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Wróbel D, Wrona P, Homa T, Jakobschy K, Wrona G, Sawczyńska K, Giełczyński M, Popiela T, Słowik A, Turaj W. Sex Alters the Effect of Perfusion Deficits on Functional Outcome in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy. Cerebrovasc Dis 2024:1-10. [PMID: 38631293 DOI: 10.1159/000538633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 03/25/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION The discourse surrounding differences in cerebral hemodynamics and clinical outcomes among male and female patients treated with mechanical thrombectomy (MT) for acute ischemic stroke (AIS) remains unresolved. We aimed to elucidate these differences by employing computed tomography perfusion (CTP) imaging before MT and examining the influence of perfusion deficits on the 90-day functional outcome. METHODS This single-center retrospective analysis involved patients with anterior circulation AIS treated with MT at the Comprehensive Stroke Center, University Hospital, Krakow, from January 2019 to July 2023. We compared male and female patients in terms of baseline characteristics, CTP deficits, hypoperfusion intensity ratio (HIR, defined as T10max/T6max), and complications. The endpoints included the 90-day excellent functional outcome, defined as modified Rankin Score <2, and the 90-day mortality rate. RESULTS We included 794 patients, of whom 408 were female (51.4%). Female patients had a smaller early infarct volume (median [interquartile range]: 7 mL [0-24.8] vs. 10 mL [0-33], p = 0.004), smaller penumbra volume (77.5 mL [46-117] vs. 99.5 mL [59.8-140], p < 0.001), lower HIR (0.34 [0.16-0.5] vs. 0.37 [0.2-9.53], p = 0.043) and were less likely to achieve an excellent functional outcome (55.6% vs. 66.1%, p = 0.003). For every 10 mL increase in early infarct volume, the odds for achieving an excellent outcome were lower in females (odds ratio [OR]: 0.82 [95% confidence interval: 0.73-0.92]) compared to males (OR: 0.96 [0.88-1.04]), whereas the risk of death was higher for females (OR: 1.25 [1.13-1.39] than for males (OR: 1.05 [0.98-1.14]). DISCUSSION Despite more favorable cerebral hemodynamic profile, female AIS patients have worse outcomes than their male counterparts. This effect seems to be independently mediated by the more pronounced impact of early infarct volume on the prognosis in female patients. These findings underscore the possible explanatory power arising from sex-specific interpretation of early infarct volume in clinical practice.
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Affiliation(s)
- Dominik Wróbel
- Jagiellonian University Medical College, Student Scientific Group in Cerebrovascular Diseases, Krakow, Poland
| | - Paweł Wrona
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
- Department of Neurology, University Hospital, Krakow, Poland
| | - Tomasz Homa
- Department of Neurology, University Hospital, Krakow, Poland
| | - Klaudia Jakobschy
- Jagiellonian University Medical College, Student Scientific Group in Cerebrovascular Diseases, Krakow, Poland
| | | | - Katarzyna Sawczyńska
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
- Department of Neurology, University Hospital, Krakow, Poland
| | - Mateusz Giełczyński
- Jagiellonian University Medical College, Student Scientific Group in Cerebrovascular Diseases, Krakow, Poland
| | - Tadeusz Popiela
- Department of Radiology, University Hospital, Krakow, Poland
- Department of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Słowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
- Department of Neurology, University Hospital, Krakow, Poland
| | - Wojciech Turaj
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
- Department of Neurology, University Hospital, Krakow, Poland
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Oura D, Gekka M, Sugimori H. The montage method improves the classification of suspected acute ischemic stroke using the convolution neural network and brain MRI. Radiol Phys Technol 2024; 17:297-305. [PMID: 37934345 DOI: 10.1007/s12194-023-00754-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 11/08/2023]
Abstract
This study investigated the usefulness of the montage method that combines four different magnetic resonance images into one images for automatic acute ischemic stroke (AIS) diagnosis with deep learning method. The montage image was consisted from diffusion weighted image (DWI), fluid attenuated inversion recovery (FLAIR), arterial spin labeling (ASL), and apparent diffusion coefficient (ASL). The montage method was compared with pseudo color map (pCM) which was consisted from FLAIR, ASL and ADC. 473 AIS patients were classified into four categories: mechanical thrombectomy, conservative therapy, hemorrhage, and other diseases. The results showed that the montage image significantly outperformed pCM in terms of accuracy (montage image = 0.76 ± 0.01, pCM = 0.54 ± 0.05) and the area under the curve (AUC) (montage image = 0.94 ± 0.01, pCM = 0.76 ± 0.01). This study demonstrates the usefulness of the montage method and its potential for overcoming the limitations of pCM.
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Affiliation(s)
- Daisuke Oura
- Department of Radiology, Otaru General Hospital, Otaru, 047-0152, Japan
- Graduate School of Health Sciences, Hokkaido University, Sapporo, 060-0812, Japan
| | - Masayuki Gekka
- Department of Neurosurgery, Otaru General Hospital, Otaru, 047-0152, Japan
| | - Hiroyuki Sugimori
- Faculty of Health Sciences, Hokkaido University, Sapporo, 060-0812, Japan.
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Kong J, Zhang D. Current status and quality of radiomics studies for predicting outcome in acute ischemic stroke patients: a systematic review and meta-analysis. Front Neurol 2024; 14:1335851. [PMID: 38229595 PMCID: PMC10789857 DOI: 10.3389/fneur.2023.1335851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/15/2023] [Indexed: 01/18/2024] Open
Abstract
Background Pre-treatment prediction of reperfusion and long-term prognosis in acute ischemic stroke (AIS) patients is crucial for effective treatment and decision-making. Recent studies have demonstrated that the inclusion of radiomics data can improve the performance of predictive models. This paper reviews published studies focused on radiomics-based prediction of reperfusion and long-term prognosis in AIS patients. Methods We systematically searched PubMed, Web of Science, and Cochrane databases up to September 9, 2023, for studies on radiomics-based prediction of AIS patient outcomes. The methodological quality of the included studies was evaluated using the phase classification criteria, the radiomics quality scoring (RQS) tool, and the Prediction model Risk Of Bias Assessment Tool (PROBAST). Two separate meta-analyses were performed of these studies that predict long-term prognosis and reperfusion in AIS patients. Results Sixteen studies with sample sizes ranging from 67 to 3,001 were identified. Ten studies were classified as phase II, and the remaining were categorized as phase 0 (n = 2), phase I (n = 1), and phase III (n = 3). The mean RQS score of all studies was 39.41%, ranging from 5.56 to 75%. Most studies (87.5%, 14/16) were at high risk of bias due to their retrospective design. The remaining two studies were categorized as low risk and unclear risk, respectively. The pooled area under the curve (AUC) was 0.88 [95% confidence interval (CI) 0.84-0.92] for predicting the long-term prognosis and 0.80 (95% CI 0.74-0.86) for predicting reperfusion in AIS. Conclusion Radiomics has the potential to predict immediate reperfusion and long-term outcomes in AIS patients. Further external validation and evaluation within the clinical workflow can facilitate personalized treatment for AIS patients. This systematic review provides valuable insights for optimizing radiomics prediction systems for both reperfusion and long-term outcomes in AIS patients. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023461671, identifier CRD42023461671.
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Affiliation(s)
- Jinfen Kong
- Department of Radiology, Yuhuan Second People's Hospital, Yuhuan, Taizhou, Zhejiang, China
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Yadav I, Kumar R, Fatima Z, Rema V. Ocimum sanctum [Tulsi] as a Potential Immunomodulator for the Treatment of Ischemic Injury in the Brain. Curr Mol Med 2024; 24:60-73. [PMID: 36515030 DOI: 10.2174/1566524023666221212155340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 10/12/2022] [Accepted: 10/12/2022] [Indexed: 12/15/2022]
Abstract
Stroke causes brain damage and is one of the main reasons for death. Most survivors of stroke face long-term physical disabilities and cognitive dysfunctions. In addition, they also have persistent emotional and behavioral changes. The two main treatments that are effective are reperfusion with recombinant tissue plasminogen activator and recanalization of penumbra using mechanical thrombectomy. However, these treatments are suitable only for a few patients due to limitations such as susceptibility to hemorrhage and the requirement for administering tissue plasminogen activators within the short therapeutic window during the early hours following a stroke. The paucity of interventions and treatments could be because of the multiple pathological mechanisms induced in the brain by stroke. The ongoing immune response following stroke has been attributed to the worsening brain injury. Hence, novel compounds with immunomodulatory properties that could improve the outcome of stroke patients are required. Natural compounds and medicinal herbs with anti-inflammatory activities and having minimal or no adverse systemic effect could be beneficial in treating stroke. Ocimum sanctum is a medicinal herb that can be considered an effective therapeutic option for ischemic brain injury. Ocimum sanctum, commonly known as holy basil or "Tulsi," is mentioned as the "Elixir of Life" for its healing powers. Since antiquity, Tulsi has been used in the Ayurvedic and Siddha medical systems to treat several diseases. It possesses immuno-modulatory activity, which can alter cellular and humoral immune responses. Tulsi can be considered a potential option as an immuno-modulator for treating various diseases, including brain stroke. In this review, we will focus on the immunomodulatory properties of Tulsi, specifically its effect on both innate and adaptive immunity, as well as its antioxidant and antiinflammatory properties, which could potentially be effective in treating ongoing immune reactions following ischemic brain injury.
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Affiliation(s)
- Inderjeet Yadav
- National Brain Research Centre [NBRC], Manesar, Haryana, 122052, India
| | - Ravi Kumar
- National Brain Research Centre [NBRC], Manesar, Haryana, 122052, India
| | - Zeeshan Fatima
- Department of Medical Laboratory Sciences, College of Applied Medical Sciences, University of Bisha, Bisha 61922, Saudi Arabia
- Amity Institute of Biotechno logy, Amity University Haryana, Gurugram (Manesar)-122413, India
| | - Velayudhan Rema
- National Brain Research Centre [NBRC], Manesar, Haryana, 122052, India
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Fainardi E, Busto G, Morotti A. Automated advanced imaging in acute ischemic stroke. Certainties and uncertainties. Eur J Radiol Open 2023; 11:100524. [PMID: 37771657 PMCID: PMC10523426 DOI: 10.1016/j.ejro.2023.100524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023] Open
Abstract
The purpose of this is study was to review pearls and pitfalls of advanced imaging, such as computed tomography perfusion and diffusion-weighed imaging and perfusion-weighted imaging in the selection of acute ischemic stroke (AIS) patients suitable for endovascular treatment (EVT) in the late time window (6-24 h from symptom onset). Advanced imaging can quantify infarct core and ischemic penumbra using specific threshold values and provides optimal selection parameters, collectively called target mismatch. More precisely, target mismatch criteria consist of core volume and/or penumbra volume and mismatch ratio (the ratio between total hypoperfusion and core volumes) with precise cut-off values. The parameters of target mismatch are automatically calculated with dedicated software packages that allow a quick and standardized interpretation of advanced imaging. However, this approach has several limitations leading to a misclassification of core and penumbra volumes. In fact, automatic software platforms are affected by technical artifacts and are not interchangeable due to a remarkable vendor-dependent variability, resulting in different estimate of target mismatch parameters. In addition, advanced imaging is not completely accurate in detecting infarct core, that can be under- or overestimated. Finally, the selection of candidates for EVT remains currently suboptimal due to the high rates of futile reperfusion and overselection caused by the use of very stringent inclusion criteria. For these reasons, some investigators recently proposed to replace advanced with conventional imaging in the selection for EVT, after the demonstration that non-contrast CT ASPECTS and computed tomography angiography collateral evaluation are not inferior to advanced images in predicting outcome in AIS patients treated with EVT. However, other authors confirmed that CTP and PWI/DWI postprocessed images are superior to conventional imaging in establishing the eligibility of patients for EVT. Therefore, the routine application of automatic assessment of advanced imaging remains a matter of debate. Recent findings suggest that the combination of conventional and advanced imaging might improving our selection criteria.
