1
|
Mei T, Zhang P, Hu Y, Xiao L, Hou J, Nagasaki Y. Engineering hirudin encapsulation in pH-responsive antioxidant nanoparticles for therapeutic efficacy in ischemic stroke model mice. Biomaterials 2024; 314:122860. [PMID: 39366183 DOI: 10.1016/j.biomaterials.2024.122860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 09/20/2024] [Accepted: 09/26/2024] [Indexed: 10/06/2024]
Abstract
This study introduces a novel pH-sensitive, hirudin-loaded antioxidant nanoparticle (HD@iNanoAOX) aimed at addressing the challenges of hirudin's short half-life and hemorrhagic transformation. HD@iNanoAOX was engineered to safeguard and prolong hirudin's bioactivity by encapsulating it within antioxidative nanoparticles, facilitating its gradual release in acidic environments. The efficacy of this approach was validated through both ex vivo and in vivo experiments. Ex vivo thrombolytic assays demonstrated that HD@iNanoAOX maintained effective clot lysis activity under acidic conditions. In vivo assessments revealed that HD@iNanoAOX significantly prolonged hirudin's half-life and reduced cerebral infarct volume in a mouse model of middle cerebral artery occlusion (MCAO). Furthermore, HD@iNanoAOX treatment mitigated cerebral oxidative stress, suppressed hemorrhagic transformation, and prevented blood-brain barrier (BBB) disruption. These findings suggest that the combined thrombolytic and antioxidative properties of HD@iNanoAOX offer a promising therapeutic approach for ischemic stroke. Nonetheless, further research is warranted to optimize the formulation and assess its safety and efficacy in clinical settings.
Collapse
Affiliation(s)
- Ting Mei
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, 102488, China
| | - Peiwen Zhang
- Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing, 100029, China
| | - Yifan Hu
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, 102488, China
| | - Liman Xiao
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, 102488, China
| | - Junling Hou
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, 102488, China
| | - Yukio Nagasaki
- Department of Materials Science, Faculty of Pure and Applied Sciences, University of Tsukuba, Tennoudai 1-1-1, Tsukuba, Ibaraki, 305-8573, Japan; Master's School in Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tennoudai 1-1-1, Tsukuba, Ibaraki, 305-8573, Japan; Center for Research in Radiation and Earth System Sciences (CRiES), University of Tsukuba, Tennoudai 1-1-1, Tsukuba, Ibaraki, 305-8573, Japan; Department of Chemistry, Graduate School of Science, The University of Tokyo, Tokyo, Bunkyo-ku, 113-8656, Japan; High-value Biomaterials Research and Commercialization Center (HBRCC), National Taipei University of Technology, Taipei, 10608, Taiwan.
| |
Collapse
|
2
|
Ospel JM, Ganesh A, Goyal M. Pragmatic outcomes for stroke research. Lancet Neurol 2024; 23:860-862. [PMID: 39152023 DOI: 10.1016/s1474-4422(24)00316-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Accepted: 07/12/2024] [Indexed: 08/19/2024]
Affiliation(s)
- Johanna M Ospel
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, T2N2T9, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, AB, T2N2T9, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, T2N2T9, Canada
| | - Mayank Goyal
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, T2N2T9, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, AB, T2N2T9, Canada.
| |
Collapse
|
3
|
Xiong Y, Wang L, Li G, Yang KX, Hao M, Li S, Pan Y, Wang Y. Tenecteplase versus alteplase for acute ischaemic stroke: a meta-analysis of phase III randomised trials. Stroke Vasc Neurol 2024; 9:360-366. [PMID: 37640500 PMCID: PMC11420912 DOI: 10.1136/svn-2023-002396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 08/02/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Tenecteplase (TNK) was found non-inferior to alteplase in recent clinical trials. We aimed to elucidate the efficacy and safety of TNK versus alteplase for acute ischaemic stroke (AIS). METHODS Systematic literature search and a meta-analysis of phase III clinical trials in ischaemic stroke patients with TNK use were conducted. The primary outcome was excellent functional outcome which was defined as modified Rankin Scale score of 0-1 at 90 days and safety outcomes included symptomatic intracerebral haemorrhage and death at 90 days. We used random-effects model to estimate the pooled risk difference and 95% CI in R package 'Meta'. The included trials were adapted to the non-inferiority analysis with a margin of -4%. RESULTS Three trials enrolling 4094 patients were identified by systematic search. All trials included AIS patients within 4.5 hours time window. Meta-analysis indicated that 1089 (53.0%) of 2056 patients in the TNK arm and 1016 (50.5%) of 2012 in the alteplase arm had excellent functional outcome at 90 days (0.03 (95% CI -0.00 to 0.06); I2=0%), meeting the prespecified non-inferiority threshold. And TNK thrombolysis was not correlated with increased risk of symptomatic intracerebral haemorrhage (0.00 (95% CI -0.01 to 0.01); I2=0%) or death (0.01 (95% CI -0.01 to 0.02); I2=0%) at 90 days. The sensitivity analysis with the 0.25 mg/kg trials exclusively showed similar results to the main analysis. CONCLUSIONS TNK was non-inferior to alteplase for achieving excellent functional outcome at 90 days without increasing the safety concern in treating patients with AIS. These findings suggest that TNK can be an alternative to alteplase. PROSPERO REGISTRATION NUMBER CRD42022354342.
Collapse
Affiliation(s)
- Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
| | - Liyuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangshuo Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kai-Xuan Yang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Manjun Hao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuya Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| |
Collapse
|
4
|
Ospel JM, Dowlatshahi D, Demchuk A, Volders D, Möhlenbruch M, Nimjee S, Kennedy J, Buck B, Shankar JJ, Booth TC, Jumaa MA, Fahed R, Ganesh A, Zhang Q, Doram C, Ryckborst KJ, Hill MD, Goyal M. Endovascular treatment to improve outcomes for medium vessel occlusions: The ESCAPE-MeVO trial. Int J Stroke 2024:17474930241262642. [PMID: 38845180 DOI: 10.1177/17474930241262642] [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: 06/22/2024]
Abstract
RATIONALE Clinical outcomes in acute ischemic stroke due to medium vessel occlusion (MeVO) are often poor when treated with best medical management. Data from non-randomized studies suggest that endovascular treatment (EVT) may improve outcomes in MeVO stroke, but randomized data on potential benefits and risks are hitherto lacking. Thus, there is insufficient evidence to guide EVT decision-making in MeVO stroke. AIMS The primary aim of the ESCAPE-MeVO trial is to demonstrate that acute, rapid EVT in patients with acute ischemic stroke due to MeVO results in better clinical outcomes compared to best medical management. Secondary outcomes are to demonstrate the safety of EVT, its impact on self-reported health-related quality of life, and cost-effectiveness. SAMPLE SIZE ESTIMATES Based on previously published data, we estimate a sample size of 500 subjects to achieve a power of 85% with a two-sided alpha of 0.05. To account for potential loss to follow-up, 530 subjects will be recruited. METHODS AND DESIGN ESCAPE-MeVO is a multicenter, prospective, randomized, open-label study with blinded endpoint evaluation (PROBE design), clinicaltrials.gov: NCT05151172. Subjects with acute ischemic stroke due to MeVO meeting the trial eligibility criteria will be allocated in a 1:1 ratio to best medical care plus EVT versus best medical care only. Patients will be screened only at comprehensive stroke centers to determine if they are eligible for the trial, regardless of whether they were previously treated at a primary care center. Key eligibility criteria are (1) acute ischemic stroke due to MeVO that is clinically and technically eligible for EVT, (2) last-known well within the last 12 h, (3) National Institutes of Health Stroke Scale > 5 or 3-5 with disabling deficit, (4) high likelihood of salvageable tissue on non-invasive neuroimaging. STUDY OUTCOMES The primary outcome is the modified Rankin scale 90 days after randomization (shift analysis), whereby modified Rankin Score 5 and 6 will be collapsed into one category. Secondary outcomes include dichotomizations of the modified Rankin Score at 90 days, 24 h National Institutes of Health Stroke Score, difference between 24 h and baseline National Institutes of Health Stroke Score, mortality at 90 days, health-related quality of life (EQ-5D-5 L), Lawton scale of instrumental activities of daily living score, reperfusion quality (MeVO expanded Thrombolysis in Cerebral Infarction Score) and infarct volume at 24 h, and cost-effectiveness of endovascular recanalization. Safety outcomes include symptomatic and asymptomatic intracranial hemorrhage and procedural complications. DISCUSSION The ESCAPE-MeVO trial will demonstrate the effect of endovascular thrombectomy in addition to best medical management vis-à-vis best medical management in patients with acute ischemic stroke due to MeVO and provide data for evidence-based treatment decision-making in acute MeVO stroke. DATA ACCESS STATEMENT The raw data discussed in this mansucript will be made available by the corresponding author upon reasonable request.
Collapse
Affiliation(s)
- Johanna M Ospel
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Departments of Radiology and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Dar Dowlatshahi
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Andrew Demchuk
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Departments of Radiology and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - David Volders
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Markus Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Shahid Nimjee
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - James Kennedy
- Acute Multidisciplinary Imaging and Interventional Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jai Jai Shankar
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Thomas C Booth
- Department of Neuroradiology, Ruskin Wing, King's College Hospital NHS Foundation Trust, London, UK
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | | | - Robert Fahed
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Aravind Ganesh
- Departments of Radiology and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Qiao Zhang
- Departments of Radiology and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Craig Doram
- Departments of Radiology and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Karla J Ryckborst
- Departments of Radiology and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Michael D Hill
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Departments of Radiology and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Mayank Goyal
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Departments of Radiology and Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| |
Collapse
|
5
|
Heuts S, Gabrio A, Veenstra L, Maesen B, Kats S, Maessen JG, Walton AS, Nanayakkara S, Lansky AJ, van 't Hof AWJ, Vriesendorp PA. Stroke reduction by cerebral embolic protection devices in transcatheter aortic valve implantation: a systematic review and Bayesian meta-analysis. Heart 2024; 110:757-765. [PMID: 37996242 DOI: 10.1136/heartjnl-2023-323359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/19/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVES The use of cerebral embolic protection (CEP) during transcatheter aortic valve implantation (TAVI) has been studied in several randomised trials. We aimed to perform a systematic review and Bayesian meta-analysis of randomised CEP trials, focusing on a clinically relevant reduction in disabling stroke. METHODS A systematic search was applied to three electronic databases, including trials that randomised TAVI patients to CEP versus standard treatment. The primary outcome was the risk of disabling stroke. Outcomes were presented as relative risk (RR), absolute risk differences (ARDs), numbers needed to treat (NNTs) and the 95% credible intervals (CrIs). The minimal clinically important difference was determined at 1.1% ARD, per expert consensus (NNT 91). The principal Bayesian meta-analysis was performed under a vague prior, and secondary analyses were performed under two informed literature-based priors. RESULTS Seven randomised studies were included for meta-analysis (n=3996: CEP n=2126, control n=1870). Under a vague prior, the estimated median RR of CEP use for disabling stroke was 0.56 (95% CrI 0.28 to 1.19, derived ARD 0.56% and NNT 179, I2=0%). Although the estimated posterior probability of any benefit was 94.4%, the probability of a clinically relevant effect was 0-0.1% under the vague and informed literature-based priors. Results were robust across multiple sensitivity analyses. CONCLUSION There is a high probability of a beneficial CEP treatment effect, but this is unlikely to be clinically relevant. These findings suggest that future trials should focus on identifying TAVI patients with an increased baseline risk of stroke, and on the development of new generation devices. PROSPERO REGISTRATION NUMBER CRD42023407006.
Collapse
Affiliation(s)
- Samuel Heuts
- Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Andrea Gabrio
- Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Leo Veenstra
- Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Bart Maesen
- Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Suzanne Kats
- Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jos G Maessen
- Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Antony S Walton
- Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Shane Nanayakkara
- Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Alexandra J Lansky
- Yale Cardiovascular Research Group, Yale Medical School, New Haven, Connecticut, USA
| | - Arnoud W J van 't Hof
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Pieter A Vriesendorp
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| |
Collapse
|
6
|
Ospel JM, Rinkel L, Ganesh A, Demchuk A, Heran M, Sauvageau E, Joshi M, Haussen D, Jayaraman M, Coutts S, Yu A, Puetz V, Iancu D, Bang OY, Tarpley J, Holmin S, Kelly M, Tymianski M, Hill M, Goyal M. How Do Quantitative Tissue Imaging Outcomes in Acute Ischemic Stroke Relate to Clinical Outcomes? J Stroke 2024; 26:252-259. [PMID: 38836272 PMCID: PMC11164591 DOI: 10.5853/jos.2023.02180] [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: 07/08/2023] [Revised: 12/24/2023] [Accepted: 01/15/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Infarct volume and other imaging markers are increasingly used as surrogate measures for clinical outcome in acute ischemic stroke research, but how improvements in these imaging surrogates translate into better clinical outcomes is currently unclear. We investigated how changes in infarct volume at 24 hours alter the probability of achieving good clinical outcome (modified Rankin Scale [mRS] 0-2). METHODS Data are from endovascular thrombectomy patients from the randomized controlled ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke) trial. Infarct volume at 24 hours was manually segmented on non-contrast computed tomography or diffusion-weighted magnetic resonance imaging. Probabilities of achieving good outcome based on infarct volume were obtained from a multivariable logistic regression model. The probability of good outcome was plotted against infarct volume using linear spline regression. RESULTS A total of 1,099 patients were included in the analysis (median final infarct volume 24.9 mL [interquartile range: 6.6-92.2]). The relationship between total infarct volume and good outcome probability was nearly linear for infarct volumes between 0 mL and 250 mL. In this range, a 10% increase in the probability of achieving mRS 0-2 required a decrease in infarct volume of approximately 34.0 mL (95% confidence interval: -32.5 to -35.6). At infarct volumes above 250 mL, the probability of achieving mRS 0-2 probability was near zero. The relationships of tissue-specific infarct volumes and parenchymal hemorrhage volume generally showed similar patterns, although variability was high. CONCLUSION There seems to be a near-linear association between total infarct volume and probability of achieving good outcome for infarcts up to 250 mL, whereas patients with infarct volumes greater than 250 mL are highly unlikely to have a favorable outcome.
