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Shimura S, Saito R, Yagi T, Yoshioka H, Kinouchi H. Hemorrhagic cervical juxta-facet cyst presenting with Brown-Séquard syndrome: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 5:CASE23163. [PMID: 37249142 PMCID: PMC10550674 DOI: 10.3171/case23163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/01/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Intraspinal juxta-facet cysts of the spine are known to predominate at the lumbar level and is relatively rare at the cervical level. Most cervical spinal lesions are found incidentally, but they sometimes cause myelopathy or radiculopathy in a chronic course. OBSERVATIONS The authors present a rare case of hemorrhagic cervical juxta-facet cyst presenting with Brown-Séquard syndrome. An 86-year-old woman presented with acute-onset right hemiparesis following neck pain and was admitted to the local hospital. She was started on antithrombotic therapy with a suspected diagnosis of cerebral infarction, but quadriplegia progressed 2 days later. Cervical magnetic resonance imaging revealed an intraspinal mass at the C4-5 level and she was referred to the authors' hospital. Her neurological findings on admission revealed right Brown-Séquard syndrome. In emergency surgery, the mass was resected with a posterior approach. Pathological findings showed hemosiderin deposition and fibroblast proliferation, consistent with a juxta-facet cyst with intracystic hemorrhage. The patient recovered well and returned to an independent daily life. LESSONS Rarely, juxta-facet cyst of the cervical spine can cause acute Brown-Séquard syndrome due to intraspinal hemorrhage. In a case of hemiparesis that develops following neck pain, hemorrhagic cervical juxta-facet cyst should be taken into consideration as a differentiation.
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Liu JST, Ding Y, Schoenwaelder S, Liu X. Improving treatment for acute ischemic stroke—Clot busting innovation in the pipeline. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:946367. [PMID: 35978568 PMCID: PMC9376378 DOI: 10.3389/fmedt.2022.946367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/05/2022] [Indexed: 11/13/2022] Open
Abstract
Acute ischemic stroke is a consequence of disrupted blood flow to the brain, caused by thrombosis—the pathological formation of occlusive clots within blood vessels, which can embolize distally to downstream tissues and microvasculature. The highest priority of stroke treatment is the rapid removal of occlusive clots and restoration of tissue perfusion. Intravenous thrombolysis is the pharmacological standard-of-care for the dissolution of blood clots, wherein thrombolytic drugs are administered to restore vessel patency. While the introduction of recombinant tissue-plasminogen activator (rtPA) in 1996 demonstrated the benefit of acute thrombolysis for clot removal, this was countered by severe limitations in terms of patient eligibility, lytic efficacy, rethrombosis and safety implications. Development of safer and efficacious treatment strategies to improve clot lysis has not significantly progressed over many decades, due to the challenge of maintaining the necessary efficacy-safety balance for these therapies. As such, rtPA has remained the sole approved acute therapeutic for ischemic stroke for over 25 years. Attempts to improve thrombolysis with coadministration of adjunct antithrombotics has demonstrated benefit in coronary vessels, but remain contraindicated for stroke, given all currently approved antithrombotics adversely impact hemostasis, causing bleeding. This Perspective provides a brief history of stroke drug development, as well as an overview of several groups of emerging drugs which have the potential to improve thrombolytic strategies in the future. These include inhibitors of the platelet receptor glycoprotein VI and the signaling enzyme PI3-Kinase, novel anticoagulants derived from hematophagous creatures, and proteolysis-targeting chimeras.
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Affiliation(s)
- Joanna Shu Ting Liu
- Heart Research Institute, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, School of Medical Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Yiran Ding
- Faculty of Science, School of Chemistry, The University of Sydney, Sydney, NSW, Australia
| | - Simone Schoenwaelder
- Heart Research Institute, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, School of Medical Sciences, The University of Sydney, Sydney, NSW, Australia
- *Correspondence: Simone Schoenwaelder
| | - Xuyu Liu
- Heart Research Institute, The University of Sydney, Sydney, NSW, Australia
- Faculty of Science, School of Chemistry, The University of Sydney, Sydney, NSW, Australia
- Xuyu Liu
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Development of a Carotid Artery Thrombolysis (iCAT) Stroke Model in Mice. Blood Adv 2022; 6:5449-5462. [PMID: 35767737 PMCID: PMC9631707 DOI: 10.1182/bloodadvances.2021006008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 06/21/2022] [Indexed: 11/20/2022] Open
Abstract
Development of a mouse carotid artery thrombolysis model of stroke. iCAT enables assessment of adjunctive antithrombotic therapies on arterial recanalization, cerebral perfusion, and stroke outcomes.
Recanalization with restored cerebral perfusion is the primary goal of thrombolytic therapy in acute ischemic stroke. The identification of adjunctive therapies that can be safely used to enhance thrombolysis in stroke remains an elusive goal. We report here the development of a mouse in situ carotid artery thrombolysis (iCAT) stroke model involving graded cerebral ischemia to induce unihemispheric infarction after thrombotic occlusion of the common carotid artery (CCA). Electrolytic-induced thrombotic occlusion of the left CCA enabled real-time assessment of recanalization and rethrombosis events after thrombolysis with recombinant tissue-type plasminogen activator (rtPA). Concurrent transient stenosis of the right CCA induced unihemispheric hypoperfusion and infarction in the left middle cerebral artery territory. Real-time assessment of thrombolysis revealed recanalization rates <30% in rtPA-treated animals with high rates of rethrombosis. Addition of the direct thrombin inhibitor argatroban increased recanalization rates to 50% and reduced rethrombosis. Paradoxically, this was associated with increased cerebral ischemia and stroke-related mortality (25%-42%). Serial analysis of carotid and cerebral blood flow showed that coadministration of argatroban with rtPA resulted in a marked increase in carotid artery embolization, leading to distal obstruction of the middle cerebral artery. Real-time imaging of carotid thrombi revealed that adjunctive anticoagulation destabilized platelet-rich thrombi at the vessel wall, leading to dislodgement of large platelet emboli. These studies confirm the benefits of anticoagulants in enhancing thrombolysis and large artery recanalization; however, at high levels of anticoagulation (∼3-fold prolongation of activated partial thromboplastin time), this effect is offset by increased incidence of carotid artery embolization and distal middle cerebral artery occlusion. The iCAT stroke model should provide important new insight into the effects of adjunctive antithrombotic agents on real-time thrombus dynamics during thrombolysis and their correlation with stroke outcomes.
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Tsivgoulis G, Katsanos AH, Christogiannis C, Faouzi B, Mavridis D, Dixit AK, Palaiodimou L, Khurana D, Petruzzellis M, Psychogios K, Macleod MJ, Ahmed N. IV thrombolysis with tenecteplase for the treatment of acute ischemic stroke. Ann Neurol 2022; 92:349-357. [PMID: 35713213 DOI: 10.1002/ana.26445] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Intravenous thrombolysis (IVT) with tenecteplase has been associated with better clinical outcomes in acute ischemic stroke (AIS) patients with confirmed large vessel occlusions compared to IVT with alteplase. However, the utility of tenecteplase for the treatment of all AIS patients eligible for IVT has not been established. METHODS We compared the safety and efficacy of tenecteplase vs. alteplase in AIS patients by analysing propensity score matched data from 20 centres participating in the SITS-ISTR registry. Patients receiving IVT with tenecteplase were matched with up to three patients receiving alteplase from the same centre. The primary outcome of interest was the distribution of 3-month functional outcomes. Secondary outcomes included the rates of patients with symptomatic intracranial hemorrhage (SICH) in the first 24 hours, excellent (mRS-scores of 0-1) or good (mRS-scores of 0-2) functional outcome, and all-cause mortality at 3 months. RESULTS A total of 331 tenecteplase-treated AIS patients were matched to 797 patients treated with alteplase [median age of 70 years; 43.9% women; median NIHSS-score: 11 (IQR: 6-17)]. Patients treated with tenecteplase had better three-month functional outcomes (common OR=1.54,95%CI:1.18-2.00) with higher odds of good functional outcome (OR=2.00,95%CI:1.45-2.77) and a lower likelihood of all-cause mortality (OR=0.43,95%CI:0.27-0.67) at three months, compared to alteplase-treated patients. No difference was found in the likelihood of the three-month excellent functional outcomes (OR=1.31,95%CI:0.96-1.78) and 24-hour SICH (1.0% vs. 1.3%; OR=0.72,95%CI:.20-2.64). INTERPRETATION IVT with tenecteplase was associated with better three-month clinical outcomes compared to IVT with alteplase in AIS patients, with no increased risk of symptomatic intracranial bleeding. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON, Canada
| | | | - Belahsen Faouzi
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Paris Descartes University, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Anand K Dixit
- Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Newcastle-Upon-Tyne, UK
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Marco Petruzzellis
- Neurology Unit and Stroke Center, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Klearchos Psychogios
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - Mary Joan Macleod
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Mosconi MG, Paciaroni M, Ageno W. Investigational drugs for ischemic stroke: what's in the clinical development pipeline for acute phase and prevention? Expert Opin Investig Drugs 2022; 31:645-667. [PMID: 35486110 DOI: 10.1080/13543784.2022.2072725] [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: 11/04/2022]
Abstract
INTRODUCTION Stroke is a leading cause of disability and mortality and its burden expected to increase. The only approved drug for acute ischemic stroke is the intravenous thrombolytic alteplase. The risk of bleeding complications is one of the reasons for the undertreatment of eligible patients. Numerous drugs are currently being developed to improve safety-efficacy. AREAS COVERED We reviewed literature from January 1st, 2000, to 15th January 2022 for the development and testing of novel drugs with the aim of targeting treatment at prevention of ischemic stroke: PubMed, MEDLINE, Google Scholar, and ClinicalTrial.gov. EXPERT OPINION The pathophysiology of ischemic stroke involves multiple pathways causing cerebral artery obstruction and brain tissue ischemia. Data suggest that tenecteplase is a more promising fibrinolytic agent with a superior efficacy-safety profile, compared to the currently approved alteplase. Current guidelines consider a short-term cycle of mannitol or hypertonic saline to be advisable in patients with space-occupying hemispheric infarction. Regarding primary and secondary prevention, research is primarily focused on identifying mechanisms to improve the safety-efficacy profile using a "hemostasis-sparing" approach. Further evaluation on those agents that have already shown promise for their risk/benefit profiles, would benefit greatly a neurologist's capacity to successfully prevent and treat ischemic stroke patients.
