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Ferguson E, Lun R, Rosenberg H. Just the facts: management of thrombolytic complications in acute stroke care in the emergency department. CAN J EMERG MED 2024; 26:386-388. [PMID: 38796809 DOI: 10.1007/s43678-024-00713-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/27/2024] [Indexed: 05/29/2024]
Affiliation(s)
- Emma Ferguson
- Department of Emergency Medicine, University of Ottawa, The Ottawa Hospital, Civic Campus, Ottawa, ON, Canada.
| | - Ronda Lun
- Department of Vascular Neurology, Stanford Hospital, Palo Alto, CA, USA
| | - Hans Rosenberg
- Department of Emergency Medicine, University of Ottawa, The Ottawa Hospital, Civic Campus, Ottawa, ON, Canada
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2
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Guo K, Wang G, Zhang L, Feng Z, Xia X, Sun X, Yan Z, Jiao Z, Feng D. Hemorrhage induced by antithrombotic agents: new insights from a real-world pharmacovigilance study. Expert Opin Drug Saf 2024; 23:487-495. [PMID: 38497691 DOI: 10.1080/14740338.2024.2327502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/15/2023] [Indexed: 03/19/2024]
Abstract
BACKGROUND Hemorrhage represents the most common and serious side effect of antithrombotic agents. Many studies have compared the risk of bleeding between different antithrombotic agents, but analysis of time-to-onset for hemorrhage induced by these drugs is yet sparse. METHODS We conducted a retrospective study based on the adverse drug reaction reports on antithrombotic agents collected by the Henan Adverse Drug Reaction Monitoring Center. We assessed the reporting odds ratio to determine the disproportionate reporting signals for bleeding and the Weibull shape parameter was used to evaluate the time-to-onset data. RESULTS In the signal detection, crude low molecular weight heparin-hemorrhage was found as a positive signal. The hemorrhage for most antithrombotic agents was random failure profiles. In particular, the hazard of hemorrhage decreased over time for warfarin and clopidogrel and increased for alteplase, nadroparin, and dipyridamole. CONCLUSION We found that the risk of bleeding in patients taking Crude low molecular weight heparins was significantly higher compared to other antithrombotic agents, but with a small magnificence, which may be attributed to the severely irrational use of this medication under improper management. Statistics in days, results showed that the risk of bleeding decreased over time for warfarin and clopidogrel and increased for alteplase, nadroparin, and dipyridamole.
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Affiliation(s)
- Kangyuan Guo
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ganyi Wang
- College of Public Administration, Huazhong University of Science and Technology, Wuhan, China
| | - Li Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhanchun Feng
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xudong Xia
- Center for Drug Reevaluation of Henan, Zhengzhou, China
| | - Xiaobo Sun
- School of Statistics and Mathematics, Zhongnan University of Economics and Law, Wuhan, China
| | - Ziqi Yan
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiming Jiao
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Da Feng
- School of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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3
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Gu Y, Xu C, Zhang Z, Fang C, Yu J, He D, Xu G. Association between infarct location and haemorrhagic transformation of acute ischaemic stroke after intravenous thrombolysis. Clin Radiol 2024; 79:e401-e407. [PMID: 38135575 DOI: 10.1016/j.crad.2023.11.024] [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: 09/15/2023] [Accepted: 11/07/2023] [Indexed: 12/24/2023]
Abstract
AIM To evaluate the association between computed tomography (CT)-based imaging variables at the time of admission and haemorrhagic transformation (HT) after intravenous thrombolysis (IVT). MATERIALS AND METHODS One hundred and eight patients who were treated with IVT for acute ischaemic stroke (AIS) during January 2021 to July 2023 were analysed retrospectively. The infarct location was classified as cortical or subcortical in accordance with the Alberta Stroke Program Early CT Score (ASPECTS) system. Logistic regression and receiver operating characteristic curve analyses were performed to determine the relationship between ischaemic variables and HT. RESULTS Of the total, 18 (16.7%) patients had HT and seven (6.5%) had symptomatic intracerebral haemorrhage (sICH). Multivariate analysis revealed that cortical ASPECTS was independently associated with HT (odds ratio [OR], 0.197; 95% confidence interval [CI], 0.076-0.511; p=0.001) and cortical ASPECTS was independently associated with sICH (OR, 0.066; 95% CI, 0.009-0.510; p=0.009). To predict HT and sICH, cortical ASPECTS (HT area under the curve [AUC] = 0.881, sICH AUC = 0.971) provided a higher AUC compared with ASPECTS (HT AUC = 0.850, sICH AUC = 0.918). CONCLUSION Cortical ASPECTS seen on CT at the time of admission is associated with HT and sICH after IVT.
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Affiliation(s)
- Y Gu
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou 215000, China
| | - C Xu
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou 215000, China
| | - Z Zhang
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou 215000, China
| | - C Fang
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou 215000, China
| | - J Yu
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou 215000, China
| | - D He
- Department of Neurology, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou 215000, China
| | - G Xu
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou 215000, China.
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Bao Q, Wu X, Li Y, Chen S, Zhang Q, Yang M, Yang P. Intravenous thrombolysis in acute ischemic stroke patients with pre-stroke disability: A systematic review and meta-analysis. Brain Behav 2024; 14:e3431. [PMID: 38361315 PMCID: PMC10869883 DOI: 10.1002/brb3.3431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Intravenous thrombolysis (IVT), which is safe and effective, is the first-line therapy for acute ischemic stroke (AIS). However, its benefit for AIS patients with pre-stroke disability (PSD) is controversial. OBJECTIVE We determined the association of PSD with the safety and efficacy of IVT among patients with AIS. METHODS We searched PubMed, Embase, and the Cochrane Library from inception to May 23, 2022. The articles focusing on outcomes of AIS patients with PSD receiving IVT were retrieved. We used the random-effects model to pool outcomes including mortality, 24 h NIHSS improvement, symptomatic intracerebral hemorrhage (sICH), favorable functional outcome (FFO), the favorable outcome, and mortality prevalence. RESULTS Ten studies (including 245,773 participants) that reported the outcomes of AIS patients with PSD undergoing IVT were included. In unadjusted analyses, PSD was associated with mortality (10 studies; odds ratio [OR] 1.739, 95% confidence interval [CI], 1.336-2.407), FFO (7 studies; OR 1.057, 95% CI, 1.015-1.100), 24 h NIHSS improvement (5 studies; OR .840, 95% CI, .819-.917, p = .000), and sICH (9 studies; OR .773, 95% CI, .481-1.243). In adjusted analyses, PSD was associated with mortality (seven studies; ORadj 1.789, 95% CI, 1.413-2.264), FFO (five studies; ORadj 1.087, 95% CI, 1.002-1.179), 24 h NIHSS improvement (five studies; ORadj .837, 95% CI, .799-.876), and sICH (five studies; ORadj .857, 95% CI, .725-1.012). The prevalence of FFO and mortality in patients with pre-stroke modified Rankin Scale scores of 2-5 were 49% (0.42-0.56) and 37% (0.21-0.53), respectively. CONCLUSIONS Patients with PSD undergoing IVT had a higher mortality rate than those without PSD. Meanwhile, PSD was associated with FFO, and there was no significant difference in sICH and 24 h NIHSS improvement. High-quality data are needed to clarify the benefits of administering IVT in these patients.
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Affiliation(s)
- Qiangji Bao
- Department of NeurosurgeryGuang'an People's HospitalGuang'anSichuanChina
| | - Xinting Wu
- Department of AnesthesiaGuang'an People's HospitalGuang'anSichuanChina
| | - Yiming Li
- Graduate SchoolQinghai UniversityXiningQinghaiChina
| | - Shujun Chen
- Graduate SchoolQinghai UniversityXiningQinghaiChina
| | - Qiang Zhang
- Department of NeurosurgeryQinghai Provincial People's HospitalXiningQinghaiChina
| | - Mingfei Yang
- Department of NeurosurgeryQinghai Provincial People's HospitalXiningQinghaiChina
| | - Peng Yang
- Department of NeurosurgeryQinghai Provincial People's HospitalXiningQinghaiChina
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Khalil S, Kanapathipillai M. Exosome-Coated tPA/Catalase Nanoformulation for Thrombolytic Therapy. Bioengineering (Basel) 2023; 10:bioengineering10020177. [PMID: 36829671 PMCID: PMC9952084 DOI: 10.3390/bioengineering10020177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/19/2023] [Accepted: 01/21/2023] [Indexed: 02/01/2023] Open
Abstract
Current tissue plasminogen-based therapeutic strategies for stroke suffer from systemic side effects and poor efficacy. Hence, novel drug delivery methods are needed to overcome these shortcomings. Exosome-based drug formulations have been shown to have superior therapeutic outcomes compared to conventional systemic drug delivery approaches. In this paper, we report exosome surface-coated tissue plasminogen activator (tPA)/catalase nanoformulations with improved thrombolytic efficacy compared to free tPA, which also reduce side effects. The results showed that the tPA exosome formulations retained tPA activity, improved tPA stability, exhibited significant fibrinolysis, and showed no significant toxicity effects. Further, when combined with antioxidant enzyme catalase, the formulation was able to inhibit hydrogen peroxide-mediated oxidative stress and toxicity. Hence, exosome-based tPA/catalase nanoformulations could have the potential to offer a safer and effective thrombolytic therapy.
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Wang Y, Jiang G, Zhang J, Wang J, You W, Zhu J. Blood glucose level affects prognosis of patients who received intravenous thrombolysis after acute ischemic stroke? A meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1120779. [PMID: 37124754 PMCID: PMC10130663 DOI: 10.3389/fendo.2023.1120779] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 03/29/2023] [Indexed: 05/02/2023] Open
Abstract
Background and objectives Intravenous recombinant tissue plasminogen activator (rtPA) thrombolysis is an effective treatment for acute ischemic stroke. Hyperglycemia is a major risk factor for the occurrence, development, and prognosis of ischemic stroke. This meta-analysis purposefully estimates the association between hyperglycemia and poor prognosis in acute ischemic stroke patients receiving intravenous rtPA thrombolytic therapy. Materials and methods According to the predefined inclusion criteria, we searched PubMed, Web of Science, and Cochrane Library databases. The association of high blood glucose(>140mg/dl) with symptomatic intracranial hemorrhage (sICH), poor clinical outcome and mortality at 90 days post-rtPA thrombolysis was studied using both a common effects model and a random effects model. Odds ratios (ORs) were plotted on forest plots. Results Of a total cohort of 2565 patients who received intravenous thrombolytic therapy, 721 had higher blood glucose. High glucose level significantly increased the odds of sICH (OR 1.80; 95% confidence interval(95%CI): 1.30- 2.50) and poor clinical outcome at 90 days (OR 1.82; 95%CI: 1.52-2.19), and all-cause mortality at 90 days (OR 2.51; 95%CI:1.65-3.82). Conclusions In our meta-analysis, high blood glucose was significantly associated with sICH, poor clinical outcome and higher mortality at 90 days.
