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Kim HI, Lee JC, Kim DW, Shin MC, Cho JH, Ahn JH, Lim SS, Kang IJ, Park JH, Won MH, Lee TK. Hypothermia Induced by Oxcarbazepine after Transient Forebrain Ischemia Exerts Therapeutic Neuroprotection through Transient Receptor Potential Vanilloid Type 1 and 4 in Gerbils. Int J Mol Sci 2021; 23:ijms23010237. [PMID: 35008663 PMCID: PMC8745517 DOI: 10.3390/ijms23010237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 11/16/2022] Open
Abstract
In the present study, we investigated the neuroprotective effect of post-ischemic treatment with oxcarbazepine (OXC; an anticonvulsant compound) against ischemic injury induced by transient forebrain ischemia and its mechanisms in gerbils. Transient ischemia was induced in the forebrain by occlusion of both common carotid arteries for 5 min under normothermic conditions (37 ± 0.2 °C). The ischemic gerbils were treated with vehicle, hypothermia (whole-body cooling; 33.0 ± 0.2 °C), or 200 mg/kg OXC. Post-ischemic treatments with vehicle and hypothermia failed to attenuate and improve, respectively, ischemia-induced hyperactivity and cognitive impairment (decline in spatial and short-term memory). However, post-ischemic treatment with OXC significantly attenuated the hyperactivity and the cognitive impairment, showing that OXC treatment significantly reduced body temperature (to about 33 °C). When the hippocampus was histopathologically examined, pyramidal cells (principal neurons) were dead (lost) in the subfield Cornu Ammonis 1 (CA1) of the gerbils treated with vehicle and hypothermia on Day 4 after ischemia, but these cells were saved in the gerbils treated with OXC. In the gerbils treated with OXC after ischemia, the expression of transient receptor potential vanilloid type 1 (TRPV1; one of the transient receptor potential cation channels) was significantly increased in the CA1 region compared with that in the gerbils treated with vehicle and hypothermia. In brief, our results showed that OXC-induced hypothermia after transient forebrain ischemia effectively protected against ischemia–reperfusion injury through an increase in TRPV1 expression in the gerbil hippocampal CA1 region, indicating that TRPV1 is involved in OXC-induced hypothermia.
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Affiliation(s)
- Hyung-Il Kim
- Department of Emergency Medicine, Dankook University Hospital, College of Medicine, Dankook University, Cheonan 31116, Chungnam, Korea;
- Department of Emergency Medicine, Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon 24289, Gangwon, Korea; (M.C.S.); (J.H.C.)
| | - Jae-Chul Lee
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon 24341, Gangwon, Korea; (J.-C.L.); (J.H.A.)
| | - Dae Won Kim
- Department of Biochemistry and Molecular Biology, Research Institute of Oral Sciences, College of Dentistry, Gangnung-Wonju National University, Gangneung 25457, Gangwon, Korea;
| | - Myoung Cheol Shin
- Department of Emergency Medicine, Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon 24289, Gangwon, Korea; (M.C.S.); (J.H.C.)
| | - Jun Hwi Cho
- Department of Emergency Medicine, Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon 24289, Gangwon, Korea; (M.C.S.); (J.H.C.)
| | - Ji Hyeon Ahn
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon 24341, Gangwon, Korea; (J.-C.L.); (J.H.A.)
- Department of Physical Therapy, College of Health Science, Youngsan University, Yangsan 50510, Gyeongnam, Korea
| | - Soon-Sung Lim
- Department of Food Science and Nutrition, Hallym University, Chuncheon 24252, Gangwon, Korea; (S.-S.L.); (I.J.K.)
| | - Il Jun Kang
- Department of Food Science and Nutrition, Hallym University, Chuncheon 24252, Gangwon, Korea; (S.-S.L.); (I.J.K.)
| | - Joon Ha Park
- Department of Anatomy, College of Korean Medicine, Dongguk University, Gyeongju 38066, Gyeongbuk, Korea;
| | - Moo-Ho Won
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon 24341, Gangwon, Korea; (J.-C.L.); (J.H.A.)
