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Du L, He X, Xiong X, Zhang X, Jian Z, Yang Z. Vagus nerve stimulation in cerebral stroke: biological mechanisms, therapeutic modalities, clinical applications, and future directions. Neural Regen Res 2024; 19:1707-1717. [PMID: 38103236 PMCID: PMC10960277 DOI: 10.4103/1673-5374.389365] [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: 06/11/2023] [Revised: 08/31/2023] [Accepted: 09/26/2023] [Indexed: 12/18/2023] Open
Abstract
Stroke is a major disorder of the central nervous system that poses a serious threat to human life and quality of life. Many stroke victims are left with long-term neurological dysfunction, which adversely affects the well-being of the individual and the broader socioeconomic impact. Currently, post-stroke brain dysfunction is a major and difficult area of treatment. Vagus nerve stimulation is a Food and Drug Administration-approved exploratory treatment option for autism, refractory depression, epilepsy, and Alzheimer's disease. It is expected to be a novel therapeutic technique for the treatment of stroke owing to its association with multiple mechanisms such as altering neurotransmitters and the plasticity of central neurons. In animal models of acute ischemic stroke, vagus nerve stimulation has been shown to reduce infarct size, reduce post-stroke neurological damage, and improve learning and memory capacity in rats with stroke by reducing the inflammatory response, regulating blood-brain barrier permeability, and promoting angiogenesis and neurogenesis. At present, vagus nerve stimulation includes both invasive and non-invasive vagus nerve stimulation. Clinical studies have found that invasive vagus nerve stimulation combined with rehabilitation therapy is effective in improving upper limb motor and cognitive abilities in stroke patients. Further clinical studies have shown that non-invasive vagus nerve stimulation, including ear/cervical vagus nerve stimulation, can stimulate vagal projections to the central nervous system similarly to invasive vagus nerve stimulation and can have the same effect. In this paper, we first describe the multiple effects of vagus nerve stimulation in stroke, and then discuss in depth its neuroprotective mechanisms in ischemic stroke. We go on to outline the results of the current major clinical applications of invasive and non-invasive vagus nerve stimulation. Finally, we provide a more comprehensive evaluation of the advantages and disadvantages of different types of vagus nerve stimulation in the treatment of cerebral ischemia and provide an outlook on the developmental trends. We believe that vagus nerve stimulation, as an effective treatment for stroke, will be widely used in clinical practice to promote the recovery of stroke patients and reduce the incidence of disability.
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Affiliation(s)
- Li Du
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Xuan He
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Xiaoxing Xiong
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Xu Zhang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Zhihong Jian
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Zhenxing Yang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
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Heit JJ, Chaudhary N, Mascitelli JR, Al-Kawaz M, Baker A, Bulsara KR, Burkhardt JK, Marden FA, Raper D, Tjoumakaris SI, Schirmer CM, Hetts SW. Focused update to guidelines for endovascular therapy for emergent large vessel occlusion: basilar artery occlusion patients. J Neurointerv Surg 2024; 16:752-755. [PMID: 38670791 DOI: 10.1136/jnis-2024-021705] [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: 03/09/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Endovascular therapy (EVT) dramatically improves clinical outcomes for patients with anterior circulation emergent large vessel occlusion (ELVO) strokes. With recent publication of two randomized controlled trials in favor of EVT for basilar artery occlusions, the Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee provides this focused update for the existing SNIS guideline, 'Current endovascular strategies for posterior circulation large vessel occlusion stroke.' METHODS A structured literature review and analysis of studies related to posterior circulation large vessel occlusion (basilar or vertebral artery) strokes treated by EVT was performed. Based on the strength and quality of the evidence, recommendations were made by consensus of the writing committee, with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS Based on the results of the most recent randomized, controlled trials on EVT for basilar or vertebral artery occlusion, the expert panel agreed on the following recommendations. For patients presenting with an acute ischemic stroke due to an acute basilar or vertebral artery occlusion confirmed on CT angiography, National Institutes of Health Stroke Scale (NIHSS) score of ≥6, posterior circulation Alberta Stroke Program Early CT Score (PC-ASPECTS) ≥6, and age 18-89 years: (1) thrombectomy is indicated within 12 hours since last known well (class I, level B-R); (2) thrombectomy is reasonable within 12-24 hours from the last known well (class IIa, level B-R); (3) thrombectomy may be considered on a case by case basis for patients presenting beyond 24 hours since last known well (class IIb, level C-EO). In addition, thrombectomy may be considered on a case by case basis for patients aged <18 years or >89 years on a case by case basis (class IIb, level C-EO). CONCLUSIONS The indications for EVT of ELVO strokes continue to expand and now include patients with basilar artery occlusion. Further prospective, randomized controlled trials are warranted to elucidate the efficacy and safety of EVT in populations not included in this set of recommendations, and to confirm long term outcomes.
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Affiliation(s)
- Jeremy Josef Heit
- Departments of Radiology and Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Neeraj Chaudhary
- Departments of Radiology, Neurosurgery, and Otorhinolaryngology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Mais Al-Kawaz
- Departments of Neurology, Neurosurgery, and Radiology, University of Kentucky, Lexington, KY, USA
| | - Amanda Baker
- Department of Radiology, Montefiore Medical Center, New York, NY, USA
| | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Franklin A Marden
- Alexian Brothers Medical Center, Brain and Spine Institute, Elk Grove Village, Illinois, USA
| | - Daniel Raper
- Departments of Neurological Surgery, Radiology, and Biomedical Imaging, University of California, San Francisco, California, USA
| | | | - Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger and Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania, USA
| | - Steven W Hetts
- Departments of Radiology, Biomedical Imaging and Neurological Surgery, University of California, San Francisco, California, USA
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Zarei H, Ebrahimzade M, Hajiqasemi M, Janmohamadi M, Adel Ramawad H, Haji Aghajani M, Yousefifard M. Diagnostic accuracy of 3-item stroke scale for detection of cerebral large vessel occlusion: A systematic review and meta-analysis. Am J Emerg Med 2024; 83:114-125. [PMID: 39003928 DOI: 10.1016/j.ajem.2024.07.004] [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: 05/01/2024] [Revised: 06/26/2024] [Accepted: 07/01/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Prompt identification of large vessel occlusion (LVO) in acute ischemic stroke (AIS) is crucial for expedited endovascular therapy (EVT) and improved patient outcomes. Prehospital stroke scales, such as the 3-Item Stroke Scale (3I-SS), could be beneficial in detecting LVO in suspected patients. This meta-analysis evaluates the diagnostic accuracy of 3I-SS for LVO detection in AIS. METHODS A systematic search was conducted in Medline, Embase, Scopus, and Web of Science databases until February 2024 with no time and language restrictions. Prehospital and in-hospital studies reporting diagnostic accuracy were included. Review articles, studies without reported 3I-SS cut-offs, and studies lacking the required data were excluded. Pooled effect sizes, including area under the curve (AUC), sensitivity, specificity, diagnostic odds ratio (DOR), positive and negative likelihood ratios (PLR and NLR) with 95% confidence intervals (CI) were calculated. RESULTS Twenty-two studies were included in the present meta-analysis. A 3I-SS score of 2 or higher demonstrated sensitivity of 76% (95% CI: 52%-90%) and specificity of 74% (95% CI: 57%-86%) as the optimal cut-off, with an AUC of 0.81 (95% CI: 0.78-0.84). DOR, PLR, and NLR, were 9 (95% CI: 5-15), 2.9 (95% CI: 2.0-4.3) and 0.32 (95% CI: 0.17-0.61), respectively. Sensitivity analysis confirmed the analyses' robustness in suspected to stroke patients, anterior circulation LVO, assessment by paramedics, and pre-hospital settings. Meta-regression analyses pinpointed LVO definition (anterior circulation, posterior circulation) and patient setting (suspected stroke, confirmed stroke) as potential sources of heterogeneity. CONCLUSION 3I-SS demonstrates good diagnostic accuracy in identifying LVO stroke and may be valuable in the prompt identification of patients for direct transfer to comprehensive stroke centers.
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Affiliation(s)
- Hamed Zarei
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Mandana Ebrahimzade
- Department of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Hajiqasemi
- Department of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahrokh Janmohamadi
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamzah Adel Ramawad
- Department of Emergency Medicine, NYC Health & Hospitals Coney Island, New York, NY, USA
| | - Mohammad Haji Aghajani
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Li G, Zhao Y, Ma W, Gao Y, Zhao C. Systems-level computational modeling in ischemic stroke: from cells to patients. Front Physiol 2024; 15:1394740. [PMID: 39015225 PMCID: PMC11250596 DOI: 10.3389/fphys.2024.1394740] [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: 03/02/2024] [Accepted: 06/14/2024] [Indexed: 07/18/2024] Open
Abstract
Ischemic stroke, a significant threat to human life and health, refers to a class of conditions where brain tissue damage is induced following decreased cerebral blood flow. The incidence of ischemic stroke has been steadily increasing globally, and its disease mechanisms are highly complex and involve a multitude of biological mechanisms at various scales from genes all the way to the human body system that can affect the stroke onset, progression, treatment, and prognosis. To complement conventional experimental research methods, computational systems biology modeling can integrate and describe the pathogenic mechanisms of ischemic stroke across multiple biological scales and help identify emergent modulatory principles that drive disease progression and recovery. In addition, by running virtual experiments and trials in computers, these models can efficiently predict and evaluate outcomes of different treatment methods and thereby assist clinical decision-making. In this review, we summarize the current research and application of systems-level computational modeling in the field of ischemic stroke from the multiscale mechanism-based, physics-based and omics-based perspectives and discuss how modeling-driven research frameworks can deliver insights for future stroke research and drug development.
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Affiliation(s)
- Geli Li
- Gusu School, Nanjing Medical University, Suzhou, China
- School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Yanyong Zhao
- School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Wen Ma
- School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Yuan Gao
- QSPMed Technologies, Nanjing, China
| | - Chen Zhao
- School of Pharmacy, Nanjing Medical University, Nanjing, China
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Bae JW, Hyun DK. Endovascular Thrombectomy for Acute Ischemic Stroke : Current Concept in Management. J Korean Neurosurg Soc 2024; 67:397-410. [PMID: 38549263 PMCID: PMC11220414 DOI: 10.3340/jkns.2023.0181] [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: 08/28/2023] [Revised: 10/30/2023] [Accepted: 11/23/2023] [Indexed: 07/04/2024] Open
Abstract
Endovascular thrombectomy (EVT) has been established as the standard of care in the treatment of acute ischemic stroke (AIS) based on landmark randomized controlled trials. Nevertheless, while the strict eligibility of EVT for AIS patients restrict the wide application of EVT, a considerable population still undergoes off-label EVT. Besides, it is important to acknowledge that recanalization is not achieved in approximately 20% of procedures, and more than 50% of patients who undergo EVT still do not experience a favorable outcome. This article reviews the brief history of EVT trials and recent progressions in the treatment of AIS, with focusing on the expanding eligibility criteria, new target for EVT, and the evolution of EVT techniques.
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Affiliation(s)
- Jin Woo Bae
- Department of Neurosurgery, Inha University Hospital, Incheon, Korea
- Incheon Regional Cardio-cerebrovascular Disease Center, Incheon, Korea
| | - Dong Keun Hyun
- Department of Neurosurgery, Inha University Hospital, Incheon, Korea
- Incheon Regional Cardio-cerebrovascular Disease Center, Incheon, Korea
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Li J, Liu T, Rong Q. Retrograde cerebral embolism and pulmonary embolism caused by patent ductus arteriosus: a case report. J Cardiothorac Surg 2024; 19:393. [PMID: 38937830 PMCID: PMC11210163 DOI: 10.1186/s13019-024-02901-w] [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: 03/08/2024] [Accepted: 06/15/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Although rare, paradoxical embolism sometimes occurs with patent ductus arteriosus (PDA). This study presents a case of PDA-associated paradoxical embolism with acute ischemic stroke (AIS) and pulmonary embolism (PE) following thoracoscopic surgery. CASE PRESENTATION A 65-year-old woman developed acute-onset aphasia and right hemiparesis on the third day following thoracoscopic resection for a right lung tumor. Brain magnetic resonance imaging revealed multiple infarcts, and lower extremity venous Doppler ultrasound revealed deep vein thrombosis. The patient subsequently developed dyspnea, tachycardia, and hypoxemia. PE was confirmed by percutaneous transfemoral venous selective pulmonary angiography, which meanwhile demonstrated a PDA lesion. The patient, after receiving catheter-directed thrombolysis and inferior vena cava filter placement, improved in both neurological and respiratory status. CONCLUSION For an uncommon but potentially fatal case with PDA-induced paradoxical embolism causing AIS and PE, early recognition and treatment are vital. Further studies are warranted to determine the optimal management and prognosis of patients with PDA-related embolic events.
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Affiliation(s)
- Jian Li
- Department of Neurology, The People's Hospital of Huantai County (The 9 th People's Hospital of Zibo), No. 2198 Huantai Avenue, Suo Town, Huantai Country, Zibo, Shandong Province, 256400, China
| | - Tihua Liu
- Department of Neurology, The People's Hospital of Huantai County (The 9 th People's Hospital of Zibo), No. 2198 Huantai Avenue, Suo Town, Huantai Country, Zibo, Shandong Province, 256400, China
| | - Qinfeng Rong
- Department of Neurology, The People's Hospital of Huantai County (The 9 th People's Hospital of Zibo), No. 2198 Huantai Avenue, Suo Town, Huantai Country, Zibo, Shandong Province, 256400, China.
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Tsai CY, Liao WL, Wu HM, Chang CW, Chen WL, Hsieh CL. Acupuncture improves neurological function and anti-inflammatory effect in patients with acute ischemic stroke: A double-blinded randomized controlled trial. Complement Ther Med 2024; 82:103049. [PMID: 38729273 DOI: 10.1016/j.ctim.2024.103049] [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: 12/27/2023] [Revised: 03/31/2024] [Accepted: 05/06/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND AND PURPOSE Acupuncture exerts an anti-inflammatory effect and is recommended by the World Health Organization as a complementary therapy for stroke. This study investigated the improvement in neurological function outcome in acute-stage intervention of acute ischemic stroke (AIS), and the anti-inflammatory effect of early acupuncture. METHODS Fifty patients with AIS were randomly assigned to either a control group (CG, 25 patients, received sham acupuncture) or treatment group (TG, 25 patients, received acupuncture treatment). Acupuncture intervention was administered twice a week for a total of 8 sessions over 4 consecutive weeks. The primary outcome was the changes in the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and Barthel Index (BI) scores. The secondary outcome was the changes in serum inflammation-related biomarker levels.(ANAIS trial) RESULTS: A total of 35 patients (18 patients in the CG and 17 patients in the TG) completed the trial. The reduction in NIHSS scores was greater in the TG than in the CG between V2 (second assessment administered after acupuncture intervention) and V1 (first assessment administered before acupuncture intervention; 4.33 ± 1.91 vs. 2.68 ± 1.42, p = 0.005) and between V3 (third assessment administered 28 days after last acupuncture intervention) and V1 (6.00 ± 2.53 vs. 3.83 ± 2.31, p = 0.012). The increase in BI scores was greater in the TG than in the CG between V2 and V1 (28.89 ± 15.39 vs. 14.21 ± 19.38, p = 0.016) and between V3 and V1 (39.41 ± 20.98 vs. 25.00 ± 18.47, p = 0.038). Among participants with high inflammation, the increase in serum IL-12p70 level between V2 and V1 was greater in the TG than in the CG (0.20 ± 0.19 vs. -0.14 ± 0.30, pg/mL p = 0.006). CONCLUSIONS Acupuncture improved the neurological function of patients with AIS, and the relationship between acupuncture improving neurological function and anti-inflammatory effect needs further study. In addition, studies with larger sample sizes and longer follow-ups as well as multicenter clinical trials are expected in the future.
