1
|
Valencia Morales DJ, Garbajs NZ, Tawfic SS, Jose T, Laporta ML, Schroeder DR, Weingarten TN, Sprung J. Intraoperative Blood Pressure Variability and Early Postoperative Stroke: A Case-Control Study. Am Surg 2023; 89:5191-5200. [PMID: 36426383 DOI: 10.1177/00031348221136578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND This study aims to assess the association of postoperative stroke with intraoperative hemodynamic variability and transfusion management. METHODS In this case-control study, adult patients (≥ 18 years) who had a stroke within 72 hours of a surgical procedure were matched to 2 control patients according to age, sex, and procedure type. Primary risk factors assessed were intraoperative fluid administration, blood product transfusion, vasopressor use, and measures of variability in systolic and diastolic blood pressure and heart rate: maximum, minimum, range, SD, and average real variability. The variables were analyzed with conditional logistic regression, which accounted for the 1:2 matched case-control study design. RESULTS Among 687 581 procedures, we identified 64 postoperative strokes (incidence, 9.3 [95% CI, 7.2-11.9] strokes per 100 000 procedures). These cases were matched with 128 controls. Stroke cases had higher Charlson cmorbidity index scores than did controls (P = .046). Blood pressure and heart rate variability measures were not associated with stroke. The risk of stroke was increased with red blood cell (RBC) transfusion (odds ratio [OR], 14.82; 95% CI, 3.40-64.66; P < .001), vasopressor use (OR, 3.91; 95% CI, 1.59-9.60; P = .003), and longer procedure duration (OR, 1.23/h; 95% CI, 1.01-1.51; P = .04). Multivariable analysis of procedure duration, RBC transfusion, and vasopressor use showed that only RBC transfusion was independently associated with an increased risk of stroke (OR, 10.10; 95% CI, 2.14-47.72; P = .004). CONCLUSIONS Blood pressure variability was not associated with an increased risk of postoperative stroke; however, RBC transfusion was an independent risk factor.
Collapse
Affiliation(s)
| | - Nika Zorko Garbajs
- Department of Vascular Neurology and Intensive Therapy, University Medical Centre, Ljubljana, Slovenia
| | - Sarah S Tawfic
- Department of Internal Medicine, Mayo Clinic Rochester, Minnesota
| | - Thulasee Jose
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Darrell R Schroeder
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
2
|
Hu M, Zhu Y, Chen Z, Li W, Li L, Li Y, Xia Y, Zhang T, Feng Q, Wu J, Wu M. Relationship between mean blood pressure during hospitalization and clinical outcome after acute ischemic stroke. BMC Neurol 2023; 23:156. [PMID: 37081452 PMCID: PMC10116692 DOI: 10.1186/s12883-023-03209-3] [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: 01/01/2023] [Accepted: 04/14/2023] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVE The optimal blood pressure (BP) targets for acute ischemic stroke are unclear. We aimed to assess the relationship between Mean BP and clinical outcomes during hospitalization. MATERIALS AND METHODS We included 649 patients with Acute ischemic stroke (AIS) from December 2020 to July 2021. BP was measured daily, and mean blood pressure was calculated. Clinical events recorded within 90 days of randomization were: recurrent ischemic stroke, symptomatic intracranial hemorrhage, and death. The modified Rankin Scale (mRS) was used to measure primary outcomes 3 months after AIS. Logistic multiple regression analysis was performed by statistical software R. RESULT There is a nonlinear U-shaped relationship between SBP and poor outcomes. This means higher SBP and lower SBP will increase the incidence of poor outcomes. The optimal mean SBP during hospitalization was 135-150 mmHg, and patients with SBP < 135mmhg OR 2.4 [95% Cl, (1.16 ~ 4.97)], P = 0.018; and > 150mmhg OR 2.04 [95% Cl, 1.02 ~ 4.08], p = 0.045 had a higher probability of poor outcomes. CONCLUSION Our study shows that the optimal SBP of patients with AIS during hospitalization was 135-150 mmHg. The findings suggest that the relationship between mean SBP and 3-month functional outcome after AIS was U-shaped. Both higher SBP and lower SBP lead to poor prognosis in AIS patients.
Collapse
Affiliation(s)
- Manyan Hu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Yuan Zhu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Zhaoyao Chen
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Wenlei Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Li Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Yunze Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Yangjingyi Xia
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Tianrui Zhang
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Qinghua Feng
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Jiacheng Wu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Minghua Wu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China.
| |
Collapse
|
3
|
Uniken Venema SM, Dankbaar JW, van der Lugt A, Dippel DWJ, van der Worp HB. Cerebral Collateral Circulation in the Era of Reperfusion Therapies for Acute Ischemic Stroke. Stroke 2022; 53:3222-3234. [PMID: 35938420 DOI: 10.1161/strokeaha.121.037869] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinical outcomes of patients with acute ischemic stroke depend in part on the extent of their collateral circulation. A good collateral circulation has also been associated with greater benefit of intravenous thrombolysis and endovascular treatment. Treatment decisions for these reperfusion therapies are increasingly guided by a combination of clinical and imaging parameters, particularly in later time windows. Computed tomography and magnetic resonance imaging enable a rapid assessment of both the collateral extent and cerebral perfusion. Yet, the role of the collateral circulation in clinical decision-making is currently limited and may be underappreciated due to the use of rather coarse and rater-dependent grading methods. In this review, we discuss determinants of the collateral circulation in patients with acute ischemic stroke, report on commonly used and emerging neuroimaging techniques for assessing the collateral circulation, and discuss the therapeutic and prognostic implications of the collateral circulation in relation to reperfusion therapies for acute ischemic stroke.
Collapse
Affiliation(s)
- Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands. (S.M.U.V., H.B.v.d.W.)
| | - Jan Willem Dankbaar
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, the Netherlands. (J.W.D.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center Rotterdam, the Netherlands. (A.v.d.L.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus Medical Center Rotterdam, the Netherlands. (D.W.J.D.)
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands. (S.M.U.V., H.B.v.d.W.)
| |
Collapse
|
4
|
Saima B, Mikel T, Maria B, Yolanda S, Juan ÁC, Victor VM, Laura P, Montserrat R, Carme GM, Alan M, Joaquín S. Progressive Lacunar Atrokes: A Predictive Score. J Stroke Cerebrovasc Dis 2022; 31:106510. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/01/2022] [Accepted: 04/08/2022] [Indexed: 02/05/2023] Open
|
5
|
Strømsnes TA, Kaugerud Hagen TJ, Ouyang M, Wang X, Chen C, Rygg SE, Hewson D, Lenthall R, McConachie N, Izzath W, Bath PM, Dhillon PS, Podlasek A, England T, Sprigg N, Robinson TG, Advani R, Ihle-Hansen H, Sandset EC, Krishnan K. Pressor therapy in acute ischaemic stroke: an updated systematic review. Eur Stroke J 2022; 7:99-116. [PMID: 35647316 PMCID: PMC9134777 DOI: 10.1177/23969873221078136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/17/2022] [Indexed: 11/15/2022] Open
Abstract
Background Low blood pressure (BP) in acute ischaemic stroke (AIS) is associated with poor functional outcome, death, or severe disability. Increasing BP might benefit patients with post-stroke hypotension including those with potentially salvageable ischaemic penumbra. This updated systematic review considers the present evidence regarding the use of vasopressors in AIS. Methods We searched the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and trial databases using a structured search strategy. We examined reference lists of relevant publications for additional studies examining BP elevation in AIS. Results We included 27 studies involving 1886 patients. Nine studies assessed increasing BP during acute reperfusion therapy (intravenous thrombolysis, mechanical thrombectomy, intra-arterial thrombolysis or combined). Eighteen studies tested BP elevation alone. Phenylephrine was the most commonly used agent to increase BP (n = 16 studies), followed by norepinephrine (n = 6), epinephrine (n = 3) and dopamine (n = 2). Because of small patient numbers and study heterogeneity, a meta-analysis was not possible. Overall, BP elevation was feasible in patients with fluctuating or worsening neurological symptoms, large vessel occlusion with labile BP, sustained post-stroke hypotension and ineligible for intravenous thrombolysis or after acute reperfusion therapy. The effects on functional outcomes were largely unknown and close monitoring is advised if such intervention is undertaken. Conclusion Although theoretical arguments support increasing BP to improve cerebral blood flow and sustain the ischaemic penumbra in selected AIS patients, the data are limited and results largely inconclusive. Large, randomised controlled trials are needed to identify the optimal BP target, agent, duration of treatment and effects on clinical outcomes.
