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Chlorogiannis DD, Mavridis T, Adamou A, Kyriakoulis I, Stamatiou I, Botou P, Chen HS, Ntaios G. Argatroban as an Add-On to rtPA in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:563. [PMID: 38256696 PMCID: PMC10816854 DOI: 10.3390/jcm13020563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/05/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
Current treatment options for acute ischemic stroke, including intravenous thrombolysis (IVT) and mechanical thrombectomy, have undoubtedly revolutionized stroke care. The need for additional treatment options has brought into the light direct thrombin inhibitors (DTIs) and, specifically, argatroban as a promising candidate. However, there is uncertainty regarding the safety of adding argatroban to IVT, mainly due to the increased hemorrhagic risk. In this study, we performed a systematic review and meta-analysis examining the safety and efficacy of argatroban as an add-on treatment for IVT. The following databases were searched from inception until the 14th of May 2023: Pubmed/MEDLINE, ClinicalTrials.gov, the EU Clinical Trials Register, EMBASE/Scopus, and the Cochrane Library. Only randomized clinical trials (RCTs) enrolling patients with acute ischemic stroke who underwent IVT evaluating the add-on use of any DTIs were selected for the systematic review and further meta-analysis. The PRISMA guidelines were followed at all stages. Four studies with argatroban were included in the final analysis. Analysis of risk ratio and relative risk shows that the add-on therapy with argatroban seems to be effective and favors a good clinical outcome (mRS 0-2) at 90 days, similar to that of alteplase. All studies showed a low pooled incidence of symptomatic intracerebral hemorrhage (5%), parenchymal hematoma (3%), and other major bleeding (1%). Argatroban as an add-on treatment to IVT seems not to be associated with excessive bleeding risk; however, its efficacy remains unproven. According to this synopsis of the currently available evidence, it is premature to use argatroban as an add-on to IVT treatment outside the current clinical trial setting.
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Affiliation(s)
| | - Theodoros Mavridis
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
- Department of Neurology, Tallaght University Hospital, D24 NR0A Dublin, Ireland
| | - Anastasia Adamou
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (A.A.); (I.K.)
| | - Ioannis Kyriakoulis
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (A.A.); (I.K.)
| | - Iliana Stamatiou
- Department of Internal Medicine, University Hospital of Alexandroupolis, 68100 Alexandroupolis, Greece;
| | - Polyxeni Botou
- Department of Anaesthesiology, Hippocration General Hospital of Athens, 11527 Athens, Greece;
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang 110017, China;
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (A.A.); (I.K.)
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Al-Salihi MM, Saha R, Ayyad A, Al-Jebur MS, Al-Salihi Y, Roy A, Dalal SS, Rivet D, Spiotta AM, Qureshi AI. Efficacy and safety of argatroban in the management of acute ischemic stroke: A systematic literature review and meta-analysis. Clin Neurol Neurosurg 2024; 236:108097. [PMID: 38176219 DOI: 10.1016/j.clineuro.2023.108097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/30/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Acute ischemic stroke (AIS) is a leading cause of death and disability. AIS is caused by an embolus or thrombus that restricts blood flow to the brain tissue. Despite intravenous thrombolysis and endovascular thrombectomy, a substantial number of patients do not achieve effective reperfusion. Argatroban, a direct thrombin inhibitor, can potentially improve neurological outcomes in AIS patients. However, there are conflicting results in the medical literature regarding the efficacy and safety of argatroban in this context. OBJECTIVE This study aims to evaluate the efficacy and safety of argatroban as monotherapy or adjunct therapy for acute ischemic stroke. METHODS Five major databases (PubMed, Embase, Scopus, Web of Science, and Cochrane Library) were searched for randomized controlled trials (RCTs) that compared the efficacy and safety of using argatroban alone or in combination with recombinant tissue plasminogen activator (r-TPA) in the management protocol of the AIS. We used Review Manager Software (RevMan 5.4.1) for data analysis. RESULTS We included 1393 patients from eight RCTs (of them, 726 were treated with argatroban alone or combined with r-TPA, while 667 received the placebo, standard therapy (standard treatments based on current guidelines including antihypertensive, antiplatelet agents, and statins) or endovascular r-TPA). Neither argatroban vs control nor argatroban with r-TPA vs r-TPA showed significant difference regarding the activity in daily living; (SMD= 1.69, 95% CI [-0.23, 3.61]; p = 0.09), (SMD= 0.99, 95% CI [-0.88, 2.86]; p = 0.30), respectively. Also, there was no significant difference in the National Institutes of Health Stroke Scale (NIHSS) score at seven days, the number of patients achieving modified Rankin Scale (mRS) of 0-1 or 0-2 at 90 days (p > 0.05). Argatroban did not significantly increase the risk of adverse events or symptomatic intracranial hemorrhage (ICH), or major systemic bleeding compared to control or r-TPA (p > 0.05) CONCLUSIONS: Argatroban does not demonstrate superior efficacy compared to placebo or standard therapy in terms of ADL, NIHSS and mRS outcomes. Importantly, argatroban does not significantly increase the incidence of adverse events, including symptomatic ICH and systemic bleeding.
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Affiliation(s)
- Mohammed Maan Al-Salihi
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
| | - Ram Saha
- Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Ali Ayyad
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar; Department of Neurosurgery, Saarland University Hospital, Homburg, Germany
| | | | | | - Anil Roy
- Department of Neurosurgery, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Shamser Singh Dalal
- Department of Radiology, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Dennis Rivet
- Department of Neurosurgery, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical College of South Carolina, Charleston, SC, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and University of Missouri, Columbia, MO, USA
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Sakamoto Y, Nito C, Nishiyama Y, Suda S, Matsumoto N, Aoki J, Saito T, Suzuki K, Okubo S, Mishina M, Kimura K. Safety of Antithrombotic Therapy within 24 Hours after Recombinant Tissue-Plasminogen Activator Treatment for Large-Artery Atherosclerosis Stroke: Insights from Emergent PTA/CAS Cases. J NIPPON MED SCH 2024; 91:307-315. [PMID: 38972743 DOI: 10.1272/jnms.jnms.2024_91-309] [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: 07/09/2024]
Abstract
BACKGROUND Antithrombotic therapy (AT) should generally be avoided within 24 hours after recombinant tissue-plasminogen activator (rt-PA) treatment but should be considered in patients with large-artery atherosclerosis (LAA) who undergo concomitant emergent endovascular treatment (EVT). The aim of the present study was to assess the safety of AT within 24 hours after rt-PA treatment in patients with hyperacute ischemic stroke due to LAA who received concomitant EVT. METHODS From January 2013 through July 2019, consecutive patients with acute ischemic cerebrovascular disease due to LAA who were admitted within 6 hours from symptom onset were recruited. The patients were classified into six groups based on the reperfusion treatment and early (within 24 hours) AT from rt-PA treatment. Safety outcomes were compared among the groups. RESULTS A total of 155 patients (35 women [23%], median age 74 [IQR 66-79] years; NIHSS score 3 [1-10]) were included in the present study. Of these, 73 (47%) received no reperfusion therapy, 24 (15%) received rt-PA treatment and early AT, seven (6%) received rt-PA without early AT, 26 (17%) received EVT only, six (4%) received both rt-PA and EVT without early AT, and 19 (12%) received rt-PA and EVT with early AT. AT was administered a median of 3.9 (1.6-8.0) hours after rt-PA in patients with rt-PA+EVT with early AT. AT within 24 hours after rt-PA and EVT treatment did not increase hemorrhagic complications (p > 0.05 for all). CONCLUSION In this retrospective analyses, early AT administration for patients with hyperacute stroke due to LAA treated with rt-PA plus EVT did not increase hemorrhagic events.
