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Becker RC, Tantry US, Khan M, Gurbel PA. The COVID-19 thrombus: distinguishing pathological, mechanistic, and phenotypic features and management. J Thromb Thrombolysis 2024:10.1007/s11239-024-03028-4. [PMID: 39179952 DOI: 10.1007/s11239-024-03028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2024] [Indexed: 08/26/2024]
Abstract
A heightened risk for thrombosis is a hallmark of COVID-19. Expansive clinical experience and medical literature have characterized small (micro) and large (macro) vessel involvement of the venous and arterial circulatory systems. Most events occur in patients with serious or critical illness in the hyperacute (first 1-2 weeks) or acute phases (2-4 weeks) of SARS-CoV-2 infection. However, thrombosis involving the venous, arterial, and microcirculatory systems has been reported in the subacute (4-8 weeks), convalescent (> 8-12 weeks) and chronic phases (> 12 weeks) among patients with mild-to-moderate illness. The purpose of the current focused review is to highlight the distinguishing clinical features, pathological components, and potential mechanisms of venous, arterial, and microvascular thrombosis in patients with COVID-19. The overarching objective is to better understand the proclivity for thrombosis, laying a solid foundation for screening and surveillance modalities, preventive strategies, and optimal patient management.
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Affiliation(s)
- Richard C Becker
- Cardiovascular Center, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Baltimore, USA
| | - Muhammad Khan
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Baltimore, USA
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2
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Stamm SM, Wagner R, Lang DA, Skerra A, Gebauer M. Development of a Clonal and High-Yield Mammalian Cell Line for the Manufacturing of a Hyperactive Human DNase I with Extended Plasma Half-Life Using PASylation ® Technology. Pharmaceutics 2024; 16:967. [PMID: 39065664 PMCID: PMC11280007 DOI: 10.3390/pharmaceutics16070967] [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: 05/30/2024] [Revised: 06/27/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
Cumulative evidence from several pre-clinical studies suggests that restoration of plasma DNase activity in a thrombo-inflammatory state may improve clinical outcomes. Following injury, hyperactivated immune cells release large amounts of granular proteins together with DNA, which often accumulate in the surrounding environment in so-called neutrophil extracellular traps (NETs). Degradation of excess NETs by systemic DNase administration offers a promising therapeutic approach to ameliorate inflammation and dissolve intravascular clots. In order to expand the therapeutic utility of human DNase I, a variant of the enzyme was developed that has both a prolonged systemic half-life and a higher catalytic activity compared to Dornase alfa (Pulmozyme®), the recombinant form of DNase I approved for inhaled therapy of cystic fibrosis. The hyperactive enzyme was "PASylated" by genetic fusion with a strongly hydrophilic and biodegradable PAS-polypeptide to increase its hydrodynamic volume and retard kidney filtration. A stable TurboCell™ CHO-K1-based cell line was generated which is suitable for the future production of PASylated DNase I according to good manufacturing practice (GMP). Furthermore, a robust bioprocess strategy was devised and an effective downstream process was developed. The final protein product is characterized by excellent purity, favorable physicochemical properties, a 14-fold higher DNA-degrading activity than Dornase alfa and a sustained pharmacokinetic profile, with a 22-fold slower clearance in rats.
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Affiliation(s)
- Serge M. Stamm
- Rentschler Biopharma SE, Erwin-Rentschler-Str. 21, 88471 Laupheim, Germany; (S.M.S.); (R.W.)
| | - Roland Wagner
- Rentschler Biopharma SE, Erwin-Rentschler-Str. 21, 88471 Laupheim, Germany; (S.M.S.); (R.W.)
| | - Dietmar A. Lang
- Rentschler Biopharma SE, Erwin-Rentschler-Str. 21, 88471 Laupheim, Germany; (S.M.S.); (R.W.)
