque monkeys (n=4). Application of parallel imaging technique substantially reduced the scanning duration of most MRI data acquisitions, allowing for fast and repeated evaluation of acute stroke injury. Hence, the use of the multiparameter MRI approach with up to five quantitative measures can provide significant advantages in preclinical or clinical studies of stroke disease.
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Affiliation(s)
- Xiaodong Zhang
- 1 Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA ; 2 Department of Radiology, School of Medicine, Emory University, Atlanta, GA 30322, USA ; 3 the Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30322, USA ; 4 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA ; 5 Sony Corporation, Tokyo, Japan ; 6 Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan ; 7 Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Frank Tong
- 1 Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA ; 2 Department of Radiology, School of Medicine, Emory University, Atlanta, GA 30322, USA ; 3 the Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30322, USA ; 4 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA ; 5 Sony Corporation, Tokyo, Japan ; 6 Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan ; 7 Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Chun-Xia Li
- 1 Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA ; 2 Department of Radiology, School of Medicine, Emory University, Atlanta, GA 30322, USA ; 3 the Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30322, USA ; 4 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA ; 5 Sony Corporation, Tokyo, Japan ; 6 Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan ; 7 Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Yumei Yan
- 1 Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA ; 2 Department of Radiology, School of Medicine, Emory University, Atlanta, GA 30322, USA ; 3 the Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30322, USA ; 4 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA ; 5 Sony Corporation, Tokyo, Japan ; 6 Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan ; 7 Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Govind Nair
- 1 Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA ; 2 Department of Radiology, School of Medicine, Emory University, Atlanta, GA 30322, USA ; 3 the Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30322, USA ; 4 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA ; 5 Sony Corporation, Tokyo, Japan ; 6 Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan ; 7 Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Tsukasa Nagaoka
- 1 Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA ; 2 Department of Radiology, School of Medicine, Emory University, Atlanta, GA 30322, USA ; 3 the Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30322, USA ; 4 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA ; 5 Sony Corporation, Tokyo, Japan ; 6 Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan ; 7 Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Yoji Tanaka
- 1 Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA ; 2 Department of Radiology, School of Medicine, Emory University, Atlanta, GA 30322, USA ; 3 the Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30322, USA ; 4 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA ; 5 Sony Corporation, Tokyo, Japan ; 6 Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan ; 7 Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Stuart Zola
- 1 Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA ; 2 Department of Radiology, School of Medicine, Emory University, Atlanta, GA 30322, USA ; 3 the Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30322, USA ; 4 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA ; 5 Sony Corporation, Tokyo, Japan ; 6 Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan ; 7 Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Leonard Howell
- 1 Yerkes National Primate Research Center, Emory University, Atlanta, GA 30329, USA ; 2 Department of Radiology, School of Medicine, Emory University, Atlanta, GA 30322, USA ; 3 the Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30322, USA ; 4 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA ; 5 Sony Corporation, Tokyo, Japan ; 6 Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan ; 7 Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA 30322, USA
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Dirnagl U, Endres M. Found in translation: preclinical stroke research predicts human pathophysiology, clinical phenotypes, and therapeutic outcomes. Stroke 2014; 45:1510-8. [PMID: 24652307 DOI: 10.1161/strokeaha.113.004075] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Ulrich Dirnagl
- From the Departments of Neurology and Experimental Neurology, Center for Stroke Research Berlin, and Excellence Cluster NeuroCure, Charité-Universitätsmedizin Berlin, Berlin, Germany (U.D., M.E.); German Center for Neurodegeneration Research (DZNE), Partner Site, Berlin, Germany (U.D.); and German Center for Cardiovascular Diseases (DZHK), Partner Site, Berlin, Germany (U.D., M.E.)
