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Zonneveld TP, Vermeer SE, van Zwet EW, Groot AED, Algra A, Aerden LAM, Alblas KCL, de Beer F, Brouwers PJAM, de Gans K, van Gemert HMA, van Ginneken BCAM, Grooters GS, Halkes PHA, van der Heijden-Montfroy TAMHG, Jellema K, de Jong SW, Lövenich-Ciccarello H, van der Meulen WDM, Peters EW, van der Ree TC, Remmers MJM, Richard E, Rovers JMP, Saxena R, van Schaik SM, Schonewille WJ, Schreuder TAHCML, de Schryver ELLM, Schuiling WJ, Spaander FH, van Tuijl JH, Visser MC, Zinkstok SM, Zock E, Dippel DWJ, Kappelle LJ, van Oostenbrugge RJ, Roos YBWEM, Vermeij FH, Wermer MJH, van der Worp HB, Nederkoorn PJ, Kruyt ND. Safety and efficacy of active blood-pressure reduction to the recommended thresholds for intravenous thrombolysis in patients with acute ischaemic stroke in the Netherlands (TRUTH): a prospective, observational, cluster-based, parallel-group study. Lancet Neurol 2024; 23:807-815. [PMID: 38763149 DOI: 10.1016/s1474-4422(24)00177-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Intravenous thrombolysis is contraindicated in patients with ischaemic stroke with blood pressure higher than 185/110 mm Hg. Prevailing guidelines recommend to actively lower blood pressure with intravenous antihypertensive agents to allow for thrombolysis; however, there is no robust evidence for this strategy. Because rapid declines in blood pressure can also adversely affect clinical outcomes, several Dutch stroke centres use a conservative strategy that does not involve the reduction of blood pressure. We aimed to compare the clinical outcomes of both strategies. METHODS Thrombolysis and Uncontrolled Hypertension (TRUTH) was a prospective, observational, cluster-based, parallel-group study conducted across 37 stroke centres in the Netherlands. Participating centres had to strictly adhere to an active blood-pressure-lowering strategy or to a non-lowering strategy. Eligible participants were adults (≥18 years) with ischaemic stroke who had blood pressure higher than 185/110 mm Hg but were otherwise eligible for intravenous thrombolysis. The primary outcome was functional status at 90 days, measured using the modified Rankin Scale and assessed through telephone interviews by trained research nurses. Secondary outcomes were symptomatic intracranial haemorrhage, the proportion of patients treated with intravenous thrombolysis, and door-to-needle time. All ordinal logistic regression analyses were adjusted for age, sex, stroke severity, endovascular thrombectomy, and baseline imbalances as fixed-effect variables and centre as a random-effect variable to account for the clustered design. Analyses were done according to the intention-to-treat principle, whereby all patients were analysed according to the treatment strategy of the participating centre at which they were treated. FINDINGS Recruitment began on Jan 1, 2015, and was prematurely halted because of a declining inclusion rate and insufficient funding on Jan 5, 2022. Between these dates, we recruited 853 patients from 27 centres that followed an active blood-pressure-lowering strategy and 199 patients from ten centres that followed a non-lowering strategy. Baseline characteristics of participants from the two groups were similar. The 90-day mRS score was missing for 15 patients. The adjusted odds ratio (aOR) for a shift towards a worse 90-day functional outcome was 1·27 (95% CI 0·96-1·68) for active blood-pressure reduction compared with no active blood-pressure reduction. 798 (94%) of 853 patients in the active blood-pressure-lowering group were treated with intravenous thrombolysis, with a median door-to-needle time of 35 min (IQR 25-52), compared with 104 (52%) of 199 patients treated in the non-lowering group with a median time of 47 min (29-78). 42 (5%) of 852 patients in the active blood-pressure-lowering group had a symptomatic intracranial haemorrhage compared with six (3%) of 199 of those in the non-lowering group (aOR 1·28 [95% CI 0·62-2·62]). INTERPRETATION Insufficient evidence was available to establish a difference between an active blood-pressure-lowering strategy-in which antihypertensive agents were administered to reduce blood pressure below 185/110 mm Hg-and a non-lowering strategy for the functional outcomes of patients with ischaemic stroke, despite higher intravenous thrombolysis rates and shorter door-to-needle times among those in the active blood-pressure-lowering group. Randomised controlled trials are needed to inform the use of an active blood-pressure-lowering strategy. FUNDING Fonds NutsOhra.
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Affiliation(s)
- Thomas P Zonneveld
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Sarah E Vermeer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Adrien E D Groot
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Ale Algra
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands; Julius Center, University Medical Center Utrecht, Netherlands; Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Netherlands
| | - Leo A M Aerden
- Department of Neurology, Reinier de Graaf Gasthuis, Delft, Netherlands
| | - Kees C L Alblas
- Department of Neurology, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | - Frank de Beer
- Department of Neurology, Spaarne Gasthuis, Haarlem, Netherlands
| | | | - Koen de Gans
- Department of Neurology, Groene Hart Hospital, Gouda, Netherlands
| | | | | | | | | | | | - Korné Jellema
- Department of Neurology, Haaglanden Medisch Centrum, The Hague, Netherlands; University Neurovascular Center Leiden-the Hague, Leiden, Netherlands; University Neurovascular Center Leiden-the Hague, the Hague, Netherlands
| | - Sonja W de Jong
- Department of Neurology, St Jansdal Hospital, Harderwijk, Netherlands
| | | | | | - Edwin W Peters
- Department of Neurology, Admiraal de Ruyter Hospital, Vlissingen, Netherlands
| | | | | | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Ritu Saxena
- Department of Neurology, Maasstad Hospital, Rotterdam, Netherlands
| | | | | | | | | | | | | | - Julia H van Tuijl
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Marieke C Visser
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | | | - Elles Zock
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | | | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht UMC+, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht UMC+, Maastricht, Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Frederique H Vermeij
- Department of Neurology, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | | | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands; University Neurovascular Center Leiden-the Hague, Leiden, Netherlands; University Neurovascular Center Leiden-the Hague, the Hague, Netherlands.
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Liu G, Wang D, Jia J, Hao C, Ge Q, Xu L, Zhang C, Li X, Mi Y, Wang H, Miao L, Chen Y, Zhou J, Xu X, Liu Y. Neuroprotection of Human Umbilical Cord-Derived Mesenchymal Stem Cells (hUC-MSCs) in Alleviating Ischemic Stroke-Induced Brain Injury by Regulating Inflammation and Oxidative Stress. Neurochem Res 2024:10.1007/s11064-024-04212-x. [PMID: 39026086 DOI: 10.1007/s11064-024-04212-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 07/10/2024] [Accepted: 07/11/2024] [Indexed: 07/20/2024]
Abstract
Brain injury caused by stroke has a high rate of mortality and remains a major medical challenge worldwide. In recent years, there has been significant attention given to the use of human Umbilical cord-derived Mesenchymal Stem Cells (hUC-MSCs) for the treatment of stroke in different adult and neonate animal models of stroke. However, using hUC-MSCs by systemic administration to treat ischemic stroke has not been investigated sufficiently. In this study, we conducted various experiments to explore the neuroprotection of hUC-MSCs in rats. Our findings demonstrate that an intravenous injection of a high dose of hUC-MSCs at 2 × 10^7 cells/kg markedly ameliorated brain injury resulting from ischemic stroke. This improvement was observed one day after inducing transient middle cerebral artery occlusion (MCAO) and subsequent reperfusion in rats. Notably, the efficacy of this single administration of hUC-MSCs surpassed that of edaravone, even when the latter was used continuously over three days. Mechanistically, secretory factors derived from hUC-MSCs, such as HGF, BDNF, and TNFR1, ameliorated the levels of MDA and T-SOD to regulate oxidative stress. In particular, TNFR1 also improved the expression of NQO-1 and HO-1, important proteins associated with oxidative stress. More importantly, TNFR1 played a significant role in reducing inflammation by modulating IL-6 levels in the blood. Furthermore, TNFR1 was observed to influence the permeability of the blood-brain barrier (BBB) as demonstrated in the evan's blue experiment and protein expression of ZO-1. This study represented a breakthrough in traditional methods and provided a novel strategy for clinical medication and trials.
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Affiliation(s)
- Guangyang Liu
- Stem Cell Biology and Regenerative Medicine Institution, Beijing YiChuang Institute of Bio-Industry, Beijing, China
| | - Daohui Wang
- Stem Cell Biology and Regenerative Medicine Institution, Beijing YiChuang Institute of Bio-Industry, Beijing, China
| | - Jianru Jia
- Baoding People's Hospital, Baoding, China
| | - Chunhua Hao
- State Key Laboratory of Drug Delivery and Pharmacokinetics, Tianjin Institute of Pharmaceutical Research, Tianjin, China
| | - Qinggang Ge
- Department of Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Liqiang Xu
- Stem Cell Biology and Regenerative Medicine Institution, Beijing YiChuang Institute of Bio-Industry, Beijing, China
| | - Chenliang Zhang
- Stem Cell Biology and Regenerative Medicine Institution, Beijing YiChuang Institute of Bio-Industry, Beijing, China
| | - Xin Li
- Stem Cell Biology and Regenerative Medicine Institution, Beijing YiChuang Institute of Bio-Industry, Beijing, China
| | - Yi Mi
- Stem Cell Biology and Regenerative Medicine Institution, Beijing YiChuang Institute of Bio-Industry, Beijing, China
| | - Herui Wang
- Stem Cell Biology and Regenerative Medicine Institution, Beijing YiChuang Institute of Bio-Industry, Beijing, China
| | - Li Miao
- Stem Cell Biology and Regenerative Medicine Institution, Beijing YiChuang Institute of Bio-Industry, Beijing, China
| | - Yaoyao Chen
- Stem Cell Biology and Regenerative Medicine Institution, Beijing YiChuang Institute of Bio-Industry, Beijing, China
| | - Jingwen Zhou
- Stem Cell Biology and Regenerative Medicine Institution, Beijing YiChuang Institute of Bio-Industry, Beijing, China
| | - Xiaodan Xu
- Stem Cell Biology and Regenerative Medicine Institution, Beijing YiChuang Institute of Bio-Industry, Beijing, China
| | - Yongjun Liu
- Stem Cell Biology and Regenerative Medicine Institution, Beijing YiChuang Institute of Bio-Industry, Beijing, China.
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Delgado-Martín S, Martínez-Ruiz A. The role of ferroptosis as a regulator of oxidative stress in the pathogenesis of ischemic stroke. FEBS Lett 2024. [PMID: 38676284 DOI: 10.1002/1873-3468.14894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/25/2024] [Accepted: 04/02/2024] [Indexed: 04/28/2024]
Abstract
Ferroptosis is a unique form of cell death that was first described in 2012 and plays a significant role in various diseases, including neurodegenerative conditions. It depends on a dysregulation of cellular iron metabolism, which increases free, redox-active, iron that can trigger Fenton reactions, generating hydroxyl radicals that damage cells through oxidative stress and lipid peroxidation. Lipid peroxides, resulting mainly from unsaturated fatty acids, damage cells by disrupting membrane integrity and propagating cell death signals. Moreover, lipid peroxide degradation products can further affect cellular components such as DNA, proteins, and amines. In ischemic stroke, where blood flow to the brain is restricted, there is increased iron absorption, oxidative stress, and compromised blood-brain barrier integrity. Imbalances in iron-transport and -storage proteins increase lipid oxidation and contribute to neuronal damage, thus pointing to the possibility of brain cells, especially neurons, dying from ferroptosis. Here, we review the evidence showing a role of ferroptosis in ischemic stroke, both in recent studies directly assessing this type of cell death, as well as in previous studies showing evidence that can now be revisited with our new knowledge on ferroptosis mechanisms. We also review the efforts made to target ferroptosis in ischemic stroke as a possible treatment to mitigate cellular damage and death.
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Affiliation(s)
- Susana Delgado-Martín
- Unidad de Investigación, Hospital Santa Cristina, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Antonio Martínez-Ruiz
- Unidad de Investigación, Hospital Santa Cristina, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
- Departamento de Bioquímica y Biología Molecular, Facultad de Farmacia, Universidad Complutense de Madrid, Spain
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Panda BK, Suryawanshi VR, Attarde G, Borkar N, Iyer S, Shah J. Correlation of Quality Metrics of Acute Stroke Care with Clinical Outcomes in an Indian Tertiary-care University Hospital: A Prospective Evidence-based Study. Indian J Crit Care Med 2023; 27:806-815. [PMID: 37936803 PMCID: PMC10626231 DOI: 10.5005/jp-journals-10071-24566] [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: 08/09/2023] [Accepted: 09/25/2023] [Indexed: 11/09/2023] Open
Abstract
Aim To characterize the impact of adherence to quality metrics of stroke care on the clinical outcomes of ischemic stroke (IS) and intracerebral hemorrhage (ICH) admissions. Methods Consecutive patients with acute stroke were prospectively followed up for their demographic and clinical characteristics, acute stroke management, and associated clinical outcomes at discharge. Stroke quality metrics [adopted from the American Heart Association (AHA)/American Stroke Association's Get with The Guidelines (GWTG)] with a specific interest in an association between acute reperfusion therapies and functional recovery in stroke patients are analyzed and presented. A composite measure of care was considered "0 (non-adherence) to 1 (adherence)." An all-or-none measure of care was calculated to check whether eligible patients received all the quality-of-care interventions. Multivariate Cox regression models were used to study an association between optimal adherence and clinical outcomes. Results During the study period, of the total 256 stroke admissions, 200 (78.1%) patients had IS, and the remaining 56 (21.9%) patients had ICH. The median [interquartile range (IQR)] age of total stroke admissions was 57 (36-78) years. Male preponderance was observed (IS: 80% and ICH: 67.9%). The conformity of performance metrics in IS patients was from 69.1% [95% confidence interval (CI), 68.5-69.6] for the use of deep vein thrombosis prophylaxis (DVTp) to 97.8% (95% CI, 96.2-98.6) for the use of statins. In ICH patients, it ranged from 61.7% (95% CI, 60.4-62.5) for the use of DVTp to 89.9% (95% CI, 88.6-89.7) for stroke rehabilitation. The unadjusted odds ratio (OR) of mortality (in-hospital plus the 28th-day postdischarge) was higher in ICH patients vs IS patients (4.42, p = 0.005). Optimal adherence with intravenous recombinant tissue plasminogen activator (IV-rtPA) therapy [hazards ratio (HR) = 0.23], in-hospital acute measures [IS (HR = 0.41) and ICH (HR = 0.63)], and discharge measures [IS (HR = 0.35) and ICH (HR = 0.45)] were associated with reduced hazards of the 28th-day mortality in both cohorts. Compared to ICH, IS patients had significantly improved neurofunctional recovery [modified Rankin score (mRS) ≤ 2, p < 0.01]. Conclusion Adherence to quality metrics and performance measures was associated with low mortality and favorable clinical outcomes. Also, DVTp as an in-hospital (acute) measure of stroke care needs attention in both cerebrovascular events. How to cite this article Panda BK, Suryawanshi VR, Attarde G, Borkar N, Iyer S, Shah J. Correlation of Quality Metrics of Acute Stroke Care with Clinical Outcomes in an Indian Tertiary-care University Hospital: A Prospective Evidence-based Study. Indian J Crit Care Med 2023;27(11):806-815.
