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Li J, Zhang P, Wu S, Yi X, Wang C, Liu M. Factors associated with favourable outcome in large hemispheric infarctions. BMC Neurol 2018; 18:152. [PMID: 30236075 PMCID: PMC6149207 DOI: 10.1186/s12883-018-1148-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/07/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Large hemispheric infarction (LHI) is a devastating condition with high mortality and poor functional outcome in most conservatively treated patients. The purpose of this study was to explore factors associated with favorable outcome in patients with LHI. METHODS We prospectively enrolled consecutive patients with LHI. Favorable outcome was defined as a modified Rankin Scale (mRS) score of 0 to 3 at 90 days. Multivariate logistic regression analysis was employed to identify the independent factors associated with favorable outcome. RESULTS Two hundred fifty-six cases with LHI were identified: 41 (16.0%) died during hospitalization, 94 (36.7%) died at 3 month, and 113 (44.1%) survived with favorable outcome at day 90. Compared with patients with unfavorable outcome, the favorable cases were younger (55.8 ± 14.7 vs. 66.2 ± 14.1), had less history of hypertension (38.9% vs. 59.3%), lower baseline NIHSS score (median NIHSS score 11 vs. 17), lower blood pressure on admission (systolic 134.7 ± 24.9 vs. 145.1 ± 26.1 mmHg; diastolic 80.2 ± 14.9 vs. 86.9 ± 16.2 mmHg; respectively), lower level of baseline serum glucose (7.2 ± 3.3 vs. 8.2 ± 3.3 mmol/L), a lower frequency of stroke-related complications (55.8% vs. 91.4%), more use of antiplatelets (93.8% vs. 57.1%) and statins (46.9% vs. 25.7%) in the acute phase of stroke, but less use of osmotic agents (69.9% vs. 89.3%), mechanical ventilation (1.8% vs. 20.0%) or decompressive hemicraniectomy (1.8% vs. 15.7%). Multivariable analysis identified the following factors associated with favorable outcome: age (odds ratio, OR 0.95, 95% confidence interval [CI] 0.92-0.98, p < 0.001), baseline NIHSS score (OR 0.90, 95% CI 0.84-0.96, p = 0.002), statins used in acute phase (OR 2.49, 95% CI 1.10-5.65, p = 0.029), brain edema (OR 0.05, 95% CI 0.01-0.21, p < 0.001) and pneumonia (OR 0.42, 95% CI 0.19-0.93, p = 0.032). CONCLUSION More than one third of patients with LHI have relatively favorable clinical outcomes at 90 days. Younger age, lower baseline NIHSS score, absence of brain edema and pneumonia, and statins used in the acute phase were associated with favorable outcome of patients with LHI at 90 days.
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Affiliation(s)
- Jie Li
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China
| | - Ping Zhang
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China
| | - Simiao Wu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No. 37, GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Xingyang Yi
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China
| | - Chun Wang
- Department of Neurology, People's Hospital of Deyang City, No.173, North Taishan Road, Deyang, 618000, Sichuan Province, People's Republic of China.
| | - Ming Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No. 37, GuoXue Xiang, Chengdu, 610041, Sichuan Province, People's Republic of China.
