1
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Caffaratti H, Slater B, Shaheen N, Rhone A, Calmus R, Kritikos M, Kumar S, Dlouhy B, Oya H, Griffiths T, Boes AD, Trapp N, Kaiser M, Sallet J, Banks MI, Howard MA, Zanaty M, Petkov CI. Neuromodulation with Ultrasound: Hypotheses on the Directionality of Effects and a Community Resource. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.14.24308829. [PMID: 38947047 PMCID: PMC11213082 DOI: 10.1101/2024.06.14.24308829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Low-intensity Transcranial Ultrasound Stimulation (TUS) is a promising non-invasive technique for deep-brain stimulation and focal neuromodulation. Research with animal models and computational modelling has raised the possibility that TUS can be biased towards enhancing or suppressing neural function. Here, we first conduct a systematic review of human TUS studies for perturbing neural function and alleviating brain disorders. We then collate a set of hypotheses on the directionality of TUS effects and conduct an initial meta-analysis on the human TUS study reported outcomes to date (n = 32 studies, 37 experiments). We find that parameters such as the duty cycle show some predictability regarding whether the targeted area's function is likely to be enhanced or suppressed. Given that human TUS sample sizes are exponentially increasing, we recognize that results can stabilize or change as further studies are reported. Therefore, we conclude by establishing an Iowa-Newcastle (inTUS) resource for the systematic reporting of TUS parameters and outcomes to support further hypothesis testing for greater precision in brain stimulation and neuromodulation with TUS.
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Affiliation(s)
- Hugo Caffaratti
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Ben Slater
- Biosciences Institute, Newcastle University Medical School, Newcastle upon Tyne, UK
| | - Nour Shaheen
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Ariane Rhone
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Ryan Calmus
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Michael Kritikos
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Sukhbinder Kumar
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Brian Dlouhy
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Hiroyuki Oya
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Tim Griffiths
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
- Biosciences Institute, Newcastle University Medical School, Newcastle upon Tyne, UK
| | - Aaron D Boes
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Nicholas Trapp
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Marcus Kaiser
- NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Rui Jin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jérôme Sallet
- Stem Cell and Brain Research Institute, INSERM U1208, University of Lyon, Lyon, France
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Matthew I Banks
- Department of Anesthesiology, University of Wisconsin at Madison, WI, USA
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Christopher I Petkov
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
- Biosciences Institute, Newcastle University Medical School, Newcastle upon Tyne, UK
- Iowa Neuroscience Institute, University of Iowa, Iowa City, IA, USA
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2
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Arumugham S, Narayan SK, Aghoram R. Effect of continuous 2 MHz transcranial ultrasound as an adjunct to tenecteplase thrombolysis in acute anterior circulation ischemic stroke patients: an open labeled non-randomized clinical trial. J Thromb Thrombolysis 2024; 57:788-796. [PMID: 38393673 DOI: 10.1007/s11239-023-02922-7] [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] [Accepted: 11/05/2023] [Indexed: 02/25/2024]
Abstract
The treatment of acute ischemic stroke has improved in last few decades. While meta-analyses of several trials have established the safety and efficacy of Intravenous (IV) Tenecteplase thrombolysis, concomitant continuous transcranial doppler (TCD) ultrasound administration has not been assessed in any clinical trial. The aim of this study was to determine the effects of continuous 2 MHz TCD ultrasound during IV Tenecteplase thrombolysis for Middle cerebral artery (MCA) stroke. A total of 19 patients were included, 13 received TCD ultrasound and 6 sham TCD with IV Tenecteplase. TCD spectrum and difference in Pre and post TCD parameters were measured. Asymptomatic hemorrhagic transformation of infarct was seen in two patients. There was no mortality or clinical worsening in the sonothrombolysis group as against sham sonothrombolysis group. Median of peak systolic velocity was increased in both the sonothrombolysis (P = 0.0002) and sham sonothrombolysis group (P-value = 0.001). The difference in change in mean flow velocity between two groups, sonothrombolysis (11 cm/sec) and sham sonothrombolysis (3.5 cm/sec) were also significantly different (P = 0.014). This pilot work has established safety of continuous 30 min TCD application along with IV Tenecteplase thrombolysis and it concludes that concomitant 2 MHz TCD ultrasound administration significantly increased the MCA blood flow compared to chemothrombolysis alone.CTRI Registered Number: CTRI/2021/02/031418.
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Affiliation(s)
- Semparuthi Arumugham
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvanthari Nagar, Puducherry, 605006, India
| | - Sunil K Narayan
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvanthari Nagar, Puducherry, 605006, India.
| | - Rajeswari Aghoram
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvanthari Nagar, Puducherry, 605006, India
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3
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Zhu S, Meng B, Jiang J, Wang X, Luo N, Liu N, Shen H, Wang L, Li Q. The Updated Role of Transcranial Ultrasound Neuromodulation in Ischemic Stroke: From Clinical and Basic Research. Front Cell Neurosci 2022; 16:839023. [PMID: 35221926 PMCID: PMC8873076 DOI: 10.3389/fncel.2022.839023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/17/2022] [Indexed: 12/31/2022] Open
Abstract
Ischemic stroke is a common cause of death and disability worldwide, which leads to serious neurological and physical dysfunction and results in heavy economic and social burdens. For now, timely and effective dissolution of thrombus, and ultimately improvement in the recovery of neurological functions, is the treatment strategy focus. Recently, many studies have reported that transcranial ultrasound stimulation (TUS), as a non-invasive method, can dissolve thrombus, improve cerebral blood circulation, and exert a neuroprotective effect post-stroke. TUS can promote functional recovery and improve rehabilitation efficacy among patients with ischemic stroke. This mini-review summarizes the potential mechanism and limitation of TUS in stroke aims to provide a new strategy for the future treatment of patients with ischemic stroke.