Collapse
Affiliation(s)
- Johanna M. Ospel
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Leon Rinkel
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Andrew Demchuk
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Manraj Heran
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Hospital, Jacksonville, FL, USA
| | - Manish Joshi
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Diogo Haussen
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Mahesh Jayaraman
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Shelagh Coutts
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Amy Yu
- University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Volker Puetz
- University Hospital Carl Gustav Carus at the Technische Universität Dresden, Department of Neurology and Dresden Neurovascular Center, Dresden, Germany
| | - Dana Iancu
- Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea
| | - Jason Tarpley
- Providence Little Company of Mary Medical Center, Providence Saint John’s Health Center and The Pacific Neuroscience Institute, Torrance, CA, USA
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet and Departments of Neuroradiology and Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Kelly
- Royal University Hospital, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - Michael Hill
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - the ESCAPE-NA1 Investigators
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
- Lyerly Neurosurgery, Baptist Hospital, Jacksonville, FL, USA
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
- University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- University Hospital Carl Gustav Carus at the Technische Universität Dresden, Department of Neurology and Dresden Neurovascular Center, Dresden, Germany
- Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea
- Providence Little Company of Mary Medical Center, Providence Saint John’s Health Center and The Pacific Neuroscience Institute, Torrance, CA, USA
- Department of Clinical Neuroscience, Karolinska Institutet and Departments of Neuroradiology and Neurology, Karolinska University Hospital, Stockholm, Sweden
- Royal University Hospital, University of Saskatchewan, Saskatoon, SK, Canada
- NoNO Inc., Toronto, ON, Canada
| |
Collapse
|
7
|
Mishra B, Sudheer P, Agarwal A, Nilima N, Srivastava MVP, Vishnu VY. Minimal Clinically Important Difference of Scales Reported in Stroke Trials: A Review. Brain Sci 2024; 14:80. [PMID: 38248295 PMCID: PMC10813687 DOI: 10.3390/brainsci14010080] [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: 12/15/2023] [Revised: 01/07/2024] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
There is a growing awareness of the significance of using minimum clinically important differences (MCIDs) in stroke research. An MCID is the smallest change in an outcome measure that is considered clinically meaningful. This review is the first to provide a comprehensive summary of various scales and patient-reported outcome measures (PROMs) used in stroke research and their MCID values reported in the literature, including a concise overview of the concept of and methods for determining MCIDs in stroke research. Despite the controversies and limitations surrounding the estimation of MCIDs, their importance in modern clinical trials cannot be overstated. Anchor-based and distribution-based methods are recommended for estimating MCIDs, with patient self-evaluation being a crucial component in capturing the patient's perspective on their health. A combination of methods can provide a more comprehensive understanding of the clinical relevance of treatment effects, and incorporating the patient's perspective can enhance the care of stroke patients.
Collapse
Affiliation(s)
- Biswamohan Mishra
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (B.M.); (P.S.); (A.A.); (M.V.P.S.)
| | - Pachipala Sudheer
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (B.M.); (P.S.); (A.A.); (M.V.P.S.)
| | - Ayush Agarwal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (B.M.); (P.S.); (A.A.); (M.V.P.S.)
| | - Nilima Nilima
- Department of Biostatics, All India Institute of Medical Sciences, New Delhi 110029, India;
| | | | - Venugopalan Y. Vishnu
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India; (B.M.); (P.S.); (A.A.); (M.V.P.S.)
| |
Collapse
|
8
|
Cao X, Luo J, Xu B, Xiao Y, Yang T, Sun X, Sui Y. Best medical management versus intravenous thrombolysis for mild non-disabling ischemic stroke: A prospective noninferiority registry study. J Neurol Sci 2023; 451:120706. [PMID: 37379725 DOI: 10.1016/j.jns.2023.120706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVES The efficacy and safety of intravenous thrombolysis uncertain in patients with non-disabling mild ischemic stroke. Our aim was to investigate whether best medical management only is noninferior to intravenous thrombolysis plus best medical management therapy for achieving favorable functional outcome at 90 days. MATERIALS AND METHODS In a prospective acute ischemic stroke registry from 2018 through 2020, 314 non-disabling mild ischemic stroke patients received best medical management only and 638 underwent intravenous thrombolysis plus best medical management. The primary outcome was modified Rankin Scale ≤1 at Day 90. The noninferiority margin was -5%. Secondary outcomes of hemorrhagic transformation, early neurologic deterioration and mortality were also evaluated. RESULTS The best medical management only was noninferior to the combined therapy of intravenous thrombolysis and best medical management with regard to the primary outcome (unadjusted risk difference, 1.16%; 95% CI, -3.48% ∼ 5.8%; p = 0.0046 for noninferiority; adjusted risk difference, 3.01%; 95% CI, -3.39% ∼ 9.41%). After propensity score matching, p < 0.0001 for noninferiority. RD, 4.03%; 95% CI, -1.59% ∼ 9.69%. p < 0.0001 for noninferiority. Adjusted RD, 5.23%; 95% CI, -1.88% ∼ 9.97%. The occurrence of hemorrhagic transformation was significantly increased in the group of combination therapy (OR, 4.26; 95% CI, 1.30 to 13.99; p = 0.008), while no significant difference was detected in early neurologic deterioration (OR, 1.11; 95% CI, 0.49-2.52; p = 0.808) and mortality (OR, 0.57; 95% CI, 0.20 to 1.69; p = 0.214) between groups. CONCLUSIONS In the present study, we found the best medical management only was noninferior to the combination therapy of intravenous thrombolysis plus best medical management for non-disabling mild ischemic stroke within 4.5 h after onset. Best medical management may be a treatment of choice for non-disabling mild ischemic stroke patients. Further randomized controlled studies are warranted.
Collapse
Affiliation(s)
- Xiaopan Cao
- Department of Neurology, The Fourth Affiliated Hospital of China Medical University, 4 Chongshandong Road, Huanggu District, Shenyang 110004, Liaoning, China; Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China.
| | - Jianfeng Luo
- Department of Biostatistics, School of Public Health, Fudan University, 223 Handan Road, Yangpu District, Shanghai 200436, China.
| | - Bing Xu
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China
| | - Ying Xiao
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China
| | - Tuo Yang
- Department of Neurology, The Fourth Affiliated Hospital of China Medical University, 4 Chongshandong Road, Huanggu District, Shenyang 110004, Liaoning, China
| | - Xiaohong Sun
- Department of Neurology, The Fourth Affiliated Hospital of China Medical University, 4 Chongshandong Road, Huanggu District, Shenyang 110004, Liaoning, China.
| | - Yi Sui
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China.
| |
Collapse
|
9
|
Dong W, Gong T, Zhao S, Wen S, Chen Q, Jiang M, Ye W, Huang Q, Wang C, Yang C, Liu X, Wang Y. A novel extract from Ginkgo biloba inhibits neuroinflammation and maintains white matter integrity in experimental stroke. Neuroscience 2023:S0306-4522(23)00226-9. [PMID: 37225050 DOI: 10.1016/j.neuroscience.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 05/10/2023] [Accepted: 05/16/2023] [Indexed: 05/26/2023]
Abstract
Ginkgo biloba L. leaf extract (GBE) has been added in many commercial herbal formulations such as EGb 761 and Shuxuening Injection to treat cardiovascular diseases and stroke worldwide. However, the comprehensive effects of GBE on cerebral ischemia remained unclear. Using a novel GBE (nGBE), which consists of all the compounds of traditional (t)GBE and one new compound, pinitol, we investigated its effect on inflammation, white matter integrity, and long-term neurological function in an experimental stroke model. Both transient middle cerebral artery occlusion (MCAO) and distal MCAO were conducted in male C57/BL6 mice. We found that nGBE significantly reduced infarct volume at 1, 3, and 14 days after ischemia. Sensorimotor and cognitive functions were superior in nGBE treated mice after MCAO. nGBE inhibited the release of IL-1β in the brain, promoted microglial ramification, and regulated the microglial M1 to M2 phenotype shift at 7 days post injury. In vitro analyses showed that nGBE treatment reduced the production of IL-1β and TNFα in primary microglia. Administration of nGBE also decreased the SMI-32/MBP ratio and enhanced myelin integrity, thus exhibiting improved white matter integrity at 28 days post stroke. These findings demonstrate that nGBE protects against cerebral ischemia by inhibiting microglia-related inflammation and promoting white matter repair, suggesting that nGBE is a promising therapeutic strategy for long-term recovery after stroke.
Collapse
Affiliation(s)
- Wen Dong
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China
| | - Ting Gong
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China; Department of Biomedicine, Beijing City University, Beijing, 100094, P.R. China
| | - Shunying Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China
| | - Shaohong Wen
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China
| | - Qingfang Chen
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China
| | - Mingyu Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China
| | - Weizhen Ye
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China
| | - Qiuru Huang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China
| | - Chunjuan Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China
| | - Chunmei Yang
- Department of Biomedicine, Beijing City University, Beijing, 100094, P.R. China
| | - Xiangrong Liu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P.R. China.
| |
Collapse
|
10
|
Zhang P, Xu J, Cui Q, Lin G, Wang F, Ding X, You S, Sang N, Tan J, Xu W, Zhan C, Zhu Y, Zhang J. Multi-pathway neuroprotective effects of a novel salidroside derivative SHPL-49 against acute cerebral ischemic injury. Eur J Pharmacol 2023; 949:175716. [PMID: 37059375 DOI: 10.1016/j.ejphar.2023.175716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/28/2023] [Accepted: 04/11/2023] [Indexed: 04/16/2023]
Abstract
SHPL-49 ((2R,3S,4S,5R,6R)-2-(hydroxymethyl)-6-(4-(4-methoxyphenyl) butoxy) tetrahydro-2H-pyran-3,4,5-triol) is a novel glycoside derivative obtained from structural modification of salidroside, which is isolated from the medicinal plant Rhodiola rosea L. SHPL-49 was administered to rats with permanent middle cerebral artery occlusion (pMCAO) for 5 days, and it was found that SHPL-49 could alleviate the cerebral infarct volume and reduce the neurological deficit score. Moreover, the effective time window of SHPL-49 in the pMCAO model was from 0.5 to 8 h after embolization. In addition, the result of immunohistochemistry showed that SHPL-49 could increase the number of neurons in the brain tissue and reduce the occurrence of apoptosis. Morris water maze and Rota-rod experiments showed that SHPL-49 could improve neurological deficits, repair neurocognitive and motor dysfunction, and enhance learning and memory ability in the pMCAO model after 14 days of SHPL-49 treatment. Further in vitro experiments showed that SHPL-49 significantly reduced the calcium overload of PC-12 cells and the production of reactive oxygen species (ROS) induced by oxygen and glucose deprivation (OGD), and increased the levels of antioxidant enzymes superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px), decreased the production of malondialdehyde (MDA). Furthermore, SHPL-49 could reduce cell apoptosis by increasing protein expression ratio of anti-apoptotic factor Bcl-2 to pro-apoptotic factor Bax in vitro. SHPL-49 also regulated the expression of Bcl-2 and Bax in ischemic brain tissue, and even inhibited the caspase cascade of pro-apoptotic proteins Cleaved-caspase 9 and Cleaved-caspase 3. Taken together, SHPL-49 exhibited neuroprotective effects against cerebral ischemic injury through multiple pathways, such as alleviating calcium overload, reducing oxidative stress damage, and inhibiting apoptosis.