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Kim ES, Lee SK, Kwon MJ, Lee PH, Ju YS, Yoon DY, Kim HJ, Lee KS. Assessment of Blood-Brain Barrier Permeability by Dynamic Contrast-Enhanced MRI in Transient Middle Cerebral Artery Occlusion Model after Localized Brain Cooling in Rats. Korean J Radiol 2016; 17:715-24. [PMID: 27587960 PMCID: PMC5007398 DOI: 10.3348/kjr.2016.17.5.715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 05/17/2016] [Indexed: 12/21/2022] Open
Abstract
Objective The purpose of this study was to evaluate the effects of localized brain cooling on blood-brain barrier (BBB) permeability following transient middle cerebral artery occlusion (tMCAO) in rats, by using dynamic contrast-enhanced (DCE)-MRI. Materials and Methods Thirty rats were divided into 3 groups of 10 rats each: control group, localized cold-saline (20℃) infusion group, and localized warm-saline (37℃) infusion group. The left middle cerebral artery (MCA) was occluded for 1 hour in anesthetized rats, followed by 3 hours of reperfusion. In the localized saline infusion group, 6 mL of cold or warm saline was infused through the hollow filament for 10 minutes after MCA occlusion. DCE-MRI investigations were performed after 3 hours and 24 hours of reperfusion. Pharmacokinetic parameters of the extended Tofts-Kety model were calculated for each DCE-MRI. In addition, rotarod testing was performed before tMCAO, and on days 1-9 after tMCAO. Myeloperoxidase (MPO) immunohisto-chemistry was performed to identify infiltrating neutrophils associated with the inflammatory response in the rat brain. Results Permeability parameters showed no statistical significance between cold and warm saline infusion groups after 3-hour reperfusion 0.09 ± 0.01 min-1 vs. 0.07 ± 0.02 min-1, p = 0.661 for Ktrans; 0.30 ± 0.05 min-1 vs. 0.37 ± 0.11 min-1, p = 0.394 for kep, respectively. Behavioral testing revealed no significant difference among the three groups. However, the percentage of MPO-positive cells in the cold-saline group was significantly lower than those in the control and warm-saline groups (p < 0.05). Conclusion Localized brain cooling (20℃) does not confer a benefit to inhibit the increase in BBB permeability that follows transient cerebral ischemia and reperfusion in an animal model, as compared with localized warm-saline (37℃) infusion group.
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Affiliation(s)
- Eun Soo Kim
- Department of Radiology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang 14068, Korea
| | - Seung-Koo Lee
- Department of Radiology, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Mi Jung Kwon
- Department of Pathology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang 14068, Korea
| | - Phil Hye Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Young-Su Ju
- Department of Industrial Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang 14068, Korea
| | - Dae Young Yoon
- Department of Radiology, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul 05355, Korea
| | - Hye Jeong Kim
- Department of Radiology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Korea
| | - Kwan Seop Lee
- Department of Radiology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang 14068, Korea
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Neugebauer H, Kollmar R, Niesen WD, Bösel J, Schneider H, Hobohm C, Zweckberger K, Heuschmann PU, Schellinger PD, Jüttler E. DEcompressive Surgery plus hypoTHermia for Space-Occupying Stroke (DEPTH-SOS): A Protocol of a Multicenter Randomized Controlled Clinical Trial and a Literature Review. Int J Stroke 2013; 8:383-7. [DOI: 10.1111/ijs.12086] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Rationale Although decompressive hemicraniectomy clearly reduces mortality in severe space-occupying middle cerebral artery infarction (so-called malignant middle cerebral artery infarction), every fifth patient still dies in the acute phase and every third patient is left with moderate to severe disability. Therapeutic hypothermia is a neuroprotective and antiedematous treatment option that has shown promising effects in severe stroke. A combination of both treatment strategies may have the potential to further reduce mortality and morbidity in malignant middle cerebral artery infarction, but needs evaluation of its efficacy within the setting of a randomized clinical trial. Aims The DEcompressive surgery Plus hypoTHermia for Space-Occupying Stroke (DEPTH-SOS) trial aims to investigate safety and feasibility of moderate therapeutic hypothermia (33°C ± 1) over at least 72 h in addition to early decompressive hemicraniectomy (≤48 hours after symptom onset) in patients with malignant middle cerebral artery infarction. Design The DEcompressive surgery Plus hypoTHermia for Space-Occupying Stroke is a prospective, multicenter, open, two-arm (1:1) comparative, randomized, controlled trial. Study outcomes The primary end-point is mortality at day 14. The secondary end-points include functional outcome at day 14 and at 12 months follow-up, and complications related to hypothermia. Discussion The results of this trial will provide data on safety and feasibility of moderate hypothermia in addition to decompressive hemicraniectomy in malignant middle cerebral artery infarction. Furthermore, efficacy data on early mortality and long-term functional outcome will be obtained, forming the basis of subsequent trials.