| | - Arne Skerra
- XL-Protein GmbH, Lise-Meitner-Str. 30, 85354 Freising, Germany
- Lehrstuhl für Biologische Chemie, Technische Universität München, Emil-Erlenmeyer-Forum 5, 85354 Freising, Germany
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3
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Vandelanotte S, De Meyer SF. Acute Ischemic Stroke Thrombus Composition. Neuroscience 2024; 550:11-20. [PMID: 38185279 DOI: 10.1016/j.neuroscience.2023.12.010] [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: 10/27/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/09/2024]
Abstract
Ischemic stroke is caused by a thrombus blocking one or multiple arteries in the brain, resulting in irreversible damage in the associated brain tissue. The aim of therapy is to restore the blood flow as fast as possible. Two recanalization strategies are currently available: pharmacological thrombolysis using recombinant tissue plasminogen activator (rt-PA) and mechanical removal of the thrombus. Despite recent advancements, achieving efficient recanalization remains a challenge. The precise causes of therapy failure are not fully understood but thrombus composition is likely a key factor in successful recanalization. This review explores acute ischemic stroke thrombus composition, its recently identified components, and how it affects stroke treatment. It also discusses how new insights could enhance current recanalization strategies for ischemic stroke patients.
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Affiliation(s)
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium.
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Vandelanotte S, François O, Desender L, Staessens S, Vanhoorne A, Van Gool F, Tersteeg C, Vanhoorelbeke K, Vanacker P, Andersson T, De Meyer SF. R-tPA Resistance Is Specific for Platelet-Rich Stroke Thrombi and Can Be Overcome by Targeting Nonfibrin Components. Stroke 2024; 55:1181-1190. [PMID: 38525646 DOI: 10.1161/strokeaha.123.045880] [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: 11/29/2023] [Accepted: 02/15/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Resistance to r-tPA (recombinant tissue-type plasminogen activator) is a well-known but poorly understood phenomenon that hampers successful recanalization in patients with acute ischemic stroke. Using clinically relevant thrombi from patients with acute ischemic stroke, we investigated if and how thrombus composition impacts r-tPA-mediated lysis. In addition, we explored strategies to overcome r-tPA resistance. METHODS Thrombi were split into 2 parts, 1 of which was used for thrombolysis and the other for detailed histological analysis. Thrombolysis was performed in normal human plasma using r-tPA alone, using r-tPA in combination with DNase-1 or using r-tPA in combination with N,N'-diacetyl-l-cystine. Thrombus lysis was calculated as the percentage of residual thrombus weight compared with its initial weight and the degree of lysis was linked to thrombus composition determined via histology. RESULTS Interestingly, we found that the efficacy of r-tPA-mediated thrombolysis was strongly correlated with the composition of the thrombi. Thrombi containing high amounts of red blood cells and low amounts of DNA and von Willebrand Factor were efficiently degraded by r-tPA, whereas thrombi containing low amounts of red blood cells and higher amounts of DNA and von Willebrand Factor were resistant to r-tPA. Importantly, combination of r-tPA with DNase-1 or N,N'-diacetyl-l-cystine significantly and specifically improved the lysis of these r-tPA-resistant thrombi. CONCLUSIONS Using patient thrombus material, our results for the first time show that the composition of stroke thrombi largely determines their susceptibility to r-tPA-mediated thrombolysis. Red blood cell-poor thrombi have a specific resistance to r-tPA, which can be overcome by targeting nonfibrin components using DNase-1 or N,N'-diacetyl-l-cystine.
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Affiliation(s)
- Sarah Vandelanotte
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (S.V., L.D., S.S., C.T., K.V., S.F.D.M.)
| | - Olivier François
- Departments of Medical Imaging (O.F., F.V.G., T.A.), AZ Groeninge, Kortrijk, Belgium
| | - Linda Desender
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (S.V., L.D., S.S., C.T., K.V., S.F.D.M.)
| | - Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (S.V., L.D., S.S., C.T., K.V., S.F.D.M.)
| | | | - Fréderick Van Gool
- Departments of Medical Imaging (O.F., F.V.G., T.A.), AZ Groeninge, Kortrijk, Belgium
| | - Claudia Tersteeg
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (S.V., L.D., S.S., C.T., K.V., S.F.D.M.)
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (S.V., L.D., S.S., C.T., K.V., S.F.D.M.)
| | - Peter Vanacker
- Neurology (A.V., P.V.), AZ Groeninge, Kortrijk, Belgium
- Department of Translational Neuroscience, University of Antwerp, Belgium (P.V.)
| | - Tommy Andersson
- Departments of Medical Imaging (O.F., F.V.G., T.A.), AZ Groeninge, Kortrijk, Belgium
- Department of Neuroradiology, Karolinska University Hospital, and Clinical Neuroscience Karolinska Institutet, Stockholm, Sweden (T.A.)
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (S.V., L.D., S.S., C.T., K.V., S.F.D.M.)