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Affiliation(s)
- Chueh-Yi Tsai
- Department of Neurology, Chung Shan Medical University Hospital, Taichung, Taiwan; Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan; Department of Neurology, Nantou Hospital, Ministry of Health and Welfare, Nantou, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
| | - Wen-Ling Liao
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan; Center for Personalized Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Ming Wu
- Department of Neurology, Chung Shan Medical University Hospital, Taichung, Taiwan; Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Chia-Wei Chang
- Department of Neurology, Nantou Hospital, Ministry of Health and Welfare, Nantou, Taiwan
| | - Wei-Liang Chen
- Center for the Neuroscience and Behavioral Medicine, Children's National Research Institute, Children's National Medical Center, Washington D.C, USA; George Washington University, Washington D.C, USA
| | - Ching-Liang Hsieh
- Graduate Institute of Acupuncture Science, China Medical University, Taichung, Taiwan; Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan; Chinese Medicine Research Center, China Medical University, Taichung, Taiwan.
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Zhao Y, Huang L, Li W, Cai L. A bibliometric analysis of acupuncture for cerebral infarction from 1993 to 2023. Front Neurol 2024; 15:1386164. [PMID: 38756219 PMCID: PMC11096454 DOI: 10.3389/fneur.2024.1386164] [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: 02/23/2024] [Accepted: 04/08/2024] [Indexed: 05/18/2024] Open
Abstract
Objective This research aims to explore the trends and knowledge domain of acupuncture for cerebral infarction through bibliometrics. Methods Publications related to acupuncture for cerebral infarction were retrieved from the Web of Science core collection database from 1993 to December 31, 2023. A domain knowledge graph was then constructed using VOSviewer, CiteSpace, GraphPad Prism, and Scimago Graphica. Results The cumulative publication trend shows a steady increase over the years, with China being the most productive country. Notably, Europe exhibits significant close collaboration. Institutional cooperation is primarily observed among Chinese universities specializing in traditional Chinese medicine. Tao Jing is the most prolific author, with his highest number of publications is in "Stroke" journal, and Acupuncture Electro Therapeutics Research is the significant journal. Zhang SH is the most cited author, and Si QM is a prominent author in this field. Rehabilitation treatment after cerebral infarction emerges as a prevalent research focus, with nerve regeneration being a keyword. Long EZ's 1989 paper, published in the journal Stroke, holds significant importance. The prominent papers are Donnan et al. and Wu et al., which covers the following topics: "population-based study," "Baihui Acupoint," "memory deficits," "neurotrophic factor," and "randomized trial." Conclusion This bibliometric analysis of acupuncture for cerebral infarction offers insights into the Web of Science database, delineates a knowledge map of countries, authors, institutions, cited authors, keywords, cited references in the field of acupuncture for cerebral infarction, which has a momentous guiding significance for quickly and accurately positioning the key information in the field.
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Affiliation(s)
- Yanqing Zhao
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | | | - Wentao Li
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Alshehri A, Ince J, Panerai RB, Divall P, Robinson TG, Minhas JS. Physiological Variability during Prehospital Stroke Care: Which Monitoring and Interventions Are Used? Healthcare (Basel) 2024; 12:835. [PMID: 38667597 PMCID: PMC11050416 DOI: 10.3390/healthcare12080835] [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: 02/13/2024] [Revised: 03/24/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Prehospital care is a fundamental component of stroke care that predominantly focuses on shortening the time between diagnosis and reaching definitive stroke management. With growing evidence of the physiological parameters affecting long-term patient outcomes, prehospital clinicians need to consider the balance between rapid transfer and increased physiological-parameter monitoring and intervention. This systematic review explores the existing literature on prehospital physiological monitoring and intervention to modify these parameters in stroke patients. The systematic review was registered on PROSPERO (CRD42022308991) and conducted across four databases with citation cascading. Based on the identified inclusion and exclusion criteria, 19 studies were retained for this review. The studies were classified into two themes: physiological-monitoring intervention and pharmacological-therapy intervention. A total of 14 included studies explored prehospital physiological monitoring. Elevated blood pressure was associated with increased hematoma volume in intracerebral hemorrhage and, in some reports, with increased rates of early neurological deterioration and prehospital neurological deterioration. A reduction in prehospital heart rate variability was associated with unfavorable clinical outcomes. Further, five of the included records investigated the delivery of pharmacological therapy in the prehospital environment for patients presenting with acute stroke. BP-lowering interventions were successfully demonstrated through three trials; however, evidence of their benefit to clinical outcomes is limited. Two studies investigating the use of oxygen and magnesium sulfate as neuroprotective agents did not demonstrate an improvement in patient's outcomes. This systematic review highlights the absence of continuous physiological parameter monitoring, investigates fundamental physiological parameters, and provides recommendations for future work, with the aim of improving stroke patient outcomes.
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Affiliation(s)
- Abdulaziz Alshehri
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (T.G.R.)
- College of Applied Medical Sciences, University of Najran, Najran P.O. Box 1988, Saudi Arabia
| | - Jonathan Ince
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (T.G.R.)
| | - Ronney B. Panerai
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (T.G.R.)
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Pip Divall
- University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, UK;
| | - Thompson G. Robinson
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (T.G.R.)
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Jatinder S. Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (T.G.R.)
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
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Piano M, Jansen O, Marnat G, Gory B, Nordmeyer H, Eckert B, Pedicelli A, Cognard C, Loehr C, Zanoni M, Schaefer A, Macera A, Fiehler J, Doyle K, Lobotesis K. Prospective evaluation to characterize the real-world performance of the EMBOVAC aspiration catheter for neurothrombectomy: a post-market clinical follow-up trial. J Neurointerv Surg 2024:jnis-2023-021407. [PMID: 38609174 DOI: 10.1136/jnis-2023-021407] [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: 12/20/2023] [Accepted: 03/04/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND A direct aspiration first pass technique (ADAPT) is an effective alternative to stent retriever thrombectomy for patients with large vessel occlusion (LVO). The PERFECT study evaluated direct aspiration with the EMBOVAC large bore aspiration catheter in patients with LVO strokes. METHODS PERFECT was a prospective, post-market, single-arm, multicenter, observational study of patients enrolled across 11 European centers between October 2020 and July 2022. Three direct aspiration passes with EMBOVAC were mandated before switching strategy. The primary endpoint was core-lab assessed successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b) post-procedure. Other outcomes included first pass mTICI ≥2c, independent 90-day modified Rankin Scale (mRS) evaluation, and symptomatic intracerebral hemorrhage (sICH) at 24 hours by a clinical events committee. RESULTS EMBOVAC was used in 100 patients (mean age 70.4±14.0 years, 59.0% (59/100) female). Final mTICI ≥2b was achieved in 98.0% (97/99), final mTICI ≥2b with no change in frontline therapy or thrombolytics use during the procedure was achieved in 87.9% (87/99), final mTICI ≥2c in 86.9% (86/99), and first pass mTICI ≥2c in 53.5% (53/99). sICH at 24 hours was 0%. The 90-day mRS ≤2 rate was 56.6% (56/99) and all-cause mortality was 12.9%. One device-related serious adverse event occurred within 90 days (1.0%). CONCLUSIONS PERFECT demonstrates that EMBOVAC achieves successful reperfusion rates and favorable clinical outcomes when used in the endovascular treatment of acute ischemic stroke (AIS) using a direct aspiration technique as first line therapy in a real-world setting in patients with AIS secondary to large vessel occlusion. TRIAL REGISTRATION www. CLINICALTRIALS gov Unique identifier: NCT04531904.
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Affiliation(s)
| | - Olav Jansen
- University Hospital, Christian-Albrechts - University Kiel, Kiel, Germany
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
| | - Hannes Nordmeyer
- Neuroradiology, Städtisches Klinikum Solingen, Department of Diagnostic and Interventional Neuroradiology, Solingen, Germany
- Witten/Herdecke University, Department of Health, School of Medicine, Witten, Germany
| | - Bernd Eckert
- Neuroradiology, Asklepios Clinic Altona, Hamburg, Germany
| | - Alessandro Pedicelli
- Radiological Sciences, Catholic University of Sacred Heart, "A. Gemelli" Hospital, Rome, Italy
| | - Christophe Cognard
- Diagnostic and Therapeutic Neuroradiology, Hôpital Purpan, Toulouse, France
| | - Christian Loehr
- Department of Radiology and Neuroradiology, Klinikum Vest GmbH, Recklinghausen, Nordrhein-Westfalen, Germany
| | - Matteo Zanoni
- Department of Medicine, Surgery and Neurosciences, Diagnostic Imaging Unit, University of Siena, Siena, Siena, Italy
| | - Axel Schaefer
- Klinikum Vest Knappschaftskrankenhaus Recklinghausen, Department of Radiology and Neuroradiology, Recklinghausen, Germany
| | - Antonio Macera
- Department of Advanced Biomedical Sciences, Ospedale Niguarda Ca Granda, Milano, Lombardia, Italy
| | - Jens Fiehler
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Eppdata GmbH, Hamburg, Germany
| | - Karen Doyle
- Physiology, CURAM, University of Galway, Galway, Ireland
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11
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Yang Y, Gu B, Xu XY. In silico study of combination thrombolytic therapy with alteplase and mutant pro-urokinase for fibrinolysis in ischemic stroke. Comput Biol Med 2024; 171:108141. [PMID: 38367449 DOI: 10.1016/j.compbiomed.2024.108141] [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: 10/09/2023] [Revised: 01/03/2024] [Accepted: 02/12/2024] [Indexed: 02/19/2024]
Abstract
The synergistic advantage of combining tissue plasminogen activator (tPA) with pro-urokinase (proUK) for thrombolysis has been demonstrated in several in vitro experiments, and a single site proUK mutant (m-proUK) has been developed for better stability in plasma. Based on these studies, combination thrombolytic therapy with intravenous tPA and m-proUK has been suggested as a promising treatment for patients with ischemic stroke. This paper evaluates the efficacy and safety of the dual therapy by computational simulations of pharmacokinetics and pharmacodynamics coupled with a local fibrinolysis model. Seven dose regimens are simulated and compared with the standard intravenous tPA monotherapy. Our simulation results provide more insights into the complementary reaction mechanisms of tPA and m-proUK during clot lysis and demonstrate that the dual therapy can achieve a similar recanalization time (about 50 min) to tPA monotherapy, while keeping the circulating fibrinogen level within a normal range. Specifically, our results show that for all dual therapies with a 5 mg tPA bolus, the plasma concentration of fibrinogen remains stable at around 7.5 μM after a slow depletion over 50 min, whereas a rapid depletion of circulating fibrinogen (to 5 μM) is observed with the standard tPA therapy, indicating the potential advantage of dual therapy in reducing the risk of intracranial hemorrhage. Through simulations of varying dose combinations, it has been found that increasing tPA bolus can significantly affect fibrinogen level but only moderately improves recanalization time. Conversely, m-proUK doses and infusion duration exhibit a mild impact on fibrinogen level but significantly affect recanalization time. Therefore, future optimization of dose regimen should focus on limiting the tPA bolus while adjusting m-proUK dosage and infusion rate. Such adjustments could potentially maximize the therapeutic advantages of this combination therapy for ischemic stroke treatment.
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Affiliation(s)
- Yilin Yang
- Department of Chemical Engineering, Imperial College London, London, SW7 2AZ, United Kingdom.
| | - Boram Gu
- School of Chemical Engineering, Chonnam National University, 77 Yongbong-ro, Buk-gu, Gwangju, Republic of Korea.
| | - Xiao Yun Xu
- Department of Chemical Engineering, Imperial College London, London, SW7 2AZ, United Kingdom.
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12
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Al-Mufti F, Marden FA, Burkhardt JK, Raper D, Schirmer CM, Baker A, Chen PR, Bulsara KR, Narsinh KH, Amans MR, Cooper J, Yaghi S, Al-Kawaz M, Hetts SW. Endovascular therapy for anterior circulation emergent large vessel occlusion stroke in patients with large ischemic cores: a report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg 2024:jnis-2023-021444. [PMID: 38395601 DOI: 10.1136/jnis-2023-021444] [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: 01/03/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Early clinical trials validating endovascular therapy (EVT) for emergent large vessel occlusion (ELVO) ischemic stroke in the anterior circulation initially focused on patients with small or absent completed infarctions (ischemic cores) to maximize the probability of detecting a clinically meaningful and statistically significant benefit of EVT. Subsequently, real-world experience suggested that patients with large core ischemic strokes (LCS) at presentation may also benefit from EVT. Several large, retrospective, and prospective randomized clinical trials have recently been published that further validate this approach. These guidelines aim to provide an update for endovascular treatment of LCS. METHODS A structured literature review of LCS studies available since 2019 and grading the strength and quality of the evidence was performed. Recommendations were made based on these new data by consensus of the authors, with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The management of ELVO strokes with large ischemic cores continues to evolve. The expert panel agreed on several recommendations: Recommendation 1: In patients with anterior circulation ELVO who present within 24 hours of last known normal with large infarct core (70-149 mL or ASPECTS 3-5) and meet other criteria of RESCUE-Japan LIMIT, SELECT2, ANGEL-ASPECT, TESLA, TENSION, or LASTE trials, thrombectomy is indicated (Class I, Level A). Recommendations 2-7 flow directly from recommendation 1. Recommendation 2: EVT in patients with LCS aged 18-85 years is beneficial (Class I, Level A). Recommendation 3: EVT in patients with LCS >85 years of age may be beneficial (Class I, Level B-R). Recommendation 4: Patients with LCS and NIHSS score 6-30 benefit from EVT in LCS (Class I, Level A). Recommendation 5: Patients with LCS and NIHSS score <6 and >30 may benefit from EVT in LCS (Class IIa, Level A). Recommendation 6: Patients with LCS and low baseline mRS (0-1) benefit from EVT (Class I, Level A). Recommendation 7: Patients with LCS and time of last known well 0-24 hours benefit from EVT (Class I, Level A). Recommendation 8: It is recommended that patients with ELVO LCS who also meet the criteria for on-label or guideline-directed use of IV thrombolysis receive IV thrombolysis, irrespective of whether endovascular treatments are being considered (Class I, Level B-NR). CONCLUSIONS The indications for endovascular treatment of ELVO strokes continue to expand and now include patients with large ischemic cores on presentation. Further prospective randomized studies, including follow-up to assess the population-based efficacy of treating patients with LCS, are warranted.
