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Yoo J, Jeon J, Baik M, Kim J. Association between statin therapy and the risk of stroke in patients with moyamoya disease: a nationwide cohort study. Stroke Vasc Neurol 2023; 8:276-283. [PMID: 36549762 PMCID: PMC10512045 DOI: 10.1136/svn-2022-001985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/04/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Knowledge regarding the pharmacological treatment for moyamoya disease (MMD), a chronic and progressive cerebrovascular disease conferring greater stroke risk, is limited. In the present study, whether statin therapy is associated with a reduced risk of stroke in patients with MMD was investigated. METHODS This was a retrospective cohort study in which the occurrence of stroke in patients with newly diagnosed MMD was investigated using the nationwide health insurance database in Korea from January 2007 to March 2021. A multivariable Cox proportional hazards regression model was constructed for stroke, in which statin therapy after MMD diagnosis was treated as a time-dependent variable. Adjustment was done for sex, age, presence of comorbidities, concurrent stroke, revascularisation surgery and treatment with antiplatelets. RESULTS The present study included 13 373 newly diagnosed patients with MMD; 40.8% had a concurrent stroke at the time of MMD diagnosis. During the mean follow-up of 5.1±3.3 years, 631 patients (4.7%) suffered a stroke event (haemorrhagic stroke: 458 patients, ischaemic stroke: 173 patients). Statin therapy after MMD diagnosis was significantly associated with a reduced risk of stroke (adjusted HR 0.74; 95% CI 0.60 to 0.91, p=0.004). In the secondary outcome analysis, the risk of haemorrhagic stroke (adjusted HR 0.74; 95% CI 0.58 to 0.95, p=0.018) and ischaemic stroke (adjusted HR 0.75; 95% CI 0.52 to 1.08, p=0.124) were reduced with the statin treatment. Taking statins was also associated with a lower risk of all-cause mortality (adjusted HR 0.47; 95% CI 0.33 to 0.67, p<0.001). CONCLUSION In patients with MMD, statin therapy was associated with a reduced risk of subsequent stroke. The findings indicate statin treatment may be beneficial for patients with MMD, however the results should be confirmed in randomised controlled trials.
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Affiliation(s)
- Joonsang Yoo
- Department of Neurology, Yongin Severance Hospital, Yonsei College of Medicine, Yongin-si, Korea (the Republic of)
| | - Jimin Jeon
- Department of Neurology, Yongin Severance Hospital, Yonsei College of Medicine, Yongin-si, Korea (the Republic of)
| | - Minyoul Baik
- Department of Neurology, Yongin Severance Hospital, Yonsei College of Medicine, Yongin-si, Korea (the Republic of)
| | - Jinkwon Kim
- Department of Neurology, Yongin Severance Hospital, Yonsei College of Medicine, Yongin-si, Korea (the Republic of)
- Institute for Innovation in Digital Healthcare, Yonsei University, Seoul, Korea (the Republic of)
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2
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Kimura K, Kubo Y, Dobashi K, Katakura Y, Chida K, Kobayashi M, Yoshida K, Fujiwara S, Terasaki K, Kawamura T, Ogasawara K. Angiographic, Cerebral Hemodynamic, and Cognitive Outcomes of Indirect Revascularization Surgery Alone for Adult Patients With Misery Perfusion due to Ischemic Moyamoya Disease. Neurosurgery 2022; 90:676-683. [PMID: 35311740 DOI: 10.1227/neu.0000000000001907] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Revascularization surgery for adult patients with ischemic moyamoya disease (MMD) may improve both cognitive function and cerebral perfusion. OBJECTIVE To determine angiographic, cerebral hemodynamic, and cognitive outcomes of indirect revascularization surgery alone for adult patients with misery perfusion due to ischemic MMD (IDR group) and to test the superiority of indirect revascularization surgery for cognitive improvement by conducting comparisons with historical control patients who had undergone direct revascularization surgery (DR group) through prospective cohort study with historical controls. METHODS Twenty adult patients with cerebral misery perfusion underwent encephalo-duro-myo-arterio-pericranial-synangiosis alone. Cerebral angiography through arterial catheterization, brain perfusion single-photon emission computed tomography, and neuropsychological testing were performed preoperatively and at 6 months postoperatively. RESULTS In 17 patients of the IDR group, collateral flows that were newly formed after surgery on angiograms fed more than one-third of the middle cerebral artery (MCA) cortical territory. In the IDR group, perfusion in the MCA territory was significantly increased after surgery (P < .0001), and the difference in MCA perfusion between before and after surgery was significantly greater (P = .0493) compared with the DR group. Improved cognition was significantly more frequent in the IDR group (65%) than in the DR group (31%, P = .0233). CONCLUSION Indirect revascularization surgery alone forms sufficient collateral circulation, improves cerebral hemodynamics, and recovers cognitive function in adult patients with misery perfusion due to ischemic MMD. The latter 2 beneficial effects may be higher when compared with patients undergoing direct revascularization surgery.
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Affiliation(s)
- Kazuto Kimura
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
| | - Yoshitaka Kubo
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
| | - Kazumasa Dobashi
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
| | - Yasukazu Katakura
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
| | - Kohei Chida
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
- Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, Japan
| | - Masakazu Kobayashi
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
- Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, Japan
| | - Kenji Yoshida
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
| | - Shunrou Fujiwara
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
| | - Kazunori Terasaki
- Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, Japan
| | | | - Kuniaki Ogasawara
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
- Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, Japan
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Pan N, Li ZC, Li ZH, Chen SH, Jiang MH, Yang HY, Liu YS, Hu R, Zeng YW, Dai LH, Liu L, Wang GL. Antiplatelet and Antithrombotic Effects of Isaridin E Isolated from the Marine-Derived Fungus via Downregulating the PI3K/Akt Signaling Pathway. Mar Drugs 2021; 20:23. [PMID: 35049878 PMCID: PMC8780978 DOI: 10.3390/md20010023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/21/2021] [Accepted: 12/21/2021] [Indexed: 02/07/2023] Open
Abstract
Isaridin E, a cyclodepsipeptide isolated from the marine-derived fungus Amphichorda felina (syn. Beauveria felina) SYSU-MS7908, has been demonstrated to possess anti-inflammatory and insecticidal activities. Here, we first found that isaridin E concentration-dependently inhibited ADP-induced platelet aggregation, activation, and secretion in vitro, but did not affect collagen- or thrombin-induced platelet aggregation. Furthermore, isaridin E dose-dependently reduced thrombosis formation in an FeCl3-induced mouse carotid model without increasing the bleeding time. Mechanistically, isaridin E significantly decreased the ADP-mediated phosphorylation of PI3K and Akt. In conclusion, these results suggest that isaridin E exerts potent antithrombotic effects in vivo without increasing the risk of bleeding, which may be due to its important role in inhibiting ADP-induced platelet activation, secretion and aggregation via the PI3K/Akt pathways.