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Affiliation(s)
- Maria Giulia Mosconi
- Emergency and vascular medicine Stroke Unit University of Perugia, Perugia, Italy
| | - Maurizio Paciaroni
- Emergency and vascular medicine Stroke Unit University of Perugia, Perugia, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Robichon E, Maïer B, Mazighi M. Endovascular therapy for acute ischemic stroke: The importance of blood pressure control, sedation modality and anti-thrombotic management to improve functional outcomes. Rev Neurol (Paris) 2022; 178:175-184. [DOI: 10.1016/j.neurol.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 08/08/2021] [Accepted: 09/27/2021] [Indexed: 01/04/2023]
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Multiphysics Modelling and Simulation of Thrombolysis via Activated Platelet-Targeted Nanomedicine. Pharm Res 2022; 39:41-56. [PMID: 35044591 PMCID: PMC8837543 DOI: 10.1007/s11095-021-03161-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/22/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE This study establishes a multiphysics simulation platform for both conventional and targeted thrombolysis using tissue plasminogen activator (tPA). Based on our computational results, the effects of therapeutic parameters on the dynamics of thrombolysis and the risk of side effects are investigated. METHODS The model extends our previously developed one-dimensional(1D) mathematical models for fibrinolysis by incorporating targeted thrombolysis. It consists of two parts: (i) a coupled mathematical model of systemic pharmacokinetics (PK) and pharmacodynamics (PD) and local PD in a 1D occluded artery, and (ii) a mechanistic model for a targeted thrombolytic system via activated platelet-targeted tPA-loaded nanovesicles (tPA-NV), with model parameters derived from our in vitro experiments. A total of 16 therapeutic scenarios are simulated by varying the clot location and composition as well as the dosing regimen with free tPA or tPA-NV. RESULTS Our simulation results indicate that tPA-NV offers several advantages over free tPA for thrombolysis. It reduces systemic exposure of tPA, thereby minimising the risk of bleeding complications. Simulations with different tPA-NV doses reveal that tPA-NV at 10% of the recommended dose can be as effective as the standard regimen with the full recommended dose of free tPA, demonstrating the potential of our tPA-NV as a new thrombolytic strategy with a reduced tPA dose. Moreover, faster recanalisation can be achieved with tPA-NV, especially for platelet-rich(or fibrin-poor) clots. CONCLUSIONS Our simulation platform for thrombolysis with well-tuned model parameters can be used to evaluate and optimise treatment regimens of existing and new thrombolytic therapies via benefit/risk assessment under various therapeutic scenarios.
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Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021; 6:I-LXII. [PMID: 33817340 DOI: 10.1177/2396987321989865] [Citation(s) in RCA: 493] [Impact Index Per Article: 164.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the 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 wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
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Affiliation(s)
- Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Heinrich Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Gian Marco De Marchis
- University Hospital of Basel & University of Basel, Department for Neurology & Stroke Center, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Chiara Padiglioni
- Neurology Unit-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - 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, TN, USA
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hopital Sainte-Anne, Université de Paris, Paris, France.,INSERM U1266.,FHU NeuroVasc
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Assessing the risk of stroke development following retinal artery occlusion. J Stroke Cerebrovasc Dis 2020; 29:105002. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/22/2020] [Accepted: 05/25/2020] [Indexed: 11/18/2022] Open
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Wang XS, Yue J, Hu LN, Tian Z, Zhang K, Yang L, Zhang HN, Guo YY, Feng B, Liu HY, Wu YM, Zhao MG, Liu SB. Activation of G protein-coupled receptor 30 protects neurons by regulating autophagy in astrocytes. Glia 2020; 68:27-43. [PMID: 31429156 DOI: 10.1002/glia.23697] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 07/23/2019] [Accepted: 07/24/2019] [Indexed: 12/24/2022]
Abstract
Ischemic stroke leads to neuronal damage induced by excitotoxicity, inflammation, and oxidative stress. Astrocytes play diverse roles in stroke and ischemia-induced inflammation, and autophagy is critical for maintaining astrocytic functions. Our previous studies showed that the activation of G protein-coupled receptor 30 (GPR30), an estrogen membrane receptor, protected neurons from excitotoxicity. However, the role of astrocytic GPR30 in maintaining autophagy and neuroprotection remained unclear. In this study, we found that the neuroprotection induced by G1 (GPR30 agonist) in wild-type mice after a middle cerebral artery occlusion was completely blocked in GPR30 conventional knockout (KO) mice but partially attenuated in astrocytic or neuronal GPR30 KO mice. In cultured primary astrocytes, glutamate exposure induced astrocyte proliferation and decreased astrocyte autophagy by activating mammalian target of rapamycin (mTOR) and c-Jun N-terminal kinase (JNK) and inhibiting p38 mitogen-activated protein kinase (MAPK) pathway. G1 treatment restored autophagy to its basal level by regulating the p38 pathway but not the mTOR and JNK signaling pathways. Our findings revealed a key role of GPR30 in neuroprotection via the regulation of astrocyte autophagy and support astrocytic GPR30 as a potential drug target against ischemic brain damage.
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Affiliation(s)
- Xin-Shang Wang
- Department of Pharmacology, School of Pharmacy, Fourth Military Medical University, Xi'an, China.,Precision Pharmacy & Drug Development Center, Department of Pharmacy, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Jiao Yue
- Department of Pharmacology, School of Pharmacy, Fourth Military Medical University, Xi'an, China.,Precision Pharmacy & Drug Development Center, Department of Pharmacy, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Li-Ning Hu
- Department of Pharmacology, School of Pharmacy, Fourth Military Medical University, Xi'an, China.,Precision Pharmacy & Drug Development Center, Department of Pharmacy, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhen Tian
- Department of Pharmacology, School of Pharmacy, Fourth Military Medical University, Xi'an, China.,Precision Pharmacy & Drug Development Center, Department of Pharmacy, Tangdu Hospital, Fourth Military Medical University, Xi'an, China.,Department of Pharmacy, The 154th Central Hospital of PLA, Xinyang, China
| | - Kun Zhang
- Department of Pharmacology, School of Pharmacy, Fourth Military Medical University, Xi'an, China.,Precision Pharmacy & Drug Development Center, Department of Pharmacy, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Le Yang
- Department of Pharmacology, School of Pharmacy, Fourth Military Medical University, Xi'an, China.,Precision Pharmacy & Drug Development Center, Department of Pharmacy, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Hui-Nan Zhang
- Department of Pharmacology, School of Pharmacy, Fourth Military Medical University, Xi'an, China.,Precision Pharmacy & Drug Development Center, Department of Pharmacy, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Yan-Yan Guo
- Department of Pharmacology, School of Pharmacy, Fourth Military Medical University, Xi'an, China.,Precision Pharmacy & Drug Development Center, Department of Pharmacy, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Bin Feng
- State Key Laboratory of Military Stomatology, Department of pharmacy, School of Stomatology, National Clinical Research Center for Oral Diseases, Shaanxi Engineering Research Center for Dental Materials and Advanced Manufacture, Fourth Military Medical University, Xi'an, China
| | - Hai-Yan Liu
- State Key Laboratory of Military Stomatology, Department of pharmacy, School of Stomatology, National Clinical Research Center for Oral Diseases, Shaanxi Engineering Research Center for Dental Materials and Advanced Manufacture, Fourth Military Medical University, Xi'an, China
| | - Yu-Mei Wu
- Department of Pharmacology, School of Pharmacy, Fourth Military Medical University, Xi'an, China.,Precision Pharmacy & Drug Development Center, Department of Pharmacy, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Ming-Gao Zhao
- Department of Pharmacology, School of Pharmacy, Fourth Military Medical University, Xi'an, China.,Precision Pharmacy & Drug Development Center, Department of Pharmacy, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Shui-Bing Liu
- Department of Pharmacology, School of Pharmacy, Fourth Military Medical University, Xi'an, China.,Precision Pharmacy & Drug Development Center, Department of Pharmacy, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
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11
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Li F, Liu WC, Wang Q, Sun Y, Wang H, Jin X. NG2-glia cell proliferation and differentiation by glial growth factor 2 (GGF2), a strategy to promote functional recovery after ischemic stroke. Biochem Pharmacol 2019; 171:113720. [PMID: 31751533 DOI: 10.1016/j.bcp.2019.113720] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 11/14/2019] [Indexed: 12/16/2022]
Abstract
Stroke is the leading cause of adult disability. Spontaneous functional recovery occurs after ischemic stroke, but it is very limited. Therefore, it is urgent to find a strategy to promote functional recovery after stroke in clinical setting. Gray matter damage has received extensive attention owing to the important roles of the gray matter in synaptic plasticity, cognitive, and motor function. However, stroke also causes white matter damage, which accounts for half of the infarct volume and can be aggravated by blood brain barrier damage. Disruption of white matter integrity, which is characterized by death of oligodendrocytes (OLs), loss of myelin, and axonal injury, greatly contributes to impaired neurological function. Impaired proliferation and differentiation of OL precursor cell (OPC, NG2-glia cells) play an important role in limited functional recovery after ischemic stroke and inhibitor of differentiation 2 (ID2) is a key factor controlling NG2-glia cells differentiation. It has been reported that the number of NG2-glia cells in the peri-infarction area significantly increases after ischemic stroke and glial growth factor (GGF2) administration promotes the proliferation and differentiation of NG2-glia cells as well as functional recovery after spinal cord injury. On the basis of the important roles of GGF2 in functional recovery and those of ID2 in NG2-glia cell proliferation and differentiation, we propose that after binding with the ErBb receptor on the surface of NG2-glia cells, GGF2 promotes NG2-glia cell proliferation and differentiation, thereby repairing BBB and white matter integrity and promoting neural functional recovery after ischemic stroke.