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Affiliation(s)
- Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Italy
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Andrea Morotti
- Department of Neurological and Vision Sciences, Neurology Unit, ASST Spedali Civili, Brescia, Italy
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Li M, Lv Y, Wang M, Zhang Y, Pan Z, Luo Y, Zhang H, Wang J. Magnetic Resonance Perfusion-Weighted Imaging in Predicting Hemorrhagic Transformation of Acute Ischemic Stroke: A Retrospective Study. Diagnostics (Basel) 2023; 13:3404. [PMID: 37998540 PMCID: PMC10670343 DOI: 10.3390/diagnostics13223404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/25/2023] Open
Abstract
Hemorrhagic transformation (HT) is one of the common complications in patients with acute ischemic stroke (AIS). This study aims to investigate the value of different thresholds of Tmax generated from perfusion-weighted MR imaging (PWI) and the apparent diffusion coefficient (ADC) value in the prediction of HT in AIS. A total of 156 AIS patients were enrolled in this study, with 55 patients in the HT group and 101 patients in non-HT group. The clinical baseline data and multi-parametric MRI findings were compared between HT and non-HT groups to identify indicators related to HT. The optimal parameters for predicting HT and the corresponding cutoff values were obtained using the receiver operating characteristic curve analysis of the volumes of ADC < 620 × 10-6 mm2/s and Tmax > 6 s, 8 s, and 10 s. The results showed that the volumes of ADC < 620 × 10-6 mm2/s and Tmax > 6 s, 8 s, and 10 s in the HT group were all significantly larger than that in the non-HT group and were all independent risk factors for HT. Early measurement of the volume of Tmax > 10 s had the highest value, with a cutoff lesion volume of 10.5 mL.
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Affiliation(s)
- Ming Li
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (M.L.); (Z.P.)
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Yifan Lv
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Mingming Wang
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Yaying Zhang
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Zilai Pan
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (M.L.); (Z.P.)
| | - Yu Luo
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Haili Zhang
- Southeast University Hospital, Southeast University, Nanjing 210096, China
| | - Jing Wang
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
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Deshpande A, Elliott J, Jiang B, Tahsili-Fahadan P, Kidwell C, Wintermark M, Laksari K. End to end stroke triage using cerebrovascular morphology and machine learning. Front Neurol 2023; 14:1217796. [PMID: 37941573 PMCID: PMC10628321 DOI: 10.3389/fneur.2023.1217796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/20/2023] [Indexed: 11/10/2023] Open
Abstract
Background Rapid and accurate triage of acute ischemic stroke (AIS) is essential for early revascularization and improved patient outcomes. Response to acute reperfusion therapies varies significantly based on patient-specific cerebrovascular anatomy that governs cerebral blood flow. We present an end-to-end machine learning approach for automatic stroke triage. Methods Employing a validated convolutional neural network (CNN) segmentation model for image processing, we extract each patient's cerebrovasculature and its morphological features from baseline non-invasive angiography scans. These features are used to detect occlusion's presence and the site automatically, and for the first time, to estimate collateral circulation without manual intervention. We then use the extracted cerebrovascular features along with commonly used clinical and imaging parameters to predict the 90 days functional outcome for each patient. Results The CNN model achieved a segmentation accuracy of 94% based on the Dice similarity coefficient (DSC). The automatic stroke detection algorithm had a sensitivity and specificity of 92% and 94%, respectively. The models for occlusion site detection and automatic collateral grading reached 96% and 87.2% accuracy, respectively. Incorporating the automatically extracted cerebrovascular features significantly improved the 90 days outcome prediction accuracy from 0.63 to 0.83. Conclusion The fast, automatic, and comprehensive model presented here can improve stroke diagnosis, aid collateral assessment, and enhance prognostication for treatment decisions, using cerebrovascular morphology.
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Affiliation(s)
- Aditi Deshpande
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States
- Department of Mechanical Engineering, University of California, Riverside, Riverside, CA, United States
| | - Jordan Elliott
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States
| | - Bin Jiang
- Department of Radiology, Stanford University, Stanford, CA, United States
| | - Pouya Tahsili-Fahadan
- Department of Medical Education, University of Virginia, Inova Campus, Falls Church, VA, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Chelsea Kidwell
- Department of Neurology, University of Arizona, Tucson, AZ, United States
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Center, University of Texas, Houston, TX, United States
| | - Kaveh Laksari
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States
- Department of Mechanical Engineering, University of California, Riverside, Riverside, CA, United States
- Department of Aerospace and Mechanical Engineering, University of Arizona, Tucson, AZ, United States
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Lu W, Hou D, Chen X, Zhong P, Liu X, Wu D. Elevated SIRT2 of serum exosomes is positively correlated with diagnosis of acute ischemic stroke patients. BMC Neurol 2023; 23:321. [PMID: 37684620 PMCID: PMC10485972 DOI: 10.1186/s12883-023-03348-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 07/28/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Silent Information Regulator 2 (SIRT2) protein inhibition has been shown to play a neuroprotective role in acute ischemic stroke (AIS) in mice. However, its role in AIS patients has not been fully understood. In this study, we aimed to analyze SIRT2 protein expression in serum exosomes of AIS and non-AIS patients, and evaluate its potential role in diagnosis and prognosis of AIS. METHODS Serum exosomes from 75 non-AIS subjects and 75 AIS patients were isolated. The SIRT2 protein levels in exosomes were analyzed using enzyme linked immunosorbent assay (ELISA). The National Institutes of Health Stroke Scale (NIHSS) was used to evaluate the severity of the disease. The modified Rankin Scale (mRS) was employed to assess the functional outcomes of the patients at 3-months following stroke onset. RESULTS The SIRT2 protein concentration of serum exosomes were higher in AIS patients than non-AIS patients (p < 0.001). Furthermore, the receiver operative characteristic curve (ROC) demonstrated that higher serum exosome SIRT2 could differentiate AIS patients from non-AIS patients with a sensitivity of 81.3% and a specificity of 75.3%. The area under the curve was 0.838 (95% CI: 0.775, 0.902). Additionally, higher SIRT2 concentration of serum exosomes were associated with NIHSS ≥ 4 (p < 0.001) and mRS ≥ 3 (p = 0.025) in AIS patients. The ROC analysis showed SIRT2 could discriminate stroke with NIHSS ≥ 4 from mild stroke (NIHSS < 4) with a sensitivity of 75.0% and a specificity of 69.6%. The area under the curve was 0.771 (95% CI: 0.661,0.881). Similarly, the test showed SIRT2 could differentiate between AIS patients with mRS ≥ 3 from those with mRS < 3 with a sensitivity of 78.3% and a specificity of 51.9%. The area under the curve was 0.663 (95% CI: 0.531,0.796). The logistic regression analysis revealed that SIRT2 concentration in serum exosomes can independently predict the diagnosis of AIS (odd ratio = 1.394, 95%CI 1.231-1.577, p < 0.001) and higher NIHSS scores (≥ 4) (odd ratio = 1.258, 95%CI 1.084-1.460, p = 0.002). However, it could not independently predict the prognosis of AIS (odd ratio = 1.065, 95%CI 0.983-1.154, p = 0.125). CONCLUSION The elevation of SIRT2 in serum exosomes may be a valuable biomarker of AIS, which may be a potential diagnostic tool to facilitate decision making for AIS patients.
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Affiliation(s)
- Wenmei Lu
- Department of Neurology, Shanghai Fifth People's Hospital, Fudan University, 801 Heqing Road, Shanghai, China
| | - Duanlu Hou
- Department of Neurology, Shanghai Fifth People's Hospital, Fudan University, 801 Heqing Road, Shanghai, China
| | - Xin Chen
- Department of Geriatrics, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai, China
| | - Ping Zhong
- Department of Neurology, Shanghai Yangpu District Shidong Hospital, 999 Shiguang Road, Shanghai, China
| | - Xueyuan Liu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Middle Yanchang Road, Shanghai, China.
| | - Danhong Wu
- Department of Neurology, Shanghai Fifth People's Hospital, Fudan University, 801 Heqing Road, Shanghai, China.
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Helms AM, Yang H, Karamchandani RR, Williams L, Singh S, DeFilipp GJ, Asimos AW. A Telestroke Nurse and Neuroradiologist Model for Extended Window Code Stroke Triage. J Neurosci Nurs 2023; 55:74-79. [PMID: 36800500 DOI: 10.1097/jnn.0000000000000700] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
ABSTRACT BACKGROUND: Distinguishing features of our stroke network include routine involvement of a telestroke nurse (TSRN) for code stroke activations at nonthrombectomy centers and immediate availability of neuroradiologists for imaging interpretation. On May 1, 2021, we implemented a new workflow for code stroke activations presenting beyond 4.5 hours from last known well that relied on a TSRN supported by a neuroradiologist for initial triage. Patients without a target large vessel occlusion (LVO) were managed without routine involvement of a teleneurologist, which represented a change from the preimplementation period. METHODS: We collected data 6 months before and after implementation of the new workflow. We compared preimplementation process metrics for patients managed with teleneurologist involvement with the postimplementation patients managed without teleneurologist involvement. RESULTS: With the new workflow, teleneurologist involvement decreased from 95% (n = 953) for patients presenting beyond 4.5 hours from last known well to 37% (n = 373; P < .001). Compared with patients in the preimplementation period, postimplementation patients without teleneurologist involvement experienced less inpatient hospital admission and observation (87% vs 90%; unadjusted P = .038, adjusted P = .06). Among the preimplementation and postimplementation admitted patients, there was no statistically significant difference in follow-up neurology consultation or nonstroke diagnoses. A similar percentage of LVO patients were transferred to the thrombectomy center (54% pre vs 49% post, P = .612), whereas more LVO transfers in the postimplementation cohort received thrombectomy therapy (75% post vs 39% pre, P = .014). Among LVO patients (48 pre and 41 post), no statistical significance was observed in imaging and management times. CONCLUSION: Our work shows the successful teaming of a TSRN and a neuroradiologist to triage acute stroke patients who present beyond an eligibility window for systemic thrombolysis, without negatively impacting care and process metrics. This innovative partnering may help to preserve the availability of teleneurologists by limiting their involvement when diagnostic imaging drives decision making.
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Rajendram P, Ikram A, Fisher M. Combined Therapeutics: Future Opportunities for Co-therapy with Thrombectomy. Neurotherapeutics 2023; 20:693-704. [PMID: 36943636 PMCID: PMC10275848 DOI: 10.1007/s13311-023-01369-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/23/2023] Open
Abstract
Stroke is an urgent public health issue with millions of patients worldwide living with its devastating effects. The advent of thrombolysis and endovascular thrombectomy has transformed the hyperacute care of these patients. However, a significant proportion of patients receiving these therapies still goes on to have unfavorable outcomes and many more remain ineligible for these therapies based on our current guidelines. The future of stroke care will depend on an expansion of the scope of thrombolysis and endovascular thrombectomy to patients outside traditional time windows, more distal occlusions, and large vessel occlusions with mild clinical deficits, for whom clinical trial results have not proven therapeutic efficacy. Novel cytoprotective therapies targeting the ischemic cascade and reperfusion injury therapy, in combination with our existing treatment modalities, should be explored to further improve outcomes for these patients with acute ischemic stroke. In this review, we will review the current status of thrombolysis and thrombectomy, suggest additional data that is needed to enhance these therapies, and discuss how cytoprotection might be combined with thrombectomy.
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Affiliation(s)
- Phavalan Rajendram
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Palmer Building Room 127, 330 Brookline Avenue, Boston, MA, 02215-5400, USA.
| | - Asad Ikram
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Palmer Building Room 127, 330 Brookline Avenue, Boston, MA, 02215-5400, USA
| | - Marc Fisher
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Palmer Building Room 127, 330 Brookline Avenue, Boston, MA, 02215-5400, USA
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Meschia JF. Diagnostic Evaluation of Stroke Etiology. Continuum (Minneap Minn) 2023; 29:412-424. [PMID: 37039402 DOI: 10.1212/con.0000000000001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Precise therapies require precise diagnoses. This article provides an evidence-based approach to confirming the diagnosis of ischemic stroke, characterizing comorbidities that provide insights into the pathophysiologic mechanisms of stroke, and identifying targets for treatment to optimize the prevention of recurrent stroke. LATEST DEVELOPMENTS Identifying the presence of patent foramen ovale, intermittent atrial fibrillation, and unstable plaque is now routinely included in an increasingly nuanced workup in patients with stroke, even as ongoing trials seek to clarify the best approaches for treating these and other comorbidities. Multicenter trials have demonstrated the therapeutic utility of patent foramen ovale closure in select patients younger than age 60 years. Insertable cardiac monitors detect atrial fibrillation lasting more than 30 seconds in about one in ten patients monitored for 12 months following a stroke. MRI of carotid plaque can detect unstable plaque at risk of being a source of cerebral embolism. ESSENTIAL POINTS To optimize the prevention of recurrent stroke, it is important to consider pathologies of intracranial and extracranial blood vessels and of cardiac structure and rhythm as well as other inherited or systemic causes of stroke. Some aspects of the stroke workup should be done routinely, while other components will depend on the clinical circumstances and preliminary testing results.