Collapse
Affiliation(s)
- Torbjørn Austveg Strømsnes
- Department of Neurosurgery, Oslo University hospital, Norway
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Department of Clinical Medicine, University of Bergen, Norway
| | - Truls Jørgen Kaugerud Hagen
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Department of Geriatric Medicine, Oslo University hospital, Norway
| | - Menglu Ouyang
- The George Institute for Global Health, Faulty of Medicine, University of New South Wales, Australia
| | - Xia Wang
- The George Institute for Global Health, Faulty of Medicine, University of New South Wales, Australia
| | - Chen Chen
- The George Institute for Global Health, Faulty of Medicine, University of New South Wales, Australia
- The George Institute for Global Health, Peking University Health Science Center, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Silje-Emilie Rygg
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Department of Geriatric Medicine, Oslo University hospital, Norway
| | - David Hewson
- Department of Anaesthesia, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rob Lenthall
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Norman McConachie
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Wazim Izzath
- Department of Neuroradiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Philip M Bath
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham, Queen’s Medical Centre campus, Nottingham, UK
| | - Permesh Singh Dhillon
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Anna Podlasek
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Timothy England
- Department of Stroke Medicine, Royal Derby Hospital, Derby, UK
| | - Nikola Sprigg
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham, Queen’s Medical Centre campus, Nottingham, UK
| | - Thompson G Robinson
- College of Life Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Rajiv Advani
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
| | - Hege Ihle-Hansen
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
| | - Else Charlotte Sandset
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Norwegian Air Ambulance Foundation, Norway
| | - Kailash Krishnan
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham, Queen’s Medical Centre campus, Nottingham, UK
| |
Collapse
|
6
|
Kojima D, Fujimoto K, Kashimura H, Akamatsu Y. Successful Leptomeningeal Enhancement in a Patient with Tandem Occlusion of a Carotid and Middle Cerebral Artery Following Carotid Artery Stenting for Contralateral Carotid Artery Stenosis. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 16:381-386. [PMID: 37502347 PMCID: PMC10370919 DOI: 10.5797/jnet.cr.2021-0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 11/01/2021] [Indexed: 07/29/2023]
Abstract
Objective Although the presence of leptomeningeal anastomosis is known as a predictor of favorable outcome in patients with acute large vessel occlusion, the efficacy of enhancing leptomeningeal collateral flow has rarely been demonstrated. Case Presentation A 73-year-old man previously diagnosed with asymptomatic bilateral carotid stenosis was admitted to our emergency department 2 hours after the onset of fluctuating symptoms, including aphasia, left conjugate deviation, and right hemiparesis. CT demonstrated no hemorrhagic lesion. Considering the history of the patient, emergent angiography was performed and demonstrated tandem occlusion of the left cervical internal carotid artery (ICA) with left common carotid injection, leptomeningeal flow compensating for distal territory of occluded segment of left middle cerebral artery (MCA) via the left anterior cerebral artery through severe cervical ICA stenosis with right common carotid injection, and the proximal segment of the left MCA through the posterior communicating artery and occlusion of the M2 segment with left vertebral injection. Given the results of angiography and fluctuating symptoms, hemodynamic insufficiency was considered the underlying stroke mechanism for this case. Although recanalization of tandem lesions was initially considered, the risk of distal clot migration was a concern, so the patient underwent right carotid artery stenting (CAS) to enhance leptomeningeal collateral flow. This resulted in immediate resolution of symptoms after right CAS. Conclusion Stenting for carotid artery stenosis contralateral to tandem occlusive lesion may offer an effective alternative when both Willisian and leptomeningeal collaterals are robust.
Collapse
Affiliation(s)
- Daigo Kojima
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Iwate, Japan
| | - Kentaro Fujimoto
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Iwate, Japan
| | - Hiroshi Kashimura
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Iwate, Japan
| | - Yosuke Akamatsu
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Iwate, Japan
| |
Collapse
|
7
|
Gigliotti MJ, Feidt AE, Cockroft KM, Wilkinson DA, Simon SD, Church EW. Management of neurophysiological monitoring changes during carotid endarterectomy exposure. Clin Neurol Neurosurg 2021; 211:107032. [PMID: 34801880 DOI: 10.1016/j.clineuro.2021.107032] [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: 06/29/2021] [Revised: 10/20/2021] [Accepted: 11/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is a safe and effective operation in the management of carotid stenosis. Intraoperative neurophysiologic monitoring (IONM) changes during carotid clamping has been well studied, but there is scant evidence detailing IONM changes during carotid exposure. OBJECTIVE We analyzed our experience with IONM changes during CEA exposure to determine whether multimodal IONM changes during exposure predict outcomes and how best to manage this challenging clinical scenario. METHODS We reviewed all CEAs performed at our medical center between January 2015 and June 2020 and identified patients with multimodal IONM changes during exposure of the carotid artery. Our primary outcomes were perioperative stroke and functional outcomes. Functional outcomes were measured by modified Rankin scale (mRS), with good functional outcome defined at mRS scores 0-3. We also reviewed our intraoperative IONM change management strategies. RESULTS Five patients (4 males, 1 female) with an average age of 67 ± 12 years had intraoperative IONM changes during carotid exposure. Among these, three patients were discharged with good functional outcome, and four patients had a good functional outcome at last follow-up. Two patients had perioperative stroke, half of which resulted in significant disability. One patient was transferred to the neuroendovascular suite intraoperatively for evaluation for thromboembolism followed by angioplasty and stenting with distal protection. CONCLUSION Intraoperative IONM changes during carotid exposure predict outcomes in CEA. We propose that transition to the neuroendovascular suite following significant IONM changes during carotid exposure may be a useful strategy for management of this challenging clinical scenario. This approach provides the opportunity to evaluate and treat thromboembolism and still complete carotid revascularization when appropriate. This algorithm may be particularly useful in the era of dual trained vascular neurosurgeons.
Collapse
Affiliation(s)
- Michael J Gigliotti
- Department of Neurosurgery, Penn State Health, 500 University Drive, Hershey, PA 17033, USA
| | - Amy E Feidt
- Department of Neurosurgery, Penn State Health, 500 University Drive, Hershey, PA 17033, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Health, 500 University Drive, Hershey, PA 17033, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery, Penn State Health, 500 University Drive, Hershey, PA 17033, USA
| | - Scott D Simon
- Department of Neurosurgery, Penn State Health, 500 University Drive, Hershey, PA 17033, USA
| | - Ephraim W Church
- Department of Neurosurgery, Penn State Health, 500 University Drive, Hershey, PA 17033, USA.
| |
Collapse
|
8
|
Sandset EC, Anderson CS, Bath PM, Christensen H, Fischer U, Gąsecki D, Lal A, Manning LS, Sacco S, Steiner T, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. Eur Stroke J 2021; 6:XLVIII-LXXXIX. [PMID: 34780578 PMCID: PMC8370078 DOI: 10.1177/23969873211012133] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/05/2021] [Indexed: 12/13/2022] Open
Abstract
The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke.The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels >180/105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups. There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.
Collapse
Affiliation(s)
- Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- The George Institute China at Peking University Health Science Center, Beijing, PR China
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital & University of Copenhagen, Copenhagen, Denmark
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dariusz Gąsecki
- Department of Adult Neurology, Medical University of Gdańsk, Gdańsk, Poland
| | - Avtar Lal
- Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Lisa S Manning
- Department of Stroke Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| |
Collapse
|
9
|
Shin DW, Gorelick PB, Bae HJ. Time-dependent shift of the relationship between systolic blood pressure and clinical outcome in acute lacunar stroke. Int J Stroke 2021; 17:400-406. [PMID: 33724096 DOI: 10.1177/17474930211006243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS This study explores the relationship between systolic blood pressure during the acute period of stroke and poor functional outcome in patients with lacunar stroke, emphasizing a possible time-dependent nature of the relationship. METHODS Based on multicenter stroke registry data, patients with acute lacunar stroke were identified, and systolic blood pressure levels at eight time points (1, 2, 4, 8, 16, 24, 48, and 72 h) after stroke onset were extracted at the 15 participating centers in South Korea. Poor functional outcome was defined as a three-month modified Rankin Scale score of 2-6. Non-linear restricted cubic spline and linear models were used for assessing the relationship at each time point. RESULTS A total of 97,349 systolic blood pressure measurements of 3,042 patients were analyzed. At 1 h and 4 h after stroke onset, the relationship between systolic blood pressure and poor outcome showed a non-linear association. The nadir was 155 mmHg at 1 h and 124 mmHg at 4 h. After this time period, a higher systolic blood pressure was associated with a poorer outcome. This linear relationship weakened over time after 12 h (coefficient values of the adjusted linear models: 0.0081 at 8 h, 0.0105 at 12 h, 0.0102 at 24 h, 0.0082 at 48 h, 0.0054 at 72 h). CONCLUSIONS Based on our cohort of large number of lacunar stroke patients, our findings suggest that systolic blood pressure levels may follow a time-dependent course in relation to prediction of outcome at three months. The findings may be valuable for hypothesis generation in association with clinical trial development for blood pressure control in acute stroke patients.
Collapse
Affiliation(s)
- Dong W Shin
- Department of Neurology and Cerebrovascular Center, 65462Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Philip B Gorelick
- Davee Department of Neurology, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, 65462Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | | |
Collapse
|
10
|
Abstract
The neurological intensive care unit plays an integral role in the management of cerebrovascular disease in the acute and perioperative period. Understanding the use of intracranial pressure (ICP) monitoring and how to apply the appropriate intervention for ICP elevation to ensure adequate cerebral perfusion is the foundation of neurocritical care. Careful management of the interplay between cerebral and systemic physiology, particularly in disorders of cerebral autoregulation, is critical in preventing secondary brain injury. Finally, understanding the cerebral pathophysiology of the underlying injured brain in acute stroke, subarachnoid hemorrhage, and arterial stenosis can help to guide the optimal use of interventional endovascular procedures in these disease states.