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Affiliation(s)
- Ni Pan
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China; (N.P.); (Z.-C.L.); (Z.-H.L.); (H.-Y.Y.); (Y.-S.L.); (R.H.); (Y.-W.Z.)
- Institute of Pediatrics, Guangzhou Women and Children’s Medical Centre, Guangzhou Medical University, Guangzhou 510080, China
| | - Zi-Cheng Li
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China; (N.P.); (Z.-C.L.); (Z.-H.L.); (H.-Y.Y.); (Y.-S.L.); (R.H.); (Y.-W.Z.)
| | - Zhi-Hong Li
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China; (N.P.); (Z.-C.L.); (Z.-H.L.); (H.-Y.Y.); (Y.-S.L.); (R.H.); (Y.-W.Z.)
| | - Sen-Hua Chen
- School of Marine Sciences, Sun Yat-sen University, Guangzhou 510080, China; (S.-H.C.); (M.-H.J.)
| | - Ming-Hua Jiang
- School of Marine Sciences, Sun Yat-sen University, Guangzhou 510080, China; (S.-H.C.); (M.-H.J.)
| | - Han-Yan Yang
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China; (N.P.); (Z.-C.L.); (Z.-H.L.); (H.-Y.Y.); (Y.-S.L.); (R.H.); (Y.-W.Z.)
| | - Yao-Sheng Liu
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China; (N.P.); (Z.-C.L.); (Z.-H.L.); (H.-Y.Y.); (Y.-S.L.); (R.H.); (Y.-W.Z.)
| | - Rui Hu
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China; (N.P.); (Z.-C.L.); (Z.-H.L.); (H.-Y.Y.); (Y.-S.L.); (R.H.); (Y.-W.Z.)
| | - Yu-Wei Zeng
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China; (N.P.); (Z.-C.L.); (Z.-H.L.); (H.-Y.Y.); (Y.-S.L.); (R.H.); (Y.-W.Z.)
| | - Le-Hui Dai
- Department of Basic Medical Sciences, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China;
| | - Lan Liu
- School of Marine Sciences, Sun Yat-sen University, Guangzhou 510080, China; (S.-H.C.); (M.-H.J.)
| | - Guan-Lei Wang
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China; (N.P.); (Z.-C.L.); (Z.-H.L.); (H.-Y.Y.); (Y.-S.L.); (R.H.); (Y.-W.Z.)
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Seo WK, Kim JY, Choi EH, Kim YS, Chung JW, Saver JL, Bang OY, Kim GM. Association of Antiplatelet Therapy, Including Cilostazol, With Improved Survival in Patients With Moyamoya Disease in a Nationwide Study. J Am Heart Assoc 2021; 10:e017701. [PMID: 33615836 PMCID: PMC8174237 DOI: 10.1161/jaha.120.017701] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Although antiplatelet agents are frequently prescribed in moyamoya disease in routine clinical practice, there are no large‐scale epidemiologic trials or randomized trial evidence to support their use in patients with moyamoya disease. Methods and Results Using the Korean National Health Insurance Service database, patients diagnosed with moyamoya disease between 2002 and 2016 were followed up for up to 14 years to assess, using time‐dependent Cox regression in all patients and in a propensity score–matched cohort, the association of antiplatelet therapy and individual antiplatelet agents with survival. Among 25 978 patients with newly diagnosed moyamoya disease, mean age was 37.6±19.9 years, 61.6% were women, and total follow‐up was 163 347 person‐years. Among 9154 patients who were prescribed antiplatelet agents at least once during the follow‐up period, the proportion prescribed cilostazol gradually increased from 5.5% in 2002 to 56.0% in 2016. Any antiplatelet use was associated with reduced risk of death (hazard ratio, 0.77; 95% CI, 0.70–0.84) in a multivariate model. Among individual antiplatelet agents, cilostazol was associated with greater reduction in mortality than the 5 other antiplatelet regimens. Subgroup analysis, according to the age group and history of ischemic stroke, and sensitivity analysis, using propensity score–matched analysis, revealed consistent results. Conclusions Antiplatelet therapy is associated with substantial improvement in survival in patients with moyamoya disease, and cilostazol is associated with greater survival benefit compared with other antiplatelet regimens. These results provisionally support the use of antiplatelet therapy in patients with moyamoya disease and the conduct of confirmatory randomized controlled trials.