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13
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Ledezma CJ, Fiebach JB, Wintermark M. Modern imaging of the infarct core and the ischemic penumbra in acute stroke patients: CT versus MRI. Expert Rev Cardiovasc Ther 2014; 7:395-403. [DOI: 10.1586/erc.09.7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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14
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Artzi M, Aizenstein O, Jonas-Kimchi T, Bornstein N, Shopin L, Hallevi H, Ben Bashat D. Classification of lesion area in stroke patients during the subacute phase: a multiparametric MRI study. Magn Reson Med 2013; 72:1381-8. [PMID: 24243644 DOI: 10.1002/mrm.25031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 10/09/2013] [Accepted: 10/14/2013] [Indexed: 01/28/2023]
Abstract
PURPOSE Stroke imaging studies during the acute phase are likely to precede several vascular brain mechanisms, which have an important role in patient outcome. The aim of this study was to identify within the lesion area during the subacute phase (≥1 day) reactive tissue, which may have the potential for recovery. METHODS Twenty seven stroke patients from two cohorts were included. MRI performed during the subacute phase included conventional, perfusion and diffusion imaging. In cohort I, unsupervised multiparametric classification of the lesion area was performed. In cohort II threshold based classification was performed during the subacute phase, and radiological outcome was assessed at follow-up scan. RESULTS Three tissue classes were identified in cohort I, referred to as irreversibly damaged, intermediary, and reactive tissue. Based on threshold values defined in cohort I, the reactive tissue was identified in 11/13 patients in cohort II, and showed tissue preservation/partial recovery in 9/11 patients at follow-up scan. The irreversibly damaged tissue was identified in 7/13 patients in cohort II, and predicted tissue necrosis in all cases. CONCLUSION Identification of reactive tissue following stroke during the subacute phase can improve radiological assessment, contribute to the understanding of brain recovery processes and has implications for new therapeutic approaches.
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Affiliation(s)
- Moran Artzi
- The Functional Brain Center, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Maija R, Gaida K, Karlis K, Evija M. Perfusion computed tomography relative threshold values in definition of acute stroke lesions. Acta Radiol Short Rep 2013; 2:2047981613486099. [PMID: 23986859 PMCID: PMC3736965 DOI: 10.1177/2047981613486099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 03/18/2013] [Indexed: 11/18/2022] Open
Abstract
Background Perfusion computed tomography (CT) is a relatively new technique that allows fast evaluation of cerebral hemodynamics by providing perfusion maps and gives confirmation of perfusion deficits in ischemic areas. Some controversies exist regarding accuracy of quantitative detection of tissue viability: penumbra (tissue at risk) or core (necrosis). Purpose To define brain tissue viability grade on the basis of the perfusion CT parameters in acute stroke patients. Material and Methods A multimodal CT imaging protocol; unenhanced CT of the brain, CT angiography of head and neck blood vessels, followed by brain perfusion CT and 24 h follow-up brain CT was performed. Perfusion deficits were detected first visually, with subsequent manual quantitative and relative measurements in affected and contra-lateral hemisphere in 87 acute stroke patients. Results Visual perfusion deficit on perfusion CT images was found in 78 cases (38 women, 40 men; mean age, 30–84 years). Penumbra lesions (n = 49) and core lesions (n = 42) were detected by increased mean transit time (MTT) on perfusion CT maps in comparison to contra-lateral hemispheres. Cerebral blood volume (CBV) mean values in the penumbra group were increased in the penumbra group and decreased in the core group. Cerebral blood flow (CBF) values were decreased in penumbra and markedly decreased in core lesion. Conclusion Perfusion CT measurements are reliable in estimation of penumbra and core lesions in acute stroke patients, if relative threshold values are used. The most accurate parameter of hypoperfusion is increased MTT above 190%. Relative threshold values for irreversible lesion are CBF <30–40% and CBV <40% in comparison to contra-lateral hemisphere. Penumbra lesion is characterized by MTT increase and CBF decrease, while CBV shows variable values.
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Affiliation(s)
- Radzina Maija
- Radiology Department, Riga Stradins University , Riga
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16
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The potential roles of 18F-FDG-PET in management of acute stroke patients. BIOMED RESEARCH INTERNATIONAL 2013; 2013:634598. [PMID: 23762852 PMCID: PMC3671294 DOI: 10.1155/2013/634598] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 04/14/2013] [Indexed: 01/17/2023]
Abstract
Extensive efforts have recently been devoted to developing noninvasive imaging tools capable of delineating brain tissue viability (penumbra) during acute ischemic stroke. These efforts could have profound clinical implications for identifying patients who may benefit from tPA beyond the currently approved therapeutic time window and/or patients undergoing neuroendovascular treatments. To date, the DWI/PWI MRI and perfusion CT have received the most attention for identifying ischemic penumbra. However, their routine use in clinical settings remains limited. Preclinical and clinical PET studies with [18F]-fluoro-2-deoxy-D-glucose (18F-FDG) have consistently revealed a decreased 18F-FDG uptake in regions of presumed ischemic core. More importantly, an elevated 18F-FDG uptake in the peri-ischemic regions has been reported, potentially reflecting viable tissues. To this end, this paper provides a comprehensive review of the literature on the utilization of 14C-2-DG and 18F-FDG-PET in experimental as well as human stroke studies. Possible cellular mechanisms and physiological underpinnings attributed to the reported temporal and spatial uptake patterns of 18F-FDG are addressed. Given the wide availability of 18F-FDG in routine clinical settings, 18F-FDG PET may serve as an alternative, non-invasive tool to MRI and CT for the management of acute stroke patients.
