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Song S, Ma D, Xu L, Wang Q, Liu L, Tong X, Yan H. Low-intensity pulsed ultrasound-generated singlet oxygen induces telomere damage leading to glioma stem cell awakening from quiescence. iScience 2022; 25:103558. [PMID: 34988401 PMCID: PMC8693467 DOI: 10.1016/j.isci.2021.103558] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/09/2021] [Accepted: 12/01/2021] [Indexed: 12/27/2022] Open
Abstract
Cancer stem cells, quiescent and drug resistant, have become a therapeutic target. Unlike high-intensity focused ultrasound directly killing tumor, low-intensity pulsed ultrasound (LIPUS), a new noninvasive physical device, promotes pluripotent stem cell differentiation and is primarily applied in tissue engineering but rarely in oncotherapy. We explored the effect and mechanism of LIPUS on glioma stem cell (GSC) expulsion from quiescence. Here, we observed that LIPUS led to attenuated expression of GSC biomarkers, promoted GSC escape from G0 quiescence, and significantly weakened the Wnt and Hh pathways. Of note, LIPUS transferred sonomechanical energy into cytochrome c and B5 proteins, which converted oxygen molecules into singlet oxygen, triggering telomere crisis. The in vivo and in vitro results confirmed that LIPUS enhanced the GSC sensitivity to temozolomide. These results demonstrated that LIPUS "waked up" GSCs to improve their sensitivity to chemotherapy, and importantly, we confirmed the direct targeted proteins of LIPUS in GSCs.
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Affiliation(s)
- Sirong Song
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin 300070, China
| | - Dongbin Ma
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin 300070, China
| | - Lixia Xu
- Tianjin Neurosurgical Institute, Tianjin Key Laboratory of Cerebrovascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Tianjin 300350, P.R.China
| | - Qiong Wang
- Tianjin Neurosurgical Institute, Tianjin Key Laboratory of Cerebrovascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Tianjin 300350, P.R.China
| | - Lanxiang Liu
- Department of Magnetic Resonance Imaging, Qinhuangdao Municipal No. 1 Hospital, No. 258 Wenhua Road, Qinhuangdao 066000, Hebei Province, P.R. China
| | - Xiaoguang Tong
- Tianjin Neurosurgical Institute, Tianjin Key Laboratory of Cerebrovascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Tianjin 300350, P.R.China
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, P.R. China
- Corresponding author
| | - Hua Yan
- Tianjin Neurosurgical Institute, Tianjin Key Laboratory of Cerebrovascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Tianjin 300350, P.R.China
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, P.R. China
- Corresponding author
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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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Chang A, Beheshtian E, Llinas EJ, Idowu OR, Marsh EB. Intravenous Tissue Plasminogen Activator in Combination With Mechanical Thrombectomy: Clot Migration, Intracranial Bleeding, and the Impact of "Drip and Ship" on Effectiveness and Outcomes. Front Neurol 2020; 11:585929. [PMID: 33424741 PMCID: PMC7794010 DOI: 10.3389/fneur.2020.585929] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/16/2020] [Indexed: 01/19/2023] Open
Abstract
Purpose: Intravenous tissue plasminogen activator (tPA) is indicated prior to mechanical thrombectomy (MT) to treat large vessel occlusion (LVO). However, administration takes time, and rates of clot migration complicating successful retrieval and hemorrhagic transformation may be higher. Given time-to-effectiveness, the benefit of tPA may vary significantly based on whether administration occurs at a thrombectomy-capable center or transferring hospital. Methods: We prospectively evaluated 170 individuals with LVO involving the anterior circulation who underwent MT at our Comprehensive Stroke Center over a 3.5 year period. Two thirds (n = 114) of patients were admitted through our Emergency Department (ED). The other 33% were transferred from outside hospitals (OSH). Patients meeting criteria were bridged with IV tPA; the others were treated with MT alone. Clot migration, recanalization times, TICI scores, and hemorrhage rates were compared for those bridged vs. treated with MT alone, along with modified Rankin scores (mRS) at discharge and 90-day follow-up. Multivariable regression was used to determine the relationship between site of presentation and effect of tPA on outcomes. Results: Patients presenting to an OSH had longer mean discovery to puncture/recanalization times, but were actually more likely to receive IV tPA prior to MT (70 vs. 42%). The rate of clot migration was low (11%) and similar between groups, though slightly higher for those receiving IV tPA. There was no difference in symptomatic ICH rate after tPA. TICI scores were also not significantly different; however, more patients achieved TICI 2b or higher reperfusion (83 vs. 67%, p = 0.027) after tPA, and TICI 0 reperfusion was seen almost exclusively in patients who were not treated with tPA. Those bridged at an OSH required fewer passes before successful recanalization (2.4 vs. 1.6, p = 0.037). Overall, mean mRS scores on discharge and at 90 days were significantly better for those receiving IV tPA (3.9 vs. 4.6, 3.4 vs. 4.4 respectively, p ~ 0.01) and differences persisted when comparing only patients recanalized in under 6 h. Conclusion: Independent of site of presentation, IV tPA before MT appears to lead to better radiographic outcomes, without increased rates of clot migration or higher intracranial hemorrhage risk, and overall better functional outcomes.
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Affiliation(s)
- Adam Chang
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Elham Beheshtian
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Edward J. Llinas
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Oluwatoyin R. Idowu
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Elisabeth B. Marsh
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
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Efficacy and safety of sonothrombolysis in patients with acute ischemic stroke: A systematic review and meta-analysis. J Neurol Sci 2020; 416:116998. [PMID: 32623143 DOI: 10.1016/j.jns.2020.116998] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/21/2020] [Accepted: 06/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Accumulating clinical evidence has indicated that sonothrombolysis can aid in the treatment of ischemic stroke; however, these findings remain controversial. The purpose of the present meta-analysis was to assess randomized clinical studies concerning the effects of sonothrombolysis on ischemic stroke to evaluate its safety and efficacy. METHODS We systematically searched the Cochrane Library, PubMed, and EMBASE databases for literature published between the inception of electronic data and May 2019 regarding sonothrombolysis for acute ischemic stroke. Only randomized controlled trials were included. Data extraction was based on patient characteristics, ultrasound variables (any duration or frequency, without microbubble), and outcome variables (safety and efficacy). RESULTS Five trials were included in the present study. Clinical functional recovery was evaluated at different time points (several days or 3 months), and heterogeneity was low. Sonothrombolysis did not lead to an increase in symptomatic intracranial hemorrhagic complications or death. Our results demonstrated that patients treated with sonothrombolysis had significantly higher rates of recanalization and asymptomatic intracerebral hemorrhage than patients treated with intravenous thrombolysis alone. In the subgroup of middle cerebral artery (MCA) occlusion patients, sonothrombolysis was found to greatly increase the efficacy outcomes compared to intravenous thrombolysis. CONCLUSIONS Evidence suggests that sonothrombolysis is a technically feasible and potentially effective treatment that has beneficial effects on recanalization and increases the rate of asymptomatic intracerebral hemorrhage in stroke patients. Additionally, short- and long-term clinical outcome analyses were improved in the MCA occlusion sonothrombolysis subgroup. Larger clinical trials of MCA occlusion patients are necessary to verify these findings.