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Affiliation(s)
- Yuki Sakamoto
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Chikako Nito
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Yasuhiro Nishiyama
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Satoshi Suda
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Noriko Matsumoto
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Tomonari Saito
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Kentaro Suzuki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Seiji Okubo
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | | | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
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Liu A, Sun J, Tiwari S, Wong J, Wang H, Tang D, Han Z. Effect of Chinese herbal formulae (BU-SHEN-YI-QI granule) treatment on thrombin expression after ischemia/reperfusion. ALL LIFE 2023. [DOI: 10.1080/26895293.2023.2173311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Affiliation(s)
- Aihua Liu
- Department of Integrative Medicine, Huashan Hospital Affiliated to Fudan University, Shanghai, P.R. People’s Republic of China
| | - Jing Sun
- Department of Integrative Medicine, Huashan Hospital Affiliated to Fudan University, Shanghai, P.R. People’s Republic of China
| | - Sagun Tiwari
- Department of Neurology and Rehabilitation, Seventh People's Hospital of Shanghai University of TCM, Shanghai, P.R. People’s Republic of China
- International Education College, Shanghai University of TCM, Shanghai, P.R. People’s Republic of China
| | - John Wong
- School of Nursing and Department of Occupational Therapy, MGH Institute of Health Professions, Boston, MA, USA
| | - Honglin Wang
- Department of Neurology and Rehabilitation, Seventh People's Hospital of Shanghai University of TCM, Shanghai, P.R. People’s Republic of China
| | - Dongxu Tang
- Department of Neurology and Rehabilitation, Seventh People's Hospital of Shanghai University of TCM, Shanghai, P.R. People’s Republic of China
| | - Zhenxiang Han
- Department of Neurology and Rehabilitation, Seventh People's Hospital of Shanghai University of TCM, Shanghai, P.R. People’s Republic of China
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Chen HS, Cui Y, Zhou ZH, Dai YJ, Li GH, Peng ZL, Zhang Y, Liu XD, Yuan ZM, Jiang CH, Yang QC, Duan YJ, Ma GB, Zhao LW, Wang RX, Sun YL, Shen L, Wang EQ, Wang LH, Feng YF, Wang FY, Zou RL, Yang HP, Wang K, Wang DL, Wang YL. Effect of Argatroban Plus Intravenous Alteplase vs Intravenous Alteplase Alone on Neurologic Function in Patients With Acute Ischemic Stroke: The ARAIS Randomized Clinical Trial. JAMA 2023; 329:640-650. [PMID: 36757755 PMCID: PMC9912168 DOI: 10.1001/jama.2023.0550] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/16/2023] [Indexed: 02/10/2023]
Abstract
IMPORTANCE Previous studies suggested a benefit of argatroban plus alteplase (recombinant tissue-type plasminogen activator) in patients with acute ischemic stroke (AIS). However, robust evidence in trials with large sample sizes is lacking. OBJECTIVE To assess the efficacy of argatroban plus alteplase for AIS. DESIGN, SETTING, AND PARTICIPANTS This multicenter, open-label, blinded end point randomized clinical trial including 808 patients with AIS was conducted at 50 hospitals in China with enrollment from January 18, 2019, through October 30, 2021, and final follow-up on January 24, 2022. INTERVENTIONS Eligible patients were randomly assigned within 4.5 hours of symptom onset to the argatroban plus alteplase group (n = 402), which received intravenous argatroban (100 μg/kg bolus over 3-5 minutes followed by an infusion of 1.0 μg/kg per minute for 48 hours) within 1 hour after alteplase (0.9 mg/kg; maximum dose, 90 mg; 10% administered as 1-minute bolus, remaining infused over 1 hour), or alteplase alone group (n = 415), which received intravenous alteplase alone. Both groups received guideline-based treatments. MAIN OUTCOMES AND MEASURES The primary end point was excellent functional outcome, defined as a modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]) of 0 to 1 at 90 days. All end points had blinded assessment and were analyzed on a full analysis set. RESULTS Among 817 eligible patients with AIS who were randomized (median [IQR] age, 65 [57-71] years; 238 [29.1%] women; median [IQR] National Institutes of Health Stroke Scale score, 9 [7-12]), 760 (93.0%) completed the trial. At 90 days, 210 of 329 participants (63.8%) in the argatroban plus alteplase group vs 238 of 367 (64.9%) in the alteplase alone group had an excellent functional outcome (risk difference, -1.0% [95% CI, -8.1% to 6.1%]; risk ratio, 0.98 [95% CI, 0.88-1.10]; P = .78). The percentages of participants with symptomatic intracranial hemorrhage, parenchymal hematoma type 2, and major systemic bleeding were 2.1% (8/383), 2.3% (9/383), and 0.3% (1/383), respectively, in the argatroban plus alteplase group and 1.8% (7/397), 2.5% (10/397), and 0.5% (2/397), respectively, in the alteplase alone group. CONCLUSIONS AND RELEVANCE Among patients with acute ischemic stroke, treatment with argatroban plus intravenous alteplase compared with alteplase alone did not result in a significantly greater likelihood of excellent functional outcome at 90 days. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03740958.