Collapse
Affiliation(s)
- Vineeta Singh
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States.
| | - Roger Cheng
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| |
Collapse
|
11
|
Hemodynamics in acute stroke: Cerebral and cardiac complications. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:295-317. [PMID: 33632449 DOI: 10.1016/b978-0-12-819814-8.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hemodynamics is the study of blood flow, where parameters have been defined to quantify blood flow and the relationship with systemic circulatory changes. Understanding these perfusion parameters, the relationship between different blood flow variables and the implications for ischemic injury are outlined in the ensuing discussion. This chapter focuses on the hemodynamic changes that occur in ischemic stroke, and their contribution to ischemic stroke pathophysiology. We discuss the interaction between cardiovascular response and hemodynamic changes in stroke. Studying hemodynamic changes has a key role in stroke prevention, therapeutic implications and prognostic importance in acute ischemic stroke: preexisting hemodynamic and autoregulatory impairments predict the occurrence of stroke. Hemodynamic failure predisposes to the formation of thromboemboli and accelerates infarction due to impairing compensatory mechanisms. In ischemic stroke involving occlusion of a large vessel, persistent collateral circulation leads to preservation of ischemic penumbra and therefore justifying endovascular thrombectomy. Following thrombectomy, impaired autoregulation may lead to reperfusion injury and hemorrhage.
Collapse
|
12
|
Shin JA, Lee KJ, Lee JS, Kang J, Kim BJ, Han MK, Kim JY, Jang MS, Yang MH, Lee J, Gorelick PB, Bae HJ. Relationship between blood pressure and outcome changes over time in acute ischemic stroke. Neurology 2020; 95:e1362-e1371. [PMID: 32641533 DOI: 10.1212/wnl.0000000000010203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 03/16/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate whether the relationship between systolic blood pressure (SBP) and stroke outcome varies during the acute stage of ischemic stroke as a function of the elapsed time after stroke onset. METHODS Patients who were hospitalized due to ischemic stroke within 6 hours of onset were retrospectively analyzed. SBP data were collected at 8 time points (1, 2, 4, 8, 16, 24, 48, and 72 hours after onset). The primary functional outcome measure was a poor outcome, defined as a modified Rankin Scale score of >2 at 3 months after stroke. Linear and quadratic models were constructed at each time point to assess relationships between SBP and outcome. RESULTS Of the 2,546 patients, 728 (28.6%) had a poor outcome. SBP, as either a linear or quadratic term, had a significant effect on functional outcome, except at 4 hours after onset. For the initial 2 hours after onset, SBP had nonlinear U-shaped relationships with functional outcome, and patients with SBP of approximately 165 mm Hg were the least likely to have a poor outcome. Quadratic models exhibited a significantly better model fit. For 8-24 hours postonset, SBP exhibited linear relationships with functional outcome. For 48-72 hours postonset, SBP exhibited a J-shaped relationship with functional outcome, and the predicted probability of poor outcome was the lowest in patients with SBP of approximately 125 mm Hg. These relationships were relatively consistent across various sensitivity analyses. CONCLUSION This study revealed that the relationship between SBP and functional outcome may depend on elapsed time from stroke onset.
Collapse
Affiliation(s)
- Ji-Ah Shin
- From the Seoul National University College of Medicine (J.-A.S.); Department of Neurology, Cerebrovascular Center (K.-J.L., J.K., B.J.K., M.-K.H., J.Y.K., M.S.J., M.H.Y., H.-J.B.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Biostatistics (J.L.), Korea University, Seoul; and Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Keon-Joo Lee
- From the Seoul National University College of Medicine (J.-A.S.); Department of Neurology, Cerebrovascular Center (K.-J.L., J.K., B.J.K., M.-K.H., J.Y.K., M.S.J., M.H.Y., H.-J.B.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Biostatistics (J.L.), Korea University, Seoul; and Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ji Sung Lee
- From the Seoul National University College of Medicine (J.-A.S.); Department of Neurology, Cerebrovascular Center (K.-J.L., J.K., B.J.K., M.-K.H., J.Y.K., M.S.J., M.H.Y., H.-J.B.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Biostatistics (J.L.), Korea University, Seoul; and Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jihoon Kang
- From the Seoul National University College of Medicine (J.-A.S.); Department of Neurology, Cerebrovascular Center (K.-J.L., J.K., B.J.K., M.-K.H., J.Y.K., M.S.J., M.H.Y., H.-J.B.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Biostatistics (J.L.), Korea University, Seoul; and Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Beom Joon Kim
- From the Seoul National University College of Medicine (J.-A.S.); Department of Neurology, Cerebrovascular Center (K.-J.L., J.K., B.J.K., M.-K.H., J.Y.K., M.S.J., M.H.Y., H.-J.B.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Biostatistics (J.L.), Korea University, Seoul; and Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Moon-Ku Han
- From the Seoul National University College of Medicine (J.-A.S.); Department of Neurology, Cerebrovascular Center (K.-J.L., J.K., B.J.K., M.-K.H., J.Y.K., M.S.J., M.H.Y., H.-J.B.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Biostatistics (J.L.), Korea University, Seoul; and Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jun Yup Kim
- From the Seoul National University College of Medicine (J.-A.S.); Department of Neurology, Cerebrovascular Center (K.-J.L., J.K., B.J.K., M.-K.H., J.Y.K., M.S.J., M.H.Y., H.-J.B.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Biostatistics (J.L.), Korea University, Seoul; and Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Myung Suk Jang
- From the Seoul National University College of Medicine (J.-A.S.); Department of Neurology, Cerebrovascular Center (K.-J.L., J.K., B.J.K., M.-K.H., J.Y.K., M.S.J., M.H.Y., H.-J.B.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Biostatistics (J.L.), Korea University, Seoul; and Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mi Hwa Yang
- From the Seoul National University College of Medicine (J.-A.S.); Department of Neurology, Cerebrovascular Center (K.-J.L., J.K., B.J.K., M.-K.H., J.Y.K., M.S.J., M.H.Y., H.-J.B.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Biostatistics (J.L.), Korea University, Seoul; and Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Juneyoung Lee
- From the Seoul National University College of Medicine (J.-A.S.); Department of Neurology, Cerebrovascular Center (K.-J.L., J.K., B.J.K., M.-K.H., J.Y.K., M.S.J., M.H.Y., H.-J.B.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Biostatistics (J.L.), Korea University, Seoul; and Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Philip B Gorelick
- From the Seoul National University College of Medicine (J.-A.S.); Department of Neurology, Cerebrovascular Center (K.-J.L., J.K., B.J.K., M.-K.H., J.Y.K., M.S.J., M.H.Y., H.-J.B.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Biostatistics (J.L.), Korea University, Seoul; and Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Hee-Joon Bae
- From the Seoul National University College of Medicine (J.-A.S.); Department of Neurology, Cerebrovascular Center (K.-J.L., J.K., B.J.K., M.-K.H., J.Y.K., M.S.J., M.H.Y., H.-J.B.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam; Clinical Research Center (J.S.L.), Asan Medical Center, Seoul; Department of Biostatistics (J.L.), Korea University, Seoul; and Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL.
| |
Collapse
|
13
|
He L, Xu R, Wang J, Zhang L, Zhang L, Zhou F, Dong W. Capsular warning syndrome: clinical analysis and treatment. BMC Neurol 2019; 19:285. [PMID: 31722675 PMCID: PMC6854731 DOI: 10.1186/s12883-019-1522-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/05/2019] [Indexed: 11/30/2022] Open
Abstract
Background Capsular warning syndrome (CWS) is a rare clinical syndrome, which is defined as a recurrent transient lacunar syndrome. The mechanism and clinical management of CWS remain unclear. The aim of the study was to discuss the clinical characteristics of CWS and evaluate the different outcome between rt-PA and no rt-PA therapy. Methods The present multicenter retrospective study involved three medical centers, and the clinical data were collected from patients with CWS between January 2013 and December 2018. The clinical characteristics of CWS were analyzed. Patients were divided into two groups: rt-PA and no rt-PA groups. The therapeutic effects and prognosis of these two groups were analyzed. A good prognosis was defined as 3-month modified Rankin Scale (mRS) ≤ 2. Results Our study included 72 patients, 27 patients were assigned to rt-PA group, 45 in no rt-PA group. Hypertension and dyslipidemia were the most common risk factors. The mean number of episodes before irreversible neurological impairment or the symptoms completely disappeared was five times (range: 3–11 times). A total of 58 (80.55%) patients had acute infarction lesions on the diffusion weighted imaging (DWI). The most common infarct location was the internal capsule (41,70.69%), followed by the thalamus and pons. The difference in therapeutic effects between the rt-PA, single and double antiplatelet groups was not statistically significant (P > 0.05). A good prognosis was observed in 61 (84.72%) patients after 3 months, in which 23 (23/27, 85.19%) patients were from the rt-PA group and 38 (38/45,84.44%) patients were from the no rt-PA group (P > 0.05). After 3 months of follow-up, two patients had recurrent ischemic stroke. Conclusion The most effective treatment of CWS remains unclear. Intravenous thrombolysis is safe for CWS patients. Regardless of the high frequency of infarction in CWS patients, more than 80% patients had a favorable functional prognosis.