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Montrief T, Alerhand S, Jewell C, Scott J. Incorporation of Transcranial Doppler into the ED for the neurocritical care patient. Am J Emerg Med 2019; 37:1144-1152. [PMID: 30894296 DOI: 10.1016/j.ajem.2019.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/05/2019] [Accepted: 03/04/2019] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION In the catastrophic neurologic emergency, a complete neurological exam is not always possible or feasible given the time-sensitive nature of the underlying disease process, or if emergent airway management is indicated. As the neurologic exam may be limited in some patients, the emergency physician is reliant on the assessment of brainstem structures to determine neurological function. Physicians thus routinely depend on advanced imaging modalities to further investigate for potential catastrophic diagnoses. Acquiring these tests introduces the risks of transport as well as delays in managing time-sensitive neurologic processes. A more immediate, non-invasive bedside approach complementing these modalities has evolved: Transcranial Doppler (TCD). OBJECTIVE This narrative review will provide a description of scenarios in which TCD may be applicable. It will summarize the sonographic findings and associated underlying pathophysiology in such neurocritical care patients. An illustrated tutorial, along with pearls and pitfalls, is provided. DISCUSSION Although there are numerous formalized TCD protocols utilizing four views (transtemporal, submandibular, suboccipital, and transorbital), point-of-care TCD is best accomplished through the transtemporal window. The core applications include the evaluation of midline shift, vasospasm after subarachnoid hemorrhage, acute ischemic stroke, and elevated intracranial pressure. An illustrative tutorial is provided. CONCLUSIONS With the wide dissemination of bedside ultrasound within the emergency department, there is a unique opportunity for the emergency physician to utilize TCD for a variety of conditions. While barriers to training exist, emergency physician performance of limited point-of-care TCD is feasible and may provide rapid and reliable clinical information with high temporal resolution.
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Affiliation(s)
- Tim Montrief
- Department of Emergency Medicine, Jackson Memorial Health System, Miami, FL 33136, USA.
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Corlin Jewell
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
| | - Jeffery Scott
- Department of Emergency Medicine, Jackson Memorial Health System, Miami, FL 33136, USA
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Chong WK, Papadopoulou V, Dayton PA. Imaging with ultrasound contrast agents: current status and future. Abdom Radiol (NY) 2018; 43:762-772. [PMID: 29508011 DOI: 10.1007/s00261-018-1516-1] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Microbubble ultrasound contrast agents (UCAs) were recently approved by the Food and Drug administration for non-cardiac imaging. The physical principles of UCAs, methods of administration, dosage, adverse effects, and imaging techniques both current and future are described. UCAs consist of microbubbles in suspension which strongly interact with the ultrasound beam and are readily detectable by ultrasound imaging systems. They are confined to the blood pool when administered intravenously, unlike iodinated and gadolinium contrast agents. UCAs have a proven safety record based on over two decades of use, during which they have been used in echocardiography in the U.S. and for non-cardiac imaging in the rest of the world. Adverse effects are less common with UCAs than CT/MR contrast agents. Compared to CT and MR, contrast-enhanced ultrasound has the advantages of real-time imaging, portability, and reduced susceptibility to metal and motion artifact. UCAs are not nephrotoxic and can be used in renal failure. High acoustic amplitudes can cause microbubbles to fragment in a manner that can result in short-term increases in capillary permeability or capillary rupture. These bioeffects can be beneficial and have been used to enhance drug delivery under appropriate conditions. Imaging with a mechanical index of < 0.4 preserves the microbubbles and is not typically associated with substantial bioeffects. Molecularly targeted ultrasound contrast agents are created by conjugating the microbubble shell with a peptide, antibody, or other ligand designed to target an endothelial biomarker associated with tumor angiogenesis or inflammation. These microbubbles then accumulate in the microvasculature at target sites where they can be imaged. Ultrasound contrast agents are a valuable addition to the diagnostic imaging toolkit. They will facilitate cross-sectional abdominal imaging in situations where contrast-enhanced CT and MR are contraindicated or impractical.
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Affiliation(s)
- Wui K Chong
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Unit 1473 | FCT15.5092, 1400 Pressler Street, Houston, TX, 77030, USA.
| | - Virginie Papadopoulou
- UNC-NC State Joint Department of Biomedical Engineering, Chapel Hill, NC, 27599, USA
| | - Paul A Dayton
- UNC Biomedical Research Imaging Center, Chapel Hill, NC, 27599, USA
- UNC-NC State Joint Department of Biomedical Engineering, Chapel Hill, NC, 27599, USA
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Bonaventura A, Montecucco F, Dallegri F. Update on the effects of treatment with recombinant tissue-type plasminogen activator (rt-PA) in acute ischemic stroke. Expert Opin Biol Ther 2016; 16:1323-1340. [PMID: 27548625 DOI: 10.1080/14712598.2016.1227779] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Acute ischemic stroke (AIS) represents a major cause of death and disability all over the world. The recommended therapy aims at dissolving the clot to re-establish quickly the blood flow to the brain and reduce neuronal injury. Intravenous administration of recombinant tissue-type plasminogen activator (rt-PA) is clinically used with this goal. AREAS COVERED A description of beneficial and detrimental effects of rt-PA treatment is addressed. An overview of new therapies against AIS, such as new thrombolytics, sonolysis and sonothrombolysis, endovascular procedures, and association therapies is provided. Updates on the pathophysiological process leading to intracranial hemorrhage (ICH) is also discussed. EXPERT OPINION rt-PA treatment in AIS patients is beneficial to recovery outcomes. To weaken risks and improve benefits, it might be relevant to consider: i) a definitive identification of risk factors for symptomatic ICH; ii). a better organization of the health care system to reduce time-to-treatment and enhance discharge management. The pharmacological improvement of new thrombolytic drugs (such as tenecteplase and desmoteplase) targeting harmful and maximally exploiting beneficial effects might further reduce mortality and disability in AIS.