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Affiliation(s)
- Fei Li
- School of Pharmaceutical Sciences, Hubei University of Medicine, Shiyan 442000, China; Hubei Key Laboratory of Wudang Local Chinese Medicine Research, Hubei University of Medicine, Shiyan 442000, China
| | - Wen-Cao Liu
- Shanxi Provincial People's Hospital, Taiyuan 030001, China
| | - Qi Wang
- Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Yanyun Sun
- Jiangsu Key Laboratory of Neuro-Psychiatry Research and Institute of Neuroscience, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China.
| | - Hongbo Wang
- Key Laboratory of Molecular Pharmacology and Drug Evaluation, School of Pharmacy, Yantai University, Yantai, China.
| | - Xinchun Jin
- Jiangsu Key Laboratory of Neuro-Psychiatry Research and Institute of Neuroscience, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China; Key Laboratory of Molecular Pharmacology and Drug Evaluation, School of Pharmacy, Yantai University, Yantai, China.
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12
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Alexandrov AV, Köhrmann M, Soinne L, Tsivgoulis G, Barreto AD, Demchuk AM, Sharma VK, Mikulik R, Muir KW, Brandt G, Alleman J, Grotta JC, Levi CR, Molina CA, Saqqur M, Mavridis D, Psaltopoulou T, Vosko M, Fiebach JB, Mandava P, Kent TA, Alexandrov AW, Schellinger PD. Safety and efficacy of sonothrombolysis for acute ischaemic stroke: a multicentre, double-blind, phase 3, randomised controlled trial. Lancet Neurol 2019; 18:338-347. [DOI: 10.1016/s1474-4422(19)30026-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 01/02/2023]
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13
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Mendez AA, Samaniego EA, Sheth SA, Dandapat S, Hasan DM, Limaye KS, Hindman BJ, Derdeyn CP, Ortega-Gutierrez S. Update in the Early Management and Reperfusion Strategies of Patients with Acute Ischemic Stroke. Crit Care Res Pract 2018; 2018:9168731. [PMID: 30050694 PMCID: PMC6046146 DOI: 10.1155/2018/9168731] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 05/03/2018] [Indexed: 01/01/2023] Open
Abstract
Acute ischemic stroke (AIS) remains a leading cause of death and long-term disability. The paradigms on prehospital care, reperfusion therapies, and postreperfusion management of patients with AIS continue to evolve. After the publication of pivotal clinical trials, endovascular thrombectomy has become part of the standard of care in selected cases of AIS since 2015. New stroke guidelines have been recently published, and the time window for mechanical thrombectomy has now been extended up to 24 hours. This review aims to provide a focused up-to-date review for the early management of adult patients with AIS and introduce the new upcoming areas of ongoing research.
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Affiliation(s)
- Aldo A. Mendez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Edgar A. Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Sunil A. Sheth
- Department of Neurology and Neurosurgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sudeepta Dandapat
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - David M. Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Kaustubh S. Limaye
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Bradley J. Hindman
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Colin P. Derdeyn
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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14
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Mendes JF, Amorim J, Calvão-Santos G. Systemic intravenous abciximab: a novel treatment for acute central retinal artery occlusion? Acta Ophthalmol 2018; 96:e101-e102. [PMID: 28470954 DOI: 10.1111/aos.13446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - José Amorim
- Department of Neurorradiology, Hospital de Braga, Braga, Portugal
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15
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Bhaskar S, Stanwell P, Cordato D, Attia J, Levi C. Reperfusion therapy in acute ischemic stroke: dawn of a new era? BMC Neurol 2018; 18:8. [PMID: 29338750 PMCID: PMC5771207 DOI: 10.1186/s12883-017-1007-y] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/14/2017] [Indexed: 12/14/2022] Open
Abstract
Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.
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Affiliation(s)
- Sonu Bhaskar
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Peter Stanwell
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Dennis Cordato
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
| | - John Attia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
- Centre for Clinical Epidemiology & Biostatistics, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW Australia
| | - Christopher Levi
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
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16
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Derex L, Paris C, Nighoghossian N. Combining Intravenous Thrombolysis and Antithrombotic Agents in Stroke: An Update. J Am Heart Assoc 2018; 7:JAHA.117.007454. [PMID: 29331961 PMCID: PMC5850163 DOI: 10.1161/jaha.117.007454] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Laurent Derex
- Department of Neurology, Stroke Center, Neurological Hospital, Hospices Civils de Lyon University of Lyon, Bron cedex, France .,EA 7425 HESPER, Health Services and Performance Research, Claude Bernard Lyon 1 University, Lyon, France
| | - Chloé Paris
- Department of Neurology, Stroke Center, Neurological Hospital, Hospices Civils de Lyon University of Lyon, Bron cedex, France
| | - Norbert Nighoghossian
- Department of Neurology, Stroke Center, Neurological Hospital, Hospices Civils de Lyon University of Lyon, Bron cedex, France
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17
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Bourcier R, Alexandre PL, Eugène F, Delasalle-Guyomarch B, Guillon B, Kerleroux B, Saleme S, Marnat G, Boucebci S, Mirza M, Ferré JC, Papagiannaki C, Desal H. Is bridging therapy still required in stroke due to carotid artery terminus occlusions? J Neurointerv Surg 2017; 10:625-628. [PMID: 29146829 DOI: 10.1136/neurintsurg-2017-013398] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Studies comparing endovascular stroke treatment using mechanical thrombectomy (MT) with or without prior IV tissue plasminogen activator (tPa) have included only 30% of internal carotid artery terminus occlusions (ICA-O), a known predictor of recanalization failure with IV tPa. OBJECTIVE To carry out a retrospective multicenter analysis of prospectively collected data of consecutive patients to investigate the impact of intravenous thrombolysis on ICA-O by comparing patients treated with MT alone or bridging therapy (BT). MATERIAL AND METHODS Patients with ICA-O treated with MT alone or BT were retrospectively examined and compared. Demographic data, vascular risk factors, treatment modalities, complications, technical and clinical outcomes were recorded. A propensity score (PS) analysis was used to compare modified Rankin Scale (mRS) score at 3 months and intracerebral hemorrhage (ICH) between groups. RESULTS 141 consecutive patients (60% BT/40% MT) were included between January 2014 and June 2016. Baseline characteristics did not differ between the groups. There was no significant difference in the rate of Thrombolysis in Cerebral Infarction 2b/3, distal emboli, and median number of passes between the groups. There was a significant difference between BT and MT groups in the median time between imaging and groin puncture (median 97 min vs 75, p=0.007), the rate of ICH (44% vs 27%, p=0.05), but not for symptomatic ICH (18% vs 13%, p=0.49). With PS, there was a trend towards a higher rate of ICH (OR=2.3, 95% CI 0.9 to 5.9, p=0.09) in the BT group compared with the MT alone group, with no difference in mRS score ≤2 at 3 months (OR=1.6, 95% CI 0.7 to 3.7, p=0.29). CONCLUSION There was no significant difference in clinical outcomes between patients receiving bridging therapy versus direct thrombectomy. Bridging therapy delayed time to groin puncture and increased ICH rate.
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Affiliation(s)
- Romain Bourcier
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | | | - François Eugène
- Department of Neuroradiology, University Hospital of Rennes, Rennes, France
| | | | - Benoit Guillon
- Stroke Unit, University Hospital of Nantes, Nantes, France
| | | | - Suzana Saleme
- Interventional Neuroradiology, CHU Limoges, Limoges, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Samy Boucebci
- Department of Neuroradiology, University Hospital of Poitiers, Poitiers, France
| | | | | | | | - Hubert Desal
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
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18
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Zhou J, Kochan J, Yin O, Warren V, Zamora C, Atiee G, Pav J, Orihashi Y, Vashi V, Dishy V. A first-in-human study of DS-1040, an inhibitor of the activated form of thrombin-activatable fibrinolysis inhibitor, in healthy subjects. J Thromb Haemost 2017; 15:961-971. [PMID: 28211169 DOI: 10.1111/jth.13658] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Indexed: 11/30/2022]
Abstract
Essentials DS-1040 inhibits the activated form of thrombin-activatable fibrinolysis inhibitor (TAFIa). Infusion of DS-1040 was safe and well tolerated in healthy young and elderly subjects. DS-1040 substantially decreased TAFIa activity but had no impact on bleeding time. DS-1040 may provide an option of safer thrombolytic therapy. SUMMARY Background Current treatments for acute ischemic stroke and venous thromboembolism, such as recombinant tissue-type plasminogen activator and thrombectomy, are limited by a narrow time window and the risk of bleeding. DS-1040 is a novel low molecular weight compound that inhibits the activated form of thrombin-activatable fibrinolysis inhibitor (TAFIa), and was developed as a fibrinolysis enhancer for the treatment of thromboembolic diseases. Objectives This first-in-human, randomized, placebo-controlled, three-part, phase 1 study was conducted to evaluate the safety, pharmacokinetics and pharmacodynamics of DS-1040 in healthy subjects. Subjects/Methods Young (18-45 years) or elderly (65-75 years) subjects (N = 103) were randomized to receive single ascending doses of DS-1040 ranging from 0.1 mg to 40 mg, or placebo, administered either as a 0.5-h intravenous infusion or as a 24-h continuous infusion. Results All doses of DS-1040 were tolerated, and no serious adverse events (AEs) or discontinuations resulting from AEs occurred during the study. Bleeding time remained within the normal range for all doses tested in all subjects. Plasma exposure of DS-1040 increased proportionally with increase in dose. Elderly subjects had higher exposures to DS-1040 and prolonged elimination times, probably because of decreased renal clearance. DS-1040 caused a substantial dose-dependent and time-dependent decrease in TAFIa activity and in 50% clot lysis time. The levels of D-dimer, indicative of endogenous fibrinolysis, increased in some individuals following DS-1040 treatment. No effects of DS-1040 on coagulation parameters or platelet aggregation were observed. Conclusions The novel fibrinolysis-enhancing agent DS-1040 has favorable pharmacokinetic/pharmacodynamic properties and a favorable safety profile, warranting further clinical development.