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Affiliation(s)
- Yue Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Guannan Jiang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jie Zhang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jingfeng Wang
- Department of Neurology, The Second People’s Hospital of Kunshan, Suzhou, China
| | - Wanchun You
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
- *Correspondence: Wanchun You, ; Juehua Zhu,
| | - Juehua Zhu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
- *Correspondence: Wanchun You, ; Juehua Zhu,
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7
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Su EJ, Lawrence DA. Diabetes and the treatment of ischemic stroke. J Diabetes Complications 2022; 36:108318. [PMID: 36228562 DOI: 10.1016/j.jdiacomp.2022.108318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/23/2022] [Indexed: 11/23/2022]
Abstract
This white paper examines the current challenges for treating ischemic stroke in diabetic patients. The need for a greater understanding of the mechanisms that underlie the relationship between diabetes and the cerebral vascular responses to ischemia is discussed. The critical need to improve the efficacy and safety of thrombolysis is addressed, as is the need for a better characterization the off-target actions of tPA, the only currently approved thrombolytic for the treatment of ischemic stroke.
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Affiliation(s)
- Enming J Su
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniel A Lawrence
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, USA.
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8
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Yuan CX, Zhang YN, Chen XY, Hu BL. Association between malnutrition risk and hemorrhagic transformation in patients with acute ischemic stroke. Front Nutr 2022; 9:993407. [PMID: 36276820 PMCID: PMC9579279 DOI: 10.3389/fnut.2022.993407] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/09/2022] [Indexed: 11/28/2022] Open
Abstract
Background and aims Malnutrition is a prevalent problem occurring in different diseases. Hemorrhagic transformation (HT) is a severe complication of acute ischemic stroke (AIS). Few studies have evaluated the association between malnutrition risk and hemorrhagic transformation in patients with acute stroke. We aim to investigate the influence of malnutrition risk on the risk of hemorrhagic transformation in patients with AIS. Methods A total of 182 consecutive adults with HT and 182 age- and sex-matched patients with stroke were enrolled in this study. The controlling nutritional status (CONUT) score was calculated to evaluate the malnutrition risk. HT was detected by follow-up imaging assessment and was radiologically classified as hemorrhagic infarction type 1 or 2 or parenchymal hematoma type 1 or 2. Logistic regression models were conducted when participants were divided into different malnutrition risk groups according to the objective nutritional score to assess the risk for HT. Results The prevalence of moderate to severe malnutrition risk in patients with AIS was 12.5%, according to the CONUT score. Univariate analysis showed that the CONUT score is significantly higher in patients with HT than those without HT. After adjusting for potential covariables, the patients with mild risk and moderate to severe malnutrition risk were associated with a higher risk of HT compared to the patients in the normal nutritional status group [odds ratio, 3.180 (95% CI, 1.139–8.874), P = 0.027; odds ratio, 3.960 (95% CI, 1.015–15.453), P = 0.048, respectively]. Conclusion Malnutrition risk, measured by CONUT score, was significantly associated with an increased risk of hemorrhagic transformation in patients with AIS.
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Affiliation(s)
- Cheng-Xiang Yuan
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yi-Ni Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xuan-Yu Chen
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bei-Lei Hu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,*Correspondence: Bei-Lei Hu
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Zhu A, Rajendram P, Tseng E, Coutts SB, Yu AYX. Alteplase or tenecteplase for thrombolysis in ischemic stroke: An illustrated review. Res Pract Thromb Haemost 2022; 6:e12795. [PMID: 36186106 PMCID: PMC9487449 DOI: 10.1002/rth2.12795] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/21/2022] [Accepted: 07/22/2022] [Indexed: 11/09/2022] Open
Abstract
Intravenous thrombolysis is a standard of care treatment for patients with acute ischemic stroke. Tissue plasminogen activator (tPA) has been the main thrombolytic agent used since the publication of the seminal National Institutes of Neurological Disorders and Stroke trial in 1995. There is now mounting evidence to support the routine use of Tenecteplase (TNK) to treat acute ischemic stroke. TNK is a genetically modified tPA with higher fibrin specificity, longer half‐life, and reduced systemic coagulopathy. In this illustrated review, we compare the indications, doses, mechanisms of action, efficacy and safety of TNK and tPA. We provide an overview of published clinical trials studying TNK in acute ischemic stroke, including dose‐escalation studies and head‐to‐head comparisons with tPA. Finally, we summarize current acute stroke guideline recommendations and suggest treatment algorithms to manage the two main complications of intravenous thrombolysis: symptomatic intracerebral hemorrhage and angioedema.
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Affiliation(s)
- Annie Zhu
- Department of Medicine (Neurology) University of Toronto, Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Phavalan Rajendram
- Department of Medicine (Neurology) University of Toronto, Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Eric Tseng
- Department of Medicine (Hematology) University of Toronto, Unity Health Toronto Toronto Ontario Canada
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology and Community Health Sciences Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary Calgary Alberta Canada
| | - Amy Y X Yu
- Department of Medicine (Neurology) University of Toronto, Sunnybrook Health Sciences Centre Toronto Ontario Canada
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Roland M, Markaki I, Andersson T, Arnberg F, Sjöstrand C. Mechanical thrombectomy in stroke patients of working age: Real-world outcomes in Sweden. Eur Stroke J 2022; 7:41-47. [PMID: 35300257 PMCID: PMC8921781 DOI: 10.1177/23969873211067883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 12/02/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Outcomes after mechanical thrombectomy (MT) in young stroke patients remain elusive due to small patient cohorts. We sought to determine outcomes after MT in stroke patients between ages 18 and 64 years and compare with outcomes in older patients in a large national stroke cohort. Patients and methods We used the Swedish National Stroke Registry and the Swedish National Endovascular Thrombectomy Registry to identify all patients treated with MT for anterior circulation occlusions. We examined outcome measures in terms of functional independence at 90 days (modified Rankin Scale score of 0–2), symptomatic intracerebral hemorrhage (sICH), and mortality at 90 days with multivariable logistic regression analysis. Results Of 2143 patients, 565 were between 18 and 64 years (26.4%) and 1179 (55.0%) were males. Analysis showed that patient aged 18–64 achieved higher rate of functional independence at 90 days (46.2% vs 28.4%, p < .001), had less often sICH (5.5% vs 6.8%, p = .008), and lower 90-day mortality rate (6.9% vs 17.7%, p < .001). Increasing age was associated with a lesser probability of functional independence at 90 days (adjusted odds ratio (aOR), 0.94; [95% confidence intervals (CIs) 0.93–0.95]), higher odds of mortality at 90 days (aOR, 1.05; [95% CIs 1.03–1.06]), and of sICH (aOR 1.03; [95% CIs 1.01–1.05]). Conclusion Patients aged 18–64 years demonstrated better outcome after thrombectomy regarding functional independence, sICH, and mortality at 90 days when compared to older ages.
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Affiliation(s)
- Mihae Roland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ioanna Markaki
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center of Neurology, Academic Specialist Center, Stockholm, Sweden
| | - Tommy Andersson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Christina Sjöstrand
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Li J, Xiong J, Chen K, Sun J, Fu Q, Yin B. Comparison of magnetic resonance imaging versus computed tomography-based thrombolysis treatment in patients with acute ischemic stroke. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:176-181. [PMID: 34986280 DOI: 10.1002/jcu.23126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/20/2021] [Accepted: 11/03/2021] [Indexed: 06/14/2023]
Abstract
PURPOSE To evaluate the efficacy and safety of magnetic resonance imaging (MRI)-based comparing with computed tomography (CT)-based selection for intravenous thrombolysis in patients with acute ischemic stroke (AIS). METHODS Totally 462 consecutive AIS patients treated with intravenous thrombolysis within a 4.5 h window from Jan. 2016 to Dec. 2019 were enrolled. The primary endpoint was the good functional outcome defined by a modified Rankin Scale (mRS) of 0-2 at 3 months. Secondary outcomes include the excellent functional outcome defined by a mRS of 0-1 at 3 months, occurrences of symptomatic intracranial hemorrhage (SICH), 7-day mortality, and 3-month mortality. RESULTS Overall 172 patients received MRI and 290 received CT before they were treated with thrombolysis. The difference in the good or excellent functional outcome was not statistically significant between MRI and CT groups (both P > 0.05). The incidences of 7-day mortality (3.5% vs. 8.6%, P < 0.01), 30-day mortality (12.8% vs. 21.0%, P = 0.03), and SICH (12.2% vs. 20.3%, P < 0.01) were obviously lower for MRI-based regimen compared with CT-based regimen. Multivariate logistic regression indicated that MRI-based regimen was significantly associated with a lower risk of 7-day mortality (OR = 0.72, 95% CI: 0.53-0.91; P < 0.01), 30-day mortality (OR = 0.58, 95% CI: 0.47-0.73; P < 0.01), and SICH (OR = 0.44, 95% CI: 0.20-0.65; P < 0.01) after controlling for potential confounding factors. CONCLUSION Despite MRI-based thrombolysis was not demonstrated to be associated with the good functional outcome, it significantly reduced risks of mortality and SICH in patients with AIS compared with CT-based thrombolysis.
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Affiliation(s)
- Juan Li
- Department of Radiology, North Hospital of Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jiandong Xiong
- Department of Radiology, North Hospital of Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Kaixiang Chen
- Department of Radiology, North Hospital of Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jun Sun
- Department of Radiology, North Hospital of Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Qirui Fu
- Department of Radiology, North Hospital of Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Bo Yin
- Department of Radiology, North Hospital of Huashan Hospital Affiliated to Fudan University, Shanghai, China
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12
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Dzialowski I, Puetz V, Parsons M, Bivard A, von Kummer R. Computed Tomography-Based Evaluation of Cerebrovascular Disease. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00047-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Jin T, Chen D, Chen Z, Feng D, Zheng M, Wang P, Xu C. Post-Thrombolytic D-Dimer Elevation Predicts Symptomatic Intracranial Hemorrhage and Poor Functional Outcome After Intravenous Thrombolysis in Acute Ischemic Stroke Patients. Neuropsychiatr Dis Treat 2022; 18:2737-2745. [PMID: 36444217 PMCID: PMC9700443 DOI: 10.2147/ndt.s389469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We aimed to investigate the association of post-thrombolytic D-dimer elevation with symptomatic intracranial hemorrhage (sICH) and functional outcome in AIS patients receiving intravenous thrombolysis. METHODS We retrospectively reviewed our database for patients with AIS who received intravenous thrombolysis between August 2018 and December 2021. ΔD-dimer was calculated as follow-up D-dimer minus baseline D-dimer. Poor functional outcome was defined as 3 months modified Rankin score (mRS) 3-6. sICH was defined as cerebral hemorrhagic transformation in combination with clinical deterioration of National Institutes of Health Stroke Scale (NIHSS) score ≥4 points at 24 hours. Binary logistic regression analysis was used to investigate the association of post-thrombolytic D-dimer parameters with sICH and poor functional outcome. The receiver operating characteristic (ROC) curve derived optimal cut-off of different D-dimer parameters was determined at the maximal Youden's Index. RESULTS A total of 325 patients were finally included. After controlling for clinical variables, follow-up D-dimer level (OR 1.230; 95% CI 1.119 to 1.351; P < 0.001) and ΔD-dimer (OR 1.347; 95% CI 1.165 to 1.559; P < 0.001) were independently associated with poor functional outcome. Additionally, follow-up D-dimer level (OR 1.095; 95% CI 1.009 to 1.188; P = 0.030) was independently related to sICH. The optimal cut-off value of follow-up D-dimer level for predicting sICH was 4185 μg/L (area under the curve 0.760; sensitivity 76.0%; specificity 81.3%); and the optimal cut-off value of follow-up D-dimer level and ΔD-dimer as a predictor for poor functional outcome was projected to be 3838 μg/L and 2190 μg/L, which yielded a sensitivity and a specificity of 62.3%, 84.5% and 73.8%, 85.2%, respectively. CONCLUSION Elevated follow-up D-dimer levels are associated with sICH and poor functional outcome in AIS patients following intravenous rt-PA. Moreover, post-thrombolytic D-dimer elevation, measured by ΔD-dimer, was a better predictive biomarker for long-term outcome at 3 months.