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Cao R, Lu Y, Qi P, Wang Y, Hu H, Jiang Y, Chen M, Chen J. Collateral Circulation and BNP in Predicting Outcome of Acute Ischemic Stroke Patients with Atherosclerotic versus Cardioembolic Cerebral Large-Vessel Occlusion Who Underwent Endovascular Treatment. Brain Sci 2023; 13:brainsci13040539. [PMID: 37190504 DOI: 10.3390/brainsci13040539] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/17/2023] [Accepted: 03/22/2023] [Indexed: 05/17/2023] Open
Abstract
PURPOSE The aim of this study was to verify the value of collateral circulation and B-type natriuretic peptide (BNP) in predicting clinical outcomes of patients with acute ischemic stroke (AIS) and their biomarker value for stroke subtypes before endovascular treatment (EVT). PATIENTS AND METHODS In this retrospective study, 182 patients who underwent EVT for unilateral anterior circulation large-vessel occlusion between March 2016 and January 2022 were analyzed. The modified collateral circulation scoring system on four-dimensional computed tomography angiography (4D CTA-CS) was used to assess collateral status, and stroke subtypes were determined according to the TOAST classification criteria. Patients were divided into good (mRS ≤ 2) and poor outcome (mRS > 2) groups based on their modified Rankin Scale (mRS) score at 3 months. RESULTS 4D CTA-CS was an independent predictor of the clinical outcome for all AIS patients (odds ratio = 0.253; 95% CI, 0.147-0.437; p < 0.001), CE stroke patients (odds ratio = 0.513; 95% CI, 0.280-0.939; p = 0.030), and LAA stroke patients (odds ratio = 0.148; 95% CI, 0.049-0.447; p = 0.001). The BNP was a biomarker for clinical outcome prediction in CE (odds ratio = 1.004; 95% CI, 1.001-1.008; p = 0.005) but not in LAA patients. Combined with BNP, 4D CTA-CS improved predictive values for clinical outcomes (p < 0.05). CONCLUSION Collateral status and BNP could be used as independent predictors of clinical outcomes in AIS patients and could determine stroke subtypes (CE stroke or LAA stroke). In addition, the model of 4D CTA-CS combined with BNP was the most effective in predicting clinical outcomes compared with collateral status or BNP alone.
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Affiliation(s)
- Ruoyao Cao
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
- Graduate School of Peking Union Medical College, Beijing 100730, China
| | - Yao Lu
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Peng Qi
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yanyan Wang
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Hailong Hu
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yun Jiang
- Department of Neurology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Min Chen
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
- Graduate School of Peking Union Medical College, Beijing 100730, China
| | - Juan Chen
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
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ElBeheiry AA, Hanora MA, Youssef AF, Al Neikedy AAM, Elhabashy A, Khater HM. Role of arterial spin labeling magnetic resonance perfusion in acute ischemic stroke. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2023. [DOI: 10.1186/s43055-023-00980-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Abstract
Background
Arterial spin labeling (ASL) is a recently used magnetic resonance imaging (MRI) perfusion technique in acute cerebrovascular stroke conditions; it can detect the hypo perfused areas on basis of qualitative and quantitative measurements and also identify the area at risk known as penumbra by detecting the diffusion/perfusion mismatch. The purpose of this study was to assess the role of ASL perfusion technique in management of acute ischemic stroke and its ability to predict the clinical outcome of acute stroke patients. The study was prospectively carried out on 33 patients clinically presented with acute stroke from the first of August 2020 till the first of August 2021. All cases were clinically assessed by stroke consultant followed by brain imaging including conventional MRI and ASL perfusion technique, based upon which management was established. These imaging data were correlated with the clinical outcome after 3 months using Modified Rankin Scale.
Results
Sixteen cases (48.48%) showed ischemic penumbra with diffusion perfusion mismatch with three cases presenting within the first 4 h managed by intravenous thrombolytic therapy and 13 cases presenting later than 4 h, 10 of whom were managed by endovascular intervention. The group with ischemic penumbra showed significant positive correlation with favorable clinical outcome while the group without ischemic penumbra showed significant positive correlation with poor clinical outcome. Quantitative ASL values were statistically significantly higher (p ≤ 0.05) in patients with favorable clinical outcome than those with poor clinical outcome. The estimated cut off values of ASL absolute cerebral blood flow and relative cerebral blood flow to predict favorable or poor outcome using ROC curve analysis were 19 ml/100gm/min and 74% compared to the contralateral side respectively.
Conclusion
The use of MRI as a primary diagnostic tool in arterial ischemic stroke with the application of non-contrast ASL perfusion sequence allows precise detection of perfusion deficit and diffusion perfusion mismatch (penumbra) and provides a reliable insight into outcome prediction.
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Recurrence of ischaemic stroke using epidemiology and neuroimaging: A retrospective study in Gansu Province. Heliyon 2023; 9:e13495. [PMID: 36825169 PMCID: PMC9941996 DOI: 10.1016/j.heliyon.2023.e13495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 12/30/2022] [Accepted: 01/31/2023] [Indexed: 02/08/2023] Open
Abstract
Objectives This retrospective study aimed to investigate the clinical and imaging recurrence of ischaemic stroke (IS), and to evaluate the risk factors for recurrence. A combined clinical and imaging diagnostic model is important for stroke prevention and management. Methods and materials In accordance with the inclusion and exclusion criteria, we retrospectively analysed consecutively hospitalised patients with acute IS at the Affiliated Hospital of Gansu University of Chinese Medicine. Based on the epidemiological and imaging results, stroke episodes were divided into four categories: clinical first episode (CFE), clinical recurrence (CR), imaging first episode (IFE), and imaging recurrence (IR). Based on the above categories and clinical practice, a joint diagnostic system for IS was established for the first time, including the following five types: IFE, IR, CFE and IFE, CFE and IR, and CR and IR. A binomial logistic regression analysis was conducted to determine the factors which contributed to CR and IR. Results In total, 280 patients were assessed. The CR rate was 22.9% (64/280) and the IR rate was 62.9% (176/280). The only predictor of CR was hypertension (P = 0.019, odds ratio [OR] = 3.041, 95% confidence interval [95%CI] = 1.200-7.704). The factors of hypertension (P < 0.001, OR = 3.551, 95%CI = 1.781-7.080) and age (P = 0.031, OR = 1.031, 95%CI = 1.003-1.060) were predictors of IR. Conclusion The IR rates for IS were three times higher than the CR rates. The key to preventing IR and CR in IS was the management of blood pressure. Neuroimaging examinations were important for the early detection of IFE and IR in elderly patients with hypertension. A combined clinical imaging diagnostic model was developed for the first time.
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Predicting a Favorable (mRS 0-2) or Unfavorable (mRS 3-6) Stroke Outcome by Arterial Spin Labeling and Amide Proton Transfer Imaging in Post-Thrombolysis Stroke Patients. J Pers Med 2023; 13:jpm13020248. [PMID: 36836482 PMCID: PMC9962289 DOI: 10.3390/jpm13020248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/26/2023] [Accepted: 01/28/2023] [Indexed: 01/31/2023] Open
Abstract
(1) Background: The objective of this study was to determine whether arterial spin labeling (ASL), amide proton transfer (APT), or their combination could distinguish between patients with a low and high modified Rankin Scale (mRS) and forecast the effectiveness of the therapy; (2) Methods: Fifty-eight patients with subacute phase ischemic stroke were included in this study. Based on cerebral blood flow (CBF) and asymmetry magnetic transfer ratio (MTRasym) images, histogram analysis was performed on the ischemic area to acquire imaging biomarkers, and the contralateral area was used as a control. Imaging biomarkers were compared between the low (mRS 0-2) and high (mRS 3-6) mRS score groups using the Mann-Whitney U test. Receiver operating characteristic (ROC) curve analysis was used to evaluate the performance of the potential biomarkers in differentiating between the two groups; (3) Results: The rAPT 50th had an area under the ROC curve (AUC) of 0.728, with a sensitivity of 91.67% and a specificity of 61.76% for differentiating between patients with low and high mRS scores. Moreover, the AUC, sensitivity, and specificity of the rASL max were 0.926, 100%, and 82.4%, respectively. Combining the parameters with logistic regression could further improve the performance in predicting prognosis, leading to an AUC of 0.968, a sensitivity of 100%, and a specificity of 91.2%; (4) Conclusions: The combination of APT and ASL may be a potential imaging biomarker to reflect the effectiveness of thrombolytic therapy for stroke patients, assisting in guiding treatment approaches and identifying high-risk patients such as those with severe disability, paralysis, and cognitive impairment.
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Motolese F, Lanzone J, Todisco A, Rossi M, Santoro F, Cruciani A, Capone F, Di Lazzaro V, Pilato F. The role of neurophysiological tools in the evaluation of ischemic stroke evolution: a narrative review. Front Neurol 2023; 14:1178408. [PMID: 37181549 PMCID: PMC10172480 DOI: 10.3389/fneur.2023.1178408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/23/2023] [Indexed: 05/16/2023] Open
Abstract
Ischemic stroke is characterized by a complex cascade of events starting from vessel occlusion. The term "penumbra" denotes the area of severely hypo-perfused brain tissue surrounding the ischemic core that can be potentially recovered if blood flow is reestablished. From the neurophysiological perspective, there are local alterations-reflecting the loss of function of the core and the penumbra-and widespread changes in neural networks functioning, since structural and functional connectivity is disrupted. These dynamic changes are closely related to blood flow in the affected area. However, the pathological process of stroke does not end after the acute phase, but it determines a long-term cascade of events, including changes of cortical excitability, that are quite precocious and might precede clinical evolution. Neurophysiological tools-such as Transcranial Magnetic Stimulation (TMS) or Electroencephalography (EEG)-have enough time resolution to efficiently reflect the pathological changes occurring after stroke. Even if they do not have a role in acute stroke management, EEG and TMS might be helpful for monitoring ischemia evolution-also in the sub-acute and chronic stages. The present review aims to describe the changes occurring in the infarcted area after stroke from the neurophysiological perspective, starting from the acute to the chronic phase.
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Affiliation(s)
- Francesco Motolese
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psichiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- *Correspondence: Francesco Motolese,
| | - Jacopo Lanzone
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation Unit of Milan Institute, Milan, Italy
| | - Antonio Todisco
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psichiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Mariagrazia Rossi
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psichiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Francesca Santoro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psichiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Alessandro Cruciani
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psichiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Fioravante Capone
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psichiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psichiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Fabio Pilato
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psichiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
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Huang J, Chen J, Wang X, Hao L, Zhang J, Zhang X, Sheng Z, Liu K. The diagnostic value of quantitative parameters on dual-layer detector-based spectral CT in identifying ischaemic stroke. Front Neurol 2023; 14:1056941. [PMID: 36908613 PMCID: PMC9996291 DOI: 10.3389/fneur.2023.1056941] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/03/2023] [Indexed: 02/25/2023] Open
Abstract
Objective To investigate the diagnostic value of quantitative parameters of spectral computed tomography (CT) in ischaemic stroke areas. Methods The medical records of 57 patients with acute ischaemic stroke (AIS) who underwent plain computed tomography (CT) head scans, CT angiography (CTA), and CT perfusion (CTP) were retrospectively reviewed. The ischaemic areas (including the core infarct area and penumbra) and non-ischaemic areas in each patient were quantitatively analyzed using F-STROKE software. Two independent readers measured the corresponding values of the spectroscopic quantitative parameters (effective atomic number [Zeff value], iodine density value, and iodine-no-water value) in the ischaemic area and contralateral normal area alone. The differences in spectroscopic quantitative parameters between the two groups were compared, and their diagnostic efficacy was obtained. Results The Zeff, iodine-no-water value, and iodine density value of the ischaemic area all showed significant lower than those of non-ischaemic tissue (P < 0.001). For differentiating the ischaemic area from non-ischaemic tissue, the area under the curve (AUC) of the Zeff value reached 0.869 (cut-off value: 7.385; sensitivity: 93.0%; specificity: 70.2%), the AUC of the iodine density value reached 0.932 (cut-off value: 0.235; sensitivity: 91.2%; specificity: 82.5%), and the AUC of the iodine-no-water value reached 0.922 (cut-off value: 0.205; sensitivity: 96.5%; specificity: 78.9%). Conclusion The study showed the spectral CT would be a potential novel rapid method for identifying AIS. The spectral CT quantitative parameters (Zeff, iodine density values, and iodine-no-water values) can effectively differentiate the ischaemic area from non-ischaemic tissue in stroke patients.