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Affiliation(s)
- J Zhou
- Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | - J Kochan
- Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | - O Yin
- Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | - V Warren
- Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | - C Zamora
- Worldwide Clinical Trials, San Antonio, TX, USA
| | - G Atiee
- Worldwide Clinical Trials, San Antonio, TX, USA
| | - J Pav
- Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | - Y Orihashi
- Daiichi Sankyo Development Ltd, Gerrards Cross, UK
| | - V Vashi
- Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | - V Dishy
- Daiichi Sankyo Pharma Development, Edison, NJ, USA
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19
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Gao S, Zhu Q, Dong X, Chen Z, Liu Z, Xie F. Guided longer pulses from a diagnostic ultrasound and intraclot microbubble enhanced catheter-directed thrombolysis in vivo. J Thromb Thrombolysis 2017; 44:48-56. [PMID: 28417266 DOI: 10.1007/s11239-017-1500-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The mechanism of ultrasound thrombolysis (UT) is generally attributed to cavitation. The insufficiency of microbubbles (MB) to serve as cavitation nuclei in the vessel-obstructing thrombi significantly reduces the effectiveness of UT. Taking advantage of the widely performed catheter-directed therapy (CDT), in a thrombo-embolized rabbit IVC model with a simultaneous catheter directed rt-PA thrombolysis procedure, guided moderate mechanical index longer pulses from a modified diagnostic ultrasound transducer, combined with an intraclot infusion of MB, significantly accelerated the thrombolysis process. The higher thrombolysis efficacy score and consistent elevated post-treatment plasma concentration level of D-Dimer, a product of fibrinolysis, both indicated the superiority of CDT + UT over CDT/UT alone. Pathologic examination of the treated occluded IVC segments revealed an almost complete dissolution of the thrombi treated with CDT + UT. There was no evidences of thrombo-embolism or local thrombus formation in the cardiac-pulmonary vessels. Combined with intraclot infusion of MB, guided longer pulse ultrasound from a diagnostic transducer is able to safely and significantly improve a catheter-directed thrombolysis procedure. It thus has the potential to achieve earlier clot removal, administration of a lower dosage of thrombolytic agent and, consequently, a lower incidence of thrombolysis-related side effects.
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Affiliation(s)
- Shunji Gao
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Qiong Zhu
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Xiaoxiao Dong
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Zhong Chen
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Zheng Liu
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
| | - Feng Xie
- Internal Medicine Cardiology, University of Nebraska Medical Center, Omaha, NE, USA
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20
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Abstract
The presence of a salvageable penumbra, a region of ischemic brain tissue with sufficient energy for short-term survival, has been widely agreed as the premise for thrombolytic therapy with tissue plasminogen activator (tPA), which remains the only United States Food and Drug Administration (FDA) approved treatment for acute ischemia stroke. However, the use of tPA has been profoundly constrained due to its narrow therapeutic time window and the increased risk of potentially deadly hemorrhagic transformation (HT). Blood brain barrier (BBB) damage within the thrombolytic time window is an indicator for tPA-induced HT and both normobaric hyperoxia (NBO) and hypothermia have been shown to protect the BBB from ischemia/reperfusion injury. Therefore, providing the O2 as soon as possible (NBO treatment), freezing the brain (hypothermia treatment) to slow down ischemia-induced BBB damage or their combined use may extend the time window for the treatment of tPA. In this review, we summarize the protective effects of NBO, hypothermia or their use combined with tPA on ischemia stroke, based on which, the combination of NBO and hypothermia may be an ideal early stroke treatment to preserve the ischemic penumbra. Given this, there is an urge for large randomized controlled trials to address the effect.
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Affiliation(s)
- Wen-Cao Liu
- Department of Emergency, Shanxi Provincial People's Hospital, Taiyuan, Shanxi Province, China
| | - Xin-Chun Jin
- Jiangsu Key Laboratory of Translational Research and Therapy for Neuro-Psycho-Diseases and Institute of Neuroscience, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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21
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Bonnard T, Tennant Z, Niego B, Kanojia R, Alt K, Jagdale S, Law LS, Rigby S, Medcalf RL, Peter K, Hagemeyer CE. Novel Thrombolytic Drug Based on Thrombin Cleavable Microplasminogen Coupled to a Single-Chain Antibody Specific for Activated GPIIb/IIIa. J Am Heart Assoc 2017; 6:JAHA.116.004535. [PMID: 28159824 PMCID: PMC5523756 DOI: 10.1161/jaha.116.004535] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Thrombolytic therapy for acute thrombosis is limited by life‐threatening side effects such as major bleeding and neurotoxicity. New treatment options with enhanced fibrinolytic potential are therefore required. Here, we report the development of a new thrombolytic molecule that exploits key features of thrombosis. We designed a recombinant microplasminogen modified to be activated by the prothrombotic serine‐protease thrombin (HtPlg), fused to an activation‐specific anti–glycoprotein IIb/IIIa single‐chain antibody (SCE5), thereby hijacking the coagulation system to initiate thrombolysis. Methods and Results The resulting fusion protein named SCE5‐HtPlg shows in vitro targeting towards the highly abundant activated form of the fibrinogen receptor glycoprotein IIb/IIIa expressed on activated human platelets. Following thrombin formation, SCE5‐HtPlg is activated to contain active microplasmin. We evaluate the effectiveness of our targeted thrombolytic construct in two models of thromboembolic disease. Administration of SCE5‐HtPlg (4 μg/g body weight) resulted in effective thrombolysis 20 minutes after injection in a ferric chloride–induced model of mesenteric thrombosis (48±3% versus 92±5% for saline control, P<0.01) and also reduced emboli formation in a model of pulmonary embolism (P<0.01 versus saline). Furthermore, at these effective therapeutic doses, the SCE5‐HtPlg did not prolong bleeding time compared with saline (P=0.99). Conclusions Our novel fusion molecule is a potent and effective treatment for thrombosis that enables in vivo thrombolysis without bleeding time prolongation. The activation of this construct by thrombin generated within the clot itself rather than by a plasminogen activator, which needs to be delivered systemically, provides a novel targeted approach to improve thrombolysis.
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Affiliation(s)
- Thomas Bonnard
- NanoBiotechnology Laboratory, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia.,Vascular Biotechnology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Zachary Tennant
- Vascular Biotechnology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Be'Eri Niego
- Molecular Neurotrauma and Haemostasis Laboratory, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Ruchi Kanojia
- Vascular Biotechnology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia.,Atherothrombosis and Vascular Biology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Karen Alt
- NanoBiotechnology Laboratory, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia.,Vascular Biotechnology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia.,Atherothrombosis and Vascular Biology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Shweta Jagdale
- NanoBiotechnology Laboratory, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia.,Vascular Biotechnology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Lok Soon Law
- Vascular Biotechnology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Sheena Rigby
- Vascular Biotechnology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia.,Atherothrombosis and Vascular Biology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Robert Lindsay Medcalf
- Molecular Neurotrauma and Haemostasis Laboratory, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia.,RMIT University, Melbourne, Australia
| | - Christoph Eugen Hagemeyer
- NanoBiotechnology Laboratory, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia .,Vascular Biotechnology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia.,RMIT University, Melbourne, Australia
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Liu Y, Hua Y, Feng W, Ovbiagele B. Multimodality ultrasound imaging in stroke: current concepts and future focus. Expert Rev Cardiovasc Ther 2016; 14:1325-1333. [PMID: 27785921 DOI: 10.1080/14779072.2016.1254043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Stroke is a leading cause of disability and mortality worldwide. Ultrasound is a real-time imaging technique that is inexpensive, portable, non-invasive, and safe, with high diagnostic accuracy. Ultrasonic imaging can provide useful direct and indirect information about the characteristics of various vessels in the both intracranial and extracranial segments. Areas covered: In this review, we will discuss multimodal applications of ultrasonic imaging in stroke prevention and management including checking carotid intima-media thickness progression, evaluating the plaque morphology, calibrating the degree of stenosis, detecting the presence of patent foramen ovale, monitoring microembolization, and screening for stroke risk in patients with sickle cell disease. We present the conventional ultrasonography as well as the novel ultrasound techniques including gray scale median, 3-dementional ultrasound, elastography, intravascular ultrasound, and contrast-enhanced ultrasound. Expert commentary: Ultrasonography is a non-invasive, low-cost, safe, fast, and real-time imaging technology for stroke risk assessment. Each modality has its own advantage as well as limitation. Future research should be focused on developing new technologies that can improve the quality of imaging and accuracy of diagnosis.