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Affiliation(s)
- Shuiping Zhu
- Department of Geriatric Medicine, Rongjun Hospital, Jiaxing, China
| | - Bin Meng
- Department of Ultrasound, Rongjun Hospital, Jiaxing, China
| | - Jianping Jiang
- Department of Geriatric Medicine, Rongjun Hospital, Jiaxing, China
| | - Xiaotao Wang
- Department of Ultrasound, Rongjun Hospital, Jiaxing, China
| | - Na Luo
- Department of Ultrasound, Rongjun Hospital, Jiaxing, China
| | - Ning Liu
- Department of Ultrasound, Rongjun Hospital, Jiaxing, China
| | - Huaping Shen
- Department of Ultrasound, Rongjun Hospital, Jiaxing, China
| | - Lu Wang
- Starbody Plastic Surgery Clinic, Hangzhou, China
| | - Qian Li
- Department of Ultrasound, Rongjun Hospital, Jiaxing, China
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4
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Tsivgoulis G, Safouris A, Alexandrov AV. Ultrasonography. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00046-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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5
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Tsivgoulis G, Katsanos AH, Eggers J, Larrue V, Thomassen L, Grotta JC, Seitidis G, Schellinger PD, Mavridis D, Demchuk A, Novotny V, Molina CA, Veroniki AA, Köhrmann M, Soinne L, Khanevski AN, Barreto AD, Saqqur M, Psaltopoulou T, Muir KW, Fiebach JB, Rothlisberger T, Kent TA, Mandava P, Alexandrov AW, Alexandrov AV. Sonothrombolysis in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: An Individual Patient Data Meta-Analysis. Stroke 2021; 52:3786-3795. [PMID: 34428930 DOI: 10.1161/strokeaha.120.030960] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Evidence about the utility of ultrasound-enhanced thrombolysis (sonothrombolysis) in patients with acute ischemic stroke (AIS) is conflicting. We aimed to evaluate the safety and efficacy of sonothrombolysis in patients with AIS with large vessel occlusion, by analyzing individual patient data of available randomized-controlled clinical trials. METHODS We included all available randomized-controlled clinical trials comparing sonothrombolysis with or without addition of microspheres (treatment group) to intravenous thrombolysis alone (control group) in patients with AIS with large vessel occlusion. The primary outcome measure was the rate of complete recanalization at 1 to 36 hours following intravenous thrombolysis initiation. We present crude odds ratios (ORs) and ORs adjusted for the predefined variables of age, sex, baseline stroke severity, systolic blood pressure, and onset-to-treatment time. RESULTS We included 7 randomized controlled clinical trials that enrolled 1102 patients with AIS. A total of 138 and 134 confirmed large vessel occlusion patients were randomized to treatment and control groups respectively. Patients randomized to sonothrombolysis had increased odds of complete recanalization compared with patients receiving intravenous thrombolysis alone (40.3% versus 22.4%; OR, 2.17 [95% CI, 1.03-4.54]; adjusted OR, 2.33 [95% CI, 1.02-5.34]). The likelihood of symptomatic intracranial hemorrhage was not significantly different between the 2 groups (7.3% versus 3.7%; OR, 2.03 [95% CI, 0.68-6.11]; adjusted OR, 2.55 [95% CI, 0.76-8.52]). No differences in the likelihood of asymptomatic intracranial hemorrhage, 3-month favorable functional and 3-month functional independence were documented. CONCLUSIONS Sonothrombolysis was associated with a nearly 2-fold increase in the odds of complete recanalization compared with intravenous thrombolysis alone in patients with AIS with large vessel occlusions. Further study of the safety and efficacy of sonothrombolysis is warranted.
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Affiliation(s)
- Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis (G.T., A.W.A., A.V.A.).,Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (G.T.)
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K.)
| | - Jürgen Eggers
- Department of Neurology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany (J.E.).,Department of Neurology, Sana Hospital Lübeck, Germany (J.E.)
| | - Vincent Larrue
- Department of Neurology, University of Toulouse, Hospital Pierre Paul Riquet, France (V.L.)
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway (L.T.).,Institute of Clinical Medicine, University of Bergen, Norway (L.T., V.N., A.N.K.)
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital-Texas Medical Center, Houston (J.C.G.)
| | - Georgios Seitidis
- Department of Primary Education, School of Education, University of Ioannina, Greece (G.S., D.M.)
| | - Peter D Schellinger
- Departments of Neurology and Neurogeriatry, John Wesling Medical Center Minden, Ruhr University Bochum, Germany (P.D.S.)
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Greece (G.S., D.M.).,Faculté de Médecine, Université Paris Descartes, France (D.M.)
| | - Andrew Demchuk
- Cumming School of Medicine, University of Calgary, AB, Canada (A.D.).,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Calgary, AB, Canada (A.D.)
| | - Vojtech Novotny
- Institute of Clinical Medicine, University of Bergen, Norway (L.T., V.N., A.N.K.)
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (C.A.M)
| | - Areti Angeliki Veroniki
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada (A.A.V.).,Institute of Reproductive and Developmental Biology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, United Kingdom (A.A.V.)
| | - Martin Köhrmann
- Department of Neurology, University Duisburg-Essen, Germany (M.K.)
| | - Lauri Soinne
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, Neurology, University of Helsinki Finland (L.S.)
| | | | - Andrew D Barreto
- Department of Neurology, University of Texas Health Science Center at Houston (A.D.B.)
| | - Maher Saqqur
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada (M.S.).,Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar (M.S.)
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Greece (T.P.)
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, United Kingdom (K.W.M.)
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité-University Medicine Berlin, Germany (J.B.F.)
| | | | - Thomas A Kent
- Texas A&M Health Science Center-Houston campus, University of Texas (T.A.K.).,Department of Neurology, Houston Methodist Hospital, TX (T.A.K.)
| | - Pitchaiah Mandava
- Michael E. DeBakey VA Medical Center, Houston, TX (P.M.).,Department of Neurology, Baylor College of Medicine, Houston, TX (P.M.)
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis (G.T., A.W.A., A.V.A.)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis (G.T., A.W.A., A.V.A.)
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6
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Michel P, Diepers M, Mordasini P, Schubert T, Bervini D, Rouvé JD, Gasche Y, Schwegler G, Bonvin C, Nedeltchev K, Carrera E, Kägi G, Cereda C, Nyffeler T, Wetzel S, Wegener S, Gensicke H, Engelter S, Arnold M. Acute revascularization in ischemic stroke: Updated Swiss guidelines. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2021. [DOI: 10.1177/2514183x21999228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In acute ischemic stroke, intravenous thrombolysis (IVT) and acute endovascular therapy (EVT) have been shown to reduce long-term disability in randomized trials. International guidelines are partially not up to date and may not address situations for which there is limited scientific evidence. The goals of the present guidelines are to summarize the current scientific data for acute revascularization treatments to make sure that all Swiss Centers apply a similar, evidence, or consensus-based treatment standard. A multidisciplinary working group of the Swiss Stroke Society (SSS) searched and reviewed the literature on new randomized controlled trials (RCTs), large case series, meta-analyses, and other guidelines since the previous recommendations in 2009 to elaborate the consensus guidelines. The new RCTs have confirmed the effectiveness of IVT in various populations up to 4.5 h and proven the benefit of acute EVT up to approximately 8 h. For patients with unknown onset (including wake-up stroke), IVT and EVT can be effective up to 24 h after last proof of good health if patients are selected with advanced neuroimaging. Multiple case series and meta-analyses allow narrowing down the indications and relative and absolute contraindications to optimize the benefit–risk ratio of acute revascularization.