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Affiliation(s)
- Tianyu Jin
- Department of Neurology, The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, People's Republic of China
| | - Danyu Chen
- Department of Neurology, Tongxiang First People's Hospital, Tongxiang, People's Republic of China
| | - Zhicai Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, People's Republic of China
| | - Dujin Feng
- Department of Laboratory, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, People's Republic of China
| | - Manqi Zheng
- Department of Psychiatry, The Third Hospital of Quzhou, Quzhou, People's Republic of China
| | - Peng Wang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, People's Republic of China
| | - Chao Xu
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, People's Republic of China
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14
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Lasek-Bal A, Binek Ł, Żak A, Student S, Krzan A, Puz P, Bal W, Uchwat U. Clinical and Non-Clinical Determinants of the Effect of Mechanical Thrombectomy and Post-Stroke Functional Status of Patients in Short and Long-Term Follow-Up. J Clin Med 2021; 10:5084. [PMID: 34768603 PMCID: PMC8584929 DOI: 10.3390/jcm10215084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/10/2021] [Accepted: 10/26/2021] [Indexed: 01/07/2023] Open
Abstract
To date, inconsistent results evaluating the effect of parameters on mechanical thrombectomy (MT) outcomes in stroke-patients have been published. This study aimed to identify the key parameters for functional status after MT in stroke-patients in short and long-term follow-up. METHOD The study analysis focused on the relevance of selected clinical and non-clinical parameters to the functional status of the patients after MT. RESULTS 417 stroke-patients (mean age 67.8 ± 13.2 years) were qualified. Atrial fibrillation, and leukocytosis were significant for the neurological status on the first day of stroke (p = 0.036, and p = 0.0004, respectively). The parameters with the strongest effect on the functional status on day 10 were: age (p = 0.009), NIHSS (p = 0.002), hyperglycemia (p = 0.009), the result in TICI (p = 0.046), and first pass effect (p = 0.043). The parameters with the strongest effect on the functional status on day 365 were: age and NIHSS on the first day of stroke (p = 0.0002 and 0.002, respectively). Leukocytosis and the neurological status at baseline were key parameters associated with ICB after MT (p = 0.007 and p = 0.003, respectively). CONCLUSIONS Age and neurological status in the ultra-acute phase of stroke are crucial for the functional status in short and long-term observations of patients treated with mechanical thrombectomy. Atrial fibrillation, hyperglycemia, and inflammatory state are relevant to the short-term post-stroke functional status. First pass effect and the degree of post-interventional reperfusion are important technical parameters to the short-term functional status. Neurological status and white blood count during the acute phase are associated with a high rate of post-procedural intracranial bleeding.
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Affiliation(s)
- Anetta Lasek-Bal
- Department of Neurology, School of Health Sciences, Medical University of Silesia, 40-055 Katowice, Poland; (A.Ż.); (A.K.); (P.P.)
- Department of Neurology, Upper-Silesian Medical Centre, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.B.); (U.U.)
| | - Łukasz Binek
- Department of Neurology, Upper-Silesian Medical Centre, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.B.); (U.U.)
| | - Amadeusz Żak
- Department of Neurology, School of Health Sciences, Medical University of Silesia, 40-055 Katowice, Poland; (A.Ż.); (A.K.); (P.P.)
- Department of Neurology, Upper-Silesian Medical Centre, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.B.); (U.U.)
| | - Sebastian Student
- Faculty of Automatic Control, Electronics and Computer Science, Silesian University of Technology, 44-100 Gliwice, Poland;
- Biotechnology Center, Silesian University of Technology, 44-100 Gliwice, Poland
| | - Aleksandra Krzan
- Department of Neurology, School of Health Sciences, Medical University of Silesia, 40-055 Katowice, Poland; (A.Ż.); (A.K.); (P.P.)
- Department of Neurology, Upper-Silesian Medical Centre, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.B.); (U.U.)
| | - Przemysław Puz
- Department of Neurology, School of Health Sciences, Medical University of Silesia, 40-055 Katowice, Poland; (A.Ż.); (A.K.); (P.P.)
- Department of Neurology, Upper-Silesian Medical Centre, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.B.); (U.U.)
| | - Wiesław Bal
- Department of Outpatient Chemotherapy, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, 44-101 Gliwice, Poland;
| | - Urszula Uchwat
- Department of Neurology, Upper-Silesian Medical Centre, Medical University of Silesia, 40-055 Katowice, Poland; (Ł.B.); (U.U.)
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15
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Heparin and Arginine Based Plasmin Nanoformulation for Ischemic Stroke Therapy. Int J Mol Sci 2021; 22:ijms222111477. [PMID: 34768908 PMCID: PMC8584024 DOI: 10.3390/ijms222111477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/14/2021] [Accepted: 10/21/2021] [Indexed: 12/04/2022] Open
Abstract
Ischemic stroke is the most common type of stroke and thrombolytic therapy is the only approved treatment. However, current thrombolytic therapy with tissue plasminogen activator (tPA) is often hampered by the increased risk of hemorrhage. Plasmin, a direct fibrinolytic, has a significantly superior hemostatic safety profile; however, if injected intravenously it becomes rapidly inactivated by anti-plasmin. Nanoformulations have been shown to increase drug stability and half-life and hence could be applied to increase the plasmin therapeutic efficacy. Here in this paper, we report a novel heparin and arginine-based plasmin nanoformulation that exhibits increased plasmin stability and efficacy. In vitro studies revealed significant plasmin stability in the presence of anti-plasmin and efficient fibrinolytic activity. In addition, these particles showed no significant toxicity or oxidative stress effects in human brain microvascular endothelial cells, and no significant blood brain barrier permeability. Further, in a mouse photothrombotic stroke model, plasmin nanoparticles exhibited significant efficacy in reducing stroke volume without overt intracerebral hemorrhage (ICH) compared to free plasmin treatment. The study shows the potential of a plasmin nanoformulation in ischemic stroke therapy.
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16
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Soni M, Wijeratne T, Ackland DC. A risk score for prediction of symptomatic intracerebral haemorrhage following thrombolysis. Int J Med Inform 2021; 156:104586. [PMID: 34649112 DOI: 10.1016/j.ijmedinf.2021.104586] [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: 05/03/2021] [Revised: 08/29/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous recombinant tissue plasminogen activator (rt-PA) remains the only FDA approved pharmacological therapy for acute ischemic stroke (AIS), but this treatment is associated with symptomatic intracerebral haemorrhage (SICH). The aim of this study was to derive and validate an accurate measure of SICH risk in ischemic stroke patients treated with rt-PA using data readily available from patient clinical records. METHODS Demographics, physiological parameters, and clinical data were obtained from 1,270 ischemic stroke patients treated with thrombolysis at 20 hospitals. This included age, sex, weight, blood pressure, glucose levels, smoking preferences, and presence of previous clinical conditions. Using a bivariate analysis on a training dataset of 890 patients, SICH cases were compared against SICH-free patients and key risk factors associated with SICH were identified. Continuous variables were stratified using k-means clustering, and odds ratios computed for each of the categorical risk factors employed in the risk score. The SICH risk score, which was assessed using an independent validation dataset comprising 380 patients, was defined between 0 and 53, and stratified into 4 categories: very low risk (0-6), low risk (7-12), moderate risk (13-19), and high risk (>20). RESULTS Older age (age > 75 years), higher blood pressure, higher severity of stroke, pre-treatment antithrombotic and history of hypertension and hyperlipidaemia, were shown to be significant risk factors for SICH following rt-PA treatment (p < 0.05). A number of interaction effects with age produced greater overall SICH risk than that of individual variables alone, including age*weight, age*NIHSS, age*diastolic blood pressure, and age*hypertension. The SICH prediction tool demonstrated a C-statistic of 0.75 for continuous risk scoring (0-53) and 0.71 for stratified risk levels. CONCLUSION A novel, computationally efficient risk score utilising data readily available from patient clinical records was shown to predict SICH risk following thrombolysis treatment with high accuracy. This tool may be useful for pre-screening patients for SICH risk to reduce the morbidity and mortality associated with thrombolysis treatment.
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Affiliation(s)
- Mukesh Soni
- Department of Biomedical Engineering, The University of Melbourne, Australia
| | - Tissa Wijeratne
- Department of Medicine and Neurology, AIMSS, Melbourne Medical School, University of Melbourne and Western Health, Sunshine Hospital, St. Albans, Victoria, Australia; School of Psychology & Public Health, Department of Psychology & Counselling, La Trobe University, Bundoora, VIC, Australia; Department of Medicine, Faculty of Medicine, University of Rajarata, Saliyapura, Anuradhapura, Sri Lanka
| | - David C Ackland
- Department of Biomedical Engineering, The University of Melbourne, Australia.
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17
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Quality of Care and One-Year Outcomes in Patients with Diabetes Hospitalised for Stroke or TIA: A Linked Registry Study. J Stroke Cerebrovasc Dis 2021; 30:106083. [PMID: 34517297 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106083] [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: 04/18/2021] [Revised: 08/18/2021] [Accepted: 08/24/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To evaluate key quality indicators for acute care and one-year outcomes following acute ischaemic stroke (IS), intracerebral haemorrhage (ICH), or transient ischaemic attack (TIA) by diabetes status. MATERIALS AND METHODS Observational cohort study (2009-2013) using linked data from the Australian Stroke Clinical Registry and hospital records. Diabetes was ascertained through review of hospital records. Multilevel regression models were used to evaluate the association between diabetes and outcomes, including discharge destination, and mortality and hospital readmissions within one-year of stroke/TIA. RESULTS Among 14,132 patients (median age 76 years, 46% female), 22% had diabetes. Compared to patients without diabetes, those with diabetes were equally likely to receive stroke unit care, but were more often discharged on antihypertensive agents (79% vs. 68%) or with a care plan (50% vs. 47%). In patients with TIA, although 86% returned directly home after acute care, those with diabetes more often had a different discharge destination than those without diabetes. Diabetes was associated with greater all-cause mortality (hazard ratio 1.13, 95% CI 1.04-1.23) in patients with IS/ICH; and with both greater all-cause (1.81, CI 1.35-2.43) and CVD mortality (1.75, CI 1.06-2.91) in patients with TIA. Similarly, diabetes was associated with greater rates of all-cause readmission in both patients with IS/ICH and TIA. CONCLUSIONS Despite good adherence to best care standards for acute stroke/TIA, patients with comorbid diabetes had worse outcomes at one-year than those without comorbid diabetes. Associations of diabetes with poorer outcomes were more pronounced in patients with TIA than those with IS/ICH.