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Affiliation(s)
- Woo-Keun Seo
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea.,Department of Digital Health Samsung Advanced Institute for Health Sciences & TechnologySungkyunkwan University Seoul Korea
| | - Jae-Young Kim
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea.,Department of Digital Health Samsung Advanced Institute for Health Sciences & TechnologySungkyunkwan University Seoul Korea
| | - Eun-Hyeok Choi
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea
| | - Ye-Sel Kim
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea
| | - Jong-Won Chung
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea
| | - Jeffrey L Saver
- Department of Digital Health Samsung Advanced Institute for Health Sciences & TechnologySungkyunkwan University Seoul Korea.,Department of Neurology University of California Los Angeles CA
| | - Oh Young Bang
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea
| | - Gyeong-Moon Kim
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea
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Cilostazol Addition to Aspirin could not Reduce the Neurological Deterioration in TOAST Subtypes: ADS Post-Hoc Analysis. J Stroke Cerebrovasc Dis 2020; 30:105494. [PMID: 33278804 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/15/2020] [Accepted: 11/20/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Our previous trial acute dual study (ADS) reported that dual antiplatelet therapy (DAPT) using cilostazol and aspirin did not reduce the rate of short-term neurological worsening in non-cardioembolic stroke patients. Present post-hoc analysis investigated whether the impact of combined cilostazol and aspirin differed among stroke subtypes and factors associated with neurological deterioration and/or stroke recurrence. METHODS Using the ADS registry, the rate of neurological deterioration, defined as clinical worsening and/or recurrent stroke, including transient ischemic attack was calculated. Stroke subtypes included large-artery atherosclerosis (LAA), small vessel occlusion (SVO), other determined etiology (Others), and undetermined etiology of stroke (Undetermined). RESULTS Data of 1022 patients were analyzed. Deterioration was seen in 104 (10%) patients, and the rates were not markedly different between patients treated with DAPT vs. aspirin in any stroke subtypes: LAA, 19% vs. 11%, (p=0.192); SVO, 10% vs. 10% (p=1.000); Others, 6% vs. 6% (p=1.000); Undetermined, 11% vs. 8% (p=0.590). Diabetes mellitus was the independent factor associated with deterioration (odds ratio 4.360, 95% confidence interval 1.139-16.691, p=0.032) in the LAA group. Age (1.030 [1.004-1.057], p=0.026), systolic blood pressure (1.012 [1.003-1.022], p=0.010), and infarct size (2.550 [1.488-4.371], p=0.001) were associated with deterioration in SVO group, and intracranial stenosis/occlusion was associated with it in the Undetermined group (3.744 [1.138-12.318], p=0.030). CONCLUSIONS Combined cilostazol and aspirin did not reduce the rate of short-term neurological deterioration in any clinical stroke subtype. The characteristics of patients whose condition deteriorates in the acute period may differ based on the stroke subtypes.
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Mustapha M, Nassir CMNCM, Aminuddin N, Safri AA, Ghazali MM. Cerebral Small Vessel Disease (CSVD) - Lessons From the Animal Models. Front Physiol 2019; 10:1317. [PMID: 31708793 PMCID: PMC6822570 DOI: 10.3389/fphys.2019.01317] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 09/30/2019] [Indexed: 12/28/2022] Open
Abstract
Cerebral small vessel disease (CSVD) refers to a spectrum of clinical and imaging findings resulting from pathological processes of various etiologies affecting cerebral arterioles, perforating arteries, capillaries, and venules. Unlike large vessels, it is a challenge to visualize small vessels in vivo, hence the difficulty to directly monitor the natural progression of the disease. CSVD might progress for many years during the early stage of the disease as it remains asymptomatic. Prevalent among elderly individuals, CSVD has been alarmingly reported as an important precursor of full-blown stroke and vascular dementia. Growing evidence has also shown a significant association between CSVD's radiological manifestation with dementia and Alzheimer's disease (AD) pathology. Although it remains contentious as to whether CSVD is a cause or sequelae of AD, it is not far-fetched to posit that effective therapeutic measures of CSVD would mitigate the overall burden of dementia. Nevertheless, the unifying theory on the pathomechanism of the disease remains elusive, hence the lack of effective therapeutic approaches. Thus, this chapter consolidates the contemporary insights from numerous experimental animal models of CSVD, to date: from the available experimental animal models of CSVD and its translational research value; the pathomechanical aspects of the disease; relevant aspects on systems biology; opportunities for early disease biomarkers; and finally, converging approaches for future therapeutic directions of CSVD.
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Affiliation(s)
- Muzaimi Mustapha
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | | | - Niferiti Aminuddin
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Basic Medical Sciences, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia
| | - Amanina Ahmad Safri
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Mazira Mohamad Ghazali
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
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Aoki J, Iguchi Y, Urabe T, Yamagami H, Todo K, Fujimoto S, Idomari K, Kaneko N, Iwanaga T, Terasaki T, Tanaka R, Yamamoto N, Tsujino A, Nomura K, Abe K, Uno M, Okada Y, Matsuoka H, Yamagata S, Yamamoto Y, Yonehara T, Inoue T, Yagita Y, Kimura K. Acute Aspirin Plus Cilostazol Dual Therapy for Noncardioembolic Stroke Patients Within 48 Hours of Symptom Onset. J Am Heart Assoc 2019; 8:e012652. [PMID: 31347430 PMCID: PMC6761671 DOI: 10.1161/jaha.119.012652] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background The aim of the present study was to investigate the efficacy and safety of antiplatelet (aspirin plus cilostazol) dual therapy for patients with noncardioembolic stroke within 48 hours of symptom onset. Methods and Results The ADS (Acute Aspirin Plus Cilostazol Dual Therapy for Non‐Cardiogenic Stroke Patients Within 48 Hours of Symptom Onset ) study is an investigator‐initiated, prospective, multicenter (34 hospitals in Japan), randomized, open‐label, and aspirin‐controlled trial. Acute stroke patients with noncardioembolic stroke within 48 hours of onset were studied. The subjects were randomly allocated to combination therapy with aspirin 81 to 200 mg plus cilostazol 200 mg (dual group) and single therapy with aspirin 81 to 200 mg (aspirin group) for 14 days. After the 14 days, all patients took the cilostazol 200 mg for 3 months. A primary efficacy outcome was defined as any one of the following occurring (neurological deterioration, symptomatic stroke recurrence, or transient ischemic attack) within 14 days. A primary safety outcome included intracerebral hemorrhage and subarachnoid hemorrhage. Between May 2011 and June 2017, 1201 patients (796 [66%] men; median age, 69 [61–77] years) randomized 1:1 to either the dual group or the aspirin group were analyzed. Initial National Institutes of Health Stroke Scale score was 2 (1–4) in both groups (P=0.830). A primary efficacy outcome was observed in 11% in the dual group and 11% in the aspirin group (P=0.853). A primary safety outcome occurred in 2 (0.3%) in the dual group and in 1 (0.2%) in the aspirin group (P=0.624). Conclusions Dual antiplatelet therapy using cilostazol and aspirin was safe but did not reduce the rate of short‐term neurological worsening. Clinical Trial Registration URL: umin.ac.jp/ctr/index/htm. Unique identifier: UMIN000004950.