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Affiliation(s)
- Hermann Neugebauer
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Berlin, Germany
- Department of Neurology, University Hospital, Ulm, Germany
| | - Rainer Kollmar
- Department of Neurology, University Hospital, Erlangen, Germany
| | | | - Julian Bösel
- Department of Neurology, University Hospital, Heidelberg, Germany
| | - Hauke Schneider
- Department of Neurology, Dresden University of Technology, Germany
| | - Carsten Hobohm
- Department of Neurology, University Hospital, Leipzig, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
| | - Peter U. Heuschmann
- Institute for Clinical Epidemiology and Biometry, Center for Clinical Studies, and Comprehensive Heart Failure Center, University of Wurzburg, Wurzburg, Germany
| | | | - Eric Jüttler
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Berlin, Germany
- Department of Neurology, University Hospital, Ulm, Germany
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Di Lazzaro V, Profice P, Dileone M, Della Marca G, Colosimo C, Pravatà E, Pavone A, Pennisi M, Maviglia R, Pilato F. Delayed hypothermia in malignant ischaemic stroke. Neurol Sci 2011; 33:661-4. [PMID: 22002074 DOI: 10.1007/s10072-011-0824-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 10/07/2011] [Indexed: 11/26/2022]
Abstract
Moderate hypothermia may reduce mortality in malignant brain infarction. However, due to the extremely limited number of patients treated, it is still unknown whether it may be beneficial if undertaken several days after acute stroke, when the probability of a malignant oedema is higher. We report on a patient with malignant brain oedema after middle cerebral artery infarction, who was treated with moderate hypothermia on the third day after stroke when he became comatose. Hypothermia was induced at a rate of 1.25°C/h by an intravascular cooling catheter. The target temperature of 32°C was reached in about 6 h. After 36 h of hypothermia, the patient was actively re-warmed at a rate of 0.2°C/h. The patient survived and showed a progressive reduction of mass effect on CT scan. This single case study suggests a beneficial effect of hypothermia in the treatment of severe space-occupying ischemic infarction even on the third day after stroke onset.
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Affiliation(s)
- Vincenzo Di Lazzaro
- Institute of Neurology, Università Cattolica, L.go A. Gemelli 8, 00168, Rome, Italy.
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Poca MA, Benejam B, Sahuquillo J, Riveiro M, Frascheri L, Merino MA, Delgado P, Alvarez-Sabin J. Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful? J Neurosurg 2010; 112:648-57. [DOI: 10.3171/2009.7.jns081677] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Intracranial pressure (ICP) monitoring is increasingly used in the treatment of patients with malignant middle cerebral artery (MCA) infarction. However, neurological deterioration may exist independent from intracranial hypertension. This study aimed to present the findings of continuous ICP monitoring in a cohort of patients with malignant MCA infarction and to correlate these findings with clinical and radiological features.
Methods
The authors studied a prospective cohort of 25 patients with malignant MCA infarction consecutively admitted to the neurotrauma intensive care unit of the Vall d'Hebron University Hospital between March 2002 and September 2006. The patients were treated using a combined protocol of initial moderate hypothermia and hemicraniectomy. The latter was performed when patients showed a midline shift (MLS) ≥ 5 mm or ICP > 20 mm Hg. Six patients had an MLS ≥ 5 mm on the first CT scan and underwent surgery without prior ICP monitoring. This study focuses on the subgroup of 19 patients who underwent intraparenchymatous ICP monitoring before surgery.