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Affiliation(s)
- Fawaz Al-Mufti
- Departments of Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Franklin A Marden
- Interventional Neuroradiology, Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Raper
- Departments of Neurological Surgery, Radiology, and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Wilkes-Barre, Pennsylvania, USA
| | - Amanda Baker
- Departments of Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
| | - Peng Roc Chen
- Neurosurgery, The University of Texas Health Science Center at Houston Vivian L Smith Department of Neurosurgery, Houston, Texas, USA
| | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Kazim H Narsinh
- Departments of Radiology, Biomedical Imaging, and Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matthew Robert Amans
- Departments of Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
- Department of Neurology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Mais Al-Kawaz
- Departments of Neurology, Neurosurgery, and Radiology, University of Kentucky, Lexington, Kentucky, USA
- Mount Sinai Health System, New York, New York, USA
| | - Steven W Hetts
- Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
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13
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Hetts SW, Al-Mufti F, Dabus G, Fifi JT, Mocco J, Jayaraman MV. Focused update to guidelines for endovascular therapy for emergent large vessel occlusion: large core and basilar artery occlusion patients. J Neurointerv Surg 2024; 16:113-114. [PMID: 37479479 DOI: 10.1136/jnis-2023-020763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Steven W Hetts
- Radiology, University of California San Francisco (UCSF), Biomedical Imaging and Neurological Surgery, San Francisco, California, USA
| | - Fawaz Al-Mufti
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | | | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Mount Sinai Health System, New York, New York, USA
| | - Mahesh V Jayaraman
- Diagnostic Imaging, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
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14
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Patel K, Hamedani AG, Taneja K, Koneru M, Wolfe J, Sprankle K, Patel P, Mullen MT, Siegler JE. Differential thrombectomy utilization across hospital classifications in the United States. J Stroke Cerebrovasc Dis 2023; 32:107401. [PMID: 37897885 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107401] [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: 06/21/2023] [Revised: 09/11/2023] [Accepted: 09/29/2023] [Indexed: 10/30/2023] Open
Abstract
OBJECTIVES To determine hospital-level factors associated with thrombectomy uptake. MATERIALS AND METHODS The Nationwide Emergency Department Sample was retrospectively queried to determine the total number of thrombectomies performed based on different hospital characteristics. Joint point analysis was used to determine which years were associated with significant increases in the number of high-volume thrombectomy centers (ostensibly defined as >50 thrombectomies/year), thrombectomy-capable centers (>15 thrombectomies/year), and total number of thrombectomies performed. Multivariable logistic regression was used to determine hospital factors associated with having an increased odds of performing thrombectomies, and of being classified as a high-volume thrombectomy or a thrombectomy-capable center. RESULTS Between 2007-2020 there was a stepwise increase in the number of thrombectomy-capable and high-volume thrombectomy centers in the United States. In 2020, there were a total of 15,705 thrombectomies performed, with 89 high-volume thrombectomy centers, and 359 thrombectomy-capable centers. The number of thrombectomy-capable centers significantly increased after 2011. After 2013 and 2016 there was a significant change in the growth rate of high-volume thrombectomy centers. There was also a significant increase in the total number of thrombectomies performed after 2016. Hospital characteristics that were associated with an increased likelihood of being classified as thrombectomy-capable or high-volume included trauma level 1 and 2 hospitals. CONCLUSIONS Between 2007 and 2020, there was a marked growth in thrombectomy utilization for acute ischemic stroke. This growth outpaced new diagnoses of ischemic stroke, and was driven largely by certain hospital types, with the greatest rises following seminal publications of positive randomized thrombectomy trials.
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Affiliation(s)
- Karan Patel
- Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Ali G Hamedani
- Departments of Neurology and Ophthalmology and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kamil Taneja
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Manisha Koneru
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jared Wolfe
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | - Pratit Patel
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Michael T Mullen
- Department of Neurology, Lewis Katz School of Medicine at Temple University, USA
| | - James E Siegler
- Cooper Medical School of Rowan University, Camden, NJ, USA; Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
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15
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Biose IJ, Rutkai I, Clossen B, Gage G, Schechtman K, Adkisson HD, Bix GJ. Recombinant Human Perlecan DV and Its LG3 Subdomain Are Neuroprotective and Acutely Functionally Restorative in Severe Experimental Ischemic Stroke. Transl Stroke Res 2023; 14:941-954. [PMID: 36508132 PMCID: PMC10258221 DOI: 10.1007/s12975-022-01089-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/01/2022] [Accepted: 09/20/2022] [Indexed: 12/14/2022]
Abstract
Despite recent therapeutic advancements, ischemic stroke remains a major cause of death and disability. It has been previously demonstrated that ~ 85-kDa recombinant human perlecan domain V (rhPDV) binds to upregulated integrin receptors (α2β1 and α5β1) associated with neuroprotective and functional improvements in various animal models of acute ischemic stroke. Recombinant human perlecan laminin-like globular domain 3 (rhPDVLG3), a 21-kDa C-terminal subdomain of rhPDV, has been demonstrated to more avidly bind to the α2β1 integrin receptor than its parent molecule and consequently was postulated to evoke significant neuroprotective and functional effects. To test this hypothesis, fifty male C57Bl/6 J mice studied in a t-MCAO model were randomly allocated to either rhPDV treatment, rhPDVLG3, or equivalent volume of PBS at the time of reperfusion in a study where all procedures and analyses were conducted blind to treatment. On post-MCAO day 7, 2,3,5-triphenyltetrazolium chloride staining of brain slices was used to quantify infarct volume. We observed that treatment with rhPDVLG3 reduced infarct volume by 65.6% (p = 0.0001), improved weight loss (p < 0.05), and improved functional outcome measures (p < 0.05) when compared to PBS controls, improvements which were generally greater in magnitude than those observed for 2 mg/kg of rhPDV. In addition, treatment with 6 mg/kg of rhPDVLG3 was observed to significantly reduce mortality due to stroke in one model, an outcome not previously observed for rhPDV. Our initial findings suggest that treatment with rhPDVLG3 provides significant improvement in neuroprotective and functional outcomes in experimental stroke models and that further investigation of rhPDVLG3 as a novel neuroprotective therapy for patients with stroke is warranted.
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Affiliation(s)
- Ifechukwude Joachim Biose
- Department of Neurosurgery, Clinical Neuroscience Research Center, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Ibolya Rutkai
- Department of Neurosurgery, Clinical Neuroscience Research Center, Tulane University School of Medicine, New Orleans, LA, 70112, USA
- Tulane Brain Institute, Tulane University, New Orleans, LA, 70112, USA
| | - Bryan Clossen
- Stream Biomedical, Inc., 2450 Holcombe, Suite J, Houston, TX, 77021, USA
| | - Gary Gage
- Stream Biomedical, Inc., 2450 Holcombe, Suite J, Houston, TX, 77021, USA
| | - Kenneth Schechtman
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - H Davis Adkisson
- Stream Biomedical, Inc., 2450 Holcombe, Suite J, Houston, TX, 77021, USA.
| | - Gregory J Bix
- Department of Neurosurgery, Clinical Neuroscience Research Center, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
- Tulane Brain Institute, Tulane University, New Orleans, LA, 70112, USA.
- Department of Neurology, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
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16
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Dabhi N, Kumar JS, Ironside N, Kellogg RT, Sowlat MM, Uchida K, Maier I, Al Kasab S, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Samaniego EA, Arthur AS, Yoshimura S, Cuellar H, Howard BM, Alawieh A, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka AJ, Osbun JW, Crosa RJ, Matouk C, Levitt MR, Brinjikji W, Moss M, Dumont TM, Williamson R, Navia P, Kan P, De Leacy R, Chowdhry SA, Ezzeldin M, Spiotta AM, Park MS. Mechanical thrombectomy for the treatment of primary and secondary anterior cerebral artery occlusions: insights from STAR. J Neurointerv Surg 2023:jnis-2023-020997. [PMID: 37968114 DOI: 10.1136/jnis-2023-020997] [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: 09/09/2023] [Accepted: 11/04/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND The safety and efficacy of mechanical thrombectomy (MT) for the treatment of acute anterior cerebral artery (ACA) occlusions have not clearly been delineated. Outcomes may be impacted based on whether the occlusion is isolated to the ACA (primary ACA occlusion) or occurs in conjunction with other cerebral arteries (secondary). METHODS We performed a retrospective review of the multicenter Stroke Thrombectomy and Aneurysm (STAR) database. All patients with MT-treated primary or secondary ACA occlusions were included. Baseline characteristics, procedural outcomes, complications, and clinical outcomes were collected. Primary and secondary ACA occlusions were compared using the Mann-Whitney U test and Kruskal-Willis test for continuous variables and the χ2 test for categorical variables. RESULTS The study cohort comprised 238 patients with ACA occlusions (49.2% female, median (SD) age 65.6 (16.7) years). The overall rate of successful recanalization was 75%, 90-day good functional outcome was 23%, and 90-day mortality was 35%. There were 44 patients with a primary ACA occlusion and 194 patients with a secondary ACA occlusion. When adjusted for baseline variables, the rates of successful recanalization (68% vs 76%, P=0.27), 90-day good functional outcome (41% vs 19%, P=0.38), and mortality at 90 days (25% vs 38%, P=0.12) did not differ between primary and secondary ACA occlusion groups. CONCLUSION Clinical and procedural outcomes are similar between MT-treated primary and secondary ACA occlusions for select patients. Our findings demonstrate the need for established criteria to determine ideal patient and ACA stroke characteristics amenable to MT treatment.
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Affiliation(s)
- Nisha Dabhi
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jeyan Sathia Kumar
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Natasha Ironside
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Ryan T Kellogg
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Mohammad-Mahdi Sowlat
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kazutaka Uchida
- Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Ilko Maier
- Department of Neurosurgery, University Medicine Goettingen, Goettingen, Germany
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joon-Tae Kim
- Department of Neurosurgery, Chonnam National University Hospital, Gwangju, Korea (the Republic of)
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar Rai
- Department of Neurosurgery, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | | | - Edgar A Samaniego
- Department of Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Hugo Cuellar
- Department of Neurosurgery, LSUHSC, Shreveport, Louisiana, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Daniele G Romano
- Department of Neurosurgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Justin Mascitelli
- Deparment of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Isabel Fragata
- Department of Neurosurgery, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Joshua W Osbun
- Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | | | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Mark Moss
- Department of Neurosurgery, Washington Regional Medical Center, Fayetteville, Arkansas, USA
| | - Travis M Dumont
- Department of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Richard Williamson
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Pedro Navia
- Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shakeel A Chowdhry
- Department of Neurosurgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Mohamad Ezzeldin
- Department of Neurosurgery, University of Houston, Houston, Texas, USA
- Neuroendovascular Surgery, HCA Houston, Houston, Texas, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Min S Park
- Department of Neurosurgery, Universitätsspital Basel, Basel, Switzerland
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17
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Ancelet C, Neveü S, Venditti L, Cortese J, Chassin O, Pelissou C, Berthou ET, Babin M, Nasser G, Benoudiba F, Legris N, Rivière MS, Chausson N, Spelle L, Denier C. Pre-treatment risk markers for hemorrhagic transformation in posterior circulation acute ischemic stroke treated with reperfusion therapy. J Neurol 2023; 270:5493-5501. [PMID: 37515733 DOI: 10.1007/s00415-023-11886-w] [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: 05/16/2023] [Revised: 06/23/2023] [Accepted: 07/17/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Hemorrhagic transformation (HT) is an uncommon complication of posterior circulation acute ischemic stroke (PCS) compared to anterior circulation stroke. Nevertheless, it remains a major concern especially following reperfusion therapy. This study aimed at identifying potential predictive factors associated with HT in PCS. METHODS Consecutive patients, from a multicenter cohort, with PCS treated by IVT or EVT or the combination of both, were included from December 2015 to May 2019. The European Cooperative Acute Stroke Study criteria was used to identify HT. Potential risk factors were analyzed using univariate and multivariable testing models. RESULTS A total of 96 patients were included in our study. Median age was 66 (57-83) years, 54 patients (56%) were male and median baseline NIHSS was 8 (4-14). 77 patients (80%) received IVT and 54 patients (56%) benefited from EVT. HT occurred in 19 patients (20%), while sHT occurred in 3 patients (3%). HT was found to be associated with poor functional status at 3 months in univariate analysis (p = 0.0084). Multivariable analysis confirmed that higher baseline NIHSS (OR 1.1008; 95% CI [1.0216-1.1862]; p = 0.0117) and lobar topography of ischemia (OR 4.4275; 95% CI [1.3732-14.2753]; p = 0.0127) were independent predictors of the occurrence of HT. DISCUSSION HT is associated with increased morbidity in patients with PCS; higher NIHSS and lobar ischemia were independent predictors of HT in our population. Easy-to-use predictive markers may help to tailor therapeutic management of patients with PCS.
