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Vollmuth C, Fiessler C, Montellano FA, Kollikowski AM, Essig F, Oeckl P, Barba L, Steinacker P, Schulz C, Ungethüm K, Wolf J, Pham M, Schuhmann MK, Heuschmann PU, Haeusler KG, Stoll G, Otto M, Neugebauer H. Incremental value of serum neurofilament light chain and glial fibrillary acidic protein as blood-based biomarkers for predicting functional outcome in severe acute ischemic stroke. Eur Stroke J 2024; 9:751-762. [PMID: 38400734 DOI: 10.1177/23969873241234436] [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] [Indexed: 02/26/2024] Open
Abstract
INTRODUCTION Blood-based biomarkers may improve prediction of functional outcome in patients with acute ischemic stroke. The role of neurofilament light chain (NfL) and glial fibrillary acidic (GFAP) as potential biomarkers especially in severe stroke patients is unknown. PATIENTS AND METHODS Prospective, monocenter, cohort study including consecutive patients with severe ischemic stroke in the anterior circulation on admission (NIHSS score ⩾ 6 points or indication for mechanical thrombectomy). Outcome was assessed 3 months after the index stroke by the modified Rankin Scale (mRS). Serum biomarkers levels of NfL and GFAP were determined by ultrasensitive ELISA. Univariate and multivariate logistic regression models were performed to determine the association of biomarker levels and functional disability. Discrimination, calibration, and overall performance were analyzed in different models via AUROC, calibration plots (with Emax and Eavg), Brier-score and R2 using variables, identified as important covariates for functional outcome in previous studies. RESULTS Between 06/2020 and 08/2021, 213 patients were included [47% female, mean age 76 (SD ± 12) years, median NIHSS score 13 (interquartile range, IQR 9; 17)]. Biomarker serum levels were measured at a median of 1 [IQR, 1; 2] day after admission. Compared to patients with mRS 0-2 at 3 months, patients with mRS 3-6 had higher serum levels of NfL (median: 136 pg/ml vs 41 pg/ml; p < 0.0001) and GFAP (700 ng/ml vs 9.6 ng/ml; p < 0.0001). Both biomarkers were significantly associated with functional outcome [adjusted logistic regression, odds ratio (95% CI) for NfL: 2.63 (1.62; 4.56), GFAP: 2.16 (1.58; 3.09)]. In all models the addition of serum NfL led to a significant improvement in the AUROC, as did the addition of serum GFAP. Calibration plots showed high agreement between the predicted and observed outcomes and after addition of the two blood-based biomarkers there was an improvement of the overall performance. CONCLUSION Prediction of functional outcome after severe acute ischemic stroke was improved by the blood-based biomarkers serum NfL and GFAP, measured in the acute phase of stroke. These findings have to be replicated in independent external cohorts.Study registration: DRKS00022064.
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Affiliation(s)
- Christoph Vollmuth
- University Hospital Würzburg, Department of Neurology, Würzburg, Germany
| | - Cornelia Fiessler
- University of Würzburg, Institute for Clinical Epidemiology and Biometry, Würzburg, Germany
| | - Felipe A Montellano
- University Hospital Würzburg, Department of Neurology, Würzburg, Germany
- University of Würzburg, Institute for Clinical Epidemiology and Biometry, Würzburg, Germany
| | | | - Fabian Essig
- University Hospital Würzburg, Department of Neurology, Würzburg, Germany
| | - Patrick Oeckl
- University Hospital Ulm, Department of Neurology, Ulm, Germany
- German Center for Neurodegenerative Diseases e.V. (DZNE) Ulm, Ulm, Germany
| | - Lorenzo Barba
- Martin-Luther-University of Halle-Wittenberg, Department of Neurology, Halle (Saale), Germany
| | - Petra Steinacker
- Martin-Luther-University of Halle-Wittenberg, Department of Neurology, Halle (Saale), Germany
| | - Cara Schulz
- University Hospital Würzburg, Department of Neurology, Würzburg, Germany
| | - Kathrin Ungethüm
- University of Würzburg, Institute for Clinical Epidemiology and Biometry, Würzburg, Germany
| | - Judith Wolf
- University Hospital Würzburg, Department of Neurology, Würzburg, Germany
| | - Mirko Pham
- University Hospital Würzburg, Department of Neuroradiology, Würzburg, Germany
| | | | - Peter U Heuschmann