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17
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d’Esterre CD, Fainardi E, Aviv RI, Lee TY. Improving Acute Stroke Management with Computed Tomography Perfusion: A Review of Imaging Basics and Applications. Transl Stroke Res 2012; 3:205-20. [DOI: 10.1007/s12975-012-0178-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 04/09/2012] [Accepted: 04/12/2012] [Indexed: 10/28/2022]
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18
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Bazan NG, Eady TN, Khoutorova L, Atkins KD, Hong S, Lu Y, Zhang C, Jun B, Obenaus A, Fredman G, Zhu M, Winkler JW, Petasis NA, Serhan CN, Belayev L. Novel aspirin-triggered neuroprotectin D1 attenuates cerebral ischemic injury after experimental stroke. Exp Neurol 2012; 236:122-30. [PMID: 22542947 DOI: 10.1016/j.expneurol.2012.04.007] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 04/05/2012] [Accepted: 04/11/2012] [Indexed: 11/30/2022]
Abstract
Acute ischemic stroke triggers complex neurovascular, neuroinflammatory and synaptic alterations. Aspirin and docosahexaenoic acid (DHA), an omega-3 essential fatty acid family member, have beneficial effects on cerebrovascular diseases. DHA is the precursor of neuroprotectin D1 (NPD1), which downregulates apoptosis and, in turn, promotes cell survival. Here we have tested the effect of aspirin plus DHA administration and discovered the synthesis of aspirin-triggered NPD1 (AT-NPD1) in the brain. Then we performed the total chemical synthesis of this molecule and tested in the setting of 2h middle cerebral artery occlusion (MCAo) in Sprague-Dawley rats. Neurological status was evaluated at 24h, 48 h, 72 h, and 7 days. At 3h post-stroke onset, an intravenous administration of 333 μg/kg of AT-NPD1 sodium salt (AT-NPD1-SS) or methyl-ester (AT-NPD1-ME) or vehicle (saline) as treatment was given. On day 7, ex vivo magnetic resonance imaging (MRI) of the brains was conducted on 11.7 T MRI. T2WI, 3D volumes, and apparent diffusion coefficient (ADC) maps were generated. In addition, infarct volumes and number of GFAP (reactive astrocytes), ED-1 (activated microglia/macrophages) and SMI-71-positive vessels were counted in the cortex and striatum at the level of the central lesion. All animals showed similar values for rectal and cranial temperatures, arterial blood gases, and plasma glucose during and after MCAo. Treatment with both AT-NPD1-SS and AT-NPD1-ME significantly improved neurological scores compared to saline treatment at 24h, 48 h, 72 h and 7 days. Total lesion volumes computed from T2WI images were significantly reduced by both AT-NPD1-SS and AT-NPD1-ME treatment in the cortex (by 44% and 81%), striatum (by 61% and 77%) and total infarct (by 48% and 78%, respectively). Brain edema, computed from T2WI in the cortex (penumbra) and striatum (core), was elevated in the saline group. In contrast, both AT-NPD1 decreased water content in the striatum on day 7. 3D volumes, computed from T2WI, were dramatically reduced with both AT-NPD1 and the lesion was mostly localized in the subcortical areas. Treatment with both AT-NPD1-SS and AT-NPD1-ME significantly reduced cortical (by 76% and 96%), subcortical (by 61% and 70%) and total (69% and 84%, respectively) infarct volumes as defined by histopathology. In conclusion, a novel biosynthetic pathway that leads to the formation of AT-NPD1 mediator in the brain was discovered. In addition, administration of synthetic AT-NPD1, in either its sodium salt or as the methyl ester, was able to attenuate cerebral ischemic injury which leads to a novel approach for pharmaceutical intervention and clinical translation.