Results
Intracranial pressure readings were evaluated and correlated with pupillary abnormalities, MLS, and ischemic tissue volume. In 12 of the 19 patients, ICP values were always ≤ 20 mm Hg, despite a mean (± SD) MLS of 6.7 ± 2 mm and a mean ischemic tissue volume of 241.3 ± 83 cm3. In 2 patients with anisocoria, ICP values were also normal.
Conclusions
In patients with a malignant MCA infarction, pupillary abnormalities and severe brainstem compression may be present despite normal ICP values. Therefore, continuous ICP monitoring cannot substitute for close clinical and radiological follow-up in the management of these patients.
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Affiliation(s)
- Maria Antonia Poca
- 1Department of Neurosurgery,
- 2Neurotraumatology-Neurosurgery Research Unit,
| | | | - Juan Sahuquillo
- 1Department of Neurosurgery,
- 2Neurotraumatology-Neurosurgery Research Unit,
| | | | | | | | - Pilar Delgado
- 5Neurovascular Unit and Neurology Department, Vall d'Hebron University Hospital, Institut Recerca Vall d'Hebron, Autonomous University of Barcelona, Spain
| | - Jose Alvarez-Sabin
- 5Neurovascular Unit and Neurology Department, Vall d'Hebron University Hospital, Institut Recerca Vall d'Hebron, Autonomous University of Barcelona, Spain
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Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol 2009; 8:949-58. [DOI: 10.1016/s1474-4422(09)70224-8] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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The protective effect of early hypothermia on PTEN phosphorylation correlates with free radical inhibition in rat stroke. J Cereb Blood Flow Metab 2009; 29:1589-600. [PMID: 19553907 PMCID: PMC3221613 DOI: 10.1038/jcbfm.2009.81] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We recently showed that intraischemic moderate hypothermia (30 degrees C) reduces ischemic damage through the Akt pathway after permanent distal middle cerebral artery occlusion in rats. The only Akt pathway component preserved by hypothermia is phosphorylated phosphatase and tensin homolog deleted on chromosome 10 (p-PTEN), which suggests that p-PTEN may have a central role in neuroprotection. Reactive oxygen species (ROS) are critically involved in mediating ischemic damage after stroke by interacting with signaling molecules, including Akt, PTEN, and delta-protein kinase C (PKC). We investigated the protective mechanisms of moderate hypothermia on these signaling proteins after transient focal ischemia in rats. Early moderate hypothermia (3 h) was administered 15 mins before reperfusion, and delayed moderate hypothermia (3 h) was applied 15 mins after reperfusion. Our results indicate that early hypothermia reduced infarction, whereas delayed hypothermia did not. However, both early and delayed hypothermia maintained levels of Mn-SOD (superoxide dismutase) and phosphorylated Akt and blocked delta-PKC cleavage, suggesting that these factors may not be critical to the protection of hypothermia. Nevertheless, early hypothermia preserved p-PTEN levels after reperfusion, whereas delayed hypothermia did not. Furthermore, ROS inhibition maintained levels of p-PTEN after stroke. Together, these findings suggest that phosphorylation levels of PTEN are closely associated with the protective effect of early hypothermia against stroke.
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Kollmar R, Schwab S. Hypothermia in Focal Ischemia: Implications of Experiments and Experience. J Neurotrauma 2009; 26:377-86. [DOI: 10.1089/neu.2008.0564] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Rainer Kollmar
- Department of Neurology, University of Erlangen-Nurnberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nurnberg, Erlangen, Germany
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Schneider A, Popp E, Teschendorf P, Böttiger BW. [Therapeutic hypothermia]. Anaesthesist 2008; 57:197-206; quiz 207-8. [PMID: 18246320 DOI: 10.1007/s00101-008-1311-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The use of therapeutic hypothermia has been shown to improve survival and neurological outcome following cardiac arrest. Patients with traumatic brain injury or ischemic stroke also responded positively to therapeutic hypothermia, which may be induced by various procedures including surface cooling, endovascular cooling catheter and cold infusion. Possible side effects include infection and hemorrhage, as well as changes in water and electrolyte levels. It is the aim of this article to provide an overview of studies to date, as well as practical guidance for the application of therapeutic hypothermia.