- University of Würzburg, Institute for Clinical Epidemiology and Biometry, Würzburg, Germany
- Institute for Medical Data Science, University Hospital Würzburg, Würzburg, Germany
- Clinical Trial Centre, University Hospital Würzburg, Würzburg, Germany
| | | | - Guido Stoll
- University Hospital Würzburg, Department of Neurology, Würzburg, Germany
| | - Markus Otto
- Martin-Luther-University of Halle-Wittenberg, Department of Neurology, Halle (Saale), Germany
| | - Hermann Neugebauer
- University Hospital Würzburg, Department of Neurology, Würzburg, Germany
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Nishiwaki T, Enomoto Y, Egashira Y, Matsubara H, Hori T, Sasaki N, Yoshida T, Nakayama N, Ohe N, Ogura S. Timeliness and accuracy of the 7-Item Japan Urgent Stroke Triage (JUST-7) score, a prehospital stroke triage tool, assessed by emergency medical services. PLoS One 2024; 19:e0309326. [PMID: 39172872 PMCID: PMC11340938 DOI: 10.1371/journal.pone.0309326] [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: 12/24/2023] [Accepted: 08/07/2024] [Indexed: 08/24/2024] Open
Abstract
The prompt initiation of stroke treatment significantly influences patient outcomes, highlighting the crucial role of prehospital triage. This study aimed to assess the implementation of the 7-Item Japan Urgent Stroke Triage (JUST-7) score by emergency medical services (EMS) in our region and its effect on emergency transportation for suspected stroke patients. Data were collected from patients suspected of having an acute stroke with a Cincinnati Prehospital Stroke Scale (CPSS) score of 1 or more who were transferred by ambulance within 24 h of symptom onset. Two prehospital stroke scales were employed during different periods: period 1 with CPSS alone (January to December 2020) and period 2 with both CPSS and JUST-7 (January 2021 to March 2023). On-scene time data were obtained from the EMS crews, and data regarding the final diagnosis of patients and their outcomes were obtained from the respective hospitals to which the patients were transferred. These data were compared between periods 1 and 2 and between the CPSS and JUST-7. The results revealed that additional evaluation with JUST-7 did not affect ambulance transport time. The CPSS+JUST-7 approach demonstrated higher specificity in identifying stroke and major artery occlusion than with the CPSS alone; however, an appropriate cut-off value needs to be considered. The JUST-7 achieved a diagnostic concordance rate of 35.9% for the most likely stroke type and 64.0% for the first two most likely types. This research emphasizes the potential of JUST-7 as a valuable addition to prehospital stroke diagnosis protocols. Its flexibility in adapting cut-off values based on regional factors and available medical resources optimizes its utility in diverse healthcare settings. The JUST-7 score is a promising tool for improving patient outcomes through prompt and accurate prehospital assessments.
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Affiliation(s)
- Takayuki Nishiwaki
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yusuke Egashira
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hirofumi Matsubara
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takamitsu Hori
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Nozomi Sasaki
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takahiro Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Noriyuki Nakayama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Naoyuki Ohe
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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Kollikowski AM, Pham M, März AG, Feick J, Vogt ML, Xiong Y, Strinitz M, Vollmuth C, Essig F, Neugebauer H, Haeusler KG, Hametner C, Zimmermann L, Stoll G, Schuhmann MK. MMP-9 release into collateral blood vessels before endovascular thrombectomy to assess the risk of major intracerebral haemorrhages and poor outcome for acute ischaemic stroke: a proof-of-concept study. EBioMedicine 2024; 103:105095. [PMID: 38579365 PMCID: PMC11002809 DOI: 10.1016/j.ebiom.2024.105095] [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: 07/12/2023] [Revised: 03/17/2024] [Accepted: 03/17/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Matrix metalloproteinases (MMPs) are implied in blood-brain barrier degradation and haemorrhagic