Collapse
Affiliation(s)
- Pei Zhang
- The Research Center of Chiral Drugs, Innovation Research Institute of Traditional Chinese Medicine (IRI), Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Jiazhen Xu
- The Research Center of Chiral Drugs, Innovation Research Institute of Traditional Chinese Medicine (IRI), Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Qianfei Cui
- The Research Center of Chiral Drugs, Innovation Research Institute of Traditional Chinese Medicine (IRI), Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Guoqiang Lin
- The Research Center of Chiral Drugs, Innovation Research Institute of Traditional Chinese Medicine (IRI), Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Feiyun Wang
- The Research Center of Chiral Drugs, Innovation Research Institute of Traditional Chinese Medicine (IRI), Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Xinyue Ding
- The Research Center of Chiral Drugs, Innovation Research Institute of Traditional Chinese Medicine (IRI), Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Suxin You
- The Research Center of Chiral Drugs, Innovation Research Institute of Traditional Chinese Medicine (IRI), Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Nina Sang
- The Research Center of Chiral Drugs, Innovation Research Institute of Traditional Chinese Medicine (IRI), Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Junchao Tan
- The Research Center of Chiral Drugs, Innovation Research Institute of Traditional Chinese Medicine (IRI), Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Wenwen Xu
- Shanghai Hutchison Pharmaceuticals Limited, Shanghai Engineering Research Center for Innovation of Solid Preparation of TCM, Shanghai, China
| | - Changsen Zhan
- Shanghai Hutchison Pharmaceuticals Limited, Shanghai Engineering Research Center for Innovation of Solid Preparation of TCM, Shanghai, China
| | - Yuying Zhu
- The Research Center of Chiral Drugs, Innovation Research Institute of Traditional Chinese Medicine (IRI), Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Jiange Zhang
- The Research Center of Chiral Drugs, Innovation Research Institute of Traditional Chinese Medicine (IRI), Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| |
Collapse
|
11
|
Goyal M, McDonough R, Fisher M, Ospel J. The Challenge of Designing Stroke Trials That Change Practice: MCID vs. Sample Size and Pragmatism. J Stroke 2022; 24:49-56. [PMID: 35135059 PMCID: PMC8829472 DOI: 10.5853/jos.2021.02740] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/13/2021] [Indexed: 11/11/2022] Open
Abstract
Randomized controlled trials (RCT) are the basis for evidence-based acute stroke care. For an RCT to change practice, its results have to be statistically significant and clinically meaningful. While methods to assess statistical significance are standardized and widely agreed upon, there is no clear consensus on how to assess clinical significance. Researchers often refer to the minimal clinically important difference (MCID) when describing the smallest change in outcomes that is considered meaningful to patients and leads to a change in patient management. It is widely accepted that a treatment should only be adopted when its effect on outcome is equal to or larger than the MCID. There are however situations in which it is reasonable to decide against adopting a treatment, even when its beneficial effect matches or exceeds the MCID, for example when it is resource- intensive and associated with high costs. Furthermore, while the MCID represents an important concept in this regard, defining it for an individual trial is difficult as it is highly context specific. In the following, we use hypothetical stroke trial examples to review the challenges related to MCID, sample size and pragmatic considerations that researchers face in acute stroke trials, and propose a framework for designing meaningful stroke trials that have the potential to change clinical practice.
Collapse
Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Rosalie McDonough
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Johanna Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
12
|
Jang KM, Choi HH, Jang MJ, Cho YD. Direct Endovascular Thrombectomy Alone vs. Bridging Thrombolysis for Patients with Acute Ischemic Stroke : A Meta-analysis. Clin Neuroradiol 2021; 32:603-613. [PMID: 34767050 DOI: 10.1007/s00062-021-01116-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/20/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Although the current guidelines recommend bridging thrombolysis (BT) therapy, which is intravenous thrombolysis (IVT) followed by endovascular thrombectomy (EVT), for patients with acute ischemic stroke from large vessel occlusion (AIS-LVO), the effectiveness and safety of IVT remain controversial. We performed a meta-analysis to demonstrate the non-inferiority of direct EVT alone (DEVT) compared to BT for the efficacy and safety in patients with AIS-LVO who were eligible for IVT. METHODS The literature was searched in big databases between 1 January 1990 and 1 April 2021. The search included both randomized clinical trials (RCTs) and nonrandomized studies (NRSs) that compared DEVT with BT for patients with AIS-LVO who were eligible for IVT (time from stroke onset ≤ 4.5 h). Only NRSs with good intergroup variable matching were included in the study. Outcomes measured included 90-day functional independence, mortality, symptomatic intracranial hemorrhage (sICH), and successful recanalization. The noninferiority margin for risk difference was set at 5% from the literature review. RESULTS Three RCTs (n = 1094) and four NRSs (n = 1366) were included in the meta-analysis. There were 1227 patients (49.9%) in the DEVT group and 1233 patients (50.1%) in the BT group. A statistically significant noninferiority of DEVT compared to BT was concluded in 90-day functional independence, mortality and successful reperfusion. Even in the sICH rate, DEVT group showed a superiority (risk difference, -2%; 95% confidence interval, -4 to -0.002%). CONCLUSION Evidence from RCTs and observational NRSs supports the use of DEVT (without IVT) as the first choice for treatment of patients with AIS-LVO within a time span of 4.5 h or less from stroke onset.
Collapse
Affiliation(s)
- Kyoung Min Jang
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea (Republic of)
| | - Hyun Ho Choi
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea (Republic of)
| | - Myoung-Jin Jang
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea (Republic of)
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea (Republic of).
| |
Collapse
|
13
|
Nebulization of Low-Dose S-Nitrosoglutathione in Diabetic Stroke Enhances Benefits of Reperfusion and Prevents Post-Thrombolysis Hemorrhage. Biomolecules 2021; 11:biom11111587. [PMID: 34827584 PMCID: PMC8615482 DOI: 10.3390/biom11111587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/03/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022] Open
Abstract
The COVID-19 pandemic has escalated the occurrence of hypoxia including thrombotic stroke worldwide, for which nitric oxide (NO) therapy seems very promising and translatable. Therefore, various modes/routes of NO-delivery are now being tested in different clinical trials for safer, faster, and more effective interventions against ischemic insults. Intravenous (IV) infusion of S-Nitrosoglutathione (GSNO), the major endogenous molecular pool of NO, has been reported to protect against mechanical cerebral ischemia-reperfusion (IR); however, it has been never tested in any kind of “clinically” relevant thromboembolic stroke models with or without comorbidities and in combination with the thrombolytic reperfusion therapy. Moreover, “IV-effects” of higher dose of GSNO following IR-injury have been contradicted to augment stroke injury. Herein, we tested the hypothesis that nebulization of low-dose GSNO will not alter blood pressure (BP) and will mitigate stroke injury in diabetic mice via enhanced cerebral blood flow (CBF) and brain tissue oxygenation (PbtO2). GSNO-nebulization (200 μg/kgbwt) did not alter BP, but augmented the restoration of CBF, improved behavioral outcomes and reduced stroke injury. Moreover, GSNO-nebulization increased early reoxygenation of brain tissue/PbtO2 as measured at 6.5 h post-stroke following thrombolytic reperfusion, and enervated unwanted effects of late thrombolysis in diabetic stroke. We conclude that the GSNO-nebulization is safe and effective for enhancing collateral microvascular perfusion in the early hours following stroke. Hence, nebulized-GSNO therapy has the potential to be developed and translated into an affordable field therapy against ischemic events including strokes, particularly in developing countries with limited healthcare infrastructure.
Collapse
|
14
|
Gusev EI, Martynov MY, Nikonov AA, Shamalov NA, Semenov MP, Gerasimets EA, Yarovaya EB, Semenov AM, Archakov AI, Markin SS. Non-immunogenic recombinant staphylokinase versus alteplase for patients with acute ischaemic stroke 4·5 h after symptom onset in Russia (FRIDA): a randomised, open label, multicentre, parallel-group, non-inferiority trial. Lancet Neurol 2021; 20:721-728. [PMID: 34418399 DOI: 10.1016/s1474-4422(21)00210-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/23/2021] [Accepted: 06/25/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Non-immunogenic staphylokinase is modified recombinant staphylokinase with low immunogenicity, high thrombolytic activity, and selectivity to fibrin. We aimed to assess the safety and efficacy of a single intravenous bolus of non-immunogenic staphylokinase compared with alteplase in patients with acute ischaemic stroke within 4·5 h after symptom onset. METHODS We did a randomised, open-label, multicentre, parallel-group, non-inferiority trial in 18 clinical sites in Russia. We included patients aged 18 years and older with a diagnosis of acute ischaemic stroke (up to 25 points on the National Institutes of Health Stroke Scale). The study drug had to be administered within 4·5 h after the onset of symptoms. Patients were randomly assigned to receive either non-immunogenic staphylokinase (10 mg) or alteplase (0·9 mg/kg, maximum 90 mg), both administered intravenously. The randomisation sequence was created by an independent biostatistician using computer-generated random numbers. 84 blocks (block size of four) of opaque sealed envelopes were numbered sequentially from 1 to 336 and were opened in numerical order. Patients were unaware of their assigned treatment and were assessed by the study investigators who were also unaware of the treatment assignment on all trial days. Emergency department staff, who administered the assigned drug and opened the envelopes, were not masked to treatment. The primary efficacy endpoint was a favourable outcome, defined as a modified Rankin scale (mRS) score of 0-1 on day 90. The margin of non-inferiority was established as 16% for the difference in mRS score of 0-1 on day 90. Non-inferiority was tested using Welch's t-test for the primary outcome only. Endpoints were analysed in the per-protocol population, which comprised all randomly assigned patients who completed treatment without any protocol violations; this population was identical to the intention-to-treat population. This trial is completed and registered at ClinicalTrials.gov, NCT03151993. FINDINGS Of 385 patients recruited from March 18, 2017, to March 23, 2019, 336 (87%) were included in the trial. 168 (50%) patients were randomly assigned to receive non-immunogenic staphylokinase and 168 (50%) to receive alteplase. The median duration of follow-up was 89 days (IQR 89-89). 84 (50%) of 168 patients in the non-immunogenic staphylokinase group had a favourable outcome at day 90 compared with 68 (40%) of 168 patients in the alteplase group (odds ratio [OR] 1·47, 95% CI 0·93 to 2·32; p=0·10). The difference in the rate of favourable outcome at day 90 was 9·5% (95% CI -1·7 to 20·7) and the lower limit did not cross the margin of non-inferiority (pnon-inferiority <0·0001). Symptomatic intracranial haemorrhage occurred in five (3%) patients in the non-immunogenic staphylokinase group and in 13 (8%) patients in the alteplase group (p=0·087). On day 90, 17 (10%) patients in the non-immunogenic staphylokinase group and 24 (14%) patients in the alteplase group had died (p=0·32). 22 (13%) patients in the non-immunogenic staphylokinase group had serious adverse events, compared with 37 (22%) patients in the alteplase group (p=0·044). INTERPRETATION Non-immunogenic staphylokinase was non-inferior to alteplase for patients with acute ischaemic stroke. Mortality, symptomatic intracranial haemorrhage, and serious adverse events did not differ significantly between groups. Future studies are needed to continue to assess the safety and efficacy of non-immunogenic staphylokinase in patients with acute ischaemic stroke within the 4·5 h time window, and to assess the drug in patients with acute ischaemic stroke outside this time window with reperfusion CT or magnetic resonance angiography followed by thrombectomy if necessary. FUNDING The Russian Academy of Sciences.
Collapse
Affiliation(s)
- Eugene I Gusev
- Department of Neurology, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Moscow, Russia.
| | - Mikhail Yu Martynov
- Department of Neurology, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Moscow, Russia
| | - Alexey A Nikonov
- Department of Neurology, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Moscow, Russia
| | - Nikolay A Shamalov
- Federal State Budgetary Institution, Federal Center of Brain Research and Neurotechnologies of the Federal Medical Biological Agency, Moscow, Russia
| | - Michail P Semenov
- Medical Department, Peoples' Friendship University of Russia, Moscow, Russia
| | - Eugene A Gerasimets
- Medical Department, Peoples' Friendship University of Russia, Moscow, Russia
| | - Elena B Yarovaya
- Faculty of Mechanics and Mathematics, Lomonosov Moscow State University, Moscow, Russia
| | - Andrey M Semenov
- Medical Department, Peoples' Friendship University of Russia, Moscow, Russia; SuperGene, Moscow, Russia
| | | | - Sergey S Markin
- Institute of Biomedical Chemistry, Moscow, Russia; SuperGene, Moscow, Russia
| | | |
Collapse
|
15
|
Saver JL, Chaisinanunkul N, Campbell BCV, Grotta JC, Hill MD, Khatri P, Landen J, Lansberg MG, Venkatasubramanian C, Albers GW. Standardized Nomenclature for Modified Rankin Scale Global Disability Outcomes: Consensus Recommendations From Stroke Therapy Academic Industry Roundtable XI. Stroke 2021; 52:3054-3062. [PMID: 34320814 DOI: 10.1161/strokeaha.121.034480] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The modified Rankin Scale (mRS), a 7-level, clinician-reported, measure of global disability, is the most widely employed outcome scale in acute stroke trials. The scale's original development preceded the advent of modern clinimetrics, but substantial subsequent work has been performed to enable the mRS to meet robust contemporary scale standards. Prior research and consensus recommendations have focused on modernizing 2 aspects of the mRS: operationalized assignment of scale scores and statistical analysis of scale distributions. Another important characteristic of the mRS still requiring elaboration and specification to contemporary clinimetric standards is the Naming of scale outcomes. Recent clinical trials have used a bewildering variety, often mutually contradictory, of rubrics to describe scale states. Understanding of the meaning of mRS outcomes by clinicians, patients, and other clinical trial stakeholders would be greatly enhanced by use of a harmonized, uniform set of labels for the distinctive mRS outcomes that would be used consistently across trials. This statement advances such recommended rubrics, developed by the Stroke Therapy Academic Industry Roundtable collaboration using an iterative, mixed-methods process. Specific guidance is provided for health state terms (eg, Symptomatic but Nondisabled for mRS score 1; requires constant care for mRS score 5) and valence terms (eg, excellent for mRS score 1; very poor for mRS score 5) to employ for 23 distinct numeric mRS outcomes, including: all individual 7 mRS levels; all 12 positive and negative dichotomized mRS ranges, positive and negative sliding dichotomies; and utility-weighted analysis of the mRS.