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5
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Fang H, Bo Y, Hao Z, Mang G, Jin J, Wang H. A promising frontier: targeting NETs for stroke treatment breakthroughs. Cell Commun Signal 2024; 22:238. [PMID: 38654328 PMCID: PMC11036592 DOI: 10.1186/s12964-024-01563-4] [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: 11/22/2023] [Accepted: 03/07/2024] [Indexed: 04/25/2024] Open
Abstract
Stroke is a prevalent global acute cerebrovascular condition, with ischaemic stroke being the most frequently occurring type. After a stroke, neutrophils accumulate in the brain and subsequently generate and release neutrophil extracellular traps (NETs). The accumulation of NETs exacerbates the impairment of the blood‒brain barrier (BBB), hampers neovascularization, induces notable neurological deficits, worsens the prognosis of stroke patients, and can facilitate the occurrence of t-PA-induced cerebral haemorrhage subsequent to ischaemic stroke. Alternative approaches to pharmacological thrombolysis or endovascular thrombectomy are being explored, and targeting NETs is a promising treatment that warrants further investigation.
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Affiliation(s)
- Huijie Fang
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Yunfei Bo
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Zhongfei Hao
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Ge Mang
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiaqi Jin
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
| | - Hongjun Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150001, China.
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Chen X, Liu Y, Ren L, Dai X, Zhao J, Gao C, Zhang S, Dong J, Zhao Z, Li Y, Wang J, Zhao H, Gong G, He X, Bian Y. Extraction, purification, structural characteristics and biological properties of the polysaccharides from Armillaria mellea (Vahl) P. Kumm.: A review. Int J Biol Macromol 2024; 259:129175. [PMID: 38181916 DOI: 10.1016/j.ijbiomac.2023.129175] [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: 09/16/2023] [Revised: 12/01/2023] [Accepted: 12/29/2023] [Indexed: 01/07/2024]
Abstract
Armillaria mellea (Vahl) P. Kumm. is a well-known homoeopathic plant with medicinal and culinary uses. Modern phytochemical researchers have successfully extracted and purified over 40 types of A. mellea polysaccharides (AMPs) from the fruiting bodies, hyphae and fermentation broth of A. mellea, and some of them have been analyzed and identified by their chemical structures. The impressive biological activity of these polysaccharides has been recognized by scientists worldwide. Many studies show that AMPs have remarkable antioxidant, anti-diabetic, anti-tumor, anti-inflammatory, immunoregulatory, hypolipidemic, thrombectomy, anti-aging, pulmonary protective, hepatic protective, anti-Alzheimer's properties, etc. However, the current understanding of the relationships between their chemical structure and biological activity, toxicological effects and pharmacokinetics remains limited. This article provides a systematic review of the research conducted over the past decades on the extraction and purification methods, structural characteristics, biological activity and mechanism of action of AMPs. The aim is to provide a research base that will benefit the future application of AMPs as therapeutic drugs and functional foods, and also provide insights for the further development of AMPs.
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Affiliation(s)
- Xufei Chen
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Yinghai Liu
- Department of Anesthesiology, General Hospital of the Western Theater Command of the Chinese People's Liberation Army, Chengdu, Sichuan 610036, China
| | - Ling Ren
- Department of Anesthesiology, General Hospital of the Western Theater Command of the Chinese People's Liberation Army, Chengdu, Sichuan 610036, China
| | - Xufen Dai
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Juanjuan Zhao
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Chunli Gao
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Shengxiang Zhang
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Jianhui Dong
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Zeyuan Zhao
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Yanfeng Li
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Jia Wang
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Hui Zhao
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China
| | - Gu Gong
- Department of Anesthesiology, General Hospital of the Western Theater Command of the Chinese People's Liberation Army, Chengdu, Sichuan 610036, China
| | - Xirui He
- School of Bioengineering, Zhuhai Campus, Zunyi Medical University, Zhuhai, Guangdong 519041, China.
| | - Yangyang Bian
- Key Laboratory of Resource Biology and Modern Biotechnology in Western China, College of Life Science, Northwest University, Xi'an, Shaanxi 710069, China.