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Affiliation(s)
- Bijoy Kumar Panda
- Department of Pharmacy Practice, Krishna Institute of Pharmacy, Krishna Vishwa Vidyapeeth (Deemed to be University), Karad, Maharashtra, India
| | - Vaibhav R Suryawanshi
- Department of Pharmacy Practice, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, India
| | - Gargi Attarde
- Department of Pharmacy Practice, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, India
| | - Nilima Borkar
- Department of Pharmacy Practice, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, India
| | - Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth (Deemed to be University), Medical College, Pune, Maharashtra, India
| | - Jignesh Shah
- Department of Critical Care Medicine, Bharati Vidyapeeth (Deemed to be University), Medical College, Pune, Maharashtra, India
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Skolarus LE, Bailey S, Corches CL, Sales AE, Lin CC, Bi R, Springer MV, Oliver A, Robles MC, Brooks T, Tupper M, Jaggi M, Al-Qasmi M, Trevithick BA, Barber K, Majjhoo A, Zimmerman MA, Meurer WJ, Brown DL, Morgenstern LB, Burke JF. Association of the Stroke Ready Community-Based Participatory Research Intervention With Incidence of Acute Stroke Thrombolysis in Flint, Michigan. JAMA Netw Open 2023; 6:e2321558. [PMID: 37399011 PMCID: PMC10318478 DOI: 10.1001/jamanetworkopen.2023.21558] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/17/2023] [Indexed: 07/04/2023] Open
Abstract
Importance Acute stroke treatment rates in the US lag behind those in other high-income nations. Objective To assess whether a hospital emergency department (ED) and community intervention was associated with an increased proportion of patients with stroke receiving thrombolysis. Design, Setting, and Participants This nonrandomized controlled trial of the Stroke Ready intervention took place in Flint, Michigan, from October 2017 to March 2020. Participants included adults living in the community. Data analysis was completed from July 2022 to May 2023. Intervention Stroke Ready combined implementation science and community-based participatory research approaches. Acute stroke care was optimized in a safety-net ED, and then a community-wide, theory-based health behavior intervention, including peer-led workshops, mailers, and social media, was conducted. Main Outcomes and Measures The prespecified primary outcome was the proportion of patients hospitalized with ischemic stroke or transient ischemic attack from Flint who received thrombolysis before and after the intervention. The association between thrombolysis and the Stroke Ready combined intervention, including the ED and community components, was estimated using logistic regression models, clustering at the hospital level and adjusting for time and stroke type. In prespecified secondary analyses, the ED and community intervention were explored separately, adjusting for hospital, time, and stroke type. Results In total, 5970 people received in-person stroke preparedness workshops, corresponding to 9.7% of the adult population in Flint. There were 3327 ischemic stroke and TIA visits (1848 women [55.6%]; 1747 Black individuals [52.5%]; mean [SD] age, 67.8 [14.5] years) among patients from Flint seen in the relevant EDs, including 2305 in the preintervention period from July 2010 to September 2017 and 1022 in the postintervention period from October 2017 to March 2020. The proportion of thrombolysis usage increased from 4% in 2010 to 14% in 2020. The combined Stroke Ready intervention was not associated with thrombolysis use (adjusted odds ratio [OR], 1.13; 95% CI, 0.74-1.70; P = .58). The ED component was associated with an increase in thrombolysis use (adjusted OR, 1.63; 95% CI, 1.04-2.56; P = .03), but the community component was not (adjusted OR, 0.99; 95% CI, 0.96-1.01; P = .30). Conclusions and Relevance This nonrandomized controlled trial found that a multilevel ED and community stroke preparedness intervention was not associated with increased thrombolysis treatments. The ED intervention was associated with increased thrombolysis usage, suggesting that implementation strategies in partnership with safety-net hospitals may increase thrombolysis usage. Trial Registration ClinicalTrials.gov Identifier: NCT036455900.
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Affiliation(s)
- Lesli E. Skolarus
- Davee Department of Neurology, Stroke and Vascular Neurology, Northwestern University, Chicago, Illinois
- Department of Neurology, University of Michigan, Ann Arbor
| | | | | | - Anne E. Sales
- Department of Family and Community Medicine, Sinclair School of Nursing, University of Missouri, Columbia
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Chun Chieh Lin
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Neurology, Ohio State University, Columbus
| | - Ran Bi
- Department of Neurology, University of Michigan, Ann Arbor
| | | | | | | | - Tia Brooks
- Department of Neurology, University of Michigan, Ann Arbor
| | - Michael Tupper
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Emergency Medicine, Hurley Medical Center, Flint, Michigan
| | - Michael Jaggi
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Emergency Medicine, Hurley Medical Center, Flint, Michigan
| | - Mohammed Al-Qasmi
- Department of Emergency Medicine, Hurley Medical Center, Flint, Michigan
| | | | - Kimberly Barber
- Department of Clinical & Academic Research, Genesys Regional Medical Center, Grand Blanc, Michigan
| | - Aniel Majjhoo
- Department of Neurology, McLaren Flint Hospital, Flint, Michigan
| | | | | | - Devin L. Brown
- Department of Neurology, University of Michigan, Ann Arbor
| | - Lewis B. Morgenstern
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
| | - James F. Burke
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Neurology, Ohio State University, Columbus
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Lu Z, Xiong Y, Yang K, Gu H, Duan C, Zhao X, Meng X, Wang Y. What predicts large vessel occlusion in mild stroke patients? BMC Neurol 2023; 23:29. [PMID: 36658535 PMCID: PMC9850683 DOI: 10.1186/s12883-022-03020-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/09/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND AND PURPOSE Mild acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) may benefit from thrombolysis or thrombectomy therapy. However, the predictors for LVO in mild AIS patients have not been extensively explored. We aimed to investigate the predictors for LVO in mild AIS patients. METHODS We collected the data of consecutive AIS patients with a National Institutes of Health Stroke Scale (NIHSS) score ≤ 5 from The Third China National Stroke Registry - a prospective nationwide registry of AIS or transient ischemic attack (TIA) patients in China from August 2015 to March 2018. Patients were divided into LVO and non-LVO group based on the vascular imaging during the hospitalization. Multivariable regression analyses involving clinical characteristics and NIHSS subitems was performed to detect the predictors for LVO. RESULT A total of 7653 mild AIS patients from The Third China National Stroke Registry were included in this study. Among them, 620 patients (8.1%) had LVO. The level of consciousness (adjusted odds ratio, 1.87; 95% confidence interval, 1.08 to 3.23), visual field (adjusted odds ratio, 2.10; 95% confidence interval, 1.43 to 3.06) and sensory (adjusted odds ratio, 0.75; 95% confidence interval, 0.60 to 0.94) were predictors for mild AIS patients with LVO. CONCLUSIONS Impaired LOC, visual field and sensory were independently predictors for LVO in mild stroke patients. Further studies are warranted to test these predictors in prehospital setting and in other population.
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Affiliation(s)
- Zhengzhao Lu
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yunyun Xiong
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,grid.510934.a0000 0005 0398 4153Chinese Institute for Brain Research, Beijing, China
| | - Kaixuan Yang
- grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Hongqiu Gu
- grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Chunmiao Duan
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,grid.24696.3f0000 0004 0369 153XDepartment of Neurology, Beijing Daxing District People’s Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,grid.510934.a0000 0005 0398 4153Chinese Institute for Brain Research, Beijing, China ,grid.506261.60000 0001 0706 7839Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, 2019RU018, Beijing, China
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Kamal H, Assaf S, Kabalan M, El Maissi R, Salhab D, Rahme D, Lahoud N. Evaluation of stroke pre-hospital management in Lebanon from symptoms onset to hospital arrival and impact on patients' status at discharge: a pilot study. BMC Neurol 2022; 22:494. [PMID: 36539720 PMCID: PMC9764570 DOI: 10.1186/s12883-022-03018-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Hospital arrival time after acute ischemic stroke onset is the major factor limiting the eligibility of patients to receive intravenous thrombolysis. Shortening the prehospital delay is crucial to reducing morbidity and mortality for stroke patients. The study was conducted to investigate the factors that influence hospital arrival time after acute stroke onset in the Lebanese population and to assess the effect of the prehospital phase on patients' prognosis at discharge. METHOD A prospective cross-sectional study was performed in eleven hospitals from April to July 2021 including 100 patients having stroke symptoms or transient ischemic attack (TIA). Two questionnaires were used to collect data addressing patient management in the pre-hospital phase and the in-hospital phase. Descriptive and bivariate analyses were done to evaluate the potential associations between prognosis, pre-hospital characteristics, and other factors. RESULTS The patients' mean age was 70.36 ± 12.25 years, 43 (53.8%) of them were females, and 79 (85%) arrived within 3 hours after symptoms onset. Diabetic patients had a significant delay in hospital arrival compared with non-diabetics (27.0%vs.7.1%, p-value = 0.009). Moreover, 37 (75.5%) of school-level education patients arrived early at the hospital compared to 7 (100%) of university-level education (p-value = 0.009). The modified Rankin Scale (mRS) at discharge in patients with hemorrhagic stroke (10 (90%)) was worse than that in patients with ischemic stroke (38 (80%)) or TIA (3 (15%)) (p-value< 0.001). CONCLUSION The study findings make it imperative to raise awareness about stroke symptoms among the Lebanese population. Emergency Medical Services should be utilized appropriately in the transportation of stroke patients to achieve optimal patient outcomes.
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Affiliation(s)
- Hiba Kamal
- grid.411324.10000 0001 2324 3572Faculty of Public Health, Lebanese University, Fanar, Lebanon
| | - Sara Assaf
- grid.411324.10000 0001 2324 3572Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
| | - Mayssan Kabalan
- grid.411324.10000 0001 2324 3572Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
| | - Raneem El Maissi
- grid.411324.10000 0001 2324 3572Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
| | - Dima Salhab
- grid.411324.10000 0001 2324 3572Faculty of Public Health, Lebanese University, Fanar, Lebanon
| | - Deema Rahme
- grid.18112.3b0000 0000 9884 2169Pharmacy Practice Department, Faculty of Pharmacy, Beirut Arab University, Beirut, Lebanon
| | - Nathalie Lahoud
- grid.411324.10000 0001 2324 3572Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
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8
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Qu T, Bao Y, Zhu W, Ding H, Wang L, Yang J, Huang D. The influence of unexpected early termination of intravenous rt-PA treatment on clinical outcome in acute ischemic stroke patients. Acta Neurol Belg 2022; 122:1329-1335. [PMID: 35917016 DOI: 10.1007/s13760-022-02042-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 07/18/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION This study aimed to explore the impact of unexpected early termination during intravenous thrombolysis on clinical prognosis in patients with acute ischemic stroke (AIS). METHODS Patients who received intravenous thrombolysis were divided into an early termination group and a normal treatment group. The causes of unexpected termination were analyzed, and the prognosis was compared between the groups. RESULTS The main causes of early termination of thrombolytic therapy included subjective wishes of family members (11.8%, 4) and persistently elevated blood pressure (14.7%, 5). The effective rate of thrombolytic therapy in the early termination group was significantly lower than that in the normal treatment group (P < 0.05). The rate of early neurological deterioration in the early termination group was significantly higher than that in the normal treatment group (P < 0.05). There was no significant difference in the incidence of symptomatic intracranial hemorrhage after thrombolysis between the two groups (P > 0.05). The average mRS score of the early termination group was significantly higher than that of the normal treatment group (P < 0.05). Multivariate analysis indicated that early termination of thrombolytic therapy and cumulative dosage of rt-PA before termination were the main factors affecting the 3-month prognosis. CONCLUSION Subjective wishes of family members and persistently elevated blood pressure may be the main causes of early termination of thrombolysis, and the 3-month prognosis of patients could be adversely affected by early termination of thrombolytic therapy and cumulative dosage of rt-PA. Certain measures, such as popularizing thrombolytic health education and optimizing blood pressure management before and during thrombolysis, may be helpful for the normal operation of intravenous thrombolysis.
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Affiliation(s)
- Tingting Qu
- Department of Neurology, School of Medicine, Tongji University, East Hospital, No. 150 Jimo Road, Shanghai, 200120, People's Republic of China
| | - Yiwen Bao
- Department of Neurology, School of Medicine, Tongji University, East Hospital, No. 150 Jimo Road, Shanghai, 200120, People's Republic of China
| | - Wenxia Zhu
- Department of Neurology, School of Medicine, Tongji University, East Hospital, No. 150 Jimo Road, Shanghai, 200120, People's Republic of China
| | - Hao Ding
- Department of Neurology, School of Medicine, Tongji University, East Hospital, No. 150 Jimo Road, Shanghai, 200120, People's Republic of China
| | - Lufeng Wang
- Department of Neurology, School of Medicine, Tongji University, East Hospital, No. 150 Jimo Road, Shanghai, 200120, People's Republic of China
| | - Jie Yang
- Department of Neurology, School of Medicine, Tongji University, East Hospital, No. 150 Jimo Road, Shanghai, 200120, People's Republic of China.
| | - Dongya Huang
- Department of Neurology, School of Medicine, Tongji University, East Hospital, No. 150 Jimo Road, Shanghai, 200120, People's Republic of China.
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9
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Nakano T, Tagashira Y, Egashira S, Morimoto M, Irie K, Hosokawa M, Hayashi T, Egawa T, Hayakawa K, Mishima K. Therapeutic effect of anti-HMGB1 antibody in a mouse model of 4-h middle cerebral artery occlusion: comparison with tissue plasminogen activator. Neuroreport 2022; 33:297-303. [PMID: 35594440 DOI: 10.1097/wnr.0000000000001780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Delayed tissue plasminogen activator (tPA) treatment increases the risk of intracerebral hemorrhage in patients with ischemic stroke. We previously demonstrated that tPA treatment caused hemorrhagic complications in a 4-h middle cerebral artery occlusion (MCAO) mouse model when administered after reperfusion. In the present study, we administered an anti-high mobility group box 1 (αHMGB1) antibody to 4-h MCAO mice to evaluate the usability of αHMGB1 antibody treatment in the delayed phase of ischemia, beyond the therapeutic time window of tPA. METHODS αHMGB1 antibody, tPA and control IgG were dissolved in normal saline and administered intravenously into the tail vein of the mice after reperfusion. Infarct volume, hemorrhagic volume, brain swelling, functional outcomes and levels of pro-inflammatory cytokines, such as HMGB1, interleukin (IL)-6 and tumor necrosis factor (TNF)-α, were evaluated 24 h after MCAO. RESULTS tPA treatment was not only ineffective but also caused a massive intracerebral hemorrhage. Treatment with αHMGB1 antibody reduced the infarct volume and swelling and ameliorated neurologic impairment and motor coordination without hemorrhagic complications by inhibiting HMGB1 activity. Moreover, the αHMGB1 antibody suppressed pathways of secondary inflammatory responses, such as IL-6 and TNF-α, after cerebral ischemia. CONCLUSION These results indicate that αHMGB1 antibody may be therapeutically efficient in the delayed phase of ischemia, where tPA treatment is no longer an eligible option. Treatment with an αHMGB1 antibody may be an effective therapeutic option in patients who exceed the tPA therapeutic time window.
