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Guo ZN, Yue BH, Fan L, Liu J, Zhu Y, Zhao Y, Zhong J, Lou Z, Liu XL, Abuduxukuer R, Zhang P, Qu Y, Shen Z, Shi B, Zhang KJ, Liu J, Chang J, Jin H, Sun X, Yang Y. Effectiveness of butylphthalide on cerebral autoregulation in ischemic stroke patients with large artery atherosclerosis (EBCAS study): A randomized, controlled, multicenter trial. J Cereb Blood Flow Metab 2023; 43:1702-1712. [PMID: 37021629 PMCID: PMC10581234 DOI: 10.1177/0271678x231168507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/15/2023] [Accepted: 02/22/2023] [Indexed: 04/07/2023]
Abstract
Finding appropriate drugs to improve cerebral autoregulation (CA) in patients with acute ischemic stroke (AIS) is necessary to improve prognosis. We aimed to investigate the effect of butylphthalide on CA in patients with AIS. In this randomized controlled trial, 99 patients were 2:1 randomized to butylphthalide or placebo group. The butylphthalide group received intravenous infusion with a preconfigured butylphthalide-sodium chloride solution for 14 days and an oral butylphthalide capsule for additional 76 days. The placebo group synchronously received an intravenous infusion of 100 mL 0.9% saline and an oral butylphthalide simulation capsule. The transfer function parameter, phase difference (PD), and gain were used to quantify CA. The primary outcomes were CA levels on the affected side on day 14 and day 90. Eighty patients completed the follow-up (52 in the butylphthalide group and 28 in the placebo group). The PD of the affected side on 14 days or discharge and on 90 days was higher in the butylphthalide group than in the placebo group. The differences in safety outcomes were not significant. Therefore, butylphthalide treatment for 90 days can significantly improve CA in patients with AIS.Trial registration: ClinicalTrial.gov: NCT03413202.
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Affiliation(s)
- Zhen-Ni Guo
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
- Neuroscience Research Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Bing-Hong Yue
- Department of Neurology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Lei Fan
- Department of Neurology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Jie Liu
- Department of Neurology, The People's Hospital of Lixin County, Bozhou, China
| | - Yuanyuan Zhu
- Department of Neurology, The People's Hospital of Lixin County, Bozhou, China
| | - Yuanqi Zhao
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jingxin Zhong
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhan Lou
- Department of Neurology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Xing-Liang Liu
- Department of Neurology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Reziya Abuduxukuer
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Peng Zhang
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Yang Qu
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Ziduo Shen
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Baoyang Shi
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Ke-Jia Zhang
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Jia Liu
- Laboratory for Engineering and Scientific Computing, Institute of Advanced Computing and Digital Engineering, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Junlei Chang
- Center for Protein and Cell-based Drugs, Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Hang Jin
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Xin Sun
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Yi Yang
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
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Wu X, Zhou Y, Qi W, Shen Y, Lei Z, Xiao K, Zhang P, Liu J, Ren L. Clinical factors associated with cerebral autoregulation in ischemic stroke related to small artery occlusion. BMC Neurol 2022; 22:364. [PMID: 36138338 PMCID: PMC9494772 DOI: 10.1186/s12883-022-02854-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Existing data suggest that cerebral autoregulation (CA) varies among different subtypes of ischaemic stroke. CA is globally impaired in patients with small artery occlusion (SAO). However, the factors influencing CA impairment in patients remains to be elucidated. Methods Stroke patients with SAO who underwent brain magnetic resonance imaging (MRI) were prospectively studied. Within 7 days after stroke onset, CA was recorded from the middle cerebral artery blood flow velocity and arterial blood pressure was simultaneously measured. Transfer function analysis was used to derive CA parameters, including gain and phase. Clinical characteristics, mean arterial pressure (MAP), biochemical findings, and cerebral small vessel disease (CSVD) markers on MRI were assessed in each patient. Factors associated with CA parameters were investigated. Univariate and multivariate linear regression analyses were conducted to determine the relationship between clinical factors and CA parameters. Results Sixty-three SAO patients (age, 56.3 ± 9.9 years; 55 men) were enrolled in the study. In the multiple linear regression analysis, after controlling for relevant clinical factors, MAP on admission (ipsilateral OR = 0.99 and contralateral OR = 0.99, both P < 0.005) was a significant independent predictor of bilateral gain. MAP > 105 mmHg on admission (OR = 0.77, P = 0.019) was significantly associated with ipsilateral gain. Diabetes mellitus was a significant predictive factor for bilateral gain (ipsilateral OR = 1.32 and contralateral OR = 1.22, both P < 0.005). No correlations were found between CA parameters and CSVD characteristics. Conclusion In SAO-related ischaemic stroke, patients with MAP > 105 mmHg on admission tended to have better ipsilateral CA. Diabetes mellitus appears to be an independent risk factor for CA impairment in patients with SAO-related stroke. CSVD may not be the main factor affecting bilateral CA in patients with SAO. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02854-4.