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18
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Won YD, Kim JM, Ryu JI, Koh SH, Han MH, Cheong JH. The Osteoporotic Condition as a Predictive Factor for Hemorrhagic Transformation in Acute Cardioembolic Stroke. J Korean Neurosurg Soc 2021; 64:763-775. [PMID: 34428885 PMCID: PMC8435655 DOI: 10.3340/jkns.2021.0150] [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: 06/15/2021] [Accepted: 07/05/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Hemorrhagic transformation (HT) can be occurred after acute cerebral infarction. HT can worse symptoms in severe cases and adversely affect long-term prognosis. As bone and vascular smooth muscle are composed of type 1 collagen, we aimed to identify a potential relationship between bone mineral density (BMD) and HT after acute cardioembolic stroke.
Methods As an indicator of BMD, we used mean frontal skull Hounsfield unit (HU) values on brain computed tomography (CT). Multivariative hazard ratios were calculated using Cox regression analysis to identify whether the osteoporotic condition was an independent predictor of HT after acute cardioembolic stroke.
Results This 11-year analysis enrolled 506 patients who diagnosed as acute cardioembolic infarction. The first tertile of skull HU value was an independent predictor of HT development compared to the third tertile (hazard ratio, 2.12; 95% confidence interval, 1.13–3.98; p=0.020). We observed no interactions between age and skull HU with respect to HT statistically.
Conclusion The results of this study revealed an association between osteoporotic conditions and HT development after acute cardioembolic stroke. A convenient method to measure the cancellous bone HU value of the frontal skull using brain CT images may be useful for predicting HT in patients with acute cerebral infarction.
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Affiliation(s)
- Yu Deok Won
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
| | - Jae-Min Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
| | - Je-Il Ryu
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
| | - Seong-Ho Koh
- Department of Neurology, Hanyang University Guri Hospital, Guri, Korea
| | - Myung-Hoon Han
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
| | - Jin-Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
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19
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Zonjee VJ, Slenders JPL, de Beer F, Visser MC, Ter Meulen BC, Van den Berg-Vos RM, van Schaik SM. Practice variation in the informed consent procedure for thrombolysis in acute ischemic stroke: a survey among neurologists and neurology residents. BMC Med Ethics 2021; 22:114. [PMID: 34433444 PMCID: PMC8390276 DOI: 10.1186/s12910-021-00684-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022] Open
Abstract
Background Obtaining informed consent for intravenous thrombolysis in acute ischemic stroke can be challenging, and little is known about if and how the informed consent procedure is performed by neurologists in clinical practice. This study examines the procedure of informed consent for intravenous thrombolysis in acute ischemic stroke in high-volume stroke centers in the Netherlands. Methods In four high volume stroke centers, neurology residents and attending neurologists received an online questionnaire concerning informed consent for thrombolysis with tissue-type plasminogen activator (tPA). The respondents were asked to report their usual informed consent practice for tPA treatment and their considerations on whether informed consent should be obtained. Results From the 203 invited clinicians, 50% (n = 101) completed the questionnaire. One-third of the neurology residents (n = 21) and 21% of the neurologists (n = 8) reported that they always obtain informed consent for tPA treatment. If a patient is not capable of providing informed consent, 30% of the residents (n = 19) reported that they start tPA treatment without informed consent. In these circumstances, 53% of the neurologists (n = 20) reported that the resident under their supervision would start tPA treatment without informed consent. Most neurologists (n = 21; 55%) and neurology residents (n = 45; 72%) obtained informed consent within one minute. None of the respondents used more than five minutes for informed consent. Important themes regarding obtaining informed consent for treatment were patients’ capacity, and medical, ethical and legal considerations. Conclusion The current practice of informed consent for thrombolysis in acute ischemic stroke varies among neurologists and neurology residents. If informed consent is obtained, most clinicians stated to obtain informed consent within one minute. In the future, a shortened information provision process may be applied, making a shift from informed consent to informed refusal, while still considering the patient’s capacity, stroke severity, and possible treatment delays. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00684-6.
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Affiliation(s)
- Valentijn J Zonjee
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands.
| | - Jos P L Slenders
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
| | - Frank de Beer
- Department of Neurology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Marieke C Visser
- Department of Neurology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Bastiaan C Ter Meulen
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
| | - Renske M Van den Berg-Vos
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands.,Department of Neurology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Sander M van Schaik
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
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20
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Chen J, Duris K, Yang X. Effect of cerebral microbleeds on hemorrhagic transformation and functional prognosis after intravenous thrombolysis of cerebral infarction. BRAIN HEMORRHAGES 2021. [DOI: 10.1016/j.hest.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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21
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Jiang J, Tan C, Zhou W, Peng W, Zhou X, Du J, Wang H, Mo L, Liu X, Chen L. Plasma C-Reactive Protein Level and Outcome of Acute Ischemic Stroke Patients Treated by Intravenous Thrombolysis: A Systematic Review and Meta-Analysis. Eur Neurol 2021; 84:145-150. [PMID: 33839726 DOI: 10.1159/000514099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/25/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The plasma C-reactive protein (CRP) level in predicting prognosis of acute ischemic stroke (AIS) patients receiving intravenous thrombolysis (IVT) is not yet established. This study is aiming to investigate the relationship between the plasma CRP level and outcome of AIS patients receiving IVT. METHODS PubMed and EMBASE were searched for relevant studies that evaluated the relationship between the CRP level and outcome of AIS patients receiving IVT. STATA 12.0 was used to pool the data for meta-analysis. RESULTS In total, 8 studies were included. Six studies reported a positive relationship between the high CRP level and unfavorable outcome at 3 months. Five studies associated the high plasma CRP level with high mortality at 3 months. And meta-analysis further confirmed that the high CRP level was related to unfavorable outcomes (odds ratio [OR] = 1.716, 95% CI: 1.170-2.517, p = 0.006) and mortality (OR = 2.751, 95% CI: 1.613-4.693, p < 0.001) at 3 months. However, an elevated CRP level was not found to increase the risk of symptomatic intracerebral hemorrhage. CONCLUSION A high plasma CRP level was associated with a 3-month poor outcome of AIS patients treated with IVT. CRP may be used as a biomarker for the risk stratification of AIS patients as candidates receiving IVT or other alternative therapy such as mechanical thrombectomy.
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Affiliation(s)
- Jin Jiang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Changhong Tan
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wen Zhou
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wuxue Peng
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuan Zhou
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Juncong Du
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hui Wang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lijuan Mo
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xi Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lifen Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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22
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Ohta M. Causality assessment between reported fatal cerebral haemorrhage and suspected drugs: developing a new algorithm based on the analysis of the Japanese Adverse Event Report (JADER) database and literature review. Eur J Clin Pharmacol 2021; 77:1443-1452. [PMID: 33829295 DOI: 10.1007/s00228-021-03131-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Cerebral haemorrhage is a life-threatening event with various causes including adverse drug reactions (ADRs). Several methods have been proposed for the causality assessment of ADRs, but none specific for cerebral haemorrhage. The purpose of this study was to develop an algorithm for causality assessment between drugs and fatal cerebral haemorrhage, based on the analysis of data from the Japanese Adverse Drug Event Report (JADER) database and literature review. METHODS All fatal ADRs reported in the JADER database between April 2004 and March 2020 were searched, and literature on drug-related cerebral haemorrhage or general causality assessment was reviewed to summarise the information on causality between cerebral haemorrhage and ADRs. RESULTS Of the 50,095 cases identified in the JADER database, cerebral haemorrhage was the fifth most reported cause of fatal ADRs, but the causality of >80% of the events was published as 'Unassessable'. The literature review identified articles on drug-related cerebral haemorrhage and causality assessment methods in general. Based on these articles, information on five categories (temporal relationship, previous knowledge about the relationship between drug action and ADRs, alternative aetiological candidate, appropriateness of drug use, and the relationship between death and ADRs) was determined for causality assessment between a suspected drug and fatal cerebral haemorrhage; a new algorithm was created using this information. CONCLUSION In this study, the information considered necessary for causality assessment between drugs and fatal cerebral haemorrhage was reviewed and an assessment algorithm was developed. Future studies are needed to validate the usefulness of this method.
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Affiliation(s)
- Miki Ohta
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia.
- Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan.
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Effect of off-hour versus work-hour thrombolysis for acute ischemic stroke on emergency department patients' outcome: a retrospective study. Eur J Emerg Med 2021; 28:104-110. [PMID: 33136733 DOI: 10.1097/mej.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Early management of patients with acute ischemic stroke is crucial regardless of the time of presentation. The aim of the study was to evaluate the effect of off-hours management of patients with ischemic stroke that underwent thrombolytic therapy in the emergency department. METHODS This is a single-center retrospective study included ischemic stroke patients who received thrombolysis in the emergency department from January 2009 to April 2017. Patients who presented between 08:00 and 17:00 Monday to Friday were in the 'work-hour group (group 1)' versus others who were considered 'off-hours (group 2)'. Primary endpoint was 3-month mortality. Secondary endpoints included the National Institutes of Health Stroke Scale and dramatic recovery rate at 24 h, intracranial hemorrhage, systemic hemorrhage and modified Rankin Scale at the 3 months. Symptom-to-needle time, door-to-computed tomography time, and door-to-needle time were also compared between groups. RESULTS A total of 399 ischemic stroke patients were included in the analysis, 137 (34%) during work-hours and 262 (66%) during off-hours. The mortality rate was not different at 3 months between groups: 24 (17.5%) in the work-hours group versus 38 (14.5%) in the off-hours group [odds ratio 1.25; 95% confidence interval (CI), 0. 72-2.19]. There were no differences between groups on secondary endpoints. The mean time of symptom-to-needle was significantly higher during off-hours (mean difference: 18.4 min; 95% CI, 7.81-29.0). CONCLUSIONS In this study, there were no significant differences in mortality and functional outcomes at 3 months between patients who underwent off-hour or work-hour thrombolysis in the emergency department.
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Lee JS, Hwang YH, Sohn SI. Factors Contributing to an Efficacious Endovascular Treatment for Acute Ischemic Stroke in Asian Population. Neurointervention 2021; 16:91-110. [PMID: 33765729 PMCID: PMC8261106 DOI: 10.5469/neuroint.2020.00339] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 02/19/2021] [Indexed: 12/13/2022] Open
Abstract
Although randomized control trials about endovascular treatment (EVT) of emergent large vessel occlusion (LVO) have demonstrated the success of mechanical thrombectomy as the choice of treatment, a wide range of caveats remain unaddressed. Asian patients were rarely included in the trials, thereby raising the question of whether the treatment could be generalized. In addition, there remains a concern on the feasibility of the method with respect to its application against intracranial atherosclerosis (ICAS)-related LVO, frequently observed in the Asian population. It is important to include evidence on ICAS LVO from Asian countries in the future for a comprehensive understanding of LVO etiology. Besides the issues with EVT, prognostic concerns in diabetes patients, acute kidney injury following EVT, neuroprotective management against reperfusion injury, and other peri-EVT issues should be considered in clinical practice. In the current article, we present an in-depth review of the literature that revises information pertaining to such concerns.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Kyemyung University School of Medicine, Daegu, Korea
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Abstract
Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.
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Affiliation(s)
- Arturo Montaño
- Departments of Neurology and Neurosurgery, University of Colorado, Aurora, CO, United States
| | - Daniel F Hanley
- Departments of Neurology and Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - J Claude Hemphill
- Departments of Neurology and Neurosurgery, University of California San Francisco, San Francisco, CA, United States.