Collapse
Affiliation(s)
- Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA, Los Angeles, CA (J.L.S.)
| | | | - Bruce C V Campbell
- Department of Neurology & Melbourne Brain Centre, Royal Melbourne Hospital, Australia (B.C.V.C.)
| | - James C Grotta
- Memorial Hermann Hospital-Texas Medical Center, Houston (J.C.G.)
| | - Michael D Hill
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, AB, Canada (M.D.H.)
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Sciences, University of Cincinnati, OH (P.K.)
| | | | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences and the Stanford Stroke Center, Stanford University (M.G.L.)
| | - Chitra Venkatasubramanian
- Division of Stroke and Neurocritical Care, Department of Neurology and Neurological Sciences and the Stanford Stroke Center, Stanford University (C.V., G.W.A.)
| | - Gregory W Albers
- Division of Stroke and Neurocritical Care, Department of Neurology and Neurological Sciences and the Stanford Stroke Center, Stanford University (C.V., G.W.A.)
| | | |
Collapse
|
16
|
Lin CH, Saver JL, Ovbiagele B, Huang WY, Lee M. Endovascular thrombectomy without versus with intravenous thrombolysis in acute ischemic stroke: a non-inferiority meta-analysis of randomized clinical trials. J Neurointerv Surg 2021; 14:227-232. [PMID: 34266909 PMCID: PMC8862103 DOI: 10.1136/neurintsurg-2021-017667] [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] [Received: 04/15/2021] [Accepted: 06/25/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To conduct a meta-analysis of randomized trials to comprehensively compare the effect of endovascular thrombectomy (EVT) versus intravenous thrombolysis (IVT) plus EVT on functional independence (modified Rankin Scale (mRS) 0-2) after acute ischemic stroke due to large vessel occlusions (AIS-LVO). METHODS We searched Pubmed, EMBASE, CENTRAL, and clinicaltrials.gov from January 2000 to February 2021 and abstracts presented at the International Stroke Conference in March 2021 to identify trials comparing EVT alone versus IVT plus EVT in AIS-LVO. Five non-inferiority margins established in the literature were assessed: -15%, -10%, -6.5%, -5%, and -1.3% for the risk difference for functional independence at 90 days. RESULTS Four trials met the selection criteria, enrolling 1633 individuals, with 817 participants randomly assigned to EVT alone and 816 to IVT plus EVT. Crude cumulative rates of 90-day functional independence were 46.0% with EVT alone versus 45.5% with IVT plus EVT. Pooled results showed the risk difference of functional independence was 1% (95% CI -4% to 5%) between EVT alone versus IVT plus EVT. The lower 95% CI bound of -4% fell within the non-inferiority margins of -15%, -10%, -6.5%, and -5%, but not -1.3%. Pooled results also showed the risk difference between EVT alone versus IVT plus EVT was 1% (95% CI -3% to 5%) for mRS 0-1, and 1% (95% CI -1% to 3%) for symptomatic intracranial hemorrhage. CONCLUSIONS This meta-analysis suggests that EVT alone is non-inferior to IVT plus EVT for several, but not the most stringent, non-inferiority margins.
Collapse
Affiliation(s)
- Chun-Hsien Lin
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Puzi, Taiwan
| | - Jeffrey L Saver
- Department of Neurology and Stroke Center, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, California, USA
| | - Wen-Yi Huang
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Puzi, Taiwan
| |
Collapse
|
17
|
Paul S, Candelario-Jalil E. Emerging neuroprotective strategies for the treatment of ischemic stroke: An overview of clinical and preclinical studies. Exp Neurol 2020; 335:113518. [PMID: 33144066 DOI: 10.1016/j.expneurol.2020.113518] [Citation(s) in RCA: 323] [Impact Index Per Article: 80.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 12/12/2022]
Abstract
Stroke is the leading cause of disability and thesecond leading cause of death worldwide. With the global population aged 65 and over growing faster than all other age groups, the incidence of stroke is also increasing. In addition, there is a shift in the overall stroke burden towards younger age groups, particularly in low and middle-income countries. Stroke in most cases is caused due to an abrupt blockage of an artery (ischemic stroke), but in some instances stroke may be caused due to bleeding into brain tissue when a blood vessel ruptures (hemorrhagic stroke). Although treatment options for stroke are still limited, with the advancement in recanalization therapy using both pharmacological and mechanical thrombolysis some progress has been made in helping patients recover from ischemic stroke. However, there is still a substantial need for the development of therapeutic agents for neuroprotection in acute ischemic stroke to protect the brain from damage prior to and during recanalization, extend the therapeutic time window for intervention and further improve functional outcome. The current review has assessed the past challenges in developing neuroprotective strategies, evaluated the recent advances in clinical trials, discussed the recent initiative by the National Institute of Neurological Disorders and Stroke in USA for the search of novel neuroprotectants (Stroke Preclinical Assessment Network, SPAN) and identified emerging neuroprotectants being currently evaluated in preclinical studies. The underlying molecular mechanism of each of the neuroprotective strategies have also been summarized, which could assist in the development of future strategies for combinational therapy in stroke treatment.
Collapse
Affiliation(s)
- Surojit Paul
- Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA.
| | - Eduardo Candelario-Jalil
- Department of Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA
| |
Collapse
|
18
|
Lin CJ, Saver JL. The Minimal Clinically Important Difference for Achievement of Substantial Reperfusion With Endovascular Thrombectomy Devices in Acute Ischemic Stroke Treatment. Front Neurol 2020; 11:524220. [PMID: 33123069 PMCID: PMC7569750 DOI: 10.3389/fneur.2020.524220] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 08/17/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Recent noninferiority clinical trials of novel endovascular thrombectomy devices for acute ischemic stroke have used substantial reperfusion as the primary outcome of achievement. Determining the minimal clinically important difference (MCID) is an essential step for the design of noninferiority clinical trials. Materials and Methods: We surveyed international neuro-interventionalist and noninterventional vascular neurologist investigators. The questionnaire included demographic characteristics, level of clinical experience, and their MCID clinical scenario-based judgment regarding the MCID for the outcome substantial reperfusion (thrombolysis in cerebral infarction score 2b-3) within 3 passes. Results: Survey responses were received from 58 of 200 experts. Among responders, 75.9% were neuro-interventionalists (most commonly interventional neuroradiologists and interventional neurologists, followed by endovascular neurosurgeons), and 24.1% were noninterventional vascular neurologists; 87.9% had been in practice for more than 5 years, and 67.3% devoted more than half of their practice to stroke care. Responder-nonresponder and continuum of resistance analysis indicated responders were representative of the full expert population. Among experts, the median MCID for substantial reperfusion was 3.1-5% (interquartile range 1.1-3% to 5.1-10%). MCID distributions did not differ among neuro-interventionalists and noninterventional vascular neurologists. Conclusions: Neuro-interventionl and noninterventional stroke experts judged that the minimal clinically important difference in comparing thrombectomy devices for achieving substantial reperfusion is 3.1-5%. This MCID, lower than noninferiority margins used in several recent clinical trials, can inform trial designs and clinical development.
Collapse
Affiliation(s)
- Chun-Jen Lin
- Neurological Institute, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jeffrey L Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| |
Collapse
|
19
|
Vahidinia Z, Karimian M, Joghataei MT. Neurosteroids and their receptors in ischemic stroke: From molecular mechanisms to therapeutic opportunities. Pharmacol Res 2020; 160:105163. [DOI: 10.1016/j.phrs.2020.105163] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/17/2020] [Accepted: 08/17/2020] [Indexed: 01/09/2023]
|
20
|
Fréchou M, Zhu X, Liere P, Pianos A, Schumacher M, Mattern C, Guennoun R. Dose-dependent and long-term cerebroprotective effects of intranasal delivery of progesterone after ischemic stroke in male mice. Neuropharmacology 2020; 170:108038. [PMID: 32151648 DOI: 10.1016/j.neuropharm.2020.108038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 02/25/2020] [Accepted: 03/04/2020] [Indexed: 11/29/2022]
Abstract
Intranasal administration is emerging as a very promising route to deliver therapeutics to the brain. We have recently shown that the intranasal delivery of progesterone at 8 mg/kg is neuroprotective after stroke in male mice. To explore the translational potential of intranasal progesterone treatment, we performed a dose-response study and analyzed outcomes at 48 h after middle cerebral artery occlusion (MCAO). The effects on functional outcomes at long-term were examined by using the optimal dose. In the first experiment, male C57BL/6JRj mice were treated with progesterone at 8, 16 or 24 mg/kg, or with placebo at 1, 6 and 24 h post-MCAO. Our results show that the dose of 8 mg/kg was optimal in counteracting the early histopathological impairments as well as in improving functional recovery. Steroid profiling in plasma showed that the dose of 8 mg/kg is the one that leads to sustained high levels of progesterone and its neuroactive metabolites. In the second experiment, the dose of 8 mg/kg was used and analyzes were performed at 2, 7 and 21 days post-MCAO. Progesterone increased survival, glycemia and body weight. Furthermore, progesterone decreased neurological deficits and improved performances of mice on the rotarod and pole as early as 2 days and up to 21 days post-MCAO. These findings show that intranasal administration of progesterone has a significant translational potential as a cerebroprotective treatment after stroke that can be effective to reduce mortality, to limit tissue and cell damage at the acute phase; and to confer a long-term functional recovery.
Collapse
Affiliation(s)
- Magalie Fréchou
- U1195 Inserm and University Paris-Sud and University Paris-Saclay, 80 rue du Général Leclerc, 94276 Kremlin-Bicêtre, France.
| | - Xiaoyan Zhu
- U1195 Inserm and University Paris-Sud and University Paris-Saclay, 80 rue du Général Leclerc, 94276 Kremlin-Bicêtre, France.
| | - Philippe Liere
- U1195 Inserm and University Paris-Sud and University Paris-Saclay, 80 rue du Général Leclerc, 94276 Kremlin-Bicêtre, France.
| | - Antoine Pianos
- U1195 Inserm and University Paris-Sud and University Paris-Saclay, 80 rue du Général Leclerc, 94276 Kremlin-Bicêtre, France.
| | - Michael Schumacher
- U1195 Inserm and University Paris-Sud and University Paris-Saclay, 80 rue du Général Leclerc, 94276 Kremlin-Bicêtre, France.
| | - Claudia Mattern
- M et P Pharma AG, Schynweg 7, P.O.Box 138, 6376, Emmetten, Switzerland.
| | - Rachida Guennoun
- U1195 Inserm and University Paris-Sud and University Paris-Saclay, 80 rue du Général Leclerc, 94276 Kremlin-Bicêtre, France.
| |
Collapse
|
21
|
Lin CJ, Saver JL. Noninferiority Margins in Trials of Thrombectomy Devices for Acute Ischemic Stroke. Stroke 2019; 50:3519-3526. [DOI: 10.1161/strokeaha.119.026717] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background and Purpose—
Novel endovascular thrombectomy (EVT) devices for acute ischemic stroke are often cleared by regulatory agencies on the basis of noninferiority trials. The relation between the noninferiority margins used in trials and the minimal clinically important differences (MCIDs) determined by experts have not been systematically investigated.
Methods—
Systematic searches were performed to identify (1) all noninferiority design or noninferiority-presented stroke-EVT trials for acute ischemic stroke, (2) all studies determining the MCIDs for the same outcomes, and (3) all noninferiority coronary revascularization trials. Stroke-EVT trial results were reanalyzed using the broad noninferiority margins originally used and narrower noninferiority margins derived from formal MCID studies.