- Correspondence: (M.-H.W.); (T.-K.L.); Tel.: +82-33-250-8891 (M.-H.W.); +82-33-248-2135 (T.-K.L.); Fax: +82-33-256-1614 (M.-H.W.); +82-33-255-4787 (T.-K.L.)
| | - Tae-Kyeong Lee
- Department of Food Science and Nutrition, Hallym University, Chuncheon 24252, Gangwon, Korea; (S.-S.L.); (I.J.K.)
- Correspondence: (M.-H.W.); (T.-K.L.); Tel.: +82-33-250-8891 (M.-H.W.); +82-33-248-2135 (T.-K.L.); Fax: +82-33-256-1614 (M.-H.W.); +82-33-255-4787 (T.-K.L.)
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Abstract
BACKGROUND Gamma aminobutyric acid (GABA) receptor agonists have been shown to have a neuroprotectant effect in reducing infarct size and improving functional outcome in animal models of cerebrovascular disease. However, the sedative effects of GABA receptor agonists have limited their wider application in people with acute stroke, due to the potential risk of stupor. This is an update of a Cochrane Review first published in 2013, and previously updated in 2014 and 2016. OBJECTIVES To determine the efficacy and safety of GABA receptor agonists in the treatment of acute stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (accessed May 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) 2018, Issue 4 (accessed May 2018), MEDLINE (from 1949 to May 2018), Embase (from 1980 to May 2018), CINAHL (from 1982 to May 2018), AMED (from 1985 to May 2018), and 11 Chinese databases (accessed May 2018). In an effort to identify further published, unpublished, and ongoing trials we searched ongoing trial registers, reference lists, and relevant conference proceedings, and contacted authors and pharmaceutical companies. SELECTION CRITERIA We included randomized controlled trials (RCTs) investigating GABA receptor agonists versus placebo for people with acute stroke (within 12 hours after stroke onset), with the primary outcomes of efficacy and safety. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of identified records, selected studies for inclusion, extracted eligible data, cross-checked the data for accuracy, and assessed the risk of bias. We used the GRADE approach to assess the quality of the evidence. MAIN RESULTS We included five trials with 3838 participants (acute ischemic or hemorrhagic stroke patients, 3758 analyzed). Most of the participants recruited had acute ischaemic stroke, with limited data available from participants with other stroke subtypes, including total anterior circulation syndrome (TACS). The methodological quality of the included trials was generally good, with an unclear risk for selection bias only. For death and dependency at three months, pooled results did not find a significant difference for chlormethiazole versus placebo (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.96 to 1.11; four trials; 2909 participants; moderate-quality evidence) and for diazepam versus placebo (RR 0.94, 95% CI 0.82 to 1.07; one trial; 849 participants; moderate-quality evidence). The most frequent adverse events related to chlormethiazole were somnolence (RR 4.56, 95% CI 3.50 to 5.95; two trials; 2527 participants; moderate-quality evidence) and rhinitis (RR 4.75, 95% CI 2.67 to 8.46; two trials; 2527 participants; moderate-quality evidence). AUTHORS' CONCLUSIONS This review provides moderate-quality evidence that fails to support the use of GABA receptor agonists (chlormethiazole or diazepam) for the treatment of people with acute stroke. More well-designed RCTs with large samples of participants with total anterior circulation syndrome are required to determine if there are benefits for this subgroup. Somnolence and rhinitis are frequent adverse events related to chlormethiazole.