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Affiliation(s)
- Jian Huang
- Department of Radiology, Taicang Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Taicang, Jiangsu, China.,Department of Radiology, Taicang Hospital, The Affiliated Hospital of Jiangsu Vocational College of Medicine, Yancheng, Jiangsu, China
| | - Jinghua Chen
- Department of Radiology, Taicang Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Taicang, Jiangsu, China.,Department of Radiology, Taicang Hospital, The Affiliated Hospital of Jiangsu Vocational College of Medicine, Yancheng, Jiangsu, China
| | - Ximing Wang
- Department of Radiology, First Affiliated Hospital of Suzhou University, Suzhou, Jiangsu, China
| | - Ling Hao
- Department of Radiology, Taicang Hospital, The Affiliated Hospital of Jiangsu Vocational College of Medicine, Yancheng, Jiangsu, China
| | - Jinfeng Zhang
- Department of Neurology, Taicang Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Taicang, Jiangsu, China
| | - Xiaohui Zhang
- Clinical Science, Philips Healthcare, Shanghai, China
| | | | - Kefu Liu
- Department of Radiology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu, China
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Muacevic A, Adler JR, Alves M, Papoila AL, Nunes AP. Functional Outcome of Endovascular Treatment in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: Mothership Versus Drip-and-Ship Model in a Portuguese Urban Region. Cureus 2022; 14:e32659. [PMID: 36660499 PMCID: PMC9844243 DOI: 10.7759/cureus.32659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Endovascular treatment (EVT) with mechanical thrombectomy and acute carotid stenting has become an integral part of the treatment of acute ischemic stroke with large vessel occlusion. Despite being included in the most recent stroke guidelines, only comprehensive centers can offer EVT and thus patients frequently need to be transferred from primary hospitals. We aimed to assess which pre-hospital model of care - direct admission to a comprehensive stroke center (mothership) or transfer to a comprehensive stroke center after the first admission to the nearest hospital (drip-and-ship) - had the most benefit in stroke patients in a Portuguese urban region. Methods We selected patients admitted to a comprehensive stroke center who underwent EVTs between January 2018 and December 2020, in Lisbon, Portugal. We used data from the Safe Implementation of Treatments in Stroke (SITS) International registry on stroke severity, previous modified Rankin Scale (mRS), time from symptom onset to the first admission, time from symptom onset to the procedure, and mRS three months post stroke. We defined an unfavorable outcome as having an mRS >2 at three months post stroke. For patients with previous mRS >2, an unfavorable outcome was defined as any increase in mRS at three months post stroke. Results We analyzed the data of 1154 patients, of which 407 were admitted through a mothership approach and 747 through a drip-and-ship approach. Both groups were similar regarding sociodemographic characteristics, stroke risk factors, previous disability, and stroke severity. Median onset-to-door time was higher (126 vs 110 minutes, p-value=0.002) but onset-to-procedure time was lower (199 vs 339 minutes, p-value<0.001) in the mothership group. The mothership group had a higher proportion of patients with mRS <3 at three months post stroke than the drip-and-ship group (41.3% vs 34.9%, p-value=0.035). Mortality was similar in both groups. A multivariate logistic regression model confirmed a lower probability of unfavorable outcomes with the mothership approach (OR = 0.677, 95% CI 0.514-0.892, p-value=0.006). Surprisingly, onset-to-procedure time did not have an impact on functional outcomes. Conclusion Our findings show that the mothership model results in better functional outcomes for patients with acute ischemic stroke with large vessel occlusion. Further studies are needed to better define patient selection for this strategy and the impact of a mothership model in comprehensive stroke centers.
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Ischemic Stroke, Lessons from the Past towards Effective Preclinical Models. Biomedicines 2022; 10:biomedicines10102561. [PMID: 36289822 PMCID: PMC9599148 DOI: 10.3390/biomedicines10102561] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/07/2022] [Accepted: 10/09/2022] [Indexed: 11/17/2022] Open
Abstract
Ischemic stroke is a leading cause of death worldwide, mainly in western countries. So far, approved therapies rely on reperfusion of the affected brain area, by intravenous thrombolysis or mechanical thrombectomy. The last approach constitutes a breakthrough in the field, by extending the therapeutic window to 16-24 h after stroke onset and reducing stroke mortality. The combination of pharmacological brain-protective strategies with reperfusion is the future of stroke therapy, aiming to reduce brain cell death and decrease patients' disabilities. Recently, a brain-protective drug-nerinetide-reduced brain infarct and stroke mortality, and improved patients' functional outcomes in clinical trials. The success of new therapies relies on bringing preclinical studies and clinical practice close together, by including a functional outcome assessment similar to clinical reality. In this review, we focused on recent upgrades of in vitro and in vivo stroke models for more accurate and effective evaluation of therapeutic strategies: from spheroids to organoids, in vitro models that include all brain cell types and allow high throughput drug screening, to advancements in in vivo preclinical mouse stroke models to mimic the clinical reality in surgical procedures, postsurgical care, and functional assessment.
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Yang K, Zeng L, Ge A, Wang S, Zeng J, Yuan X, Mei Z, Wang G, Ge J. A systematic review of the research progress of non-coding RNA in neuroinflammation and immune regulation in cerebral infarction/ischemia-reperfusion injury. Front Immunol 2022; 13:930171. [PMID: 36275741 PMCID: PMC9585453 DOI: 10.3389/fimmu.2022.930171] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/08/2022] [Indexed: 11/15/2022] Open
Abstract
Cerebral infarction/ischemia-reperfusion injury is currently the disease with the highest mortality and disability rate of cardiovascular disease. Current studies have shown that nerve cells die of ischemia several hours after ischemic stroke, which activates the innate immune response in the brain, promotes the production of neurotoxic substances such as inflammatory cytokines, chemokines, reactive oxygen species and − nitrogen oxide, and mediates the destruction of blood-brain barrier and the occurrence of a series of inflammatory cascade reactions. Meanwhile, the expression of adhesion molecules in cerebral vascular endothelial cells increased, and immune inflammatory cells such as polymorphonuclear neutrophils, lymphocytes and mononuclear macrophages passed through vascular endothelial cells and entered the brain tissue. These cells recognize antigens exposed by the central nervous system in the brain, activate adaptive immune responses, and further mediate secondary neuronal damage, aggravating neurological deficits. In order to reduce the above-mentioned damage, the body induces peripheral immunosuppressive responses through negative feedback, which increases the incidence of post-stroke infection. This process is accompanied by changes in the immune status of the ischemic brain tissue in local and systemic systems. A growing number of studies implicate noncoding RNAs (ncRNAs) as novel epigenetic regulatory elements in the dysfunction of various cell subsets in the neurovascular unit after cerebral infarction/ischemia-reperfusion injury. In particular, recent studies have revealed advances in ncRNA biology that greatly expand the understanding of epigenetic regulation of immune responses and inflammation after cerebral infarction/ischemia-reperfusion injury. Identification of aberrant expression patterns and associated biological effects of ncRNAs in patients revealed their potential as novel biomarkers and therapeutic targets for cerebral infarction/ischemia-reperfusion injury. Therefore, this review systematically presents recent studies on the involvement of ncRNAs in cerebral infarction/ischemia-reperfusion injury and neuroimmune inflammatory cascades, and elucidates the functions and mechanisms of cerebral infarction/ischemia-reperfusion-related ncRNAs, providing new opportunities for the discovery of disease biomarkers and targeted therapy. Furthermore, this review introduces clustered regularly interspaced short palindromic repeats (CRISPR)-Display as a possible transformative tool for studying lncRNAs. In the future, ncRNA is expected to be used as a target for diagnosing cerebral infarction/ischemia-reperfusion injury, judging its prognosis and treatment, thereby significantly improving the prognosis of patients.
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Affiliation(s)
- Kailin Yang
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha, China
| | - Liuting Zeng
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha, China
| | - Anqi Ge
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Shanshan Wang
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha, China
| | - Jinsong Zeng
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Xiao Yuan
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha, China
| | - Zhigang Mei
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha, China
| | - Guozuo Wang
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha, China
| | - Jinwen Ge
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha, China
- Hunan Academy of Chinese Medicine, Changsha, China
- *Correspondence: Jinwen Ge,
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Kim Y, Khose S, Zaidat OO, Hassan AE, Fifi JT, Nanda A, Atchie B, Woodward B, Doerfler A, Tomasello A, Yoo AJ, Sheth SA. Duration of Ischemia Affects Outcomes Independent of Infarct Size in Stroke. STROKE (HOBOKEN, N.J.) 2022; 2:e000163. [PMID: 37377482 PMCID: PMC10296784 DOI: 10.1161/svin.121.000163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 02/09/2022] [Indexed: 06/29/2023]
Abstract
BACKGROUND Delays in endovascular reperfusion for patients with large vessel occlusion stroke are known to worsen outcomes, and the mechanism is believed to be time-dependent expansion of the ischemic infarction. In this study, we hypothesize that delays in onset to reperfusion (OTR) assert an effect on outcomes independent of effects of final infarct (FI). METHODS We performed a subgroup analysis from the prospective multicenter COMPLETE (International Acute Ischemic Stroke Registry With the Penumbra System Aspiration Including the 3D Revascularization Device; Penumbra, Inc) registry for 257 patients with anterior circulation large vessel occlusion who underwent endovascular therapy with successful reperfusion (modified treatment in cerebral infarction score 2b/3). FI was measured by Alberta Stroke Program Early CT score and volume on 24- to 48-hour computed tomography or magnetic resonance imaging. The likelihood of 90-day good functional outcome (modified Rankin scale 0-2) was assessed by OTR and absolute risk difference (ARD) was estimated using multivariable logistic regressions adjusting for patient characteristics including FI. RESULTS In univariable analysis, longer OTR was associated with a decreased likelihood of good functional outcome (ARD -3% [95% CI -4.5 to -1.0]/h delay). In multivariable analysis accounting for FI, the association between OTR and functional outcome remained significant (ARD -2% [95% CI -3.5 to -0.4]/h delay) with similar ARD. This finding was maintained in the subset of patients with FI imaging using CT only, using Alberta Stroke Program Early CT Score or volumetric FI measurements, and also in patients with larger versus smaller FIs. CONCLUSIONS The impact of OTR on outcomes appears to be mostly through a mechanism that is independent of FI. Our findings suggest that although the field has moved toward imaging infarct core definitions of eligibility for endovascular treatment, time remains an important predictor of outcome, independent of infarct core.
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Affiliation(s)
- Youngran Kim
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Swapnil Khose
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Osama O Zaidat
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Ameer E Hassan
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Johanna T Fifi
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Ashish Nanda
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Benjamin Atchie
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Britton Woodward
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Arnd Doerfler
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Alejandro Tomasello
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Albert J Yoo
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Sunil A Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
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22
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Flat Detector CT with Cerebral Pooled Blood Volume Perfusion in the Angiography Suite: From Diagnostics to Treatment Monitoring. Diagnostics (Basel) 2022; 12:diagnostics12081962. [PMID: 36010312 PMCID: PMC9406673 DOI: 10.3390/diagnostics12081962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
C-arm flat-panel detector computed tomographic (CT) imaging in the angiography suite increasingly plays an important part during interventional neuroradiological procedures. In addition to conventional angiographic imaging of blood vessels, flat detector CT (FD CT) imaging allows simultaneous 3D visualization of parenchymal and vascular structures of the brain. Next to imaging of anatomical structures, it is also possible to perform FD CT perfusion imaging of the brain by means of cerebral blood volume (CBV) or pooled blood volume (PBV) mapping during steady state contrast administration. This enables more adequate decision making during interventional neuroradiological procedures, based on real-time insights into brain perfusion on the spot, obviating time consuming and often difficult transportation of the (anesthetized) patient to conventional cross-sectional imaging modalities. In this paper we review the literature about the nature of FD CT PBV mapping in patients and demonstrate its current use for diagnosis and treatment monitoring in interventional neuroradiology.