Collapse
Affiliation(s)
- Lanying He
- Department of Neurology, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China
| | - Ronghua Xu
- Department of Neurosurgery, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China.
| | - Jian Wang
- Department of Neurology, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China
| | - Lili Zhang
- Department of Neurology, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China
| | - Lijuan Zhang
- Department of Neurology, The Second Affiliated Hospital of Chengdu College, Nuclear Industry 416 Hospital, Chengdu, 610021, People's Republic of China
| | - Fangfang Zhou
- Department of Neurology, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China
| | - Weiwei Dong
- Department of Neurology, First Affiliated Hospital, Chongqing Medical University, Chongqing, China, 400030, People's Republic of China
| |
Collapse
|
14
|
Bang OY, Chung JW, Kim SK, Kim SJ, Lee MJ, Hwang J, Seo WK, Ha YS, Sung SM, Kim EG, Sohn SI, Han MK. Therapeutic-induced hypertension in patients with noncardioembolic acute stroke. Neurology 2019; 93:e1955-e1963. [PMID: 31645472 DOI: 10.1212/wnl.0000000000008520] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 06/06/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To evaluate the safety and efficacy of induced hypertension in patients with acute ischemic stroke. METHODS In this multicenter randomized clinical trial, patients with acute noncardioembolic ischemic stroke within 24 hours of onset who were ineligible for revascularization therapy and those with progressive stroke during hospitalization were randomly assigned (1:1) to the control and intervention groups. In the intervention group, phenylephrine was administered intravenously to increase systolic blood pressure (SBP) up to 200 mm Hg. The primary efficacy endpoint was early neurologic improvement (reduction in NIH Stroke Scale [NIHSS] score of ≥2 points during the first 7 days). The secondary efficacy endpoint was a modified Rankin Scale score of 0 to 2 at 90 days. Safety outcomes included symptomatic intracranial hemorrhage/edema, myocardial infarction, and death. RESULTS In the modified intention-to-treat analyses, 76 and 77 patients were included in the intervention and control groups, respectively. After adjustment for age and initial stroke severity, induced hypertension increased the occurrence of the primary (odds ratio 2.49, 95% confidence interval [CI] 1.25-4.96, p = 0.010) and secondary (odds ratio 2.97, 95% CI 1.32-6.68, p = 0.009) efficacy endpoints. Sixty-seven (88.2%) patients of the intervention group exhibited improvements in NIHSS scores of ≥2 points during induced hypertension (mean SBP 179·7 ± 19.1 mm Hg). Safety outcomes did not significantly differ between groups. CONCLUSION Among patients with noncardioembolic stroke who were ineligible for revascularization therapy and those with progressive stroke, phenylephrine-induced hypertension was safe and resulted in early neurologic improvement and long-term functional independence. CLINICALTRIALSGOV IDENTIFIER NCT01600235. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for patients with acute ischemic stroke, therapeutic-induced hypertension increases the probability of early neurologic improvement.
Collapse
Affiliation(s)
- Oh Young Bang
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Jong-Won Chung
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Soo-Kyoung Kim
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Suk Jae Kim
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Mi Ji Lee
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jaechun Hwang
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Woo-Keun Seo
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yeon Soo Ha
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Min Sung
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Eung-Gyu Kim
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung-Il Sohn
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Moon-Ku Han
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| |
Collapse
|
15
|
Maïer B, Fahed R, Khoury N, Guenego A, Labreuche J, Taylor G, Blacher J, Zuber M, Lapergue B, Blanc R, Piotin M, Mazighi M. Association of Blood Pressure During Thrombectomy for Acute Ischemic Stroke With Functional Outcome: A Systematic Review. Stroke 2019; 50:2805-2812. [PMID: 31462188 DOI: 10.1161/strokeaha.119.024915] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background and Purpose- Optimal blood pressure (BP) targets during mechanical thrombectomy (MT) for acute ischemic stroke (AIS) are unknown, and randomized controlled trials addressing this issue are lacking. We aimed to perform a systematic review of studies evaluating the influence of periprocedural BP on functional outcome after MT. Methods- Studies assessing periprocedural BP effect on functional outcome published after January 1st, 2012 were included in the systematic review. The PRISMA checklist and flow diagram were followed for the design and reporting of this work. Results- Nine studies were included, for a total of 1037 patients. The heterogeneity in findings with respect to BP monitoring and studied parameters precluded a meta-analysis. Mean arterial pressure was the most frequently reported parameter to describe BP variability during MT, and systolic BP was the main parameter used to define periprocedural BP targets. Five studies suggested an association between 3 types of BP drops as predictors of poor functional outcome at 3 months: >40% drop in mean arterial pressure compared with baseline (odds ratio=2.8; [1.09-7.19]; P=0.032), lowest mean arterial pressure before recanalization (odds ratio=1.28; [1.01-1.62] per 10 mm Hg drop below 100 mm Hg; P=0.04), and MAP drops (odds ratio=4.38; [1.53-12.6] for drops >10%). Four studies did not show an association between BP during MT and functional outcome, including 3 studies with strict periprocedural systolic BP targets (within a 140-180 mm Hg). Conclusions- BP drops during MT may be associated with a worse functional outcome. When strict systolic BP targets are achieved, no association between BP and functional outcome was also noted. Both conclusions require further evaluation in randomized studies.
Collapse
Affiliation(s)
- Benjamin Maïer
- From the Interventional Neuroradiology Department, Fondation Rothschild, Paris, France (B.M., R.F., R.B., M.P., M.M.)
| | - Robert Fahed
- From the Interventional Neuroradiology Department, Fondation Rothschild, Paris, France (B.M., R.F., R.B., M.P., M.M.)
| | - Naim Khoury
- HSHS Neuroscience Center, HSHS St John's Hospital, Springfield, Illinois (N.K.)
| | - Adrien Guenego
- Interventional Neuroradiology Department, Toulouse Hospital, France (A.G.)
| | - Julien Labreuche
- Univ. Lille, CHU Lille, EA 2694-Santé publique: épidémiologie et qualité des soins, F-59000 Lille, France (J.L.)
| | - Guillaume Taylor
- Intensive Care Department, Fondation Rothschild, Paris, France (G.T.)
| | - Jacques Blacher
- Paris-Descartes University, AP-HP, Diagnosis and Therapeutic Center, Hôtel Dieu, Paris, France (J.B.)
| | - Mathieu Zuber
- Neurology Department, Saint-Joseph Hospital, Paris, France (M.Z.)
| | - Bertrand Lapergue
- Stroke Center, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France (B.L.)
| | - Raphaël Blanc
- From the Interventional Neuroradiology Department, Fondation Rothschild, Paris, France (B.M., R.F., R.B., M.P., M.M.).,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France (R.B., M.P., M.M.)
| | - Michel Piotin
- From the Interventional Neuroradiology Department, Fondation Rothschild, Paris, France (B.M., R.F., R.B., M.P., M.M.).,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France (R.B., M.P., M.M.)
| | - Mikael Mazighi
- From the Interventional Neuroradiology Department, Fondation Rothschild, Paris, France (B.M., R.F., R.B., M.P., M.M.).,Laboratory of Vascular Translational Science, INSERM U1148, Paris, France (R.B., M.P., M.M.).,Paris Diderot and Paris University, France (M.M.).,DHU NeuroVasc, Paris, France (M.M.)
| |
Collapse
|
16
|
Kamo H, Miyamoto N, Otani H, Kurita N, Nakajima S, Ueno Y, Yamashiro K, Tanaka R, Hattori N. The Importance of Combined Antithrombotic Treatment for Capsular Warning Syndrome. J Stroke Cerebrovasc Dis 2018; 27:3095-3099. [PMID: 30077604 DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/22/2018] [Accepted: 06/30/2018] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Capsular warning syndrome (CWS) is characterized by recurrent conventional episodes of motor and/or sensory deficits without cortical symptoms. The purpose of this case series study was to evaluate the safety and appropriate treatment for CWS to prevent the development of complete stroke. METHODS We reviewed our hospital records and previous reports to find patients with neurologically fluctuating profiles, and excluded those with unknown details of initial treatment/final treatment of antiplatelet therapy or radiological findings. RESULTS We retrieved two cases of CWS from our hospital, which presented motor and/or sensory symptoms followed by complete resolution without complete ischemia. The recurring episodes in both were unable to be stabilized by single antiplatelet therapy but were successfully managed using two or more antiplatelet drugs. In 11 previously reported cases of CWS, the recurring episode was frequency stabilized with plural antiplatelet therapy. CONCLUSION Multiplicate antiplatelet therapy is important for treatment of CWS, and caution is needed regarding hemorrhagic complications.
Collapse
Affiliation(s)
- Hikaru Kamo
- Department of Neurology, Juntendo University Hospital, Bunkyo, Tokyo, Japan
| | - Nobukazu Miyamoto
- Department of Neurology, Juntendo University Hospital, Bunkyo, Tokyo, Japan.
| | - Hana Otani
- Department of Neurology, Juntendo University Hospital, Bunkyo, Tokyo, Japan
| | - Naohide Kurita
- Department of Neurology, Juntendo University Hospital, Bunkyo, Tokyo, Japan
| | - Sho Nakajima
- Department of Neurology, Juntendo University Hospital, Bunkyo, Tokyo, Japan
| | - Yuji Ueno
- Department of Neurology, Juntendo University Hospital, Bunkyo, Tokyo, Japan
| | - Kazuo Yamashiro
- Department of Neurology, Juntendo University Hospital, Bunkyo, Tokyo, Japan
| | - Ryota Tanaka
- Department of Neurology, Juntendo University Hospital, Bunkyo, Tokyo, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University Hospital, Bunkyo, Tokyo, Japan
| |
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW Severe ischemic or hemorrhagic stroke is a devastating cerebrovascular disease often demanding critical care. Optimal management of blood pressure (BP) in the acute phase is controversial. The purpose of this review is to display insights from recent studies on BP control in both conditions. RECENT FINDINGS BP control in acute ischemic stroke has recently been investigated with regard to endovascular recanalizing therapies. Decreases from baseline BP and hypotension during the intervention have been found detrimental. Overall, a periinterventional SBP between 140 and 160 mmHg appeared favorable in several studies. In acute hemorrhagic stroke, the recently completed Antihypertensive Treatment of Acute Cerebral Hemorrhage II trial confirmed feasibility of early aggressive BP reduction but failed to demonstrate a reduction in hematoma growth or a clinical benefit. SUMMARY Recent findings do not support benefits of intensive BP lowering in both acute hemorrhagic and ischemic stroke, with the possible exception of the postinterventional phase after successful endovascular recanalization of large-vessel occlusions. Although optimal ranges of BP values remain to be defined, high BP should still be treated according to guidelines. As stroke patients requiring critical care are underrepresented in most studies on BP, caution in transferring these findings is warranted and prospective research in that patient population needed.