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Liaptsi E, Merkouris E, Polatidou E, Tsiptsios D, Gkantzios A, Kokkotis C, Petridis F, Christidi F, Karatzetzou S, Karaoglanis C, Tsagkalidi AM, Chouliaras N, Tsamakis K, Protopapa M, Pantazis-Pergaminelis D, Skendros P, Aggelousis N, Vadikolias K. Targeting Neutrophil Extracellular Traps for Stroke Prognosis: A Promising Path. Neurol Int 2023; 15:1212-1226. [PMID: 37873833 PMCID: PMC10594510 DOI: 10.3390/neurolint15040076] [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: 08/01/2023] [Revised: 09/15/2023] [Accepted: 09/19/2023] [Indexed: 10/25/2023] Open
Abstract
Stroke has become the first cause of functional disability and one of the leading causes of mortality worldwide. Therefore, it is of crucial importance to develop accurate biomarkers to assess stroke risk and prognosis. Emerging evidence suggests that neutrophil extracellular trap (NET) levels may serve as a valuable biomarker to predict stroke occurrence and functional outcome. NETs are known to create a procoagulant state by serving as a scaffold for tissue factor (TF) and platelets inducing thrombosis by activating coagulation pathways and endothelium. A literature search was conducted in two databases (MEDLINE and Scopus) to trace all relevant studies published between 1 January 2016 and 31 December 2022, addressing the potential utility of NETs as a stroke biomarker. Only full-text articles in English were included. The current review includes thirty-three papers. Elevated NET levels in plasma and thrombi seem to be associated with increased mortality and worse functional outcomes in stroke, with all acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage included. Additionally, higher NET levels seem to correlate with worse outcomes after recanalization therapies and are more frequently found in strokes of cardioembolic or cryptogenic origin. Additionally, total neutrophil count in plasma seems also to correlate with stroke severity. Overall, NETs may be a promising predictive tool to assess stroke severity, functional outcome, and response to recanalization therapies.
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Affiliation(s)
- Eirini Liaptsi
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.L.); (E.M.); (E.P.); (A.G.); (F.C.); (S.K.); (C.K.); (A.-M.T.); (N.C.); (K.V.)
| | - Ermis Merkouris
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.L.); (E.M.); (E.P.); (A.G.); (F.C.); (S.K.); (C.K.); (A.-M.T.); (N.C.); (K.V.)
| | - Efthymia Polatidou
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.L.); (E.M.); (E.P.); (A.G.); (F.C.); (S.K.); (C.K.); (A.-M.T.); (N.C.); (K.V.)
| | - Dimitrios Tsiptsios
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.L.); (E.M.); (E.P.); (A.G.); (F.C.); (S.K.); (C.K.); (A.-M.T.); (N.C.); (K.V.)
| | - Aimilios Gkantzios
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.L.); (E.M.); (E.P.); (A.G.); (F.C.); (S.K.); (C.K.); (A.-M.T.); (N.C.); (K.V.)
| | - Christos Kokkotis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (M.P.); (D.P.-P.); (N.A.)
| | - Foivos Petridis
- Third Department of Neurology, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Foteini Christidi
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.L.); (E.M.); (E.P.); (A.G.); (F.C.); (S.K.); (C.K.); (A.-M.T.); (N.C.); (K.V.)
| | - Stella Karatzetzou
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.L.); (E.M.); (E.P.); (A.G.); (F.C.); (S.K.); (C.K.); (A.-M.T.); (N.C.); (K.V.)
| | - Christos Karaoglanis
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.L.); (E.M.); (E.P.); (A.G.); (F.C.); (S.K.); (C.K.); (A.-M.T.); (N.C.); (K.V.)
| | - Anna-Maria Tsagkalidi
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.L.); (E.M.); (E.P.); (A.G.); (F.C.); (S.K.); (C.K.); (A.-M.T.); (N.C.); (K.V.)
| | - Nikolaos Chouliaras
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.L.); (E.M.); (E.P.); (A.G.); (F.C.); (S.K.); (C.K.); (A.-M.T.); (N.C.); (K.V.)
| | - Konstantinos Tsamakis
- King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London SE5 8AF, UK;
| | - Maria Protopapa
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (M.P.); (D.P.-P.); (N.A.)
| | - Dimitrios Pantazis-Pergaminelis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (M.P.); (D.P.-P.); (N.A.)
| | - Panagiotis Skendros
- First Department of Internal Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece;
| | - Nikolaos Aggelousis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece; (C.K.); (M.P.); (D.P.-P.); (N.A.)
| | - Konstantinos Vadikolias
- Neurology Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (E.L.); (E.M.); (E.P.); (A.G.); (F.C.); (S.K.); (C.K.); (A.-M.T.); (N.C.); (K.V.)