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23
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Uniken Venema SM, Dankbaar JW, van der Lugt A, Dippel DWJ, van der Worp HB. Cerebral Collateral Circulation in the Era of Reperfusion Therapies for Acute Ischemic Stroke. Stroke 2022; 53:3222-3234. [PMID: 35938420 DOI: 10.1161/strokeaha.121.037869] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinical outcomes of patients with acute ischemic stroke depend in part on the extent of their collateral circulation. A good collateral circulation has also been associated with greater benefit of intravenous thrombolysis and endovascular treatment. Treatment decisions for these reperfusion therapies are increasingly guided by a combination of clinical and imaging parameters, particularly in later time windows. Computed tomography and magnetic resonance imaging enable a rapid assessment of both the collateral extent and cerebral perfusion. Yet, the role of the collateral circulation in clinical decision-making is currently limited and may be underappreciated due to the use of rather coarse and rater-dependent grading methods. In this review, we discuss determinants of the collateral circulation in patients with acute ischemic stroke, report on commonly used and emerging neuroimaging techniques for assessing the collateral circulation, and discuss the therapeutic and prognostic implications of the collateral circulation in relation to reperfusion therapies for acute ischemic stroke.
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Affiliation(s)
- Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands. (S.M.U.V., H.B.v.d.W.)
| | - Jan Willem Dankbaar
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, the Netherlands. (J.W.D.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center Rotterdam, the Netherlands. (A.v.d.L.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus Medical Center Rotterdam, the Netherlands. (D.W.J.D.)
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands. (S.M.U.V., H.B.v.d.W.)
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24
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Scopelliti G, Pero G, Macera A, Quilici L, Cervo A, Platania G, Tadeo CS, Prelle AC, Muscia F, Riggio MG, Zilioli A, Agostoni EC, Piano M, Pantoni L. Outcome of a Real-World Cohort of Patients Subjected to Endovascular Treatment for Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2022; 31:106511. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 11/26/2022] Open
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25
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Carrera E, Baron JC. Patient Selection for Thrombectomy Using Brain Imaging: Does Time Still Matter? Neurology 2022; 98:867-868. [PMID: 35450965 DOI: 10.1212/wnl.0000000000200719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Emmanuel Carrera
- From the Stroke Center, Department of Clinical Neurosciences (E.C.), Geneva University Hospital; Faculty of Medicine (E.C.), Geneva, Switzerland; Department of Neurology (J.-C.B.), Hôpital Sainte-Anne and Université de Paris; INSERM U1266 (J.-C.B.), Institut de Psychiatrie et Neurosciences de Paris, France
| | - Jean-Claude Baron
- From the Stroke Center, Department of Clinical Neurosciences (E.C.), Geneva University Hospital; Faculty of Medicine (E.C.), Geneva, Switzerland; Department of Neurology (J.-C.B.), Hôpital Sainte-Anne and Université de Paris; INSERM U1266 (J.-C.B.), Institut de Psychiatrie et Neurosciences de Paris, France
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26
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Giammello F, De Martino SRM, Simonetti L, Agati R, Battaglia S, Cirillo L, Gentile M, Migliaccio L, Forlivesi S, Romoli M, Princiotta C, Tonon C, Stagni S, Galluzzo S, Lodi R, Trimarchi G, Toscano A, Musolino RF, Zini A. Predictive value of Tmax perfusion maps on final core in acute ischemic stroke: an observational single-center study. LA RADIOLOGIA MEDICA 2022; 127:414-425. [PMID: 35226245 DOI: 10.1007/s11547-022-01467-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 02/01/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE To assess utility of computed tomography perfusion (CTP) protocols for selection of patients with acute ischemic stroke (AIS) for reperfusive treatments and compare the diagnostic accuracy (ACC) in predicting follow-up infarction, using time-to-maximum (Tmax) maps. METHODS We retrospectively reviewed consecutive AIS patients evaluated for reperfusive treatments at comprehensive stroke center, employing a multimodal computed tomography. To assess prognostic accuracy of CTP summary maps in predicting final infarct area (FIA) in AIS patients, we assumed the best correlation between non-viable tissue (NVT) and FIA in early and fully recanalized patients and/or in patients with favorable clinical response (FCR). On the other hand, the tissue at risk (TAR) should better correlate with FIA in untreated patients and in treatment failure. RESULTS We enrolled 158 patients, for which CTP maps with Tmax thresholds of 9.5 s and 16 s, presented sensitivity of 82.5%, specificity of 74.6%, and ACC of 75.9%. In patients selected for perfusion deficit in anterior circulation territory, CTP-Tmax > 16 s has proven relatively reliable to identify NVT in FCR patients, with a tendency to overestimate NVT. Similarly, CTP-Tmax > 9.5 s was reliable for TAR, but it was overestimated comparing to FIA, in patients with unfavorable outcomes. CONCLUSIONS In our experience, Tmax thresholds have proven sufficiently reliable to identify global hypoperfusion, with tendency to overestimate both NVT and TAR, not yielding satisfactory differentiation between true penumbra and benign oligoemia. In particular, the overestimation of NVT could have serious consequences in not selecting potential candidates for a reperfusion treatment.
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Affiliation(s)
- Fabrizio Giammello
- International PhD Translational Molecular Medicine and Surgery, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Polyclinic Hospital, Via Consolare Valeria 1, 98125, Messina, Italy.
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - Sara Rosa Maria De Martino
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Bellaria Hospital, Bologna, Italy
| | - Luigi Simonetti
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Raffaele Agati
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Programma Neuroradiologia Con Tecniche Ad Elevata Complessità, Bellaria Hospital, Bologna, Italy
| | - Stella Battaglia
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Programma Neuroradiologia Con Tecniche Ad Elevata Complessità, Bellaria Hospital, Bologna, Italy
| | - Luigi Cirillo
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Bellaria Hospital, Bologna, Italy
- DIMES, Department of Specialty, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - Mauro Gentile
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Ludovica Migliaccio
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Stefano Forlivesi
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Michele Romoli
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Ciro Princiotta
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Bellaria Hospital, Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Silvia Stagni
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Simone Galluzzo
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Raffaele Lodi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | | | - Antonio Toscano
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Rosa Fortunata Musolino
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
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27
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Duvekot MHC, van Es ACGM, Venema E, Wolff L, Rozeman AD, Moudrous W, Vermeij FH, Lingsma HF, Bakker J, Plaisier AS, Hensen JHJ, Lycklama À Nijeholt GJ, Jan van Doormaal P, Dippel DWJ, Kerkhoff H, Roozenbeek B, van der Lugt A. Accuracy of CTA evaluations in daily clinical practice for large and medium vessel occlusion detection in suspected stroke patients. Eur Stroke J 2022; 6:357-366. [PMID: 35342807 DOI: 10.1177/23969873211058576] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Early detection of large vessel occlusion (LVO) is essential to facilitate fast endovascular treatment. CT angiography (CTA) is used to detect LVO in suspected stroke patients. We aimed to assess the accuracy of CTA evaluations in daily clinical practice in a large cohort of suspected stroke patients. PATIENTS AND METHODS We used data from the PRESTO study, a multicenter prospective observational cohort study that included suspected stroke patients between August 2018 and September 2019. Baseline CTAs were re-evaluated by an imaging core laboratory and compared to the local assessment. LVO was defined as an occlusion of the intracranial internal carotid artery, M1 segment, or basilar artery. Medium vessel occlusion (MeVO) was defined as an A1, A2, or M2 occlusion. We calculated the accuracy, sensitivity, and specificity to detect LVO and LVO+MeVO, using the core laboratory evaluation as reference standard. RESULTS We included 656 patients. The core laboratory detected 89 LVOs and 74 MeVOs in 155 patients. Local observers missed 6 LVOs (7%) and 28 MeVOs (38%), of which 23 M2 occlusions. Accuracy of LVO detection was 99% (95% CI: 98-100%), sensitivity 93% (95% CI: 86-97%), and specificity 100% (95% CI: 99-100%). Accuracy of LVO+MeVO detection was 95% (95% CI: 93-96%), sensitivity 79% (95% CI: 72-85%), and specificity 99% (95% CI: 98-100%). DISCUSSION AND CONCLUSION CTA evaluations in daily clinical practice are highly accurate and LVOs are adequately recognized. The detection of MeVOs seems more challenging. The evolving EVT possibilities emphasize the need to improve CTA evaluations in the acute setting.
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Affiliation(s)
- Martijne H C Duvekot
- Department of Neurology, Albert Schweitzer hospital, Dordrecht, the Netherlands.,Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Esmee Venema
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Anouk D Rozeman
- Department of Neurology, Albert Schweitzer hospital, Dordrecht, the Netherlands
| | - Walid Moudrous
- Department of Neurology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Frédérique H Vermeij
- Department of Neurology, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jeannette Bakker
- Department of Radiology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Aarnout S Plaisier
- Department of Radiology, IJsselland Hospital, Capelle a/d IJssel, the Netherlands
| | - Jan-Hein J Hensen
- Department of Radiology, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer hospital, Dordrecht, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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28
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Huang L, Xu G, Zhang R, Wang Y, Ji J, Long F, Sun Y. Increased admission serum total bile acids can be associated with decreased 3-month mortality in patients with acute ischemic stroke. Lipids Health Dis 2022; 21:15. [PMID: 35065639 PMCID: PMC8783998 DOI: 10.1186/s12944-021-01620-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/28/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Bile acids (BAs) not only play an important role in lipid metabolism and atherosclerosis but also have antiapoptotic and neuroprotective effects. However, few studies have focused on the relationship of the total bile acid (TBA) levels with the severity and prognosis of acute ischemic stroke (AIS). OBJECTIVES The aim of this study was to investigate the potential associations of the fasting serum TBA levels on admission with the stroke severity, in-hospital complication incidence and 3 -month all-cause mortality in patients with AIS. METHODS A total of 777 consecutive AIS patients were enrolled in this study and were divided into four groups according to the quartiles of the serum TBA levels on admission. Univariate and multivariate logistic regression analyses were used to explore the relationship between the fasting TBA levels and the stroke severity, in-hospital complications, and 3-month mortality in AIS patients. RESULTS Patients in group Q3 had the lowest risk of severe AIS (NIHSS > 10) regardless of the adjustments for confounders (P < 0.05). During hospitalization, 115 patients (14.8%) had stroke progression (NIHSS score increased by ≥ 2), and 222 patients (28.6%) developed at least one complication, with no significant difference among the four groups (P > 0.05). There was no significant difference in the incidence of pneumonia, urinary tract infection (UTI), hemorrhagic transformation (HT), gastrointestinal bleeding (GIB), seizures or renal insufficiency (RI) among the four groups (P > 0.05). A total of 114 patients (14.7%) died from various causes (including in-hospital deaths) at the 3-month follow-up, including 42 (21.3%), 26 (13.3%), 19 (9.9%) and 27 (13.9%) patients in groups Q1, Q2, Q3 and Q4 respectively, with significant differences (P = 0.013). After adjusting for confounding factors, the risk of death decreased (P -trend < 0.05) in groups Q2, Q3, and Q4 when compared with group Q1, and the OR values were 0.36 (0.16-0.80), 0.30 (0.13-0.70), and 0.29 (0.13-0.65), respectively. CONCLUSIONS TBA levels were inversely associated with the 3-month mortality of AIS patients but were not significantly associated with the severity of stroke or the incidence of complications.
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Affiliation(s)
- Lingling Huang
- Department of Neurology, Zhangjiagang TCM Hospital, Nanjing University of Chinese Medicine in China, 215600, Suzhou, China
| | - Ge Xu
- Department of Neurology, Zhangjiagang TCM Hospital, Nanjing University of Chinese Medicine in China, 215600, Suzhou, China
| | - Rong Zhang
- Department of Neurology, Zhangjiagang TCM Hospital, Nanjing University of Chinese Medicine in China, 215600, Suzhou, China
| | - Yadong Wang
- Department of Neurology, Zhangjiagang TCM Hospital, Nanjing University of Chinese Medicine in China, 215600, Suzhou, China
| | - Jiahui Ji
- Department of Neurology, Zhangjiagang TCM Hospital, Nanjing University of Chinese Medicine in China, 215600, Suzhou, China
| | - Fengdan Long
- Department of Neurology, Zhangjiagang TCM Hospital, Nanjing University of Chinese Medicine in China, 215600, Suzhou, China
| | - Yaming Sun
- Department of Neurology, Zhangjiagang TCM Hospital, Nanjing University of Chinese Medicine in China, 215600, Suzhou, China.