transformation following ischaemic stroke, but their local relevance in the hyperacute disease phase is unknown. We aimed to examine ultra-early MMP-9 and MMP-2 release into collateral blood vessels, and to assess its prognostic value before therapeutic recanalisation by endovascular thrombectomy (EVT). METHODS We report a cross-sectional proof-of-concept study including patients undergoing EVT for large-vessel ischaemic stroke at the University Hospital Würzburg, Germany. We obtained liquid biopsies from the collateral circulation before recanalisation, and systemic control samples. Laboratory workup included quantification of MMP-9 and MMP-2 plasma concentrations by cytometric bead array, immunohistochemical analyses of cellular MMP-9 and MMP-2 expression, and detection of proteolytic activity by gelatine zymography. The clinical impact of MMP concentrations was assessed by stratification according to intracranial haemorrhagic lesions on postinterventional computed tomography (Heidelberg Bleeding Classification, HBC) and early functional outcome (modified Rankin Scale, mRS). We used multivariable logistic regression, receiver-operating-characteristic (ROC) curves, and fixed-level estimates of test accuracy measures to study the prognostic value of MMP-9 concentrations. FINDINGS Between August 3, 2018, and September 16, 2021, 264 matched samples from 132 patients (86 [65.2%] women, 46 [34.8%] men, aged 40-94 years) were obtained. Median (interquartile range, IQR) MMP-9 (279.7 [IQR 126.4-569.6] vs 441 [IQR 223.4-731.5] ng/ml, p < 0.0001) but not MMP-2 concentrations were increased within collateral blood vessels. The median MMP-9 expression level of invading neutrophils was elevated (fluorescence intensity, arbitrary unit: 2276 [IQR 1007-5086] vs 3078 [IQR 1108-7963], p = 0.0018). Gelatine zymography experiments indicated the locally confined proteolytic activity of MMP-9 but not of MMP-2. Pretherapeutic MMP-9 release into stroke-affected brain regions predicted the degree of intracerebral haemorrhages and clinical stroke severity after recanalisation, and independently increased the odds of space-occupying parenchymal haematomas (HBC1c-3a) by 1.54 times, and the odds of severe disability or death (mRS ≥5 at hospital discharge) by 2.33 times per 1000 ng/ml increase. Excessive concentrations of MMP-9 indicated impending parenchymal haematomas and severe disability or death with high specificity. INTERPRETATION Measurement of MMP-9 within collateral blood vessels is feasible and identifies patients with stroke at risk of major intracerebral haemorrhages and poor outcome before therapeutic recanalisation by EVT, thereby providing evidence of the concept validity of ultra-early local stroke biomarkers. FUNDING This work was funded by the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG) and the Interdisciplinary Centre for Clinical Research (IZKF) at the University of Würzburg.
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Affiliation(s)
| | - Mirko Pham
- Department of Neuroradiology, University Hospital Würzburg, Würzburg, Germany.
| | - Alexander G März
- Department of Neuroradiology, University Hospital Würzburg, Würzburg, Germany.
| | - Jörn Feick
- Department of Neuroradiology, University Hospital Würzburg, Würzburg, Germany; Department of Radiology, University Hospital Würzburg, Würzburg, Germany.
| | - Marius L Vogt
- Department of Neuroradiology, University Hospital Würzburg, Würzburg, Germany.
| | - Yanyan Xiong
- Department of Neuroradiology, University Hospital Würzburg, Würzburg, Germany.
| | - Marc Strinitz
- Department of Neuroradiology, University Hospital Würzburg, Würzburg, Germany; Department of Neuroradiology, Rechts der Isar Hospital, Technical University Munich, Munich, Germany.
| | - Christoph Vollmuth
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany.
| | - Fabian Essig
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany.
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany.
| | | | - Christian Hametner
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany.
| | - Lena Zimmermann
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany.
| | - Guido Stoll
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany; Institute of Experimental Biomedicine, University Hospital Würzburg, Würzburg, Germany.