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Affiliation(s)
- Nicolas G Bazan
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA.
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19
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Gauberti M, Obiang P, Guedin P, Balossier A, Gakuba C, Diependaele AS, Chazalviel L, Vivien D, Young AR, Agin V, Orset C. Thrombotic stroke in the anesthetized monkey (Macaca mulatta): characterization by MRI--a pilot study. Cerebrovasc Dis 2012; 33:329-39. [PMID: 22343114 DOI: 10.1159/000335309] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 11/17/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The lack of a relevant stroke model in large nonhuman primates hinders the development of innovative diagnostic/therapeutic approaches concerned with this cerebrovascular disease. Our objective was to develop a novel and clinically relevant model of embolic stroke in the anesthetized monkey that incorporates readily available clinical imaging techniques and that would allow the possibility of drug delivery including strategies of reperfusion. METHODS Thrombin was injected into the lumen of the middle cerebral artery (MCA) in 12 anesthetized (sevoflurane) male rhesus macaques (Macaca mulatta). Sequential MRI studies (including angiography, FLAIR, PWI, DWI, and gadolinium-enhanced T1W imaging) were performed in a 3T clinical MRI. Physiological and biochemical parameters were monitored throughout the investigations. RESULTS Once standardized, the surgical procedure induced transient occlusion of the middle cerebral artery in all operated animals. All animals studied showed spontaneous reperfusion, which occurred some time between 2 h and 7 days post-ictus. Eighty percent of the studied animals showed diffusion/perfusion mismatch. The ischemic lesions at 24 h spared both superficial and profound territories of the MCA. Some animals presented hemorrhagic transformation at 7 days post-ictus. CONCLUSION In this study, we developed a pre-clinically relevant model of embolic stroke in the anesthetized nonhuman primate.
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Affiliation(s)
- Maxime Gauberti
- INSERM U919, Serine Proteases and Pathophysiology of the Neurovascular Unit, GIP Cyceron, Université de Caen-Basse Normandie, Caen, France
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Walberer M, Backes H, Rueger MA, Neumaier B, Endepols H, Hoehn M, Fink GR, Schroeter M, Graf R. Potential of Early [
18
F]-2-Fluoro-2-Deoxy-D-Glucose Positron Emission Tomography for Identifying Hypoperfusion and Predicting Fate of Tissue in a Rat Embolic Stroke Model. Stroke 2012; 43:193-8. [DOI: 10.1161/strokeaha.111.624551] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Experimental stroke models are essential to study in vivo pathophysiological processes of focal cerebral ischemia. In this study, an embolic stroke model in rats was applied (1) to characterize early development of regional cerebral blood flow and metabolism with positron emission tomography (PET) using [
15
O]H
2
O and [
18
F]-2-fluoro-2-deoxy-D-glucose (FDG); and (2) to identify potential parameters for predicting tissue fate.
Methods—
Remote occlusion of the middle cerebral artery was induced in 10 Wistar rats by injection of 4 TiO
2
macrospheres. Sequential [
15
O]H
2
O-PET (baseline, 5, 30, 60 minutes after middle cerebral artery occlusion) and FDG-PET measurements (75 minutes after middle cerebral artery occlusion) were performed. [
15
O]H
2
O-PET data and FDG kinetic parameters were compared with MRIs and histology at 24 hours.
Results—
Regional cerebral blood flow decreased substantially within 30 minutes after middle cerebral artery occlusion (41% to 58% of baseline regional cerebral blood flow;
P
<0.001) with no relevant changes between 30 and 60 minutes. At 60 minutes, regional cerebral blood flow correlated well with the unidirectional transport parameter
K1
of FDG in all animals (
r
=0.86±0.09;
P
<0.001). Tissue fate could be accurately predicted taking into account
K1
and net influx rate constant
Ki
of FDG. The infarct volume predicted by FDG-PET (375.8±102.3 mm
3
) correlated significantly with the infarct size determined by MRI after 24 hours (360.8±93.7 mm
3
;
r
=0.85).