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Affiliation(s)
- Xiaohong Wu
- Department of Neurology, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, 518035, China
| | - Yanxia Zhou
- Department of Neurology, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, 518035, China
| | - Wenwei Qi
- Tianjin Institute of Cardiology, the Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Yanxia Shen
- Department of Neurology, Pinghu Hospital of Shenzhen University, Shenzhen, China
| | - Zhihao Lei
- Department of Neurology, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, 518035, China
| | - Kun Xiao
- Department of Neurology, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, 518035, China
| | - Pandeng Zhang
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Jia Liu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Lijie Ren
- Department of Neurology, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, 518035, China.
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Blood Pressure Variability Indices for Outcome Prediction After Thrombectomy in Stroke by Using High-Resolution Data. Neurocrit Care 2022; 37:220-229. [PMID: 35606560 PMCID: PMC9343264 DOI: 10.1007/s12028-022-01519-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/11/2022] [Indexed: 11/25/2022]
Abstract
Background Blood pressure variability (BPV) is associated with outcome after endovascular thrombectomy in acute large vessel occlusion stroke. We aimed to provide the optimal sampling frequency and BPV index for outcome prediction by using high-resolution blood pressure (BP) data. Methods Patient characteristics, 3-month outcome, and BP values measured intraarterially at 1 Hz for up to 24 h were extracted from 34 patients treated at a tertiary care center neurocritical care unit. Outcome was dichotomized (modified Rankin Scale 0–2, favorable, and 3–6, unfavorable) and associated with systolic BPV (as calculated by using standard deviation, coefficient of variation, averaged real variability, successive variation, number of trend changes, and a spectral approach using the power of specific BP frequencies). BP values were downsampled by either averaging or omitting all BP values within each prespecified time bin to compare the different sampling rates. Results Out of 34 patients (age 72 ± 12.7 years, 67.6% men), 10 (29.4%) achieved a favorable functional outcome and 24 (70.6%) had an unfavorable functional outcome at 3 months. No group differences were found in mean absolute systolic BP (SBP) (130 ± 18 mm Hg, p = 0.82) and diastolic BP (DBP) (59 ± 10 mm Hg, p = 1.00) during the monitoring time. BPV only reached predictive significance when using successive variation extracted from downsampled (averaged over 5 min) SBP data (median 4.8 mm Hg [range 3.8–7.1]) in patients with favorable versus 7.1 mmHg [range 5.5–9.7] in those with unfavorable outcome, area under the curve = 0.74 [confidence interval (CI) 0.57–0.85; p = 0.031], or the power of midrange frequencies between 1/20 and 1/5 min [area under the curve = 0.75 (CI 0.59–0.86), p = 0.020]. Conclusions Using high-resolution BP data of 1 Hz, downsampling by averaging all BP values within 5-min intervals is essential to find relevant differences in systolic BPV, as noise can be avoided (confirmed by the significance of the power of midrange frequencies). These results demonstrate how high-resolution BP data can be processed for effective outcome prediction. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-022-01519-x.
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Abstract
PURPOSE OF REVIEW Cerebral autoregulation (CA) is a mechanism that maintains cerebral blood flow constant despite fluctuations in systemic arterial blood pressure. This review will focus on recent studies that measured CA non-invasively in acute cerebrovascular events, a feature unique to the transcranial Doppler ultrasound. We will summarize the rationale for CA assessment in acute cerebrovascular disorders and specifically evaluate the existing data on the value of CA measures in relation to clinical severity, guiding management decisions, and prognostication. RECENT FINDINGS Existing data suggest that CA is generally impaired in various cerebrovascular disorders. In patients with small vessel ischemic stroke, CA has been shown to be impaired in both hemispheres, whereas in large territorial strokes, CA impairment has been limited to the affected hemisphere. In these latter patients, impaired CA is also predictive of secondary complications such as hemorrhagic transformation and cerebral edema, hence worse functional outcome. In patients with carotid stenosis, impaired CA may also be associated with a higher ipsilateral hemispheric stroke risk. CA is also strongly linked to outcome in patients with intracranial hemorrhage. In patients with intraparenchymal hemorrhage, CA impairment correlated with clinical and imaging severity, whereas in those with subarachnoid hemorrhage, CA measures have a predictive value for development of delayed cerebral ischemia and radiographic vasospasm. Assessment of CA is increasingly more accessible in acute cerebrovascular disorders and promises to be a valuable measure in guiding hemodynamic management and predicting secondary complication, thus enhancing the care of these patients in the acute setting.
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Affiliation(s)
- Pedro Castro
- Department of Neurology, São João Hospital Center, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology, São João Hospital Center, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Farzaneh Sorond
- Department of Neurology, Division of Stroke and Neurocritical, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Ward 12-140, Chicago, IL, 60611, USA.