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Affiliation(s)
- Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Zhong-He Zhou
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Ying-Jie Dai
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Gao-Hua Li
- Department of Neurology, Liaoning Health Industry Group Fukuang General Hospital, Fushun, China
| | - Zhao-Long Peng
- Department of Neurology, The Affiliated Nanshi Hospital of Henan University, Nanyang, China
| | - Yi Zhang
- Department of Neurology, Tieling County Central Hospital, Tieling, China
| | - Xiao-Dong Liu
- Department of Neurology, Tonghua Vascular Disease Hospital, Tonghua, China
| | - Zhi-Mei Yuan
- Department of Neurology, Tonghua Vascular Disease Hospital, Tonghua, China
| | - Chang-Hao Jiang
- Department of Neurology, Lvshunkou Traditional Chinese Medicine Hospital, Dalian, China
| | - Qing-Cheng Yang
- Department of Neurology, Anyang People’s Hospital, Anyang, China
| | - Ying-Jie Duan
- Department of Neurology, Liaoning Health Industry Group Fuxinkuang General Hospital, Fuxin, China
| | - Guang-Bin Ma
- Department of Neurology, Haicheng Traditional Chinese Medicine Hospital, Haicheng, China
| | - Li-Wei Zhao
- Department of Neurology, Anshan Changda Hospital, Anshan, China
| | - Rui-Xian Wang
- Department of Neurology, Tianjin Beichen Traditional Chinese Hospital, Tianjin, China
| | - Yuan-Lin Sun
- Department of Neurology, Panjin Central Hospital, Panjin, China
| | - Lei Shen
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Er-Qiang Wang
- Department of Neurology, Fuqing Hospital, Fuqing, China
| | - Li-Hua Wang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ye-Fang Feng
- Department of Neurology, Huludao Second People’s Hospital, Huludao, China
| | - Feng-Yun Wang
- Department of Neurology, Liaocheng Brain Hospital, Liaocheng, China
| | - Ren-Lin Zou
- Department of Neurology, Wafangdian Third Hospital, Dalian, China
| | - He-Ping Yang
- Department of Neurology, Guangxi Zhuang Autonomous Region People’s Hospital, Nanning, China
| | - Kai Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Duo-Lao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Yi-Long Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Farhoudi M, Sadigh-Eteghad S, Farjami A, Salatin S. Nanoparticle and Stem Cell Combination Therapy for the Management of Stroke. Curr Pharm Des 2023; 29:15-29. [PMID: 36515043 DOI: 10.2174/1381612829666221213113119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 12/15/2022]
Abstract
Stroke is currently one of the primary causes of morbidity and mortality worldwide. Unfortunately, the available treatments for stroke are still extremely limited. Indeed, stem cell (SC) therapy is a new option for the treatment of stroke that could significantly expand the therapeutic time window of stroke. Some proposed mechanisms for stroke-based SC therapy are the incorporation of SCs into the host brain to replace dead or damaged cells/tissues. Moreover, acute cell delivery can inhibit apoptosis and decrease lesion size, providing immunomudolatory and neuroprotection effects. However, several major SC problems related to SCs such as homing, viability, uncontrolled differentiation, and possible immune response, have limited SC therapy. A combination of SC therapy with nanoparticles (NPs) can be a solution to address these challenges. NPs have received considerable attention in regulating and controlling the behavior of SCs because of their unique physicochemical properties. By reviewing the pathophysiology of stroke and the therapeutic benefits of SCs and NPs, we hypothesize that combined therapy will offer a promising future in the field of stroke management. In this work, we discuss recent literature in SC research combined with NP-based strategies that may have a synergistic outcome after stroke incidence.
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Affiliation(s)
- Mehdi Farhoudi
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saeed Sadigh-Eteghad
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Afsaneh Farjami
- Food and Drug Safety Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Pharmaceutical Analysis Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sara Salatin
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
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7
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Abstract
The treatment of acute ischemic stroke continues to advance. The mainstay of treatment remains intravenous thrombolysis with alteplase. Recent studies demonstrated that later treatment with alteplase is beneficial in patients selected with advanced imaging techniques. Tenecteplase has been evaluated as an alternative thrombolytic drug and evidence suggests that it is as least as effective as alteplase and may lyse large vessel clots more effectively. Endovascular therapy with mechanical thrombectomy has now been shown to be beneficial up to 24 hours after stroke onset in carefully selected patients with proximal, large vessel occlusions. Ongoing studies are evaluating the effectiveness of thrombectomy in patients with more distal vessel occlusions and patients with proximal large vessel occlusions with larger ischemic core volumes and also in patients with milder neurological deficits. Cytoprotection is another potential acute stroke therapy that has not demonstrated efficacy in prior clinical trials. It should be reconsidered as an adjunct to reperfusion and a variety of new clinical trials can be envisioned to evaluate the potential benefits of cytoprotection in patients before and after reperfusion.
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Affiliation(s)
- Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.X.).,Chinese Institute of Brain Research (Y.X.)
| | - Ajay K Wakhloo
- Department of Neurointerventional Radiology Beth Israel Lahey Health Medical Center, Tufts University School of Medicine, Burlington' MA (A.K.W.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School' Boston' MA (M.F.)
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8
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Lv B, Guo FF, Lin JC, Jing F. Efficacy and safety of argatroban in treatment of acute ischemic stroke: A meta-analysis. World J Clin Cases 2022; 10:585-593. [PMID: 35097084 PMCID: PMC8771382 DOI: 10.12998/wjcc.v10.i2.585] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/14/2021] [Accepted: 12/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Argatroban is a novel direct thrombin inhibitor that has been used for treatment of acute ischemic stroke (AIS). To our knowledge, no systematic analysis has assessed the efficacy and safety of argatroban for treatment of AIS.
AIM To evaluate the efficacy and safety of argatroban for treatment of AIS.
METHODS Cochrane Library, Medline, PubMed, and Web of Science were searched to retrieve all studies associated with argatroban and AIS. Effective rate, adverse events rate, and 95% confidence intervals were calculated and pooled using meta-analysis methodology.
RESULTS We only found four randomized controlled studies, comprising 354 cases with 213 in the argatroban group and 141 in the control group. Great heterogeneity was found in the four studies (c2 = 11.44, I2 = 74%, P = 0.01). Subgroup analysis could not be performed because of the absence of detailed data. The two most recent studies showed acceptable heterogeneity (c2 = 1.56, I2 = 36%, P = 0.21). Our analysis showed that argatroban was not more effective than the control therapy in the acute phase of ischemic stroke (Z = 0.01, P = 0.99). Argatroban did not increase the risk of bleeding compared with the control group (c2 = 0.37, I2 = 0%, P = 0.54, Z = 0.80, P = 0.42).
CONCLUSION Patients with AIS might not benefit from argatroban and combination therapy with argatroban does not increase bleeding tendency.