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Lam TJR, Liu Z, Tan BYQ, Ng YY, Tan CK, Wong XY, Venketasubramanian N, Yeo LLL, Ho AFW, Ong MEH. Prehospital stroke care in Singapore. Singapore Med J 2024:00077293-990000000-00102. [PMID: 38449072 DOI: 10.4103/singaporemedj.smj-2023-066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/03/2023] [Indexed: 03/08/2024]
Abstract
ABSTRACT Due to the narrow window of opportunity for stroke therapeutics to be employed, effectiveness of stroke care systems is predicated on the efficiency of prehospital stroke systems. A robust prehospital stroke system of care that provides a rapid and well-coordinated response maximises favourable poststroke outcomes, but achieving this presents a unique set of challenges dependent on demographic and geographical circumstances. Set in the context of a highly urbanised first-world nation with a rising burden of stroke, Singapore's prehospital stroke system has evolved to reflect the environment in which it operates. This review aims to characterise the current state of prehospital stroke care in Singapore, covering prehospital aspects of the stroke survival chain from symptom onset till arrival at the emergency department. We identify areas for improvement and innovation, as well as provide insights into the possible future of prehospital stroke care in Singapore.
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Affiliation(s)
| | - Zhenghong Liu
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Yih Ying Ng
- Department of Preventive and Population Medicine, Tan Tock Seng Hospital, Singapore
- Ministry of Home Affairs, Singapore Civil Defence Force, Singapore
| | - Colin Kaihui Tan
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore
| | - Xiang Yi Wong
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore
| | | | | | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-Hospital and Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-Hospital and Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
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Feick J, Pham M, März AG, Vogt ML, Strinitz M, Stoll G, Schuhmann MK, Kollikowski AM. Distinct Alterations in Oxygenation, Ion Composition and Acid-Base Balance in Cerebral Collaterals During Large-Vessel Occlusion Stroke. Clin Neuroradiol 2023; 33:973-984. [PMID: 37284875 PMCID: PMC10654170 DOI: 10.1007/s00062-023-01296-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/24/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE Disturbances of blood gas and ion homeostasis including regional hypoxia and massive sodium (Na+)/potassium (K+) shifts are a hallmark of experimental cerebral ischemia but have not been sufficiently investigated for their relevance in stroke patients. METHODS We report a prospective observational study on 366 stroke patients who underwent endovascular thrombectomy (EVT) for large-vessel occlusion (LVO) of the anterior circulation (18 December 2018-31 August 2020). Intraprocedural blood gas samples (1 ml) from within cerebral collateral arteries (ischemic) and matched systemic control samples were obtained according to a prespecified protocol in 51 patients. RESULTS We observed a significant reduction in cerebral oxygen partial pressure (-4.29%, paO2ischemic = 185.3 mm Hg vs. paO2systemic = 193.6 mm Hg; p = 0.035) and K+ concentrations (-5.49%, K+ischemic = 3.44 mmol/L vs. K+systemic = 3.64 mmol/L; p = 0.0083). The cerebral Na+:K+ ratio was significantly increased and negatively correlated with baseline tissue integrity (r = -0.32, p = 0.031). Correspondingly, cerebral Na+ concentrations were most strongly correlated with infarct progression after recanalization (r = 0.42, p = 0.0033). We found more alkaline cerebral pH values (+0.14%, pHischemic = 7.38 vs. pHsystemic = 7.37; p = 0.0019), with a time-dependent shift towards more acidotic conditions (r = -0.36, p = 0.055). CONCLUSION These findings suggest that stroke-induced changes in oxygen supply, ion composition and acid-base balance occur and dynamically progress within penumbral areas during human cerebral ischemia and are related to acute tissue damage.