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Affiliation(s)
- Junya Aoki
- Department of Neurological Science Graduate School of Medicine Nippon Medical School Tokyo Japan.,Department of Stroke Medicine Kawasaki Medical School Okayama Japan
| | - Yasuyuki Iguchi
- Department of Neurology Jikei University School of Medicine Tokyo Japan
| | - Takao Urabe
- Department of Neurology Juntendo University Urayasu Hospital Chiba Japan
| | - Hiroshi Yamagami
- Department of Neurology, Stroke Center Kobe City Medical Center General Hospital Hyogo Japan
| | - Kenichi Todo
- Department of Neurology, Stroke Center Kobe City Medical Center General Hospital Hyogo Japan
| | - Shigeru Fujimoto
- Department of Cerebrovascular Medicine, Stroke Center Steel Memorial Yawata Hospital Fukuoka Japan
| | - Koji Idomari
- Department of Stroke Medicine Okinawa Kyodo Hospital Okinawa Japan
| | - Nobuyuki Kaneko
- Department of Stroke Medicine Okinawa Kyodo Hospital Okinawa Japan
| | - Takeshi Iwanaga
- Department of Stroke Medicine Okayama Red Cross Hospital Okayama Japan
| | - Tadashi Terasaki
- Department of Neurology Japanese Red Cross Kumamoto Hospital Kumamoto Japan
| | - Ryota Tanaka
- Department of Neurology Faculty of Medicine Juntendo University Tokyo Japan
| | - Nobuaki Yamamoto
- Department of Clinical Neurosciences Institute of Biomedical Sciences Tokushima University Tokushima Japan
| | - Akira Tsujino
- Department of Neurology and Strokology Nagasaki University Hospital Nagasaki Japan
| | | | - Koji Abe
- Department of Neurology Okayama University Medical School Okayama Japan
| | - Masaaki Uno
- Department of Neurosurgery Kawasaki Medical School Okayama Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Hideki Matsuoka
- Department of Cerebrovascular Medicine NHO Kagoshima Medical Center Kagoshima Japan
| | - Sen Yamagata
- Department of Neurosurgery Kurashiki Central Hospital Okayama Japan
| | | | - Toshiro Yonehara
- Department of Neurology Stroke Center Saiseikai Kumamoto Hospital Kumamoto Japan
| | - Takeshi Inoue
- Department of Stroke Medicine Kawasaki Medical School General Medical Center Kawasaki Medical School Okayama Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine Kawasaki Medical School Okayama Japan
| | - Kazumi Kimura
- Department of Neurological Science Graduate School of Medicine Nippon Medical School Tokyo Japan.,Department of Stroke Medicine Kawasaki Medical School Okayama Japan
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Blair GW, Appleton JP, Flaherty K, Doubal F, Sprigg N, Dooley R, Richardson C, Hamilton I, Law ZK, Shi Y, Stringer MS, Thrippleton MJ, Boyd J, Shuler K, Bath PM, Wardlaw JM. Tolerability, safety and intermediary pharmacological effects of cilostazol and isosorbide mononitrate, alone and combined, in patients with lacunar ischaemic stroke: The LACunar Intervention-1 (LACI-1) trial, a randomised clinical trial. EClinicalMedicine 2019; 11:34-43. [PMID: 31317131 PMCID: PMC6611094 DOI: 10.1016/j.eclinm.2019.04.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Lacunar stroke, a frequent clinical manifestation of small vessel disease (SVD), differs pathologically from other ischaemic stroke subtypes and has no specific long-term secondary prevention. Licenced drugs, isosorbide mononitrate (ISMN) and cilostazol, have relevant actions to prevent SVD progression. METHODS We recruited independent patients with clinically confirmed lacunar ischaemic stroke without cognitive impairment to a prospective randomised clinical trial, LACunar Intervention-1 (LACI-1). We randomised patients using a central web-based system, 1:1:1:1 with minimisation, to masked ISMN 25 mg bd, cilostazol 100 mg bd, both ISMN and cilostazol started immediately, or both with start delayed. We escalated doses to target over two weeks, sustained for eight weeks. Primary outcome was the proportion achieving target dose. Secondary outcomes included symptoms, safety (haemorrhage, recurrent vascular events), cognition, haematology, vascular function, and neuroimaging. LACI-1 was powered (80%, alpha 0.05) to detect 35% (90% versus 55%) difference between the proportion reaching target dose on one versus both drugs at 55 patients. Registration ISRCTN12580546. FINDINGS LACI-1 enrolled 57 participants between March 2016 and August 2017: 18 (32%) females, mean age 66 (SD 11, range 40-85) years, onset-randomisation 203 (range 6-920) days. Most achieved full (64%) or over half (87%) dose, with no difference between cilostazol vs ISMN, single vs dual drugs. Headache and palpitations increased initially then declined similarly with dual versus single drugs. There was no between-group difference in BP, pulse-wave velocity, haemoglobin or platelet function, but pulse rate was higher (mean difference, MD, 6.4, 95%CI 1.2-11.7, p = 0.02), platelet count higher (MD 35.7, 95%CI 2.8, 68.7, p = 0.03) and white matter hyperintensities reduced more (Chi-square p = 0.007) with cilostazol versus no cilostazol. INTERPRETATION Cilostazol and ISMN are well tolerated when the dose is escalated, without safety concerns, in patients with lacunar stroke. Larger trials with longer term follow-up are justified. FUNDING Alzheimer's Society (AS-PG-14-033).