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Affiliation(s)
- Bin Lv
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
| | - Fang-Fang Guo
- Health Management Institute, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Jia-Cai Lin
- Department of Neurology, Hainan Hospital of Chinese PLA General Hospital, Sanya 572022, Hainan Province, China
| | - Feng Jing
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
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9
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Adams HP, Davis PH. Antithrombotic Therapy for Treatment of Acute Ischemic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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10
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Zhang X, Zhang Q, Huang L, Liu M, Cheng Z, Zheng Y, Xu W, Lu J, Liu J, Huang M. Pien-Tze-Huang attenuates neuroinflammation in cerebral ischaemia-reperfusion injury in rats through the TLR4/NF-κB/MAPK pathway. PHARMACEUTICAL BIOLOGY 2021; 59:828-839. [PMID: 34196587 PMCID: PMC8253189 DOI: 10.1080/13880209.2021.1942926] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
CONTEXT Pien-Tze-Huang (PTH) is traditionally applied to treat various inflammation-related diseases including stroke. However, literature regarding the anti-inflammatory effects and possible mechanisms of PTH in ischaemic stroke is unavailable. OBJECTIVE This study investigates the anti-inflammatory effects and its underlying mechanism of PTH on ischaemic stroke. MATERIALS AND METHODS Cerebral ischaemia-reperfusion injury was induced through 2 h middle cerebral artery occlusion (MCAO) followed by 24 h reperfusion in male Sprague-Dawley (SD) rats receiving oral pre-treatment with PTH (180 mg/kg) for 4 days. TLR4 antagonist TAK-242 (3 mg/kg) was injected intraperitoneally at 1.5 h after MCAO. MRI, HE staining, qRT-PCR, western blot, and immunofluorescence methods were employed. RESULTS PTH treatment markedly reduced cerebral infarct volume (by 51%), improved neurological function (by 33%), and ameliorated brain histopathological damage in MCAO rats. It also reduced the levels of four inflammatory mediators including IL-1β (by 70%), IL-6 (by 78%), TNF-α (by 60%) and MCP-1 (by 58%); inhibited microglia and astrocyte activation; and decreased protein expression of iNOS and COX-2 in injured brains. Moreover, PTH down-regulated the protein expressions of TLR4, MyD88, and TRAF6; reduced the expression and nuclear translocation of NF-κB; and lowered the protein expressions of p-ERK1/2, p-JNK, and p-p38. Similar effects were observed in MCAO rats with TAK-242 treatment. However, combined administration of PTH and TAK-242 did not significantly reinforce the anti-inflammatory effects of PTH. DISCUSSION AND CONCLUSION PTH improved cerebral ischaemia-reperfusion injury by inhibiting neuroinflammation partly via the TLR4/NF-κB/MAPK signalling pathway, which will help guide its clinical application.
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Affiliation(s)
- Xiaoqin Zhang
- College of Pharmacy, Fujian Key laboratory of Chinese Materia Medica, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Qing Zhang
- College of Pharmacy, Fujian Key laboratory of Chinese Materia Medica, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Lili Huang
- College of Pharmacy, Fujian Key laboratory of Chinese Materia Medica, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Mingzhen Liu
- College of Pharmacy, Fujian Key laboratory of Chinese Materia Medica, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Zaixing Cheng
- College of Pharmacy, Fujian Key laboratory of Chinese Materia Medica, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Yanfang Zheng
- College of Pharmacy, Fujian Key laboratory of Chinese Materia Medica, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Wen Xu
- College of Pharmacy, Fujian Key laboratory of Chinese Materia Medica, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Jinjian Lu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China
| | - Jian Liu
- College of Pharmacy, Fujian Key laboratory of Chinese Materia Medica, Fujian University of Traditional Chinese Medicine, Fuzhou, China
- CONTACT Jian Liu
| | - Mingqing Huang
- College of Pharmacy, Fujian Key laboratory of Chinese Materia Medica, Fujian University of Traditional Chinese Medicine, Fuzhou, China
- Mingqing Huang College of Pharmacy, Fujian University of Traditional Chinese Medicine, No.1 Huatuo Road, Shangjie University Town, Fuzhou350108, PR China
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Wang PF, Sun ZR, Yu JC, Geng N, Liu LY, Zhu LN, Li J, Yuan HC, Zhao GC, Li ZG. Early argatroban and antiplatelet combination therapy in acute non-lacunar single subcortical infarct associated with mild intracranial atherosclerosis. BMC Neurol 2021; 21:440. [PMID: 34753435 PMCID: PMC8579679 DOI: 10.1186/s12883-021-02435-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/30/2021] [Indexed: 12/02/2022] Open
Abstract
Background Patients with acute non-lacunar single subcortical infarct (SSI) associated with mild intracranial atherosclerosis (ICAS) have a relatively high incidence of early neurological deterioration (END), resulting in unfavorable functional outcomes. Whether the early administration of argatroban and aspirin or clopidogrel within 6–12 h after symptom onset is effective and safe in these patients is unknown. Methods A review of the stroke database of Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University and Qingdao Center Hospital, Qingdao University Medical College in China was undertaken from May 2017 to January 2020 to identify all patients with non-lacunar SSI caused by ICAS within 6–12 h of symptom onset based on MRI screening. Patients were divided into two groups, one comprising those who received argatroban and mono antiplatelet therapy with aspirin or clopidogrel on admission (argatroban group), and the other those who received dual antiplatelet therapy (DAPT) with aspirin and clopidogrel during hospitalization (DAPT group). The primary outcome was recovery by 90 days after stroke based on a modified Rankin scale (mRS) score (0 to 1). The secondary outcome was END incidence within 120 h of admission. Safety outcomes were intracranial hemorrhage (ICH) and major extracranial bleeding. The probability of clinical benefit (mRS score 0–1 at 90 days) was estimated using multivariable logistic regression analysis. Results A total of 304 acute non-lacunar SSI associated with mild ICAS patients were analyzed. At 90 days, 101 (74.2%) patients in the argatroban group and 80 (47.6%) in the DAPT group had an mRS score that improved from 0 to 1 (P < 0.001). The relative risk (95% credible interval) for an mRS score improving from 0 to 1 in the argatroban group was 1.50 (1.05–2.70). END occurred in 10 (7.3%) patients in the argatroban group compared with 37 (22.0%) in the DAPT group (P < 0.001). No patients experienced symptomatic hemorrhagic transformation. Conclusions Early combined administration of argatroban and an antiplatelet agent (aspirin or clopidogrel) may be beneficial for patients with non-lacunar SSI associated with mild ICAS identified by MRI screening and may attenuate progressive neurological deficits. Trial registration Our study is a retrospectively registered trial. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02435-x.