Results—
We identified 7 noninferiority-designed or noninferiority-interpreted stroke-EVT controlled trials, enrolling 1766 patients, variously comparing coil retrievers, first- and second-generation stent retrievers, and aspiration devices. In 6 trials, the primary outcome was achievement of reperfusion, using noninferiority margins of 15% (3 trials), 10% (2 trials), and 8% (1 trial). In contrast, a stroke expert survey identified the MCID for reperfusion as 3.1% to 5%, and cardiac trials used noninferiority margins of 3.5% to 4.4%. In one stroke-EVT trial, the primary outcome was functional independence, using a noninferiority margin of 15%. However, 2 stroke expert survey studies identified MCIDs for functional independence as having lower values, 5% and 1% to 1.5%. For both reperfusion and functional independence outcomes, all 7 trials demonstrated noninferiority with the broadest noninferiority margin, but only 4 and 3 trials demonstrated noninferiority with actual expert-derived margins for reperfusion and functional independence, respectively.
Conclusions—
Noninferiority margins used in EVT device trials have regularly exceeded the MCIDs determined by stroke experts, as well as margins used for cardiac devices. New approaches, such as the use of reasonably adequate performance margins, rather than noninferiority margins, are needed to optimize stroke-EVT trial design integrity and trial performance feasibility.
Collapse
Affiliation(s)
- Chun-Jen Lin
- From the Division of Cerebrovascular Diseases, Neurological Institute, Taipei Veterans General Hospital, Taiwan (C.-J.L.)
| | - Jeffrey L. Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| |
Collapse
|
22
|
Johnston KC, Bruno A, Pauls Q, Hall CE, Barrett KM, Barsan W, Fansler A, Van de Bruinhorst K, Janis S, Durkalski-Mauldin VL. Intensive vs Standard Treatment of Hyperglycemia and Functional Outcome in Patients With Acute Ischemic Stroke: The SHINE Randomized Clinical Trial. JAMA 2019; 322:326-335. [PMID: 31334795 PMCID: PMC6652154 DOI: 10.1001/jama.2019.9346] [Citation(s) in RCA: 229] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Hyperglycemia during acute ischemic stroke is common and is associated with worse outcomes. The efficacy of intensive treatment of hyperglycemia in this setting remains unknown. OBJECTIVES To determine the efficacy of intensive treatment of hyperglycemia during acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS The Stroke Hyperglycemia Insulin Network Effort (SHINE) randomized clinical trial included adult patients with hyperglycemia (glucose concentration of >110 mg/dL if had diabetes or ≥150 mg/dL if did not have diabetes) and acute ischemic stroke who were enrolled within 12 hours from stroke onset at 63 US sites between April 2012 and August 2018; follow-up ended in November 2018. The trial included 1151 patients who met eligibility criteria. INTERVENTIONS Patients were randomized to receive continuous intravenous insulin using a computerized decision support tool (target blood glucose concentration of 80-130 mg/dL [4.4-7.2 mmol/L]; intensive treatment group: n = 581) or insulin on a sliding scale that was administered subcutaneously (target blood glucose concentration of 80-179 mg/dL [4.4-9.9 mmol/L]; standard treatment group: n = 570) for up to 72 hours. MAIN OUTCOMES AND MEASURES The primary efficacy outcome was the proportion of patients with a favorable outcome based on the 90-day modified Rankin Scale score (a global stroke disability scale ranging from 0 [no symptoms or completely recovered] to 6 [death]) that was adjusted for baseline stroke severity. RESULTS Among 1151 patients who were randomized (mean age, 66 years [SD, 13.1 years]; 529 [46%] women, 920 [80%] with diabetes), 1118 (97%) completed the trial. Enrollment was stopped for futility based on prespecified interim analysis criteria. During treatment, the mean blood glucose level was 118 mg/dL (6.6 mmol/L) in the intensive treatment group and 179 mg/dL (9.9 mmol/L) in the standard treatment group. A favorable outcome occurred in 119 of 581 patients (20.5%) in the intensive treatment group and in 123 of 570 patients (21.6%) in the standard treatment group (adjusted relative risk, 0.97 [95% CI, 0.87 to 1.08], P = .55; unadjusted risk difference, -0.83% [95% CI, -5.72% to 4.06%]). Treatment was stopped early for hypoglycemia or other adverse events in 65 of 581 patients (11.2%) in the intensive treatment group and in 18 of 570 patients (3.2%) in the standard treatment group. Severe hypoglycemia occurred only among patients in the intensive treatment group (15/581 [2.6%]; risk difference, 2.58% [95% CI, 1.29% to 3.87%]). CONCLUSIONS AND RELEVANCE Among patients with acute ischemic stroke and hyperglycemia, treatment with intensive vs standard glucose control for up to 72 hours did not result in a significant difference in favorable functional outcome at 90 days. These findings do not support using intensive glucose control in this setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01369069.
Collapse
Affiliation(s)
| | - Askiel Bruno
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta
| | - Qi Pauls
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Christiana E. Hall
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, Texas
| | | | - William Barsan
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Amy Fansler
- Brain Institute, University of Virginia, Charlottesville
| | | | - Scott Janis
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | | |
Collapse
|
23
|
Burgos AM, Saver JL. Evidence that Tenecteplase Is Noninferior to Alteplase for Acute Ischemic Stroke: Meta-Analysis of 5 Randomized Trials. Stroke 2019; 50:2156-2162. [PMID: 31318627 DOI: 10.1161/strokeaha.119.025080] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- TNK (tenecteplase), a newer fibrinolytic agent, has practical delivery advantages over ALT (alteplase) that would make it a useful agent if noninferior in acute ischemic stroke treatment outcome. Accordingly, the most recent US American Heart Association/American Stroke Association acute ischemic stroke guideline recognized TNK as an alternative to ALT, but only based on informal consideration, rather than formal meta-analysis, of completed randomized control trials. Methods- Systematic literature search and formal meta-analysis were conducted per PRISMA guidelines (Preferred Reporting Items for Systemic Reviews and Meta-Analyses), adapted to noninferiority analysis. The primary outcome of freedom from disability (modified Rankin Scale score, 0-1) outcome at 3 m, and additional efficacy and safety outcomes, were analyzed. Results- Systematic search identified 5 trials enrolling 1585 patients (828 TNK, 757 ALT). Across all trials, mean age was 70.8, 58.5% male, baseline National Institutes of Health Stroke Scale mean 7.0, and time from last known well to treatment start mean 148 minutes. All ALT patients received standard 0.9 mg/kg dosing, while TNK dosing was 0.1 mg/kg in 6.8%, 0.25 mg/kg in 24.6%, and 0.4 mg/kg in 68.6%. For the primary end point, crude cumulative rates of disability-free (modified Rankin Scale score, 0-1) 3 m outcome were TNK 57.9% versus ALT 55.4%. Informal, random-effects meta-analysis, the risk difference was 4% (95% CI, -1% to 8%). The lower 95% CI bound fell well within the prespecified noninferiority margin. Similar results were seen for the additional efficacy end points: functional independence (modified Rankin Scale score, 0-2): crude TNK 71.9% versus ALT 70.5%, risk difference 2% (95% CI, -3% to 6%); and modified Rankin Scale shift analysis, common odds ratio 1.21 (95% CI, 0.93-1.57). For safety end points, lower event rates reduced power, but point estimates were also consistent with noninferiority Conclusions- Accumulated clinical trial data provides strong evidence that TNK is noninferior to ALT in the treatment of acute ischemic stroke. These findings provide formal support for the recent guideline recommendation to consider TNK an alternative to ALT.
Collapse
Affiliation(s)
- Adrian M Burgos
- From the Comprehensive Stroke Center and Department of Neurology, Geffen School of Medicine at UCLA, CA
| | - Jeffrey L Saver
- From the Comprehensive Stroke Center and Department of Neurology, Geffen School of Medicine at UCLA, CA
| |
Collapse
|
24
|
Morris DC, Zhang ZG, Chopp M. Thymosin β4 for the treatment of acute stroke: neurorestorative or neuroprotective? Expert Opin Biol Ther 2019; 18:149-158. [PMID: 30063858 DOI: 10.1080/14712598.2018.1484100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Thymosin β4 (Tβ4) is a 5K peptide which influences cellular migration by inhibiting organization of the actin-cytoskeleton. Treatment of acute stroke presently involves use of rt-PA and/or endovascular treatment with thrombectomy, both of which have time limitations. Therefore, development of a treatment beyond these times is necessary as most stroke patients present beyond these time limits. A drug which could be administered within 24 h from symptom onset would provide substantial benefit. AREAS COVERED This review summarizes the data and results of two in-vivo studies testing Tβ4 in an embolic stroke model of young and aged rats. In addition, we describe in-vitro investigations of the neurorestorative and neuroprotective properties of Tβ4 in a variety of neuroprogenitor and oligoprogenitor cell models. EXPERT OPINION Tβ4 acts as a neurorestorative agent when employed in a young male rat model of embolic stroke while in an aged model it acts a neuroprotectant. However evaluation of Tβ4 as a treatment of stroke requires further preclinical evaluation in females and in males and females with comorbidities such as, hypertension and diabetes in models of embolic stroke to further define the mechanism of action and potential as a treatment of stroke in humans.
Collapse
Affiliation(s)
- Daniel C Morris
- a Department of Emergency Medicine , Henry Ford Health Systems , Detroit , MI , USA
| | - Zheng G Zhang
- b Department of Neurology , Henry Ford Health Systems , Detroit , MI , USA
| | - Michael Chopp
- b Department of Neurology , Henry Ford Health Systems , Detroit , MI , USA.,c Department of Physics , Oakland University , Rochester , MI , USA
| |
Collapse
|
25
|
Abstract
Since the inception of the British Neuroscience Association, there have been major advances in our knowledge of the mechanistic basis for stroke-induced brain damage. Identification of the ischaemic cascade led to the development of hundreds of new drugs, many showing efficacy in preclinical (animal-based) studies. None of these drugs has yet translated to a successful stroke treatment, current therapy being limited to thrombolysis/thrombectomy. However, this translational failure has led to significant improvements in the quality of animal-based stroke research, with the refinement of rodent models, introduction of new technologies (e.g. transgenics, in vivo brain imaging) and improvements in study design (e.g. STAIR, ARRIVE and IMPROVE guidelines). This has run in parallel with advances in clinical diagnostic imaging for detection of ischaemic versus haemorrhagic stroke, differentiating penumbra from ischaemic core, and improved clinical trial design. These preclinical and clinical advances represent the foundation for successful translation from the bench to the bedside in the near future.
Collapse
Affiliation(s)
- I. Mhairi Macrae
- Institute of Neuroscience and Psychology, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
| | - Stuart M. Allan
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Stuart M. Allan, Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, AV Hill Building, Manchester M13 9PT, UK.
| |
Collapse
|
26
|
Gaidhani N, Uteshev VV. Treatment duration affects cytoprotective efficacy of positive allosteric modulation of α7 nAChRs after focal ischemia in rats. Pharmacol Res 2018; 136:121-132. [PMID: 30205140 PMCID: PMC6218269 DOI: 10.1016/j.phrs.2018.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/22/2018] [Accepted: 09/02/2018] [Indexed: 12/30/2022]
Abstract
To minimize irreversible brain injury after acute ischemic stroke (AIS), the time to treatment (i.e., treatment delay) should be minimized. However, thus far, all cytoprotective clinical trials have failed. Analysis of literature identified short treatment durations (≤72 h) as a common motif among completed cytoprotective clinical trials. Here, we argue that short cytoprotective regimens even if given early after AIS may only slow down the evolution of ischemic brain injury and fail to deliver sustained long-term solutions leading to relapses that may be misinterpreted for conceptual failure of cytoprotection. In this randomized blinded study, we used young adult male rats subjected to transient 90 min suture middle cerebral artery occlusion (MCAO) and treated with acute vs. sub-chronic regimens of PNU120596, a prototypical positive allosteric modulator of α7 nicotinic acetylcholine receptors with anti-inflammatory cytoprotective properties to test the hypothesis that insufficient treatment durations may reduce therapeutic benefits of otherwise efficacious cytoprotectants after AIS. A single acute treatment 90 min after MCAO significantly reduced brain injury and neurological deficits 24 h later, but these effects vanished 72 h after MCAO. These relapses were avoided by utilizing sub-chronic treatments. Thus, extending treatment duration augments therapeutic efficacy of PNU120596 after MCAO. Furthermore, sub-chronic treatments could offset the negative effects of prolonged treatment delays in cases where the acute treatment window after MCAO was left unexploited. We conclude that a combination of short treatment delays and prolonged treatment durations may be required to maximize therapeutic effects of PNU120596, reduce relapses and ensure sustained therapeutic efficacy after AIS. Similar concepts may hold for other cytoprotectants including those that failed in clinical trials.