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Affiliation(s)
- Aldo Bonaventura
- a First Clinic of Internal Medicine, Department of Internal Medicine , University of Genoa School of Medicine , Genoa , Italy.,b IRCCS AOU San Martino - IST, Genoa , Genoa , Italy
| | - Fabrizio Montecucco
- a First Clinic of Internal Medicine, Department of Internal Medicine , University of Genoa School of Medicine , Genoa , Italy.,b IRCCS AOU San Martino - IST, Genoa , Genoa , Italy.,c Centre of Excellence for Biomedical Research (CEBR) , University of Genoa , Genoa , Italy
| | - Franco Dallegri
- a First Clinic of Internal Medicine, Department of Internal Medicine , University of Genoa School of Medicine , Genoa , Italy.,b IRCCS AOU San Martino - IST, Genoa , Genoa , Italy
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Haršány M, Tsivgoulis G, Alexandrov AV. Ultrasonography. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00046-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Thrombolytic therapy with rt-PA and transcranial color Doppler ultrasound (TCCS) combined with microbubbles for embolic thrombus. Thromb Res 2015; 136:1027-32. [DOI: 10.1016/j.thromres.2015.08.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/29/2015] [Accepted: 08/29/2015] [Indexed: 11/22/2022]
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Dorn F, Prothmann S, Patzig M, Lockau H, Kabbasch C, Nikoubashman O, Liebig T, Zimmer C, Brückmann H, Wiesmann M, Stetefeld H, Poppert H, Reich A, Kellert L, Fesl G. Stent Retriever Thrombectomy in Patients Who Are Ineligible for Intravenous Thrombolysis: A Multicenter Retrospective Observational Study. AJNR Am J Neuroradiol 2015; 37:305-10. [PMID: 26338915 DOI: 10.3174/ajnr.a4520] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 06/27/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous thrombolysis with rtPA is the standard of care for patients with acute ischemic stroke within 4.5 hours after symptom onset. However, a considerable number of patients are ineligible for IV thrombolysis due to various contraindications. Recent studies have proved the superiority of mechanical thrombectomy for patients with large-vessel occlusions in combination with IV rtPA compared with IV rtPA alone. We aimed to demonstrate the efficacy of mechanical thrombectomy for patients who are ineligible for IV rtPA. MATERIALS AND METHODS Patients from the stroke registries of 4 dedicated centers who were treated with mechanical thrombectomy from January 2010 to October 2014 were retrospectively evaluated. Inclusion criteria were the following: acute stroke due to proved large-artery occlusion, ineligibility for IV thrombolysis, and a timeframe of ≤4.5 hours between stroke and the start of mechanical thrombectomy. Recanalization success, periprocedural complications, clinical outcome, and hemorrhages were evaluated. RESULTS One hundred thirty endovascular recanalization procedures were identified. The locations were the following: proximal ICA in 17 (13.1%), terminus ICA in 25 (19.2%), M1 segment in 77 (59.2%), and M2 segment in 11 (8.5%). TICI 2b/3 results were achieved in 101 (77.7%), and an mRS score of 0-2 in 47 patients (37.9%). There was a significant correlation between TICI 2b/3 results and good clinical outcomes (87.2% versus 6.8%; P = .048). A good clinical result was most frequent when recanalization was achieved within 4.5 hours (37/74 = 50% versus 10/50 = 20.0%; P = .001). Symptomatic hemorrhage occurred in 13.1% of patients; mortality was 24.2%. Periprocedural complications were recorded in 10 patients (7.7%). CONCLUSIONS Mechanical thrombectomy can achieve good clinical outcomes in patients with acute large-artery occlusion ineligible for IV thrombolysis, in particular when recanalization is reached early.
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Affiliation(s)
- F Dorn
- From the Departments of Neuroradiology and Radiology (F.D., H.L., C.K., T.L.) Departments of Neuroradiology (F.D., M.P., H.B., G.F.)
| | | | - M Patzig
- Departments of Neuroradiology (F.D., M.P., H.B., G.F.)
| | - H Lockau
- From the Departments of Neuroradiology and Radiology (F.D., H.L., C.K., T.L.)
| | - C Kabbasch
- From the Departments of Neuroradiology and Radiology (F.D., H.L., C.K., T.L.)
| | | | - T Liebig
- From the Departments of Neuroradiology and Radiology (F.D., H.L., C.K., T.L.)
| | - C Zimmer
- Departments of Neuroradiology (S.P., C.Z.)
| | - H Brückmann
- Departments of Neuroradiology (F.D., M.P., H.B., G.F.)
| | - M Wiesmann
- Departments of Neuroradiology (O.N., M.W.)
| | - H Stetefeld
- Neurology (H.S.), University Hospital of Cologne, Cologne, Germany
| | - H Poppert
- Neurology (H.P.), Klinikum Rechts der Isar, Technical University, Munich, Germany
| | - A Reich
- Neurology (A.R.), University Hospital of Aachen, Aachen, Germany
| | - L Kellert
- Neurology (L.K.), University Hospital of Munich, Munich, Germany
| | - G Fesl
- Departments of Neuroradiology (F.D., M.P., H.B., G.F.)
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Desjouy C, Fouqueray M, Lo CW, Muleki Seya P, Lee JL, Bera JC, Chen WS, Inserra C. Counterbalancing the use of ultrasound contrast agents by a cavitation-regulated system. ULTRASONICS SONOCHEMISTRY 2015; 26:163-168. [PMID: 25682465 DOI: 10.1016/j.ultsonch.2014.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 11/24/2014] [Accepted: 12/26/2014] [Indexed: 06/04/2023]
Abstract
The stochastic behavior of cavitation can lead to major problems of initiation and maintenance of cavitation during sonication, responsible of poor reproducibility of US-induced bioeffects in the context of sonoporation for instance. To overcome these disadvantages, the injection of ultrasound contrast agents as cavitation nuclei ensures fast initiation and lower acoustic intensities required for cavitation activity. More recently, regulated-cavitation devices based on the real-time modulation of the applied acoustic intensity have shown their potential to maintain a stable cavitation state during an ultrasonic shot, in continuous or pulsed wave conditions. In this paper is investigated the interest, in terms of cavitation activity, of using such regulated-cavitation device or injecting ultrasound contrast agents in the sonicated medium. When using fixed applied acoustic intensity, results showed that introducing ultrasound contrast agents increases reproducibility of cavitation activity (coefficient of variation 62% and 22% without and with UCA, respectively). Moreover, the use of the regulated-cavitation device ensures a given cavitation activity (coefficient of variation less 0.4% in presence of UCAs or not). This highlights the interest of controlling cavitation over time to free cavitation-based application from the use of UCAs. Interestingly, during a one minute sonication, while ultrasound contrast agents progressively disappear, the regulated-cavitation device counterbalance their destruction to sustain a stable inertial cavitation activity.