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Affiliation(s)
- Patrik Michel
- Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Michael Diepers
- Neuroradiology Division, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Pasquale Mordasini
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital Bern and University of Bern, Berne, Switzerland
| | - Tilman Schubert
- Diagnostic and Interventional Neuroradiology, Department of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - David Bervini
- Department of Neurosurgery, Inselspital Bern and University of Bern, Berne, Switzerland
| | - Jean-Daniel Rouvé
- Anesthesiology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Yvan Gasche
- Department of Anesthesiology, Pharmacology, Intensive Care & Emergency Medicine, University of Geneva, Geneva, Switzerland
| | - Guido Schwegler
- Division of Neurology, Hospital Limmattal, Schlieren, Switzerland
| | - Christophe Bonvin
- Division of Neurology and Stroke Unit, Hôpital du Valais, Sion, Switzerland
| | | | - Emmanuel Carrera
- Neurology Service, University Hospitals of Geneva, Geneva, Switzerland
| | - Georg Kägi
- Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Carlo Cereda
- Department of Neurology, Neurocentro della Svizzera Italiana, Lugano Civic Hospital, Lugano, Switzerland
| | - Thomas Nyffeler
- Neurozentrum, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | | | - Susanne Wegener
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
| | - Stefan Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital Bern and University of Bern, Bern, Switzerland
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7
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Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021; 6:I-LXII. [PMID: 33817340 DOI: 10.1177/2396987321989865] [Citation(s) in RCA: 467] [Impact Index Per Article: 155.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
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Affiliation(s)
- Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Heinrich Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Gian Marco De Marchis
- University Hospital of Basel & University of Basel, Department for Neurology & Stroke Center, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Chiara Padiglioni
- Neurology Unit-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hopital Sainte-Anne, Université de Paris, Paris, France.,INSERM U1266.,FHU NeuroVasc
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8
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Blood pressure excursions in acute ischemic stroke patients treated with intravenous thrombolysis. J Hypertens 2020; 39:266-272. [PMID: 32956103 DOI: 10.1097/hjh.0000000000002628] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the association of blood pressure BP excursions, defined as greater than 185 SBP or greater than 105 DBP, with the probability of intracranial hemorrhage (ICH) and worse functional outcomes in patients with acute ischemic stroke (AIS) treated with tissue plasminogen activator (tPA). METHODS We performed a post hoc analysis of the CLOTBUST-ER trial. Serial BP measurements were conducted using automated cuff recording according to the recommended BP protocol guidelines for tPA administration. The outcomes were prespecified efficacy and safety endpoints of CLOTBUST-ER. RESULTS The mean number of serial BP recordings per patient was 37. Of the 674 patients, 227 (34%) had at least one BP excursion (>185/105 mmHg) during the first 24 h following tPA-bolus. The majority of BP excursions (46%) occurred within the first 75 min from tPA-bolus. Patients with at least one BP excursion in the first 24 h following tPA bolus had significantly lower rates of independent functional outcome at 90 days (31 vs. 40.1%, P = 0.028). The total number of BP excursions was associated with decreased odds of 24-h clinical recovery (OR = 0.88, 95% CI:0.80-0.96), 24-h neurological improvement (OR = 0.87, 95% CI: 0.81-0.94), 7-day functional improvement (common OR = 0.92, 95% CI: 0.87-0.97), 90-day functional improvement (common OR = 0.94, 95% CI: 0.88-0.98) and 90-day independent functional outcome (OR = 0.90, 95% CI: 0.82-0.98) in analyses adjusted for potential confounders. DBP excursions were independently associated with increased odds of any intracranial hemorrhage (OR = 1.26, 95% CI: 1.04-1.53). CONCLUSION BP excursions above guideline thresholds during the first 24 h following tPA administration for AIS are common and are independently associated with adverse clinical outcomes.
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9
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Katsanos AH, Alexandrov AV, Mandava P, Köhrmann M, Soinne L, Barreto AD, Sharma VK, Mikulik R, Muir KW, Rothlisberger T, Grotta JC, Levi CR, Molina CA, Saqqur M, Palaiodimou L, Psaltopoulou T, Vosko MR, Moreira T, Fiebach JB, Rubiera M, Sandset EC, Havenon A, Kent TA, Alexandrov AW, Schellinger PD, Tsivgoulis G. Pulse pressure variability is associated with unfavorable outcomes in acute ischaemic stroke patients treated with intravenous thrombolysis. Eur J Neurol 2020; 27:2453-2462. [DOI: 10.1111/ene.14447] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/15/2020] [Indexed: 01/07/2023]
Affiliation(s)
- A. H. Katsanos
- Division of Neurology McMaster University/Population Health Research Institute Hamilton ON Canada
- Second Department of Neurology ‘Attikon’ University Hospital School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - A. V. Alexandrov
- Department of Neurology University of Tennessee Health Science Center Memphis TN USA
| | - P. Mandava
- Stroke Outcomes Laboratory Department of Neurology Baylor College of Medicine Houston TX USA
- Michael E. DeBakey VA Medical Center Stroke Program and Center for Translational Research on Inflammatory Diseases Houston TX USA
| | - M. Köhrmann
- Department of Neurology University Hospital Essen Essen Germany
| | - L. Soinne
- Department of Neurology Helsinki University Hospital and Clinical Neurosciences University of Helsinki Helsinki Finland
| | - A. D. Barreto
- Department of Neurology University of Texas Health Science Center at Houston Houston TX USA
| | - V. K. Sharma
- Department of Medicine Yong Loo Lin School of Medicine National University of Singapore and Division of Neurology National University Hospital Singapore Singapore
| | - R. Mikulik
- International Clinical Research Centre and Department of Neurology St Anne’s University Hospital in Brno and Medical FacultyMasaryk University Brno Czech Republic
| | - K. W. Muir
- Institute of Neuroscience and Psychology University of GlasgowQueen Elizabeth University Hospital Glasgow UK
| | | | - J. C. Grotta
- Clinical Innovation and Research Institute Memorial Hermann Hospital‐Texas Medical Center Houston TX USA
| | - C. R. Levi
- Department of Neurology John Hunter Hospital University of Newcastle Newcastle NSW Australia
| | - C. A. Molina
- Stroke Unit Department of Neurology Vall d'Hebron University Hospital Vall d'Hebron Research Institute Autonomous University of Barcelona Barcelona Spain
| | - M. Saqqur
- Department of Medicine (Neurology) University of Alberta Edmonton Alberta Canada
- Neuroscience Institute Hamad Medical Corporation Doha Qatar
| | - L. Palaiodimou
- Second Department of Neurology ‘Attikon’ University Hospital School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - T. Psaltopoulou
- Department of Hygiene, Epidemiology, and Medical Statistics School of Medicine National and Kapodistrian University of Athens Athens Greece
| | - M. R. Vosko
- Department of Neurology 2 Med Campus III Kepler University Hospital Linz Austria
| | - T. Moreira
- Department of Neurology Karolinska University Hospital Stockholm Sweden
| | - J. B. Fiebach
- Center for Stroke Research Berlin Charité‐University Medicine Berlin Berlin Germany
| | - M. Rubiera
- Stroke Unit Department of Neurology Vall d'Hebron University Hospital Vall d'Hebron Research Institute Autonomous University of Barcelona Barcelona Spain