Collapse
|
18
|
Ginsberg MD. The cerebral collateral circulation: Relevance to pathophysiology and treatment of stroke. Neuropharmacology 2017; 134:280-292. [PMID: 28801174 DOI: 10.1016/j.neuropharm.2017.08.003] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/28/2017] [Accepted: 08/06/2017] [Indexed: 12/29/2022]
Abstract
The brain's collateral circulation consists of arterial anastomotic channels capable of providing nutrient perfusion to brain regions whose normal sources of flow have become compromised, as occurs in acute ischemic stroke. Modern CT-based neuroimaging is capable of providing detailed information as to collateral extent and sufficiency and is complemented by magnetic resonance-based methods. In the present era of standard-of-care IV thrombolysis for acute ischemic stroke, and following the recent therapeutic successes of randomized clinical trials of acute endovascular intervention, the sufficiency of the collateral circulation has been convincingly established as a key factor influencing the likelihood of successful reperfusion and favorable clinical outcome. This article reviews the features of the brain's collateral circulation; methods for its evaluation in the acute clinical setting; the relevance of collateral circulation to prognosis in acute ischemic stroke; the specific insights into the collateral circulation learned from recent trials of endovascular intervention; and the major influence of genetic factors. Finally, we emphasize the need to develop therapeutic approaches to augment collateral perfusion as an adjunctive strategy to be employed along with, or prior to, thrombolysis and endovascular interventions, and we highlight the possible potential of inhaled nitric oxide, albumin, and other approaches. This article is part of the Special Issue entitled 'Cerebral Ischemia'.
Collapse
Affiliation(s)
- Myron D Ginsberg
- Department of Neurology, University of Miami Miller School of Medicine, Clinical Research Center, Room 1331, 1120 NW 14th Street, Miami, FL 33136, USA.
| |
Collapse
|
19
|
Regenhardt RW, Das AS, Stapleton CJ, Chandra RV, Rabinov JD, Patel AB, Hirsch JA, Leslie-Mazwi TM. Blood Pressure and Penumbral Sustenance in Stroke from Large Vessel Occlusion. Front Neurol 2017; 8:317. [PMID: 28717354 PMCID: PMC5494536 DOI: 10.3389/fneur.2017.00317] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/16/2017] [Indexed: 12/11/2022] Open
Abstract
The global burden of stroke remains high, and of the various subtypes of stroke, large vessel occlusions (LVOs) account for the largest proportion of stroke-related death and disability. Several randomized controlled trials in 2015 changed the landscape of stroke care worldwide, with endovascular thrombectomy (ET) now the standard of care for all eligible patients. With the proven success of this therapy, there is a renewed focus on penumbral sustenance. In this review, we describe the ischemic penumbra, collateral circulation, autoregulation, and imaging assessment of the penumbra. Blood pressure goals in acute stroke remain controversial, and we review the current data and suggest an approach for induced hypertension in the acute treatment of patients with LVOs. Finally, in addition to reperfusion and enhanced perfusion, efforts focused on developing therapeutic targets that afford neuroprotection and augment neural repair will gain increasing importance. ET has revolutionized stroke care, and future emphasis will be placed on promoting penumbral sustenance, which will increase patient eligibility for this highly effective therapy and reduce overall stroke-related death and disability.
Collapse
Affiliation(s)
- Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Alvin S. Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Christopher J. Stapleton
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ronil V. Chandra
- Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, VIC, Australia
| | - James D. Rabinov
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aman B. Patel
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Joshua A. Hirsch
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Thabele M. Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
20
|
The role of phenylephrine in patients with small deep subcortical infarct and progressive weakness. J Neurol Sci 2017; 377:107-111. [DOI: 10.1016/j.jns.2017.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 03/10/2017] [Accepted: 04/06/2017] [Indexed: 11/17/2022]
|
21
|
Olavarría VV, Arima H, Anderson CS, Brunser A, Muñoz-Venturelli P, Billot L, Lavados PM. Statistical analysis plan of the head position in acute ischemic stroke trial pilot (HEADPOST pilot). Int J Stroke 2016; 12:211-215. [PMID: 27742914 DOI: 10.1177/1747493016674955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The HEADPOST Pilot is a proof-of-concept, open, prospective, multicenter, international, cluster randomized, phase IIb controlled trial, with masked outcome assessment. The trial will test if lying flat head position initiated in patients within 12 h of onset of acute ischemic stroke involving the anterior circulation increases cerebral blood flow in the middle cerebral arteries, as measured by transcranial Doppler. The study will also assess the safety and feasibility of patients lying flat for ≥24 h. The trial was conducted in centers in three countries, with ability to perform early transcranial Doppler. A feature of this trial was that patients were randomized to a certain position according to the month of admission to hospital. Objective To outline in detail the predetermined statistical analysis plan for HEADPOST Pilot study. Methods All data collected by participating researchers will be reviewed and formally assessed. Information pertaining to the baseline characteristics of patients, their process of care, and the delivery of treatments will be classified, and for each item, appropriate descriptive statistical analyses are planned with comparisons made between randomized groups. For the outcomes, statistical comparisons to be made between groups are planned and described. Results This statistical analysis plan was developed for the analysis of the results of the HEADPOST Pilot study to be transparent, available, verifiable, and predetermined before data lock. Conclusions We have developed a statistical analysis plan for the HEADPOST Pilot study which is to be followed to avoid analysis bias arising from prior knowledge of the study findings. Trial registration The study is registered under HEADPOST-Pilot, ClinicalTrials.gov Identifier NCT01706094.
Collapse
Affiliation(s)
- Verónica V Olavarría
- 1 Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Medicina Interna, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Hisatomi Arima
- 2 Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.,3 The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Craig S Anderson
- 3 The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,4 Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Alejandro Brunser
- 1 Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Medicina Interna, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Paula Muñoz-Venturelli
- 1 Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Medicina Interna, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,3 The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Laurent Billot
- 3 The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Pablo M Lavados
- 1 Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Medicina Interna, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile.,5 Departamento de Ciencias Neurológicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | | |
Collapse
|
22
|
Ginsberg MD. Expanding the concept of neuroprotection for acute ischemic stroke: The pivotal roles of reperfusion and the collateral circulation. Prog Neurobiol 2016; 145-146:46-77. [PMID: 27637159 DOI: 10.1016/j.pneurobio.2016.09.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/22/2016] [Accepted: 09/10/2016] [Indexed: 12/27/2022]
Abstract
This review surveys the efforts taken to achieve clinically efficacious protection of the ischemic brain and underscores the necessity of expanding our purview to include the essential role of cerebral perfusion and the collateral circulation. We consider the development of quantitative strategies to measure cerebral perfusion at the regional and local levels and the application of these methods to elucidate flow-related thresholds of ischemic viability and to characterize the ischemic penumbra. We stress that the modern concept of neuroprotection must consider perfusion, the necessary substrate upon which ischemic brain survival depends. We survey the major mechanistic approaches to neuroprotection and review clinical neuroprotection trials, focusing on those phase 3 multicenter clinical trials for acute ischemic stroke that have been completed or terminated. We review the evolution of thrombolytic therapies; consider the lessons learned from the initial, negative multicenter trials of endovascular therapy; and emphasize the highly successful positive trials that have finally established a clinical role for endovascular clot removal. As these studies point to the brain's collateral circulation as key to successful reperfusion, we next review the anatomy and pathophysiology of collateral perfusion as it relates to ischemic infarction, as well as the molecular and genetic influences on collateral development. We discuss the current MR and CT-based diagnostic methods for assessing the collateral circulation and the prognostic significance of collaterals in ischemic stroke, and we consider past and possible future therapeutic directions.
Collapse
Affiliation(s)
- Myron D Ginsberg
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, United States.
| |
Collapse
|
23
|
Appleton JP, Sprigg N, Bath PM. Blood pressure management in acute stroke. Stroke Vasc Neurol 2016; 1:72-82. [PMID: 28959467 PMCID: PMC5435190 DOI: 10.1136/svn-2016-000020] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/20/2016] [Accepted: 05/21/2016] [Indexed: 01/05/2023] Open
Abstract
Blood pressure (BP) is elevated in 75% or more of patients with acute stroke and is associated with poor outcomes. Whether to modulate BP in acute stroke has long been debated. With the loss of normal cerebral autoregulation, theoretical concerns are twofold: high BP can lead to cerebral oedema, haematoma expansion or haemorrhagic transformation; and low BP can lead to increased cerebral infarction or perihaematomal ischaemia. Published evidence from multiple large, high-quality, randomised trials is increasing our understanding of this challenging area, such that BP lowering is recommended in acute intracerebral haemorrhage and is safe in ischaemic stroke. Here we review the evidence for BP modulation in acute stroke, discuss the issues raised and look to on-going and future research to identify patient subgroups who are most likely to benefit.