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Affiliation(s)
- C Desjouy
- INSERM, U1032, LabTAU, Universit Claude Bernard Lyon 1, 151 Cours Albert Thomas, 69003 Lyon, France
| | - M Fouqueray
- INSERM, U1032, LabTAU, Universit Claude Bernard Lyon 1, 151 Cours Albert Thomas, 69003 Lyon, France
| | - C W Lo
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital & National Taiwan University College of Medicine, No.7, Zhongshan S. Rd., Taipei 100, Taiwan
| | - P Muleki Seya
- INSERM, U1032, LabTAU, Universit Claude Bernard Lyon 1, 151 Cours Albert Thomas, 69003 Lyon, France
| | - J L Lee
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital & National Taiwan University College of Medicine, No.7, Zhongshan S. Rd., Taipei 100, Taiwan
| | - J C Bera
- INSERM, U1032, LabTAU, Universit Claude Bernard Lyon 1, 151 Cours Albert Thomas, 69003 Lyon, France
| | - W S Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital & National Taiwan University College of Medicine, No.7, Zhongshan S. Rd., Taipei 100, Taiwan
| | - C Inserra
- INSERM, U1032, LabTAU, Universit Claude Bernard Lyon 1, 151 Cours Albert Thomas, 69003 Lyon, France
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Pulicherla KK, Verma MK. Targeting therapeutics across the blood brain barrier (BBB), prerequisite towards thrombolytic therapy for cerebrovascular disorders-an overview and advancements. AAPS PharmSciTech 2015; 16:223-33. [PMID: 25613561 PMCID: PMC4370956 DOI: 10.1208/s12249-015-0287-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 12/22/2014] [Indexed: 01/23/2023] Open
Abstract
Cerebral tissues possess highly selective and dynamic protection known as blood brain barrier (BBB) that regulates brain homeostasis and provides protection against invading pathogens and various chemicals including drug molecules. Such natural protection strictly monitors entry of drug molecules often required for the management of several diseases and disorders including cerebral vascular and neurological disorders. However, in recent times, the ischemic cerebrovascular disease and clinical manifestation of acute arterial thrombosis are the most common causes of mortality and morbidity worldwide. The management of cerebral Ischemia requires immediate infusion of external thrombolytic into systemic circulation and must cross the blood brain barrier. The major challenge with available thrombolytic is their poor affinity towards the blood brain barrier and cerebral tissue subsequently. In the clinical practice, a high dose of thrombolytic often prescribed to deliver drugs across the blood brain barrier which results in drug dependent toxicity leading to damage of neuronal tissues. In recent times, more emphasis was given to utilize blood brain barrier transport mechanism to deliver drugs in neuronal tissue. The blood brain barrier expresses a series of receptor on membrane became an ideal target for selective drug delivery. In this review, the author has given more emphasis molecular biology of receptor on blood brain barrier and their potential as a carrier for drug molecules to cerebral tissues. Further, the use of nanoscale design and real-time monitoring for developed therapeutic to encounter drug dependent toxicity has been reviewed in this study.
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Affiliation(s)
- K K Pulicherla
- Center for Bioseparation Technology, VIT University, Vellore, Tamilnadu, India,
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Tsivgoulis G, Katsanos AH, Alexandrov AV. Reperfusion therapies of acute ischemic stroke: potentials and failures. Front Neurol 2014; 5:215. [PMID: 25404927 PMCID: PMC4217479 DOI: 10.3389/fneur.2014.00215] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/06/2014] [Indexed: 12/16/2022] Open
Abstract
Over the past 20 years, clinical research has focused on the development of reperfusion therapies for acute ischemic stroke (AIS), which include the use of systemic intravenous thrombolytics (alteplase, desmoteplase, or tenecteplase), the augmentation of systemic intravenous recanalization with ultrasound, the bridging of intravenous with intra-arterial thrombolysis, the use of multi-modal approaches to reperfusion including thrombectomy and thromboaspiration with different available retrievers. Clinical trials testing these acute reperfusion therapies provided novel insight regarding the comparative safety and efficacy, but also raised new questions and further uncertainty on the field. Intravenous alteplase (tPA) remains the fastest and easiest way to initiate acute stroke reperfusion treatment, and should continue to be the first-line treatment for patients with AIS within 4.5 h from onset. The use of tenecteplase instead of tPA and the augmentation of systemic thrombolysis with ultrasound are both novel therapeutical modalities that may emerge as significant options in AIS treatment. Endovascular treatments for AIS are rapidly evolving due to technological advances in catheter-based interventions and are currently emphasizing speed in order to result in timely restoration of perfusion of still-salvageable, infarcted brain tissue, since delayed recanalization of proximal intracranial occlusions has not been associated with improved clinical outcomes. Comprehensive imaging protocols in AIS may enable better patient selection for endovascular interventions and for testing multi-modal combinatory strategies.
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Affiliation(s)
- Georgios Tsivgoulis
- Department of Neurology, The University of Tennessee Health Science Center , Memphis, TN , USA ; Second Department of Neurology, School of Medicine, University of Athens, Attikon University Hospital , Athens , Greece ; International Clinical Research Center, St. Anne's University Hospital , Brno , Czech Republic
| | - Aristeidis H Katsanos
- Department of Neurology, School of Medicine, University of Ioannina , Ioannina , Greece
| | - Andrei V Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center , Memphis, TN , USA
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El-Sherbiny IM, Elkholi IE, Yacoub MH. Tissue plasminogen activator-based clot busting: Controlled delivery approaches. Glob Cardiol Sci Pract 2014; 2014:336-49. [PMID: 25780787 PMCID: PMC4352685 DOI: 10.5339/gcsp.2014.46] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 09/18/2014] [Indexed: 01/06/2023] Open
Abstract
Cardiovascular diseases are the leading cause of death worldwide. Thrombosis, the formation of blood clot (thrombus) in the circulatory system obstructing the blood flow, is one of the main causes behind various ischemic arterial syndromes such as ischemic stroke and myocardial infarction, as well as vein syndromes such as deep vein thrombosis, and consequently, pulmonary emboli. Several thrombolytic agents have been developed for treating thrombosis, the most common being tissue plasminogen activator (tPA), administrated systemically or locally via IV infusion directly proximal to the thrombus, with the aim of restoring and improving the blood flow. TPA triggers the dissolution of thrombi by inducing the conversion of plasminogen to protease plasmin followed by fibrin digestion that eventually leads to clot lysis. Although tPA provides powerful thrombolytic activity, it has many shortcomings, including poor pharmacokinetic profiles, impairment of the reestablishment of normal coronary flow, and impairment of hemostasis, leading to life-threatening bleeding consequences. The bleeding consequence is ascribed to the ability of tPA to circulate throughout the body and therefore can lysis all blood clots in the circulation system, even the good ones that prevent the bleeding and promote injury repair. This review provides an overview of the different delivery approaches for tPA including: liposomes, ultrasound-triggered thrombolysis, anti-fibrin antibody-targeted tPA, camouflaged-tPA, tpA-loaded microcarriers, and nano-modulated delivery approaches.