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Affiliation(s)
- Takafumi Nakano
- Departments of Radiology and Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts, USA
- Department of Pharmaceutical and Healthcare Management
| | | | | | | | | | - Masato Hosokawa
- Department of Immunological and Molecular Pharmacology, Fukuoka University, Fukuoka, Japan
| | | | - Takashi Egawa
- Department of Pharmaceutical and Healthcare Management
| | - Kazuhide Hayakawa
- Departments of Radiology and Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts, USA
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10
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Developing a Clinical Prediction Rule for Gait Independence at Discharge in Patients with Stroke: A Decision-Tree Algorithm Analysis. J Stroke Cerebrovasc Dis 2022; 31:106441. [PMID: 35305537 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 02/19/2022] [Accepted: 02/26/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES To develop a clinical prediction rule (CPR) for gait independence at discharge in patients with stroke, using the decision-tree algorithm and to investigate the usefulness of CPR at admission to the rehabilitation ward. MATERIALS AND METHODS We included 181 subjects with stroke during the postacute phase. The Chi-squared automatic interaction detection analysis method with 10-fold cross-validation was used to develop two CPRs; CPR 1 using easily obtainable data available at admission; CPR 2 using easily obtainable data available 1 month after admission, for prediction of gait independence at discharge. RESULTS The degree of independence of toileting was extracted as a first node in the development of two CPRs to predict gait independence at discharge. CPR 1 included the presence of delirium. CPR 2 included problem-solving abilities. The accuracy and area under the curve of CPR 1 were 84.5% and 0.911, respectively; those of CPR 2 were 89.0% and 0.958, respectively. CONCLUSIONS Toileting independence is a key factor in predicting the gait independence for the discharge of patients with stroke during the postacute phase. Early intervention, during the acute phase, for delirium and cognitive decline, as well as for toileting, increases the possibility of gait independence at discharge.
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11
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Springer MV, Bi R, Skolarus LE, Lin CC, Burke JF. Community Intent to Activate Emergency Medical Services May Be Associated with Regional tPA Treatment. Cerebrovasc Dis 2022; 51:207-213. [PMID: 34515063 PMCID: PMC8898989 DOI: 10.1159/000518729] [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: 04/27/2021] [Accepted: 07/25/2021] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Acute stroke treatments are underutilized in the USA. Enhancing stroke preparedness, the recognition of stroke symptoms, and intent to call emergency medical services (EMS) could reduce delay in hospital arrival thereby increasing eligibility for time-sensitive stroke treatments. Whether higher stroke preparedness is associated with higher tissue plasminogen activator (tPA) treatment rates is however uncertain. We therefore set out to determine the contribution of stroke preparedness to regional variation in tPA treatment. METHODS The region was defined by hospital service area (HSA). Stroke preparedness was determined by using Behavioral Risk Factor Surveillance System survey questions assessing stroke symptom recognition and intent to call 911 in response to a stroke. We used Medicare data to determine the percentage of tPA-treated hospitalized stroke patients in 2007, 2009, and 2011, adjusting for number of stroke hospitalizations in each HSA (primary outcome). We performed multivariate linear regression to estimate the association of regional stroke preparedness on log-transformed tPA treatment rates controlling for demographic, EMS, and hospital characteristics. RESULTS The adjusted percentage of stroke patients receiving tPA ranged from 1.4% (MIN) to 11.3% (MAX) of stroke/TIA hospitalizations. Across HSAs, a median (IQR) of 86% (81-90%) of responses to a witnessed stroke indicated intent to call 911, and a median (IQR) of 4.4 (4.2-4.6) out of 6 stroke symptoms was recognized. Every 1% increase in an HSA's intent to call 911 was associated with a 0.44% increase in adjusted tPA treatment rate (p = 0.05). Lower accuracy of recognition of stroke symptoms was associated with higher adjusted tPA treatment rates (p = 0.05). CONCLUSIONS There was little regional variation in intent to call EMS and stroke symptom recognition. Intent to call EMS and stroke symptom recognition are modest contributors to regional variation in tPA treatment.
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Affiliation(s)
| | - Ran Bi
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lesli E. Skolarus
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Chun Chieh Lin
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James F. Burke
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan, USA
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12
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Hasan TF, Hasan H, Kelley RE. Overview of Acute Ischemic Stroke Evaluation and Management. Biomedicines 2021; 9:1486. [PMID: 34680603 PMCID: PMC8533104 DOI: 10.3390/biomedicines9101486] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.
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Affiliation(s)
- Tasneem F. Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
| | - Hunaid Hasan
- Hasan & Hasan Neurology Group, Lapeer, MI 48446, USA;
| | - Roger E. Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
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13
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Bu ZQ, Yu HY, Wang J, He X, Cui YR, Feng JC, Feng J. Emerging Role of Ferroptosis in the Pathogenesis of Ischemic Stroke: A New Therapeutic Target? ASN Neuro 2021; 13:17590914211037505. [PMID: 34463559 PMCID: PMC8424725 DOI: 10.1177/17590914211037505] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Ischemic stroke is one of the main causes of high morbidity, mortality, and disability
worldwide; however, the treatment methods are limited and do not always achieve
satisfactory results. The pathogenesis of ischemic stroke is complex, defined by multiple
mechanisms; among them, programmed death of neuronal cells plays a significant role.
Ferroptosis is a novel type of regulated cell death characterized by iron redistribution
or accumulation and increased lipid peroxidation in the membrane. Ferroptosis is
implicated in many pathological conditions, such as cancer, neurodegenerative diseases,
and ischemia-reperfusion injury. In this review, we summarize current research findings on
ferroptosis, including possible molecular mechanisms and therapeutic applications of
ferroptosis regulators, with a focus on the involvement of ferroptosis in the pathogenesis
and treatment of ischemic stroke. Understanding the role of ferroptosis in ischemic stroke
will throw some light on the development of methods for diagnosis, treatment, and
prevention of this devastating disease.
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Affiliation(s)
- Zhong-Qi Bu
- Department of Neurology, 85024Shengjing Hospital of China Medical University, Shenyang, China
| | - Hai-Yang Yu
- Department of Neurology, 85024Shengjing Hospital of China Medical University, Shenyang, China
| | - Jue Wang
- Department of Neurology, 85024Shengjing Hospital of China Medical University, Shenyang, China
| | - Xin He
- Department of Neurology, 85024Shengjing Hospital of China Medical University, Shenyang, China
| | - Yue-Ran Cui
- Department of Neurology, 85024Shengjing Hospital of China Medical University, Shenyang, China
| | - Jia-Chun Feng
- Department of Neurology and Neuroscience Center, 117971The First Hospital of Jilin University, Changchun, China
| | - Juan Feng
- Department of Neurology, 85024Shengjing Hospital of China Medical University, Shenyang, China
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14
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Yaghi S, Mistry E, de Havenon A, Leon Guerrero CR, Nouh A, Liberman AL, Giles J, Liu A, Nagy M, Kaushal A, Azher I, Mac Grory B, Fakhri H, Brown Espaillat K, Asad SD, Pasupuleti H, Martin H, Tan J, Veerasamy M, Esenwa C, Cheng N, Moncrieffe K, Moeini-Naghani I, Siddu M, Scher E, Trivedi T, Wu T, Khan M, Keyrouz S, Furie K, Henninger N. Effect of Alteplase Use on Outcomes in Patients With Atrial Fibrillation: Analysis of the Initiation of Anticoagulation After Cardioembolic Stroke Study. J Am Heart Assoc 2021; 10:e020945. [PMID: 34323120 PMCID: PMC8475683 DOI: 10.1161/jaha.121.020945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Intravenous alteplase improves outcome after acute ischemic stroke without a benefit in 90‐day mortality. There are limited data on whether alteplase is associated with reduced mortality in patients with atrial fibrillation (AF)‐related ischemic stroke whose mortality rate is relatively high. We sought to determine the association of alteplase with hemorrhagic transformation and mortality in patients with AF. Methods and Results We retrospectively analyzed consecutive patients with acute ischemic stroke between 2015 and 2018 diagnosed with AF included in the IAC (Initiation of Anticoagulation After Cardioembolic Stroke) study, which pooled data from stroke registries at 8 comprehensive stroke centers across the United States. For our primary analysis, we included patients who did not undergo mechanical thrombectomy (MT), and secondary analyses included patients who underwent MT. We used binary logistic regression to determine whether alteplase use was associated with risk of hemorrhagic transformation and 90‐day mortality. There were 1889 patients (90.6%) who had 90‐day follow‐up data available for analyses and were included; 1367 patients (72.4%) did not receive MT, and 522 patients (27.6%) received MT. In our primary analyses we found that alteplase use was independently associated with an increased risk for hemorrhagic transformation (odds ratio [OR], 2.23; 95% CI, 1.57–3.17) but reduced risk of 90‐day mortality (OR, 0.58; 95% CI, 0.39–0.87). Among patients undergoing MT, alteplase use was not associated with a significant reduction in 90‐day mortality (OR, 0.68; 95% CI, 0.45–1.04). Conclusions Alteplase reduced 90‐day mortality of patients with acute ischemic stroke with AF not undergoing MT. Further study is required to assess the efficacy of alteplase in patients with AF undergoing MT.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology Brown University Providence RI
| | - Eva Mistry
- Department of Neurology Vanderbilt University Nashville TN
| | - Adam de Havenon
- Department of Neurology University of Utah Salt Lake City UT
| | | | - Amre Nouh
- Department of Neurology Hartford Hospital Hartford CT
| | - Ava L Liberman
- Department of Neurology Montefiore Medical Center New York NY
| | - James Giles
- Department of Neurology Washington University Saint Louis MO
| | - Angela Liu
- Department of Neurology Washington University Saint Louis MO
| | - Muhammad Nagy
- Department of Neurology Hackensack Medical Center Hackensack NJ
| | | | - Idrees Azher
- Department of Neurology Brown University Providence RI
| | | | - Hiba Fakhri
- Department of Neurology Vanderbilt University Nashville TN
| | | | | | | | - Heather Martin
- Department of Neurology Spectrum Health, Grand Rapids MI
| | - Jose Tan
- Department of Neurology Spectrum Health, Grand Rapids MI
| | | | - Charles Esenwa
- Department of Neurology Montefiore Medical Center New York NY
| | - Natalie Cheng
- Department of Neurology Montefiore Medical Center New York NY
| | | | | | - Mithilesh Siddu
- Department of Neurology George Washington University Washington DC
| | - Erica Scher
- Department of Neurology New York University New York NY
| | | | - Teddy Wu
- Department of Neurology Christchurch Hospital Christchurch New Zealand
| | - Muhib Khan
- Department of Neurology Spectrum Health, Grand Rapids MI
| | - Salah Keyrouz
- Department of Neurology Washington University Saint Louis MO
| | - Karen Furie
- Department of Neurology Brown University Providence RI
| | - Nils Henninger
- Department of Neurology University of Massachusetts Worcester MA.,Department of Psychiatry University of Massachusetts Worcester MA
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15
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Wilcock AD, Schwamm LH, Zubizarreta JR, Zachrison KS, Uscher-Pines L, Richard JV, Mehrotra A. Reperfusion Treatment and Stroke Outcomes in Hospitals With Telestroke Capacity. JAMA Neurol 2021; 78:527-535. [PMID: 33646272 DOI: 10.1001/jamaneurol.2021.0023] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Telestroke is increasingly used in hospital emergency departments, but there has been limited research on its impact on treatment and outcomes. Objective To describe differences in care patterns and outcomes among patients with acute ischemic stroke who present to hospitals with and without telestroke capacity. Design, Setting, and Participants Patients with acute ischemic stroke who first presented to hospitals with telestroke capacity were matched with patients who presented to control hospitals without telestroke capacity. All traditional Medicare beneficiaries with a primary diagnosis of acute ischemic stroke (approximately 2.5 million) who presented to a hospital between January 2008 and June 2017 were considered. Matching was based on sociodemographic and clinical characteristics, hospital characteristics, and month and year of admission. Hospitals included short-term acute care and critical access hospitals in the US without local stroke expertise. In 643 hospitals with telestroke capacity, there were 76 636 patients with stroke who were matched 1:1 to patients at similar hospitals without telestroke capacity. Data were analyzed in July 2020. Main Outcomes and Measures Receipt of reperfusion treatment through thrombolysis with alteplase or thrombectomy, mortality at 30 days from admission, spending through 90 days from admission, and functional status as measured by days spent living in the community after discharge. Results In the final sample of 153 272 patients, 88 386 (57.7%) were female, and the mean (SD) age was 78.8 (10.4) years. Patients cared for at telestroke hospitals had higher rates of reperfusion treatment compared with those cared for at control hospitals (6.8% vs 6.0%; difference, 0.78 percentage points; 95% CI, 0.54-1.03; P < .001) and lower 30-day mortality (13.1% vs 13.6%; difference, 0.50 percentage points; 95% CI, 0.17-0.83, P = .003). There were no differences in days spent living in the community following discharge or in spending. Increases in reperfusion treatment were largest in the lowest-volume hospitals, among rural residents, and among patients 85 years and older. Conclusions and Relevance Patients with ischemic stroke treated at hospitals with telestroke capacity were more likely to receive reperfusion treatment and have lower 30-day mortality.
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Affiliation(s)
- Andrew D Wilcock
- Center for Health Services Research, Department of Family Medicine, The Larner College of Medicine, University of Vermont, Burlington
| | - Lee H Schwamm
- Department of Emergency Medicine, Massachusetts General Hospital, Boston.,Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Jose R Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Harvard University, Cambridge, Massachusetts
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Jessica V Richard
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Boston, Massachusetts
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16
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Hyperbaric Oxygen Improves Cerebral Ischemia/Reperfusion Injury in Rats Probably via Inhibition of Autophagy Triggered by the Downregulation of Hypoxia-Inducing Factor-1 Alpha. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6615685. [PMID: 33816617 PMCID: PMC7987430 DOI: 10.1155/2021/6615685] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/05/2021] [Accepted: 03/03/2021] [Indexed: 01/01/2023]
Abstract
Ischemic stroke, accompanied with high mortality and morbidity, may produce heavy economic burden to societies and families. Therefore, it is of great significance to explore effective therapies. Hyperbaric oxygen (HBO) is a noninvasive, nondrug treatment method that has been proved able to save ischemic penumbra by improving hypoxia, microcirculation, and metabolism and applied in various ischemic diseases. Herewith, we fully evaluated the effect of HBO on ischemic stroke and investigated its potential mechanism in the rat ischemia/reperfusion(I/R) model. Sixty Sprague-Dawley male rats were randomly divided into three groups—sham group, MCAO group, and MCAO+HBO group. In the latter two groups, the middle cerebral artery occlusion was performed (MCAO) for 2 hours, and then the occlusion was removed in order to establish the ischemic/reperfusion model. Subsequently, HBO was performed immediately after I/R (2 hours per day for 3 days). 72 hours after MCAO, the brain was dissected for our experiment. Finally, the data from three groups were analyzed by one-way analysis of variance (ANOVA) and followed by a Bonferroni test. In this article, we reported that HBO effectively reduced the infarction and edema and improved neurological functions to a certain extent. As shown by western blot analysis, HBO significantly reduced autophagy by regulating autophagy-related proteins (mTOR, p-mTOR, Atg13, LC3B II and LC3B II) in the hippocampus 72 hours after I/R, which was accompanied by inhibiting the expression of hypoxia inducible factor-1α (HIF-1α) in hippocampus. The results suggest that HBO may improve cerebral I/R injury, possibly via inhibiting HIF-1α, the upstream molecule of autophagy, and therefore, subsequently inhibiting autophagy in the rat model of ischemic stroke.
