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Li W, Wang S, Liu L, Chen J, Lan J, Ding J, Chen Z, Yuan S, Qi Z, Wei M, Ji X. Normobaric Hyperoxia Combined With Endovascular Treatment Based on Temporal Gradient: A Dose-Escalation Study. Stroke 2024; 55:1468-1476. [PMID: 38747162 DOI: 10.1161/strokeaha.123.046106] [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: 12/05/2023] [Accepted: 03/28/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Normobaric hyperoxia (NBO) has neuroprotective effects in acute ischemic stroke. Thus, we aimed to identify the optimal NBO treatment duration combined with endovascular treatment. METHODS This is a single-center, randomized controlled, open-label, blinded-end point dose-escalation clinical trial. Patients with acute ischemic stroke who had an indication for endovascular treatment at Tianjin Huanhu Hospital were randomly assigned to 4 groups (1:1 ratio) based on NBO therapy duration: (1) control group (1 L/min oxygen for 4 hours); (2) NBO-2h group (10 L/min for 2 hours); (3) NBO-4h group (10 L/min for 4 hours); and (4) NBO-6h group (10 L/min for 6 hours). The primary outcome was cerebral infarction volume at 72 hours after randomization using an intention-to-treat analysis model. The primary safety outcome was the 90-day mortality rate. RESULTS Between June 2022 and September 2023, 100 patients were randomly assigned to the following groups: control group (n=25), NBO-2h group (n=25), NBO-4h group (n=25), and NBO-6h group (n=25). The 72-hour cerebral infarct volumes were 39.4±34.3 mL, 30.6±30.1 mL, 19.7±15.4 mL, and 22.6±22.4 mL, respectively (P=0.013). The NBO-4h and NBO-6h groups both showed statistically significant differences (adjusted P values: 0.011 and 0.027, respectively) compared with the control group. Compared with the control group, both the NBO-4h and NBO-6h groups showed significant differences (P<0.05) in the National Institutes of Health Stroke Scale scores at 24 hours, 72 hours, and 7 days, as well as in the change of the National Institutes of Health Stroke Scale scores from baseline to 24 hours. Additionally, there were no significant differences among the 4 groups in terms of 90-day mortality rate, symptomatic intracranial hemorrhage, early neurological deterioration, or severe adverse events. CONCLUSIONS The effectiveness of NBO therapy was associated with oxygen administration duration. Among patients with acute ischemic stroke who underwent endovascular treatment, NBO therapy for 4 and 6 hours was found to be more effective. Larger-scale multicenter studies are needed to validate these findings. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05404373.
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Affiliation(s)
- Weili Li
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China (W.L.)
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders (W.L., J.L., M.W., X.J.)
| | - Sifei Wang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, China (S.W.)
- Department of Neurosurgery, Tianjin Huanhu Hospital, China (S.W., M.W.)
| | - Lan Liu
- School of Statistics, University of Minnesota at Twin Cities, Minneapolis (L.L.)
| | | | - Jing Lan
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders (W.L., J.L., M.W., X.J.)
| | - Jiayue Ding
- Department of Neurology, Tianjin Medical University General Hospital, China (J.D.)
| | - Zhiying Chen
- Department of Neurology, Jiujiang University Affiliated Hospital, China (Z.C.)
| | - Shuhua Yuan
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital (S.Y., Z.Q.), Capital Medical University, Beijing, China
| | - Zhifeng Qi
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital (S.Y., Z.Q.), Capital Medical University, Beijing, China
| | - Ming Wei
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders (W.L., J.L., M.W., X.J.)
- Department of Neurosurgery, Tianjin Huanhu Hospital, China (S.W., M.W.)
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders (W.L., J.L., M.W., X.J.)