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Affiliation(s)
- Peng-Fei Wang
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Zhuo-Ran Sun
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Jin-Chao Yu
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Na Geng
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Ling-Yun Liu
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Li-Na Zhu
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Jing Li
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China
| | - Hai-Cheng Yuan
- Department of Neurology, Qingdao Central Hospital, Qingdao City, 266042, Shandong Province, China
| | - Guo-Chen Zhao
- School of Ocean Engineering, Harbin Institute of Technology at Weihai, Weihai, 264209, China
| | - Zhen-Guang Li
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No.70, Heping road, Huancui District, Weihai City, 264200, Shandong Province, China.
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12
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Hu L, Duan G, Xu Y, Cao Y. Prognostic analysis of different therapeutic regimens in patients with acute cardiogenic cerebral embolism. BMC Neurol 2021; 21:325. [PMID: 34425782 PMCID: PMC8381572 DOI: 10.1186/s12883-021-02348-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/09/2021] [Indexed: 11/17/2022] Open
Abstract
Background Few studies focused on the functional outcomes of patients at 3 months after receiving intravenous thrombolysis, anticoagulation, or antiplatelet therapy within 4.5 h of onset of the cardiogenic cerebral embolism (CCE) subtype. Methods The purpose of this retrospective study was to analyse the clinical data of patients with acute CCE and compare the 3-month functional prognoses of patients after administration of different antithrombotic therapies within 4.5 h of stroke onset. A total of 335 patients with CCE hospitalized in our institution were included in this study. The patients were stratified according to the hyperacute treatment received, and baseline clinical and laboratory data were analysed. A 3-month modified Rankin scale (mRS) score of 0–2 was defined as an excellent functional outcome. Results A total of 335 patients were divided into thrombolytic (n = 78), anticoagulant (n = 88), and antiplatelet therapy groups (n = 169). A total of 164 patients had a good prognosis at 3 months (mRS ≤ 2). After adjustments were made for age and National Institute of Health Stroke Scale (NIHSS) score, each group comprised 38 patients, and there were no significant differences in sex composition, complications, lesion characteristics, or Oxfordshire Community Stroke Project (OSCP) classification among the three groups. The plasma D-dimer level (µg/ml) in the thrombolytic group was significantly higher than those in the anticoagulant and antiplatelet groups [3.07 (1.50,5.62), 1.33 (0.95,1.89), 1.61 (0.76,2.96), P < 0.001]. After one week of treatment, the reduction in NIHSS in the thrombolytic group was significantly greater than those in the other two groups [3.00 (1.00, 8.00), 1.00 (0.00, 5.00), 1.00 (0.00, 2.00), P = 0.025]. A total of 47 patients (41.2 %) had an mRS score of ≤ 2 at 3 months, and 23 patients died (20.2 %). There was no significant difference in the proportion of patients with a good prognosis or the mortality rate among the three groups (P = 0.363, P = 0.683). Conclusions Thrombolytic therapy is effective at improving short-term and 3-month prognoses. Anticoagulant therapy may be a safe and effective treatment option for patients with the cardiac stroke subtype who fail to receive intravenous recombinant tissue plasminogen activator (r-tPA) thrombolysis within 4.5 h in addition to antiplatelet therapy, as recommended by the guidelines.
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Affiliation(s)
- Lan Hu
- Department of Neurology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gaoxin District, Room 406, Building 12, Jinyi Garden, Jiangxing West Road, Songling Town, Wujiang District, Jiangsu Province, 215004, Suzhou, China.,Department of Neurology, The Ninth People's Hospital of Soochow University, 2666 Ludang Road, Wujiang District, 215200, Suzhou, Jiangsu Province, China
| | - Guangxin Duan
- Department of Neurology, Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, Jiangsu Province, China
| | - Yuan Xu
- Department of Neurology, The Ninth People's Hospital of Soochow University, 2666 Ludang Road, Wujiang District, 215200, Suzhou, Jiangsu Province, China
| | - Yongjun Cao
- Department of Neurology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gaoxin District, Room 406, Building 12, Jinyi Garden, Jiangxing West Road, Songling Town, Wujiang District, Jiangsu Province, 215004, Suzhou, China.
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Hou X, Jin C, Pan C, Wang X, Xue J, Yang Z, Qi D. Effects of argatroban therapy for stroke patients: A meta-analysis. J Clin Neurosci 2021; 90:225-232. [PMID: 34275554 DOI: 10.1016/j.jocn.2021.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND The therapeutic efficacy and safety of argatroban for stroke patients remain controversial. The purpose of this study was to collect all evidence and perform a meta-analysis to comprehensively evaluate the effects of argatroban for stroke patients compared with no-argatroban regimens. METHODS The databases of PubMed, EMBASE and the Cochrane library were searched from their inception up to December 2020. Categorical outcomes were summarized as odds ratio (OR) and 95% confidence interval (CI); while continuous data were pooled as standardized mean difference (SMD) and 95%CI. RESULTS A total of 11 studies were enrolled. Overall meta-analysis showed infusion of argatroban significantly improved neurological functions of stroke patients compared with control treatment, showing increased National Institutes of Health Stroke Scale (NIHSS) score change (SMD = 1.02; 95% CI, 0.58-1.46, p < 0.001), modified Barthel Index (SMD = 3.81; 95% CI, 2.72-4.89, p < 0.001) as well as a decreased incidence of early neurological deterioration (OR = 0.48; 95% CI: 0.28-0.84, p = 0.01). Argatroban treatment did not increase the risk of symptomatic intracerebral hemorrhage (p = 0.733), asymptomatic intracranial hemorrhage (p = 0.608), gastrointestinal bleeding (p = 0.601), major systemic hemorrhage (p = 0.582) and mortality (p = 0.797), except minor systemic hemorrhage (OR = 2.40; 95% CI: 1.15-5.02, p = 0.020). Subgroup analyses for NIHSS score change and complications obtained the similar conclusions. CONCLUSION Argatroban infusion may be an effective and safe therapeutic option to improve functional outcomes of stroke patients.