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The Role of Ultrasound as a Diagnostic and Therapeutic Tool in Experimental Animal Models of Stroke: A Review. Biomedicines 2021; 9:biomedicines9111609. [PMID: 34829837 PMCID: PMC8615437 DOI: 10.3390/biomedicines9111609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/25/2021] [Accepted: 11/01/2021] [Indexed: 11/18/2022] Open
Abstract
Ultrasound is a noninvasive technique that provides real-time imaging with excellent resolution, and several studies demonstrated the potential of ultrasound in acute ischemic stroke monitoring. However, only a few studies were performed using animal models, of which many showed ultrasound to be a safe and effective tool also in therapeutic applications. The full potential of ultrasound application in experimental stroke is yet to be explored to further determine the limitations of this technique and to ensure the accuracy of translational research. This review covers the current status of ultrasound applied to monitoring and treatment in experimental animal models of stroke and examines the safety, limitations, and future perspectives.
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Cheung J, Doerr M, Hu R, Sun PZ. Refined Ischemic Penumbra Imaging with Tissue pH and Diffusion Kurtosis Magnetic Resonance Imaging. Transl Stroke Res 2021; 12:742-753. [PMID: 33159656 PMCID: PMC8102648 DOI: 10.1007/s12975-020-00868-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 10/14/2020] [Accepted: 10/18/2020] [Indexed: 12/19/2022]
Abstract
Imaging has played a vital role in our mechanistic understanding of acute ischemia and the management of acute stroke patients. The most recent DAWN and DEFUSE-3 trials showed that endovascular therapy could be extended to a selected group of late-presenting stroke patients with the aid of imaging. Although perfusion and diffusion MRI have been commonly used in stroke imaging, the approximation of their mismatch as the penumbra is oversimplified, particularly in the era of endovascular therapy. Briefly, the hypoperfusion lesion includes the benign oligemia that does not proceed to infarction. Also, with prompt and effective reperfusion therapy, a portion of the diffusion lesion is potentially reversible. Therefore, advanced imaging that provides improved ischemic tissue characterization may enable new experimental stroke therapeutics and eventually further individualize stroke treatment upon translation to the clinical setting. Specifically, pH imaging captures tissue of altered metabolic state that demarcates the hypoperfused lesion into ischemic penumbra and benign oligemia, which remains promising to define the ischemic penumbra's outer boundary. On the other hand, diffusion kurtosis imaging (DKI) differentiates the most severely damaged and irreversibly injured diffusion lesion from the portion of diffusion lesion that is potentially reversible, refining the inner boundary of the penumbra. Altogether, the development of advanced imaging has the potential to not only transform the experimental stroke research but also aid clinical translation and patient management.
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Affiliation(s)
- Jesse Cheung
- Emory College of Arts and Sciences, Emory University, Atlanta, GA, 30329, USA
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, 30329, USA
| | - Madeline Doerr
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, 30329, USA
- Dartmouth College, Hanover, NH, 03755, USA
| | - Ranliang Hu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton RD NE, Atlanta, GA, 30322, USA
| | - Phillip Zhe Sun
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, 30329, USA.
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton RD NE, Atlanta, GA, 30322, USA.
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Grigonyte M, Kraujelyte A, Januskeviciute E, Semys G, Kriukelyte O, Kontrimaviciute E, Valeviciene NR, Jatuzis D. The Impact of the Pandemic on Acute Ischaemic Stroke Endovascular Treatment from a Multidisciplinary Perspective: A Nonsystematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189464. [PMID: 34574386 PMCID: PMC8471435 DOI: 10.3390/ijerph18189464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, reduced admissions for cerebrovascular events were identified, but acute ischaemic stroke (AIS) has remained one of the leading causes of death and disability for many years. The aim of this article is to review current literature data for multidisciplinary team (MDT) coordination, rational management of resources and facilities, ensuring timely medical care for large vessel occlusion (LVO) AIS patients requiring endovascular treatment during the pandemic. METHODS A detailed literature search was performed in Google Scholar and PubMed databases using these keywords and their combinations: acute ischaemic stroke, emergency, anaesthesia, airway management, mechanical thrombectomy, endovascular treatment, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), COVID-19. Published studies and guidelines from inception to April 2021 were screened. The following nonsystematic review is based on a comprehensive literature search of available data, wherein 59 were chosen for detailed analysis. RESULTS The pandemic has an impact on every aspect of AIS care, including prethrombectomy, intraprocedural and post-thrombectomy issues. Main challenges include institutional preparedness, increased number of AIS patients with multiorgan involvement, different work coordination principles and considerations about preferred anaesthetic technique. Care of these patients is led by MDT and nonoperating room anaesthesia (NORA) principles are applied. CONCLUSIONS Adequate management of AIS patients requiring mechanical thrombectomy during the pandemic is of paramount importance to maximise the benefit of the endovascular procedure. MDT work and familiarity with NORA principles decrease the negative impact of the disease on the clinical outcomes for AIS patients.
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Affiliation(s)
- Milda Grigonyte
- Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania; (M.G.); (A.K.); (E.J.); (G.S.)
| | - Agne Kraujelyte
- Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania; (M.G.); (A.K.); (E.J.); (G.S.)
| | - Elija Januskeviciute
- Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania; (M.G.); (A.K.); (E.J.); (G.S.)
| | - Giedrius Semys
- Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania; (M.G.); (A.K.); (E.J.); (G.S.)
| | - Oresta Kriukelyte
- Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania; (M.G.); (A.K.); (E.J.); (G.S.)
- Correspondence:
| | - Egle Kontrimaviciute
- Clinic of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania;
| | - Nomeda Rima Valeviciene
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania;
| | - Dalius Jatuzis
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania;
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Joo L, Jung SC, Lee H, Park SY, Kim M, Park JE, Choi KM. Stability of MRI radiomic features according to various imaging parameters in fast scanned T2-FLAIR for acute ischemic stroke patients. Sci Rep 2021; 11:17143. [PMID: 34433881 PMCID: PMC8387477 DOI: 10.1038/s41598-021-96621-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/10/2021] [Indexed: 12/18/2022] Open
Abstract
From May 2015 to June 2016, data on 296 patients undergoing 1.5-Tesla MRI for symptoms of acute ischemic stroke were retrospectively collected. Conventional, echo-planar imaging (EPI) and echo train length (ETL)-T2-FLAIR were simultaneously obtained in 118 patients (first group), and conventional, ETL-, and repetition time (TR)-T2-FLAIR were simultaneously obtained in 178 patients (second group). A total of 595 radiomics features were extracted from one region-of-interest (ROI) reflecting the acute and chronic ischemic hyperintensity, and concordance correlation coefficients (CCC) of the radiomics features were calculated between the fast scanned and conventional T2-FLAIR for paired patients (1st group and 2nd group). Stabilities of the radiomics features were compared with the proportions of features with a CCC higher than 0.85, which were considered to be stable in the fast scanned T2-FLAIR. EPI-T2-FLAIR showed higher proportions of stable features than ETL-T2-FLAIR, and TR-T2-FLAIR also showed higher proportions of stable features than ETL-T2-FLAIR, both in acute and chronic ischemic hyperintensities of whole- and intersection masks (p < .002). Radiomics features in fast scanned T2-FLAIR showed variable stabilities according to the sequences compared with conventional T2-FLAIR. Therefore, radiomics features may be used cautiously in applications for feature analysis as their stability and robustness can be variable.
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Affiliation(s)
- Leehi Joo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul, 138-736, Republic of Korea
| | - Seung Chai Jung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul, 138-736, Republic of Korea.
| | - Hyunna Lee
- Bigdata Research Center, Asan Institute for Life Science, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 15505, Republic of Korea.
| | - Seo Young Park
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul, 138-736, Korea
| | - Minjae Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul, 138-736, Republic of Korea
| | - Ji Eun Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul, 138-736, Republic of Korea
| | - Keum Mi Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul, 138-736, Republic of Korea
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Rio Bartulos C, Lier D, Sahl H, Abu-Mugheisib M, Spreer A, Wiggermann P. Mechanical thrombectomy in ischemic stroke: Parameters affecting the TICI outcome. Clin Hemorheol Microcirc 2021; 79:19-26. [PMID: 34420947 DOI: 10.3233/ch-219107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is a standard stroke treatment for patients with large vessel occlusions (LVOs). A decisive factor for a successful outcome is, among other things, timely treatment. OBJECTIVE The objective was to analyze several time points in relation to outcomes and/or surrogate parameters. Furthermore, our data was placed in the context of other clinical trial data. METHODS We retrospectively evaluated 133 data sets from patients who underwent MT. The correlation of various time periods with parameters, such as the ASPECTS, NIHSS, mRS, and, particularly, the TICI score, was investigated. RESULTS A correlation was found for both the NIHSS score at discharge and the TICI score with the time periods of arrival and/or start to groin puncture as well as with arrival to the end of the intervention and the duration of the intervention. CONCLUSIONS This retrospective study is consistent with large randomized clinical trials investigating stroke management and provides data from daily clinical practice.
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Affiliation(s)
- Carolina Rio Bartulos
- Institut für Röntgendiagnostik und Nuklearmedizin, Städtisches Klinikum Braunschweig gGmbH, Salzdahlumer str. 90, Braunschweig, Germany
| | - Dennis Lier
- Institut für Röntgendiagnostik und Nuklearmedizin, Städtisches Klinikum Braunschweig gGmbH, Salzdahlumer str. 90, Braunschweig, Germany
| | - Harald Sahl
- Institut für Röntgendiagnostik und Nuklearmedizin, Städtisches Klinikum Braunschweig gGmbH, Salzdahlumer str. 90, Braunschweig, Germany
| | - Mazen Abu-Mugheisib
- Klinik für Neurologie, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Germany
| | - Annette Spreer
- Klinik für Neurologie, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Germany
| | - Philipp Wiggermann
- Institut für Röntgendiagnostik und Nuklearmedizin, Städtisches Klinikum Braunschweig gGmbH, Salzdahlumer str. 90, Braunschweig, Germany
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Egger K, Gergel I, Syrek H. [Interdisciplinary networking for optimal treatment decision-making : Fast decision-making in acute ischemic stroke management]. Radiologe 2021; 61:752-757. [PMID: 34232343 DOI: 10.1007/s00117-021-00876-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 11/28/2022]
Abstract
Every year, about 270,000 strokes occur in Germany. In the entire DACH region (Germany, Austria, Switzerland), more than 310,000 cases are reported each year. Two thirds of the surviving patients are dependent on external assistance after the stroke. Increasingly, imaging data are becoming the focus of treatment decisions. These data provide critical information about the location and extent of vessel occlusion, infarct size, volume of salvageable brain tissue, and degree of collateralization. Certified stroke units and stroke networks already specialize in state-of-the-art therapeutic options, but they need additional information technology tools to deliver the right therapy to the right patient population as quickly as possible. For multidisciplinary, seamless support in stroke care, both prehospital and in-hospital processes need to be optimized. This article presents a concept for supraregional stroke care by means of networking all involved actors in the prehospital as well as in the in-hospital area. Further needs analyses should ensure the implementation as well as the generalizability to different regions.