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Hemodynamics in acute stroke: Cerebral and cardiac complications. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:295-317. [PMID: 33632449 DOI: 10.1016/b978-0-12-819814-8.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hemodynamics is the study of blood flow, where parameters have been defined to quantify blood flow and the relationship with systemic circulatory changes. Understanding these perfusion parameters, the relationship between different blood flow variables and the implications for ischemic injury are outlined in the ensuing discussion. This chapter focuses on the hemodynamic changes that occur in ischemic stroke, and their contribution to ischemic stroke pathophysiology. We discuss the interaction between cardiovascular response and hemodynamic changes in stroke. Studying hemodynamic changes has a key role in stroke prevention, therapeutic implications and prognostic importance in acute ischemic stroke: preexisting hemodynamic and autoregulatory impairments predict the occurrence of stroke. Hemodynamic failure predisposes to the formation of thromboemboli and accelerates infarction due to impairing compensatory mechanisms. In ischemic stroke involving occlusion of a large vessel, persistent collateral circulation leads to preservation of ischemic penumbra and therefore justifying endovascular thrombectomy. Following thrombectomy, impaired autoregulation may lead to reperfusion injury and hemorrhage.
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Maïer B, Desilles JP, Mazighi M. Intracranial Hemorrhage After Reperfusion Therapies in Acute Ischemic Stroke Patients. Front Neurol 2020; 11:599908. [PMID: 33362701 PMCID: PMC7759548 DOI: 10.3389/fneur.2020.599908] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022] Open
Abstract
Reperfusion therapies are the mainstay of acute ischemic stroke (AIS) treatments and overall improve functional outcome. Among the established complications of intravenous (IV) tissue-type plasminogen activator (tPA), intracranial hemorrhage (ICH) is by far the most feared and has been extensively described by seminal works over the last two decades. Indeed, IV tPA is associated with increased odds of any ICH and symptomatic ICH responsible for increased mortality rate during the first week after an AIS. Despite these results, IV tPA has been found beneficial in several pioneering randomized trials and improves functional outcome at 3 months. Endovascular therapy (EVT) combined with IV tPA for AIS patients consecutive to an anterior circulation large-vessel occlusion does not increase ICH occurrence. Of note, EVT following IV tPA leads to significantly higher rates of early reperfusion than with IV tPA alone, with no difference in ICH, which challenges the paradigm of reperfusion as a major prognostic factor for ICH complications. However, several blood biomarkers (glycemia, platelet and neutrophil count), clinical factors (age, AIS severity, blood pressure management, diabetes mellitus), and neuroradiological factors (cerebral microbleeds, infarct size) have been identified as risk factors for ICH after reperfusion therapy. In the years to come, the ultimate goal will be to further improve either reperfusion rates and functional outcome, while reducing hemorrhagic complications. To this end, various approaches being investigated are discussed in this review, such as blood-pressure control after reperfusion or the use of new antiplatelet agents as an adjunct to IV tPA and exhibit reduced hemorrhagic potential during the early phase of AIS.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Jean Philippe Desilles
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
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Yuan CX, Ruan YT, Zeng YY, Cheng HR, Cheng QQ, Chen YB, He WL, Huang GQ, He JC. Liver Fibrosis Is Associated With Hemorrhagic Transformation in Patients With Acute Ischemic Stroke. Front Neurol 2020; 11:867. [PMID: 33013622 PMCID: PMC7512114 DOI: 10.3389/fneur.2020.00867] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/07/2020] [Indexed: 12/05/2022] Open
Abstract
Background: Hemorrhagic transformation (HT) is a frequent, often asymptomatic event that occurs after acute ischemic stroke (AIS). Liver fibrosis, usually subclinical, is common and crucial in the development of liver disease. We aimed to investigate the association between liver fibrosis and HT in patients with AIS. Methods: We performed a single-center and retrospective study. A total of 185 consecutive participants with HT and 199 age- and sex-matched stroke patients without HT were enrolled in this study. We calculated one validated fibrosis index—Fibrosis-4 (FIB-4) score—to assess the extent of liver fibrosis. HT was detected by routine CT or MRI and was radiologically classified as hemorrhagic infarction type 1 or 2 or parenchymal hematoma type 1 or 2. HT was also classified into asymptomatic or symptomatic. We used logistic regression models adjusted for previously established risk factors to assess the risks for HT. Results: The median FIB-4 score was significantly higher among patients who developed HT than among those without HT, whereas standard hepatic assays were largely normal. Patients were assigned to groups of high FIB-4 score and low FIB-4 score based on the optimal cutoff value. Compared with the subjects in the low-FIB-4-score group, incidence of HT for the high-FIB-4-score group was significantly higher. After adjustment for potential confounders, the patients with high FIB-4 score had 3.461-fold risk of HT in AIS compared to the patients with low FIB-4 score [odds ratio, 3.461 (95% CI, 1.404–8.531)]. Conclusion: Liver fibrosis, measured by FIB-4 score, was independently associated with the risk of HT in AIS patients.
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Affiliation(s)
- Cheng-Xiang Yuan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yi-Ting Ruan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ya-Ying Zeng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hao-Ran Cheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qian-Qian Cheng
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Yun-Bin Chen
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wei-Lei He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Gui-Qian Huang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jin-Cai He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Bivard A, Kleinig T, Churilov L, Levi C, Lin L, Cheng X, Chen C, Aviv R, Choi PMC, Spratt NJ, Butcher K, Dong Q, Parsons M. Permeability Measures Predict Hemorrhagic Transformation after Ischemic Stroke. Ann Neurol 2020; 88:466-476. [PMID: 32418242 PMCID: PMC7496077 DOI: 10.1002/ana.25785] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVE We sought to examine the diagnostic utility of existing predictors of any hemorrhagic transformation (HT) and compare them with new perfusion imaging permeability measures in ischemic stroke patients receiving alteplase only. METHODS A pixel-based analysis of pretreatment CT perfusion (CTP) was undertaken to define the optimal CTP permeability thresholds to predict the likelihood of HT. We then compared previously proposed predictors of HT using regression analyses and receiver operating characteristic curve analysis to produce an area under the curve (AUC). We compared AUCs using χ2 analysis. RESULTS From 5 centers, 1,407 patients were included in this study; of these, 282 had HT. The cohort was split into a derivation cohort (1,025, 70% patients) and a validation cohort (382 patients or 30%). The extraction fraction (E) permeability map at a threshold of 30% relative to contralateral had the highest AUC at predicting any HT (derivation AUC 0.85, 95% confidence interval [CI], 0.79-0.91; validation AUC 0.84, 95% CI 0.77-0.91). The AUC improved when permeability was assessed within the acute perfusion lesion for the E maps at a threshold of 30% (derivation AUC 0.91, 95% CI 0.86-0.95; validation AUC 0.89, 95% CI 0.86-0.95). Previously proposed associations with HT and parenchymal hematoma showed lower AUC values than the permeability measure. INTERPRETATION In this large multicenter study, we have validated a highly accurate measure of HT prediction. This measure might be useful in clinical practice to predict hemorrhagic transformation in ischemic stroke patients before receiving alteplase alone. ANN NEUROL 2020;88:466-476.
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Affiliation(s)
- Andrew Bivard
- Departments of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Leonid Churilov
- Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Christopher Levi
- Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Longting Lin
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, New South Wales, Australia
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chushuang Chen
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, New South Wales, Australia
| | - Richard Aviv
- Department of Radiology, Neuroradiology section, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Philip M C Choi
- Department of Neuroscience, Eastern Health. Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Neil J Spratt
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, New South Wales, Australia
| | - Kenneth Butcher
- Department of Neurology, Department of Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Mark Parsons
- Departments of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Malhotra K, Katsanos AH, Goyal N, Tayal A, Gensicke H, Mitsias PD, De Marchis GM, Berge E, Alexandrov AW, Alexandrov AV, Tsivgoulis G. Intravenous thrombolysis in patients with chronic kidney disease: A systematic review and meta-analysis. Neurology 2020; 95:e121-e130. [PMID: 32554767 DOI: 10.1212/wnl.0000000000009756] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 12/12/2019] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To determine the association of chronic kidney disease (CKD) with the safety and efficacy of IV thrombolysis (IVT) among patients with acute ischemic stroke (AIS). METHODS A systematic review and pairwise meta-analysis of studies involving patients with CKD undergoing IVT for AIS were conducted to evaluate the following outcomes: symptomatic intracranial hemorrhage (sICH), asymptomatic and any intracranial hemorrhage (ICH), in-hospital and 3-month mortality, 3-month favorable functional outcome (FFO; modified Rankin Scale [mRS] score 0-1), and 3-month functional independence (FI, mRS score 0-2). CKD was defined with estimated glomerular filtration rate (eGFR) ranging from mild (eGFR 60-89 mL/min) to moderate (eGFR 30-59 mL/min) to severe (eGFR 15-29 mL/min). RESULTS We identified 20 studies comprising 60,486 patients with AIS treated with IVT. In unadjusted analyses, CKD was associated with sICH according to the National Institute of Neurological Disorders and Stroke (NINDS) (7 studies; odds ratio [OR] 1.41, 95% confidence interval [CI] 1.19-1.67) and European Cooperative Acute Stroke Study (ECASS) II (9 studies; OR 1.37, 95% CI 1.01-1.85) definitions, any ICH (8 studies; OR 1.42, 95% CI 1.18-1.70), 3-month mortality (9 studies; OR 2.20, 95% CI 1.72-2.81), 3-month FFO (8 studies; OR 0.58, 95% CI 0.47-0.72), and 3-month FI (8 studies; OR 0.57, 95% CI 0.46-0.71). In adjusted analyses, CKD was associated with sICH according to NINDS (4 studies; ORadj 1.34, 95% CI 1.01-1.79) and ECASS II (3 studies; ORadj 2.08, 95% CI 1.27-3.43) definitions, any ICH (6 studies; ORadj 1.41, 95% CI 1.01-1.97), in-hospital mortality (2 studies; ORadj 1.19, 95% CI 1.09-1.30), and 3-month FFO (6 studies; ORadj 0.80, 95% CI 0.70-0.92). CONCLUSIONS After adjustment for confounders in this pairwise meta-analysis, moderate to severe CKD is associated with increased risks of ICH and worse functional outcomes among patients with AIS treated with IVT.