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Affiliation(s)
- Xiaojun Hou
- Department of Elderly Neurology, Heilongjiang Province Hospital, Harbin 150036, China
| | - Chunfeng Jin
- Department of Stroke Neurology, the Second Hospital of Harbin, Harbin 150000, China
| | - Chengli Pan
- Department of Elderly Neurology, Heilongjiang Province Hospital, Harbin 150036, China
| | - Xichun Wang
- Department of Elderly Neurology, Heilongjiang Province Hospital, Harbin 150036, China
| | - Jujun Xue
- Department of Elderly Neurology, Heilongjiang Province Hospital, Harbin 150036, China
| | - Zhenghua Yang
- Department of Health and Hazards Surveillance, Shinan District Center for Disease Control and Prevention, Qingdao 266000, China
| | - Dan Qi
- Department of Neurology Stroke Center, Heilongjiang Province Hospital, Harbin 150036, China.
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Diagnostic and treatment recommendations from the FACME ad-hoc expert working group on the management of cerebral venous sinus thrombosis associated with COVID-19 vaccination. NEUROLOGÍA (ENGLISH EDITION) 2021; 36:451-461. [PMID: 34112621 PMCID: PMC8164341 DOI: 10.1016/j.nrleng.2021.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/04/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Cases of cerebral venous sinus thrombosis have been reported in individuals vaccinated against COVID-19 with non-replicating adenoviral vector vaccines. We issue our recommendations on the diagnosis and management of patients presenting this complication. METHODS The multidisciplinary working group, led by the Spanish Federation of Medical and Scientific Associations (FACME) and including representatives of several scientific societies, reviewed the available evidence from the literature and reports of the European Medicines Agency. We establish a definition for suspected cases and issue diagnostic and treatment recommendations regarding vaccine-induced immune thrombotic thrombocytopaenia. RESULTS We define suspected cases as those cases of cerebral venous sinus thrombosis occurring between 3 and 21 days after the administration of non-replicating adenoviral vector vaccines, in patients with a platelet count below 150 000/μL or presenting a decrease of 50% with respect to the previous value. Findings suggestive of vaccine-induced immune thrombotic thrombocytopaenia include the presence of antibodies to platelet factor 4, D-dimer levels 4 times greater than the upper limit of normal, and unexplained thrombosis. The recommended treatment includes intravenous administration of non-specific human immunoglobulin or alternatively plasmapheresis, avoiding the use of heparin, instead employing argatroban, bivalirudin, fondaparinux, rivaroxaban, or apixaban for anticoagulation, and avoiding platelet transfusion. CONCLUSIONS Non-replicating adenoviral vector vaccines may be associated with cerebral venous sinus thrombosis with thrombocytopaenia; it is important to treat the dysimmune phenomenon and the cerebral venous sinus thrombosis.
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Diagnostic and treatment recommendations from the FACME ad-hoc expert working group on the management of cerebral venous sinus thrombosis associated with COVID-19 vaccination. Neurologia 2021; 36:451-461. [PMID: 34049738 PMCID: PMC8101796 DOI: 10.1016/j.nrl.2021.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/04/2021] [Indexed: 01/12/2023] Open
Abstract
Introducción Se han reportado casos de trombosis venosas cerebrales en personas vacunadas frente a COVID-19 con vacunas vectorizadas con adenovirus no replicantes. Aportamos recomendaciones sobre el diagnóstico y manejo de pacientes con esta complicación. Método El grupo de trabajo multidisciplinar, liderado por la Federación de Asociaciones Científico Médicas Españolas y representado por distintas sociedades científicas, revisó la evidencia disponible publicada en la literatura y en los informes de la Agencia Europea de Medicamentos. Se estableció una definición de caso sospechoso y recomendaciones diagnóstico-terapéuticas de la trombocitopenia trombótica inducida por la vacunación. Resultados Se considera caso sospechoso aquella trombosis venosa cerebral ocurrida entre 3 y 21 días tras la administración de vacunas no replicantes de adenovirus que presenten un valor de plaquetas inferior a 150.000 plaquetas por μL o un descenso del 50% respecto de la cifra previa. Los datos indicativos de trombocitopenia trombótica inducida por la vacunación incluyen la presencia de anticuerpos antifactor plaquetario tipo 4, la elevación de dímero-D 4 veces por encima del límite superior de la normalidad o la ausencia de justificación de la trombosis. En su tratamiento, se recomienda administrar inmunoglobulina humana inespecífica intravenosa o realizar plasmaféresis en su defecto, evitar el uso de heparina, empleando como anticoagulantes argatroban, bivalirudina, fondaparinux, rivaroxabán o apixabán, y evitar la transfusión de plaquetas. Conclusiones Las vacunas de vectores no replicantes de adenovirus pueden asociarse a trombosis venosas cerebrales con trombocitopenia, en cuyo manejo es importante el tratamiento del fenómeno disinmune y de la trombosis venosa cerebral.
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16
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Ismael S, Nasoohi S, Yoo A, Mirzahosseini G, Ahmed HA, Ishrat T. Verapamil as an Adjunct Therapy to Reduce tPA Toxicity in Hyperglycemic Stroke: Implication of TXNIP/NLRP3 Inflammasome. Mol Neurobiol 2021; 58:3792-3804. [PMID: 33847912 DOI: 10.1007/s12035-021-02384-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/05/2021] [Indexed: 12/23/2022]
Abstract
Thrombolytic therapy has remained quite challenging in hyperglycemic patients for its association with poor prognosis and increased hemorrhagic conversions. We recently showed that tissue plasminogen activator (tPA)-induced cerebrovascular damage is associated with thioredoxin-interacting protein (TXNIP) upregulation, which has an established role in the detrimental effects of hyperglycemia. In the present work, we investigated whether verapamil, an established TXNIP inhibitor, may provide protection against hyperglycemic stroke and tPA-induced blood-brain barrier (BBB) disruption. Acute hyperglycemia was induced by intraperitoneal administration of 20% glucose, 15 min prior to transient middle cerebral artery occlusion (tMCAO). Verapamil (0.15 mg/kg) or saline was intravenously infused with tPA at hyperglycemic reperfusion, 1 h post tMCAO. After 24 h of ischemia/reperfusion (I/R), mice were assessed for neurobehavioral deficits followed by sacrifice and evaluation of brain infarct volume, edema, and microbleeding. Alterations in TXNIP, inflammatory mediators, and BBB markers were further analyzed using immunoblotting or immunostaining techniques. As adjunctive therapy, verapamil significantly reduced tPA-induced BBB leakage, matrix metalloproteinase 9 (MMP-9) upregulation, and tight junction protein deregulation, which resulted in lesser hemorrhagic conversions. Importantly, verapamil strongly reversed tPA-induced TXNIP/NLRP3 (NOD-like receptor pyrin domain-containing-3) inflammasome activation and reduced infarct volume. This concurred with a remarkable decrease in high-mobility group box protein 1 (HMGB-1) and nuclear factor kappa B (NF-κB) stimulation, leading to less priming of NLRP3 inflammasome. This preclinical study supports verapamil as a safe adjuvant that may complement thrombolytic therapy by inhibiting TXNIP's detrimental role in hyperglycemic stroke.