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Affiliation(s)
- Karl Egger
- Tauernklinikum, Paracelsusstraße 8, 5700, Zell, Deutschland.
| | - Ingmar Gergel
- mbits imaging GmbH, Bergheimerstraße 147, 69115, Heidelberg, Deutschland
| | - Hannah Syrek
- mbits imaging GmbH, Bergheimerstraße 147, 69115, Heidelberg, Deutschland
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35
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Filep RC, Marginean L, Stoian A, Bajko Z. Diagnostic and prognostic computed tomography imaging markers in basilar artery occlusion (Review). Exp Ther Med 2021; 22:954. [PMID: 34335896 PMCID: PMC8290397 DOI: 10.3892/etm.2021.10386] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/04/2021] [Indexed: 01/05/2023] Open
Abstract
Acute ischemic stroke treatment has been revolutionized by the addition of mechanical and aspiration thrombectomy. Randomized controlled trials have proven beyond doubt, the substantial clinical impact of endovascular interventions in anterior circulation territory strokes. Unfortunately, patients with vertebrobasilar ischemic stroke could not be included in these early trials due to inherent clinical, radiological, and prognostic particularities of posterior circulation ischemia; thus, indications for the treatment of posterior fossa strokes and basilar artery occlusion (BAO) are mainly based on retrospective studies and registries. BAO carries high morbidity and mortality, despite the new improvements in endovascular therapy. Identifying patients who will likely benefit from invasive treatment and have a good clinical outcome resides in discovering clinical, biological, or imaging markers, that have prognostic implications. Such imaging markers have been described, especially in the last decade. Hyperdense Basilar Artery Sign (HDBA), Posterior Circulations-Alberta Stroke Program Early CT Score (pc-ASPECTS), Pons-Midbrain Index (PMI), Posterior Circulation Collateral Score (pc-CS), Posterior Circulation CT Angiography Score (pc-CTA), and Basilar Artery on CT Prognostic Score (BATMAN), are computed tomography (CT) markers with properties that can aid the diagnosis of BAO and can independently predict clinical outcome. This paper aims to present a comprehensive review of these imaging signs to have a thorough understanding of their diagnostic and prognostic attributes.
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Affiliation(s)
- Rares Cristian Filep
- PhD School of Medicine, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540142 Târgu Mureș, Romania
| | - Lucian Marginean
- PhD School of Medicine, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540142 Târgu Mureș, Romania
| | - Adina Stoian
- Department of Pathophysiology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540142 Târgu Mureș, Romania
| | - Zoltan Bajko
- Department of Neurology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540142 Târgu Mureș, Romania
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36
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Shaul D, Grieb B, Sapir G, Uppala S, Sosna J, Gomori JM, Katz-Brull R. The metabolic representation of ischemia in rat brain slices: A hyperpolarized 13 C magnetic resonance study. NMR IN BIOMEDICINE 2021; 34:e4509. [PMID: 33774865 DOI: 10.1002/nbm.4509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 02/15/2021] [Accepted: 02/26/2021] [Indexed: 06/12/2023]
Abstract
The ischemic penumbra in stroke is not clearly defined by today's available imaging tools. This study aimed to develop a model system and noninvasive biomarkers of ischemic brain tissue for an examination that might potentially be performed in humans, very quickly, in the course of stroke triage. Perfused rat brain slices were used as a model system and 31 P spectroscopy verified that the slices were able to recover from an ischemic insult of about 3.5 min of perfusion arrest. This was indicated as a return to physiological pH and adenosine triphosphate levels. Instantaneous changes in lactate dehydrogenase (LDH) and pyruvate dehydrogenase (PDH) activities were monitored and quantified by the metabolic conversions of hyperpolarized [1-13 C]pyruvate to [1-13 C]lactate and [13 C]bicarbonate, respectively, using 13 C spectroscopy. In a control group (n = 8), hyperpolarized [1-13 C]pyruvate was administered during continuous perfusion of the slices. In the ischemia group (n = 5), the perfusion was arrested 30 s prior to administration of hyperpolarized [1-13 C]pyruvate and perfusion was not resumed throughout the measurement time (approximately 3.5 min). Following about 110 s of the ischemic insult, LDH activity increased by 80.4 ± 13.5% and PDH activity decreased by 47.8 ± 25.3%. In the control group, the mean LDH/PDH ratio was 16.6 ± 3.3, and in the ischemia group, the LDH/PDH ratio reached an average value of 38.7 ± 16.9. The results suggest that monitoring the activity of LDH and PDH, and their relative activities, using hyperpolarized [1-13 C]pyruvate, could serve as an imaging biomarker to characterize the changes in the ischemic penumbra.
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Affiliation(s)
- David Shaul
- Department of Radiology, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Benjamin Grieb
- Department of Radiology, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
- Department of Psychiatry and Psychotherapy I (Weissenau), Ulm University, Ravensburg, Germany
| | - Gal Sapir
- Department of Radiology, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Sivaranjan Uppala
- Department of Radiology, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Jacob Sosna
- Department of Radiology, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - J Moshe Gomori
- Department of Radiology, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Rachel Katz-Brull
- Department of Radiology, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
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37
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Zhou Z, Xia C, Mair G, Delcourt C, Yoshimura S, Liu X, Chen Z, Malavera A, Carcel C, Chen X, Wang X, Al-Shahi Salman R, Robinson TG, Lindley RI, Chalmers J, Wardlaw JM, Parsons MW, Demchuk AM, Anderson CS. Thrombolysis outcomes according to arterial characteristics of acute ischemic stroke by alteplase dose and blood pressure target. Int J Stroke 2021; 17:566-575. [PMID: 34096413 DOI: 10.1177/17474930211025436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND We explored the influence of low-dose intravenous alteplase and intensive blood pressure lowering on outcomes of acute ischemic stroke according to status/location of vascular obstruction in participants of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED). METHODS ENCHANTED was a multicenter, quasi-factorial, randomized trial to determine efficacy and safety of low- versus standard-dose intravenous alteplase and intensive- versus guideline-recommended blood pressure lowering in acute ischemic stroke patients. In those who had baseline computed tomography or magnetic resonance imaging angiography, the degree of vascular occlusion was grouped according to being no (NVO), medium (MVO), or large (LVO). Logistic regression models were used to determine 90-day outcomes (modified Rankin scale [mRS] shift [primary], other mRS cut-scores, intracranial hemorrhage, early neurologic deterioration, and recanalization) by vascular obstruction status/site. Heterogeneity in associations for outcomes across subgroups was estimated by adding an interaction term to the models. RESULTS There were 940 participants: 607 in alteplase arm only, 243 in blood pressure arm only, and 90 assigned to both arms. Compared to the NVO group, functional outcome was worse in LVO (mRS shift, adjusted OR [95% CI] 2.13 [1.56-2.90]) but comparable in MVO (1.34 [0.96-1.88]) groups. There were no differences in associations of alteplase dose or blood pressure lowering and outcomes across NVO/MVO/LVO groups (mRS shift: low versus standard alteplase dose 0.84 [0.54-1.30]/0.48 [0.25-0.91]/0.99 [0.75-2.09], Pinteraction = 0.28; intensive versus standard blood pressure lowering 1.32 [0.74-2.38]/0.78 [0.31-1.94]/1.24 [0.64-2.41], Pinteraction = 0.41), except for a borderline significant difference for intensive blood pressure lowering and increased early neurologic deterioration (0.63 [0.14-2.72]/0.17 [0.02-1.47]/2.69 [0.90-8.04], Pinteraction = 0.05). CONCLUSIONS Functional outcome by dose of alteplase or intensity of blood pressure lowering is not modified by vascular obstruction status/site according to analyses from ENCHANTED, although these results are compromised by low statistical power.Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifiers: NCT01422616.
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Affiliation(s)
- Zien Zhou
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Radiology, Ren Ji Hospital, School of Medicine, 12474Shanghai Jiao Tong University, Shanghai, PR China
| | - Chao Xia
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Neurosurgery, West China Hospital, 12530Sichuan University, Chengdu, PR China
| | - Grant Mair
- Edinburgh Imaging and Centre for Clinical Brain Sciences, 3124University of Edinburgh, Edinburgh, UK
| | - Candice Delcourt
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, Australia
| | - Sohei Yoshimura
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Xiaosheng Liu
- Department of Nuclear Medicine, 12478Fudan University Shanghai Cancer Center, Shanghai, PR China
| | - Zengai Chen
- Department of Radiology, Ren Ji Hospital, School of Medicine, 12474Shanghai Jiao Tong University, Shanghai, PR China
| | - Alejandra Malavera
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia
| | - Cheryl Carcel
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Xiaoying Chen
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Xia Wang
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia
| | | | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Center, 4488University of Leicester, Leicester, UK
| | | | - John Chalmers
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia
| | - Joanna M Wardlaw
- Edinburgh Imaging and Centre for Clinical Brain Sciences, 3124University of Edinburgh, Edinburgh, UK.,UK Dementia Research Institute, 3124University of Edinburgh, Edinburgh, UK
| | - Mark W Parsons
- South Western Clinical School, 7800University of New South Wales, Sydney, Australia.,Melbourne Brain Centre, Royal Melbourne Hospital, Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, 157742Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Radiology, 157742Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Craig S Anderson
- 211065The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, Australia.,The George Institute China at Peking University Health Science Center, Beijing, PR China
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Wang H, Hu H, Xu J, Qian C. Perfusion image guided mechanical thrombectomy combined with tirofiban successfully revascularize systemic lupus erythematosus related acute large vessel occlusion: A case report. Medicine (Baltimore) 2021; 100:e25779. [PMID: 33950971 PMCID: PMC8104300 DOI: 10.1097/md.0000000000025779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/15/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Systemic lupus erythematosus (SLE) is an important cause of stroke, more than a half the cases present as acute ischemic stroke. Thrombolysis is an effective choice in most cases, but for large vessel occlusion, mechanical thrombectomy is more effective. Here we reported a case of SLE-related stroke with left middle cerebral artery (MCA) occlusion, who was successfully treated by MT and tirofiban. PATIENT CONCERN A 38-year-old female suffered from right hemiplegia and aphasia for 8 hours. She was diagnosed with SLE 20 years ago, and neuropsychiatric SLE was considered 8 months before this onset. One month ago, glucocorticoids were discontinued by herself because of deterioration of bilateral femoral head osteonecrosis. DIAGNOSIS Left MCA occlusion was confirmed by computed tomography perfusion. INTERVENTION Immediate mechanical thrombectomy was performed and tirofiban was given to prevent re-occlusion of left MCA. Twenty fourhours later oral antiplatelet was given after intracranial hemorrhage was ruled out. OUTCOMES Her neurological symptom improved several days later, and she was transferred to further rehabilitation. At 4 months follow-up she can live independently with mild hypophrasia. There was no further events of ischemic stroke in 1-year follow-up. LESSONS Mechanical thrombectomy is a highly effective and indispensable treatment for SLE related large vessel occlusion. In addition, tirofiban may reduce vessel reocclusion in special cases such as SLE and artery stenosis.
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Affiliation(s)
- Han Wang
- Department of Geriatrics, Tongde Hospital of Zhejiang Province
| | | | - Jing Xu
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Cong Qian
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
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Faber JE, Storz JF, Cheviron ZA, Zhang H. High-altitude rodents have abundant collaterals that protect against tissue injury after cerebral, coronary and peripheral artery occlusion. J Cereb Blood Flow Metab 2021; 41:731-744. [PMID: 32703056 PMCID: PMC7983333 DOI: 10.1177/0271678x20942609] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/03/2020] [Accepted: 06/22/2020] [Indexed: 12/22/2022]
Abstract
Collateral number/density varies widely in brain and other tissues among strains of Mus musculus mice due to differences in genetic background. Recent studies have shown that prolonged exposure to reduced atmospheric oxygen induces additional collaterals to form, suggesting that natural selection may favor increased collaterals in populations native to high-altitude. High-altitude guinea pigs (Cavia) and deer mice (Peromyscus) were compared with lowland species of Peromyscus, Mus and Rattus (9 species/strains examined). Collateral density, diameter and other morphometrics were measured in brain where, importantly, collateral abundance reflects that in other tissues of the same individual. Guinea pigs and high-altitude deer mice had a greater density of pial collaterals than lowlanders. Consistent with this, guinea pigs and highlander mice evidenced complete and 80% protection against stroke, respectively. They also sustained significantly less ischemia in heart and lower extremities after arterial occlusion. Vessels of the circle of Willis, including the communicating collateral arteries, also exhibited unique features in the highland species. Our findings support the hypothesis that species native to high-altitude have undergone genetic selection for abundant collaterals, suggesting that besides providing protection in obstructive disease, collaterals serve a physiological function to optimize oxygen delivery to meet oxygen demand when oxygen is limiting.