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Affiliation(s)
- Yumei Liu
- a Department of Vascular Ultrasound , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Department of Neurology, MUSC Stroke Center , Medical University of South Carolina , Charleston , USA
| | - Yang Hua
- a Department of Vascular Ultrasound , Xuanwu Hospital, Capital Medical University , Beijing , China
| | - Wuwei Feng
- b Department of Neurology, MUSC Stroke Center , Medical University of South Carolina , Charleston , USA
| | - Bruce Ovbiagele
- b Department of Neurology, MUSC Stroke Center , Medical University of South Carolina , Charleston , USA
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Bonaventura A, Montecucco F, Dallegri F. Update on the effects of treatment with recombinant tissue-type plasminogen activator (rt-PA) in acute ischemic stroke. Expert Opin Biol Ther 2016; 16:1323-1340. [PMID: 27548625 DOI: 10.1080/14712598.2016.1227779] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Acute ischemic stroke (AIS) represents a major cause of death and disability all over the world. The recommended therapy aims at dissolving the clot to re-establish quickly the blood flow to the brain and reduce neuronal injury. Intravenous administration of recombinant tissue-type plasminogen activator (rt-PA) is clinically used with this goal. AREAS COVERED A description of beneficial and detrimental effects of rt-PA treatment is addressed. An overview of new therapies against AIS, such as new thrombolytics, sonolysis and sonothrombolysis, endovascular procedures, and association therapies is provided. Updates on the pathophysiological process leading to intracranial hemorrhage (ICH) is also discussed. EXPERT OPINION rt-PA treatment in AIS patients is beneficial to recovery outcomes. To weaken risks and improve benefits, it might be relevant to consider: i) a definitive identification of risk factors for symptomatic ICH; ii). a better organization of the health care system to reduce time-to-treatment and enhance discharge management. The pharmacological improvement of new thrombolytic drugs (such as tenecteplase and desmoteplase) targeting harmful and maximally exploiting beneficial effects might further reduce mortality and disability in AIS.
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Affiliation(s)
- Aldo Bonaventura
- a First Clinic of Internal Medicine, Department of Internal Medicine , University of Genoa School of Medicine , Genoa , Italy.,b IRCCS AOU San Martino - IST, Genoa , Genoa , Italy
| | - Fabrizio Montecucco
- a First Clinic of Internal Medicine, Department of Internal Medicine , University of Genoa School of Medicine , Genoa , Italy.,b IRCCS AOU San Martino - IST, Genoa , Genoa , Italy.,c Centre of Excellence for Biomedical Research (CEBR) , University of Genoa , Genoa , Italy
| | - Franco Dallegri
- a First Clinic of Internal Medicine, Department of Internal Medicine , University of Genoa School of Medicine , Genoa , Italy.,b IRCCS AOU San Martino - IST, Genoa , Genoa , Italy
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24
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Liang LJ, Yang JM, Jin XC. Cocktail treatment, a promising strategy to treat acute cerebral ischemic stroke? Med Gas Res 2016; 6:33-38. [PMID: 27826421 PMCID: PMC5075681 DOI: 10.4103/2045-9912.179343] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Up to now, over 1,000 experimental treatments found in cells and rodents have been difficult to translate to human ischemic stroke. Since ischemia and reperfusion, two separate stages of ischemic stroke, have different pathophysiological mechanisms leading to brain injury, a combination of protective agents targeting ischemia and reperfusion respectively may obtain substantially better results than a single agent. Normobaric hyperoxia (NBO) has been shown to exhibit neuro- and vaso-protective effects by improving tissue oxygenation when it is given during ischemia, however the effect of NBO would diminish when the duration of ischemia and reperfusion was extended. Therefore, during reperfusion drug treatment targeting inflammation, oxidative stress and free radical scavenger would be a useful adjuvant to extend the therapeutic window of tissue plasminogen activator, the only United States Food and Drug Administration (FDA) approved treatment for acute ischemic stroke. In this review, we discussed the neuro- and vaso-protective effects of NBO and recent finding of combining NBO with other drugs.
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Affiliation(s)
- Li-Jun Liang
- Children's Hospital of Shanxi Province, Taiyuan, Shanxi Province, China
| | - Jin-Ming Yang
- Children's Hospital of Shanxi Province, Taiyuan, Shanxi Province, China
| | - Xin-Chun Jin
- Jiangsu Key Laboratory of Translational Research and Therapy for Neuro-Psycho-Diseases and Institute of Neuroscience, The Second Affiliated Hospital of Soochow University, Soochow University, Suzhou, Jiangsu Province, China
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25
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Asadi H, Williams D, Thornton J. Changing Management of Acute Ischaemic Stroke: the New Treatments and Emerging Role of Endovascular Therapy. Curr Treat Options Neurol 2016; 18:20. [PMID: 27017832 DOI: 10.1007/s11940-016-0403-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT Urgent reperfusion of the ischaemic brain is the aim of stroke treatment, and the last two decades have seen a rapid advancement in the medical and endovascular treatment of acute ischaemic stroke. Intravenous tissue plasminogen activator (tPA) was first introduced as a safe and effective thrombolytic agent followed by the introduction of newer thrombolytic agents as well as anticoagulant and antiplatelet agents, proposed as potentially safer drugs with more favourable interaction profiles. In addition to chemo-thrombolysis, other techniques including transcranial sonothrombolysis and microbubble cavitation have been introduced which are showing promising results, but await large-scale clinical trials. These developments in medical therapies which are undoubtedly of great importance due to their potential widespread and immediate availability are paralleled with gradual but steady improvements in endovascular recanalisation techniques which were initiated by the introduction of the MERCI (Mechanical Embolus Removal in Cerebral Ischemia) and Penumbra systems. The introduction of the Solitaire device was a significant achievement in reliable and safe endovascular recanalisation and was followed by further innovative stent retrievers. Initial trials failed to show a solid benefit in endovascular intervention compared with IV-tPA alone. These counterintuitive results did not last long, however, when a series of very well-designed randomised controlled trials, pioneered by MR-CLEAN, EXTEND-IA and ESCAPE, emerged, confirming the well-believed daily anecdotal evidence. There have now been seven positive trials of endovascular treatment for acute ischaemic stroke. Now that level I evidence regarding the superiority of endovascular recanalisation is abundantly available, the clinical challenge is how to select patients suitable for intervention and to familiarise and educate stroke care providers with this recent development in stroke care. It is important for the interventional services to be provided only in comprehensive stroke centres and endovascular interventions attempted by experienced well-trained operators, at this stage as an adjunct to the established medical treatment of IV-tPA, if there are no contraindications.
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Affiliation(s)
- Hamed Asadi
- Neuroradiology and Neurointerventional Service, Department of Radiology, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland. .,School of Medicine, Faculty of Health, Deakin University, Pigdons Road, Waurn Ponds, VIC, 3216, Australia. .,Interventional Radiology Service, Department of Radiology, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland.
| | - David Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland and Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland
| | - John Thornton
- Neuroradiology and Neurointerventional Service, Department of Radiology, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland
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Neuroprotection in acute brain injury: an up-to-date review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:186. [PMID: 25896893 PMCID: PMC4404577 DOI: 10.1186/s13054-015-0887-8] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Neuroprotective strategies that limit secondary tissue loss and/or improve functional outcomes have been identified in multiple animal models of ischemic, hemorrhagic, traumatic and nontraumatic cerebral lesions. However, use of these potential interventions in human randomized controlled studies has generally given disappointing results. In this paper, we summarize the current status in terms of neuroprotective strategies, both in the immediate and later stages of acute brain injury in adults. We also review potential new strategies and highlight areas for future research.
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Kandadai MA, Meunier JM, Hart K, Holland CK, Shaw GJ. Plasmin-loaded echogenic liposomes for ultrasound-mediated thrombolysis. Transl Stroke Res 2015; 6:78-87. [PMID: 25411015 PMCID: PMC4298464 DOI: 10.1007/s12975-014-0376-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 10/27/2014] [Accepted: 11/03/2014] [Indexed: 01/15/2023]
Abstract
Plasmin, a direct fibrinolytic, shows a significantly superior hemostatic safety profile compared to recombinant tissue plasminogen activator (rtPA), the only FDA-approved thrombolytic for the treatment of acute ischemic stroke. The improved safety of plasmin is attributed to the rapid inhibition of free plasmin by endogenous plasmin inhibitors present in very high concentrations (1 μM). However, this rapid inhibition prevents the intravenous (IV) administration of plasmin. In emergency situations, catheter-based local administration is not practical. There is a need for an alternative technique for IV administration of plasmin. A possible solution is the encapsulation of plasmin in echogenic liposomes (ELIP) for protection from inhibitors until ultrasound (US)-triggered release at the clot site. ELIP are bilayer phospholipid vesicles with encapsulated gas microbubbles. US induces oscillation and collapse of the gas bubbles, which facilitates ELIP rupture and delivery of the encapsulated contents. Plasmin-loaded ELIP (PELIP) were manufactured and characterized for size, gas and drug encapsulations, and in vitro thrombolytic efficacy using a human whole blood clot model. Clots were exposed to PELIP with and without exposure to US (center frequency 120 kHz, pulse repetition frequency 1667 Hz, peak-to-peak pressure of 0.35 MPa, 50 % duty cycle). Thrombolytic efficacy was calculated by measuring the change in clot width over a 30-min treatment period using an edge detection MATLAB program. The mean clot lysis obtained with PELIP in the presence of US exposure was 31 % higher than that obtained without US exposure and 15 % higher than that obtained with rtPA treatment (p < 0.05).The enhanced clot lysis is attributed to the US-mediated release of plasmin from the liposomes.