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Affiliation(s)
- Gordon W. Blair
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, 57 Little France Crescent, Edinburgh EH16 4TJ, UK
- Edinburgh Dementia Research Centre in the UK Dementia Research Initiative, UK
- Edinburgh Imaging, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Jason P. Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Fergus Doubal
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, 57 Little France Crescent, Edinburgh EH16 4TJ, UK
- Edinburgh Dementia Research Centre in the UK Dementia Research Initiative, UK
- Edinburgh Imaging, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Richard Dooley
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Carla Richardson
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Iona Hamilton
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, 57 Little France Crescent, Edinburgh EH16 4TJ, UK
- Edinburgh Dementia Research Centre in the UK Dementia Research Initiative, UK
- Edinburgh Imaging, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Zhe Kang Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Yulu Shi
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, 57 Little France Crescent, Edinburgh EH16 4TJ, UK
- Edinburgh Dementia Research Centre in the UK Dementia Research Initiative, UK
- Edinburgh Imaging, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Michael S. Stringer
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, 57 Little France Crescent, Edinburgh EH16 4TJ, UK
- Edinburgh Dementia Research Centre in the UK Dementia Research Initiative, UK
- Edinburgh Imaging, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Michael J. Thrippleton
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, 57 Little France Crescent, Edinburgh EH16 4TJ, UK
- Edinburgh Dementia Research Centre in the UK Dementia Research Initiative, UK
- Edinburgh Imaging, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Julia Boyd
- Edinburgh Clinical Trial's Unit, Usher Institute, University of Edinburgh, UK
| | - Kirsten Shuler
- Office for Patient-Oriented Research, Neurosciences Institute, Penn State, Milton S Hershey Medical Center, Penn State University, College of Medicine, Mail Code SB34, 200 Support Services Building, 500 University Drive, Hershey, PA 17033-0850, USA
| | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joanna M. Wardlaw
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, 57 Little France Crescent, Edinburgh EH16 4TJ, UK
- Edinburgh Dementia Research Centre in the UK Dementia Research Initiative, UK
- Edinburgh Imaging, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
- Corresponding author at: Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.
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Ando S, Tsutsui S, Miyoshi K, Sato S, Yanagihara W, Setta K, Chiba T, Fujiwara S, Kobayashi M, Yoshida K, Kubo Y, Ogasawara K. Cilostazol may improve cognition better than clopidogrel in non-surgical adult patients with ischemic moyamoya disease: subanalysis of a prospective cohort. Neurol Res 2019; 41:480-487. [PMID: 30774013 DOI: 10.1080/01616412.2019.1580455] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Adult patients with ischemic moyamoya disease (MMD) who receive treatment with antiplatelet drugs reportedly show improvements in neuropsychological test scores after around 2 years. The purpose of the present study subanalyzing the same patient cohort used in a previous study was to determine which antiplatelet drug, clopidogrel or cilostazol, results in better improvement of cognitive function among non-surgical adult patients showing ischemic MMD without severe hemodynamic compromise. METHODS Sixty-six patients without cerebral misery perfusion on 15O gas positron emission tomography were treated with pharmacotherapy alone. Patients ≥50 years old and <50 years old initially received clopidogrel and cilostazol, respectively. Any patient suffering side effects of the antiplatelet drug switched to the other antiplatelet drug. Neuropsychological tests were performed at study entry and at the end of the 2-year follow-up, and differences in each neuropsychological test score between the two time points (second test score - first test score) were calculated and defined as Δ scores. RESULTS Among the five neuropsychological tests, Δ scores for two tests were significantly greater in patients treated with cilostazol (n = 36) than in those treated with clopidogrel (n = 30), and Δ scores of the remaining three tests did not differ between patient groups. Based on Δ scores, 15 patients (23%) were defined as showing interval cognitive improvement. On multivariate analysis, cilostazol administration (95% confidence interval, 1.19-193.98; P = 0.0361) represented an independent predictor of interval cognitive improvement. CONCLUSIONS Cilostazol may improve cognition better than clopidogrel in non-surgical adult patients with ischemic MMD.
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Affiliation(s)
- Satoshi Ando
- a Department of Neurosurgery , School of Medicine, Iwate Medical University , Morioka , Japan
| | - Shouta Tsutsui
- a Department of Neurosurgery , School of Medicine, Iwate Medical University , Morioka , Japan
| | - Kenya Miyoshi
- a Department of Neurosurgery , School of Medicine, Iwate Medical University , Morioka , Japan
| | - Shinpei Sato
- a Department of Neurosurgery , School of Medicine, Iwate Medical University , Morioka , Japan
| | - Wataru Yanagihara
- a Department of Neurosurgery , School of Medicine, Iwate Medical University , Morioka , Japan
| | - Kengo Setta
- a Department of Neurosurgery , School of Medicine, Iwate Medical University , Morioka , Japan
| | - Takayuki Chiba
- a Department of Neurosurgery , School of Medicine, Iwate Medical University , Morioka , Japan
| | - Shunrou Fujiwara
- a Department of Neurosurgery , School of Medicine, Iwate Medical University , Morioka , Japan
| | - Masakazu Kobayashi
- a Department of Neurosurgery , School of Medicine, Iwate Medical University , Morioka , Japan
| | - Kenji Yoshida
- a Department of Neurosurgery , School of Medicine, Iwate Medical University , Morioka , Japan
| | - Yoshitaka Kubo
- a Department of Neurosurgery , School of Medicine, Iwate Medical University , Morioka , Japan
| | - Kuniaki Ogasawara
- a Department of Neurosurgery , School of Medicine, Iwate Medical University , Morioka , Japan
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10
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Chiba T, Setta K, Shimada Y, Yoshida J, Fujimoto K, Tsutsui S, Yoshida K, Kobayashi M, Kubo Y, Fujiwara S, Terasaki K, Ogasawara K. Comparison of Effects between Clopidogrel and Cilostazol on Cerebral Perfusion in Nonsurgical Adult Patients with Symptomatically Ischemic Moyamoya Disease: Subanalysis of a Prospective Cohort. J Stroke Cerebrovasc Dis 2018; 27:3373-3379. [PMID: 30174225 DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/11/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Adult patients with symptomatically ischemic moyamoya disease (MMD) initially undergo medical treatment alone including antiplatelet drugs when symptomatic cerebral hemispheres do not exhibit hemodynamic compromise. The purpose of the present study subanalyzing the same patient cohort used in a previous study was to determine which antiplatelet drug, clopidogrel or cilostazol, provides better improvement of cerebral perfusion in such patients. METHODS All patients without cerebral misery perfusion on 15O gas positron emission tomography (PET) did not undergo revascularization surgery and were treated with medication alone, including antiplatelet therapy. Patients ≥50years and <50years initially received clopidogrel and cilostazol, respectively. When a patient suffered side effects of an antiplatelet drug, they were switched to the other antiplatelet drug. Cerebral blood flow (CBF) in the symptomatic hemisphere was measured at inclusion and at 2years after inclusion using 15O gas PET. RESULTS Of 68 patients, 31 and 38 were treated with clopidogrel and cilostazol, respectively, for 2years after inclusion. For patients treated with clopidogrel, CBF did not differ between first and second PET. For patients treated with cilostazol, CBF was significantly greater in the second PET than in the first PET. On multivariate analysis, cilostazol administration was an independent predictor of CBF improvement in the symptomatic hemisphere (95% confidence interval, 1.34-139.20; P =.0271). CONCLUSIONS Cilostazol improves cerebral perfusion better than clopidogrel in adult patients with symptomatically ischemic MMD not accompanied by misery perfusion.