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Affiliation(s)
- Claire Ancelet
- Diagnostic and Interventional Neuroradiology Department, NEURI Brain Vascular Center, Bicêtre University-Hospital, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Sophie Neveü
- Diagnostic and Interventional Neuroradiology Department, NEURI Brain Vascular Center, Bicêtre University-Hospital, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Laura Venditti
- Department of Neurology, Hôpital Bicêtre, Stroke Center, 78 Rue du General Leclerc, 94270, Le Kremlin Bicêtre, France
| | - Jonathan Cortese
- Diagnostic and Interventional Neuroradiology Department, NEURI Brain Vascular Center, Bicêtre University-Hospital, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
- Paris-Saclay University Faculty of Medicine, INSERM U1195, Le Kremlin-Bicêtre, France
| | - Oliver Chassin
- Department of Neurology, Hôpital Bicêtre, Stroke Center, 78 Rue du General Leclerc, 94270, Le Kremlin Bicêtre, France
| | - Coralie Pelissou
- Diagnostic and Interventional Neuroradiology Department, NEURI Brain Vascular Center, Bicêtre University-Hospital, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Elsa Talab Berthou
- Diagnostic and Interventional Neuroradiology Department, NEURI Brain Vascular Center, Bicêtre University-Hospital, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Matthias Babin
- Diagnostic and Interventional Neuroradiology Department, NEURI Brain Vascular Center, Bicêtre University-Hospital, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Ghaidaa Nasser
- Diagnostic and Interventional Neuroradiology Department, NEURI Brain Vascular Center, Bicêtre University-Hospital, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Farida Benoudiba
- Diagnostic and Interventional Neuroradiology Department, NEURI Brain Vascular Center, Bicêtre University-Hospital, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Nicolas Legris
- Department of Neurology, Hôpital Bicêtre, Stroke Center, 78 Rue du General Leclerc, 94270, Le Kremlin Bicêtre, France
| | - Mariana Sarov Rivière
- Department of Neurology, Hôpital Bicêtre, Stroke Center, 78 Rue du General Leclerc, 94270, Le Kremlin Bicêtre, France
| | - Nicolas Chausson
- Paris-Saclay University Faculty of Medicine, INSERM U1195, Le Kremlin-Bicêtre, France
- Department of Neurology, Centre Hospitalier Sud Francilien, 40 Avenue Serge Dassault, 91100, Corbeil-Essonnes, France
| | - Laurent Spelle
- Diagnostic and Interventional Neuroradiology Department, NEURI Brain Vascular Center, Bicêtre University-Hospital, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
- Paris-Saclay University Faculty of Medicine, INSERM U1195, Le Kremlin-Bicêtre, France
| | - Christian Denier
- Department of Neurology, Hôpital Bicêtre, Stroke Center, 78 Rue du General Leclerc, 94270, Le Kremlin Bicêtre, France
- Paris-Saclay University Faculty of Medicine, INSERM U1195, Le Kremlin-Bicêtre, France
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18
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Gupta C, Wagh V. Exploring the Multifaceted Causes of Ischemic Stroke: A Narrative Review. Cureus 2023; 15:e47531. [PMID: 38021859 PMCID: PMC10664821 DOI: 10.7759/cureus.47531] [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: 07/19/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Neurologists are well-versed with acute ischemic stroke, a serious public health concern. Effective acute stroke treatment is built on the rapid application of reperfusion therapy. This calls for prompt symptom recognition by the general population as well as emergency workers, proper referral to specialized stroke centers, and thorough examination and assessment by the on-site stroke team. The main goal of treatment for certain individuals is to restore blood flow to the ischemic penumbra by using intravenous thrombolysis and/or endovascular thrombectomy. Acute stroke patients must be hospitalized and continuously monitored for early neurological decline in order to avoid subsequent problems. After swiftly determining the stroke mechanism, patients can start the proper secondary preventative actions.
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Affiliation(s)
- Chirag Gupta
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vasant Wagh
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Requena M, Piñana C, Olive-Gadea M, Hernández D, Boned S, De Dios M, Rodrigo M, Rivera E, Muchada M, Cuevas JL, Rubiera M, García-Tornel Á, Gramegna LL, Molina C, Ribo M, Tomasello A. Combined technique as first approach in mechanical thrombectomy: Efficacy and safety of REACT catheter combined with stent retriever. Interv Neuroradiol 2023; 29:504-509. [PMID: 35491662 PMCID: PMC10549706 DOI: 10.1177/15910199221095798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Mechanical thrombectomy (MT) with combined treatment including both a stent retriever and distal aspiration catheter may improve recanalization rates in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Here, we evaluated the effectiveness and safety of the REACT aspiration catheter used with a stent retriever. METHODS This prospective study included consecutive adult patients who underwent MT with a combined technique using REACT 68 and/or 71 between June 2020 and July 2021. The primary endpoints were final and first pass mTICI 2b-3 and mTICI 2c-3 recanalization. Analysis was performed after first pass and after each attempt. Secondary safety outcomes included procedural complications, symptomatic intracranial hemorrhage (sICH) at 24 h, in-hospital mortality, and 90-day functional independence (modified Rankin Scale [mRS] 0-2). RESULTS A total of 102 patients were included (median age 78; IQR: 73-87; 50.0% female). At baseline, median NIHSS score was 19 (IQR: 11-21), and ASPECTS was 9 (IQR: 8-10). Final mTICI 2b-3 recanalization was achieved in 91 (89.2%) patients and mTICI 2c-3 was achieved in 66 (64.7%). At first pass, mTICI 2b-3 was achieved in 55 (53.9%) patients, and mTICI 2c-3 in 37 (36.3%). The rate of procedural complications was 3.9% (4/102), sICH was 6.8% (7/102), in-hospital mortality was 12.7% (13/102), and 90-day functional independence was 35.6% (36/102). CONCLUSION A combined MT technique using a stent retriever and REACT catheter resulted in a high rate of successful recanalization and first pass recanalization in a sample of consecutive patients with AIS due to LVO in clinical use.
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Affiliation(s)
- Manuel Requena
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Carlos Piñana
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Marta Olive-Gadea
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - David Hernández
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Sandra Boned
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Marta De Dios
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Marc Rodrigo
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Eila Rivera
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Marián Muchada
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - José Luis Cuevas
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
- Servicio Neurocirugía, Hospital de Puerto Montt, Puerto Montt, Chile
| | - Marta Rubiera
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Álvaro García-Tornel
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Laura Ludovica Gramegna
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Carlos Molina
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Marc Ribo
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Alejandro Tomasello
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
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20
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Diestro JDB. Rethinking the role of CT perfusion in the management of emergent large vessel ischemic stroke. J Neurointerv Surg 2023; 15:833-834. [PMID: 37591605 DOI: 10.1136/jnis-2023-020860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/19/2023]
Affiliation(s)
- Jose Danilo Bengzon Diestro
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, Unity Health- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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21
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Satti S, Sivapatham T. Update on Neurointerventional Therapy for the Treatment of Acute Cerebral Ischemia. Dela J Public Health 2023; 9:30-32. [PMID: 37701468 PMCID: PMC10494793 DOI: 10.32481/djph.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Mechanical thrombectomy (MT) is a minimally invasive, fluoroscopically guided procedure to remove clots from the arteries in the head and neck. The procedure can be performed very quickly and effectively, with low complication rates, as techniques and technology have advanced in recent years. MT is among the most efficacious procedures performed today, with a very low number needed to treat (NNT) to impact outcomes. Expanded indications for MT include patients with large core infarcts, extended time windows from stroke onset, more distal occlusions, and milder symptoms. Trials have shown a significant benefit of MT in terms of reduced disability in nearly every patient population studied.
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Affiliation(s)
- Sudhakar Satti
- Associate Chief, Neurointerventional Surgery, ChristianaCare
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22
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Siddiq F, Bhagavan S, Ishfaq MF, Jaura A, Bhatti IA, Gomez CR, Qureshi AI. Balloon-Assisted Catheterization of Occluded Carotid Artery (BOCA) Technique in Acute Stroke. Oper Neurosurg (Hagerstown) 2023; 25:190-198. [PMID: 37133290 DOI: 10.1227/ons.0000000000000723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/08/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Acute ischemic stroke from tandem occlusion of internal carotid artery (ICA) poses a technical challenge to neurointerventionalists. OBJECTIVE To present a novel balloon-assisted catheterization of occluded carotid artery (BOCA) technique used for rapid and effective catheterization of occluded/critically stenosed ICA in tandem occlusion. METHODS A retrospective review of 10 patients with tandem carotid occlusion, treated with BOCA technique for revascularization between July 2020 and June 2021, was performed. Clinical, radiographic, and procedural data; details of BOCA technique; complications; and outcomes were reviewed. RESULTS Of the 10 patients, 8 (80%) had complete occlusion of the cervical ICA and the remaining 2 had high-grade stenosis with poor intracranial flow. The mean age was 63.2 years. The mean presenting NIH Stroke Scale was 13.4. The BOCA technique resulted in recanalization of ICA in all patients and allowed mechanical thrombectomy of middle cerebral artery. Thrombolysis in cerebral infarction grade 2b/3 was achieved in all 10 patients. The mean groin-to-reperfusion time was 41.4 minutes. The mean internal carotid artery stenosis was 99.7% preoperatively and 41.1% postoperatively. Only one patient needed stent at the end of the procedure because of dissection. CONCLUSION The BOCA technique can be used in distal first approach for acute stroke from tandem ICA occlusion. This technique allows direct guide catheterization of occluded ICA by tracking over a partially inflated balloon.
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Affiliation(s)
- Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Sachin Bhagavan
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - M Fawad Ishfaq
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Attiya Jaura
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | | | - Camilo R Gomez
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
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23
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Poongkunran M, Ulep RD, Stuntz GA, Mitchell S, Gaines KJ, Vidal G, Chehebar D, Iwuchukwu IO, McGrade H, Mohammed AE, Zweifler RM. Diagnostic accuracy of telestroke consultation: a Louisiana based tele-network experience. Front Neurol 2023; 14:1141059. [PMID: 37333002 PMCID: PMC10273670 DOI: 10.3389/fneur.2023.1141059] [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: 01/17/2023] [Accepted: 05/02/2023] [Indexed: 06/20/2023] Open
Abstract
Background and purpose Telestroke has grown significantly since its implementation. Despite growing utilization, there is a paucity of data regarding the diagnostic accuracy of telestroke to distinguish between stroke and its mimics. We aimed to evaluate diagnostic accuracy of telestroke consultations and explore the characteristics of misdiagnosed patients with a focus on stroke mimics. Methods We conducted a retrospective study of all the consultations in our Ochsner Health's TeleStroke program seen between April 2015 and April 2016. Consultations were classified into one of three diagnostic categories: stroke/transient ischemic attack, mimic, and uncertain. Initial telestroke diagnosis was compared with the final diagnosis post review of all emergency department and hospital data. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) for diagnosis of stroke/TIA versus mimic were calculated. Area under receiver-operating characteristic curve (AUC) analysis to predict true stroke was performed. Bivariate analysis based on the diagnostic categories examined association with sex, age, NIHSS, stroke risk factors, tPA given, bleeding after tPA, symptom onset to last known normal, symptom onset to consult, timing in the day, and consult duration. Logistic regression was performed as indicated by bivariate analysis. Results Eight hundred and seventy-four telestroke evaluations were included in our analysis. Accurate diagnosis through teleneurological consultation was seen in 85% of which 532 were strokes (true positives) and 170 were mimics (true negatives). Sensitivity, specificity, PPV, NPV were 97.8, 82.5, 93.7 and 93.4%, respectively. LR+ and LR- were 5.6 and 0.03. AUC (95% CI) was 0.9016 (0.8749-0.9283). Stroke mimics were more common with younger age and female gender and in those with less vascular risk factors. LR revealed OR (95% CI) of misdiagnosis for female gender of 1.9 (1.3-2.9). Lower age and lower NIHSS score were other predictors of misdiagnosis. Conclusion We report high diagnostic accuracy of the Ochsner Telestroke Program in discriminating stroke/TIA and stroke mimics, with slight tendency towards over diagnosis of stroke. Female gender, younger age and lower NIHSS score were associated with misdiagnosis.
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Affiliation(s)
- Mugilan Poongkunran
- Ochsner Neuroscience Institute, Ochsner Health, New Orleans, LA, United States
| | - Robin D. Ulep
- Ochsner Clinical School, New Orleans, LA, United States
| | | | - Sara Mitchell
- Ochsner Clinical School, New Orleans, LA, United States
| | - Kenneth J. Gaines
- Ochsner Neuroscience Institute, Ochsner Health, New Orleans, LA, United States
| | - Gabriel Vidal
- Ochsner Neuroscience Institute, Ochsner Health, New Orleans, LA, United States
| | - Daniel Chehebar
- Ochsner Neuroscience Institute, Ochsner Health, New Orleans, LA, United States
| | | | - Harold McGrade
- Ochsner Neuroscience Institute, Ochsner Health, New Orleans, LA, United States
| | - Alaa E. Mohammed
- Ochsner Center for Outcomes Research, Office of Epidemiology and Biostatistical Collaborations, Ochsner Clinic Foundation, New Orleans, LA, United States
| | - Richard M. Zweifler
- Ochsner Neuroscience Institute, Ochsner Health, New Orleans, LA, United States
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Bhole R, Solenski NJ, Donahue JH, Kellogg RT, Roach NN, Chapman SN, Worrall BB, Evans AJ, Patel SH, Mukherjee S, Park MS, Southerland AM. Best Practice Recommendations for Stroke Vascular Imaging During Iodinated Contrast Shortage. Neurol Clin Pract 2023; 13:e200119. [PMID: 37064591 PMCID: PMC10101716 DOI: 10.1212/cpj.0000000000200119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 11/01/2022] [Indexed: 03/21/2023]
Abstract
GE Healthcare© announced on April 19, 2022, that their main factory and distributor of iodinated contrast had experienced a temporary shutdown because of COVID-19 outbreak in Shanghai, China. This, along with other supply chain issues, led to a worldwide shortage of iodinated contrast agents, Omnipaque and Visipaque. Our Comprehensive Stroke Center was confronted with the cascading effect of this iodinated contrast material shortage. We took immediate steps to revise our protocols and processes to continue to provide high-quality care to our stroke patients. A multidisciplinary working group comprised of representatives of our stroke center, including vascular neurology, diagnostic neuroradiology, and neurovascular surgery, urgently met to brainstorm how to mitigate the shortage. We established parameters and local guidelines for the use of CT angiography, CT perfusion, and digital subtraction angiography for stroke patients. In this article, we propose "best practice" recommendations from a single Joint Commission approved Comprehensive Stroke Center that can be used as blueprint by other hospital systems when navigating potential future supply chain issues, to provide consistent high-quality stroke care.