| | - E. C. Sandset
- Department of Neurology Stroke Unit Oslo University Hospital Oslo Norway
| | - A. Havenon
- Department of Neurology Clinical Neurosciences Center University of Utah Salt Lake City UT USA
| | - T. A. Kent
- Texas A&M Health Science Center‐Houston campusUniversity of Texas Houston TX USA
- Department of Neurology Houston Methodist Hospital Houston TX USA
| | - A. W. Alexandrov
- Department of Neurology University of Tennessee Health Science Center Memphis TN USA
| | - P. D. Schellinger
- Departments of Neurology and Neurogeriatry John Wesling Medical Center Minden Ruhr University Bochum Minden Germany
| | - G. Tsivgoulis
- Second Department of Neurology ‘Attikon’ University Hospital School of Medicine National and Kapodistrian University of Athens Athens Greece
- Department of Neurology University of Tennessee Health Science Center Memphis TN USA
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10
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Alexandrov AV, Tsivgoulis G, Köhrmann M, Katsanos AH, Soinne L, Barreto AD, Rothlisberger T, Sharma VK, Mikulik R, Muir KW, Levi CR, Molina CA, Saqqur M, Mavridis D, Psaltopoulou T, Vosko MR, Fiebach JB, Mandava P, Kent TA, Alexandrov AW, Schellinger PD. Endovascular equipoise shift in a phase III randomized clinical trial of sonothrombolysis for acute ischemic stroke. Ther Adv Neurol Disord 2019; 12:1756286419860652. [PMID: 31320933 PMCID: PMC6628520 DOI: 10.1177/1756286419860652] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 05/07/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Results of our recently published phase III randomized clinical trial of
ultrasound-enhanced thrombolysis (sonothrombolysis) using an
operator-independent, high frequency ultrasound device revealed
heterogeneity of patient recruitment among centers. Methods: We performed a post hoc analysis after excluding subjects that were recruited
at centers reporting a decline in the balance of randomization between
sonothrombolysis and concurrent endovascular trials. Results: From a total of 676 participants randomized in the CLOTBUST-ER trial we
identified 52 patients from 7 centers with perceived equipoise shift in
favor of endovascular treatment. Post hoc sensitivity analysis in the
intention-to-treat population adjusted for age, National Institutes of
Health Scale score at baseline, time from stroke onset to tPA bolus and
baseline serum glucose showed a significant (p < 0.01) interaction of
perceived endovascular equipoise shift on the association between
sonothrombolysis and 3 month functional outcome [adjusted common odds ratio
(cOR) in centers with perceived endovascular equipoise shift: 0.22, 95% CI
0.06–0.75; p = 0.02; adjusted cOR for centers without endovascular equipoise
shift: 1.20, 95% CI 0.89–1.62; p = 0.24)]. After excluding centers with
perceived endovascular equipoise shift, patients randomized to
sonothrombolysis had higher odds of 3 month functional independence (mRS
scores 0–2) compared with patients treated with tPA only (adjusted OR: 1.53;
95% CI 1.01–2.31; p = 0.04). Conclusion: Our experience in CLOTBUST-ER indicates that increasing implementation of
endovascular therapies across major academic stroke centers raises
significant challenges for clinical trials aiming to test noninterventional
or adjuvant reperfusion strategies.
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Affiliation(s)
- Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, 855 Monroe Avenue, Suite 415, Memphis, TN 38163, USA
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Martin Köhrmann
- Department of Neurology, Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Aristeidis H Katsanos
- Second Department of Neurology, 'Attikon' University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Lauri Soinne
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, Neurology, University of Helsinki Helsinki, Finland
| | - Andrew D Barreto
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore and Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Robert Mikulik
- International Clinical Research Centre and Department of Neurology, St. Anne's University Hospital in Brno and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Christopher R Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Autonomous University of Barcelona, Barcelona, Spain
| | - Maher Saqqur
- Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Milan R Vosko
- Department of Neurology 2, Med Campus III, Kepler University Hospital, Linz, Austria
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité-University Medicine Berlin, Berlin, Germany
| | - Pitchaiah Mandava
- Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Thomas A Kent
- Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Peter D Schellinger
- Departments of Neurology and Neurogeriatry, John Wesling Medical Center Minden, Ruhr University Bochum, Minden, Germany
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11
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Choi KH, Kim JH. Therapeutic Applications of Ultrasound in Neurological Diseases. ACTA ACUST UNITED AC 2019. [DOI: 10.31728/jnn.2019.00046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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12
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Alexandrov AV, Köhrmann M, Soinne L, Tsivgoulis G, Barreto AD, Demchuk AM, Sharma VK, Mikulik R, Muir KW, Brandt G, Alleman J, Grotta JC, Levi CR, Molina CA, Saqqur M, Mavridis D, Psaltopoulou T, Vosko M, Fiebach JB, Mandava P, Kent TA, Alexandrov AW, Schellinger PD. Safety and efficacy of sonothrombolysis for acute ischaemic stroke: a multicentre, double-blind, phase 3, randomised controlled trial. Lancet Neurol 2019; 18:338-347. [DOI: 10.1016/s1474-4422(19)30026-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 01/02/2023]
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13
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Zafar A, Quadri SA, Farooqui M, Ortega-Gutiérrez S, Hariri OR, Zulfiqar M, Ikram A, Khan MA, Suriya SS, Nunez-Gonzalez JR, Posse S, Mortazavi MM, Yonas H. MRI-Guided High-Intensity Focused Ultrasound as an Emerging Therapy for Stroke: A Review. J Neuroimaging 2018; 29:5-13. [PMID: 30295987 DOI: 10.1111/jon.12568] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 09/21/2018] [Indexed: 01/23/2023] Open
Abstract
Stroke, either ischemic or hemorrhagic, accounts for significantly high morbidity and mortality rates around the globe effecting millions of lives annually. For the past few decades, ultrasound has been extensively investigated to promote clot lysis for the treatment of stroke, myocardial infarction, and acute peripheral arterial occlusions, with or without the use of tPA or contrast agents. In the age of modern minimal invasive techniques, magnetic resonance imaging-guided high-intensity focused ultrasound is a new emerging modality that seems to promise therapeutic utilities for both ischemic and hemorrhagic stroke. High-intensity focused ultrasound causes thermal heating as the tissue absorbs the mechanical energy transmitted by the ultrasonic waves leading to tissue denaturation and coagulation. Several in-vitro and in-vivo studies have demonstrated the viability of this technology for sonothrombolysis in both types of stroke and have warranted clinical trials. Apart from safety and efficacy, initiation of trials would further enable answers regarding its practical application in a clinical setup. Though this technology has been under study for treatment of various brain diseases for some decades now, relatively very few neurologists and even neurosurgeons seem to be acquainted with it. The aim of this review is to provide basic understanding of this powerful technology and discuss its clinical application and potential role as an emerging viable therapeutic option for the future management of stroke.