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Affiliation(s)
- Takayuki Chiba
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan; Cyclotron Research Center, Iwate Medical University, Morioka, Japan
| | - Kengo Setta
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan; Cyclotron Research Center, Iwate Medical University, Morioka, Japan
| | - Yasuyoshi Shimada
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan; Cyclotron Research Center, Iwate Medical University, Morioka, Japan
| | - Jun Yoshida
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan; Cyclotron Research Center, Iwate Medical University, Morioka, Japan
| | - Kentaro Fujimoto
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan; Cyclotron Research Center, Iwate Medical University, Morioka, Japan
| | - Shouta Tsutsui
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan; Cyclotron Research Center, Iwate Medical University, Morioka, Japan
| | - Kenji Yoshida
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan; Cyclotron Research Center, Iwate Medical University, Morioka, Japan
| | - Masakazu Kobayashi
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan; Cyclotron Research Center, Iwate Medical University, Morioka, Japan
| | - Yoshitaka Kubo
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan; Cyclotron Research Center, Iwate Medical University, Morioka, Japan
| | - Shunrou Fujiwara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan; Cyclotron Research Center, Iwate Medical University, Morioka, Japan
| | - Kazunori Terasaki
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan; Cyclotron Research Center, Iwate Medical University, Morioka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan; Cyclotron Research Center, Iwate Medical University, Morioka, Japan.
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11
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Wardlaw JM. William M. Feinberg Award for Excellence in Clinical Stroke: Small Vessel Disease; a Big Problem, But Fixable. Stroke 2018; 49:1770-1775. [PMID: 29895535 DOI: 10.1161/strokeaha.118.021184] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 05/01/2018] [Accepted: 05/15/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Joanna M Wardlaw
- From the Division of Neuroimaging Science, Centre for Clinical Brain Science, Edinburgh Imaging and UK Dementia Research Institute at the University of Edinburgh.
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12
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Blair GW, Appleton JP, Law ZK, Doubal F, Flaherty K, Dooley R, Shuler K, Richardson C, Hamilton I, Shi Y, Stringer M, Boyd J, Thrippleton MJ, Sprigg N, Bath PM, Wardlaw JM. Preventing cognitive decline and dementia from cerebral small vessel disease: The LACI-1 Trial. Protocol and statistical analysis plan of a phase IIa dose escalation trial testing tolerability, safety and effect on intermediary endpoints of isosorbide mononitrate and cilostazol, separately and in combination. Int J Stroke 2017; 13:530-538. [DOI: 10.1177/1747493017731947] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rationale The pathophysiology of most lacunar stroke, a form of small vessel disease, is thought to differ from large artery atherothrombo- or cardio-embolic stroke. Licensed drugs, isosorbide mononitrate and cilostazol, have promising mechanisms of action to support their testing to prevent stroke recurrence, cognitive impairment, or radiological progression after lacunar stroke. Aim LACI-1 will assess the tolerability, safety, and efficacy, by dose, of isosorbide mononitrate and cilostazol, alone and in combination, in patients with ischemic lacunar stroke. Sample size A sample of 60 provides 80+% power (significance 0.05) to detect a difference of 35% (90% versus 55%) between those reaching target dose on one versus both drugs. Methods and design LACI-1 is a phase IIa partial factorial, dose-escalation, prospective, randomized, open label, blinded endpoint trial. Participants are randomized to isosorbide mononitrate and/or cilostazol for 11 weeks with dose escalation to target as tolerated in two centers (Edinburgh, Nottingham). At three visits, tolerability, safety, blood pressure, pulse wave velocity, and platelet function are assessed, plus magnetic resonance imaging to assess cerebrovascular reactivity in a subgroup. Study outcomes Primary: proportion of patients completing study achieving target maximum dose. Secondary symptoms whilst taking medications; safety (hemorrhage, recurrent vascular events, falls); blood pressure, platelet function, arterial stiffness, and cerebrovascular reactivity. Discussion This study will inform the design of a larger phase III trial of isosorbide mononitrate and cilostazol in lacunar stroke, whilst providing data on the drugs’ effects on vascular and platelet function. Trial registration ISRCTN (ISRCTN12580546) and EudraCT (2015-001953-33).