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17
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Towfighi A, Skolarus LE. Inequities in Stroke Preparedness in Young Adults. Stroke 2020; 51:3479-3481. [DOI: 10.1161/strokeaha.120.032612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Amytis Towfighi
- Department of Neurology, University of Southern California, Los Angeles (A.T.)
- Los Angeles County Department of Health Services, CA (A.T.)
| | - Lesli E. Skolarus
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor (L.E.S.)
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18
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Iwamoto Y, Imura T, Tanaka R, Imada N, Inagawa T, Araki H, Araki O. Development and Validation of Machine Learning-Based Prediction for Dependence in the Activities of Daily Living after Stroke Inpatient Rehabilitation: A Decision-Tree Analysis. J Stroke Cerebrovasc Dis 2020; 29:105332. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105332] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/03/2020] [Accepted: 09/12/2020] [Indexed: 01/19/2023] Open
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19
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Schreiber R, Hollands R, Blokland A. A Mechanistic Rationale for PDE-4 Inhibitors to Treat Residual Cognitive Deficits in Acquired Brain Injury. Curr Neuropharmacol 2020; 18:188-201. [PMID: 31660837 PMCID: PMC7327948 DOI: 10.2174/1570159x17666191010103044] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 08/06/2019] [Accepted: 10/03/2019] [Indexed: 02/06/2023] Open
Abstract
Patients with acquired brain injury (ABI) suffer from cognitive deficits that interfere significantly with their daily lives. These deficits are long-lasting and no treatment options are available. A better understanding of the mechanistic basis for these cognitive deficits is needed to develop novel treatments. Intracellular cyclic adenosine monophosphate (cAMP) levels are decreased in ABI. Herein, we focus on augmentation of cAMP by PDE4 inhibitors and the potentially synergistic mechanisms in traumatic brain injury. A major acute pathophysiological event in ABI is the breakdown of the blood-brain-barrier (BBB). Intracellular cAMP pathways are involved in the subsequent emergence of edema, inflammation and hyperexcitability. We propose that PDE4 inhibitors such as roflumilast can improve cognition by modulation of the activity in the cAMP-Phosphokinase A-Ras-related C3 botulinum toxin substrate (RAC1) inflammation pathway. In addition, PDE4 inhibitors can also directly enhance network plasticity and attenuate degenerative processes and cognitive dysfunction by increasing activity of the canonical cAMP/phosphokinase-A/cAMP Responsive Element Binding protein (cAMP/PKA/CREB) plasticity pathway. Doublecourtin and microtubule-associated protein 2 are generated following activation of the cAMP/PKA/CREB pathway and are decreased or even absent after injury. Both proteins are involved in neuronal plasticity and may consist of viable markers to track these processes. It is concluded that PDE4 inhibitors may consist of a novel class of drugs for the treatment of residual symptoms in ABI attenuating the pathophysiological consequences of a BBB breakdown by their anti-inflammatory actions via the cAMP/PKA/RAC1 pathway and by increasing synaptic plasticity via the cAMP/PKA/CREB pathway. Roflumilast improves cognition in young and elderly humans and would be an excellent candidate for a proof of concept study in ABI patients.
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Affiliation(s)
- Rudy Schreiber
- Faculty of Psychology and Neuroscience, Section Neuropsychology and Psychopharmacology, Maastricht University, PO BOX 616, 6200 MD Maastricht, Netherlands
| | - Romain Hollands
- Faculty of Psychology and Neuroscience, Section Neuropsychology and Psychopharmacology, Maastricht University, PO BOX 616, 6200 MD Maastricht, Netherlands
| | - Arjan Blokland
- Faculty of Psychology and Neuroscience, Section Neuropsychology and Psychopharmacology, Maastricht University, PO BOX 616, 6200 MD Maastricht, Netherlands
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Corches CL, McBride AC, Robles MC, Rehman N, Bailey S, Oliver A, Skolarus LE. Development, Adaptation and Scale-up of a Community-wide, Health Behavior Theory-based Stroke Preparedness Intervention. Am J Health Behav 2020; 44:744-755. [PMID: 33081873 DOI: 10.5993/ajhb.44.6.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: Acute stroke treatments reduce the likelihood of post-stroke disability, but are vastly underutilized. In this paper, we describe the development, adaptation, and scale-up of the Stroke Ready program - a health behavior theory-based stroke preparedness intervention that addresses underlying behavioral factors that contribute to acute stroke treatment underutilization. Methods: Through a community-based participatory research (CBPR) approach, we conducted needs and determinant assessments, which informed creation and pilot testing of Stroke Ready. Based on these results, we then scaled Stroke Ready to the entire community by greatly expanding the delivery system. Results: The scaled Stroke Ready program is a community-wide stroke preparedness education program consisting of peer-led workshops, print materials, and digital, social, and broadcast media campaigns. Whereas the Stroke Ready pilot workshop was delivered to 101 participants, 5945 participants have received the scaled Stroke Ready peer-led workshop to date. Additionally, we have sent mailers to over 44,000 households and reached approximately 35,000 people through our social media campaign. Conclusion: Strategies including an expanded community advisory board, adaptation of the intervention and community-engaged recruitment facilitated the scale-up of Stroke Ready, which may serve as a model to increase acute stroke treatment rates, particularly in majority African-American communities.
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Affiliation(s)
- Casey L. Corches
- Casey L. Corches, Project Manager, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States;,
| | - A. Camille McBride
- A. Camille McBride, Research Assistant, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Maria Cielito Robles
- Maria Cielito Robles, Research Area Specialist, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Narmeen Rehman
- Narmeen Rehman, Research Assistant, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Sarah Bailey
- Sarah Bailey, Bridges Into the Future, Flint, MI, United States
| | - Alina Oliver
- Alina Oliver, Bethlehem Temple Church, Flint, MI, United States
| | - Lesli E. Skolarus
- Lesli E. Skolarus, Associate Professor, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
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21
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González-Nieto D, Fernández-Serra R, Pérez-Rigueiro J, Panetsos F, Martinez-Murillo R, Guinea GV. Biomaterials to Neuroprotect the Stroke Brain: A Large Opportunity for Narrow Time Windows. Cells 2020; 9:E1074. [PMID: 32357544 PMCID: PMC7291200 DOI: 10.3390/cells9051074] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 12/14/2022] Open
Abstract
Ischemic stroke represents one of the most prevalent pathologies in humans and is a leading cause of death and disability. Anti-thrombolytic therapy with tissue plasminogen activator (t-PA) and surgical thrombectomy are the primary treatments to recanalize occluded vessels and normalize the blood flow in ischemic and peri-ischemic regions. A large majority of stroke patients are refractory to treatment or are not eligible due to the narrow time window of therapeutic efficacy. In recent decades, we have significantly increased our knowledge of the molecular and cellular mechanisms that inexorably lead to progressive damage in infarcted and peri-lesional brain areas. As a result, promising neuroprotective targets have been identified and exploited in several stroke models. However, these considerable advances have been unsuccessful in clinical contexts. This lack of clinical translatability and the emerging use of biomaterials in different biomedical disciplines have contributed to developing a new class of biomaterial-based systems for the better control of drug delivery in cerebral disorders. These systems are based on specific polymer formulations structured in nanoparticles and hydrogels that can be administered through different routes and, in general, bring the concentrations of drugs to therapeutic levels for prolonged times. In this review, we first provide the general context of the molecular and cellular mechanisms impaired by cerebral ischemia, highlighting the role of excitotoxicity, inflammation, oxidative stress, and depolarization waves as the main pathways and targets to promote neuroprotection avoiding neuronal dysfunction. In the second part, we discuss the versatile role played by distinct biomaterials and formats to support the sustained administration of particular compounds to neuroprotect the cerebral tissue at risk of damage.
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Affiliation(s)
- Daniel González-Nieto
- Center for Biomedical Technology, Universidad Politécnica de Madrid, 28040 Madrid, Spain; (R.F.-S.); (J.P.-R.); (G.V.G.)
- Departamento de Tecnología Fotónica y Bioingeniería, ETSI Telecomunicaciones, Universidad Politécnica de Madrid, 28040 Madrid, Spain
- Biomedical Research Networking Center in Bioengineering Biomaterials and Nanomedicine (CIBER-BBN), 28029 Madrid, Spain
| | - Rocío Fernández-Serra
- Center for Biomedical Technology, Universidad Politécnica de Madrid, 28040 Madrid, Spain; (R.F.-S.); (J.P.-R.); (G.V.G.)
- Departamento de Tecnología Fotónica y Bioingeniería, ETSI Telecomunicaciones, Universidad Politécnica de Madrid, 28040 Madrid, Spain
| | - José Pérez-Rigueiro
- Center for Biomedical Technology, Universidad Politécnica de Madrid, 28040 Madrid, Spain; (R.F.-S.); (J.P.-R.); (G.V.G.)
- Biomedical Research Networking Center in Bioengineering Biomaterials and Nanomedicine (CIBER-BBN), 28029 Madrid, Spain
- Departamento de Ciencia de Materiales, ETSI Caminos, Canales y Puertos, Universidad Politécnica de Madrid, 28040 Madrid, Spain
| | - Fivos Panetsos
- Neurocomputing and Neurorobotics Research Group: Faculty of Biology and Faculty of Optics, Universidad Complutense de Madrid, 28040 Madrid, Spain;
- Brain Plasticity Group, Health Research Institute of the Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | | | - Gustavo V. Guinea
- Center for Biomedical Technology, Universidad Politécnica de Madrid, 28040 Madrid, Spain; (R.F.-S.); (J.P.-R.); (G.V.G.)
- Biomedical Research Networking Center in Bioengineering Biomaterials and Nanomedicine (CIBER-BBN), 28029 Madrid, Spain
- Departamento de Ciencia de Materiales, ETSI Caminos, Canales y Puertos, Universidad Politécnica de Madrid, 28040 Madrid, Spain
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22
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Khalil HM, Lahoud N. Knowledge of Stroke Warning Signs, Risk Factors, and Response to Stroke among Lebanese Older Adults in Beirut. J Stroke Cerebrovasc Dis 2020; 29:104716. [PMID: 32192843 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104716] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Stroke is a global burden. In Lebanon, recent studies have shown that stroke prevalence may be higher than other developing countries. While older people are particularly vulnerable to stroke, research suggests that they have poor stroke awareness. Since awareness is crucial for early hospital admission, thereby outcome, the main objectives of this study were to assess knowledge of stroke ie, symptoms, risk factors, and intended behavior in case of stroke suspicion. METHODS A community-based survey targeting adults aged 50 and above was conducted at 20 random pharmacies in Beirut from May to October 2018 through face to face interviews utilizing a structured questionnaire composed of open and closed ended questions. Descriptive and multivariable analyses were performed. MAIN RESULTS In total, 390 participants completed the questionnaire. Sixty-eight percent were able to spontaneously recall at least 1 stroke symptom, most frequently headache (29.2%), hemiparesis (25.4%), and dizziness (19.5%). Furthermore, 85.4% spontaneously recalled at least 1 risk factor, most frequently hypertension (48.2%), smoking (20.5%), and stress (43.1%). In case of stroke suspicion 57.69% would call an ambulance. Knowing a stroke patient and educational level were predictors for recall of more symptoms and risk factors for stroke. Adequate response to stroke was positively associated with identification of more stroke symptoms but inversely associated with having diabetes. CONCLUSIONS AND RECOMMENDATIONS There are major gaps in stroke knowledge among Beirut's older population. Culturally tailored awareness campaigns should be implemented at multiple levels using different media methods to target vulnerable populations at higher risk for stroke and their families. These campaigns should focus on improving stroke symptoms awareness and actions to take when suspecting stroke.
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Affiliation(s)
| | - Nathalie Lahoud
- Faculty of Pharmacy, Lebanese University, Hadat, Lebanon; Faculty of Public Health, Lebanese University, Fanar, Lebanon; CERIPH, Center for Research in Public Health, Pharmacoepidemiology Surveillance Unit, Faculty of Public Health, Lebanese University, Fanar, Lebanon; INSPECT-LB, Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie, Faculty of Public Health, Lebanese University, Fanar, Lebanon
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23
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Uivarosan D, Bungau S, Tit DM, Moisa C, Fratila O, Rus M, Bratu OG, Diaconu CC, Pantis C. Financial Burden of Stroke Reflected in a Pilot Center for the Implementation of Thrombolysis. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E54. [PMID: 32013001 PMCID: PMC7074434 DOI: 10.3390/medicina56020054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/06/2020] [Accepted: 01/27/2020] [Indexed: 01/01/2023]
Abstract
Stroke represents a serious illness and is extremely relevant from the public health point of view, implying important social and economic burdens. Introducing new procedures or therapies that reduce the costs both in the acute phase of the disease and in the long term becomes a priority for health systems worldwide. The present study quantifies and compares the direct costs for ischemic stroke in patients with thrombolysis treatment versus conservative treatment over a 24-month period from the initial diagnosis, in one of the 7 national pilot centres for the implementation of thrombolytic treatment. The significant reduction (p < 0.001) of the hospitalization period, especially of the days in the intensive care unit (ICU) for stroke, resulted in a significant reduction (p < 0.001) of the total average costs in the patients with thrombolysis, both at the first hospitalization and for the subsequent hospitalizations, during the period followed in the study. It was also found that the percentage of patients who were re-hospitalized within the first 24-months after stroke was significantly lower (p < 0.001) among thrombolyzed patients. The present study demonstrates that the quick intervention in cases of stroke is an efficient policy regarding costs, of Romanian Public Health System, Romania being the country with the highest rates of new strokes and deaths due to stroke in Europe.