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Hu X, De Silva TM, Chen J, Faraci FM. Cerebral Vascular Disease and Neurovascular Injury in Ischemic Stroke. Circ Res 2017; 120:449-471. [PMID: 28154097 PMCID: PMC5313039 DOI: 10.1161/circresaha.116.308427] [Citation(s) in RCA: 256] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/13/2016] [Accepted: 10/26/2016] [Indexed: 12/13/2022]
Abstract
The consequences of cerebrovascular disease are among the leading health issues worldwide. Large and small cerebral vessel disease can trigger stroke and contribute to the vascular component of other forms of neurological dysfunction and degeneration. Both forms of vascular disease are driven by diverse risk factors, with hypertension as the leading contributor. Despite the importance of neurovascular disease and subsequent injury after ischemic events, fundamental knowledge in these areas lag behind our current understanding of neuroprotection and vascular biology in general. The goal of this review is to address select key structural and functional changes in the vasculature that promote hypoperfusion and ischemia, while also affecting the extent of injury and effectiveness of therapy. In addition, as damage to the blood-brain barrier is one of the major consequences of ischemia, we discuss cellular and molecular mechanisms underlying ischemia-induced changes in blood-brain barrier integrity and function, including alterations in endothelial cells and the contribution of pericytes, immune cells, and matrix metalloproteinases. Identification of cell types, pathways, and molecules that control vascular changes before and after ischemia may result in novel approaches to slow the progression of cerebrovascular disease and lessen both the frequency and impact of ischemic events.
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Affiliation(s)
- Xiaoming Hu
- Center of Cerebrovascular Disease Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - T. Michael De Silva
- Biomedicine Discovery Institute, Department of Pharmacology, 9 Ancora Imparo Way, Monash University, Clayton, Vic, Australia
| | - Jun Chen
- Center of Cerebrovascular Disease Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Frank M. Faraci
- Departments of Internal Medicine and Pharmacology, Carver College of Medicine, University of Iowa, Iowa City Veterans Affairs Healthcare System, Iowa City, IA, USA
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Suh JY, Shim WH, Cho G, Fan X, Kwon SJ, Kim JK, Dai G, Wang X, Kim YR. Reduced microvascular volume and hemispherically deficient vasoreactivity to hypercapnia in acute ischemia: MRI study using permanent middle cerebral artery occlusion rat model. J Cereb Blood Flow Metab 2015; 35:1033-43. [PMID: 25690471 PMCID: PMC4640250 DOI: 10.1038/jcbfm.2015.22] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 01/11/2015] [Accepted: 01/12/2015] [Indexed: 11/09/2022]
Abstract
Vasoreactivity to hypercapnia has been used for assessing cerebrovascular tone and control altered by ischemic stroke. Despite the high prognostic potential, traits of hypercapnia-induced hemodynamic changes have not been fully characterized in relation with baseline vascular states and brain tissue damage. To monitor cerebrovascular responses, T2- and T2*-weighted magnetic resonance imaging (MRI) images were acquired alternatively using spin- and gradient-echo echo plannar imaging (GESE EPI) sequence with 5% CO2 gas inhalation in normal (n=5) and acute stroke rats (n=10). Dynamic relative changes in cerebrovascular volume (CBV), microvascular volume (MVV), and vascular size index (VSI) were assessed from regions of interest (ROIs) delineated by the percent decrease of apparent diffusion coefficient (ADC). The baseline CBV was not affected by middle cerebral artery occlusion (MCAO) whereas the baseline MVV in ischemic areas was significantly lower than that in the rest of the brain and correlated with ADC. Vasoreactivity to hypercapnic challenge was considerably attenuated in the entire ipsilesional hemisphere including normal ADC regions, in which unsolicited, spreading depression-associated increases of CBV and MVV were observed. The lesion-dependent inhomogeneity in baseline MVV indicates the effective perfusion reserve for accurately delineating the true ischemic damage while the cascade of neuronal depolarization is probably responsible for the hemispherically lateralized changes in overall neurovascular physiology.