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Affiliation(s)
- Madhuvanthi A Kandadai
- Department of Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, Suite 1551, Cincinnati, OH, 45267, USA,
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Asadi H, Yan B, Dowling R, Wong S, Mitchell P. Advances in medical revascularisation treatments in acute ischemic stroke. THROMBOSIS 2014; 2014:714218. [PMID: 25610642 PMCID: PMC4293866 DOI: 10.1155/2014/714218] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/17/2014] [Indexed: 11/17/2022]
Abstract
Urgent reperfusion of the ischaemic brain is the aim of stroke treatment and there has been ongoing research to find a drug that can promote vessel recanalisation more completely and with less side effects. In this review article, the major studies which have validated the use and safety of tPA are discussed. The safety and efficacy of other thrombolytic and anticoagulative agents such as tenecteplase, desmoteplase, ancrod, tirofiban, abciximab, eptifibatide, and argatroban are also reviewed. Tenecteplase and desmoteplase are both plasminogen activators with higher fibrin affinity and longer half-life compared to alteplase. They have shown greater reperfusion rates and improved functional outcomes in preliminary studies. Argatroban is a direct thrombin inhibitor used as an adjunct to intravenous tPA and showed higher rates of complete recanalisation in the ARTTS study with further studies which are now ongoing. Adjuvant thrombolysis techniques using transcranial ultrasound are also being investigated and have shown higher rates of complete recanalisation, for example, in the CLOTBUST study. Overall, development in medical therapies for stroke is important due to the ease of administration compared to endovascular treatments, and the new treatments such as tenecteplase, desmoteplase, and adjuvant sonothrombolysis are showing promising results and await further large-scale clinical trials.
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Affiliation(s)
- H Asadi
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - B Yan
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - R Dowling
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - S Wong
- Radiology Department, Western Hospital, Footscray, VIC, Australia
| | - P Mitchell
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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Barlinn K, Tsivgoulis G, Barreto AD, Alleman J, Molina CA, Mikulik R, Saqqur M, Demchuk AM, Schellinger PD, Howard G, Alexandrov AV. Outcomes following sonothrombolysis in severe acute ischemic stroke: subgroup analysis of the CLOTBUST trial. Int J Stroke 2014; 9:1006-10. [PMID: 25079049 PMCID: PMC4227933 DOI: 10.1111/ijs.12340] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 05/20/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sonothrombolysis is safe and may increase the likelihood of early recanalization in acute ischemic stroke patients. AIMS In preparation of a phase III clinical trial, we contrast the likelihood of achieving a sustained recanalization and functional independence in a post hoc subgroup analysis of patients randomized to transcranial Doppler monitoring plus intravenous tissue plasminogen activator (sonothrombolysis) compared with intravenous tissue plasminogen activator alone in the CLOTBUST trial. METHODS We analyzed the data from all randomized acute ischemic stroke patients with pretreatment National Institutes of Health Stroke Scale scores ≥ 10 points and proximal intracranial occlusions in the CLOTBUST trial. We compared sustained complete recanalization rate (Thrombolysis in Brain Ischemia flow grades 4-5) and functional independence (modified Rankin Scale 0-1) at 90 days. Safety was evaluated by the rate of symptomatic intracranial hemorrhage within 72 h of stroke onset. RESULTS Of 126 patients, a total of 85 acute ischemic stroke patients met our inclusion criteria: mean age 71 ± 11years, 56% men, median National Institutes of Health Stroke Scale 17 (interquartile range 14-20). Of these patients, 41 (48%) and 44 (52%) were randomized to intravenous tissue plasminogen activator alone and sonothrombolysis, respectively. More patients achieved sustained complete recanalization in the sonothrombolysis than in the intravenous tissue plasminogen activator alone group (38·6% vs. 17·1%; P = 0·032). Functional independence at 90 days was more frequently achieved in the sonothrombolysis than in the intravenous tissue plasminogen activator alone group (37·2% vs. 15·8%; P = 0·045). Symptomatic intracranial hemorrhage rate was similar in both groups (4·9% vs. 4·6%; P = 1·00). CONCLUSIONS Our results point to a signal of efficacy and provide information to guide the subsequent phase III randomized trial of sonothrombolysis in patients with severe ischemic strokes.
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Affiliation(s)
- Kristian Barlinn
- Dresden University Stroke Center,Department of Neurology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Georgios Tsivgoulis
- Department of Neurology,The University of Tennessee Health Science Center, Memphis, TN, USA
- Second Department of Neurology,School of Medicine, Attikon Hospital, University of Athens, Greece
- International Clinical Research Centre,Neurology department, St. Anne's University Hospital in Brno and Masaryk University, Czech Republic
| | | | | | - Carlos A Molina
- Neurovascular Unit, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Robert Mikulik
- International Clinical Research Centre,Neurology department, St. Anne's University Hospital in Brno and Masaryk University, Czech Republic
| | - Maher Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew M Demchuk
- University of Calgary, Department of Clinical Neurosciences, Calgary Stroke Program, Canada
| | | | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, USA
| | - Andrei V. Alexandrov
- Department of Neurology,The University of Tennessee Health Science Center, Memphis, TN, USA
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30
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Barlinn K, Seibt J, Engellandt K, Gerber J, Puetz V, Kepplinger J, Wunderlich O, Pallesen LP, Bodechtel U, Koch R, von Kummer R, Dzialowski I. Multimodal Computed Tomography Based Definition of Cerebral Imaging Profiles for Acute Stroke Reperfusion Therapy (CT-DEFINE): Results of a Prospective Observational Study. Clin Neuroradiol 2014; 25:403-10. [PMID: 25150187 DOI: 10.1007/s00062-014-0320-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/17/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE To prospectively evaluate the prognostic impact of multimodal computed tomography-based imaging in ischemic stroke patients potentially eligible for reperfusion therapy. METHODS Anterior circulation stroke patients underwent non-contrast CT (NCCT), CT-angiography, and CT-perfusion within 12 h from symptom-onset. Patients could be treated with intravenous-tissue plasminogen activator (IV-tPA), endovascular or combined reperfusion therapies. Cerebral imaging profiles (IP) were NCCT-Alberta Stroke Program Early CT Score (ASPECTS) > 7 (IP1); NCCT-ASPECTS > 5 and proximal occlusion on CT-angiography (IP2); CT-perfusion mismatch between cerebral blood volume (CBV)-ASPECTS, and cerebral blood flow (CBF)-ASPECTS ≥ 2 (IP3). Favorable outcome was defined as modified Rankin Scale ≤ 2 at 3 months. RESULTS Of 102 included patients, 62 (61%) received any reperfusion therapy. In IP2 and IP3, favorable outcome was more frequent in patients with reperfusion therapy than in those without; however, this did not reach statistical significance (IP2: 39% vs 15%, p = 0.26; IP3: 50% vs 17 %; p = 0.31). No difference was seen in IP1 (58% vs 58%, p = 1.0). In IP2, patients with IV-tPA alone achieved better functional outcome (50% vs 11%, p = 0.03) and lower mortality (0% vs 28%, p = 0.045) than those without. CONCLUSIONS Our results suggest a benefit with imaging profile selection based upon the combination of a small-to-moderate-sized infarction and a visible intracranial occlusion in patients receiving IV-tPA. Reperfusion therapy may be futile in patients without proven vessel occlusion.
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Affiliation(s)
- K Barlinn
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - J Seibt
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - K Engellandt
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - J Gerber
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - V Puetz
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - J Kepplinger
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - O Wunderlich
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - L-P Pallesen
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - U Bodechtel
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - R Koch
- Institute for Medical Informatics and Biometry, University Hospital Dresden, Dresden, Germany
| | - R von Kummer
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - I Dzialowski
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- Elblandklinikum Meissen, Department of Neurology, Academic Teaching Hospital of the University of Technology Dresden, Meissen, Germany
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31
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Menetti F, Verganti L, Zini A, Vallone S, Carpeggiani P, Andersson T. Intra-arterial therapy as a rescue strategy after clinically failed intravenous thrombolysis may increase the likelihood of a good outcome in patients with severe ischaemic stroke. A retrospective two centre study. Interv Neuroradiol 2014; 20:329-35. [PMID: 24976096 DOI: 10.15274/inr-2014-10030] [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: 10/21/2013] [Accepted: 01/12/2014] [Indexed: 11/12/2022] Open
Abstract
The purpose of this study was to evaluate the efficacy and safety of intra-arterial therapy as a rescue strategy after clinically failed intravenous thrombolysis (IVT) in acute ischaemic stroke patients. We conducted a retrospective analysis of consecutive acute ischaemic stroke patients treated with rescue therapy. The results from this study group were compared with those obtained from a control group consisting of 260 consecutive patients treated with IVT alone. The study group consisted of 52 patients with a mean age of 63 years and a median NIHSS score at admission of 17. Recanalization was achieved in 92% with a symptomatic haemorrhage rate of 9.6%. Rescue patients admitted with a severe stroke (NIHSS score >12) had a significantly better outcome at 90 days compared to patients with the same score but treated with IVT alone. No difference was seen for patients with a lower score at admission. This study indicates that rescue therapy may increase the proportion of patients with independent outcome if presenting with a severe stroke (NIHSS score >12) without increasing the rate of symptomatic haemorrhage.