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Affiliation(s)
- Atif Zafar
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM
| | - Syed A Quadri
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM.,California Institute of Neuroscience, Thousand Oaks, CA.,National Skull Base Center, Thousand Oaks, CA
| | - Mudassir Farooqui
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM
| | | | - Omid R Hariri
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Maryam Zulfiqar
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Asad Ikram
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM
| | - Muhammad Adnan Khan
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM.,California Institute of Neuroscience, Thousand Oaks, CA.,National Skull Base Center, Thousand Oaks, CA
| | - Sajid S Suriya
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM.,California Institute of Neuroscience, Thousand Oaks, CA.,National Skull Base Center, Thousand Oaks, CA
| | | | - Stefan Posse
- Department of Neurology, University of New Mexico Hospitals, Albuquerque, NM
| | - Martin M Mortazavi
- California Institute of Neuroscience, Thousand Oaks, CA.,National Skull Base Center, Thousand Oaks, CA
| | - Howard Yonas
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM
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14
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Ketelaars R, Reijnders G, van Geffen GJ, Scheffer GJ, Hoogerwerf N. ABCDE of prehospital ultrasonography: a narrative review. Crit Ultrasound J 2018; 10:17. [PMID: 30088160 PMCID: PMC6081492 DOI: 10.1186/s13089-018-0099-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/25/2018] [Indexed: 02/08/2023] Open
Abstract
Prehospital point-of-care ultrasound used by nonradiologists in emergency medicine is gaining ground. It is feasible on-scene and during aeromedical transport and allows health-care professionals to detect or rule out potential harmful conditions. Consequently, it impacts decision-making in prioritizing care, selecting the best treatment, and the most suitable transport mode and destination. This increasing relevance of prehospital ultrasonography is due to advancements in ultrasound devices and related technology, and to a growing number of applications. This narrative review aims to present an overview of prehospital ultrasonography literature. The focus is on civilian emergency (trauma and non-trauma) setting. Current and potential future applications are discussed, structured according to the airway, breathing, circulation, disability, and environment/exposure (ABCDE) approach. Aside from diagnostic implementation and specific protocols, procedural guidance, therapeutic ultrasound, and challenges are reviewed.
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Affiliation(s)
- Rein Ketelaars
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands. .,Radboud Institute for Health Sciences, Helicopter Emergency Medical Service Lifeliner 3, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Gabby Reijnders
- Department of Intensive Care, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Geert-Jan van Geffen
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Helicopter Emergency Medical Service Lifeliner 3, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Gert Jan Scheffer
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Nico Hoogerwerf
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Helicopter Emergency Medical Service Lifeliner 3, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
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15
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Zamanlu M, Farhoudi M, Eskandani M, Mahmoudi J, Barar J, Rafi M, Omidi Y. Recent advances in targeted delivery of tissue plasminogen activator for enhanced thrombolysis in ischaemic stroke. J Drug Target 2017; 26:95-109. [PMID: 28796540 DOI: 10.1080/1061186x.2017.1365874] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Tissue plasminogen activator (tPA) is the only FDA approved medical treatment for the ischaemic stroke. However, it associates with some inevitable limitations, including: short therapeutic window, extremely short half-life and low penetration in large clots. Systemic administration may lead to complications such as haemorrhagic conversion in the brain and relapse in the form of re-occlusion. Furthermore, ultrasound has been utilised in combination with contrast agents, echogenic liposome, microspheres or nanoparticles (NPs) carrying tPA for improving thrombolysis - an approach that has resulted in slight improvement of tPA delivery and facilitated thrombolysis. Most of these delivery systems are able to extend the circulating half-life and clot penetration of tPA. Various technologies employed for ameliorated thrombolytic therapy are in different phases, some are in final steps for clinical applications while some others are under investigations for their safety and efficacy in human cases. Here, recent progresses on the thrombolytic therapy using novel nano- and micro-systems incorporating tPA are articulated. Of these, liposomes and microspheres, polymeric NPs and magnetic nanoparticles (MNPs) are discussed. Key technologies implemented for efficient delivery of tPA and advanced thrombolytic therapy and their advantages/disadvantages are further expressed.