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Affiliation(s)
- J Y Suh
- 1] Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA [2] Division of Magnetic Resonance Research, Korea Basic Science Institute, Cheongwon, Chungbuk, The Republic of Korea
| | - Woo H Shim
- 1] Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA [2] Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, The Republic of Korea
| | - Gyunggoo Cho
- Division of Magnetic Resonance Research, Korea Basic Science Institute, Cheongwon, Chungbuk, The Republic of Korea
| | - Xiang Fan
- Neuroprotection Research Laboratory, Department of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Seon J Kwon
- 1] Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA [2] Department of Neurology, Kang's Medical Center, Pocheon, The Republic of Korea
| | - Jeong K Kim
- 1] Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA [2] Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, The Republic of Korea
| | - George Dai
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Xiaoying Wang
- Neuroprotection Research Laboratory, Department of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Young R Kim
- 1] Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA [2] School of Nano-Bioscience and Chemical Engineering, UNIST (Ulsan National Institute of Science and Technology), Ulsan, The Republic of Korea
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Petersen NH, Ortega-Gutierrez S, Reccius A, Masurkar A, Huang A, Marshall RS. Dynamic cerebral autoregulation is transiently impaired for one week after large-vessel acute ischemic stroke. Cerebrovasc Dis 2015; 39:144-50. [PMID: 25661277 DOI: 10.1159/000368595] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 09/23/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Dynamic cerebral autoregulation (DCA) is the continuous counterregulation of cerebral blood flow to fluctuations in blood pressure. DCA can become impaired after acute stroke, but it remains unclear to what extent and over what interval this occurs. METHODS We included 28 patients (NIHSS = 12 ± 6.5, age = 68.4 ± 17.1, 16F) with acute large-vessel ischemic stroke in the middle cerebral artery territory and 29 healthy controls (mean age 54.9 ± 9, 16F). DCA was assessed by simultaneous measurement of blood pressure together with blood flow velocities using finger plethysmography/arterial catheter and transcranial Doppler over three 10-minute recordings on days 0-2, 3-6 and ≥7 days after stroke. Transfer function analysis was applied to calculate average phase shift (PS) in the low frequency range (0.06-0.12 Hz). Less PS indicated poorer autoregulation. The affected side was compared with the unaffected side and controls. Univariate comparisons of data were performed using t tests at single time points, and generalized estimating equations with an exchangeable correlation matrix to examine the change in PS over time. RESULTS At mean 1.3 ± 0.5 days after stroke the average PS in the affected hemisphere was 29.6 ± 10.5 vs. 42.5 ± 13 degrees in the unaffected hemisphere (p = 0.004). At 4.1 ± 1 days, the PS in affected and unaffected hemisphere was 23.2 ± 19.1 vs. 41.7 ± 18.5 degrees, respectively (p = 0.003). At mean 9.75 ± 2.2 days stroke there was no difference between the affected and the unaffected hemisphere (53.2 ± 28.2 vs. 50.7 ± 29.2 degrees, p = 0.69). Control subjects had an average PS = 47.9 ± 16.8, significantly different from patients' affected hemisphere at the first two measurements (p = 0.001), but not the third (p = 0.37). The PS in controls remained unchanged on repeat testing after an average 19.1 days (48.4 ± 17.1, p = 0.61). Using the last recording as the reference, the average PS in the affected hemisphere was -23.54 (-44.1, -3) degrees lower on recording one (p = 0.025), and -31.6 (-56.1, -7.1) degrees lower on recording two (p < 0.011). Changes in the unaffected hemisphere over time were nonsignificant. DISCUSSION These data suggest that dynamic cerebral autoregulation is impaired in the affected hemisphere throughout the first week after large-vessel ischemic stroke, and then normalizes by week two. These findings may have important implications for acute blood pressure management after stroke.
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Affiliation(s)
- Nils H Petersen
- Department of Neurology, Columbia University, New York, N.Y., USA
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Abstract
SIGNIFICANCE The brain has high energetic requirements and is therefore highly dependent on adequate cerebral blood supply. To compensate for dangerous fluctuations in cerebral perfusion, the circulation of the brain has evolved intrinsic safeguarding measures. RECENT ADVANCES AND CRITICAL ISSUES The vascular network of the brain incorporates a high degree of redundancy, allowing the redirection and redistribution of blood flow in the event of vascular occlusion. Furthermore, active responses such as cerebral autoregulation, which acts to maintain constant cerebral blood flow in response to changing blood pressure, and functional hyperemia, which couples blood supply with synaptic activity, allow the brain to maintain adequate cerebral perfusion in the face of varying supply or demand. In the presence of stroke risk factors, such as hypertension and diabetes, these protective processes are impaired and the susceptibility of the brain to ischemic injury is increased. One potential mechanism for the increased injury is that collateral flow arising from the normally perfused brain and supplying blood flow to the ischemic region is suppressed, resulting in more severe ischemia. FUTURE DIRECTIONS Approaches to support collateral flow may ameliorate the outcome of focal cerebral ischemia by rescuing cerebral perfusion in potentially viable regions of the ischemic territory.