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Affiliation(s)
- Diana Uivarosan
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania;
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania; (D.M.T.); (C.M.)
| | - Delia Mirela Tit
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania; (D.M.T.); (C.M.)
| | - Corina Moisa
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania; (D.M.T.); (C.M.)
| | - Ovidiu Fratila
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (O.F.); (M.R.)
| | - Marius Rus
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (O.F.); (M.R.)
| | - Ovidiu Gabriel Bratu
- Clinical Department 3, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania;
| | - Camelia C. Diaconu
- Department 5, University of Medicine and Pharmacy ”Carol Davila”, 050474 Bucharest, Romania;
- Internal Medicine Clinic, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania
| | - Carmen Pantis
- Department of Surgical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania;
- Emergency Clinical County Hospital, 410169 Oradea, Romania
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24
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Carrera JF, Sorace BJ, Worrall BB, Southerland AM, Chiota-McCollum NA. Delay to Tissue Plasminogen Activator in Hypertensive Stroke Patients: An Analysis of Delay Duration Across Agents. J Stroke Cerebrovasc Dis 2019; 29:104525. [PMID: 31812455 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104525] [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] [Received: 09/04/2019] [Revised: 10/24/2019] [Accepted: 11/06/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE A subset of ischemic stroke patients present with blood pressures above that considered safe for thrombolytic administration, requiring antihypertensive therapy. Guideline statements are ambivalent regarding which antihypertensive agent should be used to obtain a satisfactory blood pressure < 185/110 mm Hg prior to alteplase. METHODS We reviewed data from consecutive patients at a single institution treated with alteplase from January 2014 to January 2019, collecting door-to-needle times, antihypertensive agent (if used), and antihypertensive-to-needle times. Patients were grouped by initial agent administered. We assessed for differences in door-to-needle times between those needing antihypertensive(s) and those who did not. Antihypertensive-to-needle times were compared across 3 antihypertensive groups (labetalol, nicardipine, and hydralazine). RESULTS Analysis included 239 patients: 177 receiving no antihypertensive, 44 labetalol, 13 nicardipine, and 5 hydralazine. Those not administered an antihypertensive prior to alteplase had shorter door-to-needle times (52.6 minutes versus 62.1 minutes, P = .016). We found no statistical differences when comparing door-to-needle times across all groups (no med 52.6 minutes, labetalol 64.3 minutes, nicardipine 53.0 minutes, hydralazine 67.4 minutes, P = .052). No differences were found in antihypertensive-to-needle amongst the 3 antihypertensive groups (labetalol 18.75 minutes, nicardipine 12.15 minutes, hydralazine 25.40 minutes, P = .239). CONCLUSIONS Patients requiring antihypertensives experienced slower door-to-needle times. No statistically significant changes were observed in door-to-needle times by antihypertensive used, however these results may have clinical importance. This study is limited by relatively small sample size. Pooling data from multiple institutions could provide more robust assessment and inform clinical practice.
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Affiliation(s)
| | - Brian J Sorace
- Department of Neurology, University of California San Diego, La Jolla, CA
| | - Bradford B Worrall
- Departments of Neurology & Public Health Sciences, University of Virginia, Charlottesville, VA
| | - Andrew M Southerland
- Departments of Neurology & Public Health Sciences, University of Virginia, Charlottesville, VA
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25
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Kanazawa T, Kurano T, Ibaraki H, Takashima Y, Suzuki T, Seta Y. Therapeutic Effects in a Transient Middle Cerebral Artery Occlusion Rat Model by Nose-To-Brain Delivery of Anti-TNF-Alpha siRNA with Cell-Penetrating Peptide-Modified Polymer Micelles. Pharmaceutics 2019; 11:pharmaceutics11090478. [PMID: 31540164 PMCID: PMC6781507 DOI: 10.3390/pharmaceutics11090478] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 12/15/2022] Open
Abstract
We previously reported that siRNA delivery to the brain is improved by the nose-to-brain delivery route and by conjugation with polyethylene glycol-polycaprolactone (PEG-PCL) polymer micelles and the cell-penetrating peptide, Tat (PEG-PCL-Tat). In this study, we evaluated the nose-to-brain delivery of siRNA targeting TNF-α (siTNF-α) conjugated with PEG-PCL-Tat to investigate its therapeutic effects on a transient middle cerebral artery occlusion (t-MCAO) rat model of cerebral ischemia-reperfusion injury. Intranasal treatment was provided 30 min after infarction induced via suturing. Two hours after infarction induction, the suture was removed, and blood flow was released. At 22 h post-reperfusion, we assessed the infarcted area, TNF-α production, and neurological score to determine the therapeutic effects. The infarcted area was observed over a wide range in the untreated group, whereas shrinkage of the infarcted area was observed in rats subjected to intranasal administration of siTNF-α with PEG-PCL-Tat micelles. Moreover, TNF-α production and neurological score in rats treated by intranasal administration of siTNF-α with PEG-PCL-Tat micelles were significantly lower than those in untreated and naked siTNF-α-treated rats. These results indicate that nose-to-brain delivery of siTNF-α conjugated with PEG-PCL-Tat micelles alleviated the symptoms of cerebral ischemia-reperfusion injury.
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Affiliation(s)
- Takanori Kanazawa
- School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan; (T.K.); (H.I.); (Y.T.); (Y.S.)
- School of Pharmacy, Nihon University, 7-7-1 Narashinodai, Funabashi, Chiba 274-8555, Japan;
- Correspondence: ; Tel./Fax: +81-47-465-6587
| | - Takumi Kurano
- School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan; (T.K.); (H.I.); (Y.T.); (Y.S.)
- School of Pharmacy, Nihon University, 7-7-1 Narashinodai, Funabashi, Chiba 274-8555, Japan;
| | - Hisako Ibaraki
- School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan; (T.K.); (H.I.); (Y.T.); (Y.S.)
| | - Yuuki Takashima
- School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan; (T.K.); (H.I.); (Y.T.); (Y.S.)
| | - Toyofumi Suzuki
- School of Pharmacy, Nihon University, 7-7-1 Narashinodai, Funabashi, Chiba 274-8555, Japan;
| | - Yasuo Seta
- School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan; (T.K.); (H.I.); (Y.T.); (Y.S.)
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26
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Majidi S, Luby M, Lynch JK, Hsia AW, Benson RT, Kalaria CP, Nadareishvili Z, Latour LL, Leigh R. MRI-based thrombolytic therapy in patients with acute ischemic stroke presenting with a low NIHSS. Neurology 2019; 93:e1507-e1513. [PMID: 31519779 DOI: 10.1212/wnl.0000000000008312] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 05/16/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Treatment of patients with stroke presenting with minor deficits remains controversial, and the recent Potential of rtPA for Ischemic Strokes with Mild Symptoms (PRISMS) trial, which randomized patients to thrombolysis vs aspirin, did not show benefit. We studied the safety and efficacy of thrombolysis in a population of patients with acute stroke presenting with low NIH Stroke Scale (NIHSS) scores screened using MRI. METHODS The NIH Natural History of Stroke database was reviewed from January 2006 to December 2016 to identify all patients with an initial NIHSS score ≤5 who received thrombolysis within 4.5 hours of symptom onset after being screened with MRI. The 24-hour postthrombolysis MRIs were reviewed for hemorrhagic transformation. Primary outcomes were symptomatic intracranial hemorrhage (sICH) and favorable 90-day outcome modified Rankin Scale score 0-1. Subgroup analysis was performed on patients who would have been eligible for the PRISMS trial, which enrolled patients with a nondisabling neurologic deficit. RESULTS A total of 121 patients were included in the study with a median age of 65 and an NIHSS score of 3; 63% were women. The rate of any hemorrhagic transformation was 13%, with 11% of them being limited to petechial hemorrhage. The rate of sICH was <1%. Sixty-six patients had 90-day outcome data; of those, 74% had a favorable outcome. For the subgroup of 81 PRISMS-eligible patients, none experienced sICH. Fifty of these patients had 90-day outcome data; of these, 84% had a favorable outcome. CONCLUSIONS Thrombolytic therapy was safe in our patients with stroke with minor deficits who were initially evaluated by MRI. Future studies of this population may benefit from MRI selection. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with acute ischemic stroke and NIHSS ≤5 screened with MRI, IV tissue plasminogen activator is safe.
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Affiliation(s)
- Shahram Majidi
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Marie Luby
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - John K Lynch
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Amie W Hsia
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Richard T Benson
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Chandni P Kalaria
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Zurab Nadareishvili
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Lawrence L Latour
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Richard Leigh
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD.
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27
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Zhou Y, Yan S, Song X, Gong Y, Li W, Wang M, Yin X, Hu B, Lu Z. Intravenous thrombolytic therapy for acute ischemic stroke in Hubei, China: a survey of thrombolysis rate and barriers. BMC Neurol 2019; 19:202. [PMID: 31438899 PMCID: PMC6704516 DOI: 10.1186/s12883-019-1418-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 07/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rates of thrombolysis in most countries are well below best practice benchmarks. We aimed to investigate thrombolysis utilization and its associated factors in acute ischemic stroke (AIS) patients in Hubei province, China, to assess neurologists' experiences of the treatment, and to identify barriers against the treatment from perspective of AIS patients and neurologists. METHODS Survey of 2096 AIS patients and 709 neurologists from 66 hospitals was conducted in Hubei province between 2014 and 2015. A multivariable logistic regression model was utilized to identify the factors associated with thrombolysis utilization and neurologists' experiences with thrombolysis. RESULTS Of the 2096 AIS patients, only 3.8% received thrombolysis. Of the 709 neurologists, 66.0% reported using thrombolysis for AIS patients. The main reasons for not using thrombolysis were late arrival of patients, fear of the risk of complications of thrombolysis, and light or quickly recovered stroke symptoms. The behavior and clinical characteristics of patients, including early admission to hospital (odds ratio [OR] = 5.81, 95% confidence intervals [CI] 3.31-10.20), using emergency medical services to be hospitalized (OR = 3.36, 95% CI 2.00-5.62), stroke history (OR = 0.53, 95% CI 0.28-0.99), and National Institute of Health Stroke Scale score < 4 (OR = 0.46, 95% CI 0.27-0.77) were shown to significantly affect the thrombolysis utilization in the multivariate model. In addition, hospital grade (OR = 2.84, 95% CI 1.84-4.37), education level (OR = 2.49, 95% CI 1.09-5.73), and working years (OR = 1.88, 95% CI 1.18-3.00) were strongly associated with neurologists' experiences of thrombolysis. CONCLUSIONS A very low proportion of AIS patients received thrombolysis in Hubei province, China. Considerable education programs and interventions were required regarding knowledge of stroke treatment for clinicians and proper behavior after stroke for AIS patients and their families.
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Affiliation(s)
- Yanfeng Zhou
- Department of Social Medicine and Health Management, School of Public Health Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Shijiao Yan
- School of Public Health, Hainan Medical University, Haikou, 571199, People's Republic of China.,Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, 571199, People's Republic of China
| | - Xingyue Song
- Department of Social Medicine and Health Management, School of Public Health Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Yanhong Gong
- Department of Social Medicine and Health Management, School of Public Health Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Wenzhen Li
- Department of Social Medicine and Health Management, School of Public Health Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Mengdie Wang
- Department of Neurology, Union Hospital Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Xiaoxv Yin
- Department of Social Medicine and Health Management, School of Public Health Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China.
| | - Bo Hu
- Department of Neurology, Union Hospital Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China.
| | - Zuxun Lu
- Department of Social Medicine and Health Management, School of Public Health Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China.
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Paul C, D'Este C, Ryan A, Jayakody A, Attia J, Oldmeadow C, Kerr E, Henskens F, Grady A, Levi CR. Staff perspectives from Australian hospitals seeking to improve implementation of thrombolysis care for acute stroke. SAGE Open Med 2019; 7:2050312119865656. [PMID: 31384464 PMCID: PMC6647204 DOI: 10.1177/2050312119865656] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 07/01/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Intravenous thrombolysis is one of few evidence-based treatments for acute
stroke. Treatment uptake is low outside major stroke care centres. There is
a need for greater understanding of barriers encountered by clinicians when
seeking to increase thrombolysis rates. Aim: The aim of this study is to describe physicians’ and nurses’ perceptions
regarding thrombolysis for acute stroke at hospitals in the earlier stages
of thrombolysis implementation. Methods: A cross-sectional paper survey completed by physicians’ and nurses’ was
distributed to 1127 staff at stroke care units, emergency departments or
equivalent stroke care facilities at 19 Australian hospitals, as part of a
cluster randomised controlled trial for thrombolysis implementation and
systems improvement. Results: Of 1127 potential participants, 503 (148 physicians and 355 nurses) completed
surveys (45% response rate). Over 90% agreed that thrombolysis improved the
odds of independent survival. However, 42% to 58% agreed that there were
limitations in the evidence base. A small proportion of staff indicated
deficits in technical competencies. Interactive or competency-based training
was reported by less than two-thirds of the sample. Challenges such as quick
bed availability were identified. Emergency department physicians were less
positive towards the treatment compared with nurses (p < 0.001), stroke
care unit physicians were more positive than nurses (p = 0.047) and older
clinicians were more positive than younger clinicians (p = 0.007). Conclusion: Australian hospitals seeking to address barriers to stroke thrombolysis
implementation may benefit from the availability of interactive and
competency-based training, staff performance feedback, support to make beds
available quickly and bypass arrangements to quickly deliver acute stroke
patients to appropriate facilities.
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Affiliation(s)
- Christine Paul
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Catherine D'Este
- National Centre for Epidemiology & Population Health, The Australian National University, Canberra, ACT, Australia
| | - Annika Ryan
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Amanda Jayakody
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - John Attia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Christopher Oldmeadow
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Erin Kerr
- Hunter New England Health, New Lambton Heights, NSW, Australia
| | - Frans Henskens
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Alice Grady
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia.,Hunter New England Health, New Lambton Heights, NSW, Australia.,Priority Research Centre for Health Behaviour, The University of Newcastle, Callaghan, NSW, Australia
| | - Christopher R Levi
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia.,Hunter New England Health, New Lambton Heights, NSW, Australia
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Jiang W, Tian X, Yang P, Li J, Xiao L, Liu J, Liu C, Tan W, Tu H. Enolase1 Alleviates Cerebral Ischemia-Induced Neuronal Injury via Its Enzymatic Product Phosphoenolpyruvate. ACS Chem Neurosci 2019; 10:2877-2889. [PMID: 30943007 DOI: 10.1021/acschemneuro.9b00103] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Stroke is a leading cause of disability and the second leading cause of death among adults worldwide, while the mechanisms underlying neuronal death and dysfunction remain poorly understood. Here, we investigated the differential proteomic profiles of mouse brain homogenate with 3 h of middle cerebral artery occlusion (MCAO) ischemia, or sham, using Coomassie Brilliant Blue staining, followed by mass spectrometry. We identified enolase1 (ENO1), a key glycolytic enzyme, as a potential mediator of neuronal injury in MCAO ischemic model. Reverse transcription polymerase chain reaction and western blotting data showed that ENO1 was ubiquitously expressed in various tissues, distinct regions of brain, and different postnatal age. Immunohistochemical analysis revealed that ENO1 is localized in neuronal cytoplasm and dendrites. Interestingly, the expression level of ENO1 was significantly increased in the early stage, but dramatically decreased in the late stage, of cerebral ischemia in vivo. This dynamic change was consistent with our finding in cultured hippocampal neurons treated with oxygen/glucose deprivation (OGD) in vitro. Importantly, ENO1 overexpression in cultured neurons alleviated dendritic and spinal loss caused by OGD treatment. Furthermore, the enzymatic product of ENO1, phosphoenolpyruvate (PEP), was also synchronously changed along with the dynamic ENO1 level. The neuronal injury caused by OGD treatment in vitro or ischemia in vivo was mitigated by the application of PEP. Taken together, our data revealed that ENO1 plays a novel and protective role in cerebral ischemia-induced neuronal injury, highlighting a potential of ENO1 as a therapeutic target of neuronal protection from cerebral ischemia.