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Affiliation(s)
- Jörn Feick
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Mirko Pham
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Alexander G März
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Marius L Vogt
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Marc Strinitz
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Guido Stoll
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | | | - Alexander M Kollikowski
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
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Barba L, Vollmuth C, Abu-Rumeileh S, Halbgebauer S, Oeckl P, Steinacker P, Kollikowski AM, Schultz C, Wolf J, Pham M, Schuhmann MK, Heuschmann PU, Haeusler KG, Stoll G, Neugebauer H, Otto M. Serum β-synuclein, neurofilament light chain and glial fibrillary acidic protein as prognostic biomarkers in moderate-to-severe acute ischemic stroke. Sci Rep 2023; 13:20941. [PMID: 38017278 PMCID: PMC10684607 DOI: 10.1038/s41598-023-47765-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/17/2023] [Indexed: 11/30/2023] Open
Abstract
We aimed to assess the prognostic value of serum β-synuclein (β-syn), neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP) in patients with moderate-to-severe acute ischemic stroke. We measured β-syn, GFAP and NfL in serum samples collected one day after admission in 30 adult patients with moderate-to-severe ischemic stroke due to middle cerebral artery (MCA) occlusion. We tested the associations between biomarker levels and clinical and radiological scores (National Institute of Health Stroke Scale scores, NIHSS, and Alberta Stroke Program Early CT Score, ASPECTS), as well as measures of functional outcome (modified Rankin Scale, mRS). Serum biomarkers were significantly associated with ASPECTS values (β-syn p = 0.0011, GFAP p = 0.0002) but not with NIHSS scores at admission. Patients who received mechanical thrombectomy and intravenous thrombolysis showed lower β-syn (p = 0.029) und NfL concentrations (p = 0.0024) compared to patients who received only mechanical thrombectomy. According to median biomarker levels, patients with high β-syn, NfL or GFAP levels showed, after therapy, lower clinical improvement (i.e., lower 24-h NIHSS change), higher NIHSS scores during hospitalization and higher mRS scores at 3-month follow-up. Elevated serum concentrations of β-syn (p = 0.016), NfL (p = 0.020) or GFAP (p = 0.010) were significantly associated with 3-month mRS of 3-6 vs. 0-2 even after accounting for age, sex and renal function. In patients with moderate-to-severe acute ischemic stroke, serum β-syn, NfL and GFAP levels associated with clinical and radiological scores at different timepoints and were able to predict short- and middle-term clinical outcomes.
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Affiliation(s)
- Lorenzo Barba
- Department of Neurology, Martin-Luther-University of Halle-Wittenberg, Ernst-Grube Strasse 40, 06120, Halle (Saale), Germany
| | | | - Samir Abu-Rumeileh
- Department of Neurology, Martin-Luther-University of Halle-Wittenberg, Ernst-Grube Strasse 40, 06120, Halle (Saale), Germany
| | | | - Patrick Oeckl
- Department of Neurology, University of Ulm, Ulm, Germany
- German Center for Neurodegenerative Diseases (DZNE E.V.), Ulm, Germany
| | - Petra Steinacker
- Department of Neurology, Martin-Luther-University of Halle-Wittenberg, Ernst-Grube Strasse 40, 06120, Halle (Saale), Germany
| | | | - Cara Schultz
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Judith Wolf
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Mirko Pham
- Department of Neuroradiology, University of Würzburg, Würzburg, Germany
| | | | - Peter U Heuschmann
- Institute for Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | | | - Guido Stoll
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | | | - Markus Otto
- Department of Neurology, Martin-Luther-University of Halle-Wittenberg, Ernst-Grube Strasse 40, 06120, Halle (Saale), Germany.
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Ospel JM, Dmytriw AA, Regenhardt RW, Patel AB, Hirsch JA, Kurz M, Goyal M, Ganesh A. Recent developments in pre-hospital and in-hospital triage for endovascular stroke treatment. J Neurointerv Surg 2023; 15:1065-1071. [PMID: 36241225 DOI: 10.1136/jnis-2021-018547] [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: 03/09/2022] [Accepted: 10/05/2022] [Indexed: 11/04/2022]
Abstract
Triage describes the assignment of resources based on where they can be best used, are most needed, or are most likely to achieve success. Triage is of particular importance in time-critical conditions such as acute ischemic stroke. In this setting, one of the goals of triage is to minimize the delay to endovascular thrombectomy (EVT), without delaying intravenous thrombolysis or other time-critical treatments including patients who cannot benefit from EVT. EVT triage is highly context-specific, and depends on availability of financial resources, staff resources, local infrastructure, and geography. Furthermore, the EVT triage landscape is constantly changing, as EVT indications evolve and new neuroimaging methods, EVT technologies, and adjunctive medical treatments are developed and refined. This review provides an overview of recent developments in EVT triage at both the pre-hospital and in-hospital stages. We discuss pre-hospital large vessel occlusion detection tools, transport paradigms, in-hospital workflows, acute stroke neuroimaging protocols, and angiography suite workflows. The most important factor in EVT triage, however, is teamwork. Irrespective of any new technology, EVT triage will only reach optimal performance if all team members, including paramedics, nurses, technologists, emergency physicians, neurologists, radiologists, neurosurgeons, and anesthesiologists, are involved and engaged. Thus, building sustainable relationships through continuous efforts and hands-on training forms an integral part in ensuring rapid and efficient EVT triage.