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Affiliation(s)
- Masumeh Zamanlu
- a Neurosciences Research Center (NSRC), Faculty of Medicine , Tabriz University of Medical Sciences , Tabriz , Iran.,b Research Center for Pharmaceutical Nanotechnology, Biomedicine Institute , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Mehdi Farhoudi
- a Neurosciences Research Center (NSRC), Faculty of Medicine , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Morteza Eskandani
- b Research Center for Pharmaceutical Nanotechnology, Biomedicine Institute , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Javad Mahmoudi
- a Neurosciences Research Center (NSRC), Faculty of Medicine , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Jaleh Barar
- b Research Center for Pharmaceutical Nanotechnology, Biomedicine Institute , Tabriz University of Medical Sciences , Tabriz , Iran.,c Department of Pharmaceutics, Faculty of Pharmacy , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Mohammad Rafi
- d Department of Neurology, Sidney Kimmel College of Medicine , Thomas Jefferson University , Philadelphia , PA , USA
| | - Yadollah Omidi
- b Research Center for Pharmaceutical Nanotechnology, Biomedicine Institute , Tabriz University of Medical Sciences , Tabriz , Iran.,c Department of Pharmaceutics, Faculty of Pharmacy , Tabriz University of Medical Sciences , Tabriz , Iran
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16
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Ginsberg MD. The cerebral collateral circulation: Relevance to pathophysiology and treatment of stroke. Neuropharmacology 2017; 134:280-292. [PMID: 28801174 DOI: 10.1016/j.neuropharm.2017.08.003] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/28/2017] [Accepted: 08/06/2017] [Indexed: 12/29/2022]
Abstract
The brain's collateral circulation consists of arterial anastomotic channels capable of providing nutrient perfusion to brain regions whose normal sources of flow have become compromised, as occurs in acute ischemic stroke. Modern CT-based neuroimaging is capable of providing detailed information as to collateral extent and sufficiency and is complemented by magnetic resonance-based methods. In the present era of standard-of-care IV thrombolysis for acute ischemic stroke, and following the recent therapeutic successes of randomized clinical trials of acute endovascular intervention, the sufficiency of the collateral circulation has been convincingly established as a key factor influencing the likelihood of successful reperfusion and favorable clinical outcome. This article reviews the features of the brain's collateral circulation; methods for its evaluation in the acute clinical setting; the relevance of collateral circulation to prognosis in acute ischemic stroke; the specific insights into the collateral circulation learned from recent trials of endovascular intervention; and the major influence of genetic factors. Finally, we emphasize the need to develop therapeutic approaches to augment collateral perfusion as an adjunctive strategy to be employed along with, or prior to, thrombolysis and endovascular interventions, and we highlight the possible potential of inhaled nitric oxide, albumin, and other approaches. This article is part of the Special Issue entitled 'Cerebral Ischemia'.
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Affiliation(s)
- Myron D Ginsberg
- Department of Neurology, University of Miami Miller School of Medicine, Clinical Research Center, Room 1331, 1120 NW 14th Street, Miami, FL 33136, USA.
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17
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Lee TH, Yeh JC, Tsai CH, Yang JT, Lou SL, Seak CJ, Wang CY, Wei KC, Liu HL. Improved thrombolytic effect with focused ultrasound and neuroprotective agent against acute carotid artery thrombosis in rat. Sci Rep 2017; 7:1638. [PMID: 28487554 PMCID: PMC5431649 DOI: 10.1038/s41598-017-01769-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/30/2017] [Indexed: 01/19/2023] Open
Abstract
Combination therapy with focused ultrasound (FUS) and a neuroprotective agent, BNG-1, was examined in an acute carotid thrombotic occlusion model using LED irradiation in rat to improve the thrombolytic effect of rt-PA. Seven treatment groups included (A) intravenous bolus injection of 0.45 mg/kg rt-PA, (B) intravenous bolus injection of 0.9 mg/kg, (C) sonothrombolysis with FUS alone, (D) oral administration of 2 g/kg BNG-1 for 7 days alone, (E) A + D, (F) A + C, and (G) A + C + D. Four comparison groups were made including (H) 0.45 mg/kg rt-PA 20% bolus +80% IV fusion + FUS, (I) 0.9 mg/kg rt-PA with 10% bolus + 90% intravenous fusion, (J) B + C, (K) B + D. At 7 days after carotid occlusion, small-animal carotid ultrasound and 7 T MR angiography showed the recanalization rate of ≤50% stenosis was 50% in group B and 83% in group I, but 0% in groups A and C and 17% in group D. Combination therapy improved recanalization rate to 50–63% in groups E and F, to 67–83% in groups J and K, and to 100% in groups G and H. Our study demonstrated combination therapy with different remedies can be a feasible strategy to improve the thrombolytic effect of rt-PA.
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Affiliation(s)
- Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Jih-Chao Yeh
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Chih-Hung Tsai
- Departments of Electrical Engineering, Graduate Institute of Clinical Medical Sciences, Chang-Gung University, Taoyuan, 333, Taiwan
| | - Jen-Tsung Yang
- Department of Neurosurgery, Chiayi Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Chiayi, Taiwan
| | - Shyh-Liang Lou
- Department of Biomedical Engineering, Chung Yuan Christian University, Chung Li, Taiwan
| | - Chen-June Seak
- Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Chao-Yung Wang
- Department of Cardiology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Kuo-Chen Wei
- Department of Neurosurgery, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan.
| | - Hao-Li Liu
- Departments of Electrical Engineering, Graduate Institute of Clinical Medical Sciences, Chang-Gung University, Taoyuan, 333, Taiwan. .,Department of Neurosurgery, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan. .,Institute for Radiological Research, Chang Gung University/Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan.
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18
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Wang Z, Komatsu T, Mitsumura H, Nakata N, Ogawa T, Iguchi Y, Yokoyama M. An uncovered risk factor of sonothrombolysis: Substantial fluctuation of ultrasound transmittance through the human skull. ULTRASONICS 2017; 77:168-175. [PMID: 28242510 DOI: 10.1016/j.ultras.2017.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 06/06/2023]
Abstract
Sonothrombolysis is one of the most feasible methods for enhancing clot lysis with a recombinant tissue plasminogen activator (rt-PA) in cases of acute ischemic strokes. For safe and efficient clinical practices of sonothrombolysis, accurate estimation of ultrasound transmittance through the human skull is critical. Previously, we reported substantial and periodic fluctuation of ultrasound transmittance through a bone-phantom plate following changes to ultrasound frequency, the thickness of the bone-phantom plate, and the distance between a transducer and the bone-phantom plate. In the present study, we clarify the transmittance behavior of medium-frequency ultrasound (from 400kHz to 600kHz) through the human skull, and examine reduction of the transmittance fluctuation. For the study, we measured transmittance of sinusoidal ultrasound waves at 400kHz, 500kHz, and 600kHz at 13 temple spots on 3 human skulls by changing the distance between a transducer and the skull bone, and found substantial and periodic fluctuation in the transmittance behaviors for these sinusoidal voltage excitations. Degrees of the fluctuation varied depending on the measurement spots. A fluctuation ratio between the maximum transmittance and the minimum transmittance reached 3 in some spots. This large transmittance fluctuation is considered to be a risk factor for sonothrombolysis therapies. We examined a modulated ultrasound wave to reduce the fluctuation, and succeeded in obtaining considerable reduction. The average fluctuation ratios for 400-kHz, 500-kHz, and 600-kHz waves were 2.38, 2.38, and 2.07, respectively. We successfully reduced the ratio to 1.72 by using a periodic selection of random frequency (PSRF)-type of modulation wave. The thus obtained results indicate that attention to the fluctuation in ultrasound transmittance through the skull is necessary for safe and effective sonothrombolysis therapies, and that modulated ultrasound waves constitute a powerful method for reducing the risk of fluctuation.