Collapse
Affiliation(s)
- Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| |
Collapse
|
24
|
Safety of peripheral administration of phenylephrine in a neurologic intensive care unit: A pilot study. J Crit Care 2016; 34:107-10. [PMID: 27288620 DOI: 10.1016/j.jcrc.2016.04.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 01/28/2016] [Accepted: 04/04/2016] [Indexed: 11/21/2022]
Abstract
Integral to the management of the neurocritically injured patient are the prevention and treatment of hypotension, maintenance of cerebral perfusion pressure, and occasionally blood pressure augmentation. When adequate volume resuscitation fails to meet perfusion needs, vasopressors are often used to restore end-organ perfusion. This has historically necessitated central venous access given well-documented incidence of extravasation injuries associated with peripheral administration of vasopressors. In this pilot study, we report our 6-month experience with peripheral administration of low-concentration phenylephrine (40 μg/mL) in our neurocritical care unit. We were able to administer peripheral phenylephrine, up to a dose of 2 μg/(kg min), for an average of 14.29hours (1-54.3) in 20 patients with only 1 possible minor complication and no major complications. This was achieved by adding additional safety measures in our computerized physician order entry system and additional nurse-driven safety protocols. Thus, with careful monitoring and safety precautions, peripheral administration of phenylephrine at an optimized concentration appears to have an acceptable safety profile for use in the neurocritical care unit up to a mean infusion time of 14hours.
Collapse
|
25
|
Beard DJ, Murtha LA, McLeod DD, Spratt NJ. Intracranial Pressure and Collateral Blood Flow. Stroke 2016; 47:1695-700. [PMID: 26786117 DOI: 10.1161/strokeaha.115.011147] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/30/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Daniel J Beard
- From the School of Biomedical Sciences and Pharmacy, and Hunter Medical Research Institute, University of Newcastle, Callaghan, Newcastle, New South Wales, Australia (D.J.B., L.A.M., D.D.M., N.J.S.); and Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, New Lambton Heights, Newcastle, New South Wales, Australia (N.J.S.)
| | - Lucy A Murtha
- From the School of Biomedical Sciences and Pharmacy, and Hunter Medical Research Institute, University of Newcastle, Callaghan, Newcastle, New South Wales, Australia (D.J.B., L.A.M., D.D.M., N.J.S.); and Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, New Lambton Heights, Newcastle, New South Wales, Australia (N.J.S.)
| | - Damian D McLeod
- From the School of Biomedical Sciences and Pharmacy, and Hunter Medical Research Institute, University of Newcastle, Callaghan, Newcastle, New South Wales, Australia (D.J.B., L.A.M., D.D.M., N.J.S.); and Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, New Lambton Heights, Newcastle, New South Wales, Australia (N.J.S.)
| | - Neil J Spratt
- From the School of Biomedical Sciences and Pharmacy, and Hunter Medical Research Institute, University of Newcastle, Callaghan, Newcastle, New South Wales, Australia (D.J.B., L.A.M., D.D.M., N.J.S.); and Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, New Lambton Heights, Newcastle, New South Wales, Australia (N.J.S.).
| |
Collapse
|
26
|
Burnsed BC, Arthur AS. Use of General Anesthesia for Emergent Large Vessel Occlusion Patients. World Neurosurg 2015; 84:1498-500. [PMID: 26481338 DOI: 10.1016/j.wneu.2015.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Brandon C Burnsed
- University of Mississippi Medical Center, Department of Neurological Surgery, Jackson, Mississippi, USA
| | - Adam S Arthur
- Semmes-Murphy Neurological Clinic, Memphis, Tennessee, USA
| |
Collapse
|
27
|
Mundiyanapurath S, Schönenberger S, Rosales ML, Carrilho Romeiro AM, Möhlenbruch M, Bendszus M, Hacke W, Bösel J. Circulatory and Respiratory Parameters during Acute Endovascular Stroke Therapy in Conscious Sedation or General Anesthesia. J Stroke Cerebrovasc Dis 2015; 24:1244-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.01.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/09/2015] [Accepted: 01/22/2015] [Indexed: 11/29/2022] Open
|
28
|
Beard DJ, McLeod DD, Logan CL, Murtha LA, Imtiaz MS, van Helden DF, Spratt NJ. Intracranial pressure elevation reduces flow through collateral vessels and the penetrating arterioles they supply. A possible explanation for 'collateral failure' and infarct expansion after ischemic stroke. J Cereb Blood Flow Metab 2015; 35:861-72. [PMID: 25669909 PMCID: PMC4420869 DOI: 10.1038/jcbfm.2015.2] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 12/22/2014] [Accepted: 12/27/2014] [Indexed: 01/09/2023]
Abstract
Recent human imaging studies indicate that reduced blood flow through pial collateral vessels ('collateral failure') is associated with late infarct expansion despite stable arterial occlusion. The cause for 'collateral failure' is unknown. We recently showed that intracranial pressure (ICP) rises dramatically but transiently 24 hours after even minor experimental stroke. We hypothesized that ICP elevation would reduce collateral blood flow. First, we investigated the regulation of flow through collateral vessels and the penetrating arterioles arising from them during stroke reperfusion. Wistar rats were subjected to intraluminal middle cerebral artery (MCA) occlusion (MCAo). Individual pial collateral and associated penetrating arteriole blood flow was quantified using fluorescent microspheres. Baseline bidirectional flow changed to MCA-directed flow and increased by >450% immediately after MCAo. Collateral diameter changed minimally. Second, we determined the effect of ICP elevation on collateral and watershed penetrating arteriole flow. Intracranial pressure was artificially raised in stepwise increments during MCAo. The ICP increase was strongly correlated with collateral and penetrating arteriole flow reductions. Changes in collateral flow post-stroke appear to be primarily driven by the pressure drop across the collateral vessel, not vessel diameter. The ICP elevation reduces cerebral perfusion pressure and collateral flow, and is the possible explanation for 'collateral failure' in stroke-in-progression.
Collapse
Affiliation(s)
- Daniel J Beard
- School of Biomedical Sciences and Pharmacy, University of Newcastle and Hunter Medical Research Institute, Callaghan, New South Wales, Australia
| | - Damian D McLeod
- School of Biomedical Sciences and Pharmacy, University of Newcastle and Hunter Medical Research Institute, Callaghan, New South Wales, Australia
| | - Caitlin L Logan
- School of Biomedical Sciences and Pharmacy, University of Newcastle and Hunter Medical Research Institute, Callaghan, New South Wales, Australia
| | - Lucy A Murtha
- School of Biomedical Sciences and Pharmacy, University of Newcastle and Hunter Medical Research Institute, Callaghan, New South Wales, Australia
| | - Mohammad S Imtiaz
- 1] School of Biomedical Sciences and Pharmacy, University of Newcastle and Hunter Medical Research Institute, Callaghan, New South Wales, Australia [2] Computational Cardiology Laboratory, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Dirk F van Helden
- School of Biomedical Sciences and Pharmacy, University of Newcastle and Hunter Medical Research Institute, Callaghan, New South Wales, Australia
| | - Neil J Spratt
- 1] School of Biomedical Sciences and Pharmacy, University of Newcastle and Hunter Medical Research Institute, Callaghan, New South Wales, Australia [2] Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia
| |
Collapse
|
29
|
Murtha LA, McLeod DD, Pepperall D, McCann SK, Beard DJ, Tomkins AJ, Holmes WM, McCabe C, Macrae IM, Spratt NJ. Intracranial pressure elevation after ischemic stroke in rats: cerebral edema is not the only cause, and short-duration mild hypothermia is a highly effective preventive therapy. J Cereb Blood Flow Metab 2015; 35:592-600. [PMID: 25515213 PMCID: PMC4420875 DOI: 10.1038/jcbfm.2014.230] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/19/2014] [Accepted: 11/24/2014] [Indexed: 01/25/2023]
Abstract
In both the human and animal literature, it has largely been assumed that edema is the primary cause of intracranial pressure (ICP) elevation after stroke and that more edema equates to higher ICP. We recently demonstrated a dramatic ICP elevation 24 hours after small ischemic strokes in rats, with minimal edema. This ICP elevation was completely prevented by short-duration moderate hypothermia soon after stroke. Here, our aims were to determine the importance of edema in ICP elevation after stroke and whether mild hypothermia could prevent the ICP rise. Experimental stroke was performed in rats. ICP was monitored and short-duration mild (35 °C) or moderate (32.5 °C) hypothermia, or normothermia (37 °C) was induced after stroke onset. Edema was measured in three studies, using wet-dry weight calculations, T2-weighted magnetic resonance imaging, or histology. ICP increased 24 hours after stroke onset in all normothermic animals. Short-duration mild or moderate hypothermia prevented this rise. No correlation was seen between ΔICP and edema or infarct volumes. Calculated rates of edema growth were orders of magnitude less than normal cerebrospinal fluid production rates. These data challenge current concepts and suggest that factors other than cerebral edema are the primary cause of the ICP elevation 24 hours after stroke onset.