- Department of Neurosurgery, Xuanwu Hospital (X.J.), Capital Medical University, Beijing, China
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Liang J, Qi Z, Liu W, Wang P, Shi W, Dong W, Ji X, Luo Y, Liu KJ. Normobaric hyperoxia slows blood-brain barrier damage and expands the therapeutic time window for tissue-type plasminogen activator treatment in cerebral ischemia. Stroke 2015; 46:1344-1351. [PMID: 25804925 DOI: 10.1161/strokeaha.114.008599] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 02/25/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE Prolonged ischemia causes blood-brain barrier (BBB) damage and increases the incidence of neurovasculature complications secondary to reperfusion. Therefore, targeting ischemic BBB damage pathogenesis is critical to reducing neurovasculature complications and expanding the therapeutic time window of tissue-type plasminogen activator (tPA) thrombolysis. This study investigates whether increasing cerebral tissue PO2 through normobaric hyperoxia (NBO) treatment will slow the progression of BBB damage and, thus, improve the outcome of delayed tPA treatment after cerebral ischemia. METHODS Rats were exposed to NBO (100% O2) or normoxia (21% O2) during 3-, 5-, or, 7-hour middle cerebral artery occlusion. Fifteen minutes before reperfusion, tPA was continuously infused to rats for 30 minutes. Neurological score, mortality rate, and BBB permeability were determined. Matrix metalloproteinase-9 was measured by gelatin zymography and tight junction proteins (occludin and cluadin-5) by Western blot in the isolated cerebral microvessels. RESULTS NBO slowed the progression of ischemic BBB damage pathogenesis, evidenced by reduced Evan blue leakage, smaller edema, and hemorrhagic volume in NBO-treated rats. NBO treatment reduced matrix metalloproteinase-9 induction and the loss of tight junction proteins in ischemic cerebral microvessels. NBO-afforded BBB protection was maintained during tPA reperfusion, resulting in improved neurological functions, significant reductions in brain edema, hemorrhagic volume, and mortality rate, even when tPA was given after prolonged ischemia (7 hours). CONCLUSIONS Early NBO treatment slows ischemic BBB damage pathogenesis and significantly improves the outcome of delayed tPA treatment, providing new evidence supporting NBO as an effective adjunctive therapy to extend the time window of tPA thrombolysis for ischemic stroke.
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Affiliation(s)
- Jia Liang
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China.,Central Laboratory of Liaoning Medical University, Jinzhou, Liaoning, China
| | - Zhifeng Qi
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Wenlan Liu
- Department of Pharmaceutical Sciences, University of New Mexico, Albuquerque, NM, USA
| | - Peng Wang
- Central Laboratory of Liaoning Medical University, Jinzhou, Liaoning, China
| | - Wenjuan Shi
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Wen Dong
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xunming Ji
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Yumin Luo
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Ke Jian Liu
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China.,Department of Pharmaceutical Sciences, University of New Mexico, Albuquerque, NM, USA
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3
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Abstract
Background and Purpose—
Here, we assessed how sustained is reversal of the acute diffusion lesion (RAD) observed 24 hours after intravenous thrombolysis, and the relationships between RAD fate and early neurological improvement.
Methods—
We analyzed 155 consecutive patients thrombolyzed intravenously 152 minutes (median) after stroke onset and who underwent 3 MR sessions: 1 before and 2 after treatment (median times from onset, 25.6 and 54.3 hours, respectively). Using voxel-based analysis of diffusion-weighted imaging (DWI)
1
, DWI
2
, and DWI
3
lesions on coregistered image data sets, we assessed the outcome of RAD voxels (hyperintense on DWI
1
but not on DWI
2
) as transient or sustained on DWI
3
, and their relationships with early neurological improvement, defined as ΔNational Institutes of Health Stroke Scale ≥8 or National Institutes of Health Stroke Scale ≤1 at 24 hours.
T
max
and apparent diffusion coefficient values were compared between sustained and transient RAD voxels.
Results—
The median (interquartile range) baseline National Institutes of Health Stroke Scale and DWI
1
lesion volume were 11 (7–18) mL and 15.6 (6.0–50.9) mL, respectively. The median (interquartile range) RAD volume on DWI
2
was 2.8 (1.1–6.6) mL, of which 70% was sustained on DWI
3
. Sixteen (10.3%) patients had sustained RAD ≥10 mL. As compared with transient RAD voxels, sustained RAD voxels had nonsignificantly higher baseline apparent diffusion coefficient values (median [interquartile range], 793 [717–887] versus 777 [705–869]×10
−6
mm
2
·s
−1
, respectively;
P
=0.08) and significantly better perfusion (
T
max
, mean±SD, 6.3±3.2 versus 7.8±4.0 s;
P
<0.001). At variance with transient RAD, the volume of sustained RAD was associated with early neurological improvement in multivariate analysis (odds ratio, 1.08; 95% confidence interval, [1.01–1.17], per 1-mL increase;
P
=0.03).