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Affiliation(s)
- James E Faber
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Curriculum in Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jay F Storz
- School of Biological Sciences, University of Nebraska, Lincoln, NE, USA
| | - Zachary A Cheviron
- Division of Biological Sciences, University of Montana, Missoula, MT, USA
| | - Hua Zhang
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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40
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Sapir G, Shaul D, Lev-Cohain N, Sosna J, Gomori MJ, Katz-Brull R. LDH and PDH Activities in the Ischemic Brain and the Effect of Reperfusion-An Ex Vivo MR Study in Rat Brain Slices Using Hyperpolarized [1- 13C]Pyruvate. Metabolites 2021; 11:210. [PMID: 33808434 PMCID: PMC8066106 DOI: 10.3390/metabo11040210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/25/2021] [Accepted: 03/28/2021] [Indexed: 12/11/2022] Open
Abstract
Ischemic stroke is a leading cause for neurologic disability worldwide, for which reperfusion is the only available treatment. Neuroimaging in stroke guides treatment, and therefore determines the clinical outcome. However, there are currently no imaging biomarkers for the status of the ischemic brain tissue. Such biomarkers could potentially be useful for guiding treatment in patients presenting with ischemic stroke. Hyperpolarized 13C MR of [1-13C]pyruvate is a clinically translatable method used to characterize tissue metabolism non-invasively in a relevant timescale. The aim of this study was to utilize hyperpolarized [1-13C]pyruvate to investigate the metabolic consequences of an ischemic insult immediately during reperfusion and upon recovery of the brain tissue. The rates of lactate dehydrogenase (LDH) and pyruvate dehydrogenase (PDH) were quantified by monitoring the rates of [1-13C]lactate and [13C]bicarbonate production from hyperpolarized [1-13C]pyruvate. 31P NMR of the perfused brain slices showed that this system is suitable for studying ischemia and recovery following reperfusion. This was indicated by the levels of the high-energy phosphates (tissue viability) and the chemical shift of the inorganic phosphate signal (tissue pH). Acidification, which was observed during the ischemic insult, has returned to baseline level following reperfusion. The LDH/PDH activity ratio increased following ischemia, from 47.0 ± 12.7 in the control group (n = 6) to 217.4 ± 121.3 in the ischemia-reperfusion group (n = 6). Following the recovery period (ca. 1.5 h), this value had returned to its pre-ischemia (baseline) level, suggesting the LDH/PDH enzyme activity ratio may be used as a potential indicator for the status of the ischemic and recovering brain.
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Affiliation(s)
- Gal Sapir
- Department of Radiology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (G.S.); (D.S.); (N.L.-C.); (J.S.); (M.J.G.)
| | - David Shaul
- Department of Radiology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (G.S.); (D.S.); (N.L.-C.); (J.S.); (M.J.G.)
| | - Naama Lev-Cohain
- Department of Radiology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (G.S.); (D.S.); (N.L.-C.); (J.S.); (M.J.G.)
| | - Jacob Sosna
- Department of Radiology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (G.S.); (D.S.); (N.L.-C.); (J.S.); (M.J.G.)
| | - Moshe J. Gomori
- Department of Radiology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (G.S.); (D.S.); (N.L.-C.); (J.S.); (M.J.G.)
| | - Rachel Katz-Brull
- Department of Radiology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (G.S.); (D.S.); (N.L.-C.); (J.S.); (M.J.G.)
- The Wohl Institute for Translational Medicine, Jerusalem 9112001, Israel
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41
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Elands S, Casimir P, Bonnet T, Mine B, Lubicz B, Sjøgård M, Ligot N, Naeije G. Early Venous Filling Following Thrombectomy: Association With Hemorrhagic Transformation and Functional Outcome. Front Neurol 2021; 12:649079. [PMID: 33776899 PMCID: PMC7987949 DOI: 10.3389/fneur.2021.649079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Previous studies have noted the angiographic appearance of early venous filling (EVF) following recanalisation in acute ischemic stroke. However, the prognostic implications of EVF as a novel imaging biomarker remain unclear. We aimed to evaluate the correlation between EVF with (i) the risk of subsequent reperfusion hemorrhage (RPH) and (ii) the association of EVF on both the NIHSS score at 24 h and functional outcome as assessed with the Modified Rankin Scale (mRS) score at 90 days. Methods: We conducted a retrospective cohort study of patients presenting with an acute ischemic stroke due to a proximal large-vessel occlusion of the anterior circulation treated by thrombectomy. Post-reperfusion digital subtraction angiography was reviewed to look for EVF as evidenced by the contrast opacification of any cerebral vein before the late arterial phase. Results: EVF occurred in 22.4% of the 147 cases included. The presence of EVF significantly increased the risk of RPH (p = 0.0048), including the risk of symptomatic hemorrhage (p = 0.0052). The presence of EVF (p = 0.0016) and the absence of RPH (p = 0.0021) were independently associated with a better outcome as defined by the NIHSS difference at 24 h, most significantly in the EVF+RPH- group. No significant relationship was however found between either EVF or RPH and a mRS score ≤ 2 at 90 days. Conclusion: Early venous filling on angiographic imaging is a potential predictor of reperfusion hemorrhage. The absence of subsequent RPH in this sub-group is associated with better outcomes at 24 h post-thrombectomy than in those with RPH.
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Affiliation(s)
- Sophie Elands
- Department of Neurology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Casimir
- Department of Neurology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Thomas Bonnet
- Department of Interventional Neuroradiology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Benjamin Mine
- Department of Interventional Neuroradiology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Boris Lubicz
- Department of Interventional Neuroradiology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Martin Sjøgård
- Laboratoire de Cartographie Fonctionnelle du Cerveau, Neuroscience Institute (ULB-Neuroscience Institute), Université Libre de Bruxelles, Brussels, Belgium
| | - Noémie Ligot
- Department of Neurology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Gilles Naeije
- Department of Neurology, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Abstract
PURPOSE Endovascular thrombectomy (EVT) significantly improves outcomes for acute ischemic stroke patients with large vessel occlusion (LVO) who present in a time sensitive manner. Prolonged EVT access times may reduce benefits for eligible patients. We evaluated the efficiency of EVT services including EVT rates, onset-to-CTA time and onset-to-groin puncture time in our province. MATERIALS AND METHODS Three areas were defined: zone I- urban region, zone II-areas within 1 h drive distance from the Comprehensive Stroke Center (CSC); and zone III-areas more than 1hr drive distance from the CSC. In this retrospective cohort study, EVT rate, onset-to-groin puncture time and onset-to-CTA time were compared among the three groups using Krustal-Wallis and Wilcoxon tests. RESULTS The EVT rate per 100,000 inhabitants for urban zone I was 8.6 as compared to 5.1 in zone II, and 7.5 in zone III. Compared to zone I (114 min; 95% CI (96, 132); n = 128), mean onset-to-CTA time was 19 min longer in zone II (133 min; 95% CI (77, 189); n = 23; p = 0.0459) and 103 min longer in zone III (217 min, 95% CI (162, 272); n = 44; p < 0.0001). Compared to zone I (209 min, 95% CI (181, 238)), mean onset-to-groin puncture time was 22 min longer in zone II (231 min, 95% CI (174, 288); p = 0.046) but 163 min longer in zone III (372 min, 95% CI (312, 432); p < 0.0001). CONCLUSION EVT access in rural areas is considerably reduced with significantly longer onset-to-groin puncture times and onset-to-CTA times when compared to our urban area. This may help in modifying the patient transfer policy for EVT referral.
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Fu B, Qi S, Tao L, Xu H, Kang Y, Yao Y, Yang B, Duan Y, Chen H. Image Patch-Based Net Water Uptake and Radiomics Models Predict Malignant Cerebral Edema After Ischemic Stroke. Front Neurol 2021; 11:609747. [PMID: 33424759 PMCID: PMC7786250 DOI: 10.3389/fneur.2020.609747] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/26/2020] [Indexed: 12/12/2022] Open
Abstract
Malignant cerebral edema (MCE) after an ischemic stroke results in a poor outcome or death. Early prediction of MCE helps to identify subjects that could benefit from a surgical decompressive craniectomy. Net water uptake (NWU) in an ischemic lesion is a predictor of MCE; however, CT perfusion and lesion segmentation are required. This paper proposes a new Image Patch-based Net Water Uptake (IP-NWU) procedure that only uses non-enhanced admission CT and does not need lesion segmentation. IP-NWU is calculated by comparing the density of ischemic and contralateral normal patches selected from the middle cerebral artery (MCA) area using standard reference images. We also compared IP-NWU with the Segmented Region-based NWU (SR-NWU) procedure in which segmented ischemic regions from follow-up CT images are overlaid onto admission images. Furthermore, IP-NWU and its combination with imaging features are used to construct predictive models of MCE with a radiomics approach. In total, 116 patients with an MCA infarction (39 with MCE and 77 without MCE) were included in the study. IP-NWU was significantly higher for patients with MCE than those without MCE (p < 0.05). IP-NWU can predict MCE with an AUC of 0.86. There was no significant difference between IP-NWU and SR-NWU, nor between their predictive efficacy for MCE. The inter-reader and interoperation agreement of IP-NWU was exceptional according to the Intraclass Correlation Coefficient (ICC) analysis (inter-reader: ICC = 0.92; interoperation: ICC = 0.95). By combining IP-NWU with imaging features through a random forest classifier, the radiomics model achieved the highest AUC (0.96). In summary, IP-NWU and radiomics models that combine IP-NWU with imaging features can precisely predict MCE using only admission non-enhanced CT images scanned within 24 h from onset.
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Affiliation(s)
- Bowen Fu
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China
| | - Shouliang Qi
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China.,Key Laboratory of Intelligent Computing in Medical Image, Ministry of Education, Northeastern University, Shenyang, China
| | - Lin Tao
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Haibin Xu
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yan Kang
- College of Health Science and Environment Engineering, Shenzhen Technology University, Shenzhen, China
| | - Yudong Yao
- Department of Electrical and Computer Engineering, Stevens Institute of Technology, Hoboken, NJ, United States
| | - Benqiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yang Duan
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Huisheng Chen
- Department of Electrical and Computer Engineering, Stevens Institute of Technology, Hoboken, NJ, United States
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Puig B, Yang D, Brenna S, Altmeppen HC, Magnus T. Show Me Your Friends and I Tell You Who You Are: The Many Facets of Prion Protein in Stroke. Cells 2020; 9:E1609. [PMID: 32630841 PMCID: PMC7407975 DOI: 10.3390/cells9071609] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 06/24/2020] [Accepted: 06/27/2020] [Indexed: 12/12/2022] Open
Abstract
Ischemic stroke belongs to the leading causes of mortality and disability worldwide. Although treatments for the acute phase of stroke are available, not all patients are eligible. There is a need to search for therapeutic options to promote neurological recovery after stroke. The cellular prion protein (PrPC) has been consistently linked to a neuroprotective role after ischemic damage: it is upregulated in the penumbra area following stroke in humans, and animal models of stroke have shown that lack of PrPC aggravates the ischemic damage and lessens the functional outcome. Mechanistically, these effects can be linked to numerous functions attributed to PrPC: (1) as a signaling partner of the PI3K/Akt and MAPK pathways, (2) as a regulator of glutamate receptors, and (3) promoting stem cell homing mechanisms, leading to angio- and neurogenesis. PrPC can be cleaved at different sites and the proteolytic fragments can account for the manifold functions. Moreover, PrPC is present on extracellular vesicles (EVs), released membrane particles originating from all types of cells that have drawn attention as potential therapeutic tools in stroke and many other diseases. Thus, identification of the many mechanisms underlying PrPC-induced neuroprotection will not only provide further understanding of the physiological functions of PrPC but also new ideas for possible treatment options after ischemic stroke.
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Affiliation(s)
- Berta Puig
- Neurology Department, Experimental Research in Stroke and Inflammation (ERSI), University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (D.Y.); (S.B.); (T.M.)
| | - Denise Yang
- Neurology Department, Experimental Research in Stroke and Inflammation (ERSI), University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (D.Y.); (S.B.); (T.M.)
| | - Santra Brenna
- Neurology Department, Experimental Research in Stroke and Inflammation (ERSI), University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (D.Y.); (S.B.); (T.M.)
| | | | - Tim Magnus
- Neurology Department, Experimental Research in Stroke and Inflammation (ERSI), University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (D.Y.); (S.B.); (T.M.)
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Shams M, Shams S, Wintermark M. What's new in imaging of acute stroke? Intensive Care Med 2020; 46:1453-1456. [PMID: 32394066 DOI: 10.1007/s00134-020-06070-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/22/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Mana Shams
- Department of Radiology, Division of Neuroradiology, Stanford Health Care, Stanford University, Stanford, CA, USA.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Sara Shams
- Department of Radiology, Division of Neuroradiology, Stanford Health Care, Stanford University, Stanford, CA, USA.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Max Wintermark
- Department of Radiology, Division of Neuroradiology, Stanford Health Care, Stanford University, Stanford, CA, USA.
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