Conclusions—
Hypoperfused tissue can be identified by decreased
K1
of FDG. Acute ischemic tissue can be well characterized using
K1
and
Ki
allowing for discrimination between infarct core and early viable tissue. Because FDG-PET is widely spread, our findings can be easily translated into clinical application for early diagnoses of ischemia.
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Affiliation(s)
- Maureen Walberer
- From the Department of Neurology (M.W., M.A.R., G.R.F., M.S.), University Hospital, Cologne, Germany; Max Planck Institute for Neurological Research (M.W., H.B., M.A.R., B.N., H.E., M.H., M.S., R.G.), Cologne, Germany; and the Institute of Neuroscience and Medicine (INM-3; G.R.F.), Cognitive Neurology Section, Research Centre Juelich, Juelich, Germany
| | - Heiko Backes
- From the Department of Neurology (M.W., M.A.R., G.R.F., M.S.), University Hospital, Cologne, Germany; Max Planck Institute for Neurological Research (M.W., H.B., M.A.R., B.N., H.E., M.H., M.S., R.G.), Cologne, Germany; and the Institute of Neuroscience and Medicine (INM-3; G.R.F.), Cognitive Neurology Section, Research Centre Juelich, Juelich, Germany
| | - Maria A. Rueger
- From the Department of Neurology (M.W., M.A.R., G.R.F., M.S.), University Hospital, Cologne, Germany; Max Planck Institute for Neurological Research (M.W., H.B., M.A.R., B.N., H.E., M.H., M.S., R.G.), Cologne, Germany; and the Institute of Neuroscience and Medicine (INM-3; G.R.F.), Cognitive Neurology Section, Research Centre Juelich, Juelich, Germany
| | - Bernd Neumaier
- From the Department of Neurology (M.W., M.A.R., G.R.F., M.S.), University Hospital, Cologne, Germany; Max Planck Institute for Neurological Research (M.W., H.B., M.A.R., B.N., H.E., M.H., M.S., R.G.), Cologne, Germany; and the Institute of Neuroscience and Medicine (INM-3; G.R.F.), Cognitive Neurology Section, Research Centre Juelich, Juelich, Germany
| | - Heike Endepols
- From the Department of Neurology (M.W., M.A.R., G.R.F., M.S.), University Hospital, Cologne, Germany; Max Planck Institute for Neurological Research (M.W., H.B., M.A.R., B.N., H.E., M.H., M.S., R.G.), Cologne, Germany; and the Institute of Neuroscience and Medicine (INM-3; G.R.F.), Cognitive Neurology Section, Research Centre Juelich, Juelich, Germany
| | - Mathias Hoehn
- From the Department of Neurology (M.W., M.A.R., G.R.F., M.S.), University Hospital, Cologne, Germany; Max Planck Institute for Neurological Research (M.W., H.B., M.A.R., B.N., H.E., M.H., M.S., R.G.), Cologne, Germany; and the Institute of Neuroscience and Medicine (INM-3; G.R.F.), Cognitive Neurology Section, Research Centre Juelich, Juelich, Germany
| | - Gereon R. Fink
- From the Department of Neurology (M.W., M.A.R., G.R.F., M.S.), University Hospital, Cologne, Germany; Max Planck Institute for Neurological Research (M.W., H.B., M.A.R., B.N., H.E., M.H., M.S., R.G.), Cologne, Germany; and the Institute of Neuroscience and Medicine (INM-3; G.R.F.), Cognitive Neurology Section, Research Centre Juelich, Juelich, Germany
| | - Michael Schroeter
- From the Department of Neurology (M.W., M.A.R., G.R.F., M.S.), University Hospital, Cologne, Germany; Max Planck Institute for Neurological Research (M.W., H.B., M.A.R., B.N., H.E., M.H., M.S., R.G.), Cologne, Germany; and the Institute of Neuroscience and Medicine (INM-3; G.R.F.), Cognitive Neurology Section, Research Centre Juelich, Juelich, Germany
| | - Rudolf Graf
- From the Department of Neurology (M.W., M.A.R., G.R.F., M.S.), University Hospital, Cologne, Germany; Max Planck Institute for Neurological Research (M.W., H.B., M.A.R., B.N., H.E., M.H., M.S., R.G.), Cologne, Germany; and the Institute of Neuroscience and Medicine (INM-3; G.R.F.), Cognitive Neurology Section, Research Centre Juelich, Juelich, Germany
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22
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Bivard A, Spratt N, Levi CR, Parsons MW. Acute stroke thrombolysis: time to dispense with the clock and move to tissue-based decision making? Expert Rev Cardiovasc Ther 2011; 9:451-61. [PMID: 21517729 DOI: 10.1586/erc.11.7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Currently, imaging is predominantly used to exclude patients for thrombolysis, rather than identify patients most likely to benefit. This means that patients are being selected for treatment without reference to tissue pathophysiology. Imaging of specific stroke pathophysiology may be the key to selecting patients most likely to benefit from thrombolysis, and could revolutionize acute stroke assessment and treatment. The technology is available to identify the acute infarct core and possibly the penumbra, via magnetic resonance diffusion-weighted imaging, and both magnetic resonance- and computed tomography-perfusion imaging techniques. However, these modalities require fine tuning before they can be reliably implemented in a routine clinical setting.