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Affiliation(s)
- Konark Malhotra
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece.
| | - Aristeidis H Katsanos
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Nitin Goyal
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Ashis Tayal
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Henrik Gensicke
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Panayiotis D Mitsias
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Gian Marco De Marchis
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Eivind Berge
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Anne W Alexandrov
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Andrei V Alexandrov
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Georgios Tsivgoulis
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
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Malhotra K, Katsanos AH, Goyal N, Ahmed N, Strbian D, Palaiodimou L, Karapanayiotides T, Alexandrov AW, Grotta JC, Alexandrov AV, Tsivgoulis G. Safety and efficacy of dual antiplatelet pretreatment in patients with ischemic stroke treated with IV thrombolysis: A systematic review and meta-analysis. Neurology 2020; 94:e657-e666. [PMID: 31959709 DOI: 10.1212/wnl.0000000000008961] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/29/2019] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Conflicting data exist on the safety and efficacy of IV thrombolysis (IVT) in patients with acute ischemic stroke (AIS) receiving dual antiplatelet pretreatment (DAPP). The aim of the present systematic review and meta-analysis is to assess the safety and outcome of DAPP history among patients with AIS treated with IVT. METHODS We performed a comprehensive literature review to identify studies that investigated the safety and efficacy of DAPP among patients with AIS treated with IVT. RESULTS We identified 9 studies comprising 66,675 patients. In unadjusted analyses, DAPP was associated with a higher likelihood of pooled symptomatic intracranial hemorrhage (sICH; odds ratio [OR] 2.26; 95% confidence interval [CI] 1.39-3.67) and 3-month mortality (OR 1.47; 95% CI 1.25-1.73). DAPP was also related to higher odds of sICH according to Safe Implementation of Treatments in Stroke Monitoring Study (OR 2.71; 95% CI 2.05-3.59), European Cooperative Acute Stroke Study II (OR 2.23; 95% CI 1.46-3.40), and National Institute of Neurological Disorders and Stroke (OR 1.59, 95% CI 1.38-1.83) definitions. There was no association between DAPP and 3-month favorable functional outcome (FFO, modified Rankin Scale [mRS] score 0-1) and 3-month functional independence (FI; mRS score 0-2). In adjusted analyses, history of DAPP was not associated with pooled sICH (OR 2.03; 95% CI 0.75-5.52), 3-month mortality (OR 1.11; 95% CI 0.87-1.40), 3-month FFO (OR 0.92; 95% CI 0.77-1.09), and 3-month FI (OR 1.01; 95% CI 0.89-1.15). CONCLUSIONS After adjustment for potential confounders, DAPP appears not to be associated with higher risk of adverse outcomes in patients with AIS treated with IVT.
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Affiliation(s)
- Konark Malhotra
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Aristeidis H Katsanos
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Nitin Goyal
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Niaz Ahmed
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Daniel Strbian
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Lina Palaiodimou
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Theodore Karapanayiotides
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Anne W Alexandrov
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - James C Grotta
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Andrei V Alexandrov
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston
| | - Georgios Tsivgoulis
- From the Department of Neurology (K.M.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., A.W.A., A.V.A, G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (N.A.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A.), Karolinska Institute, Stockholm, Sweden; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; Second Department of Neurology (A.H.K., L.P., G.T.), National and Kapodistrian University of Athens, "Attikon" University Hospital; Second Department of Neurology (T.K.), AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; and Clinical Innovation and Research Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston.
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Christoforidis GA, Saadat N, Kontzialis M, Karakasis CJ, Slivka AP. Predictors for the extent of pial collateral recruitment in acute ischemic stroke. Neuroradiol J 2020; 33:98-104. [PMID: 31896284 DOI: 10.1177/1971400919897389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pial arterioles can provide a variable degree of collateral flow to ischemic vascular territories during acute ischemic stroke. This study sought to identify predictive factors of the degree of pial collateral recruitment in acute ischemic stroke. METHODS Clinical information and arteriograms from 62 consecutive patients with stroke due to either middle cerebral artery (MCA) M1 segment or internal carotid artery (ICA) terminus occlusion within 6 h following symptom onset were retrospectively reviewed. Pial collaterals were defined based on the extent of reconstitution of the MCA territory. Patients with slow antegrade flow distal to the occlusion site were excluded and no anesthetics were used prior or during angiography. Results were analyzed using multivariate nominal logistic regression. RESULTS Better pial collateral recruitment was associated with proximal MCA versus ICA terminus occlusion (p = 0.005; odds ratio (OR) = 9.3; 95% confidence interval (CI), 2.16-53.3), lower presenting National Institutes of Health Stroke Scale Score (NIHSSS) (p = 0.023; OR = 6.51; 95% CI, 1.49-41.7), and lower diastolic blood pressure (p = 0.0411; OR = 5.05; 95% CI, 1.20-29.2). Age, gender, symptom duration, diabetes, laterality, systolic blood pressure, glucose level, hematocrit, platelet level, and white blood cell count at presentation were not found to have a statistically significant association with pial collateral recruitment. CONCLUSIONS Extent of pial collateral recruitment is strongly associated with the occlusion site (MCA M1 segment versus ICA terminus) and less strongly associated with presenting NIHSSS and diastolic blood pressure.
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Tapeinos C, Battaglini M, Marino A, Ciofani G. Smart diagnostic nano-agents for cerebral ischemia. J Mater Chem B 2020; 8:6233-6251. [DOI: 10.1039/d0tb00260g] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A summary of the latest developments on imaging techniques and smart nano-diagnostics used for ischemic stroke.
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Affiliation(s)
- Christos Tapeinos
- Istituto Italiano di Tecnologia
- Smart Bio-Interfaces
- 56025 Pontedera
- Italy
| | - Matteo Battaglini
- Istituto Italiano di Tecnologia
- Smart Bio-Interfaces
- 56025 Pontedera
- Italy
- Scuola Superiore Sant’Anna
| | - Attilio Marino
- Istituto Italiano di Tecnologia
- Smart Bio-Interfaces
- 56025 Pontedera
- Italy
| | - Gianni Ciofani
- Istituto Italiano di Tecnologia
- Smart Bio-Interfaces
- 56025 Pontedera
- Italy
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34
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Wang M, Li C, Shi W. Stomatin-like protein-2 confers neuroprotection effect in oxygen-glucose deprivation/reoxygenation-injured neurons by regulating AMPK/Nrf2 signalling. J Drug Target 2019; 28:600-608. [PMID: 31791154 DOI: 10.1080/1061186x.2019.1700262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Stomatin-like protein-2 (SLP-2) has emerged as a cytoprotective protein that confers a protective effect against various stresses. However, whether SLP-2 confers neuroprotection during cerebral ischemia/reperfusion injury remains unclear. In the present study, we investigated the role of SLP-2 in regulating oxygen-glucose deprivation/reoxygenation (OGD/R)-induced apoptosis and oxidative stress, which has been used as an in vitro model of cerebral ischemia/reperfusion injury. We found that OGD/R treatment resulted in a significant reduction in SLP-2 expression in neurons. Functional experiments demonstrated that SLP-2 overexpression significantly increased cell viability and decreased cell apoptosis and reactive oxygen species (ROS) production in OGD/R-exposed neurons, while SLP-2 inhibition showed the opposite effect. Notably, SLP-2 overexpression was shown to up-regulate the phosphorylation of adenosine monophosphate-activated protein kinase (AMPK). In addition, SLP-2 overexpression increased the nuclear expression of nuclear factor (erythroid-derived 2)-like 2 and reinforced the activity of Nrf2/antioxidant response element (ARE)-mediated transcription. However, AMPK inhibition or Nrf2/ARE inhibition partially reversed SLP-2-mediated neuroprotection effect in OGD/R-exposed neurons. Taken together, these results demonstrate that SLP-2 confers neuroprotection effect in OGD/R-injured neurons associated with reinforcing AMPK/Nrf2 signalling, suggesting SLP-2 as a potential therapeutic target for cerebral ischemia/reperfusion injury.
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Affiliation(s)
- Minjuan Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Neurology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, China
| | - Chengliang Li
- Department of General Practice, The First Affiliated Hospital of Xi'an Medical University, Xi'an, China
| | - Wei Shi
- Department of Neurosurgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Yan S, Zhang X, Zhang R, Xu J, Lou M. Early Fibrinogen Depletion and Symptomatic Intracranial Hemorrhage After Reperfusion Therapy. Stroke 2019; 50:2716-2721. [PMID: 31394994 DOI: 10.1161/strokeaha.119.025711] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
We aimed to thoroughly investigate the relationship between early fibrinogen depletion and symptomatic intracranial hemorrhage (sICH) in patients receiving reperfusion therapy including intravenous thrombolysis (IVT) with or without endovascular thrombectomy (EVT).
Methods—
This study included 1135 stroke patients with baseline and follow-up fibrinogen levels at 2 hours after the beginning of alteplase infusion for those with IVT only or immediately after the end of EVT for those with combined IVT and EVT. Patients received alteplase up to 9 hours after the onset or on awakening based on automated perfusion imaging. sICH was ascertained using ECASS II (The Second European-Australasian Acute Stroke Study) criteria. Δfibrinogen was calculated as follow-up fibrinogen minus baseline fibrinogen.
Results—
In patients with IVT only, baseline fibrinogen level was 3.36±0.94 g/L and decreased to 2.47±0.80 g/L at 2 hours after the beginning of alteplase infusion. In patients with IVT followed by EVT, baseline fibrinogen level was 3.35±0.82 g/L and decreased to 2.52±0.83 g/L immediately after the end of EVT. sICH was observed in 44 (3.9%) patients. The extent of Δfibrinogen was associated with sICH in patients with IVT only (odds ratio, 1.929; 95% CI, 1.402–2.654;
P
<0.001) and in those with IVT followed by EVT (odds ratio, 1.765; 95% CI, 1.135–2.743;
P
=0.012).
Conclusions—
An early decrease in fibrinogen levels was related to sICH after reperfusion therapy with alteplase. More fibrin-specific thrombolytic agents are warranted to be tested in acute ischemic stroke patients.
Clinical Trial Registration—
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT03367286.
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Affiliation(s)
- Shenqiang Yan
- From the Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xuting Zhang
- From the Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Ruoxia Zhang
- From the Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jinjin Xu
- From the Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Min Lou
- From the Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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Efficacy and Safety of Intravenous Thrombolysis in Patients with Unknown Onset Stroke: A Meta-Analysis. Behav Neurol 2019; 2019:5406923. [PMID: 31565095 PMCID: PMC6745097 DOI: 10.1155/2019/5406923] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/25/2019] [Indexed: 12/31/2022] Open
Abstract
Objectives Unknown onset stroke (UOS) is usually excluded from intravenous thrombolysis concerning the unclear symptom onset time. Attempts have been done to use thrombolytic therapy in these patients. The current meta-analysis was done to examine the efficacy and safety of intravenous thrombolysis in UOS. Methods PubMed, Web of Science, and Cochrane Library were searched for studies comparing thrombolysis with conservative therapy among UOSs. Data of good outcome (mRS, 0-2), mortality, and intracerebral hemorrhage (ICH) and symptomatic ICH (sICH) were extracted and analyzed using the Revman 5.2 software. Results In total, 8 studies with 1271 subjects (542 with thrombolysis and 729 with conservative therapy) were included in this meta-analysis. The data showed that patients receiving thrombolysis had a higher incidence of 90-day good outcome (P = 0.0005) than conservative therapy. The comparison of discharge (P = 0.89) and 90-day mortality (P = 0.10) in both groups did not find any significances. The incidences of ICH (P = 0.42) and sICH (P = 0.06) were relatively comparable between the two therapies. Conclusions Intravenous thrombolysis is a better choice for UOS patients for its efficacy and safety. In addition, pretreatment imaging assessment is beneficial for improving the efficacy of thrombolytic therapy. However, it needs more supporting evidences for clinical use in the future.