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Affiliation(s)
- Zuojun Wang
- Division of Ultrasound Development and Application, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Teppei Komatsu
- Department of Neurology, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Hidetaka Mitsumura
- Department of Neurology, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Norio Nakata
- Division of Ultrasound Development and Application, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Takeki Ogawa
- Department of Emergency Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Masayuki Yokoyama
- Division of Medical Engineering, Research Center for Medical Sciences, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan.
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19
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Abstract
In the past decade, the definition of stroke has been revised and major advances have been made for its treatment and prevention. For acute ischaemic stroke, the addition of endovascular thrombectomy of proximal large artery occlusion to intravenous alteplase increases functional independence for a further fifth of patients. The benefits of aspirin in preventing early recurrent ischaemic stroke are greater than previously recognised. Other strategies to prevent recurrent stroke now include direct oral anticoagulants as an alternative to warfarin for atrial fibrillation, and carotid stenting as an alternative to endarterectomy for symptomatic carotid stenosis. For acute intracerebral haemorrhage, trials are ongoing to assess the effectiveness of acute blood pressure lowering, haemostatic therapy, minimally invasive surgery, anti-inflammation therapy, and neuroprotection methods. Pharmacological and stem-cell therapies promise to facilitate brain regeneration, rehabilitation, and functional recovery. Despite declining stroke mortality rates, the global burden of stroke is increasing. A more comprehensive approach to primary prevention of stroke is required that targets people at all levels of risk and is integrated with prevention strategies for other diseases that share common risk factors.
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Affiliation(s)
- Graeme J Hankey
- School of Medicine & Pharmacology, The University of Western Australia, Perth, WA, Australia; Department of Neurology, Sir Charles Gairdner Hospital, Perth, WA, Australia; Western Australian Neuroscience Research Institute (WANRI), Perth, WA, Australia.
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20
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Ginsberg MD. Expanding the concept of neuroprotection for acute ischemic stroke: The pivotal roles of reperfusion and the collateral circulation. Prog Neurobiol 2016; 145-146:46-77. [PMID: 27637159 DOI: 10.1016/j.pneurobio.2016.09.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/22/2016] [Accepted: 09/10/2016] [Indexed: 12/27/2022]
Abstract
This review surveys the efforts taken to achieve clinically efficacious protection of the ischemic brain and underscores the necessity of expanding our purview to include the essential role of cerebral perfusion and the collateral circulation. We consider the development of quantitative strategies to measure cerebral perfusion at the regional and local levels and the application of these methods to elucidate flow-related thresholds of ischemic viability and to characterize the ischemic penumbra. We stress that the modern concept of neuroprotection must consider perfusion, the necessary substrate upon which ischemic brain survival depends. We survey the major mechanistic approaches to neuroprotection and review clinical neuroprotection trials, focusing on those phase 3 multicenter clinical trials for acute ischemic stroke that have been completed or terminated. We review the evolution of thrombolytic therapies; consider the lessons learned from the initial, negative multicenter trials of endovascular therapy; and emphasize the highly successful positive trials that have finally established a clinical role for endovascular clot removal. As these studies point to the brain's collateral circulation as key to successful reperfusion, we next review the anatomy and pathophysiology of collateral perfusion as it relates to ischemic infarction, as well as the molecular and genetic influences on collateral development. We discuss the current MR and CT-based diagnostic methods for assessing the collateral circulation and the prognostic significance of collaterals in ischemic stroke, and we consider past and possible future therapeutic directions.
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Affiliation(s)
- Myron D Ginsberg
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, United States.
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21
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Henninger N, Fisher M. Extending the Time Window for Endovascular and Pharmacological Reperfusion. Transl Stroke Res 2016; 7:284-93. [DOI: 10.1007/s12975-015-0444-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 12/13/2015] [Accepted: 12/14/2015] [Indexed: 01/07/2023]
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22
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Asadi H, Yan B, Dowling R, Wong S, Mitchell P. Advances in medical revascularisation treatments in acute ischemic stroke. THROMBOSIS 2014; 2014:714218. [PMID: 25610642 PMCID: PMC4293866 DOI: 10.1155/2014/714218] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/17/2014] [Indexed: 11/17/2022]
Abstract
Urgent reperfusion of the ischaemic brain is the aim of stroke treatment and there has been ongoing research to find a drug that can promote vessel recanalisation more completely and with less side effects. In this review article, the major studies which have validated the use and safety of tPA are discussed. The safety and efficacy of other thrombolytic and anticoagulative agents such as tenecteplase, desmoteplase, ancrod, tirofiban, abciximab, eptifibatide, and argatroban are also reviewed. Tenecteplase and desmoteplase are both plasminogen activators with higher fibrin affinity and longer half-life compared to alteplase. They have shown greater reperfusion rates and improved functional outcomes in preliminary studies. Argatroban is a direct thrombin inhibitor used as an adjunct to intravenous tPA and showed higher rates of complete recanalisation in the ARTTS study with further studies which are now ongoing. Adjuvant thrombolysis techniques using transcranial ultrasound are also being investigated and have shown higher rates of complete recanalisation, for example, in the CLOTBUST study. Overall, development in medical therapies for stroke is important due to the ease of administration compared to endovascular treatments, and the new treatments such as tenecteplase, desmoteplase, and adjuvant sonothrombolysis are showing promising results and await further large-scale clinical trials.