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Affiliation(s)
- Jia Liu
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyChangchun Street 45BeijingChina100053
| | - Jing Zhang
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyChangchun Street 45BeijingChina100053
| | - Lu‐Ning Wang
- Chinese PLA General HospitalDepartment of Geriatric NeurologyFuxing Road 28Haidian DistrictBeijingChina100853
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Mizuma A, Yenari MA. Anti-Inflammatory Targets for the Treatment of Reperfusion Injury in Stroke. Front Neurol 2017; 8:467. [PMID: 28936196 PMCID: PMC5594066 DOI: 10.3389/fneur.2017.00467] [Citation(s) in RCA: 162] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/23/2017] [Indexed: 12/20/2022] Open
Abstract
While the mainstay of acute stroke treatment includes revascularization via recombinant tissue plasminogen activator or mechanical thrombectomy, only a minority of stroke patients are eligible for treatment, as delayed treatment can lead to worsened outcome. This worsened outcome at the experimental level has been attributed to an entity known as reperfusion injury (R/I). R/I is occurred when revascularization is delayed after critical brain and vascular injury has occurred, so that when oxygenated blood is restored, ischemic damage is increased, rather than decreased. R/I can increase lesion size and also worsen blood barrier breakdown and lead to brain edema and hemorrhage. A major mechanism underlying R/I is that of poststroke inflammation. The poststroke immune response consists of the aberrant activation of glial cell, infiltration of peripheral leukocytes, and the release of damage-associated molecular pattern (DAMP) molecules elaborated by ischemic cells of the brain. Inflammatory mediators involved in this response include cytokines, chemokines, adhesion molecules, and several immune molecule effectors such as matrix metalloproteinases-9, inducible nitric oxide synthase, nitric oxide, and reactive oxygen species. Several experimental studies over the years have characterized these molecules and have shown that their inhibition improves neurological outcome. Yet, numerous clinical studies failed to demonstrate any positive outcomes in stroke patients. However, many of these clinical trials were carried out before the routine use of revascularization therapies. In this review, we cover mechanisms of inflammation involved in R/I, therapeutic targets, and relevant experimental and clinical studies, which might stimulate renewed interest in designing clinical trials to specifically target R/I. We propose that by targeting anti-inflammatory targets in R/I as a combined therapy, it may be possible to further improve outcomes from pharmacological thrombolysis or mechanical thrombectomy.
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Affiliation(s)
- Atsushi Mizuma
- Department of Neurology, University of California, San Francisco and Veterans Affairs Medical Center, San Francisco, CA, United States
| | - Midori A Yenari
- Department of Neurology, University of California, San Francisco and Veterans Affairs Medical Center, San Francisco, CA, United States
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Abstract
BACKGROUND Gamma aminobutyric acid (GABA) receptor agonists have been shown to have a neuroprotectant effect in reducing infarct size and improving functional outcome in animal models of cerebrovascular disease. However, the sedative effects of GABA receptor agonists have limited their wider application in people with acute stroke, due to the potential risk of stupor. This is an update of a Cochrane review first published in 2013, and previously updated in 2014. OBJECTIVES To determine the efficacy and safety of GABA receptor agonists in the treatment of acute stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (accessed March 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) 2016, Issue 3, part of the Cochrane Library (accessed March 2016), MEDLINE (from 1949 to March 2016), Embase (from 1980 to March 2016), CINAHL (from 1982 to March 2016), AMED (from 1985 to March 2016), and 11 Chinese databases (accessed March 2016). In an effort to identify further published, unpublished, and ongoing trials we searched ongoing trials registers, reference lists, and relevant conference proceedings, and contacted authors and pharmaceutical companies. SELECTION CRITERIA We included randomized controlled trials (RCTs) investigating GABA receptor agonists versus placebo for people with acute stroke (within 12 hours after stroke onset), with the primary outcomes of efficacy and safety. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of identified records, selected studies for inclusion, extracted eligible data, cross-checked the data for accuracy, and assessed the risk of bias. MAIN RESULTS We included five trials with 3838 participants (3758 analyzed). The methodological quality of the included trials was generally good, with an unclear risk for selection bias only. Four trials (N = 2909) measured death and dependency at three months for chlormethiazole versus placebo; pooled results did not find a significant difference (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.96 to 1.11). One trial (N = 849) measured this outcome for diazepam versus placebo (RR 0.94, 95% CI 0.82 to 1.07). The most frequent adverse events related to chlormethiazole were somnolence (RR 4.56, 95% CI 3.50 to 5.95; two trials; N = 2527) and rhinitis (RR 4.75, 95% CI 2.67 to 8.46; two trials; N = 2527). AUTHORS' CONCLUSIONS This review provides moderate-quality evidence that fails to support the use of GABA receptor agonists (chlormethiazole or diazepam) for the treatment of people with acute stroke. More well-designed RCTs with large samples of participants with total anterior circulation syndrome are required to determine if there are benefits for this subgroup. Somnolence and rhinitis are frequent adverse events related to chlormethiazole.