Conclusions—
After thrombolysis, over two-thirds of the DWI lesion reversal captured on 24-hour follow-up MR is sustained. Sustained DWI lesion reversal volume is a strong imaging correlate of early neurological improvement.
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Clot injection technique affects thrombolytic efficacy in a rat embolic stroke model: implications for translaboratory collaborations. J Cereb Blood Flow Metab 2014; 34:677-82. [PMID: 24424380 PMCID: PMC3982093 DOI: 10.1038/jcbfm.2014.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 12/20/2013] [Accepted: 12/23/2013] [Indexed: 01/08/2023]
Abstract
Current recommendations encourage the use of embolic stroke (ES) models and replication of results across laboratories in preclinical research. Since such endeavors employ different surgeons, we sought to ascertain the impact of injection technique on outcome and response to thrombolysis in an ES model. Embolic stroke was induced in Male Wistar Kyoto rats (n=166) by a fast or a slow clot injection (CI) technique. Saline or recombinant tissue plasminogen activator (rtPA) was given at 1 hour after stroke. Flow rate curves were assessed in 24 animals. Cerebral perfusion was assessed using laser Doppler flowmetry. Edema corrected infarct volume, hemispheric swelling, hemorrhagic transformation, and neurologic outcome were assessed at 24 hours after stroke. Clot burden was estimated in a subset of animals (n=40). Slow CI resulted in significantly smaller infarct volumes (P=0.024) and better neurologic outcomes (P=0.01) compared with fast CI at 24 hours. Unexpectedly, rtPA treatment attenuated infarct size in fast (P<0.001) but not in slow CI experiments (P=0.382), possibly related to reperfusion injury as indicated by greater hemorrhagic transformation (P<0.001) and hemispheric swelling (P<0.05). Outcome and response to thrombolysis after ES are operator dependent, which needs to be considered when comparing results obtained from different laboratories.
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Inoue M, Mlynash M, Christensen S, Wheeler HM, Straka M, Tipirneni A, Kemp SM, Zaharchuk G, Olivot JM, Bammer R, Lansberg MG, Albers GW. Early diffusion-weighted imaging reversal after endovascular reperfusion is typically transient in patients imaged 3 to 6 hours after onset. Stroke 2014; 45:1024-8. [PMID: 24558095 DOI: 10.1161/strokeaha.113.002135] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to assess the frequency and extent of early diffusion-weighted imaging (DWI) lesion reversal after endovascular therapy and to determine whether early reversal is sustained or transient. METHODS MRI with DWI perfusion imaging was performed before (DWI 1) and within 12 hours after (DWI 2) endovascular treatment; follow-up MRI was obtained on day 5. Both DWIs were coregistered to follow-up MRI. Early DWI reversal was defined as the volume of the DWI 1 lesion that was not superimposed on the DWI 2 lesion. Permanent reversal was the volume of the DWI 1 lesion not superimposed on the day 5 infarct volume. Associations between early DWI reversal and clinical outcomes in patients with and without reperfusion were assessed. RESULTS A total of 110 patients had technically adequate DWI before endovascular therapy (performed median [interquartile range], 4.5 [2.8-6.2] hours after onset); 60 were eligible for this study. Thirty-two percent had early DWI reversal >10 mL; 17% had sustained reversal. The median volume of permanent reversal at 5 days was 3 mL (interquartile range, 1.7-7.0). Only 2 patients (3%) had a final infarct volume that was smaller than their baseline DWI lesion. Early DWI reversal was not an independent predictor of clinical outcome and was not associated with early reperfusion. CONCLUSIONS Early DWI reversal occurred in about one third of patients after endovascular therapy; however, reversal was often transient and was not associated with a significant volume of tissue salvage or favorable clinical outcome.