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Affiliation(s)
- Katherine Jackman
- Brain and Mind Research Institute, Weill Cornell Medical College , New York, New York
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Vakili A, Einali MR, Bandegi AR. Protective Effect of Crocin against Cerebral Ischemia in a Dose-dependent Manner in a Rat Model of Ischemic Stroke. J Stroke Cerebrovasc Dis 2014. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.10.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Reinhard M, Rutsch S, Lambeck J, Wihler C, Czosnyka M, Weiller C, Hetzel A. Dynamic cerebral autoregulation associates with infarct size and outcome after ischemic stroke. Acta Neurol Scand 2012; 125:156-62. [PMID: 21470192 DOI: 10.1111/j.1600-0404.2011.01515.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Cerebral autoregulation is particularly challenged in acute ischemic stroke. We investigated (1) clinical and radiological factors related to dynamic cerebral autoregulation (DCA) in acute stroke and (2) the relationship between DCA and clinical outcome of stroke. METHODS A total of 45 patients with middle cerebral artery (MCA) stroke were analyzed pooling two previous studies. DCA was measured by transcranial Doppler in both MCAs early (within 48 h from onset) and late (day 5-7) using low-frequency phase and correlation analysis (index Mx). Outcome was assessed by modified Rankin scale after a mean period of 4 months. RESULTS Mx increased (i.e. autoregulation worsened) between the early and late measurement, more so on affected (P = 0.005) than on unaffected sides (P = 0.014). Poorer autoregulation as indicated by lower ipsilateral phase (early and late) and higher Mx (late measurement) were significantly related to larger infarction. More severe stroke was significantly related to poorer ipsilateral Mx and phase. Ipsilateral phase in the early (P = 0.019) and Mx in the late measurement (P =0..016) were related to poor clinical outcome according to univariate analysis. CONCLUSIONS Impairment of DCA ipsilateral to acute ischemic stroke is associated with larger infarction. Dysautoregulation tends to worsen and spread to the contralateral side over the first days post-stroke and is associated with poor clinical outcome.
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Affiliation(s)
- M Reinhard
- Department of Neurology, University of Freiburg, Germany.
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KUNZ ALEXANDER, IADECOLA COSTANTINO. Cerebral vascular dysregulation in the ischemic brain. HANDBOOK OF CLINICAL NEUROLOGY 2009; 92:283-305. [PMID: 18790280 PMCID: PMC3982865 DOI: 10.1016/s0072-9752(08)01914-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Pellegrini-Giampietro DE, Mannaioni G, Bagetta G. Post-ischemic brain damage: the endocannabinoid system in the mechanisms of neuronal death. FEBS J 2008; 276:2-12. [DOI: 10.1111/j.1742-4658.2008.06765.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
The human costs of stroke are very large and growing; it is the third largest cause of death in the United States and survivors are often faced with loss of ability to function independently. There is a large need for therapeutic approaches that act to protect neurons from the injury produced by ischemia and reperfusion. The goal of this review is to introduce and discuss the available data that endogenous cannabinoid signaling is altered during ischemia and that it contributes to the consequences of ischemia-induced injury. Overall, the available data suggest that inhibition of CB1 receptor activation together with increased CB2 receptor activation produces beneficial effects.
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Affiliation(s)
- Cecilia J Hillard
- Department of Pharmacology and Toxicology, Medical College of Wisconsin; Milwaukee, WI 53226, USA.
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Tuor UI, Wang R, Zhao Z, Foniok T, Rushforth D, Wamsteeker JI, Qiao M. Transient hypertension concurrent with forepaw stimulation enhances functional MRI responsiveness in infarct and peri-infarct regions. J Cereb Blood Flow Metab 2007; 27:1819-29. [PMID: 17377516 DOI: 10.1038/sj.jcbfm.9600472] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although functional magnetic resonance imaging (fMRI) is gaining use as a tool to assess cerebral recovery following various insults, the effects of potential confounders such as hypertension are poorly defined. We hypothesized that after stroke, transient hypertension during an fMRI study could produce a detected activation unrelated to neuronal activity within the infarct. Thus, the effect of norepinephrine induced increases in blood pressure (BP) on the fMRI response to forepaw stimulation were investigated in controls or 1 week after transient middle cerebral artery occlusion in rats. Images were smoothed spatially and voxels correlating to either forepaw stimulation or the change in BP time courses were analyzed. Transient hypertension increased the signal intensity and numbers of voxels correlating to the BP time courses within and adjacent to the ischemic infarct and these exceeded the response in the contralateral hemisphere or in controls. With left paw stimulation at normotension, there was a loss of activation in right sensory-motor cortex -- a region with necrosis and disruption of cerebral vessels. As BP increased left paw stimulation also resulted in the detection of activation in the infarcted sensory-motor cortex and peri-infarct regions. Thus, BP changes synchronous with tasks in fMRI studies can result in MR signal changes consistent with a loss of cerebral blood flow (CBF) autoregulation rather than neuronal activation in necrotic brain. After stroke, the use of stressful tasks associated with BP changes in fMRI studies should be limited or the BP change should be considered as a potential source of MR signal changes.
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Affiliation(s)
- Ursula I Tuor
- MR Technology, Institute for Biodiagnostics (West), National Research Council, Calgary, Alberta, Canada.