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Affiliation(s)
- Jia Liu
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyChangchun Street 45BeijingChina100053
| | - Lu‐Ning Wang
- Chinese PLA General HospitalDepartment of Geriatric NeurologyFuxing Road 28Haidian DistrictBeijingChina100853
| | - Xin Ma
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyChangchun Street 45BeijingChina100053
| | - Xunming Ji
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurosurgeryBeijingChina100053
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Beard DJ, Murtha LA, McLeod DD, Spratt NJ. Intracranial Pressure and Collateral Blood Flow. Stroke 2016; 47:1695-700. [PMID: 26786117 DOI: 10.1161/strokeaha.115.011147] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/30/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Daniel J Beard
- From the School of Biomedical Sciences and Pharmacy, and Hunter Medical Research Institute, University of Newcastle, Callaghan, Newcastle, New South Wales, Australia (D.J.B., L.A.M., D.D.M., N.J.S.); and Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, New Lambton Heights, Newcastle, New South Wales, Australia (N.J.S.)
| | - Lucy A Murtha
- From the School of Biomedical Sciences and Pharmacy, and Hunter Medical Research Institute, University of Newcastle, Callaghan, Newcastle, New South Wales, Australia (D.J.B., L.A.M., D.D.M., N.J.S.); and Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, New Lambton Heights, Newcastle, New South Wales, Australia (N.J.S.)
| | - Damian D McLeod
- From the School of Biomedical Sciences and Pharmacy, and Hunter Medical Research Institute, University of Newcastle, Callaghan, Newcastle, New South Wales, Australia (D.J.B., L.A.M., D.D.M., N.J.S.); and Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, New Lambton Heights, Newcastle, New South Wales, Australia (N.J.S.)
| | - Neil J Spratt
- From the School of Biomedical Sciences and Pharmacy, and Hunter Medical Research Institute, University of Newcastle, Callaghan, Newcastle, New South Wales, Australia (D.J.B., L.A.M., D.D.M., N.J.S.); and Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, New Lambton Heights, Newcastle, New South Wales, Australia (N.J.S.).
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Novel Interventions for Stroke: Nervous System Cooling. Transl Neurosci 2016. [DOI: 10.1007/978-1-4899-7654-3_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Kathirvelu B, Carmichael ST. Intracerebral hemorrhage in mouse models: therapeutic interventions and functional recovery. Metab Brain Dis 2015; 30:449-59. [PMID: 24810632 PMCID: PMC4226812 DOI: 10.1007/s11011-014-9559-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 04/28/2014] [Indexed: 12/11/2022]
Abstract
There has been strong pre-clinical research on mechanisms of initial cell death and tissue injury in intracerebral hemorrhage (ICH). This data has led to the evaluation of several therapeutics for neuroprotection or the mitigation of early tissue damage. Most of these studies have been done in the rat. Also, there has been little study of the mechanisms of tissue repair and recovery. This review examines the testing of candidate therapeutics in mouse models of ICH for their effect on tissue protection and repair. This review will help the readers compare it to the extensively researched rat model of ICH and thus enhance work that are pending in mouse model.