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Affiliation(s)
- A Schneider
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum der Universität zu Köln, Köln.
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Wessmann A, Chandler K, Garosi L. Ischaemic and haemorrhagic stroke in the dog. Vet J 2008; 180:290-303. [PMID: 18579421 DOI: 10.1016/j.tvjl.2007.12.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Revised: 12/13/2007] [Accepted: 12/20/2007] [Indexed: 11/24/2022]
Abstract
Cerebrovascular disease results from any pathological process of the blood vessels supplying the brain. Stroke, characterised by its abrupt onset, is the third leading cause of death in humans. This rare condition in dogs is increasingly being recognised with the advent of advanced diagnostic imaging. Magnetic resonance imaging (MRI) is the first choice diagnostic tool for stroke, particularly using diffusion-weighted images and magnetic resonance angiography for ischaemic stroke and gradient echo sequences for haemorrhagic stroke. An underlying cause is not always identified in either humans or dogs. Underlying conditions that may be associated with canine stroke include hypothyroidism, neoplasia, sepsis, hypertension, parasites, vascular malformation and coagulopathy. Treatment is mainly supportive and recovery often occurs within a few weeks. The prognosis is usually good if no underlying disease is found.
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Affiliation(s)
- Annette Wessmann
- Division of Companion Animal Science, Institute of Comparative Medicine, Faculty of Veterinary Medicine, University of Glasgow Veterinary School, 464 Bearsden Road, Bearsden, Glasgow G61 1QH, UK.
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Abstract
Life-threatening, space-occupying brain edema occurs in up to 10% of patients with supratentorial infarcts and is traditionally associated with a high mortality rate of up to 80%. Management of these patients is currently being changed to an earlier and more aggressive treatment regimen. Early surgical decompression has recently been proven effective to reduce mortality and increase the number of patients with a favorable outcome in randomized controlled trials and is now the "antiedema" therapy of first choice for patients with large middle cerebral artery infarction aged 60 years or younger. Several medical treatment strategies have been proposed to control brain edema and reduce intracranial pressure, including different osmotherapeutics, hyperventilation, tromethamine, hypothermia, and barbiturate coma. None of these treatments is supported by level 1 evidence of efficacy in clinical trials, and some of them may even be detrimental. Preliminary results on hypothermia for space-occupying hemispheric infarction are encouraging, but far from definitive.
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Affiliation(s)
- Juergen Bardutzky
- Department of Neurology, University of Erlangen, Schwabachanlage 6, Germany.
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Rogalewski A, Schneider A, Ringelstein EB, Schäbitz WR. Toward a Multimodal Neuroprotective Treatment of Stroke. Stroke 2006; 37:1129-36. [PMID: 16527996 DOI: 10.1161/01.str.0000209330.73175.34] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Stroke remains a common medical problem with importance attributable to the demographic changes in industrialized societies.
Summary of Review—
After years of setbacks, acute stroke therapy has finally emerged, including thrombolysis with tissue plasminogen activator (t-PA). However, t-PA treatment is limited by a narrow time window and side effects, so that only 3% of all stroke patients receive thrombolysis. Unimodal targeting of key events in stroke pathophysiology was not effective in providing long-term benefits, leading to negative results in previous clinical neuroprotective stroke trials. A successful future stroke therapy should approach multiple pathophysiological mechanisms besides revascularization at once, including reduction of t-PA–related side effects, prevention of cell death, stimulation of neuroregeneration, and plasticity.
Conclusions—
Strategies targeting these processes include multiple combination therapies as well as treatment with multimodal drugs that interact with these mechanisms. Here, we review such combination approaches, and outline how this concept could be developed into future stroke treatment.
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