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Affiliation(s)
- Johanna M Ospel
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
| | | | - Aman B Patel
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Martin Kurz
- Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Aravind Ganesh
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Fassbender K, Lesmeister M, Merzou F. Prehospital stroke management and mobile stroke units. Curr Opin Neurol 2023; 36:140-146. [PMID: 36794965 PMCID: PMC9994848 DOI: 10.1097/wco.0000000000001150] [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] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW Delayed presentation at the hospital contributes to poorer patient outcomes and undertreatment of acute stroke patients. This review will discuss recent developments in prehospital stroke management and mobile stroke units aimed to improve timely access to treatment within the past 2 years and will point towards future directions. RECENT FINDINGS Recent progress in research into prehospital stroke management and mobile stroke units ranges from interventions aimed at improving patients' help-seeking behaviour, to the education of emergency medical services team members, to the use of innovative referral methods, such as diagnostic scales, and finally to evidence of improved outcomes by the use of mobile stroke units. SUMMARY Understanding is increasing about the need for optimizing stroke management over the entire stroke rescue chain with the goal of improving access to highly effective time-sensitive treatment. In the future, we can expect that novel digital technologies and artificial intelligence will become relevant in effective interaction between prehospital and in-hospital stroke-treating teams, with beneficial effects on patients' outcomes.
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Affiliation(s)
- Klaus Fassbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
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Bui TA, Jickling GC, Winship IR. Neutrophil dynamics and inflammaging in acute ischemic stroke: A transcriptomic review. Front Aging Neurosci 2022; 14:1041333. [PMID: 36620775 PMCID: PMC9813499 DOI: 10.3389/fnagi.2022.1041333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Stroke is among the leading causes of death and disability worldwide. Restoring blood flow through recanalization is currently the only acute treatment for cerebral ischemia. Unfortunately, many patients that achieve a complete recanalization fail to regain functional independence. Recent studies indicate that activation of peripheral immune cells, particularly neutrophils, may contribute to microcirculatory failure and futile recanalization. Stroke primarily affects the elderly population, and mortality after endovascular therapies is associated with advanced age. Previous analyses of differential gene expression across injury status and age identify ischemic stroke as a complex age-related disease. It also suggests robust interactions between stroke injury, aging, and inflammation on a cellular and molecular level. Understanding such interactions is crucial in developing effective protective treatments. The global stroke burden will continue to increase with a rapidly aging human population. Unfortunately, the mechanisms of age-dependent vulnerability are poorly defined. In this review, we will discuss how neutrophil-specific gene expression patterns may contribute to poor treatment responses in stroke patients. We will also discuss age-related transcriptional changes that may contribute to poor clinical outcomes and greater susceptibility to cerebrovascular diseases.
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Affiliation(s)
- Truong An Bui
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Glen C. Jickling
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Department of Medicine, Division of Neurology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ian R. Winship
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
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Blockade of Platelet Glycoprotein Ibα Augments Neuroprotection in Orai2-Deficient Mice during Middle Cerebral Artery Occlusion. Int J Mol Sci 2022; 23:ijms23169496. [PMID: 36012752 PMCID: PMC9409377 DOI: 10.3390/ijms23169496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 11/21/2022] Open
Abstract
During ischemic stroke, infarct growth before recanalization diminishes functional outcome. Hence, adjunct treatment options to protect the ischemic penumbra before recanalization are eagerly awaited. In experimental stroke targeting two different pathways conferred protection from penumbral tissue loss: (1) enhancement of hypoxic tolerance of neurons by deletion of the calcium channel subunit Orai2 and (2) blocking of detrimental lymphocyte–platelet responses. However, until now, no preclinical stroke study has assessed the potential of combining neuroprotective with anti-thrombo-inflammatory interventions to augment therapeutic effects. We induced focal cerebral ischemia in Orai2-deficient (Orai2-/-) mice by middle cerebral artery occlusion (MCAO). Animals were treated with anti-glycoprotein Ib alpha (GPIbα) Fab fragments (p0p/B Fab) blocking GPIbα–von Willebrand factor (vWF) interactions. Rat immunoglobulin G (IgG) Fab was used as the control treatment. The extent of infarct growth before recanalization was assessed at 4 h after MCAO. Moreover, infarct volumes were determined 6 h after recanalization (occlusion time: 4 h). Orai2 deficiency significantly halted cerebral infarct progression under occlusion. Inhibition of platelet GPIbα further reduced primary infarct growth in Orai2-/- mice. During ischemia–reperfusion, upon recanalization, mice were likewise protected. All in all, we show that neuroprotection in Orai2-/- mice can be augmented by targeting thrombo-inflammation. This supports the clinical development of combined neuroprotective/anti-platelet strategies in hyper-acute stroke.