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Affiliation(s)
- Balachandar Kathirvelu
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA,
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Abstract
BACKGROUND Gamma aminobutyric acid (GABA) receptor agonists have been shown to have a neuroprotectant effect in reducing infarct size and improving functional outcome in animal models of cerebral ischemia. However, the sedation effects of GABA receptor agonists have limited their wider application in acute stroke patients due to the potential risk of stupor. OBJECTIVES To determine the efficacy and safety of GABA receptor agonists in the treatment of acute stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (February 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 5), MEDLINE (1949 to June 2014), EMBASE (1980 to June 2014), CINAHL (1982 to June 2014), AMED (1985 to June 2014) and 11 Chinese databases (June 2014). In an effort to identify further published, unpublished and ongoing trials we searched ongoing trials registers, reference lists and relevant conference proceedings, and contacted authors and pharmaceutical companies. SELECTION CRITERIA We included randomized controlled trials (RCTs) investigating GABA receptor agonists versus placebo for acute stroke patients (within 12 hours after stroke onset), with the outcomes of death or dependency, functional independence and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of identified records, selected studies for inclusion, extracted eligible data, cross-checked the data for accuracy and assessed the methodological quality. MAIN RESULTS We included five trials with 3838 patients. The methodological quality of the included trials was generally good, with low risk of bias. Four trials measured death and dependency at three months in chlormethiazole versus placebo without significant difference (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.11). One trial measured this outcome between diazepam and placebo (RR 0.94, 95% CI 0.82 to 1.07). In the subgroup analysis of total anterior circulation syndrome (TACS), a higher percentage of functional independence was found in the chlormethiazole group (RR 1.33, 95% CI 1.09 to 1.64). The frequent adverse events related to chlormethiazole were somnolence (RR 4.56, 95% CI 3.50 to 5.95) and rhinitis (RR 4.75, 95% CI 2.67 to 8.46). AUTHORS' CONCLUSIONS This review does not provide the evidence to support the use of GABA receptor agonists (chlormethiazole or diazepam) for the treatment of patients with acute ischemic or hemorrhagic stroke. Chlormethiazole appeared to be beneficial in improving functional independence in patients with TACS according to the subgroup analysis, but this result must be interpreted with great caution. More well-designed RCTs with large samples of TACS would be required for further confirmation. However, somnolence and rhinitis are frequent adverse events related to chlormethiazole.
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Affiliation(s)
- Jia Liu
- Department of Geriatric Neurology, Chinese PLA General Hospital, Fuxing Road 28, Beijing, China, 100853
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Bader MK. Clinical Q & A: translating therapeutic temperature management from theory to practice. Ther Hypothermia Temp Manag 2014; 4:99-102. [PMID: 24813504 DOI: 10.1089/ther.2014.1503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Huang WS, Muo CH, Chang SN, Chang YJ, Tsai CH, Kao CH. Benzodiazepine use and risk of stroke: a retrospective population-based cohort study. Psychiatry Clin Neurosci 2014; 68:255-62. [PMID: 24829937 DOI: 10.1111/pcn.12117] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM The aim of this study was to investigate the possible association between benzodiazepine (BZD) use and risk of incident stroke by utilizing data from 2000 to 2003 from the National Health Insurance system of Taiwan. METHODS Study subjects consisted of 38,671 patients with new BZD use and 38,663 people without BZD use who were frequency-matched for age, sex and baseline comorbidity with BZD users. All subjects had no history of stroke. Each study patient's case was followed until a new diagnosis of stroke was made or until the patient was censored by loss to follow up, death, or termination of insurance. The study lasted until the end of 2009. A Cox proportional hazards regression model was used to estimate the incidences and hazard ratios (HR) of stroke. RESULTS The HR of hemorrhagic stroke was significantly lower in the BZD group when compared with the non-BZD group. For patients aged 20-39 years, the HR of ischemic stroke was significantly higher in the BZD group when compared with the non-BZD group. Compared to the non-BZD group, patients with a lower annual dosage (<1 g) or duration (<30 days) of BZD use had a lower risk of stroke in the elder group (P < 0.0001) and patients with a higher annual dosage (≥ 4 g) or duration (≥ 95 days) of BZD use had a higher risk of stroke in all age groups (P < 0.0001). CONCLUSIONS Our findings may suggest neuroprotection under lower-dosage BZD use and neurotoxicity under higher-dosage BZD use.