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8
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Brinjikji W, Kallmes DF, Virmani R, de Meyer SF, Yoo AJ, Humphries W, Zaidat OO, Teleb MS, Jones JG, Siddiqui AH, Andersson T, Nogueira RG, Gil SM, Douglas A, Rossi R, Rentzos A, Ceder E, Carlqvist J, Dunker D, Jood K, Tatlisumak T, Doyle KM. Endotheliitis and cytokine storm as a mechanism of clot formation in COVID-19 ischemic stroke patients: A histopathologic study of retrieved clots. Interv Neuroradiol 2023:15910199231185804. [PMID: 37769315 DOI: 10.1177/15910199231185804] [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: 09/30/2023] Open
Abstract
BACKGROUND Studies during the COVID-19 pandemic have demonstrated an association between COVID-19 virus infection and the development of acute ischemic stroke, particularly large vessel occlusion (LVO). Studying the characteristics and immunohistochemistry of retrieved stroke emboli during mechanical thrombectomy for LVO may offer insights into the pathogenesis of LVO in COVID-19 patients. We examined retrieved COVID-19 emboli from the STRIP, EXCELLENT, and RESTORE registries and compared their characteristics to a control group. METHODS We identified COVID-positive LVO patients from the STRIP, RESTORE, and EXCELLENT studies who underwent mechanical thrombectomy. These patients were matched to a control group controlling for stroke etiology based on Trial of Org 10172 in Acute Stroke Treatment criteria. All clots were stained with Martius Scarlet Blue (MSB) along with immunohistochemistry for interleukin-6 (IL-6), C-reactive protein (CRP), von Willebrand factor (vWF), CD66b, fibrinogen, and citrullinated Histone H3. Clot composition was compared between groups. RESULTS Nineteen COVID-19-positive patients and 38 controls were included. COVID-19-positive patients had a significantly higher percentage of CRP and vWF. There was no difference in IL-6, fibrin, CD66b, or citrullinated Histone H3 between groups. Based on MSB staining, there was no statistically significant difference regarding the percentage of red blood cells, white blood cells, fibrin, and platelets. CONCLUSIONS Our study found higher concentrations of CRP and vWF in retrieved clots of COVID-19-positive stroke patients compared to COVID-19-negative controls. These findings support the potential role of systemic inflammation as indicated by elevated CRP and endothelial injury as indicated by elevated vWF as precipitating factors in thrombus development in these patients.
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Affiliation(s)
| | | | - Renu Virmani
- Department of Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Simon F de Meyer
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, TX, USA
| | | | - Osama O Zaidat
- Department of Neuroscience, Mercy Health St Vincent Medical Center, Toledo, OH, USA
| | - Mohamed S Teleb
- Neurointerventional Surgery, Stroke, and Neurocritical Care, Banner Health, Mesa, AZ, USA
| | - Jesse G Jones
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA
| | - Adnan H Siddiqui
- Departments of Neurosurgery and Radiology, State University of New York at Buffalo, New York, NY, USA
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Raul G Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center, UPMC Stroke Institute, Pittsburgh, PA, USA
| | - Sara Molina Gil
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland, Galway, Ireland
- CÚRAM-SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Andrew Douglas
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland, Galway, Ireland
- CÚRAM-SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Rosanna Rossi
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland, Galway, Ireland
- CÚRAM-SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Alexander Rentzos
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Erik Ceder
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Jeanette Carlqvist
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Dennis Dunker
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Jood
- Department of Clinical Neurosciences, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Department of Clinical Neurosciences, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Karen M Doyle
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland, Galway, Ireland
- CÚRAM-SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland
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Ho-Tin-Noé B, Desilles JP, Mazighi M. Thrombus composition and thrombolysis resistance in stroke. Res Pract Thromb Haemost 2023; 7:100178. [PMID: 37538503 PMCID: PMC10394565 DOI: 10.1016/j.rpth.2023.100178] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/14/2023] [Accepted: 05/05/2023] [Indexed: 08/05/2023] Open
Abstract
A State of the Art lecture titled "Thrombus Composition and Thrombolysis Resistance in Stroke" was presented at the ISTH Congress in 2022. Intravenous thrombolysis (IVT) remains the only pharmacologic option to re-establish cerebral perfusion at the acute phase of ischemic stroke. IVT is based on the administration of recombinant tissue plasminogen activator with the objective of dissolving fibrin, the major fibrillar protein component of thrombi. Almost 30 years on from its introduction, although the clinical benefits of IVT have been clearly demonstrated, IVT still suffers from a relatively low efficacy, with a rate of successful early recanalization below 50% overall. Analyses of thrombectomy-recovered acute ischemic stroke (AIS) thrombi have shown that apart from occlusion site, thrombus length, and collateral status, AIS thrombus structure and composition are also important modulators of IVT efficacy. In this article, after a brief presentation of IVT principle and current knowledge on IVT resistance, we review recent findings on how compaction and structural alterations of fibrin together with nonfibrin thrombus components such as neutrophil extracellular traps and von Willebrand factor interfere with IVT in AIS. We further discuss how these new insights could soon result in the development of original adjuvant therapies for improved IVT in AIS. Finally, we summarize relevant new data presented during the 2022 ISTH Congress.