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Affiliation(s)
- Ibrahim M El-Sherbiny
- Zewail City of Science and Technology, Center for Materials Science, University of Science and Technology, 6th October City, 12588 Giza, Egypt
| | - Islam E Elkholi
- Medical Experimental Research Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Magdi H Yacoub
- Harefield Heart Science Centre, National Heart and Lung Institute, Imperial College, London, UK
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Fransen PSS, Beumer D, Berkhemer OA, van den Berg LA, Lingsma H, van der Lugt A, van Zwam WH, van Oostenbrugge RJ, Roos YBWEM, Majoie CB, Dippel DWJ. MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: study protocol for a randomized controlled trial. Trials 2014; 15:343. [PMID: 25179366 PMCID: PMC4162915 DOI: 10.1186/1745-6215-15-343] [Citation(s) in RCA: 204] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 08/14/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Endovascular or intra-arterial treatment (IAT) increases the likelihood of recanalization in patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion. However, a beneficial effect of IAT on functional recovery in patients with acute ischemic stroke remains unproven. The aim of this study is to assess the effect of IAT on functional outcome in patients with acute ischemic stroke. Additionally, we aim to assess the safety of IAT, and the effect on recanalization of different mechanical treatment modalities. METHODS/DESIGN A multicenter randomized clinical trial with blinded outcome assessment. The active comparison is IAT versus no IAT. IAT may consist of intra-arterial thrombolysis with alteplase or urokinase, mechanical treatment or both. Mechanical treatment refers to retraction, aspiration, sonolysis, or use of a retrievable stent (stent-retriever). Patients with a relevant intracranial proximal arterial occlusion of the anterior circulation, who can be treated within 6 hours after stroke onset, are eligible. Treatment effect will be estimated with ordinal logistic regression (shift analysis); 500 patients will be included in the trial for a power of 80% to detect a shift leading to a decrease in dependency in 10% of treated patients. The primary outcome is the score on the modified Rankin scale at 90 days. Secondary outcomes are the National Institutes of Health stroke scale score at 24 hours, vessel patency at 24 hours, infarct size on day 5, and the occurrence of major bleeding during the first 5 days. DISCUSSION If IAT leads to a 10% absolute reduction in poor outcome after stroke, careful implementation of the intervention could save approximately 1% of all new stroke cases from death or disability annually. TRIAL REGISTRATION NTR1804 (7 May 2009)/ISRCTN10888758 (24 July 2012).
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Affiliation(s)
- Puck SS Fransen
- />Department of Neurology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
- />Department of Radiology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Debbie Beumer
- />Department of Neurology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
- />Department of Neurology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands
| | - Olvert A Berkhemer
- />Department of Neurology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
- />Department of Radiology, Academisch Medisch Centrum, PO Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Lucie A van den Berg
- />Department of Neurology, Academisch Medisch Centrum, PO Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Hester Lingsma
- />Department of Public Health, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Aad van der Lugt
- />Department of Radiology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Wim H van Zwam
- />Department of Radiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands
| | - Robert J van Oostenbrugge
- />Department of Neurology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands
| | - Yvo BWEM Roos
- />Department of Neurology, Academisch Medisch Centrum, PO Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Charles B Majoie
- />Department of Radiology, Academisch Medisch Centrum, PO Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Diederik WJ Dippel
- />Department of Neurology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - for the MR CLEAN Investigators
- />Department of Neurology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
- />Department of Radiology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
- />Department of Neurology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands
- />Department of Radiology, Academisch Medisch Centrum, PO Box 22660, 1100 DD Amsterdam, the Netherlands
- />Department of Neurology, Academisch Medisch Centrum, PO Box 22660, 1100 DD Amsterdam, the Netherlands
- />Department of Public Health, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
- />Department of Radiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands
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Haršány M, Tsivgoulis G, Alexandrov AV. Intravenous thrombolysis in acute ischemic stroke: standard and potential future applications. Expert Rev Neurother 2014; 14:879-92. [PMID: 24984941 DOI: 10.1586/14737175.2014.934676] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Acute ischemic stroke is a medical emergency requiring urgent treatment. Randomized clinical trial and Phase IV data have provided unequivocal evidence that intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) improves early functional outcomes by restoring brain perfusion. Moreover, these studies have shed substantial light on the factors which are associated with more favorable outcome with tPA and are related to the highest benefit-to-risk ratio. Stroke physicians should consider vascular imaging techniques to aid decision making with thrombolytic therapy. The presence of intracranial occlusion is the target of treatment with early recanalization being the goal. Successful use of intravenous thrombolysis depends on a sound understanding of the decision-making process and organization of the treating team who strives for early treatment initiation and strict adherence to the protocol. Intravenous rt-PA within 4.5 h of onset should now be a standard treatment of acute disabling ischemic stroke throughout the world. This review also summarizes intravenous thrombolysis contraindications as well as the safety of novel reperfusion therapies including tenecteplase, sonothrombolysis and the combination of alteplase with direct thrombin inhibitors or glycoprotein IIb/IIIa receptor antagonists.
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Affiliation(s)
- Michal Haršány
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
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17
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Klibanov AL. Ultrasound contrast materials in cardiovascular medicine: from perfusion assessment to molecular imaging. J Cardiovasc Transl Res 2013; 6:729-39. [PMID: 23913363 DOI: 10.1007/s12265-013-9501-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 07/08/2013] [Indexed: 11/26/2022]
Abstract
Ultrasound imaging is widely used in cardiovascular diagnostics. Contrast agents expand the range of tasks that ultrasound can perform. In the clinic in the USA, endocardial border delineation and left ventricle opacification have been an approved indication for more than a decade. However, myocardial perfusion contrast ultrasound studies are still at the clinical trials stage. Blood pool contrast and perfusion in other tissues might be an easier indication to achieve: general blood pool ultrasound contrast is in wider use in Europe, Canada, Japan, and China. Targeted (molecular) contrast microbubbles will be the next generation of ultrasound imaging probes, capable of specific delineation of the areas of disease by adherence to molecular targets. The shell of targeted microbubbles (currently in the preclinical research and early stage clinical trials) is decorated with the ligands (antibodies, peptides or mimetics, hormones, and carbohydrates) that ensure firm binding to the molecular markers of disease.
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Affiliation(s)
- Alexander L Klibanov
- Division of Cardiovascular Medicine and Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA,
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Saqqur M, Tsivgoulis G, Nicoli F, Skoloudik D, Sharma VK, Larrue V, Eggers J, Perren F, Charalampidis P, Storie D, Shuaib A, Alexandrov AV. The role of sonolysis and sonothrombolysis in acute ischemic stroke: a systematic review and meta-analysis of randomized controlled trials and case-control studies. J Neuroimaging 2013; 24:209-20. [PMID: 23607713 DOI: 10.1111/jon.12026] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 03/05/2013] [Accepted: 03/11/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To assess the evidence on the safety and efficacy of sonothrombolysis in acute stroke. SEARCH METHODS Electronic databases and grey literature were searched under different MeSH terms from 1970 to present. SELECTION CRITERIA Randomized control trials (RCTs) and case control studies (CCSs) on sonolysis and sonothrombolysis alone or with microsphere in acute stroke patients (>18 old). Outcome measures included complete recanalization (CR) at 1-2 and 24 hours, 3 months modified Rankin Scale (mRS), and symptomatic intracerebral hemorrhage (sICH). Data was extracted to Review Manager software. RESULTS Fifty-seven studies were retrieved and analyzed. Ten studies (7 RCTs and 3 CCSs) were included in our meta-analysis, which revealed that sonolysis and sonothrombolysis are safe (OR of sICH: 1.14; 95% confidence interval (CI): 0.56- 2.34;P=0.71) and effective (OR of CR at 1-2 hours: 2.95;95% CI: 1.81-4.81;P<0.00001) and have more than two-fold higher likelihood of favourable long-term outcome (3-month mRS 0-2; OR: 2.20; CI:1.52-3.19;P<0.0001). Further subgroup analysis based on the presence of microsphere revealed that it is safe (OR of sICH: 1.18; CI:0.433.24;P=0.75) and effective (OR of CR: 2.61; CI: 1.36-4.99;P=0.004). Subgroup analysis based on sonolysis revealed to be safe and effective. CONCLUSIONS This novel treatment appears safe and effective. The evidence of microsphere as an enhancement of sonothrombolysis is evolving.