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Affiliation(s)
| | | | | | | | | | | | | | - Weihong Tan
- Department of Chemistry, Department of Physiology and Functional Genomics, Center for Research at the Bio/Nano Interface, UF Health Cancer Center, UF Genetics Institute and McKnight Brain Institute University of Florida, Gainesville, Florida 32611, United States
| | - Haijun Tu
- Shenzhen Research Institute, Hunan University, Shenzhen, Guangdong 518000, China
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Absence of Collaterals is Associated with Larger Infarct Volume and Worse Outcome in Patients with Large Vessel Occlusion and Mild Symptoms. J Stroke Cerebrovasc Dis 2019; 28:1987-1992. [PMID: 31036341 DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.032] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/02/2019] [Accepted: 03/11/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy is the standard of care for patients with large vessel occlusion (LVO) presenting with severe symptoms; however, little is known about the best treatment for patients with LVO and mild symptoms. The absence of good collaterals has been associated with a worse outcome in patients with LVO. In this study, we aim to assess the use of collateral score to identify patients with LVO and mild symptoms that might benefit from mechanical thrombectomy (MT). METHODS A retrospective review of prospectively collected data on patients presenting with mild ischemic stroke (National Institute of Health Stroke Scale [NIHSS] <6) and anterior circulation LVO between September 2015 and July 2017 was performed. Collected data included baseline demographics, NIHSS on admission, Alberta Stroke Program Early CT Score (ASPECTS), location of occlusion, collateral score using Tan scoring system, final infarct volume, and 90-day modified Rankin Scale (mRS). Patients who underwent MT were excluded from this analysis. Two multivariable models were used to assess outcomes. A gamma distributed generalized linear regression model with a log link was used to examine the impact on final infarct volume. To predict the odds of a positive 90-day outcome we estimated a logistic regression. RESULTS Forty-one patients were identified. Mean age was 67.7-years with 56.1% males. Median NIHSS on admission was 3. The most common vessels involved were the middle cerebral artery (26), internal carotid artery (14), and anterior cerebral artery (1). Twelve patients received intravenous alteplase. Median ASPECTS score was 9, median collateral score was 2.3. Median infarct volume was 10.7 mL. A good functional outcome (mRS 0-2) at 90 days was achieved in 86.4% of patients. There was a negative relationship between collateral score and final infarct volume (-.3134, P = .046). Multivariable regression results showed that with a one-point increase in NIHSS on admission there was a 25% increase in final infarct volume. Higher infarct volume was associated with lower odds of achieving good functional outcome (mRS 0-2) (odds ratio .96, P = .049 [95% confidence interval .918-.999). CONCLUSIONS Most patients with anterior circulation LVO and low NIHSS achieve good long-term functional outcome, however, approximately 15% had significant disability. The absence of collaterals correlates with a larger final infarct volume and a worse long-term functional outcome. Collateral score might be a useful tool in identifying patients with LVO and low NIHSS who might benefit from MT.
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31
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Skolarus LE, Neshewat GM, Evans L, Green M, Rehman N, Landis-Lewis Z, Schrader JW, Sales AE. Understanding determinants of acute stroke thrombolysis using the tailored implementation for chronic diseases framework: a qualitative study. BMC Health Serv Res 2019; 19:182. [PMID: 30894152 PMCID: PMC6425596 DOI: 10.1186/s12913-019-4012-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 03/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Tailored Implementation in Chronic Disease (TICD) framework is a comprehensive framework describing the determinants of implementation success that has been used extensively in primary care settings. We explored the utility of the TICD to identify determinants of practice in an acute setting, namely guideline concordant acute stroke thrombolysis in a low-resourced, predominately minority serving, large, Emergency Department (ED). METHODS Through workshops and expert review, we developed an interview guide informed by the TICD framework. We then conducted semi-structured interviews with data collected through written transcripts, audio transcripts or interviewer notes based on participant availability. Three independent coders then performed a content analysis using template analysis, but open to new determinants that arose from the data, into the TICD framework. RESULTS We performed a total of 15 semi-structured interviews with ED acute stroke providers including medical technicians, nurses, and physicians. We found that guideline factors, individual health professional factors, and patient factors domains were barriers to guideline concordant acute stroke thrombolysis. The domain professional interactions was a facilitator to treatment. We identified three determinants, healthcare professional burnout, health care professional turnover and surrogate decision making, that are not part of the TICD framework. CONCLUSIONS Most determinants of acute stroke thrombolysis are included within the TICD framework. Inclusion of healthcare professional burnout, healthcare professional turnover and surrogate decision making may assist in expanding the TICD to time-sensitive ED conditions. Further work is needed to confirm this finding and to establish whether the TICD is applicable for use in non-time sensitive ED conditions. Interventions that address guideline, individual health professional and patient factors may improve guideline concordant acute stroke thrombolysis.
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Affiliation(s)
- Lesli E. Skolarus
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
- School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Gina M. Neshewat
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
| | - Lacey Evans
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
| | - Molly Green
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
- School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Narmeen Rehman
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
| | - Zach Landis-Lewis
- Department of Learning Health Science, University of Michigan, Ann Arbor, USA
| | | | - Anne E. Sales
- Department of Learning Health Science, University of Michigan, Ann Arbor, USA
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI USA
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So PW, Ekonomou A, Galley K, Brody L, Sahuri-Arisoylu M, Rattray I, Cash D, Bell JD. Intraperitoneal delivery of acetate-encapsulated liposomal nanoparticles for neuroprotection of the penumbra in a rat model of ischemic stroke. Int J Nanomedicine 2019; 14:1979-1991. [PMID: 30936698 PMCID: PMC6430000 DOI: 10.2147/ijn.s193965] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background Ischemic stroke is a devastating condition, with metabolic derangement and persistent inflammation enhancing the initial insult of ischaemia. Recombinant tissue plasminogen remains the only effective treatment but limited as therapy must commence soon after the onset of symptoms. Purpose We investigated whether acetate, which modulates many pathways including inflammation, may attenuate brain injury in stroke. As acetate has a short blood half-life and high amounts irritate the gastrointestinal tract, acetate was administered encapsulated in a liposomal nanoparticle (liposomal-encapsulated acetate, LITA). Methods Transient ischemia was induced by 90 mins middle-cerebral artery occlusion (MCAO) in Sprague-Dawley rats, and LITA or control liposomes given intraperitoneally at occlusion and daily for up to two weeks post-MCAO. Magnetic resonance imaging (MRI) was used to estimate lesion volume at 24 h, 1 and 2 weeks post-MCAO and anterior lateral ventricular volume (ALVv) at 2 weeks post-MCAO. Locomotive behaviour was tested prior to the final MRI scan. After the final scan, brains were collected, and immunohistochemistry was performed. Results Lesion volumes were decreased by ~80% from 24 h to one-week post-MCAO, in both control and LITA groups (P⩽0.05). However, the lesion was increased by ~50% over the subsequent 1 to 2 weeks after MCAO in the control group (from 24.1±10.0 to 58.7±28.6 mm3; P⩽0.05) but remained unchanged in the LITA group. ALVv were also attenuated by LITA treatment at 2 weeks post-MCAO (177.2±11.9% and 135.3±10.9% of contralateral ALVv for control and LITA groups, respectively; P⩽0.05). LITA-treated animals also appeared to have improved motor activity, moving with greater average velocity than control animals. Microglial immunoreactivity was ~40% lower in the LITA group compared to the control group (P⩽0.05), but LITA did not modulate neurogenesis, apoptosis, histone acetylation and lipid peroxidation. Conclusion LITA appears to attenuate the harmful chronic neuroinflammation observed during brain remodeling after a focal ischemic insult.
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Affiliation(s)
- Po-Wah So
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Neuroimaging, London, UK,
| | - Antigoni Ekonomou
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Neuroimaging, London, UK,
| | - Kim Galley
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Neuroimaging, London, UK,
| | - Leigh Brody
- University of Westminster, Research Centre for Optimal Health, London, UK
| | | | - Ivan Rattray
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Basic and Clinical Neuroscience, London, UK
| | - Diana Cash
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Neuroimaging, London, UK,
| | - Jimmy D Bell
- University of Westminster, Research Centre for Optimal Health, London, UK
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Skolarus LE, Sales AE, Zimmerman MA, Corches CL, Landis-Lewis Z, Robles MC, McBride AC, Rehman N, Oliver A, Islam N, Springer MV, O’Brien A, Bailey S, Morgenstern LB, Meurer WJ, Burke JF. Stroke Ready: a multi-level program that combines implementation science and community-based participatory research approaches to increase acute stroke treatment: protocol for a stepped wedge trial. Implement Sci 2019; 14:24. [PMID: 30845958 PMCID: PMC6407173 DOI: 10.1186/s13012-019-0869-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/07/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Post-stroke disability is common, costly, and projected to increase. Acute stroke treatments can substantially reduce post-stroke disability, but few patients take advantage of these cost-effective treatments. Practical, cost-efficient, and sustainable interventions to address underutilized acute stroke treatments are currently lacking. In this context, we present the Stroke Ready project, a stepped wedge design, multi-level intervention that combines implementation science and community-based participatory research approaches to increase acute stroke treatments in the predominately African American community of Flint, Michigan, USA. METHODS Guided by the Tailored Implementation of Chronic Disease (TICD) framework, we begin with optimization of acute stroke care in emergency departments, with particular attention given to our safety-net hospital partners. Then, we move to a community-wide, multi-faceted, stroke preparedness intervention, with workshops led by peer educators, over 2 years. Measures of engagement of the safety-net hospital and the feasibility and sustainability of the implementation strategy as well as community intervention reach, dose delivered, and satisfaction will be collected. The primary outcome is acute stroke treatment rates, which includes both intravenous tissue plasminogen activator, and endovascular treatment. The co-secondary outcomes are intravenous tissue plasminogen activator treatment rates and the proportion of stroke patients who arrive by ambulance. DISCUSSION If successful, Stroke Ready will increase acute stroke treatment rates through emergency department and community level interventions. The stepped wedge design and process evaluation will provide insight into how Stroke Ready works and where it might work best. By exploring the relative effectiveness of the emergency department optimization and the community intervention, we will inform hospitals and communities as they determine how best to use their resources to optimize acute stroke care. TRIAL REGISTRATION ClinicalTrials.gov Trial Identifier NCT03645590 .
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Affiliation(s)
- Lesli E. Skolarus
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109 USA
| | - Anne E. Sales
- Department of Learning Health Sciences, University of Michigan, 1111 E. Catherine St, Ann Arbor, MI 48109 USA
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Ann Arbor, MI 48105 USA
| | - Marc A. Zimmerman
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109 USA
| | - Casey L. Corches
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
| | - Zach Landis-Lewis
- Department of Learning Health Sciences, University of Michigan, 1111 E. Catherine St, Ann Arbor, MI 48109 USA
| | - Maria Cielito Robles
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
| | - A. Camille McBride
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109 USA
| | - Narmeen Rehman
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109 USA
| | - Alina Oliver
- Bethlehem Temple Church, 3401 M L King Ave, Flint, MI 48505 USA
| | - Nishat Islam
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109 USA
| | - Mellanie V. Springer
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
| | - Alison O’Brien
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109 USA
| | | | - Lewis B. Morgenstern
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109 USA
| | - William J. Meurer
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
- Emergency Department, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
| | - James F. Burke
- Stroke Program, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
- Department of Neurology, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105 USA
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Koge J. [Reperfusion therapy in patients with minor or mild ischemic stroke]. Rinsho Shinkeigaku 2019; 59:84-92. [PMID: 30700691 DOI: 10.5692/clinicalneurol.cn-001255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A significant number of patients with minor or mild stroke symptoms on initial presentation subsequently develop neurological deterioration and poor clinical outcomes at hospital discharge. The presence of an underlying large vessel occlusion is a strong predictor of both clinical worsening and poor outcome. Although patients with a low baseline National Institutes of Health Stroke Scale (NIHSS) could have been included in some randomized controlled trials, the benefits of the mechanical thrombectomy for patients with a low NIHSS score are unknown. The causes of neurological deterioration in patients with underlying large vessel occlusion are heterogeneous, but include collateral failure, and no straightforward mechanisms are found in the majority of cases. Patients with internal carotid artery occlusion, but with a patent middle cerebral artery (MCA), can occasionally have good collateral circulation and develop only minor or mild stroke. These patients exhibit collateral MCA flow via the circle of Willis despite ipsilateral internal carotid artery occlusion. However, thrombus migration may cause occlusion of collateral MCA flow, leading to dramatic neurological deterioration. Careful observation and detailed assessment are required for the management of these patients. Recent studies have examined the efficacy and optimal timing of thrombolysis or mechanical thrombectomy for patients with minor or mild stroke. Herein, we review the mechanisms of neurological deterioration, and the efficacy of reperfusion therapy, for patients with minor or mild stroke.
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Affiliation(s)
- Junpei Koge
- Division of Neurology, Saiseikai Fukuoka General Hospital
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35
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Nalleballe K, Sharma R, Kovvuru S, Brown A, Sheng S, Gundapaneni S, Ranabothu S, Veerapaneni P, Joiner R, Kapoor N, Culp W, Onteddu S. Why are acute ischemic stroke patients not receiving thrombolysis in a telestroke network? J Telemed Telecare 2019; 26:317-321. [PMID: 30741084 DOI: 10.1177/1357633x18824518] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The purpose of this study was to determine reasons for not giving intravenous tissue plasminogen activator to eligible patients with acute ischemic stroke in a telestroke network. METHODS We performed a retrospective analysis of prospectively collected data of patients who were seen as a telestroke consultation during 2015 and 2016 with the Arkansas Stroke Assistance through Virtual Emergency Support programme for possible acute ischemic stroke. RESULTS Total consultations seen were 809 in 2015 and 744 in 2016, out of which 238 patients in 2015 and 247 patients in 2016 received intravenous tissue plasminogen activator. In 2015 and 2016, out of the remaining 571 and 497 patients, 294 and 200 patients respectively were thought to be cases of acute stroke based on clinical evaluation. The most common reasons for not being treated in 2015 and 2016, respectively, were; (a) minimal deficits in 42.17% and 49.5% cases, (b) falling out of the 4.5-hour time window in 22.44% and 22% cases, (c) patient/next of kin refusal in 18.02% and 16.5% cases. Less common reasons included limited functional status, abnormal labs (thrombocytopenia, elevated international normalised ratio (INR)/prothrombin time (PT)/partial thromboplastin time (PTT), hypo or hyperglycemia etc), recent surgery and symptoms being too severe etc. CONCLUSION 'Minimal deficits' and 'out of time window' continue to be the major causes for not receiving thrombolysis during acute ischemic stroke in both traditional and telestroke systems. Patient/next of kin refusal was high in our telestroke system when compared to traditional practices. Considering the increasing utility of telestroke this needs to be further looked into, along with the ways to address it.