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Affiliation(s)
- Saifudeen Ismael
- Department of Anatomy and Neurobiology, College of Medicine, The University of Tennessee Health Science Center, 875 Monroe Avenue, Wittenborg Bldg, Room-231, Memphis, TN, 38163, USA.,Department of Pharmaceutical Sciences, The University of Tennessee Health Science Center, Memphis, TN, 38163, USA
| | - Sanaz Nasoohi
- Department of Anatomy and Neurobiology, College of Medicine, The University of Tennessee Health Science Center, 875 Monroe Avenue, Wittenborg Bldg, Room-231, Memphis, TN, 38163, USA.,Neuroscience Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arum Yoo
- Department of Anatomy and Neurobiology, College of Medicine, The University of Tennessee Health Science Center, 875 Monroe Avenue, Wittenborg Bldg, Room-231, Memphis, TN, 38163, USA.,Department of Pharmaceutical Sciences, The University of Tennessee Health Science Center, Memphis, TN, 38163, USA
| | - Golnoush Mirzahosseini
- Department of Anatomy and Neurobiology, College of Medicine, The University of Tennessee Health Science Center, 875 Monroe Avenue, Wittenborg Bldg, Room-231, Memphis, TN, 38163, USA.,Department of Pharmaceutical Sciences, The University of Tennessee Health Science Center, Memphis, TN, 38163, USA
| | - Heba A Ahmed
- Department of Anatomy and Neurobiology, College of Medicine, The University of Tennessee Health Science Center, 875 Monroe Avenue, Wittenborg Bldg, Room-231, Memphis, TN, 38163, USA.,Department of Pharmaceutical Sciences, The University of Tennessee Health Science Center, Memphis, TN, 38163, USA
| | - Tauheed Ishrat
- Department of Anatomy and Neurobiology, College of Medicine, The University of Tennessee Health Science Center, 875 Monroe Avenue, Wittenborg Bldg, Room-231, Memphis, TN, 38163, USA. .,Department of Pharmaceutical Sciences, The University of Tennessee Health Science Center, Memphis, TN, 38163, USA. .,Department of Neuroscience Institute, The University of Tennessee Health Science Center, Memphis, TN, 38163, USA.
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Gottula AL, Barreto AD, Adeoye O. Alteplase and Adjuvant Therapies for Acute Ischemic Stroke. Semin Neurol 2021; 41:16-27. [PMID: 33472270 DOI: 10.1055/s-0040-1722720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Acute ischemic stroke (AIS) is a time sensitive medical emergency and a leading cause of morbidity and mortality worldwide. Intravenous (IV) recombinant tissue plasminogen activator (IV alteplase) is currently the only proven effective medication for the treatment of AIS with promising adjuvant medications currently under investigation. Recent advances in endovascular thrombectomy have broadened therapeutic options in specific patient populations, with modern treatment strategies utilizing advanced imaging modalities to extend the window for treatment. In all cases, rapid treatment remains a priority. The future of IV alteplase and the changing standard for treatment of AIS remain unwritten with the increasing evidence for imaging selection for both endovascular thrombectomy and IV alteplase, while novel adjuncts are under investigation. In this article, we review the history of IV alteplase investigations for stroke, evidence for thrombectomy as an adjunct to IV alteplase, and the potential of novel adjuvant therapeutics currently under investigation.
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Affiliation(s)
- Adam L Gottula
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Andrew D Barreto
- Department of Neurology, University of Texas Houston, Houston, Texas
| | - Opeolu Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
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18
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Deeds SI, Barreto A, Elm J, Derdeyn CP, Berry S, Khatri P, Moy C, Janis S, Broderick J, Grotta J, Adeoye O. The multiarm optimization of stroke thrombolysis phase 3 acute stroke randomized clinical trial: Rationale and methods. Int J Stroke 2020; 16:873-880. [PMID: 33297893 DOI: 10.1177/1747493020978345] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Intravenous recombinant tissue plasminogen activator is the only proven effective medication for the treatment of acute ischemic stroke. Two approaches that may augment recombinant tissue plasminogen activator thrombolysis and prevent arterial reocclusion are direct thrombin inhibition with argatroban and inhibition of the glycoprotein 2b/3a receptor with eptifibatide. AIM The multi-arm optimization of stroke thrombolysis trial aims to determine the safety and efficacy of intravenous therapy with argatroban or eptifibatide as compared with placebo in acute ischemic stroke patients treated with intravenous recombinant tissue plasminogen activator within 3 h of symptom onset. SAMPLE SIZE ESTIMATE A maximum of 1200 randomized subjects to test the superiority of argatroban or eptifibatide to placebo in improving 90-day modified Rankin scores. METHODS AND DESIGN Multiarm optimization of stroke thrombolysis is a multicenter, multiarm, adaptive, single blind, randomized controlled phase 3 clinical trial conducted within the National Institutes of Health StrokeNet clinical trial network. Patients treated with 0.9 mg/kg intravenous recombinant tissue plasminogen activator within 3 h of stroke symptom onset are randomized to receive intravenous argatroban (100 µg/kg bolus followed by 3 µg/kg/min for 12 h), intravenous eptifibatide (135 µg/kg bolus followed by 0.75 µg/kg/min infusion for 2 h) or IV placebo. Patients may receive endovascular thrombectomy per usual care. STUDY OUTCOMES The primary efficacy outcome is improved modified Rankin score assessed at 90 days post-randomization. DISCUSSION Multiarm optimization of stroke thrombolysis is an innovative and collaborative project that is the culmination of many years of dedicated efforts to improve outcomes for stroke patients.