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Affiliation(s)
- Maher Saqqur
- From the Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada
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Abstract
High-intensity focused ultrasound (HIFU) provides focal delivery of mechanical energy deep into the body. This energy can be used to elevate the tissue temperature to such a degree that ablation is achieved. The elevated temperature can also be used to release drugs from temperature-sensitive carriers or activate therapeutic molecules using mechanical or thermal energy. Lower dose exposures modify the vasculature to allow large molecules to diffuse from blood in the surrounding tissue for local drug delivery. The energy delivery can be targeted and monitored using magnetic resonance imaging (MRI). The online image guidance and monitoring provides treatment delivery that is customized to each patient such that optimal, effective treatment can be achieved. This ability to localize and customize treatment delivery may further enhance the future potential of targeted drugs that are personalized for each patient. This review examines the rapid development of MRI-guided HIFU (MRIgHIFU) methods over the past few years and discuss their future potential.
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Affiliation(s)
- Kullervo Hynynen
- Imaging Research, Sunnybrook Health Sciences Centre, and Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.
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20
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Bor-Seng-Shu E, Nogueira RDC, Figueiredo EG, Evaristo EF, Conforto AB, Teixeira MJ. Sonothrombolysis for acute ischemic stroke: a systematic review of randomized controlled trials. Neurosurg Focus 2012; 32:E5. [PMID: 22208898 DOI: 10.3171/2011.10.focus11251] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Sonothrombolysis has recently been considered an emerging modality for the treatment of stroke. The purpose of the present paper was to review randomized clinical studies concerning the effects of sonothrombolysis associated with tissue plasminogen activator (tPA) on acute ischemic stroke. METHODS Systematic searches for literature published between January 1996 and July 2011 were performed for studies regarding sonothrombolysis combined with tPA for acute ischemic stroke. Only randomized controlled trials were included. Data extraction was based on ultrasound variables, patient characteristics, and outcome variables (rate of intracranial hemorrhages and arterial recanalization). RESULTS Four trials were included in this study; 2 trials evaluated the effect of transcranial Doppler (TCD) ultrasonography on sonothrombolysis, and 2 addressed transcranial color-coded duplex (TCCD) ultrasonography. The frequency of ultrasound waves varied from 1.8 to 2 MHz. The duration of thrombus exposure to ultrasound energy ranged from 60 to 120 minutes. Sample sizes were small, recanalization was evaluated at different time points (60 and 120 minutes), and inclusion criteria were heterogeneous. Sonothrombolysis combined with tPA did not lead to an increase in symptomatic intracranial hemorrhagic complications. Two studies demonstrated that patients treated with ultrasound combined with tPA had statistically significant higher rates of recanalization than patients treated with tPA alone. CONCLUSIONS Despite the heterogeneity and the limitations of the reviewed studies, there is evidence that sonothrombolysis associated with tPA is a safe procedure and results in an increased rate of recanalization in the setting of acute ischemic stroke when wave frequencies and energy intensities of diagnostic ultrasound systems are used.
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Affiliation(s)
- Edson Bor-Seng-Shu
- Division of Neurological Surgery, Hospital das Clinicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
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21
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Willie CK, Colino FL, Bailey DM, Tzeng YC, Binsted G, Jones LW, Haykowsky MJ, Bellapart J, Ogoh S, Smith KJ, Smirl JD, Day TA, Lucas SJ, Eller LK, Ainslie PN. Utility of transcranial Doppler ultrasound for the integrative assessment of cerebrovascular function. J Neurosci Methods 2011; 196:221-37. [PMID: 21276818 DOI: 10.1016/j.jneumeth.2011.01.011] [Citation(s) in RCA: 397] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Revised: 01/05/2011] [Accepted: 01/06/2011] [Indexed: 01/05/2023]
Abstract
There is considerable utility in the use of transcranial Doppler ultrasound (TCD) to assess cerebrovascular function. The brain is unique in its high energy and oxygen demand but limited capacity for energy storage that necessitates an effective means of regional blood delivery. The relative low cost, ease-of-use, non-invasiveness, and excellent temporal resolution of TCD make it an ideal tool for the examination of cerebrovascular function in both research and clinical settings. TCD is an efficient tool to access blood velocities within the cerebral vessels, cerebral autoregulation, cerebrovascular reactivity to CO(2), and neurovascular coupling, in both physiological states and in pathological conditions such as stroke and head trauma. In this review, we provide: (1) an overview of TCD methodology with respect to other techniques; (2) a methodological synopsis of the cerebrovascular exam using TCD; (3) an overview of the physiological mechanisms involved in regulation of the cerebral blood flow; (4) the utility of TCD for assessment of cerebrovascular pathology; and (5) recommendations for the assessment of four critical and complimentary aspects of cerebrovascular function: intra-cranial blood flow velocity, cerebral autoregulation, cerebral reactivity, and neurovascular coupling. The integration of these regulatory mechanisms from an integrated systems perspective is discussed, and future research directions are explored.
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Affiliation(s)
- C K Willie
- Department of Human Kinetics, Faculty of Health and Social Development, University of British Columbia Okanagan, 3333 University Way, Kelowna, BC, Canada V1V 1V7.
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22
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Sandhu GS, Solorio L, Broome AM, Salem N, Kolthammer J, Shah T, Flask C, Duerk JL. Whole animal imaging. WILEY INTERDISCIPLINARY REVIEWS-SYSTEMS BIOLOGY AND MEDICINE 2010; 2:398-421. [PMID: 20836038 DOI: 10.1002/wsbm.71] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Translational research plays a vital role in understanding the underlying pathophysiology of human diseases, and hence development of new diagnostic and therapeutic options for their management. After creating an animal disease model, pathophysiologic changes and effects of a therapeutic intervention on them are often evaluated on the animals using immunohistologic or imaging techniques. In contrast to the immunohistologic techniques, the imaging techniques are noninvasive and hence can be used to investigate the whole animal, oftentimes in a single exam which provides opportunities to perform longitudinal studies and dynamic imaging of the same subject, and hence minimizes the experimental variability, requirement for the number of animals, and the time to perform a given experiment. Whole animal imaging can be performed by a number of techniques including x-ray computed tomography, magnetic resonance imaging, ultrasound imaging, positron emission tomography, single photon emission computed tomography, fluorescence imaging, and bioluminescence imaging, among others. Individual imaging techniques provide different kinds of information regarding the structure, metabolism, and physiology of the animal. Each technique has its own strengths and weaknesses, and none serves every purpose of image acquisition from all regions of an animal. In this review, a broad overview of basic principles, available contrast mechanisms, applications, challenges, and future prospects of many imaging techniques employed for whole animal imaging is provided. Our main goal is to briefly describe the current state of art to researchers and advanced students with a strong background in the field of animal research.