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Affiliation(s)
- Krishna Nalleballe
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | - Rohan Sharma
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | - Sukanthi Kovvuru
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | - Aliza Brown
- Department of Neurology, University of Arkansas for Medical Sciences, USA.,Department of Radiology, University of Arkansas for Medical Sciences, USA
| | - Sen Sheng
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | | | - Saritha Ranabothu
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | | | - Renee Joiner
- Center for Distance Health, University of Arkansas for Medical Sciences, USA
| | - Nidhi Kapoor
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | - William Culp
- Department of Radiology, University of Arkansas for Medical Sciences, USA
| | - Sanjeeva Onteddu
- Department of Neurology, University of Arkansas for Medical Sciences, USA
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36
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Rosenbaum Halevi D, Bursaw AW, Karamchandani RR, Alderman SE, Breier JI, Vahidy FS, Aden JK, Cai C, Zhang X, Savitz SI. Cognitive deficits in acute mild ischemic stroke and TIA and effects of rt-PA. Ann Clin Transl Neurol 2019; 6:466-474. [PMID: 30911570 PMCID: PMC6414481 DOI: 10.1002/acn3.719] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/21/2018] [Accepted: 12/06/2018] [Indexed: 12/16/2022] Open
Abstract
Introduction It is unknown if treatment with rt-PA in mild acute ischemic stroke (MIS) is associated with improvement in long term cognition. Methods Forty-five patients with suspected acute mild stroke or transient ischemic attacks with NIHSS ≤6 were enrolled in a prospective cohort. Cognitive testing was performed within 24 h of symptom onset. Follow-up assessment was performed at Day 90 on 25 patients. Prestroke baseline cognition was based on age, years of education (YrE), history of cognitive impairment, and the Fazekas score. Results Eighty-five percent patients with suspected MIS or TIA showed cognitive abnormalities within 24 h of onset. There was no significant difference in age, sex, Fazekas score, or YrE between rt-PA versus No-rt-PA groups (N = 8 vs. 17).Two sample t-test for change in performance in the WMS-III sub-tests (follow-up - baseline) ± SD, indicated a difference between rt-PA 0.74 ± 0.77 and no-rt-PA groups -0.02 ± 0.83 (P = 0.044). Logistic regression for predicting normal status using the mental control subtest, at follow-up showed an OR 8.96, CI 0.98-82.12 (P = 0.05) favoring the rt-PA group. Improvement in Mental Control at 90 days occurred in patients with low white matter disease compared to high white matter disease, 0.60 ± 0.46 (P = 0.048). A statistical trend was observed and suggested an improvement on SDMT and Trail Making tests, 1.43 ± 0.8 (P = 0.077). Conclusion Suspected MIS and TIA patients have cognitive impairment within 24 h of onset. rt-PA administration might be associated with improvement on some cognitive tests at 90 days.
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Affiliation(s)
- David Rosenbaum Halevi
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease UTHealth Houston Texas
| | | | | | | | | | - Farhaan S Vahidy
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease UTHealth Houston Texas
| | - James K Aden
- Institute for Surgical Research Joint Base San Antonio San Antonio Texas
| | - Chunyan Cai
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease UTHealth Houston Texas
| | - Xu Zhang
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease UTHealth Houston Texas
| | - Sean I Savitz
- Department of Neurology and Institute for Stroke and Cerebrovascular Disease UTHealth Houston Texas
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Sweid A, Atallah E, Saad H, Bekelis K, Chalouhi N, Dang S, Li J, Kumar A, Turpin J, Barsoom R, Tjoumakaris S, Hasan D, DePrince M, Labella G, Rosenwasser RH, Jabbour P. Correlation between pre-admission blood pressure and outcome in a large telestroke cohort. J Clin Neurosci 2019; 62:33-37. [PMID: 30660477 DOI: 10.1016/j.jocn.2019.01.014] [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: 08/28/2018] [Accepted: 01/03/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Telemedicine rapidly connects patients, with acute ischemic stroke symptoms, with neurovascular specialists for assessment to reduce chemical thrombolysis delivery times. Management of AIS includes maintaining target systolic blood pressures (SBP). In this retrospective study, we assess the efficacy of the telestroke (TS) system at a primary stroke center and the prognostic value of SBP throughout the transportation process. METHODS Patients presenting with acute-onset neurological symptoms to the TS hospitals network, over a 5-year period, were assessed. Those with a confirmed diagnosis of AIS were included. We examined demographics, presenting-NIHSS, last SBP before transfer from the network hospital and continuous BP during transport, stroke risk factors, hospital-course, door-to-needle (DTN) time, treatments, and modified Rankin Scale(mRS). Multivariate analysis was conducted to evaluate the prognostic value of SBP on stroke outcome. RESULTS Of 2,928 patients identified, 1,353 were diagnosed with AIS. Mean age was 66.6 years (SD = 15.4), 47.6% female. Most cases affected the MCA(44.5%). Mean presenting-NIHSS was 8.67(SD = 8.38) and mean SBP was 148 mmHg(SD = 25.39). 73.2% treated using a standard protocol, 23.7% given IVrt-PA, and 6.8% received mechanical thrombectomy(MT). Mean DTN was 96 min(SD = 46; 27.3% <60 min). Age, presenting-NIHSS and pre-existing hypertension were associated with higher mortality and/or higher mRS. SBP was not associated with higher mortality and morbidity. CONCLUSIONS This study displays better clinical outcomes at latest follow-up when compared to current international TS studies. SBP during transportation to the hub hospital did not prove to be a useful prognostic metric. However, future studies should address the limitations of this study to confirm these findings.
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Affiliation(s)
- Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Hassan Saad
- Department of Neurological Surgery, Arkansas Neurosciences Institute, Little Rock, AR, United States
| | - Kimon Bekelis
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Sophia Dang
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Jonathan Li
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Ayan Kumar
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Justin Turpin
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Randa Barsoom
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - David Hasan
- Department of Neurological Surgery, University of Iowa, Department of Neurosurgery, Iowa City, IA, United States.
| | - Maureen DePrince
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Giuliana Labella
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
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Thrombolysis Therapy in Specialized and Non-specialized Stroke Units. Arch Med Res 2018; 49:588-597. [DOI: 10.1016/j.arcmed.2019.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/02/2019] [Indexed: 12/11/2022]
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Zhang H, Lin S, Chen X, Gu L, Zhu X, Zhang Y, Reyes K, Wang B, Jin K. The effect of age, sex and strains on the performance and outcome in animal models of stroke. Neurochem Int 2018; 127:2-11. [PMID: 30291954 DOI: 10.1016/j.neuint.2018.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/01/2018] [Accepted: 10/02/2018] [Indexed: 12/26/2022]
Abstract
Stroke is one of the leading causes of death worldwide, and the majority of cerebral stroke is caused by occlusion of cerebral circulation, which eventually leads to brain infarction. Although stroke occurs mainly in the aged population, most animal models for experimental stroke in vivo almost universally rely on young-adult rodents for the evaluation of neuropathological, neurological, or behavioral outcomes after stroke due to their greater availability, lower cost, and fewer health problems. However, it is well established that aged animals differ from young animals in terms of physiology, neurochemistry, and behavior. Stroke-induced changes are more pronounced with advancing age. Therefore, the overlooked role of age in animal models of stroke could have an impact on data quality and hinder the translation of rodent models to humans. In addition to aging, other factors also influence functional performance after ischemic stroke. In this article, we summarize the differences between young and aged animals, the impact of age, sex and animal strains on performance and outcome in animal models of stroke and emphasize age as a key factor in preclinical stroke studies.
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Affiliation(s)
- Hongxia Zhang
- Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, Fort Worth, TX 76107, USA
| | - Siyang Lin
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Xudong Chen
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Lei Gu
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Xiaohong Zhu
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Yinuo Zhang
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Kassandra Reyes
- Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, Fort Worth, TX 76107, USA
| | - Brian Wang
- Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, Fort Worth, TX 76107, USA
| | - Kunlin Jin
- Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, Fort Worth, TX 76107, USA; Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, China.
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Yasuda K, Fukuda S, Nakamura M, Ohtani R, Kuwata Y, Takata M, Sainouchi M, Gotou M, Masuda Y, Kawarazaki S, Kawabata Y, Murase N, Aoki T, Yonemoto N, Akao M, Tsukahara T. Predictors of Cardioembolic Stroke in Japanese Patients with Atrial Fibrillation in the Fushimi AF Registry. Cerebrovasc Dis Extra 2018; 8:50-59. [PMID: 29788021 PMCID: PMC6006634 DOI: 10.1159/000488206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 03/07/2018] [Indexed: 11/28/2022] Open
Abstract
Background Large-scale clinical trials have analyzed risk factors for any ischemic stroke in patients with atrial fibrillation (AF). However, the risk factors for cardioembolic stroke (CES), specifically, have not been reported. To clarify the risk factors for CES and clinically significant cardioembolic infarction, we examined the incidence of CES and larger infarct volume (IV) (> 30 mL) CES, employing the Fushimi AF Registry, a community-based prospective cohort of AF patients in the Fushimi ward, Kyoto, Japan. Methods A total of 4,182 Fushimi AF patients were enrolled from March 2011 to December 2014. The risk factors for CES were evaluated using multivariate analysis. Results Of 4,182 patients enrolled, 3,749 patients were observed for ≥1 year. During the follow-up period (mean duration, 979 ± 7.7 days), 91/3,749 patients experienced a CES (2.43%). Significant risk factors associated with CES were older age (odds ratio [OR], 1.31; 95% confidence interval [CI], 1.01–1.72; p = 0.046), low body weight (OR, 1.30; 95% CI, 1.03–1.65; p = 0.033), sustained AF (OR, 1.67; 95% CI, 1.05–2.71; p = 0.034), and previous stroke or transient ischemic attack (TIA) (OR, 1.94; 95% CI, 1.22–3.06; p = 0.004). Predictors of a large IV were chronic kidney disease (CKD) (OR, 2.08; 95% CI, 1.09–4.05; p = 0.027) and previous stroke/TIA (OR, 2.27; 95% CI, 1.19–4.24; p = 0.011). Conclusions In this population-based cohort of Japanese patients with AF, in addition to previous stroke/TIA and older age, sustained AF and low body weight emerged as risk factors for CES, as opposed to any stroke, which may have a different risk profile. Patients with CKD or previous stroke/TIA who developed cardioembolic infarction exhibited more advanced severity. There is a need for direct oral anticoagulants that can be used safely in patients with comorbid AF and CKD.
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Affiliation(s)
- Ken Yasuda
- Department of Neurology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.,Department of Neurology, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Shunichi Fukuda
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Michikazu Nakamura
- Department of Neurology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Ryo Ohtani
- Department of Neurology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yasuhiro Kuwata
- Department of Neurology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masaki Takata
- Department of Neurology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Makoto Sainouchi
- Department of Neurology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masahiro Gotou
- Department of Neurology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yuichi Masuda
- Department of Neurology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Satoru Kawarazaki
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yasuhiro Kawabata
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Nagako Murase
- Department of Neurology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Tomokazu Aoki
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Naohiro Yonemoto
- Department of Biostatistics, School of Public Health, Kyoto University, Kyoto, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Tetsuya Tsukahara
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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Harvey J, Al Kasab S, Almallouhi E, Guerrero WR, Debenham E, Turner N, Aysse P, Holmstedt CA. Door to needle time and functional outcome for mild ischemic stroke over telestroke. J Telemed Telecare 2018; 25:365-369. [PMID: 29754560 DOI: 10.1177/1357633x18774460] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Faster intravenous alteplase (tPA) administration from time of symptom onset is associated with better functional outcome. Lack of recognition of mild ischemic stroke (MIS) might result in delay in treatment with tPA. We hypothesise that patients with MIS have a longer door to needle (DTN) time when compared to patients with severe stroke symptoms. METHODS Data on all patients who received tPA at spoke hospitals through the Medical University of South Carolina (MUSC) telestroke network were analysed. Collected data included baseline characteristics, stroke severity on presentation measured by the National Institute of Health Stroke Scale (NIHSS), the rate of symptomatic intracerebral haemorrhage, discharge location, and discharge functional outcome measured by the modified Rankin scale. RESULTS AND DISCUSSION Of the 454 patients treated with tPA through the MUSC telestroke network in the period from January 2013 to April 2017, 98 (22%) had MIS defined as NIHSS ≤ 5 on presentation; the remaining 356 (78%) patients were found to have severe stroke defined as NIHSS > 5 on presentation. Patients presenting with MIS were found to have a delay in receiving intravenous tPA by ∼10 min (p = 0.007) and approximately 15% of them had poor functional outcome at discharge. Patients with a MIS on presentation have significantly more prolonged DTN time. Nearly 15% of low severity strokes had poor outcome even after receiving tPA.
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Affiliation(s)
- Jillian Harvey
- 1 Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sami Al Kasab
- 2 Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Eyad Almallouhi
- 3 Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Waldo R Guerrero
- 2 Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ellen Debenham
- 3 Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nancy Turner
- 3 Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Patricia Aysse
- 3 Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Christine A Holmstedt
- 3 Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
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Frank RA, Chakraborty S, McGrath T, Mungham A, Ross J, Dowlatshahi D, Shamy M, Stotts G. Diagnostic accuracy of whole-brain computed tomography perfusion for detection of ischemic stroke in patients with mild neurological symptoms. Neuroradiol J 2018; 31:464-472. [PMID: 29720033 DOI: 10.1177/1971400918770898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Mild and minor acute neurological symptoms may lead to diagnostic uncertainty, resulting in a heterogeneous group of patients with true ischemic events and stroke mimics with a potential for poor outcomes. More than half of ischemic stroke patients present as minor strokes (National Institutes of Health Stroke Scale score <6). Whole-brain computed tomography perfusion can be used as a diagnostic test for minor stroke, offering a potential method of reducing diagnostic uncertainty in these patients. We hypothesize that whole-brain computed tomography perfusion imaging features could accurately predict infarction in patients with minor neurological deficits. This retrospective chart review enrolled consecutive patients suspected of acute ischemic stroke with a National Institutes of Health Stroke Scale score <6, who underwent whole-brain computed tomography perfusion and follow-up diffusion-weighted magnetic resonance imaging at our institution. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated for whole-brain computed tomography perfusion, using follow-up diffusion-weighted magnetic resonance imaging as a reference standard. A total of 524 patients (mean age: 67 years; range: 17-96 years; 56% men) met the inclusion criteria. Patients were excluded for non-diagnostic ( n = 25) or missing maps ( n = 8) scans, non-ischemic findings ( n = 7), and lack of follow-up magnetic resonance imaging ( n = 336). The final analysis included 148 patients who underwent diffusion-weighted magnetic resonance imaging. Whole-brain computed tomography perfusion has a sensitivity of 0.57 (95% CI: 0.45-0.69) and a specificity of 0.82 (95% CI: 0.71-0.90). The positive and negative predictive values and positive and negative likelihood ratios were 75%, 67%, 3.09, and 0.53, respectively. Our analysis suggests that although whole-brain computed tomography perfusion may offer some value as an adjunctive test for improving confidence in offering stroke treatment, it is not sufficiently sensitive or specific to accurately predict cerebral infarcts in patients with minor neurological symptoms.