Collapse
Affiliation(s)
- Nikhil Gaidhani
- Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, 3500 Camp Bowie Blvd., Fort Worth, TX 76107, United States
| | - Victor V Uteshev
- Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, 3500 Camp Bowie Blvd., Fort Worth, TX 76107, United States.
| |
Collapse
|
27
|
Yu S, Xu H, Chi X, Wei L, Cheng Q, Yang Y, Zhou C, Ding F. 2-(4-Methoxyphenyl)ethyl-2-Acetamido-2-deoxy-β-d-pyranoside (A Salidroside Analog) Confers Neuroprotection with a Wide Therapeutic Window by Regulating Local Glucose Metabolism in a Rat Model of Cerebral Ischemic Injury. Neuroscience 2018; 391:60-72. [PMID: 30223020 DOI: 10.1016/j.neuroscience.2018.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 09/04/2018] [Accepted: 09/05/2018] [Indexed: 01/02/2023]
Abstract
2-(4-Methoxyphenyl)ethyl-2-acetamido-2-deoxy-β-d-pyranoside (salidroside analog-4g, SalA-4g), has shown neuroprotective prospects for the treatment of ischemic stroke. However, the dose-response and time window study for SalA-4g, and the mechanism of SalA-4g-mediated neuroprotection remain unclear. Here, we systematically investigated the therapeutic time window and dosage of SalA-4g in permanent focal cerebral ischemia in rats. SalA-4g dose-dependently improved stroke outcome. Either pre-treatment or post-treatment of SalA-4g exhibited notable neuroprotection, and maintained for up to 6 h after ischemia onset. Moreover, significant neurological functional recovery was found after SalA-4g administration in long-term functional assays. Further studies suggested that SalA-4g ameliorated neuronal cell death, elevated local glucose metabolism and enhanced the expression level of glucose transporter 1 and 3 in the ipsilateral cortex and striatum. We suggest that data of this study are critical in exploring the clinical application prospects of SalA-4g for the treatment of ischemic stroke.
Collapse
Affiliation(s)
- Shu Yu
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, Nantong University, 19 Qixiu Road, Nantong, JS 226001, PR China
| | - Hui Xu
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, Nantong University, 19 Qixiu Road, Nantong, JS 226001, PR China
| | - Xiaojing Chi
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, Nantong University, 19 Qixiu Road, Nantong, JS 226001, PR China
| | - Li Wei
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, Nantong University, 19 Qixiu Road, Nantong, JS 226001, PR China
| | - Qiong Cheng
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, Nantong University, 19 Qixiu Road, Nantong, JS 226001, PR China
| | - Yumin Yang
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, Nantong University, 19 Qixiu Road, Nantong, JS 226001, PR China
| | - Chun Zhou
- Department of Neurology, Affiliated Hospital of Nantong University, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair, 20 Xisi Road, Nantong, JS 226001, PR China.
| | - Fei Ding
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, Nantong University, 19 Qixiu Road, Nantong, JS 226001, PR China; Department of Neurology, Affiliated Hospital of Nantong University, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair, 20 Xisi Road, Nantong, JS 226001, PR China.
| |
Collapse
|
28
|
Unmet Needs and Challenges in Clinical Research of Intracerebral Hemorrhage. Stroke 2018; 49:1299-1307. [PMID: 29618558 DOI: 10.1161/strokeaha.117.019541] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/12/2018] [Accepted: 02/23/2018] [Indexed: 11/16/2022]
|
29
|
Minimal Clinically Important Difference for Safe and Simple Novel Acute Ischemic Stroke Therapies. Stroke 2017; 48:2946-2951. [DOI: 10.1161/strokeaha.117.017496] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/21/2017] [Accepted: 08/21/2017] [Indexed: 12/30/2022]
|
30
|
Yang W, Paschen W. Is age a key factor contributing to the disparity between success of neuroprotective strategies in young animals and limited success in elderly stroke patients? Focus on protein homeostasis. J Cereb Blood Flow Metab 2017; 37:3318-3324. [PMID: 28752781 PMCID: PMC5624400 DOI: 10.1177/0271678x17723783] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neuroprotection strategies to improve stroke outcome have been successful in the laboratory but not in clinical stroke trials, and thus have come under scrutiny by the medical community. Experimental stroke investigators are therefore under increased pressure to resolve this problem. Acute ischemic stroke represents a severe form of metabolic stress that activates many pathological processes and thereby impairs cellular functions. Traditionally, neuroprotection strategies were designed to improve stroke outcome by interfering with pathological processes triggered by ischemia. However, stroke outcome is also dependent on the brain's capacity to restore cellular functions impaired by ischemia, and this capacity declines with age. It is, therefore, conceivable that this age-dependent decline in the brain's self-healing capacity contributes to the disparity between the success of neuroprotective strategies in young animals, and limited success in elderly stroke patients. Here, prosurvival pathways that restore protein homeostasis impaired by ischemic stress should be considered, because their capacity decreases with increasing age, and maintenance of proteome fidelity is pivotal for cell survival. Boosting such prosurvival pathways pharmacologically to restore protein homeostasis and, thereby, cellular functions impaired by ischemic stress is expected to counterbalance the compromised self-healing capacity of aged brains and thereby help to improve stroke outcome.
Collapse
Affiliation(s)
- Wei Yang
- 1 Laboratory of Molecular Neurobiology, Multidisciplinary Neuroprotection Laboratories, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Wulf Paschen
- 1 Laboratory of Molecular Neurobiology, Multidisciplinary Neuroprotection Laboratories, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,2 Department of Neurobiology, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
31
|
Animal models of ischaemic stroke and characterisation of the ischaemic penumbra. Neuropharmacology 2017; 134:169-177. [PMID: 28923277 DOI: 10.1016/j.neuropharm.2017.09.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/08/2017] [Accepted: 09/13/2017] [Indexed: 02/07/2023]
Abstract
Over the past forty years, animal models of focal cerebral ischaemia have allowed us to identify the critical cerebral blood flow thresholds responsible for irreversible cell death, electrical failure, inhibition of protein synthesis, energy depletion and thereby the lifespan of the potentially salvageable penumbra. They have allowed us to understand the intricate biochemical and molecular mechanisms within the 'ischaemic cascade' that initiate cell death in the first minutes, hours and days following stroke. Models of permanent, transient middle cerebral artery occlusion and embolic stroke have been developed each with advantages and limitations when trying to model the complex heterogeneous nature of stroke in humans. Yet despite these advances in understanding the pathophysiological mechanisms of stroke-induced cell death with numerous targets identified and drugs tested, a lack of translation to the clinic has hampered pre-clinical stroke research. With recent positive clinical trials of endovascular thrombectomy in acute ischaemic stroke the stroke community has been reinvigorated, opening up the potential for future translation of adjunctive treatments that can be given alongside thrombectomy/thrombolysis. This review discusses the major animal models of focal cerebral ischaemia highlighting their advantages and limitations. Acute imaging is crucial in longitudinal pre-clinical stroke studies in order to identify the influence of acute therapies on tissue salvage over time. Therefore, the methods of identifying potentially salvageable ischaemic penumbra are discussed. This article is part of the Special Issue entitled 'Cerebral Ischemia'.
Collapse
|
32
|
Morris DC, Cheung WL, Loi R, Zhang T, Lu M, Zhang ZG, Chopp M. Thymosin β4 for the treatment of acute stroke in aged rats. Neurosci Lett 2017; 659:7-13. [PMID: 28864242 DOI: 10.1016/j.neulet.2017.08.064] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 08/10/2017] [Accepted: 08/28/2017] [Indexed: 12/21/2022]
Abstract
Thymosin β4 (Tβ4) is a 5K peptide which influences cellular migration by inhibiting organization of the actin-cytoskeleton. Tβ4 has neurorestorative properties and is a potential candidate for the treatment of sub-acute stroke. Previous research demonstrated that Tβ4 improved neurological outcome in a young (3 months) rat model of embolic stroke. We hypothesized that Tβ4 would improve neurological outcome in an aged rat model of embolic stroke when administered 24h after embolic stroke. Aged Male Wistar rats (Charles River, France 18-21 months) were subjected to embolic middle cerebral artery occlusion (MCAo). Rats were randomized to receive Tβ4 (12mg/kg, RegeneRx Biopharmaceuticals, Inc.) or control 24h after MCAo and then every 3days for 4 additional doses. The dose of 12mg/kg was the maximal dose of Tβ4 that showed functional improvement in a young rat model of embolic stroke. Functional tests (adhesive-removal test (ART), foot fault test (FFT) and the modified Neurological Severity Score (mNSS)) were performed weekly. The rats were sacrificed 56days after MCAo and lesion volumes were measured. Immunohistochemical analysis for oligodendrogenesis, myelination and gliosis was also performed. Twenty-three rats were included in the study: control group (n=12) and Tβ4 group (n=11). After randomization, there were three deaths in both the control and Tβ4 groups. The Tβ4 treatment reduced infarct volume by more than 50% (12.8%±9.3%, mean±SE, p<0.05) compared to the control group (26.0%±4.3%). However, Tβ4 did not show improvement in functional outcome compared to control. There was no significant increase in oligodendrogenesis, myelination and gliosis between control and treatment with Tβ4, however, we unexpectedly observed that overall (control and Tβ4 groups) astrocytic gliosis as measured by GFAP immunoreactivity was significantly inversely correlated with neurological outcome measured using the modified Neurological Severity Score (mNSS) (p<0.01), suggesting that greater gliosis may be related to improvement of neurological outcome in aged rats. In summary, Tβ4 treatment of stroke aged rats significantly reduces infarct volume compared to vehicle treated stroke, however, Tβ4 treatment did not show improvement in functional outcome, myelination or gliosis when compared to control. GFAP staining was significantly inversely correlated to improvement in the mNSS, suggesting that gliosis in the aged rat may be of benefit in improvement of functional outcome.
Collapse
Affiliation(s)
- Daniel C Morris
- Department of Emergency Medicine, Henry Ford Health System, Detroit, MI 48202, USA.
| | - Wing Lee Cheung
- Department of Emergency Medicine, Henry Ford Health System, Detroit, MI 48202, USA.
| | - Richard Loi
- Department of Emergency Medicine, Henry Ford Health System, Detroit, MI 48202, USA
| | - Talan Zhang
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI 48202, USA.
| | - Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI 48202, USA.
| | - Zheng G Zhang
- Department of Neurology, Henry Ford Health System, Detroit, MI 48202, USA.
| | - Michael Chopp
- Department of Neurology, Henry Ford Health System, Detroit, MI 48202, USA; Department of Physics, Oakland University, Rochester, MI 48309, USA.
| |
Collapse
|
33
|
Wang Z, Shi L, Xu S, Zhang J. Cerebrolysin for functional recovery in patients with acute ischemic stroke: a meta-analysis of randomized controlled trials. Drug Des Devel Ther 2017; 11:1273-1282. [PMID: 28458521 PMCID: PMC5402893 DOI: 10.2147/dddt.s124273] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cerebrolysin has been shown to have an inconsistent efficacy on functional recovery in patients with acute ischemic stroke (AIS). The present meta-analysis aims to evaluate the value of cerebrolysin and to explore the potential influencing factors. The main electronic databases, including MEDLINE, EMBASE, and the Cochrane Library, were searched. The primary outcome was functional recovery at Day 90. The secondary outcomes included mortality and adverse events. A total of 1,649 patients with AIS were pooled from six randomized controlled trials (RCTs). Cerebrolysin had no significant effect on functional recovery at Day 90 compared with the effect of placebo as shown by the modified Rankin Scale response (relative risk [RR] 1.33, 95% confidence interval [CI] 0.79–2.24, P=0.28), National Institutes of Health Stroke Scale response (RR 1.03, 95% CI 0.83–1.28, P=0.77), and Barthel Index response (RR 0.95, 95% CI 0.84–1.08, P=0.44). In safety analysis, cerebrolysin did not increase the risk of adverse events (RR 0.98, 95% CI 0.88–1.09, P=0.67), risk of serious adverse events (RR 1.20, 95% CI 0.86–1.66, P=0.29), or the mortality rate (RR 0.86, 95% CI 0.57–1.31, P=0.49). In conclusion, routine administration of cerebrolysin to patients with AIS cannot be supported by the available evidence from RCTs.