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Affiliation(s)
- Rohini Bhole
- Departments of Neurology (RB, NJS, NNR, SNC, BBW, AMS), Radiology and Medical Imaging (JHD, AJE, SHP, SM) and Neurosurgery (RTK, MSP), University of Virginia, Charlottesville
| | - Nina J Solenski
- Departments of Neurology (RB, NJS, NNR, SNC, BBW, AMS), Radiology and Medical Imaging (JHD, AJE, SHP, SM) and Neurosurgery (RTK, MSP), University of Virginia, Charlottesville
| | - Joseph H Donahue
- Departments of Neurology (RB, NJS, NNR, SNC, BBW, AMS), Radiology and Medical Imaging (JHD, AJE, SHP, SM) and Neurosurgery (RTK, MSP), University of Virginia, Charlottesville
| | - Ryan T Kellogg
- Departments of Neurology (RB, NJS, NNR, SNC, BBW, AMS), Radiology and Medical Imaging (JHD, AJE, SHP, SM) and Neurosurgery (RTK, MSP), University of Virginia, Charlottesville
| | - Necrisha N Roach
- Departments of Neurology (RB, NJS, NNR, SNC, BBW, AMS), Radiology and Medical Imaging (JHD, AJE, SHP, SM) and Neurosurgery (RTK, MSP), University of Virginia, Charlottesville
| | - Sherita N Chapman
- Departments of Neurology (RB, NJS, NNR, SNC, BBW, AMS), Radiology and Medical Imaging (JHD, AJE, SHP, SM) and Neurosurgery (RTK, MSP), University of Virginia, Charlottesville
| | - Bradford B Worrall
- Departments of Neurology (RB, NJS, NNR, SNC, BBW, AMS), Radiology and Medical Imaging (JHD, AJE, SHP, SM) and Neurosurgery (RTK, MSP), University of Virginia, Charlottesville
| | - Avery J Evans
- Departments of Neurology (RB, NJS, NNR, SNC, BBW, AMS), Radiology and Medical Imaging (JHD, AJE, SHP, SM) and Neurosurgery (RTK, MSP), University of Virginia, Charlottesville
| | - Sohil H Patel
- Departments of Neurology (RB, NJS, NNR, SNC, BBW, AMS), Radiology and Medical Imaging (JHD, AJE, SHP, SM) and Neurosurgery (RTK, MSP), University of Virginia, Charlottesville
| | - Sugoto Mukherjee
- Departments of Neurology (RB, NJS, NNR, SNC, BBW, AMS), Radiology and Medical Imaging (JHD, AJE, SHP, SM) and Neurosurgery (RTK, MSP), University of Virginia, Charlottesville
| | - Min S Park
- Departments of Neurology (RB, NJS, NNR, SNC, BBW, AMS), Radiology and Medical Imaging (JHD, AJE, SHP, SM) and Neurosurgery (RTK, MSP), University of Virginia, Charlottesville
| | - Andrew M Southerland
- Departments of Neurology (RB, NJS, NNR, SNC, BBW, AMS), Radiology and Medical Imaging (JHD, AJE, SHP, SM) and Neurosurgery (RTK, MSP), University of Virginia, Charlottesville
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Toljan K, Ashok A, Labhasetwar V, Hussain MS. Nanotechnology in Stroke: New Trails with Smaller Scales. Biomedicines 2023; 11:biomedicines11030780. [PMID: 36979759 PMCID: PMC10045028 DOI: 10.3390/biomedicines11030780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/26/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Stroke is a leading cause of death, long-term disability, and socioeconomic costs, highlighting the urgent need for effective treatment. During acute phase, intravenous administration of recombinant tissue plasminogen activator (tPA), a thrombolytic agent, and endovascular thrombectomy (EVT), a mechanical intervention to retrieve clots, are the only FDA-approved treatments to re-establish cerebral blood flow. Due to a short therapeutic time window and high potential risk of cerebral hemorrhage, a limited number of acute stroke patients benefit from tPA treatment. EVT can be performed within an extended time window, but such intervention is performed only in patients with occlusion in a larger, anatomically more proximal vasculature and is carried out at specialty centers. Regardless of the method, in case of successful recanalization, ischemia-reperfusion injury represents an additional challenge. Further, tPA disrupts the blood-brain barrier integrity and is neurotoxic, aggravating reperfusion injury. Nanoparticle-based approaches have the potential to circumvent some of the above issues and develop a thrombolytic agent that can be administered safely beyond the time window for tPA treatment. Different attributes of nanoparticles are also being explored to develop a multifunctional thrombolytic agent that, in addition to a thrombolytic agent, can contain therapeutics such as an anti-inflammatory, antioxidant, neuro/vasoprotective, or imaging agent, i.e., a theragnostic agent. The focus of this review is to highlight these advances as they relate to cerebrovascular conditions to improve clinical outcomes in stroke patients.
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Affiliation(s)
- Karlo Toljan
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Anushruti Ashok
- Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Vinod Labhasetwar
- Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Correspondence: (V.L.); (M.S.H.)
| | - M. Shazam Hussain
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Correspondence: (V.L.); (M.S.H.)
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26
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Mead GE, Sposato LA, Sampaio Silva G, Yperzeele L, Wu S, Kutlubaev M, Cheyne J, Wahab K, Urrutia VC, Sharma VK, Sylaja PN, Hill K, Steiner T, Liebeskind DS, Rabinstein AA. A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization. Int J Stroke 2023; 18:499-531. [PMID: 36725717 DOI: 10.1177/17474930231156753] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines. AIMS To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced). SUMMARY OF REVIEW Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited. CONCLUSION The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.
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Affiliation(s)
- Gillian E Mead
- Usher Institute, University of Edinburgh and Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada.,Heart & Brain Lab, Western University, London, ON, Canada.,Robarts Research Institute, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Laetitia Yperzeele
- Antwerp NeuroVascular Center and Stroke Unit, Antwerp University Hospital, Antwerp, Belgium.,Research Group on Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mansur Kutlubaev
- Department of Neurology, Bashkir State Medical University, Ufa, Russia
| | - Joshua Cheyne
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin, Ilorin, Nigeria
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Neurology, University Medicine Cluster, National University Health System, Singapore
| | - P N Sylaja
- Neurology and Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Kelvin Hill
- Stroke Treatment, Stroke Foundation, Melbourne, VIC, Australia
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst and Heidelberg University Hospital, Frankfurt, Germany
| | - David S Liebeskind
- UCLA Department of Neurology, Neurovascular Imaging Research Core, UCLA Comprehensive Stroke Center, Los Angeles, CA, USA
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27
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Bhatia A, Businger J. Perioperative Management of the Acute Stroke Patient: From Door to Needle to NeuroICU. Anesthesiol Clin 2023; 41:27-38. [PMID: 36872004 DOI: 10.1016/j.anclin.2022.11.001] [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: 03/07/2023]
Abstract
Acute ischemic stroke is a neurologic emergency that requires precise care due to high likelihood of morbidity and mortality. Current guidelines recommend thrombolytic therapy with alteplase within the first 3 to 4.5 hours of initial stroke symptoms and endovascular mechanical thrombectomy within the first 16 to 24 hours. Anesthesiologists may be involved in the care of these patients perioperatively and in the intensive care unit. Although the optimal anesthetic for these procedures remains under investigation, this article will review how to best optimize and treat these patients to achieve the best outcomes.
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Affiliation(s)
- Alisha Bhatia
- Department of Anesthesiology, Rush University Medical Center, 1645 West Congress Parkway, Jelke 736, Chicago, IL 60612, USA.
| | - Jerrad Businger
- Division of Anesthesia Critical Care, Anesthesia Critical Care, University of Louisville Hospital, 530 S. Jackson Street/ RM. C2A01, Louisville, KY 40202, USA
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28
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Yuksen C, Tienpratarn W, Treerasoradaj T, Jenpanitpong C, Termkijwanich P. The Clinical Predictive Score for Prehospital Large Vessel Occlusion Stroke: A Retrospective Cohort Study in the Asian Country. Open Access Emerg Med 2023; 15:53-60. [PMID: 36798910 PMCID: PMC9925388 DOI: 10.2147/oaem.s398061] [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: 11/30/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
Background Large vessel occlusive (LVO) stroke causes severe disabilities and occurs in more than 37% of strokes. Reperfusion therapy is the gold standard of treatment. Studies proved that endovascular thrombectomy (EVT) is more beneficial and decreases mortality. This study aimed to evaluate the factor associated with LVO stroke in an Asian population and to develop the scores to predict LVO in a prehospital setting. The score will hugely contribute to the future of stroke care in prehospital settings in the aspect of transferal suspected LVO stroke patients to appropriate EVT-capable stroke centers. Methods This study was a retrospective cohort study using an exploratory model at the emergency department of Ramathibodi Hospital, Bangkok, Thailand, between January 2018 and December 2020. We included the stroke patients aged >18 who visit ED and an available radiologic report representing LVO. Those whose stroke onset was >24 hours and no radiologic report were excluded. Multivariable logistic regression analysis developed the prediction model and score for LVO stroke. Results A total of 252 patients met the inclusion criteria; 61 cases (24%) had LVO stroke. Six independent factors were significantly predictive: comorbidity with atrial fibrillation, clinical hemineglect, gaze deviation, facial palsy, aphasia, and cerebellar sign abnormality. The predicted score had an accuracy of 92.5%. The LVO risk score was categorized into three groups: low risk (LVO score <3), moderate risk (LVO score 3-6), and high risk (LVO score >6). The positive likelihood ratio to predicting LVO stroke were 0.12 (95% CI 0.06-0.26), 2.33 (95% CI 1.53-3.53) and 45.40 (95% CI 11.16-184.78), respectively. Conclusion The Large Vessel Occlusion (LVO) Risk Score provides a screening tool for predicting LVO stroke. A clinical predictive score of ≥3 appears to be associated with LVO stroke.
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Affiliation(s)
- Chaiyaporn Yuksen
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Welawat Tienpratarn
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,Correspondence: Welawat Tienpratarn, Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand, Email
| | - Thitibud Treerasoradaj
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chetsadakon Jenpanitpong
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Phatcha Termkijwanich
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Mottahedin A, Prag HA, Dannhorn A, Mair R, Schmidt C, Yang M, Sorby-Adams A, Lee JJ, Burger N, Kulaveerasingam D, Huang MM, Pluchino S, Peruzzotti-Jametti L, Goodwin R, Frezza C, Murphy MP, Krieg T. Targeting succinate metabolism to decrease brain injury upon mechanical thrombectomy treatment of ischemic stroke. Redox Biol 2023; 59:102600. [PMID: 36630820 PMCID: PMC9841348 DOI: 10.1016/j.redox.2023.102600] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/15/2022] [Accepted: 01/02/2023] [Indexed: 01/04/2023] Open
Abstract
Current treatments for acute ischemic stroke aim to reinstate a normal perfusion in the ischemic territory but can also cause significant ischemia-reperfusion (IR) injury. Previous data in experimental models of stroke show that ischemia leads to the accumulation of succinate, and, upon reperfusion, the accumulated succinate is rapidly oxidized by succinate dehydrogenase (SDH) to drive superoxide production at mitochondrial complex I. Despite this process initiating IR injury and causing further tissue damage, the potential of targeting succinate metabolism to minimize IR injury remains unexplored. Using both quantitative and untargeted high-resolution metabolomics, we show a time-dependent accumulation of succinate in both human and mouse brain exposed to ischemia ex vivo. In a mouse model of ischemic stroke/mechanical thrombectomy mass spectrometry imaging (MSI) shows that succinate accumulation is confined to the ischemic region, and that the accumulated succinate is rapidly oxidized upon reperfusion. Targeting succinate oxidation by systemic infusion of the SDH inhibitor malonate upon reperfusion leads to a dose-dependent decrease in acute brain injury. Together these findings support targeting succinate metabolism upon reperfusion to decrease IR injury as a valuable adjunct to mechanical thrombectomy in ischemic stroke.
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Affiliation(s)
- Amin Mottahedin
- MRC Mitochondrial Biology Unit, University of Cambridge, The Keith Peters Building, Cambridge Biomedical Campus, Cambridge, UK; Department of Physiology, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.
| | - Hiran A Prag
- Department of Medicine, University of Cambridge, Cambridge University Hospitals, Cambridge, UK
| | - Andreas Dannhorn
- Imaging and Data Analytics, Clinical Pharmacology and Safety Sciences, R & D, AstraZeneca, Cambridge, UK
| | - Richard Mair
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospitals, Cambridge, UK
| | - Christina Schmidt
- CECAD Research Center, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Ming Yang
- CECAD Research Center, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Annabel Sorby-Adams
- MRC Mitochondrial Biology Unit, University of Cambridge, The Keith Peters Building, Cambridge Biomedical Campus, Cambridge, UK
| | - Jordan J Lee
- Department of Medicine, University of Cambridge, Cambridge University Hospitals, Cambridge, UK
| | - Nils Burger
- MRC Mitochondrial Biology Unit, University of Cambridge, The Keith Peters Building, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Margaret M Huang
- MRC Mitochondrial Biology Unit, University of Cambridge, The Keith Peters Building, Cambridge Biomedical Campus, Cambridge, UK
| | - Stefano Pluchino
- Department of Clinical Neurosciences and NIHR Biomedical Research Centre, University of Cambridge, UK
| | - Luca Peruzzotti-Jametti
- Department of Clinical Neurosciences and NIHR Biomedical Research Centre, University of Cambridge, UK
| | - Richard Goodwin
- Imaging and Data Analytics, Clinical Pharmacology and Safety Sciences, R & D, AstraZeneca, Cambridge, UK
| | - Christian Frezza
- CECAD Research Center, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Michael P Murphy
- MRC Mitochondrial Biology Unit, University of Cambridge, The Keith Peters Building, Cambridge Biomedical Campus, Cambridge, UK; Department of Medicine, University of Cambridge, Cambridge University Hospitals, Cambridge, UK.
| | - Thomas Krieg
- Department of Medicine, University of Cambridge, Cambridge University Hospitals, Cambridge, UK.
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Wu K, Roa JA, Nouri M, Lee J, Mocco J, Fifi J, Singh IP. Procedural and Clinical Outcome Analysis of Monoplane versus Biplane Angiography Suites in Stroke Thrombectomies. World Neurosurg 2023; 170:e695-e699. [PMID: 36436774 DOI: 10.1016/j.wneu.2022.11.088] [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: 09/26/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Thrombectomy is now the standard of care in the treatment of acute ischemic stroke caused by emergent large vessel occlusion. Therefore thrombectomy services have expanded from Comprehensive Stroke Centers to Thrombectomy-Capable Stroke Centers. Stroke interventions at these sites are performed in both biplane and monoplane angiography suites. It has been hypothesized that differences in these systems may affect time to successful reperfusion, with a potentially significant effect on neurologic outcomes. With an increase in TSCs, this study aims to evaluate the safety and efficacy of monoplane thrombectomy versus biplane thrombectomy. METHODS Patients who presented with isolated proximal middle cerebral artery M1 occlusions and underwent endovascular thrombectomy from March 2015 to August 2018 at 5 different centers within a single health system were included. Thrombectomy was performed by the same group of experienced neurointerventionalists. The primary endpoint was functional outcome as measured by the modified Rankin scale at 90 days. Secondary endpoints included recanalization grade as measured by the Thrombolysis in Cerebral Infarction score, time to final reperfusion, and incidence of hemorrhagic conversion. RESULTS A total of 197 patients were included in this study. Of them, 80.7% underwent thrombectomy on biplane systems. Time to final reperfusion was 10.2 minutes longer in the monoplane group but was not statistically significant (P = 0.252). There was no significant difference in the rates of favorable reperfusion (P = 0.755), hemorrhagic conversion (P = 0.580), or functional outcome at 90 days (favorable modified Rankin Scale 0-2, P = 0.210; favorable modified Rankin Scale 0-3, P = 0.697). CONCLUSION Despite perceived advantages of biplane systems in reducing procedural time, our study demonstrates no significant differences between systems. These data support the safety and efficacy of performing thrombectomy on monoplane systems and may also carry implications for reducing patient transfer times and potentially increasing thrombectomy access to areas of the world where biplane suites may not be available. The next step would be a prospective randomized trial comparing both systems in different settings.