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Affiliation(s)
- Andrew Bivard
- Department of Neurology and Hunter Medical Research Institute (MWP, CRL), John Hunter Hospital, University of Newcastle, NSW 2305, Australia
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23
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Liu S, Levine SR, Winn HR. Targeting ischemic penumbra Part II: selective drug delivery using liposome technologies. ACTA ACUST UNITED AC 2011; 4:16-23. [DOI: 10.6030/1939-067x-4.1.16] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sun Z, Zhang X, Zhang Y, Guo H, Zhang J, Yu C. Estimation of the ischemic penumbra based on CT perfusion a pilot study. Acad Radiol 2010; 17:1535-42. [PMID: 20947391 DOI: 10.1016/j.acra.2010.08.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 07/05/2010] [Accepted: 08/03/2010] [Indexed: 10/18/2022]
Abstract
RATIONALE AND OBJECTIVES Ischemic penumbra (IP), the target of thrombolytic therapies, could be estimated by the mismatch region between magnetic resonance imaging (MRI) diffusion- and perfusion-defined abnormalities; however, the accuracy of this method has been challenged recently. In this study, we try to establish a method for calculating IP size based on computed tomography perfusion (CTP) and to observe the early evolution of IP in detail. MATERIALS AND METHODS The middle cerebral artery occlusion (MCAO) model in monkey was used to compare the accuracy in estimating the IP between CTP and MRI methods. A receiver operating characteristic (ROC) curve was performed to calculate the IP threshold of the different CTP parameters, and then the best parameter was obtained. The dynamic evolutions of estimated size of IP by these two methods were compared. RESULTS Among the three CTP parameters, relative cerebral blood flow (rCBF) had the highest sensitivity (83.3%) and specificity (98.5%) in estimating the IP. The optimal cutoff threshold of rCBF was 0.203. During the first 15 hours of the MCAO model, the estimated size of IP by the rCBF was larger than that of the MRI method; however, this relationship was reversed 15 hours later. CONCLUSION This study suggests that the rCBF method is more accurate in estimating the IP since previous studies have reported that the MRI method underestimated the exact IP in the early stage of ischemia and overestimated the exact IP in the later stages. Further experimental and clinical studies are needed to validate the conclusion.
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Docosahexaenoic Acid therapy of experimental ischemic stroke. Transl Stroke Res 2010; 2:33-41. [PMID: 21423332 PMCID: PMC3037476 DOI: 10.1007/s12975-010-0046-0] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 09/23/2010] [Accepted: 09/26/2010] [Indexed: 10/26/2022]
Abstract
We examined the neuroprotective efficacy of docosahexaenoic acid (DHA), an omega-3 essential fatty acid family member, in acute ischemic stroke; studied the therapeutic window; and investigated whether DHA administration after an ischemic stroke is able to salvage the penumbra. In each series described below, SD rats underwent 2 h of middle cerebral artery occlusion (MCAo). In series 1, DHA or saline was administered i.v. at 3, 4, 5, or 6 h after stroke. In series 2, MRI was conducted on days 1, 3 and 7. In series 3, DHA or saline was administered at 3 h, and lipidomic analysis was conducted on day 3. Treatment with DHA significantly improved behavior and reduced total infarct volume by a mean of 40% when administered at 3 h, by 66% at 4 h, and by 59% at 5 h. Total lesion volumes computed from T2-weighted images were reduced in the DHA group at all time points. Lipidomic analysis showed that DHA treatment potentiates neuroprotectin D1 (NPD1) synthesis in the penumbra 3 days after MCAo. DHA administration provides neurobehavioral recovery, reduces brain infarction and edema, and activates NPD1 synthesis in the penumbra when administered up to 5 h after focal cerebral ischemia in rats.