Collapse
Affiliation(s)
- Zefeng Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Ligen Shi
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Shenbin Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine.,Brain Research Institute.,Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou, People's Republic of China
| |
Collapse
|
34
|
Thomas A, Detilleux J, Flecknell P, Sandersen C. Impact of Stroke Therapy Academic Industry Roundtable (STAIR) Guidelines on Peri-Anesthesia Care for Rat Models of Stroke: A Meta-Analysis Comparing the Years 2005 and 2015. PLoS One 2017; 12:e0170243. [PMID: 28122007 PMCID: PMC5266292 DOI: 10.1371/journal.pone.0170243] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 12/30/2016] [Indexed: 11/19/2022] Open
Abstract
Numerous studies using rats in stroke models have failed to translate into successful clinical trials in humans. The Stroke Therapy Academic Industry Roundtable (STAIR) has produced guidelines on the rodent stroke model for preclinical trials in order to promote the successful translation of animal to human studies. These guidelines also underline the importance of anaesthetic and monitoring techniques. The aim of this literature review is to document whether anaesthesia protocols (i.e., choice of agents, mode of ventilation, physiological support and monitoring) have been amended since the publication of the STAIR guidelines in 2009. A number of articles describing the use of a stroke model in adult rats from the years 2005 and 2015 were randomly selected from the PubMed database and analysed for the following parameters: country where the study was performed, strain of rats used, technique of stroke induction, anaesthetic agent for induction and maintenance, mode of intubation and ventilation, monitoring techniques, control of body temperature, vascular accesses, and administration of intravenous fluids and analgesics. For each parameter (stroke, induction, maintenance, monitoring), exact chi-square tests were used to determine whether or not proportions were significantly different across year and p values were corrected for multiple comparisons. An exact p-test was used for each parameter to compare the frequency distribution of each value followed by a Bonferroni test. The level of significant set at < 0.05. Results show that there were very few differences in the anaesthetic and monitoring techniques used between 2005 and 2015. In 2015, significantly more studies were performed in China and significantly fewer studies used isoflurane and nitrous oxide. The most striking finding is that the vast majority of all the studies from both 2005 and 2015 did not report the use of ventilation; measurement of blood gases, end-tidal carbon dioxide concentration, or blood pressure; or administration of intravenous fluids or analgesics. The review of articles published in 2015 showed that the STAIR guidelines appear to have had no effect on the anaesthetic and monitoring techniques in rats undergoing experimental stroke induction, despite the publication of said guidelines in 2009.
Collapse
MESH Headings
- Analgesics/administration & dosage
- Anesthesia/methods
- Anesthesia/standards
- Anesthesia/veterinary
- Anesthetics/administration & dosage
- Anesthetics/classification
- Animals
- Guideline Adherence
- Infarction, Middle Cerebral Artery
- Infusions, Intravenous/methods
- Infusions, Intravenous/standards
- Infusions, Intravenous/veterinary
- Intubation, Intratracheal/methods
- Intubation, Intratracheal/standards
- Intubation, Intratracheal/veterinary
- Models, Animal
- Monitoring, Intraoperative/methods
- Monitoring, Intraoperative/standards
- Monitoring, Intraoperative/veterinary
- Perioperative Care/methods
- Perioperative Care/standards
- Perioperative Care/veterinary
- Practice Guidelines as Topic
- Rats
- Respiration, Artificial/methods
- Respiration, Artificial/standards
- Respiration, Artificial/veterinary
- Sampling Studies
- Species Specificity
- Stroke
Collapse
Affiliation(s)
- Aurelie Thomas
- University of Liège, Faculty of Veterinary Medicine, Liege, Belgium
| | - Johann Detilleux
- University of Liège, Faculty of Veterinary Medicine, Liege, Belgium
| | - Paul Flecknell
- University of Newcastle, Comparative Biology Centre, Newcastle, United Kingdom
| | | |
Collapse
|
35
|
Amaro S, Laredo C, Renú A, Llull L, Rudilosso S, Obach V, Urra X, Planas AM, Chamorro Á. Uric Acid Therapy Prevents Early Ischemic Stroke Progression. Stroke 2016; 47:2874-2876. [DOI: 10.1161/strokeaha.116.014672] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 08/30/2016] [Indexed: 02/04/2023]
Abstract
Background and Purpose—
Identification of neuroprotective therapies in acute ischemic stroke is imperative. We report a predefined analysis of the URICO-ICTUS trial (Efficacy Study of Combined Treatment With Uric Acid and r-tPA in Acute Ischemic Stroke) assessing the efficacy of uric acid (UA) compared with placebo to prevent early ischemic worsening (EIW) and the relevance of collateral circulation.
Methods—
URICO-ICTUS was a double-blind, placebo-controlled, phase 2b trial where a total of 411 patients treated with alteplase within 4.5 hours of stroke onset were randomized (1:1) to receive UA 1000 mg (n=211) or placebo (n=200) before the end of alteplase infusion. EIW defined an increment ≥4 points in the National Institutes of Health Stroke Scale score within 72 hours of treatment in the absence of hemorrhage or recurrent stroke. Logistic regression models assessed the interaction between therapy and the collateral circulation in 112 patients who had a pretreatment computed tomographic angiography.
Results—
EIW occurred in 2 of 149 (1%) patients with good outcome and 23 of 262 (9%) patients with poor outcome (χ
2
;
P
=0.002). EIW occurred in 7 of 204 (3%) patients treated with UA and in 18 of 200 (9%) patients treated with placebo (χ
2
;
P
=0.01). There was a significant interaction between the efficacy of UA to prevent EIW and collaterals (
P
=0.029), with lower incidence in patients with good collaterals treated with UA compared with placebo (2% versus 15%, respectively;
P
=0.048).
Conclusions—
UA therapy may prevent EIW after acute stroke in thrombolysed patients. Optimal access of UA to its molecular targets through appropriate collaterals may modify the magnitude of the neuroprotective effect.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00860366.
Collapse
Affiliation(s)
- Sergio Amaro
- From the Hospital Clinic of Barcelona (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.); Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS) (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.), and Institute for Biomedical Research of Barcelona (IIBB) (A.M.P.), Barcelona, Spain; and University of Barcelona, Spain (Á.C.)
| | - Carlos Laredo
- From the Hospital Clinic of Barcelona (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.); Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS) (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.), and Institute for Biomedical Research of Barcelona (IIBB) (A.M.P.), Barcelona, Spain; and University of Barcelona, Spain (Á.C.)
| | - Arturo Renú
- From the Hospital Clinic of Barcelona (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.); Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS) (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.), and Institute for Biomedical Research of Barcelona (IIBB) (A.M.P.), Barcelona, Spain; and University of Barcelona, Spain (Á.C.)
| | - Laura Llull
- From the Hospital Clinic of Barcelona (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.); Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS) (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.), and Institute for Biomedical Research of Barcelona (IIBB) (A.M.P.), Barcelona, Spain; and University of Barcelona, Spain (Á.C.)
| | - Salvatore Rudilosso
- From the Hospital Clinic of Barcelona (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.); Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS) (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.), and Institute for Biomedical Research of Barcelona (IIBB) (A.M.P.), Barcelona, Spain; and University of Barcelona, Spain (Á.C.)
| | - Víctor Obach
- From the Hospital Clinic of Barcelona (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.); Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS) (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.), and Institute for Biomedical Research of Barcelona (IIBB) (A.M.P.), Barcelona, Spain; and University of Barcelona, Spain (Á.C.)
| | - Xabier Urra
- From the Hospital Clinic of Barcelona (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.); Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS) (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.), and Institute for Biomedical Research of Barcelona (IIBB) (A.M.P.), Barcelona, Spain; and University of Barcelona, Spain (Á.C.)
| | - Anna M. Planas
- From the Hospital Clinic of Barcelona (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.); Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS) (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.), and Institute for Biomedical Research of Barcelona (IIBB) (A.M.P.), Barcelona, Spain; and University of Barcelona, Spain (Á.C.)
| | - Ángel Chamorro
- From the Hospital Clinic of Barcelona (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.); Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS) (S.A., C.L., A.R., L.L., S.R., V.O., X.U., Á.C.), and Institute for Biomedical Research of Barcelona (IIBB) (A.M.P.), Barcelona, Spain; and University of Barcelona, Spain (Á.C.)
| |
Collapse
|
36
|
|
37
|
Amaro S, Chamorro Á. Should uric acid be administered alongside thrombolysis for stroke patients? Expert Rev Cardiovasc Ther 2016; 14:407-9. [DOI: 10.1586/14779072.2016.1144470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
|
38
|
Wali B, Ishrat T, Stein DG, Sayeed I. Progesterone improves long-term functional and histological outcomes after permanent stroke in older rats. Behav Brain Res 2016; 305:46-56. [PMID: 26921692 DOI: 10.1016/j.bbr.2016.02.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 02/16/2016] [Accepted: 02/21/2016] [Indexed: 12/22/2022]
Abstract
Previous studies have shown progesterone to be beneficial in animal models of central nervous system injury, but less is known about its longer-term sustained effects on recovery of function following stroke. We evaluated progesterone's effects on a panel of behavioral tests up to 8 weeks after permanent middle cerebral artery occlusion (pMCAO). Male Sprague-Dawley rats 12m.o. were subjected to pMCAO and, beginning 3h post-pMCAO, given intraperitoneal injections of progesterone (8mg/kg) or vehicle, followed by subcutaneous injections at 8h and then every 24h for 7 days, with tapering of the last 2 treatments. The rats were then tested on functional recovery at 3, 6 and 8 weeks post-stroke. We observed that progesterone-treated animals showed attenuation of infarct volume and improved functional outcomes at 8 weeks after stroke on grip strength, sensory neglect, motor coordination and spatial navigation tests. Progesterone treatments significantly improved motor deficits in the affected limb on a number of gait parameters. Glial fibrillary acidic protein expression was increased in the vehicle group and considerably lowered in the progesterone group at 8 weeks post-stroke. With repeated post-stroke testing, sensory neglect and some aspects of spatial learning performance showed spontaneous recovery, but on gait and grip-strength measres progesterone given only in the acute stage of stroke (first 7 days) showed sustained beneficial effects on all other measures of functional recovery up to 8 weeks post-stroke.
Collapse
Affiliation(s)
- Bushra Wali
- Department of Emergency Medicine, Brain Research Laboratory, Emory University, Atlanta, GA, USA.
| | - Tauheed Ishrat
- Department of Emergency Medicine, Brain Research Laboratory, Emory University, Atlanta, GA, USA.
| | - Donald G Stein
- Department of Emergency Medicine, Brain Research Laboratory, Emory University, Atlanta, GA, USA.
| | - Iqbal Sayeed
- Department of Emergency Medicine, Brain Research Laboratory, Emory University, Atlanta, GA, USA.
| |
Collapse
|
39
|
Linfante I. Lost in translation. J Neurointerv Surg 2015; 7:781-2. [PMID: 26468274 DOI: 10.1136/neurintsurg-2015-012056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
40
|
Koç A. Exercise in patients with subacute stroke: A randomized, controlled pilot study of home-based exercise in subacute stroke. Work 2015; 52:541-7. [DOI: 10.3233/wor-152156] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
41
|
Jickling GC, Sharp FR. Improving the translation of animal ischemic stroke studies to humans. Metab Brain Dis 2015; 30:461-7. [PMID: 24526567 PMCID: PMC4186910 DOI: 10.1007/s11011-014-9499-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 01/28/2014] [Indexed: 12/18/2022]
Abstract
Despite testing more than 1,026 therapeutic strategies in models of ischemic stroke and 114 therapies in human ischemic stroke, only one agent tissue plasminogen activator has successfully been translated to clinical practice as a treatment for acute stroke. Though disappointing, this immense body of work has led to a rethinking of animal stroke models and how to better translate therapies to patients with ischemic stroke. Several recommendations have been made, including the STAIR recommendations and statements of RIGOR from the NIH/NINDS. In this commentary we discuss additional aspects that may be important to improve the translational success of ischemic stroke therapies. These include use of tissue plasminogen activator in animal studies; modeling ischemic stroke heterogeneity in terms of infarct size and cause of human stroke; addressing the confounding effect of anesthesia; use of comparable therapeutic dosage between humans and animals based on biological effect; modeling the human immune system; and developing outcome measures in animals comparable to those used in human stroke trials. With additional study and improved animal modeling of factors involved in human ischemic stroke, we are optimistic that new stroke therapies will be developed.
Collapse
Affiliation(s)
- Glen C Jickling
- Department of Neurology, MIND Institute Wet Labs Room 2415, University of California at Davis Medical Center, 2805 50th Street, Sacramento, CA, 95817, USA,
| | | |
Collapse
|
42
|
Smith CJ, Denes A, Tyrrell PJ, Di Napoli M. Phase II anti-inflammatory and immune-modulating drugs for acute ischaemic stroke. Expert Opin Investig Drugs 2015; 24:623-43. [PMID: 25727670 DOI: 10.1517/13543784.2015.1020110] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Stroke is the second leading cause of death worldwide and the leading cause of adult neurological disability. Despite advances in stroke unit care, and increasing use of thrombolysis, there remains an urgent need for safe and effective treatments for acute ischaemic stroke. However, this is against a backdrop of multiple failures in translational drug development. Cerebral ischaemia initiates a complex cascade of immune and inflammatory pathways in the brain microvasculature and periphery, which contribute to the evolution of cerebral injury, resolution and repair. Targeting specific inflammatory or immune pathways, therefore, represents an attractive treatment strategy in acute ischaemic stroke. Although anti-inflammatory drugs have already failed in clinical trial development, several are currently at the Phase II developmental stage. AREAS COVERED The authors highlight several candidate drugs, which modulate a range of inflammatory and immune pathways, and have been investigated in pre-clinical and Phase II studies to date. EXPERT OPINION Drugs targeting inflammatory and immune pathways offer theoretical advantages including potentially longer therapeutic time windows and effects complementary to thrombolysis (ameliorating reperfusion injury). Fundamental changes in the approach to pre-clinical and clinical drug development are required to facilitate successful translation of promising candidate drugs into clinical practice.