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Baldauf K, Henrich-Noack P, Reymann KG. Detrimental effects of halothane narcosis on damage after endothelin-1-induced MCAO. J Neurosci Methods 2007; 162:14-8. [PMID: 17197033 DOI: 10.1016/j.jneumeth.2006.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Revised: 11/29/2006] [Accepted: 11/30/2006] [Indexed: 12/01/2022]
Abstract
The influence of anaesthesia in experimental stroke research is controversial. We addressed this problem using the model of endothelin-1-induced occlusion of the middle cerebral artery (eMCAO). This model provided the opportunity to compare the infarct volumes of rats which were under halothane anaesthesia during eMCAO induction with the lesions of rats which were without anaesthesia during eMCAO. All animals were implanted with guide cannulae which allowed the induction of ischaemia in freely moving animals. For comparison, one group of animals was exposed to halothane during the induction of ischaemia. Seven days after eMCAO, the average infarct volume of halothane-anaesthetised rats was significantly larger than the lesion in freely moving animals. This difference was mainly due to increased cortical damage, whereas the striatum was much less influenced. The cortical infarct volume 21 days after induction of eMCAO under anaesthesia was significantly reduced compared to the infarct volume 7 days after eMCAO under anaesthesia. Our results indicate that halothane anaesthesia during eMCAO can cause a transient cortical increase in ischaemic infarct volume. The influence of volatile anaesthetics on ischaemic pathophysiology should be taken into consideration when preclinically testing potential neuroprotective drugs for clinical applications.
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Affiliation(s)
- Kathrin Baldauf
- Leibniz Institute for Neurobiology, Brenneckestrasse 6, D-39118 Magdeburg, Germany.
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17
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Blood pressure management in patients with acute stroke: Pathophysiology and treatment strategies. Neurosurg Clin N Am 2006; 17 Suppl 1:41-56. [DOI: 10.1016/s1042-3680(06)80006-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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18
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Lee EJ, Lee MY, Chen HY, Hsu YS, Wu TS, Chen ST, Chang GL. Melatonin attenuates gray and white matter damage in a mouse model of transient focal cerebral ischemia. J Pineal Res 2005; 38:42-52. [PMID: 15617536 DOI: 10.1111/j.1600-079x.2004.00173.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We have previously shown that melatonin reduces infarct volumes and enhances neurobehavioral and electrophysiological recoveries following transient middle cerebral artery (MCA) occlusion in rats. In the study, we examined whether melatonin would display neuroprotection against neuronal, axonal and oligodendrocyte pathology after 24 hr of reperfusion following 1 hr of MCA occlusion in mice. Melatonin (5 mg/kg) or vehicle was given intraperitoneally at the commencement of reperfusion. Neurological deficits were assessed 24 hr after ischemia. Gray matter damage was evaluated by quantitative histopathology. Axonal damage was determined with amyloid precursor protein and microtubule-associated protein tau-1 immunohistochemistry to identify postischemic disrupted axonal flow and oligodendrocyte pathology, respectively. Oxidative damage was assessed by 8-hydroxy-2'-deoxyguanosine (8-OHdG) and 4-hydroxynonenal (4-HNE) immunohistochemistry. Relative to controls, melatonin-treated animals not only had a significantly reduced volume of gray matter infarction by 42% (P<0.001), but also exhibited a decreased score of axonal damage by 42% (P<0.001) and a reduction in the volume of oligodendrocyte pathology by 58% (P<0.005). Melatonin-treated animals also had significantly reduced immunopositive reactions for 8-OHdG and 4-HNE by 53% (P<0.001) and 49% (P<0.001), respectively. In addition, melatonin improved sensory and motor neurobehavioral outcomes by 47 and 30%, respectively (P<0.01). Thus, delayed (1 hr) treatment with melatonin reduced both gray and white matter damage and improved neurobehavioral outcomes following transient focal cerebral ischemia in mice. The finding of reduced oxidative damage observed with melatonin suggests that its major mechanisms of action are mediated through its antioxidant and radical scavenging activity.
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Affiliation(s)
- E-Jian Lee
- Neurophysiology Laboratory, Neurosurgical Service, Department of Surgery and Institute of Biomedical Engineering, National Cheng Kung University Medical Center and Medical School, Tainan, Taiwan.
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19
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Marshall RS. The functional relevance of cerebral hemodynamics: why blood flow matters to the injured and recovering brain. Curr Opin Neurol 2004; 17:705-9. [PMID: 15542979 DOI: 10.1097/00019052-200412000-00010] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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20
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Muthian S, Rademacher DJ, Roelke CT, Gross GJ, Hillard CJ. Anandamide content is increased and CB1 cannabinoid receptor blockade is protective during transient, focal cerebral ischemia. Neuroscience 2004; 129:743-50. [PMID: 15541895 DOI: 10.1016/j.neuroscience.2004.08.044] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2004] [Indexed: 10/26/2022]
Abstract
The role of endocannabinoid signaling in the response of the brain to injury is tantalizing but not clear. In this study, transient middle cerebral artery occlusion (MCAo) was used to produce ischemia/reperfusion injury. Brain content of N-arachidonoylethanolamine (AEA) and 2-arachidonoylglycerol were determined during MCAo. Whole brain AEA content was significantly increased after 30, 60 and 120 min MCAo compared with sham-operated brain. The increase in AEA was localized to the ischemic hemisphere after 30 min MCAo, but at 60 and 120 min, was also increased in the contralateral hemisphere. 2-Arachidonoylglycerol content was unaffected by MCAo. In a second set of studies, injury was assessed 24 h after 2 h MCAo. Rats administered a single dose (3 mg/kg) of the cannabinoid receptor type 1 (CB1) receptor antagonist SR141716 prior to MCAo exhibited a 50% reduction in infarct volume and a 40% improvement in neurological function compared with vehicle control. A second CB1 receptor antagonist, LY320135 (6 mg/kg), also significantly improved neurological function. The CB1 receptor agonist, WIN 55212-2 (0.1-1 mg/kg) did not affect either infarct volume or neurological score.