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Mack WJ. Getting ahead of stroke. J Neurointerv Surg 2022; 14:743-744. [PMID: 35835470 DOI: 10.1136/jnis-2022-019306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/04/2022]
Affiliation(s)
- William J Mack
- Department of Neurosurgery, Keck School of Medicine of USC Los Angeles, Los Angeles, CA 90033, USA
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Kollikowski AM, Pham M, März AG, Papp L, Nieswandt B, Stoll G, Schuhmann MK. Platelet Activation and Chemokine Release Are Related to Local Neutrophil-Dominant Inflammation During Hyperacute Human Stroke. Transl Stroke Res 2021; 13:364-369. [PMID: 34455571 PMCID: PMC9046342 DOI: 10.1007/s12975-021-00938-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/15/2021] [Accepted: 08/04/2021] [Indexed: 12/14/2022]
Abstract
Experimental evidence has emerged that local platelet activation contributes to inflammation and infarct formation in acute ischemic stroke (AIS) which awaits confirmation in human studies. We conducted a prospective observational study on 258 consecutive patients undergoing mechanical thrombectomy (MT) due to large-vessel-occlusion stroke of the anterior circulation (08/2018–05/2020). Intraprocedural microcatheter aspiration of 1 ml of local (occlusion condition) and systemic arterial blood samples (self-control) was performed according to a prespecified protocol. The samples were analyzed for differential leukocyte counts, platelet counts, and plasma levels of the platelet-derived neutrophil-activating chemokine C-X-C-motif ligand (CXCL) 4 (PF-4), the neutrophil attractant CXCL7 (NAP-2), and myeloperoxidase (MPO). The clinical-biological relevance of these variables was corroborated by specific associations with molecular-cellular, structural-radiological, hemodynamic, and clinical-functional parameters. Seventy consecutive patients fulfilling all predefined criteria entered analysis. Mean local CXCL4 (+ 39%: 571 vs 410 ng/ml, P = .0095) and CXCL7 (+ 9%: 693 vs 636 ng/ml, P = .013) concentrations were higher compared with self-controls. Local platelet counts were lower (− 10%: 347,582 vs 383,284/µl, P = .0052), whereas neutrophil counts were elevated (+ 10%: 6022 vs 5485/µl, P = 0.0027). Correlation analyses revealed associations between local platelet and neutrophil counts (r = 0.27, P = .034), and between CXCL7 and MPO (r = 0.24, P = .048). Local CXCL4 was associated with the angiographic degree of reperfusion following recanalization (r = − 0.2523, P = .0479). Functional outcome at discharge correlated with local MPO concentrations (r = 0.3832, P = .0014) and platelet counts (r = 0.288, P = .0181). This study provides human evidence of cerebral platelet activation and platelet-neutrophil interactions during AIS and points to the relevance of per-ischemic thrombo-inflammatory mechanisms to impaired reperfusion and worse functional outcome following recanalization.