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Affiliation(s)
- Benoit Ho-Tin-Noé
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
| | - Jean-Philippe Desilles
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France
| | - Mikael Mazighi
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France
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10
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De Michele M, d'Amati G, Leopizzi M, Iacobucci M, Berto I, Lorenzano S, Mazzuti L, Turriziani O, Schiavo OG, Toni D. Evidence of SARS-CoV-2 spike protein on retrieved thrombi from COVID-19 patients. J Hematol Oncol 2022; 15:108. [PMID: 35974404 PMCID: PMC9380658 DOI: 10.1186/s13045-022-01329-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 07/30/2022] [Indexed: 12/30/2022] Open
Abstract
The pathophysiology of COVID-19-associated coagulopathy is complex and not fully understood. SARS-CoV-2 spike protein (SP) may activate platelets and interact with fibrin(ogen). We aimed to investigate whether isolated SP can be present in clots retrieved in COVID-19 patients with acute ischemic stroke (by mechanical thrombectomy) and myocardial infarction. In this pilot study, we could detect SP, but not nucleocapsid protein, on platelets of COVID-19 patients’ thrombi. In addition, in all three COVID-19 thrombi analyzed for molecular biology, no SARS-CoV-2 RNA could be detected by real-time polymerase chain reaction. These data could support the hypothesis that free SP, besides the whole virus, may be the trigger of platelet activation and clot formation in COVID-19.
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Affiliation(s)
- Manuela De Michele
- Emergency Department, Stroke Unit, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Giulia d'Amati
- Department of Radiology, Oncology and Pathological Science, Sapienza University of Rome, Rome, Italy
| | - Martina Leopizzi
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latin, Italy
| | - Marta Iacobucci
- Department of Human Neurosciences, Neuroradiology Unit, Sapienza University of Rome, Rome, Italy
| | - Irene Berto
- Emergency Department, Stroke Unit, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Svetlana Lorenzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Laura Mazzuti
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | | | - Oscar G Schiavo
- Emergency Department, Stroke Unit, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
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11
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Desilles JP, Di Meglio L, Delvoye F, Maïer B, Piotin M, Ho-Tin-Noé B, Mazighi M. Composition and Organization of Acute Ischemic Stroke Thrombus: A Wealth of Information for Future Thrombolytic Strategies. Front Neurol 2022; 13:870331. [PMID: 35873787 PMCID: PMC9298929 DOI: 10.3389/fneur.2022.870331] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/18/2022] [Indexed: 01/01/2023] Open
Abstract
During the last decade, significant progress has been made in understanding thrombus composition and organization in the setting of acute ischemic stroke (AIS). In particular, thrombus organization is now described as highly heterogeneous but with 2 preserved characteristics: the presence of (1) two distinct main types of areas in the core—red blood cell (RBC)-rich and platelet-rich areas in variable proportions in each thrombus—and (2) an external shell surrounding the core composed exclusively of platelet-rich areas. In contrast to RBC-rich areas, platelet-rich areas are highly complex and are mainly responsible for the thrombolysis resistance of these thrombi for the following reasons: the presence of platelet-derived fibrinolysis inhibitors in large amounts, modifications of the fibrin network structure resistant to the tissue plasminogen activator (tPA)-induced fibrinolysis, and the presence of non-fibrin extracellular components, such as von Willebrand factor (vWF) multimers and neutrophil extracellular traps. From these studies, new therapeutic avenues are in development to increase the fibrinolytic efficacy of intravenous (IV) tPA-based therapy or to target non-fibrin thrombus components, such as platelet aggregates, vWF multimers, or the extracellular DNA network.