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Affiliation(s)
- Federico Menetti
- Stroke Unit, Department of Neuroscience, "S. Agostino Estense" Hospital; Modena, Italy -
| | - Luca Verganti
- Stroke Unit, Department of Neuroscience, "S. Agostino Estense" Hospital; Modena, Italy
| | - Andrea Zini
- Stroke Unit, Department of Neuroscience, "S. Agostino Estense" Hospital; Modena, Italy
| | - Stefano Vallone
- Stroke Unit, Department of Neuroscience, "S. Agostino Estense" Hospital; Modena, Italy
| | - Paolo Carpeggiani
- Stroke Unit, Department of Neuroscience, "S. Agostino Estense" Hospital; Modena, Italy
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32
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Sun YY, Morozov YM, Yang D, Li Y, Dunn RS, Rakic P, Chan PH, Abe K, Lindquist DM, Kuan CY. Synergy of combined tPA-edaravone therapy in experimental thrombotic stroke. PLoS One 2014; 9:e98807. [PMID: 24911517 PMCID: PMC4049665 DOI: 10.1371/journal.pone.0098807] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 05/07/2014] [Indexed: 01/03/2023] Open
Abstract
Edaravone, a potent antioxidant, may improve thrombolytic therapy because it benefits ischemic stroke patients on its own and mitigates adverse effects of tissue plasminogen activator (tPA) in preclinical models. However, whether the combined tPA-edaravone therapy is more effective in reducing infarct size than singular treatment is uncertain. Here we investigated this issue using a transient hypoxia-ischemia (tHI)-induced thrombotic stroke model, in which adult C57BL/6 mice were subjected to reversible ligation of the unilateral common carotid artery plus inhalation of 7.5% oxygen for 30 min. While unilateral occlusion of the common carotid artery suppressed cerebral blood flow transiently, the addition of hypoxia triggered reperfusion deficits, endogenous thrombosis, and attenuated tPA activity, leading up to infarction. We compared the outcomes of vehicle-controls, edaravone treatment, tPA treatment at 0.5, 1, or 4 h post-tHI, and combined tPA-edaravone therapies with mortality rate and infarct size as the primary end-points. The best treatment was further compared with vehicle-controls in behavioral, biochemical, and diffusion tensor imaging (DTI) analyses. We found that application of tPA at 0.5 or 1 h – but not at 4 h post-tHI – significantly decreased infarct size and showed synergistic (p<0.05) or additive benefits with the adjuvant edaravone treatment, respectively. The acute tPA-edaravone treatment conferred >50% reduction of mortality, ∼80% decline in infarct size, and strong white-matter protection. It also improved vascular reperfusion and decreased oxidative stress, inflammatory cytokines, and matrix metalloproteinase activities. In conclusion, edaravone synergizes with acute tPA treatment in experimental thrombotic stroke, suggesting that clinical application of the combined tPA-edaravone therapy merits investigation.
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Affiliation(s)
- Yu-Yo Sun
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America
| | - Yury M. Morozov
- Department of Neurobiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Dianer Yang
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America
| | - Yikun Li
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America
| | - R. Scott Dunn
- Imaging Research Center, Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Pasko Rakic
- Department of Neurobiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Pak H. Chan
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Koji Abe
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Diana M. Lindquist
- Imaging Research Center, Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Chia-Yi Kuan
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America
- * E-mail:
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33
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Machine learning for outcome prediction of acute ischemic stroke post intra-arterial therapy. PLoS One 2014; 9:e88225. [PMID: 24520356 PMCID: PMC3919736 DOI: 10.1371/journal.pone.0088225] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 01/03/2014] [Indexed: 12/14/2022] Open
Abstract
Introduction Stroke is a major cause of death and disability. Accurately predicting stroke outcome from a set of predictive variables may identify high-risk patients and guide treatment approaches, leading to decreased morbidity. Logistic regression models allow for the identification and validation of predictive variables. However, advanced machine learning algorithms offer an alternative, in particular, for large-scale multi-institutional data, with the advantage of easily incorporating newly available data to improve prediction performance. Our aim was to design and compare different machine learning methods, capable of predicting the outcome of endovascular intervention in acute anterior circulation ischaemic stroke. Method We conducted a retrospective study of a prospectively collected database of acute ischaemic stroke treated by endovascular intervention. Using SPSS®, MATLAB®, and Rapidminer®, classical statistics as well as artificial neural network and support vector algorithms were applied to design a supervised machine capable of classifying these predictors into potential good and poor outcomes. These algorithms were trained, validated and tested using randomly divided data. Results We included 107 consecutive acute anterior circulation ischaemic stroke patients treated by endovascular technique. Sixty-six were male and the mean age of 65.3. All the available demographic, procedural and clinical factors were included into the models. The final confusion matrix of the neural network, demonstrated an overall congruency of ∼80% between the target and output classes, with favourable receiving operative characteristics. However, after optimisation, the support vector machine had a relatively better performance, with a root mean squared error of 2.064 (SD: ±0.408). Discussion We showed promising accuracy of outcome prediction, using supervised machine learning algorithms, with potential for incorporation of larger multicenter datasets, likely further improving prediction. Finally, we propose that a robust machine learning system can potentially optimise the selection process for endovascular versus medical treatment in the management of acute stroke.
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Tsivgoulis G, Alleman J, Katsanos AH, Barreto AD, Kohrmann M, Schellinger PD, Molina CA, Alexandrov AV. Comparative efficacy of different acute reperfusion therapies for acute ischemic stroke: a comprehensive benefit-risk analysis of clinical trials. Brain Behav 2014; 4:789-97. [PMID: 25365799 PMCID: PMC4178251 DOI: 10.1002/brb3.279] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/09/2014] [Accepted: 08/18/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Numerous acute reperfusion therapies (RPT) are currently investigated as potential new therapeutic targets in acute ischemic stroke (AIS). We conducted a comprehensive benefit-risk analysis of available clinical studies assessing different acute RPT, and investigated the utility of each intervention in comparison to standard intravenous thrombolysis (IVT) and in relation to the onset-to-treatment time (OTT). METHODS A comprehensive literature search was conducted to identify all available published, peer-reviewed clinical studies that evaluated the efficacy of different RPT in AIS. Benefit-to-risk ratio (BRR), adjusted for baseline stroke severity, was estimated as the percentage of patients achieving favorable functional outcome (BRR1, mRS score: 0-1) or functional independence (BRR2, mRS score: 0-2) at 3 months divided by the percentage of patients who died during the same period. RESULTS A total of 18 randomized (n = 13) and nonrandomized (n = 5) clinical studies fulfilled our inclusion criteria. IV therapy with tenecteplase (TNK) was found to have the highest BRRs (BRR1 = 5.76 and BRR2 = 6.82 for low-dose TNK; BRR1 = 5.80 and BRR2 = 6.87 for high-dose TNK), followed by sonothrombolysis (BRR1 = 2.75 and BRR2 = 3.38), while endovascular thrombectomy with MERCI retriever was found to have the lowest BRRs (BRR1 range, 0.31-0.65; BRR2 range, 0.52-1.18). A second degree negative polynomial correlation was detected between favorable functional outcome and OTT (R (2) value: 0.6419; P < 0.00001) indicating the time dependency of clinical efficacy of all reperfusion therapies. CONCLUSION Intravenous thrombolysis (IVT) with TNK and sonothrombolysis have the higher BRR among investigational reperfusion therapies. The combination of sonothrombolysis with IV administration of TNK appears a potentially promising therapeutic option deserving further investigation.
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Affiliation(s)
- Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center Memphis, Tennessee ; Second Department of Neurology, "Attikon Hospital", School of Medicine, University of Athens Athens, Greece ; International Clinical Research Center, St. Anne's University Hospital in Brno Brno, Czech Republic
| | | | | | - Andrew D Barreto
- Department of Neurology, University of Texas-Houston Medical School Houston, Texas
| | - Martin Kohrmann
- Department of Neurology, University Clinic at Erlangen Erlangen, Germany
| | - Peter D Schellinger
- Departments of Neurology and Neurogeriatry, Johannes Wesling Clinic Minden Minden, Germany
| | - Carlos A Molina
- Neurovascular Unit, Department of Neurology, Hospital Vall d'Hebron Barcelona, Spain
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center Memphis, Tennessee
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35
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Barreto AD, Alexandrov AV, Shen L, Sisson A, Bursaw AW, Sahota P, Peng H, Ardjomand-Hessabi M, Pandurengan R, Rahbar MH, Barlinn K, Indupuru H, Gonzales NR, Savitz SI, Grotta JC. CLOTBUST-Hands Free. Stroke 2013; 44:3376-81. [DOI: 10.1161/strokeaha.113.002713] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew D. Barreto
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - Andrei V. Alexandrov
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - Loren Shen
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - April Sisson
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - Andrew W. Bursaw
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - Preeti Sahota
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - Hui Peng
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - Manouchehr Ardjomand-Hessabi
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - Renganayaki Pandurengan
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - Mohammad H. Rahbar
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - Kristian Barlinn
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - Hari Indupuru
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - Nicole R. Gonzales
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - Sean I. Savitz
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
| | - James C. Grotta
- From the Department of Neurology, Stroke Program (A.D.B., L.S., A.W.B., P.S., H.I., N.R.G., S.I.S., J.C.G.) and Center for Clinical and Translational Sciences (H.P., M.A.-H., R.P., M.H.R.), University of Texas Health Science Center at Houston, TX; Comprehensive Stroke Center, Department of Neurology, The University of Alabama at Birmingham (A.V.A., A.S.); and Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany (K.B.)