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Affiliation(s)
- Gordon W Blair
- Centre for Clinical Brain Sciences, University
of Edinburgh, Edinburgh, UK
- Edinburgh Dementia Research Centre in the UK
Dementia Research Institute, University of Edinburgh, Edinburgh, UK
- Fondation Leducq Network for the Study of
Perivascular Spaces in Small Vessel Disease, University of Edinburgh, Edinburgh, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical
Neuroscience,
University
of Nottingham, Nottingham, UK
| | - Zhe Kang Law
- Stroke Trials Unit, Division of Clinical
Neuroscience,
University
of Nottingham, Nottingham, UK
- Department of Medicine, National University of
Malaysia, Kuala Lumpur, Malaysia
| | - Fergus Doubal
- Centre for Clinical Brain Sciences, University
of Edinburgh, Edinburgh, UK
- Edinburgh Dementia Research Centre in the UK
Dementia Research Institute, University of Edinburgh, Edinburgh, UK
- Fondation Leducq Network for the Study of
Perivascular Spaces in Small Vessel Disease, University of Edinburgh, Edinburgh, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical
Neuroscience,
University
of Nottingham, Nottingham, UK
| | - Richard Dooley
- Stroke Trials Unit, Division of Clinical
Neuroscience,
University
of Nottingham, Nottingham, UK
| | - Kirsten Shuler
- Centre for Clinical Brain Sciences, University
of Edinburgh, Edinburgh, UK
- Edinburgh Dementia Research Centre in the UK
Dementia Research Institute, University of Edinburgh, Edinburgh, UK
- Fondation Leducq Network for the Study of
Perivascular Spaces in Small Vessel Disease, University of Edinburgh, Edinburgh, UK
| | - Carla Richardson
- Stroke Trials Unit, Division of Clinical
Neuroscience,
University
of Nottingham, Nottingham, UK
| | - Iona Hamilton
- Centre for Clinical Brain Sciences, University
of Edinburgh, Edinburgh, UK
- Edinburgh Dementia Research Centre in the UK
Dementia Research Institute, University of Edinburgh, Edinburgh, UK
- Fondation Leducq Network for the Study of
Perivascular Spaces in Small Vessel Disease, University of Edinburgh, Edinburgh, UK
| | - Yulu Shi
- Centre for Clinical Brain Sciences, University
of Edinburgh, Edinburgh, UK
- Edinburgh Dementia Research Centre in the UK
Dementia Research Institute, University of Edinburgh, Edinburgh, UK
- Fondation Leducq Network for the Study of
Perivascular Spaces in Small Vessel Disease, University of Edinburgh, Edinburgh, UK
| | - Michael Stringer
- Centre for Clinical Brain Sciences, University
of Edinburgh, Edinburgh, UK
- Edinburgh Dementia Research Centre in the UK
Dementia Research Institute, University of Edinburgh, Edinburgh, UK
- Fondation Leducq Network for the Study of
Perivascular Spaces in Small Vessel Disease, University of Edinburgh, Edinburgh, UK
| | - Julia Boyd
- Edinburgh Clinical Trial’s Unit, Western
General Hospital, Edinburgh, UK
| | - Michael J Thrippleton
- Centre for Clinical Brain Sciences, University
of Edinburgh, Edinburgh, UK
- Edinburgh Dementia Research Centre in the UK
Dementia Research Institute, University of Edinburgh, Edinburgh, UK
- Fondation Leducq Network for the Study of
Perivascular Spaces in Small Vessel Disease, University of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical
Neuroscience,
University
of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical
Neuroscience,
University
of Nottingham, Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University
of Edinburgh, Edinburgh, UK
- Edinburgh Dementia Research Centre in the UK
Dementia Research Institute, University of Edinburgh, Edinburgh, UK
- Fondation Leducq Network for the Study of
Perivascular Spaces in Small Vessel Disease, University of Edinburgh, Edinburgh, UK
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Ohnuki Y, Ohnuki Y, Kohara S, Shimizu M, Takizawa S. Dual Therapy with Aspirin and Cilostazol May Improve Platelet Aggregation in Noncardioembolic Stroke Patients: A Pilot Study. Intern Med 2017; 56:1307-1313. [PMID: 28566591 PMCID: PMC5498192 DOI: 10.2169/internalmedicine.56.7760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Objective Some previous studies have found clinical benefit of dual antiplatelet therapy with aspirin and cilostazol for prevention of secondary stroke, but the physiological mechanism involved remains unknown. We aimed to clarify the effects of aspirin/cilostazol therapy on the platelet and endothelial functions of patients with acute noncardioembolic ischemic stroke, in comparison to patients who were treated with aspirin alone. Methods The present randomized prospective pilot study enrolled 24 patients within a week after the onset of noncardioembolic ischemic stroke. The patients were randomly allocated to receive aspirin (100 mg/day) (A group; 11 patients) or cilostazol (200 mg/day) plus aspirin (100 mg/day) (CA group; 13 patients). We measured platelet aggregation, platelet activation, and the thrombomodulin (TM), highly sensitive C-reactive protein (hs-CRP), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and von Willebrand (vWF) antigen levels and vWF activity over a 4-week period after enrollment. Results There was no significant difference in the platelet functions of the A and CA groups. However, the platelet aggregation induced by adenosine diphosphate (ADP) was decreased at 2 and 4 weeks (p<0.05) after treatment in comparison to the pre-treatment values in the CA group, but not in the A group. Platelet activation, and the hs-CRP, TM, ICAM-1, VCAM-1 and vWF values did not significantly decrease after treatment in either group. Conclusion Although there were no significant differences in platelet aggregation, platelet activation or the endothelial biomarker levels of the A and CA groups, dual therapy with aspirin and cilostazol inhibited platelet aggregation in comparison to the pre-treatment values, similarly to patients who received aspirin alone. This may suggest the clinical usefulness of dual therapy with aspirin and cilostazol in the treatment of patients with noncardioembolic ischemic stroke.