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Affiliation(s)
- Manabu Inoue
- From the Stanford Stroke Center, Stanford University School of Medicine, CA
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6
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Present status and future challenges of electroencephalography- and magnetic resonance imaging-based monitoring in preclinical models of focal cerebral ischemia. Brain Res Bull 2014; 102:22-36. [PMID: 24462642 DOI: 10.1016/j.brainresbull.2014.01.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 01/07/2014] [Accepted: 01/14/2014] [Indexed: 12/16/2022]
Abstract
Animal models are useful tools for better understanding the mechanisms underlying neurological deterioration after an ischemic insult as well as subsequent evolution of changes and recovery of functions. In response to the updated requirements for preclinical investigations of stroke to include relevant functional measurement techniques and biomarker endpoints, we here review the state of knowledge on application of some translational electrophysiological and neuroimaging methods, and in particular, electroencephalography monitoring and magnetic resonance imaging in rodent models of ischemic stroke. This may lead to improvement of diagnostic methods and identification of new therapeutic targets, which would considerably advance the translational value of preclinical stroke research.
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Bouts MJRJ, Tiebosch IACW, van der Toorn A, Viergever MA, Wu O, Dijkhuizen RM. Early identification of potentially salvageable tissue with MRI-based predictive algorithms after experimental ischemic stroke. J Cereb Blood Flow Metab 2013; 33:1075-82. [PMID: 23571283 PMCID: PMC3705436 DOI: 10.1038/jcbfm.2013.51] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 03/04/2013] [Accepted: 03/05/2013] [Indexed: 01/13/2023]
Abstract
Individualized stroke treatment decisions can be improved by accurate identification of the extent of salvageable tissue. Magnetic resonance imaging (MRI)-based approaches, including measurement of a 'perfusion-diffusion mismatch' and calculation of infarction probability, allow assessment of tissue-at-risk; however, the ability to explicitly depict potentially salvageable tissue remains uncertain. In this study, five predictive algorithms (generalized linear model (GLM), generalized additive model, support vector machine, adaptive boosting, and random forest) were tested in their potency to depict acute cerebral ischemic tissue that can recover after reperfusion. Acute T2-, diffusion-, and perfusion-weighted MRI, and follow-up T2 maps were collected from rats subjected to right-sided middle cerebral artery occlusion without subsequent reperfusion, for training of algorithms (Group I), and with spontaneous (Group II) or thrombolysis-induced reperfusion (Group III), to determine infarction probability-based viability thresholds and prediction accuracies. The infarction probability difference between irreversible-i.e., infarcted after reperfusion-and salvageable tissue injury-i.e., noninfarcted after reperfusion-was largest for GLM (20±7%) with highest accuracy of risk-based identification of acutely ischemic tissue that could recover on subsequent reperfusion (Dice's similarity index=0.79±0.14). Our study shows that assessment of the heterogeneity of infarction probability with MRI-based algorithms enables estimation of the extent of potentially salvageable tissue after acute ischemic stroke.
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Affiliation(s)
- Mark J R J Bouts
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
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8
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Lapergue B, Deroide N, Pocard M, Michel JB, Meilhac O, Bonnin P. Transcranial duplex sonography for monitoring circle of Willis artery occlusion in a rat embolic stroke model. J Neurosci Methods 2011; 197:289-96. [DOI: 10.1016/j.jneumeth.2011.02.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 02/16/2011] [Accepted: 02/18/2011] [Indexed: 11/28/2022]
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9
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Sicard KM, Fisher M. Animal models of focal brain ischemia. EXPERIMENTAL & TRANSLATIONAL STROKE MEDICINE 2009; 1:7. [PMID: 20150985 PMCID: PMC2820445 DOI: 10.1186/2040-7378-1-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 11/13/2009] [Indexed: 11/25/2022]
Abstract
Stroke is a leading cause of disability and death in many countries. Understanding the pathophysiology of ischemic injury and developing therapies is an important endeavor that requires much additional research. Animal stroke models provide an important mechanism for these activities. A large number of stroke models have been developed and are currently used in laboratories around the world. These models are overviewed as are approaches for measuring infarct size and functional outcome.
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Affiliation(s)
- Kenneth M Sicard
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01453, USA
| | - Marc Fisher
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01453, USA
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10
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Henninger N, Bouley J, Bråtane BT, Bastan B, Shea M, Fisher M. Laser Doppler flowmetry predicts occlusion but not tPA-mediated reperfusion success after rat embolic stroke. Exp Neurol 2009; 215:290-7. [DOI: 10.1016/j.expneurol.2008.10.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Revised: 10/14/2008] [Accepted: 10/23/2008] [Indexed: 10/21/2022]
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