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Simon S, Grey CP, Massenzo T, Simpson DG, Longest PW. Exploring the efficacy of cyclic vs static aspiration in a cerebral thrombectomy model: an initial proof of concept study. J Neurointerv Surg 2013; 6:677-83. [PMID: 24235098 DOI: 10.1136/neurintsurg-2013-010941] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE Current technology for endovascular thrombectomy in ischemic stroke utilizes static loading and is successful in approximately 85% of cases. Existing technology uses either static suction (applied via a continuous pump or syringe) or flow arrest with a proximal balloon. In this paper we evaluate the potential of cyclic loading in aspiration thrombectomy. METHODS In order to evaluate the efficacy of cyclic aspiration, a model was created using a Penumbra aspiration system, three-way valve and Penumbra 5Max catheter. Synthetic clots were aspirated at different frequencies and using different aspiration mediums. Success or failure of clot removal and time were recorded. All statistical analyses were based on either a one-way or two-way analysis of variance, Holm-Sidak pairwise multiple comparison procedure (α=0.05). RESULTS Cyclic aspiration outperformed static aspiration in overall clot removal and removal speed (p<0.001). Within cyclic aspiration, Max Hz frequencies (∼6.3 Hz) cleared clots faster than 1 Hz (p<0.001) and 2 Hz (p=0.024). Loading cycle dynamics (specific pressure waveforms) affected speed and overall clearance (p<0.001). Water as the aspiration medium was more effective at clearing clots than air (p=0.019). CONCLUSIONS Cyclic aspiration significantly outperformed static aspiration in speed and overall clearance of synthetic clots in our experimental model. Within cyclic aspiration, efficacy is improved by increasing cycle frequency, utilizing specific pressure cycle waveforms and using water rather than air as the aspiration medium. These findings provide a starting point for altering existing thrombectomy technology or perhaps the development of new technologies with higher recanalization rates.
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Affiliation(s)
- Scott Simon
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Casey Paul Grey
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Trisha Massenzo
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - David G Simpson
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - P Worth Longest
- Department of Mechanical Engineering, Virginia Commonwealth University, Richmond, Virginia, USA Department of Pharmaceutics, Virginia Commonwealth University, Richmond, Virginia, USA
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Barreto AD, Pedroza C, Grotta JC. Adjunctive medical therapies for acute stroke thrombolysis: is there a CLEAR-ER choice? Stroke 2013; 44:2377-9. [PMID: 23887845 PMCID: PMC3845499 DOI: 10.1161/strokeaha.113.001830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew D. Barreto
- Department of Neurology, Stroke Program; University of Texas Health Science Center at Houston, Houston, Texas
| | - Claudia Pedroza
- Department of Pediatrics, Center for Clinical Research and Evidence-Based Medicine; University of Texas Health Science Center at Houston, Houston, Texas
| | - James C. Grotta
- Department of Neurology, Stroke Program; University of Texas Health Science Center at Houston, Houston, Texas
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Barlinn K, Barreto AD, Sisson A, Liebeskind DS, Schafer ME, Alleman J, Zhao L, Shen L, Cava LF, Rahbar MH, Grotta JC, Alexandrov AV. CLOTBUST-hands free: initial safety testing of a novel operator-independent ultrasound device in stroke-free volunteers. Stroke 2013; 44:1641-6. [PMID: 23598523 PMCID: PMC4156594 DOI: 10.1161/strokeaha.113.001122] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to evaluate safety and tolerability of a novel operator-independent ultrasound device among stroke-free volunteers. METHODS A headframe containing 18 ultrasound transducers (each operating at 2 MHz, pulsed-wave) was used to expose both temporal windows and the suboccipital window. The transmission characteristics were set to emulate the acoustic characteristics of the exposure levels in the Combined Lysis of Thrombus in Brain Ischemia using Transcranial Ultrasound and Systemic tPA (CLOTBUST) trial and to never exceed Food and Drug Administration mandated diagnostic ultrasound exposure limits. Volunteers underwent 2 hours of insonation with transducer activation one at a time. Safety was captured using serial neurological examinations and pre- and postinsonation MRI for detection of the blood brain barrier permeability. RESULTS A total of 15 volunteers (40% men; 49 ± 16 years; 27% black; all pre-exposure National Institutes of Health Stroke Scale scores 0) were enrolled. Five volunteers received pulsed-wave ultrasound via the best pair temporal transducers, 5 via sequential activation of the suboccipital transducers, and 5 via sequential activation of all bilateral temporal and suboccipital transducers. All subjects were safely insonated with no adverse effects as indicated by the neurological examinations during, immediately after the exposure, and at 24 hours, and no abnormality of the blood brain barrier was found on any of the MRIs. CONCLUSIONS Our novel device was well tolerated by stroke-free volunteers and did not cause any neurological dysfunction nor did it affect blood brain barrier integrity. The safety and efficacy of the device are now being tested in stroke patients receiving intravenous tissue-type plasminogen activator in phase II-III clinical trials.
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Affiliation(s)
- Kristian Barlinn
- Department of Neurology, Comprehensive Stroke Center, The University of Alabama at Birmingham, RWUH M226, 619 19th St South, Birmingham, AL 35249-3280, USA
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Abstract
OPINION STATEMENT Acute ischemic stroke remains one of the most devastating diseases when it comes to morbidity and mortality, not to mention the personal and economic burden that occurs in long-term. Intravenous thrombolysis with tissue plasminogen activator (tPA) is the only effective acute stroke therapy that improves outcome if given up to 4.5 hours from symptom onset. However, recanalization rates are meager and the majority of treated patients still have residual disability after stroke, emphasizing the need for further treatment options that may facilitate or even rival the only approved therapy. Sonothrombolysis, the adjuvant continuous ultrasound sonication of an intra-arterial occlusive thrombus during thrombolysis, enhances the clot-dissolving capabilities of intravenous tPA presumably by delivering acoustic pressure to the target brain vessel. Higher recanalization rates produce a trend towards better functional outcomes that could be safely achieved with the combination of high-frequency ultrasound and intravenous tPA. However, data on ultrasound targeting of intracranial proximal occlusive lesions other than those in the middle cerebral arteries are sparse. Moreover, recent sonothrombolysis trials were exclusively conducted with operator-dependent hand-held technology hindering its further testing in clinical sonothrombolysis trials. An operator-independent 2-MHz transcranial Doppler device has been developed allowing health care professionals not formally trained in ultrasound apparatus to provide therapeutic ultrasound as needed. Currently, this operator-independent device covering 12 proximal intracranial segments that most commonly contain thrombo-embolic occlusions enters testing in a pivotal multicenter sonothrombolysis efficacy trial. If this trial demonstrates safety and efficacy, adjuvants, such as gaseous microbubbles that further potentiate the thrombolytic effect of intravenous tPA, could be tested along with this device.
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Kepplinger J, Dzialowski I, Barlinn K, Puetz V, Wojciechowski C, Schneider H, Gahn G, Back T, Schackert G, Reichmann H, von Kummer R, Bodechtel U. Emergency Transfer of Acute Stroke Patients within the East Saxony Telemedicine Stroke Network: A Descriptive Analysis. Int J Stroke 2013; 9:160-5. [DOI: 10.1111/ijs.12032] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Telemedicine may facilitate the selection of stroke patients who require emergency transfer to a comprehensive stroke center to receive additional therapies other than intravenous tissue plasminogen activator. Aims and/or hypothesis We sought to analyze frequency, patient characteristics, and specific therapies among emergently transferred patients within the telemedical Stroke East Saxony Network. Methods We reviewed consecutive patients who were transferred emergently from remote spoke sites to hub sites. Certified stroke neurologists performed teleconsultations 24/7, with access to high-speed videoconferencing and transfer of brain images. Emergent transfers were initiated when considered necessary by the stroke neurologist. Results In 2009 and 2010, we conducted 1413 teleconsultations and subsequently recommended transfer in 339 (24%) patients [mean age 64 ± 14 years, 54% males, median National Institutes of Health Stroke Scale score 5 (interquartile range, IQR 12). The mean teleconsultation-to-arrival time was 1·7 ± 0·8 h (median 1·6 h). Sixty-eight (20%) transferred patients had a nonstroke diagnosis. The remaining 271 (80%) patients had stroke diagnoses [ischemic stroke, 114 (34%); transient ischemic attack, 8 (2%); and intracranial haemorrhage, 149 (44%)]. Forty (35%) ischemic stroke patients received tissue plasminogen activator at spoke sites (‘drip and ship’). Of the 240 stroke patients emergently transferred to the main hub site, 119 (49·6%) received at least one specific stroke therapy. Conclusion A remarkable number of stroke patients can be transferred within a telemedical network to enable the delivery of specific stroke therapies that require advanced multispecialty expertise. Whether associated logistic efforts and costs have an impact on patients' clinical outcomes needs to be evaluated.
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Affiliation(s)
- Jessica Kepplinger
- Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany
| | - Imanuel Dzialowski
- Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany
| | - Claudia Wojciechowski
- Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany
| | - Hauke Schneider
- Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany
| | - Georg Gahn
- Department of Neurology, Community Hospital Karlsruhe, Karlsruhe, Germany
| | - Tobias Back
- Department of Neurology, Saxon Hospital Arnsdorf, Arnsdorf, Germany
| | - Gabriele Schackert
- Department of Neurosurgery, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany
| | - Ruediger von Kummer
- Department of Neuroradiology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany
| | - Ulf Bodechtel
- Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany
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Liu X. Beyond the time window of intravenous thrombolysis: standing by or by stenting? INTERVENTIONAL NEUROLOGY 2012; 1:3-15. [PMID: 25187761 PMCID: PMC4031767 DOI: 10.1159/000338389] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Intravenous administration of tissue plasminogen activator within 4.5 h of symptom onset is presently the 'golden rule' for treating acute ischemic stroke. However, many patients miss the time window and others reject this treatment due to a long list of contraindications. Mechanical embolectomy has recently progressed as a potential alternative for treating patients beyond the time window for IV thrombolysis. In this paper, recent progress in mechanical embolectomy, angioplasty, and stenting in acute stroke is reviewed. Despite worries concerning the long-term clinical outcomes and increased risk of intracranial hemorrhage, favorable clinical outcomes may be achieved after mechanical embolectomy in carefully selected patients even 4.5 h after stroke onset. Potential steps should be prepared and attempted in these patients whose opportunity for recovery will elapse in a flash.
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Affiliation(s)
- Xinfeng Liu
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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