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26
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Abstract
This review focuses on mechanisms and emerging concepts that drive the science of stroke in a therapeutic direction. Once considered exclusively a disorder of blood vessels, growing evidence has led to the realization that the biological processes underlying stroke are driven by the interaction of neurons, glia, vascular cells, and matrix components, which actively participate in mechanisms of tissue injury and repair. As new targets are identified, new opportunities emerge that build on an appreciation of acute cellular events acting in a broader context of ongoing destructive, protective, and reparative processes. The burden of disease is great, and its magnitude widens as a role for blood vessels and stroke in vascular and nonvascular dementias becomes more clearly established. This review then poses a number of fundamental questions, the answers to which may generate new directions for research and possibly new treatments that could reduce the impact of this enormous economic and societal burden.
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27
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Zaro-Weber O, Moeller-Hartmann W, Heiss WD, Sobesky J. A simple positron emission tomography-based calibration for perfusion-weighted magnetic resonance maps to optimize penumbral flow detection in acute stroke. Stroke 2010; 41:1939-45. [PMID: 20671255 DOI: 10.1161/strokeaha.110.584029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Perfusion-weighted (PW) MRI is increasingly used to identify the tissue at risk. The adequate PW-MRI map and threshold remain controversial due to a considerable individual variation of values. By comparative positron emission tomography, we evaluated a simple MR-based and positron emission tomography-validated calibration of PW maps. METHODS PW-MRI and quantitative positron emission tomography (15O-water) of patients with acute stroke were used to calculate averaged as well as individual thresholds of penumbral flow (positron emission tomography cerebral blood flow (<20 mL/100 g/min) for maps of time to peak, mean transit time, cerebral blood flow, and cerebral blood volume. A linear regression analysis studied the variability of the individual thresholds using 3 different PW reference regions (hemispheric, white matter, gray matter). The best model was used for volumetric analysis to compare averaged and scaled individual thresholds and to calculate look-up tables for PW maps. RESULTS In 26 patients, the averaged thresholds were (median/interquartile range): cerebral blood flow 21.7 mL/100 g/min (19.9 to 32); cerebral blood volume 1.5 mL/100 g (0.9 to 1.8); mean transit time seconds 5.2 (3.9 to 6.9); and relative time to peak 4.2 seconds (2.8 to 5.8). The large individual variability was best explained by the mean value of the hemispheric reference derived from a region of interest on a level with the basal ganglia of the unaffected hemisphere (R(2): cerebral blood flow 0.76, cerebral blood volume 0.55, mean transit time 0.83, time to peak 0.95). Hemispheric reference-corrected thresholds clearly improved the detection of penumbral flow. Look-up tables were calculated to identify the individual thresholds according to the hemispheric reference value. CONCLUSIONS The individual variation of PW values, even if calculated by deconvolution, remains a major obstacle in quantitative PW imaging and can be significantly improved by a simple MR-based calibration. Easily applicable look-up tables identify the individual best threshold for each PW map to optimize mismatch detection.
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Affiliation(s)
- Olivier Zaro-Weber
- Max Planck Institute for Neurological Research, Gleueler Str 50, 50931 Cologne, Germany.