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Low triiodothyronine syndrome is associated with hemorrhagic transformation in patients with acute ischaemic stroke. Aging (Albany NY) 2019; 11:6385-6397. [PMID: 31454331 PMCID: PMC6738409 DOI: 10.18632/aging.102195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/10/2019] [Indexed: 12/23/2022]
Abstract
Hemorrhagic transformation (HT) is a severe complication occurring in acute ischemic stroke (AIS) patients. We explored the association between low triiodothyronine (T3) syndrome and HT in AIS patients. A total of 208 consecutive participants with HT and 208 age- and sex-matched stroke patients without HT were enrolled in this study. HT was diagnosed by follow-up imaging assessment, and was radiologically classified as hemorrhagic infarction (HI) type 1 or 2 or parenchymal hematoma (PH) type 1 or 2. HT was also classified into asymptomatic or symptomatic. The incidence of low T3 syndrome was significantly higher among patients who developed HT than among those without HT. Moreover, the more severe the HT, the lower the detected T3 levels. Multivariate-adjusted binary logistic regression showed that low T3 syndrome was an independent risk factor for HT and symptomatic HT in AIS patients. Low T3 syndrome was also significantly associated with a higher risk of PH, but not with the risk of HI. Thus, low T3 syndrome was independently associated with the risk of HT, symptomatic HT, and severe HT (PH) in AIS patients, which suggests monitoring T3 could be a useful means of preventing HT in patients with ischemic stroke.
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Abstract
PURPOSE OF REVIEW This article provides updated information regarding the diagnosis and treatment (specifically critical care management) of acute ischemic stroke. This article also discusses the increased use of thrombolysis and thrombectomy in clinical practice. RECENT FINDINGS Stroke is the leading cause of disability in the United States. A significant proportion of patients with acute ischemic stroke require critical care management. Much has changed in the early evaluation and treatment of patients presenting with acute ischemic stroke. The introduction of embolectomy in large vessel occlusions for up to 24 hours post-symptom onset has resulted in one in every three eligible patients with acute ischemic stroke with the potential to lead an independent lifestyle. These patients increasingly require recognition of complications and initiation of appropriate interventions as well as earlier admission to dedicated neurocritical care units to ensure better outcomes. SUMMARY This article emphasizes issues related to the management of patients with acute ischemic stroke undergoing mechanical thrombectomy and thrombolysis and addresses the complex physiologic changes affecting neurologic and other organ systems.
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Statin, cholesterol, and sICH after acute ischemic stroke: systematic review and meta-analysis. Neurol Sci 2019; 40:2267-2275. [PMID: 31267305 DOI: 10.1007/s10072-019-03995-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE Conflicts exist regarding relationship between prior/new statin use, cholesterol, and early poststroke intracranial hemorrhage (ICH) in acute ischemic stroke (AIS) patients. This meta-analysis is aimed at evaluating the safety of prior/new statin use, cholesterol level and risk of ICH in AIS patients. METHODS We searched PubMed and Embase for studies examining relation between statin use, cholesterol level, and early poststroke ICH in AIS. Included studies should report risk of early poststroke symptomatic ICH (sICH) or overall ICH. A random-effects model was used to pool the data. RESULTS Twenty-five articles involving 26,327 participants were included, among whom 925 had sICH. Prior statin use was not associated with overall ICH (adjusted odds ratio (OR), 1.478; 95% confidence interval (CI), 0.924-2.362; p = 0.103) and sICH in patients who received thrombolysis (adjusted OR, 1.567; 95% CI, 0.994-2.471; p = 0.053) or overall ICH in patients, most of whom had not received recanalization therapy (crude OR, 1.342; 95% CI, 0.872-2.065; p = 0.181). New statin use was associated with decreased sICH after recanalization therapy (crude OR, 0.292; 95% CI, 0.168-0.507; p < 0.001).Cholesterol level was not associated with overall ICH. CONCLUSION Prior/new statin use and lower cholesterol level are not risk factors for sICH and overall ICH in AIS patients, whether or not the patient has received recanalization therapy. New statin use is likely associated with decreased sICH.
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Cathepsin K Knockout Exacerbates Haemorrhagic Transformation Induced by Recombinant Tissue Plasminogen Activator After Focal Cerebral Ischaemia in Mice. Cell Mol Neurobiol 2019; 39:823-831. [PMID: 31065924 DOI: 10.1007/s10571-019-00682-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 04/29/2019] [Indexed: 12/19/2022]
Abstract
Severe haemorrhagic transformation (HT), a common complication of recombinant tissue plasminogen activator (rtPA) treatment, predicts poor clinical outcomes in acute ischaemic stroke. The search for agents to mitigate this effect includes investigating biomolecules involved in neovascularization. This study examines the role of Cathepsin K (Ctsk) in rtPA-induced HT after focal cerebral ischaemia in mice. After knockout of Ctsk, the gene encoding Ctsk, the outcomes of Ctsk+/+ and Ctsk-/- mice were compared 24 h after rtPA-treated cerebral ischaemia with respect to HT severity, neurological deficits, brain oedema, infarct volume, number of apoptotic neurons and activated microglia/macrophage, blood-brain barrier integrity, vascular endothelial growth factor (VEGF) expression and Akt-mTOR pathway activation. We observed that haemoglobin levels, brain oedema and infarct volume were significantly greater and resulted in more severe neurological deficits in Ctsk-/- than in Ctsk+/+ mice. Consistent with our hypothesis, the number of NeuN-positive neurons was lower and the number of TUNEL-positive apoptotic neurons and activated microglia/macrophage was higher in Ctsk-/- than in Ctsk+/+ mice. Ctsk knockout mice exhibited more severe blood-brain barrier (BBB) disruption, with microvascular endothelial cells exhibiting greater VEGF expression and lower ratios of phospo-Akt/Akt and phospo-mTOR/mTOR than in Ctsk+/+ mice. This study is the first to provide molecular insights into Ctsk-regulated HT after cerebral ischaemia, suggesting that Ctsk deficiency may disrupt the BBB via Akt/mTOR/VEGF signalling, resulting in neurological deficits and neuron apoptosis. Ctsk administration has the potential as a novel modality for improving the safety of rtPA treatment following stroke.
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Vitt JR, Trillanes M, Hemphill JC. Management of Blood Pressure During and After Recanalization Therapy for Acute Ischemic Stroke. Front Neurol 2019; 10:138. [PMID: 30846967 PMCID: PMC6394277 DOI: 10.3389/fneur.2019.00138] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 02/04/2019] [Indexed: 12/31/2022] Open
Abstract
Ischemic stroke is a common neurologic condition and can lead to significant long term disability and death. Observational studies have demonstrated worse outcomes in patients presenting with the extremes of blood pressure as well as with hemodynamic variability. Despite these associations, optimal hemodynamic management in the immediate period of ischemic stroke remains an unresolved issue, particularly in the modern era of revascularization therapies. While guidelines exist for BP thresholds during and after thrombolytic therapy, there is substantially less data to guide management during mechanical thrombectomy. Ideal blood pressure targets after attempted recanalization depend both on the degree of reperfusion achieved as well as the extent of infarction present. Following complete reperfusion, lower blood pressure targets may be warranted to prevent reperfusion injury and promote penumbra recovery however prospective clinical trials addressing this issue are warranted.
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Affiliation(s)
- Jeffrey R. Vitt
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Michael Trillanes
- Department of Pharmaceutical Services, University of California, San Francisco, San Francisco, CA, United States
| | - J. Claude Hemphill
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
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Seo KD, Suh SH, Heo JH, Kim BM, Lee KY. Increased Risk of Intracranial Hemorrhage and Mortality Following Thrombolysis in Patients with Stroke and Active Cancer. ACTA ACUST UNITED AC 2018. [DOI: 10.31728/jnn.2018.00020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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43
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Mechanical thrombectomy outcomes in large vessel stroke with high international normalized ratio. J Neurol Sci 2018; 396:193-198. [PMID: 30481657 DOI: 10.1016/j.jns.2018.11.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/29/2018] [Accepted: 11/15/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Evaluating the safety and efficacy of mechanical thrombectomy (MT) in acute stroke patients due to emergent large vessel occlusion (ELVO) with high international-normalized-ratio (INR). METHODS Consecutive ELVO patients treated with MT were evaluated from two centers. Outcome measures included symptomatic-intracranial-hemorrhage(sICH), three-month mortality, successful reperfusion(SR), and 3-month functional-independence(FI; mRS-scores of 0-2). Additionally, a meta-analysis of available cohort studies was performed to evaluate safety and efficacy of MT in ELVO patients with high INR. RESULTS A total of 315 ELVO patients were evaluated. Of those 10 patients had INR >1.7 [mean age 63.5 ± 15, median NIHSS-score: 17 points (IQR 14-22)],and remaining 305 ELVO patients had INR ≤ 1.7 ([mean age 62 ± 14.4, median NIHSS-score: 17 points (IQR 12-21)]. Patients with high INR did not differ in terms of sICH (10.0% vs. 6.9%; p = .706), 3-month mortality (20.0% vs. 24.2%; p = .762), SR (88.9% vs. 69.4%; p = .209) and 3-month FI (50% vs. 49.3%; p = .762) compared to the rest. Meta-analysis of available studies (n = 5) showed that high INR was not related to sICH (OR: 0.94, 95%CI: 0.42-2.07; p = .88), 3-month mortality (OR: 1.07, 95%CI: CI 0.72-1.60; p = .73) and 3-month FI (OR: 0.69, 95%CI: 0.34-1.40; p = .30). CONCLUSIONS MT can be performed safely and effectively in ELVO patients with high INR.
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Zhao H, Lu Y, Wang Y, Han X, Zhang Y, Han B, Wang T, Li Y, Wang S. Electroacupunture contributes to recovery of neurological deficits in experimental stroke by activating astrocytes. Restor Neurol Neurosci 2018; 36:301-312. [PMID: 29758953 DOI: 10.3233/rnn-170722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Neurological deficits is one of the most prevalent clinical manifestation after stroke. The effects of astrocytes activated by electroacupunture (EA) after stroke on the neurological recovery in middle cerebral artery occlusion (MCAO) rats was not clear and definite. OBJECTIVE Our previous study showed that treatment with EA for 7 days contributed to the activation of astrocytes in MCAO rats. The purposes of this study were to 1) confirm the effects of EA for 14 days on activation of astrocytes in MCAO rats, and 2) test the relationships between activation of astrocytes and neurological functional recovery induced by EA in MCAO rats. METHODS All rats were randomly divided into five groups: naïve control group, sham control control group, MCAO, MCAO/EAn, MCAO/EAd (n = 8, for each group). Rats in MCAO/EAn group received EA treatment at acupoints of Neiguan (PC06). MCAO/EAd group received EA stimulus at acupoints of Diji (SP08). The primary indicators were locomotor recovery, histopathology, immunohistochemistry, RT-PCR and Western blot. RESULTS The neurological deficit and histopathological improvements and activation of astrocytes were observed after EA treatment at acupoints PC06. Parametric correlation analyses revealed a cubic correlation relationship between activation of astrocytes and neurological recovery of MCAO rats treated with EA. CONCLUSION EA treatment at the acupoints of Neiguan involved in the regulation of activation of astrocytes, which our data suggested has a cubic correlation relationship with the neurological recovery of MCAO rats.