Collapse
Affiliation(s)
- Craig J Smith
- Greater Manchester Comprehensive Stroke Centre, Department of Medical Neurosciences, Salford Royal Foundation Trust , Salford , UK
| | | | | | | |
Collapse
|
43
|
Wu TC, Sarraj A, Jacobs A, Shen L, Indupuru H, Biscamp D, Ho V, Ankrom C, Grotta JC, Savitz SI, Barreto AD. Telemedicine-guided remote enrollment of patients into an acute stroke trial. Ann Clin Transl Neurol 2014; 2:38-42. [PMID: 25642433 PMCID: PMC4301673 DOI: 10.1002/acn3.150] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 10/17/2014] [Accepted: 10/22/2014] [Indexed: 11/25/2022] Open
Abstract
Background and Purpose Enrollment into acute stroke clinical trials is limited to experienced tertiary centers with emergency research infrastructure. Feasibility of remote enrollment via telemedicine into an acute thrombolytic clinical trial has never been demonstrated. Methods Using telemedicine, our hub stroke research center partnered with two spoke community hospitals to jointly participate in a randomized, phase III adjunctive thrombolysis clinical trial in the first 3 h after symptom onset to expand recruitment of the trial. Eligible patients were successfully identified, consented, randomized, and received therapy/placebo at the spoke hospitals under real-time direction by hub trialists via telemedicine. Results Ten patients were identified from May 2013 to July 2014, and six were enrolled via telemedicine. No study procedure delays, safety events, or major protocol violations occurred. Conclusions It is feasible to randomize and enroll stroke patients via remote telemedicine into an acute thrombolytic clinical trial. This novel approach could expand access and accelerate completion of clinical trials if widely implemented.
Collapse
Affiliation(s)
- Tzu-Ching Wu
- Department of Neurology, University of Texas-Health Science Center at Houston Houston, Texas
| | - Amrou Sarraj
- Department of Neurology, University of Texas-Health Science Center at Houston Houston, Texas
| | - Amber Jacobs
- Department of Neurology, University of Texas-Health Science Center at Houston Houston, Texas
| | - Loren Shen
- Department of Neurology, University of Texas-Health Science Center at Houston Houston, Texas
| | - Hari Indupuru
- Department of Neurology, University of Texas-Health Science Center at Houston Houston, Texas
| | - Donna Biscamp
- Department of Emergency Medicine, Baptist Hospitals of Southeast Texas Beaumont, Texas
| | - Victor Ho
- Department of Emergency Medicine, Baptist Hospitals of Southeast Texas Beaumont, Texas
| | - Christy Ankrom
- Department of Neurology, University of Texas-Health Science Center at Houston Houston, Texas
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital-Texas Medical Center Houston, Texas
| | - Sean I Savitz
- Department of Neurology, University of Texas-Health Science Center at Houston Houston, Texas
| | - Andrew D Barreto
- Department of Neurology, University of Texas-Health Science Center at Houston Houston, Texas
| |
Collapse
|
44
|
Goossens J, Hachimi-Idrissi S. Combination of therapeutic hypothermia and other neuroprotective strategies after an ischemic cerebral insult. Curr Neuropharmacol 2014; 12:399-412. [PMID: 25426009 PMCID: PMC4243031 DOI: 10.2174/1570159x12666140424233036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 03/14/2014] [Accepted: 04/22/2014] [Indexed: 12/31/2022] Open
Abstract
Abrupt deprivation of substrates to neuronal tissue triggers a number of pathological events (the “ischemic cascade”) that lead to cell death. As this is a process of delayed neuronal cell death and not an instantaneous event, several pharmacological and non-pharmacological strategies have been developed to attenuate or block this cascade. The most promising neuroprotectant so far is therapeutic hypothermia and its beneficial effects have inspired researchers to further improve its protective benefit by combining it with other neuroprotective agents. This review provides an overview of all neuroprotective strategies that have been combined with therapeutic hypothermia in rodent models of focal cerebral ischemia. A distinction is made between drugs interrupting only one event of the ischemic cascade from those mitigating different pathways and having multimodal effects. Also the combination of therapeutic hypothermia with hemicraniectomy, gene therapy and protein therapy is briefly discussed. Furthermore, those combinations that have been studied in a clinical setting are also reviewed.
Collapse
Affiliation(s)
- Joline Goossens
- Critical Care Department and Cerebral Resuscitation Research Group, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Saïd Hachimi-Idrissi
- Critical Care Department and Cerebral Resuscitation Research Group, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| |
Collapse
|
45
|
DeGracia DJ, Tri Anggraini F, Taha DTM, Huang ZF. Inductive and Deductive Approaches to Acute Cell Injury. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2014; 2014:859341. [PMID: 27437490 PMCID: PMC4897055 DOI: 10.1155/2014/859341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/25/2014] [Indexed: 11/28/2022]
Abstract
Many clinically relevant forms of acute injury, such as stroke, traumatic brain injury, and myocardial infarction, have resisted treatments to prevent cell death following injury. The clinical failures can be linked to the currently used inductive models based on biological specifics of the injury system. Here we contrast the application of inductive and deductive models of acute cell injury. Using brain ischemia as a case study, we discuss limitations in inductive inferences, including the inability to unambiguously assign cell death causality and the lack of a systematic quantitative framework. These limitations follow from an overemphasis on qualitative molecular pathways specific to the injured system. Our recently developed nonlinear dynamical theory of cell injury provides a generic, systematic approach to cell injury in which attractor states and system parameters are used to quantitatively characterize acute injury systems. The theoretical, empirical, and therapeutic implications of shifting to a deductive framework are discussed. We illustrate how a deductive mathematical framework offers tangible advantages over qualitative inductive models for the development of therapeutics of acutely injured biological systems.
Collapse
Affiliation(s)
- Donald J. DeGracia
- Department of Physiology, Wayne State University, 4116 Scott Hall, 540 East Canfield Avenue, Detroit, MI 48201, USA
| | - Fika Tri Anggraini
- Department of Physiology, Wayne State University, 4116 Scott Hall, 540 East Canfield Avenue, Detroit, MI 48201, USA
| | | | - Zhi-Feng Huang
- Department of Physics and Astronomy, Wayne State University, Detroit, MI 48201, USA
| |
Collapse
|
46
|
Safety and efficacy of uric acid in patients with acute stroke (URICO-ICTUS): a randomised, double-blind phase 2b/3 trial. Lancet Neurol 2014; 13:453-60. [PMID: 24703208 DOI: 10.1016/s1474-4422(14)70054-7] [Citation(s) in RCA: 191] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Uric acid is an antioxidant with neuroprotective effects in experimental models of stroke. We assessed whether uric acid therapy would improve functional outcomes at 90 days in patients with acute ischaemic stroke. METHODS URICO-ICTUS was a randomised, double-blind, placebo-controlled, phase 2b/3 trial that recruited patients with acute ischaemic stroke admitted to ten Spanish stroke centres. Patients were included if they were aged 18 years or older, had received alteplase within 4·5 h of symptom onset, and had an eligible National Institutes of Health Stroke Scale (NIHSS) score (>6 and ≤25) and premorbid (assessed by anamnesis) modified Rankin Scale (mRS) score (≤2). Patients were randomly allocated (1:1) to receive uric acid 1000 mg or placebo (both infused intravenously in 90 min during the infusion of alteplase), stratified by centre and baseline stroke severity. The primary outcome was the proportion of patients with excellent outcome (ie, an mRS score of 0-1, or 2 if premorbid score was 2) at 90 days, analysed in the target population (all randomly assigned patients who had been correctly diagnosed with ischaemic stroke and had begun study medication). The study is registered with ClinicalTrials.gov, number NCT00860366. FINDINGS Between July 1, 2011, and April 30, 2013, we randomly assigned 421 patients, of whom 411 (98%) were included in the target population (211 received uric acid and 200 received placebo). 83 (39%) patients who received uric acid and 66 (33%) patients who received placebo had an excellent outcome (adjusted risk ratio 1·23 [95% CI 0·96-1·56]; p=0·099). No clinically relevant or statistically significant differences were reported between groups with respect to death (28 [13%] patients who received uric acid vs 31 [16%] who received placebo), symptomatic intracerebral haemorrhage (nine [4%] vs six [3%]), and gouty arthritis (one [<1%] vs four [2%]). 516 adverse events occurred in the uric acid group and 532 in the placebo group, of which 61 (12%) and 67 (13%), respectively, were serious adverse events (p=0·703). INTERPRETATION The addition of uric acid to thrombolytic therapy did not increase the proportion of patients who achieved excellent outcome after stroke compared with placebo, but it did not lead to any safety concerns. FUNDING Institute of Health Carlos III of the Spanish Ministry of Health and Fundación Doctor Melchor Colet.
Collapse
|
47
|
Flores JJ, Zhang Y, Klebe DW, Lekic T, Fu W, Zhang JH. Small molecule inhibitors in the treatment of cerebral ischemia. Expert Opin Pharmacother 2014; 15:659-80. [PMID: 24491068 DOI: 10.1517/14656566.2014.884560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Stroke is the world's second leading cause of death. Although recombinant tissue plasminogen activator is an effective treatment for cerebral ischemia, its limitations and ischemic stroke's complex pathophysiology dictate an increased need for the development of new therapeutic interventions. Small molecule inhibitors (SMIs) have the potential to be used as novel therapeutic modalities for stroke, since many preclinical and clinical trials have established their neuroprotective capabilities. AREAS COVERED This paper provides a summary of the pathophysiology of stroke as well as clinical and preclinical evaluations of SMIs as therapeutic interventions for cerebral ischemia. Cerebral ischemia is broken down into four mechanisms in this article: thrombosis, ischemic insult, mitochondrial injury and immune response. Insight is provided into preclinical and current clinical assessments of SMIs targeting each mechanism as well as a summary of reported results. EXPERT OPINION Many studies demonstrated that pre- or post-treatment with certain SMIs significantly ameliorated adverse effects from stroke. Although some of these promising SMIs moved on to clinical trials, they generally failed, possibly due to the poor translation of preclinical to clinical experiments. Yet, there are many steps being taken to improve the quality of experimental research and translation to clinical trials.
Collapse
Affiliation(s)
- Jerry J Flores
- Loma Linda University School of Medicine, Department of Physiology and Pharmacology , Risley Hall, Room 223, Loma Linda, CA 92354 , USA
| | | | | | | | | | | |
Collapse
|
48
|
Wali B, Ishrat T, Won S, Stein DG, Sayeed I. Progesterone in experimental permanent stroke: a dose-response and therapeutic time-window study. Brain 2014; 137:486-502. [PMID: 24374329 PMCID: PMC3914469 DOI: 10.1093/brain/awt319] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 09/10/2013] [Accepted: 09/23/2013] [Indexed: 11/14/2022] Open
Abstract
Currently, the only approved treatment for ischaemic stroke is tissue plasminogen activator, a clot-buster. This treatment can have dangerous consequences if not given within the first 4 h after stroke. Our group and others have shown progesterone to be beneficial in preclinical studies of stroke, but a progesterone dose-response and time-window study is lacking. We tested male Sprague-Dawley rats (12 months old) with permanent middle cerebral artery occlusion or sham operations on multiple measures of sensory, motor and cognitive performance. For the dose-response study, animals received intraperitoneal injections of progesterone (8, 16 or 32 mg/kg) at 1 h post-occlusion, and subcutaneous injections at 6 h and then once every 24 h for 7 days. For the time-window study, the optimal dose of progesterone was given starting at 3, 6 or 24 h post-stroke. Behavioural recovery was evaluated at repeated intervals. Rats were killed at 22 days post-stroke and brains extracted for evaluation of infarct volume. Both 8 and 16 mg/kg doses of progesterone produced attenuation of infarct volume compared with the placebo, and improved functional outcomes up to 3 weeks after stroke on locomotor activity, grip strength, sensory neglect, gait impairment, motor coordination and spatial navigation tests. In the time-window study, the progesterone group exhibited substantial neuroprotection as late as 6 h after stroke onset. Compared with placebo, progesterone showed a significant reduction in infarct size with 3- and 6-h delays. Moderate doses (8 and 16 mg/kg) of progesterone reduced infarct size and improved functional deficits in our clinically relevant model of stroke. The 8 mg/kg dose was optimal in improving motor, sensory and memory function, and this effect was observed over a large therapeutic time window. Progesterone shows promise as a potential therapeutic agent and should be examined for safety and efficacy in a clinical trial for ischaemic stroke.
Collapse
Affiliation(s)
- Bushra Wali
- Department of Emergency Medicine, Brain Research Laboratory, Emory University, Atlanta, GA, USA
| | | | | | | | | |
Collapse
|
49
|
Neuroprotective agents in ischemic stroke: past failures and future opportunities. ACTA ACUST UNITED AC 2013. [DOI: 10.4155/cli.13.91] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
50
|
|