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Affiliation(s)
- Robert A Frank
- 1 Department of Medical Imaging, Division of Neuroradiology, Ottawa Hospital Research Institute, ,University of Ottawa, Canada
| | - Santanu Chakraborty
- 2 Department of Diagnostic Imaging, Division of Neuroradiology, Ottawa Hospital Research Institute, University of Ottawa, Canada
| | - Trevor McGrath
- 1 Department of Medical Imaging, Division of Neuroradiology, Ottawa Hospital Research Institute, ,University of Ottawa, Canada
| | - Alexander Mungham
- 2 Department of Diagnostic Imaging, Division of Neuroradiology, Ottawa Hospital Research Institute, University of Ottawa, Canada
| | - James Ross
- 2 Department of Diagnostic Imaging, Division of Neuroradiology, Ottawa Hospital Research Institute, University of Ottawa, Canada
| | - Dar Dowlatshahi
- 3 Department of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Canada
| | - Michel Shamy
- 3 Department of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Canada
| | - Grant Stotts
- 4 Department of Neurology, The Ottawa Hospital, Canada
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Sung SF, Chen K, Wu DP, Hung LC, Su YH, Hu YH. Applying natural language processing techniques to develop a task-specific EMR interface for timely stroke thrombolysis: A feasibility study. Int J Med Inform 2018; 112:149-157. [DOI: 10.1016/j.ijmedinf.2018.02.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/31/2018] [Accepted: 02/04/2018] [Indexed: 11/16/2022]
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Managing high blood pressure during acute ischemic stroke and intracerebral hemorrhage. Curr Opin Neurol 2018; 31:8-13. [DOI: 10.1097/wco.0000000000000508] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Free Radical Damage in Ischemia-Reperfusion Injury: An Obstacle in Acute Ischemic Stroke after Revascularization Therapy. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2018; 2018:3804979. [PMID: 29770166 PMCID: PMC5892600 DOI: 10.1155/2018/3804979] [Citation(s) in RCA: 284] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 12/07/2017] [Indexed: 12/16/2022]
Abstract
Acute ischemic stroke is a common cause of morbidity and mortality worldwide. Thrombolysis with recombinant tissue plasminogen activator and endovascular thrombectomy are the main revascularization therapies for acute ischemic stroke. However, ischemia-reperfusion injury after revascularization therapy can result in worsening outcomes. Among all possible pathological mechanisms of ischemia-reperfusion injury, free radical damage (mainly oxidative/nitrosative stress injury) has been found to play a key role in the process. Free radicals lead to protein dysfunction, DNA damage, and lipid peroxidation, resulting in cell death. Additionally, free radical damage has a strong connection with inducing hemorrhagic transformation and cerebral edema, which are the major complications of revascularization therapy, and mainly influencing neurological outcomes due to the disruption of the blood-brain barrier. In order to get a better clinical prognosis, more and more studies focus on the pharmaceutical and nonpharmaceutical neuroprotective therapies against free radical damage. This review discusses the pathological mechanisms of free radicals in ischemia-reperfusion injury and adjunctive neuroprotective therapies combined with revascularization therapy against free radical damage.
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Pre-stroke employment results in better patient-reported outcomes after minor stroke: Short title: Functional outcomes after minor stroke. Clin Neurol Neurosurg 2017; 165:38-42. [PMID: 29306185 DOI: 10.1016/j.clineuro.2017.12.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/20/2017] [Accepted: 12/25/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Individuals with "minor stroke" lack a dense hemiparesis or aphasia; however, commonly endorse persistent cognitive and motor problems despite low NIHSS scores. They also report problems with mood, energy, and the ability to think clearly that are less well characterized. Socioeconomic factors and stroke severity can influence patient-reported outcomes. In this study we explore patient-reported outcomes and the influence of these factors after minor stroke. PATIENTS AND METHODS Patients returning to clinic post-stroke with an NIHSS of ≤ 4 were administered a scale to quantify problems with daily activities and resulting functional burden, along with measures of fatigue and depression. T-tests, chi square analysis, and linear regression were used to compare functional outcomes of patients to controls (TIA or stroke mimic (n = 40)), and evaluate the association between patient-reported outcomes, stroke characteristics, and socioeconomic factors. RESULTS 151 stroke patients were seen a mean 83.6 days post-infarct. Patients reported more problems (11.7 versus 6.9, p = 0.02), resulting in higher functional burden (26.5 versus 12.3, p = 0.01), increased depression (p = 0.07), and greater fatigue (p = 0.02) compared to controls. There was no relationship between stroke characteristics (other than NIHSS), baseline education, income, marital status, or living situation and perception of recovery; however, those actively working prior to their stroke reported better outcomes across all categories (p for each <0.02), and differences persisted in multivariable regression models. CONCLUSION Prior occupational status may represent an important prognostic indicator for patients with minor stroke. Individuals working at the time of their infarct report better functional outcomes irrespective of age or stroke severity.
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Bowen MT, Rebello LC, Bouslama M, Haussen DC, Grossberg JA, Bianchi NA, Belagaje S, Anderson A, Frankel MR, Nogueira RG. Clinical and Imaging Outcomes of Endovascular Therapy in Patients with Acute Large Vessel Occlusion Stroke and Mild Clinical Symptoms. INTERVENTIONAL NEUROLOGY 2017; 7:91-98. [PMID: 29628948 DOI: 10.1159/000481205] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background The minimal stroke severity justifying endovascular intervention remains elusive. However, a significant proportion of patients presenting with large vessel occlusion stroke (LVOS) and mild symptoms go untreated and face poor outcomes. We aimed to evaluate the clinical outcomes of patients presenting with LVOS and low symptom scores (National Institutes of Health Stroke Scale [NIHSS] score ≤8) undergoing endovascular therapy (ET). Methods We performed a retrospective analysis of a prospectively collected ET database between September 2010 and March 2016. Endovascularly treated patients with LVOS and a baseline NIHSS score ≤8 were included. Baseline patient characteristics, procedural details, and outcome parameters were collected. Efficacy outcomes were the rate of good outcome (90-day modified Rankin Scale score 0-2) and of successful reperfusion (modified Treatment in Cerebral Infarction [mTICI] score 2b-3). Safety was assessed by the rate of parenchymal hematoma (parenchymal hematoma type 1 [PH-1] and parenchymal hematoma type 2 [PH-2]) and 90-day mortality. Logistic regression was used to identify predictors of good clinical outcomes. Results A total of 935 patients were considered; 72 patients with an NIHSS score ≤8 were included. Median [IQR] age was 61.5 years [56.2-73.0]; 39 patients (54%) were men. Mean (SD) baseline NIHSS score, computed tomography perfusion core volume, and ASPECTS were 6.3 (1.5), 7.5 mL (16.1), and 8.5 (1.3), respectively. Twenty-eight patients (39%) received intravenous tissue plasminogen activator. Occlusions locations were as follows: 29 (40%) proximal MCA-M1, 20 (28%) MCA-M2, 6 (8%) ICA terminus, and 9 (13%) vertebrobasilar. Tandem occlusion was documented in 7 patients (10%). Sixty-seven patients (93%) achieved successful reperfusion (mTICI score 2b-3); 52 (72%) had good 90-day outcomes. Mean final infarct volume was 32.2 ± 59.9 mL. Parenchymal hematoma occurred in 4 patients (6%). Ninety-day mortality was 10% (n = 7). Logistic regression showed that only successful reperfusion (OR 27.7, 95% CI 1.1-655.5, p = 0.04) was an independent predictor of good outcomes. Conclusion Our findings demonstrate that ET is safe and feasible for LVOS patients presenting with mild clinical syndromes. Future controlled studies are warranted.
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Affiliation(s)
- Meredith T Bowen
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Leticia C Rebello
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mehdi Bouslama
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nicolas A Bianchi
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Samir Belagaje
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Aaron Anderson
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael R Frankel
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Raul G Nogueira
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
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Kelly KM, Holt KT, Neshewat GM, Skolarus LE. Community Interventions to Increase Stroke Preparedness and Acute Stroke Treatment Rates. Curr Atheroscler Rep 2017; 19:64. [PMID: 29147858 DOI: 10.1007/s11883-017-0695-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW Acute stroke treatments reduce the risk of post-stroke disability. These treatments, tissue plasminogen activator (tPA) and intra-arterial treatment, are highly time-dependent; thus, one of the main barriers to treatment is pre-hospital delay. Stroke preparedness is defined as the ability to recognize stroke symptoms and the intent to activate emergency medical services (EMS). This review describes types of acute stroke treatment and preparedness interventions, including recent mass media interventions to increase acute stroke treatment rates, and adult and youth community interventions to increase stroke preparedness. RECENT FINDINGS The mass media campaigns show mixed results regarding acute stroke treatment rates, possibly attributed to the various media platforms utilized and resources available. The adult and youth community interventions reveal an overall increase in stroke symptom recognition and behavioral intent to call EMS. However, most of these community interventions were not grounded in health behavior theory, and they were tested in single group, pre-post test study designs that assessed behavioral rather than clinical outcomes. The delivery of stroke preparedness information by youth to adults, for example via home assignments, is a promising and innovative approach to stroke preparedness. Mass media and community interventions show promise to increase stroke preparedness and acute stroke treatment rates. The development of health behavior theory-based interventions that are tested via scientifically rigorous study designs are needed to prioritize which interventions should be disseminated to culturally and socially similar communities.
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Affiliation(s)
- Kathleen M Kelly
- Stroke Program, Department of Neurology, University of Michigan, 1500 East Medical Center Drive SPC#5855, Ann Arbor, MI, 48109-5855, USA
| | - Kathryn T Holt
- Stroke Program, Department of Neurology, University of Michigan, 1500 East Medical Center Drive SPC#5855, Ann Arbor, MI, 48109-5855, USA
| | - Gina M Neshewat
- Stroke Program, Department of Neurology, University of Michigan, 1500 East Medical Center Drive SPC#5855, Ann Arbor, MI, 48109-5855, USA
| | - Lesli E Skolarus
- Stroke Program, Department of Neurology, University of Michigan, 1500 East Medical Center Drive SPC#5855, Ann Arbor, MI, 48109-5855, USA.
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Chen K, Hou X, Zhou Z, Li G, Liu Q, Gui L, Hu J, Shi S. The efficacy and safety of endovascular recanalization of occluded large cerebral arteries during the subacute phase of cerebral infarction: a case series report. Stroke Vasc Neurol 2017; 2:124-131. [PMID: 28994833 PMCID: PMC5628384 DOI: 10.1136/svn-2017-000086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/28/2017] [Accepted: 06/01/2017] [Indexed: 11/20/2022] Open
Abstract
Background Intravenous tissue plasminogen activator with or without mechanical thrombectomy during the acute phase are approved therapies for ischaemic stroke. Due to the short treatment time window (<6 hours) and often treatment failure, these patients would still have an intracranial arterial occlusion (IAO). It is unclear whether these patients can benefit from subsequent interventional recanalizationof their occluded artery in the subacute phase. In this retrospective study, we have examined the efficacy and safety in patients who have received either percutaneous transluminal angioplasty (PTA) or percutaneous transluminal angioplasty and stenting (PTAS) for IAO in the subacute phase of their stroke. Methods Patients with subacute symptomatic ischaemic stroke caused by IAO were assessed to identify the responsible artery and low perfusion areas by CT angiography, MR angiography or digital subtraction angiography. In eligible patients, a PTA or PTAS was performed to reopen the occluded artery. Regular antithrombotic therapy, use of statins, control of risk factors and rehabilitation therapy were prescribed after the procedure. All patients had regular follow-up up to 12 months. Results PTA or PTAS was performed in 16 patients with cerebral infarction caused by IAO in the subacute phase. After the procedure, 12 cases were recanalized, two were partially recanalized and two failed to open. One patient with left C6 segment occlusion of the carotid artery had a central retinal artery embolism after PTAS. The perioperative adverse events were 6.25%. At 3 months, the distribution of modified Rankin scale scores was 0 (seven cases), 1 (three cases), 2 (five cases) and 3 (one case). Conclusion Selective PTA or PTAS could be performed in ischaemic stroke patients with a small infarct size and large area of hypoperfusion from an occluded large cerebral artery after the acute phase. It may improve neurological dysfunction and reduce the incidence of disability.
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Affiliation(s)
- Kangning Chen
- Department of Neurology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Xianhua Hou
- Department of Neurology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Zhenhua Zhou
- Department of Neurology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Guangjian Li
- Department of Neurology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Qu Liu
- Department of Neurology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Li Gui
- Department of Neurology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Jun Hu
- Department of Neurology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Shugui Shi
- Department of Neurology, Southwest Hospital, Third Military Medical University, Chongqing, China
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Alqahtani SA, Stemer AB, McCullough MF, Bell RS, Mai J, Liu AH, Armonda RA. Endovascular Management of Stroke Patients with Large Vessel Occlusion and Minor Stroke Symptoms. Cureus 2017; 9:e1355. [PMID: 28721323 PMCID: PMC5510978 DOI: 10.7759/cureus.1355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Endovascular mechanical thrombectomy for stroke patients with large vessel occlusion (LVO) in the anterior circulation has become the standard of care based on several major randomized clinical trials. The successful result reported by these trials constitutes what may be the largest achievement in the history of neurological sciences. However, most of these mechanical thrombectomy trials (except for the multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands, i.e., MR CLEAN and Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial, i.e., EXTEND-IA) excluded stroke patients with minor to mild stroke symptoms with National Institutes of Health Stroke Scale (NIHSS) scores of six to eight or lower. The median NIHSS score for patients who underwent acute endovascular thrombectomy was approximately 15 to 17 in all trials. To date, the evidence is lacking to support the mechanical thrombectomy in patients with acute stroke and LVO with minor to mild severity on NIHSS score. The purpose of this review was to assess the current data, safety and clinical outcomes in stroke patients with minor to mild symptoms who were treated with endovascular thrombectomy.
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Affiliation(s)
| | | | | | - Randy S Bell
- Department of Neurosurgery, Walter Reed Army Medical Center, Washington D.C
| | - Jeffrey Mai
- Neurosurgery, Medstar Georgetown University Hospital
| | - Ai-Hsi Liu
- Neurointerventional Radiology, Medstar Washington Hospital Center
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