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MESH Headings
- Animals
- Arachidonic Acids/metabolism
- Benzofurans/administration & dosage
- Benzoxazines
- Blood Pressure/drug effects
- Brain Chemistry/physiology
- Brain Infarction/pathology
- Chromatography, Liquid/methods
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Endocannabinoids
- Hemodynamics/drug effects
- Infarction, Middle Cerebral Artery/complications
- Infarction, Middle Cerebral Artery/drug therapy
- Ischemic Attack, Transient/etiology
- Ischemic Attack, Transient/metabolism
- Ischemic Attack, Transient/physiopathology
- Ischemic Attack, Transient/prevention & control
- Male
- Mass Spectrometry/methods
- Morpholines/administration & dosage
- Naphthalenes/administration & dosage
- Neurologic Examination
- Piperidines/administration & dosage
- Piperidines/pharmacology
- Polyunsaturated Alkamides
- Pyrazoles/administration & dosage
- Pyrazoles/pharmacology
- Rats
- Rats, Wistar
- Receptor, Cannabinoid, CB1/agonists
- Receptor, Cannabinoid, CB1/antagonists & inhibitors
- Receptor, Cannabinoid, CB1/physiology
- Reperfusion Injury/metabolism
- Reperfusion Injury/prevention & control
- Rimonabant
- Tetrazolium Salts
- Time Factors
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Affiliation(s)
- S Muthian
- Department of Pharmacology and Toxicology, Medical College of Wisconsin, 8701 Watertown Planck Road, Milwaukee, WI 53226, USA.
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21
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Steiner LA, Coles JP, Johnston AJ, Czosnyka M, Fryer TD, Smielewski P, Chatfield DA, Salvador R, Aigbirhio FI, Clark JC, Menon DK, Pickard JD. Responses of posttraumatic pericontusional cerebral blood flow and blood volume to an increase in cerebral perfusion pressure. J Cereb Blood Flow Metab 2003; 23:1371-7. [PMID: 14600445 DOI: 10.1097/01.wcb.0000090861.67713.10] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In and around traumatic contusions, cerebral blood flow (CBF) is often near or below the threshold for ischemia. Increasing cerebral perfusion pressure (CPP) in patients with head injuries may improve CBF in these regions. However, the pericontusional response to this intervention has not been studied. Using positron emission tomography (PET), we have quantified the response to an increase in CPP in and around contusions in 18 contusions in 18 patients. Regional CBF and cerebral blood volume (CBV) were measured with PET at CPPs of 70 and 90 mmHg using norepinephrine to control CPP. Based upon computed tomography, regions of interest (ROIs) were placed as two concentric ellipsoids, each of 1-cm width, around the core of the contusions. Measurements were compared with a control ROI in tissue with normal anatomic appearance. Baseline CBF and CBV increased significantly with increasing distance from the core of the lesion. The increase in CPP led to small increases in CBF in all ROIs except the core. The largest absolute CBF increase was found in the control ROI. Relative CBF increases did not differ between ROIs so that ischemic areas remained ischemic. Pericontusional oedema on computed tomography was associated with lower absolute values of CBF and CBV but did not differ from nonoedematous tissue in the relative response to CPP elevation.
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Affiliation(s)
- Luzius A Steiner
- Wolfson Brain Imaging Centre, University Department of Anesthesia, Academic Neurosurgery, Addenbrooke's Hospital, Cambridge, UK.