Collapse
Affiliation(s)
- Lucy A Murtha
- 1] University of Newcastle and Hunter Medical Research Institute, New Lambton, New South Wales, Australia [2] Glasgow Experimental MRI Centre, Institute of Neuroscience and Psychology, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Damian D McLeod
- University of Newcastle and Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Debbie Pepperall
- University of Newcastle and Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Sarah K McCann
- University of Newcastle and Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Daniel J Beard
- University of Newcastle and Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Amelia J Tomkins
- University of Newcastle and Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - William M Holmes
- Glasgow Experimental MRI Centre, Institute of Neuroscience and Psychology, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Christopher McCabe
- Glasgow Experimental MRI Centre, Institute of Neuroscience and Psychology, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - I Mhairi Macrae
- Glasgow Experimental MRI Centre, Institute of Neuroscience and Psychology, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Neil J Spratt
- University of Newcastle and Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| |
Collapse
|
30
|
Nishijima Y, Akamatsu Y, Weinstein PR, Liu J. Collaterals: Implications in cerebral ischemic diseases and therapeutic interventions. Brain Res 2015; 1623:18-29. [PMID: 25770816 DOI: 10.1016/j.brainres.2015.03.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 02/27/2015] [Accepted: 03/03/2015] [Indexed: 02/09/2023]
Abstract
Despite the tremendous progress made in the treatment of cerebrovascular occlusive diseases, many patients suffering from ischemic brain injury still experience dismal outcomes. Although rehabilitation contributes to post-stroke functional recovery, there is no doubt that interventions that promote the restoration of blood supply are proven to minimize ischemic injury and improve recovery. In response to the acutely decreased blood perfusion during arterial occlusion, arteriogenesis, the compensation of blood flow through the collateral circulation during arterial obstructive diseases can act not only in a timely fashion but also much more efficiently compared to angiogenesis, the sprouting of new capillaries, and a mechanism occurring in a delayed fashion while increases the total resistance of the vascular bed of the affected territory. Interestingly, despite the vast differences between the two vascular remodeling mechanisms, some crucial growth factors and cytokines involved in angiogenesis are also required for arteriogenesis. Understanding the mechanisms underlying vascular remodeling after ischemic brain injury is a critical step towards the development of effective therapies for ischemic stroke. The present article will discuss our current views in vascular remodeling acutely after brain ischemia, namely arteriogenesis, and some relevant clinical therapies available on the horizon in augmenting collateral flow that hold promise in treating ischemic brain injury. This article is part of a Special Issue entitled SI: Cell Interactions In Stroke.
Collapse
Affiliation(s)
- Yasuo Nishijima
- Department of Neurological Surgery, UCSF, San Francisco, CA 94121, USA; SFVAMC, San Francisco, CA 94121, USA; Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Yosuke Akamatsu
- Department of Neurological Surgery, UCSF, San Francisco, CA 94121, USA; SFVAMC, San Francisco, CA 94121, USA; Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Phillip R Weinstein
- Department of Neurological Surgery, UCSF, San Francisco, CA 94121, USA; SFVAMC, San Francisco, CA 94121, USA
| | - Jialing Liu
- Department of Neurological Surgery, UCSF, San Francisco, CA 94121, USA; SFVAMC, San Francisco, CA 94121, USA.
| |
Collapse
|
31
|
Abstract
OPINION STATEMENT Recent years have seen the development of novel neuroimaging techniques whose roles in the management of acute stroke are sometimes confusing and controversial. This may be attributable in part to a focus on establishing simplified algorithms and terminology that omit consideration of the basic pathophysiology of cerebral ischemia and, consequently, of the full potential for optimizing patients' care based upon their individual imaging findings. This review begins by discussing cerebral hemodynamic physiology and of the effects of hemodynamic disturbances upon the brain. Particular attention will be paid to the hemodynamic measurements and markers of tissue injury that are provided by common clinical imaging techniques, with the goal of enabling greater confidence and flexibility in understanding the potential uses of these techniques in various clinical roles, which will be discussed in the remainder of the review.
Collapse
Affiliation(s)
- William A Copen
- Massachusetts General Hospital, Division of Neuroradiology, GRB-273A, 55 Fruit Street, Boston, MA, 02114, USA,
| |
Collapse
|
32
|
Nicks B, Henley J, Mfinanga J, Manthey D. Neurologic emergencies in resource-limited settings: A review of stroke care considerations. Afr J Emerg Med 2015. [DOI: 10.1016/j.afjem.2014.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
|
33
|
Yadollahikhales G, Borhani-Haghighi A, Torabi-Nami M, Edgell R, Cruz-Flores S. Flow Augmentation in Acute Ischemic Stroke. Clin Appl Thromb Hemost 2014; 22:42-51. [PMID: 25475112 DOI: 10.1177/1076029614561320] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
There is an urgent need for additional therapeutic options for acute ischemic stroke considering the major pitfalls of the options available. Herein, we briefly review the role of cerebral blood flow, collaterals, vasoreactivity, and reperfusion injury in acute ischemic stroke. Then, we reviewed pharmacological and interventional measures such as volume expansion and induced hypertension, intra-aortic balloon counterpulsation, partial aortic occlusion, extracranial-intracranial carotid bypass surgery, sphenopalatine ganglion stimulation, and transcranial laser therapy with regard to their effects on flow augmentation and neuroprotection.
Collapse
Affiliation(s)
- Golnaz Yadollahikhales
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Afshin Borhani-Haghighi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, Iran Neurology Department, Namazi hospital, Shiraz, Fars, Iran
| | - Mohammad Torabi-Nami
- Department of Neuroscience, School of Advanced Medical Science and Technologies, Shiraz University of Medical sciences, Shiraz, Fars, Iran
| | - Randall Edgell
- Departments of Neurology and Psychiatry, Saint Louis University, Saint Louis, MO, USA
| | | |
Collapse
|
34
|
Effects of early blood pressure lowering on early and long-term outcomes after acute stroke: an updated meta-analysis. PLoS One 2014; 9:e97917. [PMID: 24853087 PMCID: PMC4031127 DOI: 10.1371/journal.pone.0097917] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 04/26/2014] [Indexed: 11/26/2022] Open
Abstract
Background Hypertension is common after acute stroke onset. Previous studies showed controversial effects of early blood pressure (BP) lowering on stroke outcomes. The aim of this study is to assess the effects of early BP lowering on early and long-term outcomes after acute stroke. Methods A meta-analysis was conducted with prospective randomized controlled trials assessing the effects of early BP lowering on early and long-term outcomes after acute stroke compared with placebo. Literature searching was performed in the databases from inception to December 2013. New evidence from recent trials were included. Outcomes were analyzed as early (within 30 days) and long-term (from 3 to 12 months) endpoints using summary estimates of relative risks (RR) and their 95% confidence intervals (CI) with the fixed-effect model or random-effect model. Results Seventeen trials providing data from 13236 patients were included. Pooled results showed that early BP lowering after acute stroke onset was associated with more death within 30 days compared with placebo (RR: 1.34 and 95% CI: 1.02, 1.74, p = 0.03). However the results showed that early BP lowering had no evident effect on early neurological deterioration, early death within 7 days, long-term death, early and long-term dependency, early and long-term combination of death or dependency, long-term stroke recurrence, long-term myocardial infarction and long-term CVE. Conclusions The new results lend no support to early BP lowering after acute stroke. Early BP lowering may increase death within 30 days after acute stroke.
Collapse
|
35
|
Goodfellow JA, Dawson J, Quinn TJ. Management of blood pressure in acute stroke. Expert Rev Neurother 2014; 13:911-23. [DOI: 10.1586/14737175.2013.814964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
36
|
Tassi R, Cerase A, Acampa M, D’Andrea P, Guideri F, Lo Giudice G, Marotta G, Bracco S, Martini G. Stroke warning syndrome: 18 new cases. J Neurol Sci 2013; 331:168-71. [DOI: 10.1016/j.jns.2013.05.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 05/17/2013] [Accepted: 05/20/2013] [Indexed: 10/26/2022]
|
37
|
Cogez J, Bonnet AL, Touzé E. Pression artérielle: quel objectif à l’occasion d’un accident vasculaire cérébral aigu ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0649-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
38
|
|
39
|
Burns JD, Green DM, Metivier K, DeFusco C. Intensive Care Management of Acute Ischemic Stroke. Emerg Med Clin North Am 2012; 30:713-44. [DOI: 10.1016/j.emc.2012.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
40
|
Pugin D, Woimant F. [Stroke care in the ICU: general supportive treatment. Experts' recommendations]. Rev Neurol (Paris) 2012; 168:490-500. [PMID: 22633150 DOI: 10.1016/j.neurol.2011.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 07/11/2011] [Accepted: 10/27/2011] [Indexed: 01/04/2023]
Abstract
The French Society of Intensive Care (SRLF) requested medical experts to publish recommendations on the management of stroke in the ICU for adult and pediatric patients. The following article describes the underlying evidence used by the experts to elaborate recommendations for general supportive treatment. Such treatment is fundamental for victims of acute stroke to avoid neurological worsening. Oxygen delivery in a normoxic patient is useless. However, if saturation is below 92 %, oxygen supplementation is needed. Hyper- and hypoglycemia worsen the neurological prognosis. As no glycemic target is known, administration of insulin is required for glucose levels higher that 10 mmol/l. Body temperature above 37.5° is associated with poorer outcome. In the acute phase of stroke, high blood pressure should not be lowered except in life-threatening situations, and if so the lowering should be done cautiously. The current consensus is to lower blood pressure if the systolic pressure is above 220 mmHg or if the diastolic pressure is above 120 mmHg for ischemic stroke. For hemorrhagic stroke and after thrombolysis, treatment is needed if systolic pressure rises above 180 mmHg and if diastolic pressure is above 105 mmHg. Small doses of heparin decrease the risk of deep venous thrombosis and pulmonary embolism without increasing cerebral bleeding. There is no consensus on the treatment of epileptic crises after stroke and no dedicated treatment. Further studies are needed to define adequate blood pressure and glycemic target values in order to limit secondary worsening after an acute stroke as well as the appropriate modalities for the treatment of epilepsy.