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Affiliation(s)
- Alexander M Kollikowski
- Department of Neuroradiology, University Hospital of Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Mirko Pham
- Department of Neuroradiology, University Hospital of Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
| | - Alexander G März
- Department of Neuroradiology, University Hospital of Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Lena Papp
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Bernhard Nieswandt
- Institute of Experimental Biomedicine, University Hospital and Rudolf Virchow Center, University of Würzburg, Würzburg, Germany
| | - Guido Stoll
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Michael K Schuhmann
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
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Strinitz M, Pham M, März AG, Feick J, Weidner F, Vogt ML, Essig F, Neugebauer H, Stoll G, Schuhmann MK, Kollikowski AM. Immune Cells Invade the Collateral Circulation during Human Stroke: Prospective Replication and Extension. Int J Mol Sci 2021; 22:9161. [PMID: 34502070 PMCID: PMC8430889 DOI: 10.3390/ijms22179161] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/17/2021] [Accepted: 08/24/2021] [Indexed: 01/09/2023] Open
Abstract
It remains unclear if principal components of the local cerebral stroke immune response can be reliably and reproducibly observed in patients with acute large-vessel-occlusion (LVO) stroke. We prospectively studied a large independent cohort of n = 318 consecutive LVO stroke patients undergoing mechanical thrombectomy during which cerebral blood samples from within the occluded anterior circulation and systemic control samples from the ipsilateral cervical internal carotid artery were obtained. An extensive protocol was applied to homogenize the patient cohort and to standardize the procedural steps of endovascular sample collection, sample processing, and laboratory analyses. N = 58 patients met all inclusion criteria. (1) Mean total leukocyte counts were significantly higher within the occluded ischemic cerebral vasculature (I) vs. intraindividual systemic controls (S): +9.6%, I: 8114/µL ± 529 vs. S: 7406/µL ± 468, p = 0.0125. (2) This increase was driven by neutrophils: +12.1%, I: 7197/µL ± 510 vs. S: 6420/µL ± 438, p = 0.0022. Leukocyte influx was associated with (3) reduced retrograde collateral flow (R2 = 0.09696, p = 0.0373) and (4) greater infarct extent (R2 = 0.08382, p = 0.032). Despite LVO, leukocytes invade the occluded territory via retrograde collateral pathways early during ischemia, likely compromising cerebral hemodynamics and tissue integrity. This inflammatory response can be reliably observed in human stroke by harvesting immune cells from the occluded cerebral vascular compartment.
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Affiliation(s)
- Marc Strinitz
- Department of Neuroradiology, University Hospital of Würzburg, 97080 Würzburg, Germany; (M.S.); (M.P.); (A.G.M.); (J.F.); (F.W.); (M.L.V.)
| | - Mirko Pham
- Department of Neuroradiology, University Hospital of Würzburg, 97080 Würzburg, Germany; (M.S.); (M.P.); (A.G.M.); (J.F.); (F.W.); (M.L.V.)
| | - Alexander G. März
- Department of Neuroradiology, University Hospital of Würzburg, 97080 Würzburg, Germany; (M.S.); (M.P.); (A.G.M.); (J.F.); (F.W.); (M.L.V.)
| | - Jörn Feick
- Department of Neuroradiology, University Hospital of Würzburg, 97080 Würzburg, Germany; (M.S.); (M.P.); (A.G.M.); (J.F.); (F.W.); (M.L.V.)
| | - Franziska Weidner
- Department of Neuroradiology, University Hospital of Würzburg, 97080 Würzburg, Germany; (M.S.); (M.P.); (A.G.M.); (J.F.); (F.W.); (M.L.V.)
| | - Marius L. Vogt
- Department of Neuroradiology, University Hospital of Würzburg, 97080 Würzburg, Germany; (M.S.); (M.P.); (A.G.M.); (J.F.); (F.W.); (M.L.V.)
| | - Fabian Essig
- Department of Neurology, University Hospital of Würzburg, 97080 Würzburg, Germany; (F.E.); (H.N.); (G.S.); (M.K.S.)
| | - Hermann Neugebauer
- Department of Neurology, University Hospital of Würzburg, 97080 Würzburg, Germany; (F.E.); (H.N.); (G.S.); (M.K.S.)
| | - Guido Stoll
- Department of Neurology, University Hospital of Würzburg, 97080 Würzburg, Germany; (F.E.); (H.N.); (G.S.); (M.K.S.)
| | - Michael K. Schuhmann
- Department of Neurology, University Hospital of Würzburg, 97080 Würzburg, Germany; (F.E.); (H.N.); (G.S.); (M.K.S.)
| | - Alexander M. Kollikowski
- Department of Neuroradiology, University Hospital of Würzburg, 97080 Würzburg, Germany; (M.S.); (M.P.); (A.G.M.); (J.F.); (F.W.); (M.L.V.)
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