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Affiliation(s)
- Wei-Shih Huang
- Department of Neurology; China Medical University Hospital; Taichung Taiwan
- Graduate Institute of Clinical Medical Science; School of Medicine; College of Medicine; China Medical University; Taichung Taiwan
| | | | | | - Yen-Jung Chang
- Management Office for Health Data; Taichung Taiwan
- Department of Health Promotion and Health Education; National Taiwan Normal University; Taipei Taiwan
| | - Chon-Haw Tsai
- Department of Neurology; China Medical University Hospital; Taichung Taiwan
- Graduate Institute of Clinical Medical Science; School of Medicine; College of Medicine; China Medical University; Taichung Taiwan
| | - Chia-Hung Kao
- Department of Nuclear Medicine and PET Center; China Medical University Hospital; Taichung Taiwan
- Graduate Institute of Clinical Medical Science; School of Medicine; College of Medicine; China Medical University; Taichung Taiwan
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Lyden PD, Hemmen TM, Grotta J, Rapp K, Raman R. Endovascular therapeutic hypothermia for acute ischemic stroke: ICTuS 2/3 protocol. Int J Stroke 2013; 9:117-25. [PMID: 24206528 DOI: 10.1111/ijs.12151] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Therapeutic hypothermia improves neurological outcome after out-of-hospital cardiac arrest or neonatal hypoxic-ischemic injury. Although supported by preclinical evidence, therapeutic hypothermia for acute stroke remains under study. In the Intravascular Cooling in the Treatment of Stroke (ICTuS) trial, awake stroke patients were successfully cooled using an endovascular cooling catheter and a novel antishivering regimen. In the ICTuS-L study, the combination of endovascular hypothermia and thrombolysis proved feasible; while hypothermia was associated with no increased risk of bleeding complications, there was an increased association with pneumonia. Despite efforts to expedite, cooling began on average six-hours after stroke onset. We designed a novel Phase 2/3 trial to further test the safety of combined thrombolysis and endovascular hypothermia and to determine if the combination shows superiority compared with thrombolysis alone. ICTuS 2 (n = 400) will assess four hypotheses, and if milestones are met, ICTuS 3 (n = 1200) will begin as a seamless continuation for a total sample of 1600 patients. The ICTuS 2 milestones include (1) target temperature reached within six-hours of symptom onset; (2) no increased risk of pneumonia; (3) no increase in signs/symptoms of fluid overload due to chilled saline infusions; and (4) sufficient recruitment to complete the trial on time. The ICTuS 2/3 protocol contains novel features - based on the previous ICTuS and ICTuS-L trials - designed to achieve these milestones. Innovations include scrupulous pneumonia surveillance, intravenous chilled saline immediately after randomization to induce rapid cooling, and a requirement for catheter placement within two-hours of thrombolysis. An Investigational Device Exemption has been obtained and an initial group of sites initiated.