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Affiliation(s)
- Katty Wu
- SUNY Downstate College of Medicine, New York, New York, USA
| | - Jorge A Roa
- Department of Neurosurgery, MedStar Franklin Square Medical Center, Georgetown University School of Medicine, Baltimore, Maryland, USA
| | - Mohsen Nouri
- Jamaica Hospital Medical Center, Stone Lion Neuro Clinic, Queens, New York, USA
| | - Joyce Lee
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - I Paul Singh
- Department of Neurosurgery and Neurology, Georgetown University Medical Center, Washington, D.C., USA.
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31
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Piasecki P, Wierzbicki M, Narloch J, Dębiec A, Staszewski J. Mechanical thrombectomy of large vessel occlusion using adjustable vs. self-expanding stent-retriever-Comparison of Tigertriever device with stent-like stent-retrievers: A propensity score analysis. Front Neurol 2023; 13:1032307. [PMID: 36742041 PMCID: PMC9889363 DOI: 10.3389/fneur.2022.1032307] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/28/2022] [Indexed: 01/20/2023] Open
Abstract
Background Stent-retrievers used for mechanical thrombectomy are self-expanding tubular stent-like devices with modified mesh structures for clot removal. Tigertriever is designed to provide manual control of its diameter and curvature. Methods A retrospective single-center study was performed to compare Tigertriever with SolitaireX and pRESET (stent-like stent-retrievers group) using propensity score analysis. Patients treated in a comprehensive stroke center due to large vessel occlusion between January 2016 and August 2021 were evaluated. Baseline characteristics and treatment results were compared between these groups before and after pair matching. Results There were 140 patients (60 in Tigertriever and 80 in the stent-like stent-retriever group). In propensity score analysis, 52 matched pairs were selected in Tigertriever and stent-like stent-retriever groups. The Tigertriever group had a better successful first pass revascularization rate [46 vs. 23%, OR (95% CI): 1.7 (1.1-2.9), p = 0.013] and 14-min shorter groin-to-revascularization time (51 vs. 65 min. p = 0.017). There were no significant differences between Tigertriever and stent-like stent-retriever groups in the following: favorable mRS 3 months, favorable recanalization rate, and symptomatic intracerebral hemorrhages. There were no observed periprocedural adverse events related to Tigertriever, SolitaireX, or pRESET. Conclusion Tigertriever had a significantly better successful first pass revascularization rate and shorter groin-to-revascularization time in the analysis done before and after propensity score matching with stent-like stent-retrievers. Tigertriever is comparable to stent-like stent-retrievers regarding mortality at 3 months, favorable mRS at 3 months, favorable recanalization rate, or symptomatic cerebral hemorrhagic events.
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Affiliation(s)
- Piotr Piasecki
- Interventional Radiology Department, Military Institute of Medicine, Warsaw, Poland,*Correspondence: Piotr Piasecki ✉
| | - Marek Wierzbicki
- Interventional Radiology Department, Military Institute of Medicine, Warsaw, Poland
| | - Jerzy Narloch
- Interventional Radiology Department, Military Institute of Medicine, Warsaw, Poland
| | | | - Jacek Staszewski
- Clinic of Neurology, Military Institute of Medicine, Warsaw, Poland
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32
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Zhao Y, Liu Y, Zhang Q, Liu H, Xu J. The Mechanism Underlying the Regulation of Long Non-coding RNA MEG3 in Cerebral Ischemic Stroke. Cell Mol Neurobiol 2023; 43:69-78. [PMID: 34988760 DOI: 10.1007/s10571-021-01176-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 11/27/2021] [Indexed: 01/07/2023]
Abstract
Cerebral ischemic stroke is one of the leading causes of morbidity and mortality worldwide, and rapidly increasing annually with no more effective therapeutic measures. Thus, the novel diagnostic and prognostic biomarkers are urgent to be identified for prevention and therapy of ischemic stroke. Recently, long noncoding RNAs (lncRNAs), a major family of noncoding RNAs with more than 200 nucleotides, have been considered as new targets for modulating pathological process of ischemic stroke. In this review, we summarized that the lncRNA-maternally expressed gene 3 (MEG3) played a critical role in promotion of neuronal cell death and inhibition of angiogenesis in response to hypoxia or ischemia condition, and further described the challenge of overcrossing blood-brain barrier (BBB) and determination of optimal carrier for delivering lncRNA' drugs into the specific brain regions. In brief, MEG3 will be a potential diagnostic biomarker and drug target in treatment and therapy of ischemic stroke in the future.
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Affiliation(s)
- Yanfang Zhao
- Institute of Biomedical Research, Shandong Provincial Research Center for Bioinformatic Engineering and Technique, Zibo Key Laboratory of New Drug Development of Neurodegenerative Diseases, School of Life Sciences and Medicine, Shandong University of Technology, Zibo, China.
| | - Yingying Liu
- Institute of Translational Medicine, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Qili Zhang
- Institute of Biomedical Research, Shandong Provincial Research Center for Bioinformatic Engineering and Technique, Zibo Key Laboratory of New Drug Development of Neurodegenerative Diseases, School of Life Sciences and Medicine, Shandong University of Technology, Zibo, China
| | - Hongliang Liu
- Institute of Biomedical Research, Shandong Provincial Research Center for Bioinformatic Engineering and Technique, Zibo Key Laboratory of New Drug Development of Neurodegenerative Diseases, School of Life Sciences and Medicine, Shandong University of Technology, Zibo, China
| | - Jianing Xu
- Institute of Biomedical Research, Shandong Provincial Research Center for Bioinformatic Engineering and Technique, Zibo Key Laboratory of New Drug Development of Neurodegenerative Diseases, School of Life Sciences and Medicine, Shandong University of Technology, Zibo, China
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Optimizing intraluminal monofilament model of ischemic stroke in middle-aged Sprague-Dawley rats. BMC Neurosci 2022; 23:75. [PMID: 36494808 PMCID: PMC9733327 DOI: 10.1186/s12868-022-00764-2] [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: 09/29/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Intraluminal monofilament model of middle cerebral artery occlusion (MCAO) is widely adopted for ischemic stroke; and Sprague-Dawley (SD) rats are commonly used rodents for preclinical research. Due to the paucity of information on the appropriate monofilament size for inducing MCAO in SD rats and the importance of including middle-aged models in ischemic stroke studies, we aimed to: (i). determine an appropriate Doccol® monofilament size for middle-aged male SD rats which weighed > 500 g following 24-h transient MCAO survival as well as (ii). demonstrate the optimal Doccol® filament size for middle-aged males (≤ 500 g) and females (273-300 g) while using young adult male SD rats (372-472 g) as control for severity of infarct volume following 7-days post-MCAO. All rats were subjected to 90-min transient MCAO. We show that 0.43 mm Doccol® monofilament size is more appropriate to induce large infarct lesion and optimal functional deficit when compared to 0.45 mm and 0.47 mm at 24 h post-MCAO. Our data on infarct volumes at 7 days post-MCAO as well as the observed weight loss and functional deficits at post-MCAO days 1, 3 and 7 demonstrate that 0.41 mm, 0.37 mm and 0.39 mm are optimal Doccol® filament sizes for middle-aged male (477.3 ± 39.61 g) and female (302.6 ± 26.28 g) as well as young-adult male (362.2 ± 28.38 g) SD rats, respectively.
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Dabhi N, Mastorakos P, Sokolowski J, Kellogg RT, Park MS. Mechanical Thrombectomy for the Treatment of Anterior Cerebral Artery Occlusion: A Systematic Review of the Literature. AJNR Am J Neuroradiol 2022; 43:1730-1735. [PMID: 36328405 DOI: 10.3174/ajnr.a7690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The overall safety and efficacy of mechanical thrombectomy for anterior cerebral artery strokes remain unclear. PURPOSE Our aim was to summarize procedural and clinical outcomes in patients who underwent mechanical thrombectomy for treatment of anterior cerebral artery ischemic stroke. DATA SOURCES A systematic literature review was performed using PubMed, Ovid MEDLINE, and the Web of Science from inception until March 4, 2022. STUDY SELECTION We identified 9 studies with a total of 168 patients with mechanical thrombectomy-treated anterior cerebral artery occlusions. DATA ANALYSIS Recanalization, procedural data, and clinical outcome at last follow-up were collected and summarized. Categoric variables were reported as proportions. The χ2 test of independence or the Kruskal-Wallis test was performed to assess the relationship between selected variables and the anterior cerebral artery embolus type (ie, primary isolated anterior cerebral artery, primary combined anterior cerebral artery, and secondary anterior cerebral artery occlusion) or the mechanical thrombectomy technique. DATA SYNTHESIS For mechanical thrombectomy-treated anterior cerebral artery occlusions, recanalization modified TICI 2b/3 was achieved in 80%, postprocedural complications occurred in 17% of patients, and the 90-day mortality rate was 19%. The rate of symptomatic intracranial hemorrhage varied depending on the anterior cerebral artery embolus type (χ2 = 8.45, P = .01). LIMITATIONS This analysis did not consider factors such as small-study effects that affect reliability and limit interpretation. CONCLUSIONS Mechanical thrombectomy for the treatment of anterior cerebral artery occlusions is safe and efficacious, offering a favorable rate of recanalization and procedural complications. Mechanical thrombectomy-treated anterior cerebral artery occlusions appear to have lower rates of short-term good functional outcomes and an increased risk of symptomatic intracerebral hemorrhage compared with mechanical thrombectomy-treated MCA/ICA occlusions. Single and multicenter studies are needed to further examine the safety and efficacy of mechanical thrombectomy-treated anterior cerebral artery occlusions.
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Affiliation(s)
- N Dabhi
- From the Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - P Mastorakos
- From the Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - J Sokolowski
- From the Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - R T Kellogg
- From the Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - M S Park
- From the Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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Memon T, Shekha TAM, Acharya P, Nishu RI, Akhter N. A Case Report of Takayasu’s Arteritis With Cerebral Infarction As Initial Presentation. Cureus 2022; 14:e30472. [PMID: 36415359 PMCID: PMC9673871 DOI: 10.7759/cureus.30472] [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] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
Takayasu’s arteritis is a chronic inflammation of the large arteries such as the aorta and its primary branches, causing progressive arterial occlusion. This leads to reduced blood flow in the limbs and organs, resulting in arm or leg claudication, diminished or absent peripheral pulses, and end-organ ischemia. Stroke is one of the common complications; however, it is rarely the initial presentation. We describe one such case of a 16-year-old female, who presented with right-sided hemiparesis and non-fluent aphasia, without any significant past history. On examination, her right arm was cold and pulseless. She was extensively investigated for the cause of her presentation. Only non-specific inflammatory markers such as erythrocyte sedimentation rate (ESR) were elevated. Imaging studies revealed left middle cerebral artery territory infarct with occlusion of common carotid arteries, bilateral bifurcation, most parts of the left internal carotid artery, and the proximal part of the right internal carotid artery. She was diagnosed with Takayasu's arteritis and was prescribed steroids, on which she gradually recovered and was discharged. In conclusion, young patients, who present with stroke, should be investigated for Takayasu’s arteritis, which leads to earlier treatment and prevention of further life-threatening end-organ damage.
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Rana A, Yu S, Reid-Herrera S, Kamen S, Hunter K, Shaikh H, Jovin T, Thon OR, Patel P, Siegler JE, Thon JM. Eptifibatide use in ischemic stroke patients undergoing endovascular thrombectomy: A matched cohort analysis. Front Neurol 2022; 13:939215. [PMID: 36237613 PMCID: PMC9551346 DOI: 10.3389/fneur.2022.939215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionSmall studies have suggested that eptifibatide (EPT) may be safe in acute ischemic stroke (AIS) following intravenous thrombolysis or during endovascular therapy (EVT) for large vessel occlusion (LVO). However, studies are called upon to better delineate the safety of EPT use during EVT.MethodsA comprehensive stroke center registry (09/2015-12/2020) of consecutive adults who had undergone EVT for anterior LVO was queried. Patients treated with EPT were matched with 2 control groups based on known factors associated with intracranial hemorrhage (ICH) risk - age, Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and number of thrombectomy passes. Safety outcomes (intracranial hemorrhage [ICH], parenchymal hematoma [PH-2] grade hemorrhagic transformation, symptomatic ICH [sICH]) and efficacy outcomes (TICI 2B/3 recanalization, 24-h National Institutes of Health Stroke Scale [NIHSS] score), were compared between matched groups using descriptive statistics. In addition, multivariable logistic regression was used to assess for an association between EPT and PH-1/PH-2 grade hemorrhages.ResultsA total of 162 patients were included, 54 of whom (33%) received EPT. The rate of ICH was similar between groups (p = 0.62), while PH-2 was significantly more frequent with EPT (16.7% EPT vs. 3.7 vs. 1.9%; p = 0.009), but without significant differences in sICH (5.6% EPT vs. 7.4 vs. 3.7%; p = 0.72). Rates of TICI Score ≥ 2B were nominally higher with EPT use (83.3 vs. 77.8 vs. 77.8%, p = 0.70). Between the EPT and control groups, there were no differences in 24-h NIHSS (p = 0.09) or 90-day mortality (p = 0.58). Our adjusted multivariate analysis identified that the number of passes (p < 0.01), EPT use (p < 0.01), and tandem occlusion (p = 0.03) were independent predictors of PH1/PH2 grade hemorrhage. Additionally, every unit increase in number of passes resulted in a 1.5 times greater odds of a high-grade hemorrhagic transformation in EPT-treated patients (adjusted OR = 1.594).ConclusionIn this single-center analysis, EPT use during EVT was associated with a significantly higher rate of PH1/PH2 grade hemorrhages, but not with differences in sICH, 24-h NIHSS, or 90-day mortality. Randomized prospective trials are needed to determine the safety and efficacy of EPT in this population.