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Affiliation(s)
- Gurpreet Singh Sandhu
- Department of Biomedical Engineering, Case Center of Imaging Research, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Luis Solorio
- Department of Biomedical Engineering, Case Center of Imaging Research, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Ann-Marie Broome
- Department of Biomedical Engineering, Case Center of Imaging Research, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Nicolas Salem
- Department of Biomedical Engineering, Case Center of Imaging Research, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Jeff Kolthammer
- Department of Biomedical Engineering, Case Center of Imaging Research, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Tejas Shah
- Department of Biomedical Engineering, Case Center of Imaging Research, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Chris Flask
- Department of Biomedical Engineering, Case Center of Imaging Research, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Jeffrey L Duerk
- Department of Biomedical Engineering, Case Center of Imaging Research, Case Western Reserve University, Cleveland, OH 44106, USA
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Marshall SA, Nyquist P, Ziai WC. The role of transcranial Doppler ultrasonography in the diagnosis and management of vasospasm after aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am 2010; 21:291-303. [PMID: 20380971 DOI: 10.1016/j.nec.2009.10.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Transcranial Doppler ultrasonography (TCD) is a tool employed by the neurosurgeon and neurointensivist in the management of vasospasm in the intensive care unit after aneurysmal subarachnoid hemorrhage. A review of the current indications, monitoring parameters, indices, and relevance of modern TCD technology is provided, as well as algorithms for the use of TCD ultrasonography in the management of patients with subarachnoid hemorrhage. Other current uses of TCD ultrasonography are also discussed in the setting of neurocritical care.
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Affiliation(s)
- Scott A Marshall
- Division of Neurosciences Critical Care, Departments of Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Meyer 8-140, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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24
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Hynynen K. MRI-guided focused ultrasound treatments. ULTRASONICS 2010; 50:221-229. [PMID: 19818981 DOI: 10.1016/j.ultras.2009.08.015] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 08/27/2009] [Accepted: 08/27/2009] [Indexed: 05/28/2023]
Abstract
Focused ultrasound (FUS) allows noninvasive focal delivery of energy deep into soft tissues. The focused energy can be used to modify and eliminate tissue for therapeutic purposes while the energy delivery is targeted and monitored using magnetic resonance imaging (MRI). MRI compatible methods to deliver these exposures have undergone rapid development over the past 10 years such that clinical treatments are now routinely performed. This paper will review the current technical and clinical status of MRI-guided focused ultrasound therapy and discuss future research and development opportunities.
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Affiliation(s)
- Kullervo Hynynen
- Sunnybrook Health Sciences Centre, Imaging Research, Department of Medical Biophysics, University of Toronto, 2075 Bayview Ave., Toronto, ON, Canada M4N 3M5.
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25
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Abstract
In a quest for stroke treatment, reperfusion proved to be the first key to the puzzle. Systemic tissue plasminogen activator (tPA), the first and currently the only approved treatment, is also the fastest way to initiate thrombolyis for acute ischemic stroke. tPA works by induction of mostly partial recanalization since stroke patients often have large thrombus burden. Thus, early augmentation of fibrinolysis and multi-modal approach to improve recanalization are desirable. This review focuses on the following strategies available to clinicians now or being tested in clinical trials: (a) faster initiation of tPA infusion; (b) sonothrombolysis; (c) intra-arterial revascularization, bridging intravenous and intra-arterial thrombolysis, mechanical thrombectomy and aspiration; and (d) novel experimental approaches. Despite these technological advances, no single strategy was yet proven to be a 'silver bullet' solution to reverse acute ischemic stroke. Better outcomes are expected with faster treatment leading to early, at times just partial flow improvement rather than achieving complete recanalization with lengthy procedures. Arterial re-occlusion can occur with any of these approaches, and it remains a challenge since it leads to poor outcomes and no clinical trial data are available yet to determine safe strategies to prevent or reverse re-occlusion.
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Affiliation(s)
- A V Alexandrov
- Comprehensive Stroke Center, Neurovascular Ultrasound Laboratory, University of Alabama Hospital, Birmingham, AL, USA.
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26
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Stride EP, Coussios CC. Cavitation and contrast: The use of bubbles in ultrasound imaging and therapy. Proc Inst Mech Eng H 2009; 224:171-91. [DOI: 10.1243/09544119jeim622] [Citation(s) in RCA: 188] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Microbubbles and cavitation are playing an increasingly significant role in both diagnostic and therapeutic applications of ultrasound. Microbubble ultrasound contrast agents have been in clinical use now for more than two decades, stimulating the development of a range of new contrast-specific imaging techniques which offer substantial benefits in echocardiography, microcirculatory imaging, and more recently, quantitative and molecular imaging. In drug delivery and gene therapy, microbubbles are being investigated/developed as vehicles which can be loaded with the required therapeutic agent, traced to the target site using diagnostic ultrasound, and then destroyed with ultrasound of higher intensity energy burst to release the material locally, thus avoiding side effects associated with systemic administration, e.g. of toxic chemotherapy. It has moreover been shown that the motion of the microbubbles increases the permeability of both individual cell membranes and the endothelium, thus enhancing therapeutic uptake, and can locally increase the activity of drugs by enhancing their transport across biologically inaccessible interfaces such as blood clots or solid tumours. In high-intensity focused ultrasound (HIFU) surgery and lithotripsy, controlled cavitation is being investigated as a means of increasing the speed and efficacy of the treatment. The aim of this paper is both to describe the key features of the physical behaviour of acoustically driven bubbles which underlie their effectiveness in biomedical applications and to review the current state of the art.