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Affiliation(s)
- Patrick D Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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12
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Abstract
BACKGROUND Gamma aminobutyric acid (GABA) receptor agonists have been shown to have a neuroprotectant effect in reducing infarct size and improving functional outcome in animal models of cerebral ischemia. However, the sedation effects of GABA receptor agonists have limited their wider application in acute stroke patients due to the potential risk of stupor. OBJECTIVES To determine the efficacy and safety of GABA receptor agonists in the treatment of acute stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (January 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE (1949 to March 2012), EMBASE (1980 to March 2012), CINAHL (1982 to March 2012), AMED (1985 to March 2012) and 11 Chinese databases (March 2012). In an effort to identify further published, unpublished and ongoing trials we searched ongoing trials registers, reference lists and relevant conference proceedings, and contacted authors and pharmaceutical companies. SELECTION CRITERIA We included randomized controlled trials (RCTs) investigating GABA receptor agonists versus placebo for acute stroke patients (within 12 hours after stroke onset), with the outcomes of death or dependency, functional independence and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of identified records, selected studies for inclusion, extracted eligible data, cross-checked the data for accuracy and assessed the methodological quality. MAIN RESULTS We included five trials with 3838 patients. The methodological quality of the included trials was generally good, with low risk of bias. Four trials measured death and dependency at three months in chlormethiazole versus placebo without significant difference (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.11). One trial measured this outcome between diazepam and placebo (RR 0.94, 95% CI 0.82 to 1.07). In the subgroup analysis of total anterior circulation syndrome (TACS), a higher percentage of functional independence was found in the chlormethiazole group (RR 1.33, 95% CI 1.09 to 1.64). The frequent adverse events related to chlormethiazole were somnolence (RR 4.56, 95% CI 3.50 to 5.95) and rhinitis (RR 4.75, 95% CI 2.67 to 8.46). AUTHORS' CONCLUSIONS This review does not provide the evidence to support the use of GABA receptor agonists (chlormethiazole or diazepam) for the treatment of patients with acute ischemic or hemorrhagic stroke. Chlormethiazole appeared to be beneficial in improving functional independence in patients with TACS according to the subgroup analysis, but this result must be interpreted with great caution. More well-designed RCTs with large samples of TACS would be required for further confirmation. However, somnolence and rhinitis are frequent adverse events related to chlormethiazole.
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Affiliation(s)
- Jia Liu
- Department of Geriatric Neurology, Chinese PLA General Hospital, Beijing, China.
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Seo M, Kim JH, Cho YE, Baek MC, Suk K. Hypothermic regulation of astrocyte proteome profile in experimental stroke. Electrophoresis 2012; 33:3835-48. [DOI: 10.1002/elps.201200331] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 08/24/2012] [Accepted: 09/16/2012] [Indexed: 01/08/2023]
Affiliation(s)
- Minchul Seo
- Department of Pharmacology; Brain Science & Engineering Institute; Kyungpook National University School of Medicine; Daegu; Korea
| | - Jong-Heon Kim
- Department of Pharmacology; Brain Science & Engineering Institute; Kyungpook National University School of Medicine; Daegu; Korea
| | - Young-Eun Cho
- Department of Molecular Medicine; Cell & Matrix Biology Research Institute; Kyungpook National University School of Medicine; Daegu; Korea
| | - Moon-Chang Baek
- Department of Molecular Medicine; Cell & Matrix Biology Research Institute; Kyungpook National University School of Medicine; Daegu; Korea
| | - Kyoungho Suk
- Department of Pharmacology; Brain Science & Engineering Institute; Kyungpook National University School of Medicine; Daegu; Korea
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Kim JH, Cho YE, Seo M, Baek MC, Suk K. Glial proteome changes in response to moderate hypothermia. Proteomics 2012; 12:2571-83. [DOI: 10.1002/pmic.201200024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Jong-Heon Kim
- Department of Pharmacology; Brain Science & Engineering Institute; Kyungpook National University School of Medicine; Daegu; Republic of Korea
| | - Young-Eun Cho
- Department of Molecular Medicine; Cell & Matrix Biology Research Institute; Kyungpook National University School of Medicine; Daegu; Republic of Korea
| | - Minchul Seo
- Department of Pharmacology; Brain Science & Engineering Institute; Kyungpook National University School of Medicine; Daegu; Republic of Korea
| | - Moon-Chang Baek
- Department of Molecular Medicine; Cell & Matrix Biology Research Institute; Kyungpook National University School of Medicine; Daegu; Republic of Korea
| | - Kyoungho Suk
- Department of Pharmacology; Brain Science & Engineering Institute; Kyungpook National University School of Medicine; Daegu; Republic of Korea
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