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Affiliation(s)
- Ameena Rana
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Siyuan Yu
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | | | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Krystal Hunter
- Cooper Research Institute, Cooper University Hospital, Camden, NJ, United States
| | - Hamza Shaikh
- Department of Radiology, Cooper University Hospital, Camden, NJ, United States
| | - Tudor Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Olga R. Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Parth Patel
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Jesse M. Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
- *Correspondence: Jesse M. Thon
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Hazelwood HS, Frank JA, Maglinger B, McLouth CJ, Trout AL, Turchan-Cholewo J, Stowe AM, Pahwa S, Dornbos DL, Fraser JF, Pennypacker KR. Plasma protein alterations during human large vessel stroke: A controlled comparison study. Neurochem Int 2022; 160:105421. [PMID: 36179808 DOI: 10.1016/j.neuint.2022.105421] [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: 08/10/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke is a major cause of death and disability in the United States. Mechanical thrombectomy (MT) 1 and tissue plasminogen activator are the current treatments for ischemic stroke, which have improved clinical outcomes. Despite these treatments, functional and cognitive deficits still occur demonstrating a need for predictive biomarkers for beneficial clinical outcomes which can be used as therapeutic targets for pharmacotherapy. The aim of this study compares the proteomic expression of systemic arterial blood collected at the time of MT to those from a matched cerebrovascular disease (CVD) control cohort. METHODS The Blood and Clot Thrombectomy Registry and Collaboration (BACTRAC) (clinicaltrials.gov NCT03153683) collects and banks arterial blood, both distal and proximal to the thrombus, from ischemic stroke subjects undergoing MT. Arterial blood from patients undergoing a diagnostic angiogram was also collected and banked as CVD controls. Changes in cardiometabolic and inflammatory proteins between stroke and CVD controls were analyzed via Olink Proteomics. RESULTS Proteins including ARTN, TWEAK, HGF, CCL28, FGF-5, CXCL9, TRANCE and GDNF were found to be decreased in stroke subjects when compared to CVD controls. CXCL1, CCL5, OSM, GP1BA, IL6, MMP-1, and CXCL5 were increased in stroke subjects when compared to CVD controls. These proteins were also significantly correlated to stroke outcome metrics such as NIHSS, infarct volume and MoCA scoring. CONCLUSION Overall, acute stroke patients had an increase in inflammatory proteins with a decrease in trophic proteins systemically compared to matched CVD controls. Using our CVD controls, proteins of interest were directly compared to stroke patients with the same cerebrovascular risk factors instead of statistically controlling for comorbidities. The novel methodology of matching an arterial blood CVD control group to a stroke group, as well as controlling for age and comorbid status add to the literature on prognostic stroke biomarkers, which are specific targets for future therapeutics.
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Affiliation(s)
- Hunter S Hazelwood
- University of Kentucky College of Medicine, 800 Rose Street, MN 150, Lexington, KY, 40536, USA
| | - Jacqueline A Frank
- University of Kentucky Department of Neurology, 740 S. Limestone Street, Kentucky Clinic J-455, Lexington, KY, 40536, USA; University of Kentucky Center for Advanced Translational Stroke Science, 741 S. Limestone Street, BBSRB B463, Lexington, KY, 40536, USA
| | - Benton Maglinger
- Department of Neurology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Christopher J McLouth
- University of Kentucky Department of Biostatistics, 725 Rose Street, 205 Multidisciplinary Science Building, Lexington, KY, 40536, USA; University of Kentucky Department of Neurology, 740 S. Limestone Street, Kentucky Clinic J-455, Lexington, KY, 40536, USA
| | - Amanda L Trout
- University of Kentucky Department of Neurosurgery, 780 Rose Street, Lexington, KY, 40536, USA; University of Kentucky Center for Advanced Translational Stroke Science, 741 S. Limestone Street, BBSRB B463, Lexington, KY, 40536, USA
| | - Jadwiga Turchan-Cholewo
- University of Kentucky Department of Neurology, 740 S. Limestone Street, Kentucky Clinic J-455, Lexington, KY, 40536, USA; University of Kentucky Center for Advanced Translational Stroke Science, 741 S. Limestone Street, BBSRB B463, Lexington, KY, 40536, USA
| | - Ann M Stowe
- University of Kentucky Department of Neurology, 740 S. Limestone Street, Kentucky Clinic J-455, Lexington, KY, 40536, USA; University of Kentucky Department of Neuroscience, 741 S. Limestone Street, BBSRB 4th Floor, Lexington, KY, 40536, USA; University of Kentucky Center for Advanced Translational Stroke Science, 741 S. Limestone Street, BBSRB B463, Lexington, KY, 40536, USA
| | - Shivani Pahwa
- University of Kentucky Department of Neurosurgery, 780 Rose Street, Lexington, KY, 40536, USA; University of Kentucky Department of Radiology, 800 Rose Street, Lexington, KY, 40536, USA; University of Kentucky Department of Neurology, 740 S. Limestone Street, Kentucky Clinic J-455, Lexington, KY, 40536, USA
| | - David L Dornbos
- University of Kentucky Department of Neurosurgery, 780 Rose Street, Lexington, KY, 40536, USA; University of Kentucky Department of Radiology, 800 Rose Street, Lexington, KY, 40536, USA
| | - Justin F Fraser
- University of Kentucky Department of Neurology, 740 S. Limestone Street, Kentucky Clinic J-455, Lexington, KY, 40536, USA; University of Kentucky Department of Neurosurgery, 780 Rose Street, Lexington, KY, 40536, USA; University of Kentucky Department of Radiology, 800 Rose Street, Lexington, KY, 40536, USA; University of Kentucky Department of Neuroscience, 741 S. Limestone Street, BBSRB 4th Floor, Lexington, KY, 40536, USA; University of Kentucky Center for Advanced Translational Stroke Science, 741 S. Limestone Street, BBSRB B463, Lexington, KY, 40536, USA
| | - Keith R Pennypacker
- University of Kentucky Department of Neurology, 740 S. Limestone Street, Kentucky Clinic J-455, Lexington, KY, 40536, USA; University of Kentucky Department of Neuroscience, 741 S. Limestone Street, BBSRB 4th Floor, Lexington, KY, 40536, USA; University of Kentucky Center for Advanced Translational Stroke Science, 741 S. Limestone Street, BBSRB B463, Lexington, KY, 40536, USA.
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Tan Z, Parsons M, Bivard A, Sharma G, Mitchell P, Dowling R, Bush S, Churilov L, Xu A, Yan B. Comparison of Computed Tomography Perfusion and Multiphase Computed Tomography Angiogram in Predicting Clinical Outcomes in Endovascular Thrombectomy. Stroke 2022; 53:2926-2934. [PMID: 35748291 DOI: 10.1161/strokeaha.122.038576] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND In patients with acute stroke who undergo endovascular thrombectomy, the relative prognostic power of computed tomography perfusion (CTP) parameters compared with multiphase CT angiogram (mCTA) is unknown. We aimed to compare the predictive accuracy of mCTA and CTP parameters on clinical outcomes. METHODS We included patients with acute ischemic stroke who had anterior circulation large vessel occlusion within 24 hours of onset in Melbourne Brain Centre at the Royal Melbourne Hospital. All patients underwent CTP for endovascular thrombectomy, and the mCTA collateral score was determined using CTP-reconstructed mCTA images. The primary outcome was 90-day functional outcomes defined by modified Rankin Scale. Multivariable logistic regression models analyzed associations between mCTA and CTP parameters and 90-day functional outcomes. The ability to discriminate 90 days-functional outcomes was compared between mCTA collateral score and CTP parameters using receiver operating curve analysis and C statistics. RESULTS One hundred and twenty patients were included. The median age was 69 years (interquartile range, 60-79), the median baseline National Institutes of Health Stroke Scale score was 14 (interquartile range, 9-19). The baseline ischemic core volume, defined by CTP-based relative cerebral blood flow <30%, was associated with excellent functional outcome (modified Rankin Scale score 0-1; odds ratio, 0.942 [-0.897 to -0.989]; P=0.015) and poor functional outcome (modified Rankin Scale score 5-6; odds ratio, 1.032 [1.007-1.056]; P=0.010) at 90 days in the analysis of multivariable regression. There was no significant association between the mCTA score and excellent functional outcome (P=0.58) or poor functional outcome (P=0.155). The relative cerebral blood flow <30%-based regression model best fit the data for the 90-day poor functional outcome (C statistic, 0.834). CONCLUSIONS The CTP-based ischemic core volume may provide better discrimination for 90-day functional outcomes for patients with acute stroke undergoing endovascular thrombectomy than the mCTA collateral score.
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Affiliation(s)
- Zefeng Tan
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China (Z.T., A.X.).,Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.).,Department of Neurology, the First People's Hospital of Foshan, China (Z.T.)
| | - Mark Parsons
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.).,Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Andrew Bivard
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.)
| | - Gagan Sharma
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.)
| | - Peter Mitchell
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Richard Dowling
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Steven Bush
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Leonid Churilov
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.)
| | - Anding Xu
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China (Z.T., A.X.)
| | - Bernard Yan
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.).,Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
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Blood Biomarkers for Triaging Patients for Suspected Stroke: Every Minute Counts. J Clin Med 2022; 11:jcm11144243. [PMID: 35888011 PMCID: PMC9323101 DOI: 10.3390/jcm11144243] [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: 04/28/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 02/04/2023] Open
Abstract
Early stroke diagnosis remains a big challenge in healthcare partly due to the lack of reliable diagnostic blood biomarkers, which in turn leads to increased rates of mortality and disability. Current screening methods are optimised to identify patients with a high risk of cardio-vascular disease, especially among the elderly. However, in young adults and children, these methods suffer low sensitivity and specificity and contribute to further delays in their triage and diagnosis. Accordingly, there is an urgent need to develop reliable blood biomarkers for triaging patients suspected of stroke in all age groups, especially children and young adults. This review explores some of the existing blood biomarkers, as single biomarkers or biomarker panels, and examines their sensitivity and specificity for predicting stroke. A review was performed on PubMed and Web of Science for journal articles published in English during the period 2001 to 2021, which contained information regarding biomarkers of stroke. In this review article, we provide comparative information on the availability, clinical usefulness, and time-window periods of seven single blood biomarkers and five biomarker panels that have been used for predicting stroke in emergency situations. The outcomes of this review can be used in future research for developing more effective stroke biomarkers.
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Staszewski J, Stȩpień A, Piusińska-Macoch R, Dȩbiec A, Gniadek-Olejniczak K, Frankowska E, Maliborski A, Chadaide Z, Balo D, Król B, Namias R, Harston G, Mróz J, Piasecki P. Efficacy of Cerebrolysin Treatment as an Add-On Therapy to Mechanical Thrombectomy in Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion: Study Protocol for a Prospective, Open Label, Single-Center Study With 12 Months of Follow-Up. Front Neurol 2022; 13:910697. [PMID: 35860483 PMCID: PMC9289167 DOI: 10.3389/fneur.2022.910697] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/30/2022] [Indexed: 12/18/2022] Open
Abstract
This study is designed to determine the efficacy of Cerebrolysin treatment as an add-on therapy to mechanical thrombectomy (MT) in reducing global disability in subjects with acute ischemic stroke (AIS). We have planned a single center, prospective, open-label, single-arm study with a 12-month follow-up of 50 patients with moderate to severe AIS, with a small established infarct core and with good collateral circulation who achieve significant reperfusion following MT and who receive additional Cerebrolysin within 8 h of stroke onset compared to 50 historical controls treated with MT alone, matched for age, clinical severity, occlusion location, baseline perfusion lesion volume, onset to reperfusion time, and use of iv thrombolytic therapy. The primary outcome measure will be the overall proportion of subjects receiving Cerebrolysin compared to the control group experiencing a favorable functional outcome (by modified Rankin Scale 0-2) at 90 days, following stroke onset. The secondary objectives are to determine the efficacy of Cerebrolysin as compared to the control group in reducing the risk of symptomatic secondary hemorrhagic transformation, improving neurological outcomes (NIHSS 0-2 at day 7, day 30, and 90), reducing mortality rates (over the 90-day and 12 months study period), and improving: activities of daily living (by Barthel Index), health-related quality of life (EQ-5D-5L) assessed at day 30, 90, and at 12 months. The other measures of efficacy in the Cerebrolysin group will include: assessment of final stroke volume and penumbral salvage (measured by CT/CTP at 30 days) and its change compared to baseline volume, changes over time in language function (by the 15-item Boston Naming Test), hemispatial neglect (by line bisection test), global cognitive function (by The Montreal Cognitive Assessment), and depression (by Hamilton Depression Rating Scale) between day 30 and day 90 assessments). The patients will receive 30 ml of Cerebrolysin within 8 h of AIS stroke onset and continue treatment once daily until day 21 (first cycle) and they will receive a second cycle of treatment (30 ml/d for 21 days given in the Outpatient Department or Neurorehabilitation Clinic) from day 69 to 90.
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Affiliation(s)
- Jacek Staszewski
- Clinic of Neurology, Military Institute of Medicine, Warsaw, Poland
| | - Adam Stȩpień
- Clinic of Neurology, Military Institute of Medicine, Warsaw, Poland
| | | | | | | | - Emilia Frankowska
- Department of Radiology, Military Institute of Medicine, Warsaw, Poland
| | - Artur Maliborski
- Department of Radiology, Military Institute of Medicine, Warsaw, Poland
| | - Zoltan Chadaide
- Brainomix Ltd., and Oxford University Hospitals NHSFT, Oxford, United Kingdom
| | - David Balo
- Brainomix Ltd., and Oxford University Hospitals NHSFT, Oxford, United Kingdom
| | - Beata Król
- Brainomix Ltd., and Oxford University Hospitals NHSFT, Oxford, United Kingdom
| | - Rafael Namias
- Brainomix Ltd., and Oxford University Hospitals NHSFT, Oxford, United Kingdom
| | - George Harston
- Brainomix Ltd., and Oxford University Hospitals NHSFT, Oxford, United Kingdom
| | - Józef Mróz
- Neurorehabilitation Clinic, Military Institute of Medicine, Warsaw, Poland
| | - Piotr Piasecki
- Department of Radiology, Military Institute of Medicine, Warsaw, Poland
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Safety and effectiveness of mechanical thrombectomy for acute ischemic stroke using single plane angiography. J Stroke Cerebrovasc Dis 2022; 31:106553. [PMID: 35689934 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106553] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/02/2022] [Accepted: 05/08/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Nearly all data on mechanical thrombectomy for acute ischemic stroke is based on procedures performed on biplane angiography systems. However, thrombectomy may be performed on single-plane systems in situations of triage or limited resources. We present the first US study comparing the safety and effectiveness of mechanical thrombectomy performed on single-plane vs. biplane systems. METHODS AND METHODS A retrospective review of a prospectively maintained database identified all patients treated with thrombectomy between July 2020 and July 2021 by a high-volume practice. Patients were dichotomized into those treated on single plane and biplane systems. Demographic, procedural, clinical and follow-up characteristics were compared. RESULTS Of the 246 patients treated with mechanical thrombectomy, 70 (33%) and 141 (66%) patients were treated on SP and BP systems, respectively. No significant differences were detected in follow-up 'good functional outcome' (mRS ≤ 2; SP 51% vs BP 43%, p = 0.14), successful recanalization (SP 87% vs BP 88%, p = 0.72), intra-procedural vascular injury (SP 3% vs BP 2%, p = 0.96), or time from groin puncture to reperfusion (SP 24 min vs BP 26 min, p = 0.58). Additionally, no significant differences were detected in peri-procedural complications, fluoroscopy times or total radiation. Patients treated on single plane systems required significantly more contrast. CONCLUSIONS Mechanical thrombectomy for acute ischemic stroke performed on single plane angiography systems is as safe and efficacious as when performed on biplane systems. Our results may have implications for increasing stroke care access, both domestically in underserved/rural areas and internationally when considering requirements for stroke care in lower-income countries.