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Affiliation(s)
- E P Stride
- Department of Mechanical Engineering, University College London, London, UK
| | - C C Coussios
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
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Rubiera M, Ribo M, Delgado-Mederos R, Santamarina E, Maisterra O, Delgado P, Montaner J, Alvarez-Sabín J, Molina CA. Do bubble characteristics affect recanalization in stroke patients treated with microbubble-enhanced sonothrombolysis? ULTRASOUND IN MEDICINE & BIOLOGY 2008; 34:1573-1577. [PMID: 18450360 DOI: 10.1016/j.ultrasmedbio.2008.02.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Revised: 02/06/2008] [Accepted: 02/14/2008] [Indexed: 05/26/2023]
Abstract
Administration of microbubbles (MB) may augment the effect of ultrasound-enhanced systemic thrombolysis in acute stroke. Bubble structural characteristics may influence the effect of MB on sonothrombolysis. We aimed to compare the effects of galactose-based air-filled MB (Levovist) and sulphur hexafluoride-filled MB (Sonovue) on recanalization and clinical outcome. One hundred thirty-eight i.v. recombinant tissue plasminogen activator-(tPA-) treated patients with middle cerebral artery (MCA) occlusion were studied. Presence and location of arterial occlusion and recanalization (RE) were assessed using the thrombolysis in brain ischemia (TIBI) flow grading system. Patients underwent 2 h of continuous transcranial Doppler (TCD) monitoring and received three bolus of MB after 2, 20 and 40 min of tPA bolus. Ninety-one patients received Levovist (LV) and 47 received Sonovue (SV). NIHSS scores were obtained at baseline and after 24 h. Modified Rankin Scale (mRS) score was used to assess outcome at 3 mo. Median admission NIHSS was 17. On TCD, 96 (69.6%) patients had a proximal and 42 (30.4%) a distal MCA occlusion. Age, baseline NIHSS, clot location, stroke subtypes and time to treatment were similar between LV and SV groups. Recanalization rates after 1 h (32.2%/35.6%), 2 h (50.0%/46.7%) and 6 h (63.8%/54.5%) were similar in LV/SV groups (p > 0.3). Clinical improvement (NIHSS decrease >or= 4 points) at 24 h was similar in both groups (54.9%/51.1%, p = 0.400), as well as symptomatic intracranial haemorrhage rate (3.3%/2.1%, p = 0.580) and in-hospital mortality (8.1%/9.3%, p = 0.531). Similarly, the type of MB administered did not affect long-term outcome after sonothrombolysis. Forty-four percent of patients in the LV group and 48.5% in the SV group achieved functional independence (mRS <or= 2) at 3 mo (p = 0.440). MB administration during sonothrombolysis is associated with a high RE rate. However, RE rates, clinical course and long-term outcome are comparable when administering galactose-based air-filled MB (Levovist) or sulphur hexafluoride-filled MB (Sonovue).
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Affiliation(s)
- Marta Rubiera
- Department of Neurology, Universitat Autonoma de Barcelona, Hospital Vall d'Hebrón, Barcelona, Spain.
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Tsivgoulis G, Culp WC, Alexandrov AV. Ultrasound enhanced thrombolysis in acute arterial ischemia. ULTRASONICS 2008; 48:303-11. [PMID: 18511094 DOI: 10.1016/j.ultras.2007.11.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 08/21/2007] [Accepted: 11/13/2007] [Indexed: 05/08/2023]
Abstract
In vitro and animal studies have shown that thrombolysis with intravenous tissue plasminogen activator (tPA) can be enhanced with ultrasound. Ultrasound delivers mechanical pressure waves to the clot, thus exposing more thrombus surface to circulating drug. Moreover, intravenous gaseous microspheres with ultrasound have been shown to be a potential alternative to fibrinolytic agents to recanalize discrete peripheral thrombotic arterial occlusions or acute arteriovenous graft thromboses. Small phase I-II randomized and non-randomized clinical trials have shown promising results concerning the potential applications of ultrasound-enhanced thrombolysis in the setting of acute cerebral ischemia. CLOTBUST was an international four-center phase II trial, which demonstrated that, in patients with acute ischemic stroke, transcranial Doppler (TCD) monitoring augments tPA-induced arterial recanalization (sustained complete recanalization rates: 38% vs. 13%) with a non-significant trend toward an increased rate of clinical recovery from stroke, as compared with placebo. The rates of symptomatic intracerebral hemorrhage (sICH) were similar in the active and placebo group (4.8% vs. 4.8%). Smaller single-center clinical trials using transcranial color-coded sonography (TCCD) reported recanalization rates ranging from 27% to 64% and sICH rates of 0-18%. A separate clinical trial evaluating the safety and efficacy of therapeutic low-frequency ultrasound was discontinued because of a concerning sICH rate of 36% in the active group. To further enhance the ability of tPA to break up thrombi, current ongoing clinical trials include phase II studies of a single beam 2 MHz TCD with perflutren-lipid microspheres. Moreover, potential enhancement of intra-arterial tPA delivery is being clinically tested with 1.7-2.1 MHz pulsed wave ultrasound (EKOS catheter) in ongoing phase II-III clinical trials. Intravenous platelet-targeted microbubbles with low-frequency ultrasound are currently investigated as a rapid noninvasive technique to identify thrombosed intracranial and peripheral vessels. Multi-national dose escalation studies of microspheres and the development of an operator independent ultrasound device are underway.
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Affiliation(s)
- Georgios Tsivgoulis
- Comprehensive Stroke Center, Department of Neurology, University of Alabama at Birmingham, Suite 226, RWUHM, 1719 6th Avenue South, Birmingham, AL 35294, USA
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Tsivgoulis G, Alexandrov AV. Ultrasound-enhanced thrombolysis in acute ischemic stroke: potential, failures, and safety. Neurotherapeutics 2007; 4:420-7. [PMID: 17599707 PMCID: PMC7479735 DOI: 10.1016/j.nurt.2007.05.012] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Experimental and pilot clinical evidence shows that thrombolysis with intravenous tissue plasminogen activator (TPA) can be enhanced with ultrasound. Ultrasound delivers mechanical pressure waves to the clot, thus exposing more thrombus surface to circulating drug. The international multicenter phase II CLOTBUST trial showed that, in patients with acute ischemic stroke, transcranial Doppler (TCD) monitoring augments TPA-induced arterial recanalization, with a nonsignificant trend toward an increased rate of recovery from stroke, compared with placebo. In the CLOTBUST trial, the dramatic clinical recovery from stroke coupled with complete recanalization within 2 hours after TPA bolus occurred in 25% of patients treated with TPA + TCD (n = 63), compared with 8% of those who received TPA alone (n = 63, P = 0.02). Different results were achieved in smaller studies that used transcranial color-coded duplex sonography (TCCD) and a nonimaging therapeutic ultrasound system. The findings of the TRUMBI trial (26 patients) underscored the adverse bioeffects of mid-kilohertz (300 kHz) ultrasound, such as promotion of bleeding in brain areas both affected and unaffected by ischemia. Exposure to multifrequency, multielement duplex ultrasound resulted in a trend toward a higher risk of hemorrhagic transformation. To further enhance the ability of TPA to break up thrombi, current ongoing clinical trials include phase II studies of a single-beam, 2-MHz TCD with perflutren lipid microspheres. Enhancement of intra-arterial TPA delivery is being clinically tested with 1.7-2.1 MHz pulsed-wave ultrasound (EKOS catheter). Multinational dose escalation studies of microspheres and the development of an operator-independent ultrasound device are underway.
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Affiliation(s)
- Georgios Tsivgoulis
- Comprehensive Stroke Center, Department of Neurology, University of Alabama at Birmingham, Suite 226, RWUHM, 1719 6th Avenue South, 35294 Birmingham, AL
| | - Andrei V. Alexandrov
- Comprehensive Stroke Center, Department of Neurology, University of Alabama at Birmingham, Suite 226, RWUHM, 1719 6th Avenue South, 35294 Birmingham, AL
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