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Affiliation(s)
- Jean-Philippe Desilles
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France.,Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France.,Université Paris Cité, Paris, France.,FHU Neurovasc, Paris, France
| | - Lucas Di Meglio
- Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France
| | - Francois Delvoye
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France.,University of Liège, Liege, Belgium
| | - Benjamin Maïer
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France.,Université Paris Cité, Paris, France.,FHU Neurovasc, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France.,Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France
| | - Benoît Ho-Tin-Noé
- Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France.,Université Paris Cité, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France.,Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France.,Université Paris Cité, Paris, France.,FHU Neurovasc, Paris, France.,Department of Neurology, Hopital Lariboisère, APHP Nord, Paris, France
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12
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El‐Qushayri AE, Reda A, Dahy A, Azzam AY, Ghozy S. The impact of COVID 19 on the outcomes of thrombectomy in stroke patients: A systematic review and meta-analysis. Rev Med Virol 2022; 33:e2379. [PMID: 35833712 PMCID: PMC9349746 DOI: 10.1002/rmv.2379] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/22/2022] [Accepted: 07/05/2022] [Indexed: 01/28/2023]
Abstract
We aimed to conduct the current meta-analysis to provide better insight into the efficacy of mechanical thrombectomy (MT) in managing COVID-19 patients suffering from a stroke. An electronic search was conducted through eight databases for collecting the current evidence about the efficacy of MT in stroke patients with COVID-19 until 18 December 2021. The results were reported as the pooled prevalence rates and the odds ratios (ORs), with their corresponding 95% confidence intervals (CI). Out of 648 records, we included nine studies. The prevalence of stroke patients with COVID-19 who received MT treatment was with TICI ≥2b 79% (95%CI: 73-85), symptomatic intracranial haemorrhage 6% (95%CI: 3-11), parenchymal haematoma type 1, 11.1% (95%CI: 5-23), and mortality 29% (95%CI: 24-35). On further comparison of MT procedure between stroke patients with COVID 19 to those without COVID-19, we found no significant difference in terms of TICI ≥2b score (OR: 0.85; 95%CI: 0.03-23; p = 0.9). However, we found that stroke patients with COVID-19 had a significantly higher mortality rate than stroke patients without COVID-19 after MT procedure (OR: 2.99; 95%CI: 2.01-4.45; p < 0.001). Stroke patients with COVID-19 can be safely and effectively treated with MT, with comparable reperfusion and complication rates to those without the disease.
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Affiliation(s)
| | | | | | | | - Sherief Ghozy
- Department of NeuroradiologyMayo ClinicRochesterMinnesotaUSA,Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC program)Oxford UniversityOxfordUK
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13
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The Assessment of Endovascular Therapies in Ischemic Stroke: Management, Problems and Future Approaches. J Clin Med 2022; 11:jcm11071864. [PMID: 35407472 PMCID: PMC8999747 DOI: 10.3390/jcm11071864] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/18/2022] [Accepted: 03/25/2022] [Indexed: 02/06/2023] Open
Abstract
Ischemic stroke accounts for over 80% of all strokes and is one of the leading causes of mortality and permanent disability worldwide. Intravenous administration of recombinant tissue plasminogen activator (rt-PA) is an approved treatment strategy for acute ischemic stroke of large arteries within 4.5 h of onset, and mechanical thrombectomy can be used for large arteries occlusion up to 24 h after onset. Improving diagnostic work up for acute treatment, reducing onset-to-needle time and urgent radiological access angiographic CT images (angioCT) and Magnetic Resonance Imaging (MRI) are real problems for many healthcare systems, which limits the number of patients with good prognosis in real world compared to the results of randomized controlled trials. The applied endovascular procedures demonstrated high efficacy, but some cellular mechanisms, following reperfusion, are still unknown. Changes in the morphology and function of mitochondria associated with reperfusion and ischemia-reperfusion neuronal death are still understudied research fields. Moreover, future research is needed to elucidate the relationship between continuously refined imaging techniques and the variable structure or physical properties of the clot along with vascular permeability and the pleiotropism of ischemic reperfusion lesions in the penumbra, in order to define targeted preventive procedures promoting long-term health benefits.
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