Collapse
Affiliation(s)
- D Pugin
- Service des soins intensifs adultes, hôpitaux universitaires de Genève, 4 rue Gabrielle-Perret-Gentil, Geneva, Switzerland.
| | | |
Collapse
|
41
|
Del Bene A, Palumbo V, Lamassa M, Saia V, Piccardi B, Inzitari D. Progressive lacunar stroke: review of mechanisms, prognostic features, and putative treatments. Int J Stroke 2012; 7:321-9. [PMID: 22463492 DOI: 10.1111/j.1747-4949.2012.00789.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Lacunar stroke is generally considered to have a fair outcome. However 20-30% of patients with lacunar stroke worsen neurologically in hours or days after onset, reaching eventually an unexpectedly severe disability status. In the field of acute stroke, progressive lacunar stroke remains an important unresolved practice problem, because as yet no treatment does exist proven to prevent or halt progression. Pathophysiology of progression is yet incompletely understood. Hemodynamic factors, extension of thrombosis, excitotoxicity, and inflammation, have been proposed as possible mechanisms of progression. A few clinical studies also aimed at establishing presentation features that may help identifying patients at risk of deterioration. In this paper, we review hypothesized mechanisms of lacunar stroke progression and possible markers of early deterioration. Moreover, based on putative mechanisms and suggestions from reported evidence, we propose a few treatments that seem worthy to be tested by randomized clinical trials.
Collapse
Affiliation(s)
- Alessandra Del Bene
- Department of Neurological and Psychiatric Sciences, University of Florence, Viale Morgagni, 85, 50134 Florence, Italy.
| | | | | | | | | | | |
Collapse
|
42
|
Copen WA, Schaefer PW, Wu O. MR perfusion imaging in acute ischemic stroke. Neuroimaging Clin N Am 2012; 21:259-83, x. [PMID: 21640299 DOI: 10.1016/j.nic.2011.02.007] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Magnetic resonance (MR) perfusion imaging offers the potential for measuring brain perfusion in acute stroke patients, at a time when treatment decisions based on these measurements may affect outcomes dramatically. Rapid advancements in both acute stroke therapy and perfusion imaging techniques have resulted in continuing redefinition of the role that perfusion imaging should play in patient management. This review discusses the basic pathophysiology of acute stroke, the utility of different kinds of perfusion images, and research on the continually evolving role of MR perfusion imaging in acute stroke care.
Collapse
Affiliation(s)
- William A Copen
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, GRB-273A, 55 Fruit Street, Boston, MA 02114, USA.
| | | | | |
Collapse
|
43
|
Abstract
Abstract
Collapse
|
44
|
Abstract
The past 40 years have seen the evolution of acute ischemic stroke management from unproven therapies du jour, such as steroids, heparin for stroke in evolution, and hypervolemic-hemodilution, to more of a scientific basis for our decision-making process. This evolution is directly related to the advancements in imaging of stroke. It is also related to carefully designed, controlled clinical trials of potential therapies, which have led to the recognition of the benefits of thrombolytic therapy in the acute setting but have also caused confusion and frustration over the lack of benefit for potential neuroprotective agents that once seemed promising.
Collapse
Affiliation(s)
- Roger E Kelley
- Department of Neurology, Tulane University School of Medicine, 1430 Tulane Avenue 8065, New Orleans, LA 70112, USA.
| | | |
Collapse
|
45
|
Lim TS, Hong JM, Lee JS, Shin DH, Choi JY, Huh K. Induced-hypertension in progressing lacunar infarction. J Neurol Sci 2011; 308:72-6. [DOI: 10.1016/j.jns.2011.06.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 06/01/2011] [Accepted: 06/07/2011] [Indexed: 10/18/2022]
|
46
|
Abstract
The initial therapeutic approach to acute ischemic stroke consists of thrombolytic therapy and early initiation of supportive care, usually commenced prior to the determination of the underlying stroke etiology. Varying stroke mechanisms may call for specific, etiology-based treatment. The majority of strokes result from cardioembolism, large-vessel atherothromboembolism, and small-vessel occlusive disease. There are scant data to support the use of acute anticoagulation therapy over anti-platelet therapy in cardioembolic stroke and large-vessel atherosclerosis, although it may be reasonable in a certain subset of patients. However, augmentation of blood flow with early surgery, stenting, or induced hypertension, may play a role in patients with large artery stenosis. The less commonly identified stroke mechanisms may warrant special consideration in treatment. Controversy remains regarding the optimal anti-thrombotic treatment of arterial dissection. Reversible cerebral vasoconstriction syndrome may benefit from therapy with calcium channel blockers, high-dose steroids, or magnesium, although spontaneous recovery may occur. Inflammatory vasculopathies, such as isolated angiitis of the central nervous system and temporal arteritis, require prompt diagnosis as the mainstay of therapy is immunosuppression. Cerebral venous thrombosis is a rare cause of stroke, but one that needs early identification and treatment with anticoagulation. Rapid determination of stroke mechanism is essential for making these critical early treatment decisions.
Collapse
Affiliation(s)
- Neelofer Shafi
- Department of Neurology, Comprehensive Stroke Center, Comprehensive Stroke Center, Philadelphia, PA 19104 USA
| | - Scott E. Kasner
- Department of Neurology, Comprehensive Stroke Center, Comprehensive Stroke Center, Philadelphia, PA 19104 USA
| |
Collapse
|
47
|
Abstract
Stroke is a leading cause of mortality and long-term disability in the western world, accounting for 5% of the UK health budget. Consequently, it has been the major focus of recent healthcare advances. Physiological disturbances are common following an acute stroke, chiefly blood pressure (BP) abnormalities (high and 'relatively' low BP), which indicate adverse prognosis. While pilot studies suggest that early intervention to moderate both extremes of BP may improve outcomes, definitive evidence is awaited from ongoing research. Long-term elevated BP is the most prevalent risk factor for future stroke, with a comprehensive evidence base supporting BP reduction to reduce the risk of vascular events, including stroke. However, adherence to secondary preventive medications, including antihypertensive agents, remains poor. This article summarizes the current understanding of the role of BP in stroke, focusing on the management of BP for secondary prevention. Further emphasis is placed on identifying deficiencies in long-term management; barriers to improved application and potential interventions to overcome these barriers are summarized.
Collapse
Affiliation(s)
- Kate Lager
- Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP, UK
| | | |
Collapse
|
48
|
Alexandrov AWW. Hyperacute ischemic stroke management: reperfusion and evolving therapies. Crit Care Nurs Clin North Am 2010; 21:451-70. [PMID: 19951763 DOI: 10.1016/j.ccell.2009.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Management of acute ischemic stroke patients is organized around several priorities aimed at ensuring optimal patient outcomes, the first of which is reperfusion therapy, followed by determination of pathogenic mechanism by provision of a comprehensive workup to determine probable cause of the ischemic stroke or transient ischemic attack, for the purpose of providing appropriate prophylaxis for subsequent events. Provision of secondary prevention measures along with therapies that prevent complications associated with neurologic disability, and evaluation for the most appropriate level of rehabilitation services are the final priorities during acute hospitalization. This article provides an overview of reperfusion therapies and emerging hemodynamic treatments for hyperacute ischemic strokes. Gaps in the scientific evidence that are driving current blood flow augmentation research are identified.
Collapse
Affiliation(s)
- Anne W Wojner Alexandrov
- Acute & Critical Care, School of Nursing, Comprehensive Stroke Center, University of Alabama, Birmingham 35249, USA.
| |
Collapse
|
49
|
Tikhonoff V, Zhang H, Richart T, Staessen JA. Blood pressure as a prognostic factor after acute stroke. Lancet Neurol 2009; 8:938-48. [DOI: 10.1016/s1474-4422(09)70184-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
50
|
Speeding stroke recovery? A systematic review of amphetamine after stroke. J Neurol Sci 2009; 285:3-9. [PMID: 19457497 DOI: 10.1016/j.jns.2009.04.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Revised: 04/09/2009] [Accepted: 04/16/2009] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The use of drugs to enhance recovery ("rehabilitation pharmacology") has been assessed. Amphetamine can improve outcome in experimental models of stroke, and several small clinical trials have assessed its use in stroke. METHODS Electronic searches were performed to identify randomised controlled trials of amphetamine in stroke (ischaemic or haemorrhagic). Outcomes included functional outcome (assessed as combined death or disability/dependency), safety (death) and haemodynamic measures. Data were analysed as dichotomous or continuous outcomes, using odds ratios (OR), weighted or standardised mean difference, (WMD or SMD) using random-effects models with 95% confidence intervals (95% CI); statistical heterogeneity was assessed. RESULTS Eleven completed trials (n=329) were identified. Treatment with amphetamine was associated with non-significant trends to increased death (OR 2.78 (95% CI, 0.75-10.23), n=329, 11 trials) and improved motor scores (WMD 3.28 (95% CI -0.48-7.04) n=257, 9 trials) but had no effect on the combined outcome of death and dependency (OR 1.15 (95% CI 0.65-2.06, n=206, 5 trials). Amphetamine increased systolic blood pressure (WMD 9.3 mmHg, 95% CI 3.3-15.3, n=106, 3 trials) and heart rate (WMD 7.6 beats per minute (bpm), 95% CI 1.8-13.4, n=106, 3 trials). Despite variations in treatment regimes, outcomes and follow-up duration there was no evidence of significant heterogeneity or publication bias. CONCLUSION No evidence exists at present to support the use of amphetamine after stroke. Despite a trend to improved motor function, doubts remain over safety and there are significant haemodynamic effects, the consequences of which are unknown.
Collapse
|