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A high resolution scanning electron microscopy analysis of intracranial thrombi embedded along the stent retrievers. Sci Rep 2022; 12:8027. [PMID: 35577906 PMCID: PMC9110407 DOI: 10.1038/s41598-022-11830-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 04/27/2022] [Indexed: 12/16/2022] Open
Abstract
Endovascular treatment with stent retriever thrombectomy is a major advancement in the standard of care in acute ischemic stroke (AIS). The modalities through which thrombi embed along stent retriever following mechanical thrombectomy (MTB) have not yet been elucidated. Using scanning electron microscopy (SEM), we analyzed the appearance of thrombi retrieved by MTB from AIS patients, when embedded into the stent retriever. We observed that the organization and structural compactness vary for compositionally different thrombi. The modalities of attachment onto the stent vary according to thrombus composition and organization.
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Elder TA, Verhey LH, Schultz H, Smith ES, Adel JG. Cervical carotid occlusion in acute ischemic stroke: Should we give tPA? Surg Neurol Int 2022; 13:177. [PMID: 35509556 PMCID: PMC9063023 DOI: 10.25259/sni_176_2022] [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: 02/16/2022] [Accepted: 04/12/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Acute ischemic stroke (AIS) due to cervical internal carotid artery (cICA) occlusion is challenging to treat, with the lower revascularization rates, higher risk for complications, and poor response to thrombolytic therapy compared to isolated intracranial occlusions. While emergent revascularization through mechanical thrombectomy (MT) improves outcomes, the impact of tissue plasminogen activator (tPA) on outcomes in this subgroup of patients remains unclear. The objective of this study is to report our preliminary experience in treating AIS with cICA occlusions secondary to severe atherosclerotic stenosis and to establish the need for further clinical studies to determine the optimal intervention strategy for these lesions. Methods: Data were collected on patients who presented with acute cICA occlusion who underwent MT and either acute or staged carotid angioplasty and stenting. We compare patients who received tPA to those who did not, analyzing revascularization times, outcomes, and complications between the two populations, and discuss how this influenced our preferred treatment approach. Results: Twenty-one patients met inclusion criteria, seven of who received tPA and 14 did not receive tPA before surgical intervention. Procedural and functional outcomes were similar between the two populations. TPA administration correlated with a higher rate of vessel reocclusion in staged procedures and trended toward higher rates of symptomatic ICH and 90-day mortality. Conclusion: Emergent revascularization with acute cICA stenting carries advantages, but its safety is precluded by tPA administration. We suggest a trial which randomizes patients with cICA occlusions to receiving either tPA or dual antiplatelet therapy before surgical intervention, aiming to ultimately improved outcomes in these patients.
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Affiliation(s)
- Theresa A. Elder
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio,
| | - Leonard H. Verhey
- Department of Clinical Neurosciences, Spectrum Health, Michigan State University College of Human Medicine, Grand Rapids,
| | - Haritha Schultz
- Department of Internal Medicine, Central Michigan University College of Medicine,
| | - Eleanor S. Smith
- Department of Neurosurgery, Central Michigan University College of Medicine,
| | - Joseph G. Adel
- Department of Neuroscience, Ascension St Mary’s Hospital, Saginaw, Michigan, United States
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Abstract
The treatment of acute ischemic stroke continues to advance. The mainstay of treatment remains intravenous thrombolysis with alteplase. Recent studies demonstrated that later treatment with alteplase is beneficial in patients selected with advanced imaging techniques. Tenecteplase has been evaluated as an alternative thrombolytic drug and evidence suggests that it is as least as effective as alteplase and may lyse large vessel clots more effectively. Endovascular therapy with mechanical thrombectomy has now been shown to be beneficial up to 24 hours after stroke onset in carefully selected patients with proximal, large vessel occlusions. Ongoing studies are evaluating the effectiveness of thrombectomy in patients with more distal vessel occlusions and patients with proximal large vessel occlusions with larger ischemic core volumes and also in patients with milder neurological deficits. Cytoprotection is another potential acute stroke therapy that has not demonstrated efficacy in prior clinical trials. It should be reconsidered as an adjunct to reperfusion and a variety of new clinical trials can be envisioned to evaluate the potential benefits of cytoprotection in patients before and after reperfusion.
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Affiliation(s)
- Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.X.).,Chinese Institute of Brain Research (Y.X.)
| | - Ajay K Wakhloo
- Department of Neurointerventional Radiology Beth Israel Lahey Health Medical Center, Tufts University School of Medicine, Burlington' MA (A.K.W.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School' Boston' MA (M.F.)
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Tan BYQ, Ho JSY, Leow AS, Chia MLJ, Sia CH, Koh YY, Seetharaman SK, Yang C, Gopinathan A, Teoh HL, Sharma VK, Seet RCS, Chan BPL, Yeo LLL, Tan LF. Effect of frailty on outcomes of endovascular treatment for acute ischaemic stroke in older patients. Age Ageing 2022; 51:6575882. [PMID: 35486669 DOI: 10.1093/ageing/afac096] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND frailty has been shown to be a better predictor of clinical outcomes than age alone across many diseases. Few studies have examined the relationship between frailty, stroke and stroke interventions such as endovascular thrombectomy (EVT). OBJECTIVE we aimed to investigate the impact of frailty measured by clinical frailty scale (CFS) on clinical outcomes after EVT for acute ischemic stroke (AIS) in older patients ≥70 years. METHODS in this retrospective cohort study, we included all consecutive AIS patients age ≥ 70 years receiving EVT at a single comprehensive stroke centre. Patients with CFS of 1-3 were defined as not frail, and CFS > 3 was defined as frail. The primary outcome was modified Rankin Score (mRS) at 90 days. The secondary outcomes included duration of hospitalisation, in-hospital mortality, carer requirement, successful reperfusion, symptomatic intracranial haemorrhage and haemorrhagic transformation. RESULTS a total of 198 patients were included. The mean age was 78.1 years and 52.0% were female. Frail patients were older, more likely to be female, had more co-morbidities. CFS was significantly associated with poor functional outcome after adjustment for age, NIHSS and time to intervention (adjusted odds ratio [aOR] 1.54, 95% confidence interval [CI] 1.04-2.28, P = 0.032). There was trend towards higher mortality rate in frail patients (frail: 18.3%; non-frail: 9.6%; P = 0.080). There were no significant differences in other secondary outcomes except increased carer requirement post discharge in frail patients (frail: 91.6%; non-frail: 72.8%; P = 0.002). CONCLUSIONS frailty was associated with poorer functional outcome at 90 days post-EVT in patients ≥ 70 years.
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Affiliation(s)
- Benjamin Y Q Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jamie S Y Ho
- Academic Foundation Programme, Royal Free London NHS Foundation Trust, London, UK
| | - Aloysius S Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Magdalene L J Chia
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Ching Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Ying Ying Koh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Cunli Yang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Anil Gopinathan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Raymond C S Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Li Feng Tan
- Healthy Ageing Programme, Department of Geriatric Medicine, Alexandra Hospital, Singapore, Singapore
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Fiehler J, Nawka MT, Meyer L. Persistent challenges in endovascular treatment decision-making for acute ischaemic stroke. Curr Opin Neurol 2022; 35:18-23. [PMID: 34812746 DOI: 10.1097/wco.0000000000001006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although endovascular treatment (EVT) is the gold standard for treating acute stroke patients with large vessel occlusion (LVO), multiple challenges in decision-making for specific conditions persist. Recent evidence on a selection of patient subgroups will be discussed in this narrative review. RECENT FINDINGS Two randomized controlled trials (RCTs) have been published in EVT of basilar artery occlusion (BAO). Large single arm studies showed promising results in Patients with low Alberta stroke program early CT score (ASPECTS) and more distal vessel occlusions. Recent data confirm patients with low National Institutes of Health Stroke Scale (NIHSS) despite LVO to represent a heterogeneous and challenging patient group. SUMMARY The current evidence does not justify withholding EVT from BAO patients as none of the RCTs showed any signal of superiority of BMT alone vs. EVT. Patients with low ASPECTS, more distal vessel occlusions and patients with low NIHSS scores should be included into RCTs if possible. Without participation in a RCT, patients should be selected for EVT based on age, severity and type of neurological impairment, time since symptom onset, location of the ischaemic lesion and perhaps also results of advanced imaging.
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Affiliation(s)
- Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Nicholls JK, Ince J, Minhas JS, Chung EML. Emerging Detection Techniques for Large Vessel Occlusion Stroke: A Scoping Review. Front Neurol 2022; 12:780324. [PMID: 35095726 PMCID: PMC8796731 DOI: 10.3389/fneur.2021.780324] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/13/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Large vessel occlusion (LVO) is the obstruction of large, proximal cerebral arteries and can account for up to 46% of acute ischaemic stroke (AIS) when both the A2 and P2 segments are included (from the anterior and posterior cerebral arteries). It is of paramount importance that LVO is promptly recognised to provide timely and effective acute stroke management. This review aims to scope recent literature to identify new emerging detection techniques for LVO. As a good comparator throughout this review, the commonly used National Institutes of Health Stroke Scale (NIHSS), at a cut-off of ≥11, has been reported to have a sensitivity of 86% and a specificity of 60% for LVO. Methods: Four electronic databases (Medline via OVID, CINAHL, Scopus, and Web of Science), and grey literature using OpenGrey, were systematically searched for published literature investigating developments in detection methods for LVO, reported from 2015 to 2021. The protocol for the search was published with the Open Science Framework (10.17605/OSF.IO/A98KN). Two independent researchers screened the titles, abstracts, and full texts of the articles, assessing their eligibility for inclusion. Results: The search identified 5,082 articles, in which 2,265 articles were screened to assess their eligibility. Sixty-two studies remained following full-text screening. LVO detection techniques were categorised into 5 groups: stroke scales (n = 30), imaging and physiological methods (n = 15), algorithmic and machine learning approaches (n = 9), physical symptoms (n = 5), and biomarkers (n = 3). Conclusions: This scoping review has explored literature on novel and advancements in pre-existing detection methods for LVO. The results of this review highlight LVO detection techniques, such as stroke scales and biomarkers, with good sensitivity and specificity performance, whilst also showing advancements to support existing LVO confirmatory methods, such as neuroimaging.
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Affiliation(s)
- Jennifer K. Nicholls
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Medical Physics, University Hospitals of Leicester, NHS Trust, Leicester, United Kingdom
| | - Jonathan Ince
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Jatinder S. Minhas
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Emma M. L. Chung
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Medical Physics, University Hospitals of Leicester, NHS Trust, Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
- School of Life Course Sciences, King's College London, London, United Kingdom
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Abbas R, Herial NA, Naamani KE, Sweid A, Weinberg JH, Habashy KJ, Tjoumakaris S, Gooch MR, Rosenwasser RH, Jabbour P. Mechanical Thrombectomy in Patients Presenting with NIHSS Score <6: A Safety and Efficacy Analysis. J Stroke Cerebrovasc Dis 2022; 31:106282. [PMID: 34998043 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/24/2021] [Accepted: 12/19/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Groundbreaking trials have shown the tremendous efficacy of mechanical thrombectomy for large vessel occlusions. Currently, mechanical thrombectomy is limited to patients with NIHSS scores ≥6. We investigated the feasibility and safety of MT in patients presenting with NIHSS scores <6. MATERIALS AND METHODS A retrospective review of patient who presented with acute ischemic stroke due to large vessel occlusion with an NIHSS score <6 between 2015 - 2021. The patients were then divided into two groups: those who received mechanical thrombectomy and those who did not. RESULTS Among 83 patients, 41 received a mechanical thrombectomy while 42 received medical treatment only. The mean age in the mechanical thrombectomy group was 66 years versus 60 years in the medical group (p = 0.06). Risk factors for stroke did not differ significantly between both groups. 14 patients (34.1%) in the mechanical thrombectomy group and 20 (47.6%) in the medical group received tissue plasminogen activator. No significant difference in clinical improvement (NIHSS) at discharge (p=0.85) or the mRS score at 90 days (p = 0.15) was noted. Mechanical thrombectomy was associated with smaller infarct size (p=0.04) and decreased mortality (p=0.03). CONCLUSIONS Mechanical thrombectomy is safe and effective for patients who present with large vessel occlusions and low initial NIHSS scores. Therefore, the decision to offer the patient mechanical thrombectomy or not should not be decided by NIHSS score alone. Rather, the decision should be multifactorial with the aim of maximizing the patients' outcomes.
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Affiliation(s)
- Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Joshua H Weinberg
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210
| | | | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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Jahan R, Saver JL. Endovascular Treatment of Acute Ischemic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00067-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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50
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Nguyen L, Maingard J, Jhamb A, Brooks M, Barras C, Kok HK, Asadi H. Intracranial atherosclerotic disease and acute ischaemic stroke: A review of diagnosis and management. J Med Imaging Radiat Oncol 2021; 66:391-403. [PMID: 34894071 DOI: 10.1111/1754-9485.13366] [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: 04/14/2021] [Accepted: 11/23/2021] [Indexed: 11/29/2022]
Abstract
Intracranial atherosclerotic disease is highly prevalent and a common cause of ischaemic stroke globally. With the increasing use of endovascular treatment for acute stroke management, computed tomography and magnetic resonance imaging have become an essential part of patient selection. In this review, we present the typical imaging findings of intracranial atherosclerosis and an overview of management as relevant to diagnostic and interventional radiologists.
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Affiliation(s)
- Lauren Nguyen
- NeuroInterventional Radiology Unit, Monash Health, Melbourne, Victoria, Australia
| | - Julian Maingard
- NeuroInterventional Radiology Unit, Monash Health, Melbourne, Victoria, Australia.,Department of Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Ashu Jhamb
- Interventional Neuroradiology Service, Austin Health, Melbourne, Victoria, Australia
| | - Mark Brooks
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,Interventional Neuroradiology Service, Austin Health, Melbourne, Victoria, Australia
| | - Christen Barras
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,The University of Adelaide, Adelaide, South Australia, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia
| | - Hamed Asadi
- NeuroInterventional Radiology Unit, Monash Health, Melbourne, Victoria, Australia.,Department of Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia.,Interventional Neuroradiology Service, Austin Health, Melbourne, Victoria, Australia
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