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Affiliation(s)
- S Iris Deeds
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Andrew Barreto
- Department of Neurology, University of Texas Health Science Center, Houston, TX, USA
| | - Jordan Elm
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Colin P Derdeyn
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH, USA
| | - Claudia Moy
- 35046National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Scott Janis
- 35046National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Joseph Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH, USA.,UC Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - James Grotta
- Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA
| | - Opeolu Adeoye
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
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Chen S, Cai D, Huang P, Liu J, Lai Y, He J, Zhou L, Sun H. Early and long-term outcomes of argatroban use in patients with acute noncardioembolic stroke. Clin Neurol Neurosurg 2020; 198:106233. [DOI: 10.1016/j.clineuro.2020.106233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 08/28/2020] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
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20
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Yang Y, Zhou Z, Pan Y, Chen H, Wang Y. Randomized trial of argatroban plus recombinant tissue-type plasminogen activator for acute ischemic stroke (ARAIS): Rationale and design. Am Heart J 2020; 225:38-43. [PMID: 32485328 DOI: 10.1016/j.ahj.2020.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/02/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Previous studies have implied the efficacy and safety of argatroban plus recombinant tissue-type plasminogen activator (r-tPA) in patients with acute ischemic stroke. Further trials are needed to establish convincing conclusions in a large sample size. RESEARCH DESIGN AND METHODS Argatroban plus r-tPA for Acute Ischemic Stroke (ARAIS) trial is a multicenter, prospective, randomized, open-label, and blind-end point trial. The trial proposes to randomize 808 patients with acute ischemic stroke National Institutes of Health Stroke Scale (NIHSS score≥ 6 at the time of randomization) within 4.5 hours of symptom onset to receive argatroban (100 μg/kg bolus followed by an infusion of 1.0 μg/kg per minute for 48 hours) plus r-tPA or r-tPA alone. The primary end point is the proportion of patients with an excellent outcome of no clinically significant residual stroke deficits (modified Rankin scale 0-1) at 90 days. Secondary end points include the proportion of patients with a good outcome (modified Rankin scale 0-2) at 90 days, early neurological improvement (NIHSS score ≥2-point decrease) at 48 hours, early neurological deterioration (NIHSS score ≥4-point increase) at 48 hours, decrease in the NIHSS score from baseline to 14 days, and stroke recurrence or other vascular events at 90 days. Safety end points include symptomatic intracerebral hemorrhage, parenchymal hematoma type 2, and major systemic bleeding. CONCLUSION ARAIS trial will evaluate whether argatroban plus r-tPA is superior to r-tPA alone in improving functional outcomes in acute ischemic stroke patients in a large sample population.
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Affiliation(s)
- Yingying Yang
- Department of Neurology, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Zhonghe Zhou
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Yuesong Pan
- Department of Neurology, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Huisheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China.
| | - Yilong Wang
- Department of Neurology, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.
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21
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Long Y, Yang Q, Xiang Y, Zhang Y, Wan J, Liu S, Li N, Peng W. Nose to brain drug delivery - A promising strategy for active components from herbal medicine for treating cerebral ischemia reperfusion. Pharmacol Res 2020; 159:104795. [PMID: 32278035 DOI: 10.1016/j.phrs.2020.104795] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 03/23/2020] [Accepted: 04/01/2020] [Indexed: 01/08/2023]
Abstract
Cerebral ischemia reperfusion injury (CIRI), one of the major causes of death from stroke in the world, not only causes tremendous damage to human health, but also brings heavy economic burden to society. Current available treatments for CIRI, including mechanical therapies and drug therapies, are often accompanied by significant side-effects. Therefore, it is necessary to discovery new strategies for treating CIRI. Many studies have confirmed that the herbal medicine has the advantages of abundant resources, good curative effect and little side effects, which can be used as potential drug for treatment of CIRI through multiple targets. It's known that oral administration commonly has low bioavailability, and injection administration is inconvenient and unsafe. Many drugs can't delivery to brain through routine pathways due to the blood-brain-barrier (BBB). Interestingly, increasing evidences have suggested the nasal administration is a potential direct route to transport drug into brain avoiding the BBB and has the characteristics of high bioavailability for treating brain diseases. Therefore, intranasal administration can be treated as an alternative way to treat brain diseases. In the present review, effective methods to treat CIRI by using active ingredients derived from herbal medicine through nose to brain drug delivery (NBDD) are updated and discussed, and some related pharmacological mechanisms have also been emphasized. Our present study would be beneficial for the further drug development of natural agents from herbal medicines via NBDD.
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Affiliation(s)
- Yu Long
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, No. 1166, Liutai Avenue, Chengdu, 611137, PR China
| | - Qiyue Yang
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, PR China
| | - Yan Xiang
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, No. 1166, Liutai Avenue, Chengdu, 611137, PR China
| | - Yulu Zhang
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, No. 1166, Liutai Avenue, Chengdu, 611137, PR China
| | - Jinyan Wan
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, No. 1166, Liutai Avenue, Chengdu, 611137, PR China
| | - Songyu Liu
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, No. 1166, Liutai Avenue, Chengdu, 611137, PR China
| | - Nan Li
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, No. 1166, Liutai Avenue, Chengdu, 611137, PR China.
| | - Wei Peng
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, No. 1166, Liutai Avenue, Chengdu, 611137, PR China.
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Kim J, Yi HJ, Lee DH, Sung JH. Safety and Feasibility of Using Argatroban Immediately After Mechanical Thrombectomy for Large Artery Occlusion. World Neurosurg 2019; 132:e341-e349. [DOI: 10.1016/j.wneu.2019.08.151] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
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Kim JS. tPA Helpers in the Treatment of Acute Ischemic Stroke: Are They Ready for Clinical Use? J Stroke 2019; 21:160-174. [PMID: 31161761 PMCID: PMC6549064 DOI: 10.5853/jos.2019.00584] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 04/15/2019] [Indexed: 12/12/2022] Open
Abstract
Tissue plasminogen activator (tPA) is the only therapeutic agent approved to treat patients with acute ischemic stroke. The clinical benefits of tPA manifest when the agent is administered within 4.5 hours of stroke onset. However, tPA administration, especially delayed administration, is associated with increased intracranial hemorrhage (ICH), hemorrhagic transformation (HT), and mortality. In the ischemic brain, vascular remodeling factors are upregulated and microvascular structures are destabilized. These factors disrupt the blood brain barrier (BBB). Delayed recanalization of the vessels in the presence of relatively matured infarction appears to damage the BBB, resulting in HT or ICH, also known as reperfusion injury. Moreover, tPA itself activates matrix metalloproteases, further aggravating BBB disruption. Therefore, attenuation of edema, HT, or ICH after tPA treatment is an important therapeutic strategy that may enable clinicians to extend therapeutic time and increase the probability of excellent outcomes. Recently, numerous agents with various mechanisms have been developed to interfere with various steps of ischemia/ reperfusion injuries or BBB destabilization. These agents successfully reduce infarct volume and decrease the incidence of ICH and HT after delayed tPA treatment in various animal stroke models. However, only some have entered into clinical trials; the results have been intriguing yet unsatisfactory. In this narrative review, I describe such drugs and discuss the problems and future directions. These “tPA helpers” may be clinically used in the future to increase the efficacy of tPA in patients with acute ischemic stroke.
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Affiliation(s)
- Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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