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Affiliation(s)
- Haijun Zhao
- Department of Anatomy and Histology, College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Changqing District, Jinan, Shandong, China
| | - Yan Lu
- Department of Experimental Acupuncture Science, College of Acumox and Tuina, Shandong University of Traditional Chinese Medicine, Changqing District, Jinan, Shandong, China
| | - Yuan Wang
- Department of Anatomy and Histology, College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Changqing District, Jinan, Shandong, China
| | - Xiaochun Han
- Department of Preventive Medicine, College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Changqing District, Jinan, Shandong, China
| | - Yanan Zhang
- Department of Pathology, College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Changqing District, Jinan, Shandong, China
| | - Bingbing Han
- Department of Pathology, College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Changqing District, Jinan, Shandong, China
| | - Tong Wang
- Department of Traditional Chinese Medicine Nursing, College of Nursing Care, Shandong University of Traditional Chinese Medicine, Changqing District, Jinan, China
| | - Yan Li
- Department of Pathology, College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Changqing District, Jinan, Shandong, China.,Department of Pharmaceutical Engineering, School of Chemistry and Pharmaceutical Engineering, Qilu University of Technology, Changqing District, Jinan, Shandong, China
| | - Shijun Wang
- Department of Pathology, College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Changqing District, Jinan, Shandong, China
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Lee SJ, Hwang YH, Hong JM, Choi JW, Yoon BS, Kang DH, Kim YW, Kim YS, Hong JH, Yoo J, Kim CH, Ovbiagele B, Demchuk AM, Sohn SI, Lee JS. Impact of varying levels of hyperglycemia on clinicoradiographic outcomes after endovascular reperfusion treatment. Sci Rep 2018; 8:9832. [PMID: 29959399 PMCID: PMC6026188 DOI: 10.1038/s41598-018-28175-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/18/2018] [Indexed: 01/04/2023] Open
Abstract
We evaluated the effects of admission hyperglycemia with different cut-off levels on 3-month outcomes, infarct growth, and hemorrhagic transformation in acute stroke patients with large artery occlusion of anterior circulation who received endovascular treatment (EVT). Between January 2011 and May 2016, patients that underwent EVT with pre-procedural and post-procedural diffusion-weighted imaging were identified from a multicenter registry. Normoglycemia was defined as a glucose level ≤ 110 mg/dL, moderate hyperglycemia as >110 and ≤170 mg/dL, and overt hyperglycemia as >170 mg/dL. Its effects on poor outcomes (3-month modified Rankin Scale score 3-6), infarct growth, and parenchymal hematoma type 2 were analyzed. Of 720 patients encountered, 341 patients were eligible. There was a statistically significant difference in glycated hemoglobin levels between the normoglycemia/moderate hyperglycemia and overt hyperglycemia groups (p < 0.001). Moderate hyperglycemia (odds ratio 2.37 [95% confidence interval 1.26-4.45], p = 0.007) and overt hyperglycemia (2.84 [1.19-6.81], p = 0.019) were associated with poor outcomes. Post-procedural infarct volumes were significantly greater in hyperglycemic patients (padjusted = 0.003). Only overt hyperglycemia (9.28 [1.66-51.88], p = 0.011) was associated with parenchymal hematoma type 2. Overall hyperglycemia was associated with poor outcomes and infarct growth, whereas overt hyperglycemia was associated with parenchymal hematoma type 2.
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Affiliation(s)
- Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University School of Medicine and Hospital, Daegu, South Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Jin Wook Choi
- Department of Radiology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Bok Seon Yoon
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, South Korea
| | - Dong-Hun Kang
- Department of Neurosurgery, Kyungpook National University School of Medicine and Hospital, Daegu, South Korea.,Department of Radiology, Kyungpook National University School of Medicine and Hospital, Daegu, South Korea
| | - Yong-Won Kim
- Department of Neurology, Kyungpook National University School of Medicine and Hospital, Daegu, South Korea.,Department of Radiology, Kyungpook National University School of Medicine and Hospital, Daegu, South Korea
| | - Yong-Sun Kim
- Department of Radiology, Kyungpook National University School of Medicine and Hospital, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Joonsang Yoo
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Bruce Ovbiagele
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Andrew M Demchuk
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea.
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea. .,Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, South Korea.
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46
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Mendez AA, Samaniego EA, Sheth SA, Dandapat S, Hasan DM, Limaye KS, Hindman BJ, Derdeyn CP, Ortega-Gutierrez S. Update in the Early Management and Reperfusion Strategies of Patients with Acute Ischemic Stroke. Crit Care Res Pract 2018; 2018:9168731. [PMID: 30050694 PMCID: PMC6046146 DOI: 10.1155/2018/9168731] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 05/03/2018] [Indexed: 01/01/2023] Open
Abstract
Acute ischemic stroke (AIS) remains a leading cause of death and long-term disability. The paradigms on prehospital care, reperfusion therapies, and postreperfusion management of patients with AIS continue to evolve. After the publication of pivotal clinical trials, endovascular thrombectomy has become part of the standard of care in selected cases of AIS since 2015. New stroke guidelines have been recently published, and the time window for mechanical thrombectomy has now been extended up to 24 hours. This review aims to provide a focused up-to-date review for the early management of adult patients with AIS and introduce the new upcoming areas of ongoing research.
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Affiliation(s)
- Aldo A. Mendez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Edgar A. Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Sunil A. Sheth
- Department of Neurology and Neurosurgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sudeepta Dandapat
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - David M. Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Kaustubh S. Limaye
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Bradley J. Hindman
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Colin P. Derdeyn
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Abstract
PURPOSE OF REVIEW Severe ischemic or hemorrhagic stroke is a devastating cerebrovascular disease often demanding critical care. Optimal management of blood pressure (BP) in the acute phase is controversial. The purpose of this review is to display insights from recent studies on BP control in both conditions. RECENT FINDINGS BP control in acute ischemic stroke has recently been investigated with regard to endovascular recanalizing therapies. Decreases from baseline BP and hypotension during the intervention have been found detrimental. Overall, a periinterventional SBP between 140 and 160 mmHg appeared favorable in several studies. In acute hemorrhagic stroke, the recently completed Antihypertensive Treatment of Acute Cerebral Hemorrhage II trial confirmed feasibility of early aggressive BP reduction but failed to demonstrate a reduction in hematoma growth or a clinical benefit. SUMMARY Recent findings do not support benefits of intensive BP lowering in both acute hemorrhagic and ischemic stroke, with the possible exception of the postinterventional phase after successful endovascular recanalization of large-vessel occlusions. Although optimal ranges of BP values remain to be defined, high BP should still be treated according to guidelines. As stroke patients requiring critical care are underrepresented in most studies on BP, caution in transferring these findings is warranted and prospective research in that patient population needed.
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48
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Outcome of Acute Ischemic Stroke after the Treatment with Edaravone and 0.6 Mg/Kg Alteplase in Japanese Patients with Diabetes. J Stroke Cerebrovasc Dis 2018; 27:1302-1310. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 12/13/2017] [Indexed: 11/23/2022] Open
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Lu T, Xian W, Liang J, Yang H, Weng B. Early changes in fibrinogen after administration of alteplase are associated with the short-term efficacy of thrombolysis. Medicine (Baltimore) 2018; 97:e0241. [PMID: 29595678 PMCID: PMC5895368 DOI: 10.1097/md.0000000000010241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The authors aimed to determine whether early changes in fibrinogen were associated with the efficacy of intravenous thrombolysis at 24 hours after alteplase infusion. The authors retrospectively reviewed a consecutive series of 56 patients with acute ischemic stroke treated with alteplase in the clinical database. The fibrinogen levels were monitored at the first and fourth hours after alteplase infusion. Additionally, the National Institutes of Health Stroke Scale (NIHSS) scores were recorded to define the short-term efficacy of intravenous thrombolysis before and 24 hours after alteplase infusion. The patients were distributed into amelioration, deterioration, and inefficiency groups according the short-term efficacy of intravenous thrombolysis. One-way ANOVA and post hoc analysis were used to compare the differences in the clinical characteristics among these groups. The relationships among changes in the fibrinogen levels, other potential risk factors, and NIHSS scores were examined using logistic regression analysis. Fifty-two patients (mean age, 65.71 ± 11.04 years; male, 57.7%) were finally enrolled in the study. The median NIHSS of these patients was 11 (range, 2-23), and the mean time from symptom onset to thrombolysis was 187.17 ± 67.53 minutes. The frequency of hypertension in the deterioration group was significantly higher than that in the inefficiency group (P = .01). Changes in the fibrinogen level were more significant in the amelioration group than in the other groups (P < .05). Logistic regression analysis revealed that changes in the fibrinogen levels between the first and fourth hours were positively associated with the short-term efficacy of alteplase infusion (odds ratio, 3.98; 95% confidence interval, 1.56-10.16; P = .004). Early changes in fibrinogen levels may be a potential predictor for the short-term efficacy of alteplase treatment in acute ischemic stroke. Additionally, these changes may be helpful for determining the short-term efficacy of alteplase treatment and early therapeutic strategies in clinical practice.
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Affiliation(s)
- Tao Lu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
- Department of Neurology and Stroke Center, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China
| | - Wenbiao Xian
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Jiahui Liang
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, Guangdong Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Hong Yang
- Department of Neurology and Stroke Center, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China
| | - Baohui Weng
- Department of Neurology and Stroke Center, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China
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50
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Heinrichs A, Nikoubashman O, Schürmann K, Tauber SC, Wiesmann M, Schulz JB, Reich A. Relevance of standard intravenous thrombolysis in endovascular stroke therapy of a tertiary stroke center. Acta Neurol Belg 2018; 118:105-111. [PMID: 29435828 DOI: 10.1007/s13760-018-0892-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/01/2018] [Indexed: 11/26/2022]
Abstract
The majority of patients undergoing endovascular stroke treatment (EST) in randomized controlled trials received additional systemic thrombolysis ("combination or bridging therapy (C/BT)"). Nevertheless, its usefulness in this subtype of acute ischemic stroke (AIS) is discussed controversially. Of all consecutive AIS patients, who received any kind of reperfusion therapy in a tertiary university stroke center between January 2015 and March 2016, those with large vessel occlusions (LVO) and EST with or without additional C/BT, were compared primarily regarding procedural aspects. Data were extracted from an investigator-initiated, single-center, prospective and blinded end-point study. 70 AIS patients with EST alone and 118 with C/BT were identified. Significant baseline differences existed in pre-existing cardiovascular disease (52.9% (EST alone) vs. 35.6% (C/BT), p = 0.023), use of anticoagulation (30.6% vs. 5.9%, p < 0.001), and frequency of unknown time of symptom onset (65.7% vs. 32.2%, p < 0.001), in-hospital stroke (18.6% vs. 1.7%, p < 0.001), pre-treatment ASPECT scores (7.9 vs. 8.9, p = 0.004), and frequency of occlusion in the posterior circulation (18.6% vs. 5.1%, p = 0.003). Pre-interventional procedural time intervals tended to be shorter in the C/BT group, reaching statistical significance in door-to-image time (30.3 (EST alone) vs. 22.2 min (C/BT), p < 0.001). Good clinical outcome (mRS d90) was reached more often in the C/BT group (24.5% vs. 11.8%, p = 0.064). Rates of symptomatic intracranial hemorrhages (sICH) were comparable (4.3% (EST alone) vs. 6.8% (C/BT), p = 0.481). Additional systemic thrombolysis did not delay EST. On the contrary, application of IVRTPA seemed to be a positive indicator for faster EST without increased side effects.
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Affiliation(s)
- Annette Heinrichs
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - Kolja Schürmann
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Simone C Tauber
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Arno Reich
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.
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