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28
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Hussein HM, Georgiadis AL, Vazquez G, Miley JT, Memon MZ, Mohammad YM, Christoforidis GA, Tariq N, Qureshi AI. Occurrence and predictors of futile recanalization following endovascular treatment among patients with acute ischemic stroke: a multicenter study. AJNR Am J Neuroradiol 2010; 31:454-8. [PMID: 20075087 DOI: 10.3174/ajnr.a2006] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Although recanalization is the goal of thrombolysis, it is well recognized that it fails to improve outcome of acute stroke in a subset of patients. Our aim was to assess the rate of and factors associated with "futile recanalization," defined by absence of clinical benefit from recanalization, following endovascular treatment of acute ischemic stroke. MATERIALS AND METHODS Data from 6 studies of acute ischemic stroke treated with mechanical and/or pharmacologic endovascular treatment were analyzed. "Futile recanalization" was defined by the occurrence of unfavorable outcome (mRS score of > or = 3 at 1-3 months) despite complete angiographic recanalization (Qureshi grade 0 or TIMI grade 3). RESULTS Complete recanalization was observed in 96 of 270 patients treated with IA thrombolysis. Futile recanalization was observed in 47 (49%). In univariate analysis, patients with futile recanalization were older (73 +/- 11 versus 58 +/- 15 years, P < .0001) and had higher median initial NIHSS scores (19 versus 14, P < .0001), more frequent BA occlusion (17% versus 4%, P = .049), less frequent MCA occlusion (53% versus 76%, P = .032), and a nonsignificantly higher rate of symptomatic hemorrhagic complications (2% versus 9%, P = .2). In logistic regression analysis, futile recanalization was positively associated with age > 70 years (OR, 4.4; 95% CI, 1.9-10.5; P = .0008) and initial NIHSS score 10-19 (OR, 3.8; 95% CI, 1.7-8.4; P = .001), and initial NIHSS score > or = 20 (OR, 64.4; 95% CI, 28.8-144; P < .0001). CONCLUSIONS Futile recanalization is a relatively common occurrence following endovascular treatment, particularly among elderly patients and those with severe neurologic deficits.
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Affiliation(s)
- H M Hussein
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota, USA.
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Liu S, Levine SR, Winn HR. Targeting ischemic penumbra: part I - from pathophysiology to therapeutic strategy. ACTA ACUST UNITED AC 2010; 3:47-55. [PMID: 20607107 DOI: 10.6030/1939-067x-3.1.47] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Penumbra is the viable tissue around the irreversibly damaged ischemic core. The purpose of acute stroke treatment is to salvage penumbral tissue and to improve brain function. However, the majority of acute stroke patients who have treatable penumbra are left untreated. Therefore, developing an effective non-recanalizational therapeutics, such as neuroprotective agents, has significant clinical applications. Part I of this serial review on "targeting penumbra" puts special emphases on penumbral pathophysiology and the development of therapeutic strategies. Bioenergetic intervention by massive metabolic suppression and direct energy delivery would be a promising future direction. An effective drug delivery system for this purpose should be able to penetrate BBB and achieve high local tissue drug levels while non-ischemic region being largely unaffected. Selective drug delivery to ischemic stroke penumbra is feasible and deserves intensive research.
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Affiliation(s)
- Shimin Liu
- Department of Neurology, Mount Sinai School of Medicine, NYU
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Penumbra, the basis of neuroimaging in acute stroke treatment: current evidence. J Neurol Sci 2009; 288:13-24. [PMID: 19875134 DOI: 10.1016/j.jns.2009.09.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Revised: 08/06/2009] [Accepted: 09/23/2009] [Indexed: 11/23/2022]
Abstract
In modern medicine brain imaging is an essential prerequisite not only to acute stroke triage but also to determining the specific therapy indicated. This article reviews the need for imaging the brain in acute stroke, penumbral pathophysiology, penumbral imaging techniques, as well as current status of various imaging modalities that are being employed to select patients for specific therapeutic approaches.
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Modo M. Long-term survival and serial assessment of stroke damage and recovery - practical and methodological considerations. ACTA ACUST UNITED AC 2009; 2:52-68. [PMID: 22389748 DOI: 10.6030/1939-067x-2.2.52] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Impairments caused by stroke remain the main cause for adult disability. Despite a vigorous research effort, only 1 thrombolytic treatment has been approved in acute stroke (<3h). The limitations of preclinical studies and how these can be overcome have been the subject of various guidelines. However, often these guidelines focus on the acute stroke setting and omit long-term outcome measures, such as behaviour and neuroimaging. The considerations and practicalities of including the serial assessment of these approaches and their significance to establish therapeutic efficacy are discussed here.
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Affiliation(s)
- Michel Modo
- King's College London, Institute of Psychiatry, Department of Neuroscience, London, UK
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