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Gervitz LM, Davies DG, Omidvar K, Fowler JC. The effect of acute hypoxemia and hypotension on adenosine-mediated depression of evoked hippocampal synaptic transmission. Exp Neurol 2003; 182:507-17. [PMID: 12895463 DOI: 10.1016/s0014-4886(03)00160-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The present study was designed to investigate the relative contributions of arterial P(O(2)), local cerebral blood flow, and oxygen delivery to the adenosine A(1) receptor-mediated depression of evoked synaptic transmission recorded in the rat hippocampus. Urethane-anesthetized rats were given a unilateral common carotid artery occlusion and then placed in a stereotaxic apparatus for stimulation and recording of bilateral hippocampal field excitatory postsynaptic potentials (fEPSPs). Arterial blood gases, mean arterial blood pressure (MAP), and bilateral hippocampal blood flow (HBF) were also measured. Arterial P(O(2)), HBF, and oxygen delivery were manipulated using normoxic hypotension, hypoxic hypotension, and hypoxic normotension. Both hypoxic hypotension and normoxic hypotension resulted in decreased HBF, decreased oxygen delivery, and a depression of the evoked fEPSP limited to the hippocampus ipsilateral to the occlusion. The enhanced HBF and oxygen delivery associated with increased MAP resulted in a restoration and maintenance of hippocampal fEPSPs despite sustained hypoxemia. The adenosine A(1) receptor-mediated depression of the fEPSP was more strongly correlated with changes in HBF and oxygen delivery than with arterial P(O(2)). We propose that adenosine plays an important role mediating the depression of neuronal activity associated with reduced oxygen delivery characteristically observed in ischemic brain tissue.
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Affiliation(s)
- L M Gervitz
- Department of Physiology, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA.
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23
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Chee VW, Lew TW. Acute intraoperative cerebral oedema: are current therapies evidence based? Anaesth Intensive Care 2003; 31:309-15. [PMID: 12879679 DOI: 10.1177/0310057x0303100313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute intraoperative ischaemic cerebral oedema following torrential haemorrhage from the left intracranial internal carotid artery occurred during resection of a recurrent middle cranial fossa meningioma. A series of immediate anaesthetic interventions was effective in reducing brain oedema, allowed for surgical haemostasis, and resulted in no permanent sequelae to patient outcome. A review of the literature indicates that direct evidence for the efficacy of extremely early interventions as described in this case report is lacking and must be extrapolated from other brain injury models.
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Affiliation(s)
- V W Chee
- Department of Anaesthesiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
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24
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Abstract
Neonatal stroke occurs in approximately 1 in 4,000 to 1 in 10,000 newborns, and more than 80% involve the vascular territory supplied by the middle cerebral artery. Neonatal stroke is associated with many acquired and genetic prothrombotic factors, and follow-up studies indicate that as many as two thirds of neonates develop neurologic deficits. In the past two decades unilateral carotid occlusion with 8% hypoxia has been used to study focal and global ischemia in the newborn, and recently a filament model of middle cerebral artery occlusion has been developed. This review describes the results of studies in these two newborn models covering aspects of the injury cascade that occurs after focal ischemia. A likely requirement is that therapeutic efforts be directed less at using thrombolytic therapy and more toward treatment of events associated with reperfusion injury, the inflammatory cascade, and apoptosis. Additional areas of research that have received attention in the past year include inhibition of nitric oxide and free-radical formation, use of iron chelating agents, the potential role of hypoxia-inducible factors and mediators of caspase activity, use of growth factors, hypothermia, and administration of magnesium sulfate.
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Affiliation(s)
- S Ashwal
- Department of Pediatrics, Division of Child Neurology, Loma Linda University School of Medicine, Loma Linda, California 12350, USA.
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Anzuini A, Briguori C, Roubin GS, Pagnotta P, Rosanio S, Airoldi F, Carlino M, Pagnotta P, Di Mario C, Sheiban I, Magnani G, Jannello A, Melissano G, Chiesa R, Colombo A. Emergency stenting to treat neurological complications occurring after carotid endarterectomy. J Am Coll Cardiol 2001; 37:2074-9. [PMID: 11419890 DOI: 10.1016/s0735-1097(01)01284-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the efficacy of emergency stent implantation for the treatment of perioperative stroke after carotid endarterectomy (CEA). BACKGROUND Carotid endarterectomy has been proven safe and effective in reducing the risk of stroke in symptomatic and asymptomatic patients with >60% carotid artery stenosis. However, perioperative stroke has been reported in 1.5% to 9% of CEA cases. The management of such a complication is challenging. Recently, percutaneous transluminal carotid angioplasty with stent deployment has emerged as a valuable and alternative strategy for the treatment of carotid artery disease. METHODS Between April 1998 and February 2000, 18 of the 995 patients (1.8%) who had CEA in our institution experienced perioperative major or minor neurological complications. Of these, 13 patients underwent emergency carotid angiogram and eventual stent implantation, whereas the remaining five had surgery re-exploration. RESULTS Carotid angiogram was performed within 20+/-10 min and revealed vessel flow-limiting dissection (five cases) or thrombosis (eight cases). Percutaneous transluminal carotid angioplasty with direct stenting (self-expandable stent) was performed in all 13 cases. Angiographic success was 100%. Complete remission of neurological symptoms occurred in 11 of the 13 patients treated by stent implantation and in one of the five patients treated by surgical re-exploration (p = 0.024). CONCLUSIONS Stent implantation seems to be a safe and effective strategy in the treatment of perioperative stroke complicating CEA, especially when carotid dissection represents the main anatomic problem.
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Affiliation(s)
- A Anzuini
- Department of Cardiology, IRCCS San Raffaele Hospital, Milan, Italy
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