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Affiliation(s)
- H Asadi
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - B Yan
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - R Dowling
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - S Wong
- Radiology Department, Western Hospital, Footscray, VIC, Australia
| | - P Mitchell
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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Barlinn K, Tsivgoulis G, Barreto AD, Alleman J, Molina CA, Mikulik R, Saqqur M, Demchuk AM, Schellinger PD, Howard G, Alexandrov AV. Outcomes following sonothrombolysis in severe acute ischemic stroke: subgroup analysis of the CLOTBUST trial. Int J Stroke 2014; 9:1006-10. [PMID: 25079049 PMCID: PMC4227933 DOI: 10.1111/ijs.12340] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 05/20/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sonothrombolysis is safe and may increase the likelihood of early recanalization in acute ischemic stroke patients. AIMS In preparation of a phase III clinical trial, we contrast the likelihood of achieving a sustained recanalization and functional independence in a post hoc subgroup analysis of patients randomized to transcranial Doppler monitoring plus intravenous tissue plasminogen activator (sonothrombolysis) compared with intravenous tissue plasminogen activator alone in the CLOTBUST trial. METHODS We analyzed the data from all randomized acute ischemic stroke patients with pretreatment National Institutes of Health Stroke Scale scores ≥ 10 points and proximal intracranial occlusions in the CLOTBUST trial. We compared sustained complete recanalization rate (Thrombolysis in Brain Ischemia flow grades 4-5) and functional independence (modified Rankin Scale 0-1) at 90 days. Safety was evaluated by the rate of symptomatic intracranial hemorrhage within 72 h of stroke onset. RESULTS Of 126 patients, a total of 85 acute ischemic stroke patients met our inclusion criteria: mean age 71 ± 11years, 56% men, median National Institutes of Health Stroke Scale 17 (interquartile range 14-20). Of these patients, 41 (48%) and 44 (52%) were randomized to intravenous tissue plasminogen activator alone and sonothrombolysis, respectively. More patients achieved sustained complete recanalization in the sonothrombolysis than in the intravenous tissue plasminogen activator alone group (38·6% vs. 17·1%; P = 0·032). Functional independence at 90 days was more frequently achieved in the sonothrombolysis than in the intravenous tissue plasminogen activator alone group (37·2% vs. 15·8%; P = 0·045). Symptomatic intracranial hemorrhage rate was similar in both groups (4·9% vs. 4·6%; P = 1·00). CONCLUSIONS Our results point to a signal of efficacy and provide information to guide the subsequent phase III randomized trial of sonothrombolysis in patients with severe ischemic strokes.
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Affiliation(s)
- Kristian Barlinn
- Dresden University Stroke Center,Department of Neurology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Georgios Tsivgoulis
- Department of Neurology,The University of Tennessee Health Science Center, Memphis, TN, USA
- Second Department of Neurology,School of Medicine, Attikon Hospital, University of Athens, Greece
- International Clinical Research Centre,Neurology department, St. Anne's University Hospital in Brno and Masaryk University, Czech Republic
| | | | | | - Carlos A Molina
- Neurovascular Unit, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Robert Mikulik
- International Clinical Research Centre,Neurology department, St. Anne's University Hospital in Brno and Masaryk University, Czech Republic
| | - Maher Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew M Demchuk
- University of Calgary, Department of Clinical Neurosciences, Calgary Stroke Program, Canada
| | | | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, USA
| | - Andrei V. Alexandrov
- Department of Neurology,The University of Tennessee Health Science Center, Memphis, TN, USA
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Zisakis AK, Varsos V, Exadaktylos A. What is New and Innovative in Emergency Neurosurgery? Emerging Diagnostic Technologies Provide Better Care and Influence Outcome: A Specialist Review. Emerg Med Int 2013; 2013:568960. [PMID: 24349786 PMCID: PMC3847970 DOI: 10.1155/2013/568960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 10/08/2013] [Indexed: 12/02/2022] Open
Abstract
The development of emergency medical services and especially neurosurgical emergencies during recent decades has necessitated the development of novel tools. Although the gadgets that the neurosurgeon uses today in emergencies give him important help in diagnosis and treatment, we still need new technology, which has rapidly developed. This review presents the latest diagnostic tools, which offer precious help in everyday emergency neurosurgery practice. New ultrasound devices make the diagnosis of haematomas easier. In stroke, the introduction of noninvasive new gadgets aims to provide better treatment to the patient. Finally, the entire development of computed tomography and progress in radiology have resulted in innovative CT scans and angiographic devices that advance the diagnosis, treatment, and outcome of the patent. The pressure on physicians to be quick and effective and to avoid any misjudgement of the patient has been transferred to the technology, with the emphasis on developing new systems that will provide our patients with a better outcome and quality of life.
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Affiliation(s)
- Athanasios K. Zisakis
- Department of Neurosurgery, Red Cross Hospital, 1st Erythrou Staurou and Athanasaki Street, 11526 Ampelokipoi, Athens, Greece
| | - Vassilios Varsos
- Department of Neurosurgery, Red Cross Hospital, 1st Erythrou Staurou and Athanasaki Street, 11526 Ampelokipoi, Athens, Greece
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Barlinn K, Barreto AD, Sisson A, Liebeskind DS, Schafer ME, Alleman J, Zhao L, Shen L, Cava LF, Rahbar MH, Grotta JC, Alexandrov AV. CLOTBUST-hands free: initial safety testing of a novel operator-independent ultrasound device in stroke-free volunteers. Stroke 2013; 44:1641-6. [PMID: 23598523 PMCID: PMC4156594 DOI: 10.1161/strokeaha.113.001122] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to evaluate safety and tolerability of a novel operator-independent ultrasound device among stroke-free volunteers. METHODS A headframe containing 18 ultrasound transducers (each operating at 2 MHz, pulsed-wave) was used to expose both temporal windows and the suboccipital window. The transmission characteristics were set to emulate the acoustic characteristics of the exposure levels in the Combined Lysis of Thrombus in Brain Ischemia using Transcranial Ultrasound and Systemic tPA (CLOTBUST) trial and to never exceed Food and Drug Administration mandated diagnostic ultrasound exposure limits. Volunteers underwent 2 hours of insonation with transducer activation one at a time. Safety was captured using serial neurological examinations and pre- and postinsonation MRI for detection of the blood brain barrier permeability. RESULTS A total of 15 volunteers (40% men; 49 ± 16 years; 27% black; all pre-exposure National Institutes of Health Stroke Scale scores 0) were enrolled. Five volunteers received pulsed-wave ultrasound via the best pair temporal transducers, 5 via sequential activation of the suboccipital transducers, and 5 via sequential activation of all bilateral temporal and suboccipital transducers. All subjects were safely insonated with no adverse effects as indicated by the neurological examinations during, immediately after the exposure, and at 24 hours, and no abnormality of the blood brain barrier was found on any of the MRIs. CONCLUSIONS Our novel device was well tolerated by stroke-free volunteers and did not cause any neurological dysfunction nor did it affect blood brain barrier integrity. The safety and efficacy of the device are now being tested in stroke patients receiving intravenous tissue-type plasminogen activator in phase II-III clinical trials.
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Affiliation(s)
- Kristian Barlinn
- Department of Neurology, Comprehensive Stroke Center, The University of Alabama at Birmingham, RWUH M226, 619 19th St South, Birmingham, AL 35249-3280, USA
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