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Affiliation(s)
- Yoichi Ohnuki
- Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Yuko Ohnuki
- Department of Molecular Life Science, Basic Medical Science and Molecular Medicine, Tokai University School of Medicine, Japan
| | - Saori Kohara
- Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Mie Shimizu
- Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Shunya Takizawa
- Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Japan
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14
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Hishikawa N, Fukui Y, Sato K, Ohta Y, Yamashita T, Abe K. Comprehensive effects of galantamine and cilostazol combination therapy on patients with Alzheimer's disease with asymptomatic lacunar infarction. Geriatr Gerontol Int 2016; 17:1384-1391. [PMID: 27578455 DOI: 10.1111/ggi.12870] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/31/2016] [Accepted: 06/19/2016] [Indexed: 11/30/2022]
Abstract
AIM The coexistence of Alzheimer's disease (AD) and cerebrovascular disease pathology increases age-dependently. We comprehensively analyzed the clinical effects of galantamine or cilostazol monotherapy to the add-on combination therapy on three major factors of dementia, such as cognitive, affective and activities of daily living functions in AD patients with asymptomatic lacunar infarction. METHODS We divided 101 AD patients with asymptomatic lacunar infarction into two subgroups: group A (n = 61, first treated with galantamine and then cilostazol added) and group B (n = 40, first treated with cilostazol and galantamine added). We compared the clinical effects before and after combination therapy of galantamine and cilostazol (i.e. 3 months [M] before (-3 M), baseline (0 M), 3 and 6 M after the add-on combination). RESULTS Galantamine monotherapy increased cognitive Hasegawa dementia score-revised scores, which were further improved with add-on cilostazol. Cilostazol monotherapy also increased the cognitive tests, which were further improved with add-on galantamine. Add-on cilostazol significantly improved Geriatric Depression Scale and Abe's behavioral and psychological symptoms of dementia scores after galantamine monotherapy. Cilostazol monotherapy also significantly improved Geriatric Depression Scale scores, with further improvements in Geriatric Depression Scale, apathy scores and Abe's behavioral and psychological symptoms of dementia scores by add-on galantamine. Activities of daily living scores continuously improved with galantamine monotherapy and add-on cilostazol. CONCLUSIONS The present study provides a clinical possibility that galantamine or cilostazol monotherapy and the combination therapy maintained or even improved cognitive, affective, and activities of daily living functions in AD with asymptomatic lacunar infarction. Geriatr Gerontol Int 2017; 17: 1384-1391.
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Affiliation(s)
- Nozomi Hishikawa
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yusuke Fukui
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kota Sato
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuyuki Ohta
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toru Yamashita
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koji Abe
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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15
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Protective effects of cilostazol against hemorrhagic stroke: Current and future perspectives. J Pharmacol Sci 2016; 131:155-61. [DOI: 10.1016/j.jphs.2016.04.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 11/17/2022] Open
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Godinho J, de Oliveira JN, Ferreira EDF, Zaghi GGD, Bacarin CC, de Oliveira RMW, Milani H. Cilostazol but not sildenafil prevents memory impairment after chronic cerebral hypoperfusion in middle-aged rats. Behav Brain Res 2015; 283:61-8. [DOI: 10.1016/j.bbr.2015.01.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/15/2015] [Accepted: 01/16/2015] [Indexed: 01/02/2023]
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17
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Bath PM, Wardlaw JM. Pharmacological treatment and prevention of cerebral small vessel disease: a review of potential interventions. Int J Stroke 2015; 10:469-78. [PMID: 25727737 PMCID: PMC4832291 DOI: 10.1111/ijs.12466] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 01/06/2015] [Indexed: 12/21/2022]
Abstract
Small vessel disease encompasses lacunar stroke, white matter hyperintensities, lacunes and microbleeds. It causes a quarter of all ischemic strokes, is the commonest cause of vascular dementia, and the cause is incompletely understood. Vascular prophylaxis, as appropriate for large artery disease and cardioembolism, includes antithrombotics, and blood pressure and lipid lowering; however, these strategies may not be effective for small vessel disease, or are already used routinely so precluding further detailed study. Further, intensive antiplatelet therapy is known to be hazardous in small vessel disease through enhanced bleeding. Whether acetylcholinesterase inhibitors, which delay the progression of Alzheimer's dementia, are relevant in small vessel disease remains unclear. Potential prophylactic and treatment strategies might be those that target brain microvascular endothelium and the blood brain barrier, microvascular function and neuroinflammation. Potential interventions include endothelin antagonists, neurotrophins, nitric oxide donors and phosphodiesterase 5 inhibitors, peroxisome proliferator‐activated receptor‐gamma agonists, and prostacyclin mimics and phosphodiesterase 3 inhibitors. Several drugs that have relevant properties are licensed for other disorders, offering the possibility of drug repurposing. Others are in development. Since influencing multiple targets may be most effective, using multiple agents and/or those that have multiple effects may be preferable. We focus on potential small vessel disease mechanistic targets, summarize drugs that have relevant actions, and review data available from randomized trials on their actions and on the available evidence for their use in lacunar stroke.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Joanna M Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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18
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Neuroprotective effects of cilostazol are mediated by multiple mechanisms in a mouse model of permanent focal ischemia. Brain Res 2015; 1602:53-61. [DOI: 10.1016/j.brainres.2015.01.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/08/2015] [Accepted: 01/12/2015] [Indexed: 01/26/2023]
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19
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Toda Y, Katsura KI, Saito M, Inaba T, Sakurazawa M, Katayama Y. The effect of cilostazol and aspirin pre-treatment against subsequent transient focal cerebral ischemia in rat. Neurol Res 2014; 36:1011-9. [DOI: 10.1179/1743132814y.0000000389] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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20
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Fukuoka T, Hayashi T, Hirayama M, Maruyama H, Tanahashi N. Cilostazol Inhibits Platelet–Endothelial Cell Interaction in Murine Microvessels after Transient Bilateral Common Carotid Artery Occlusion. J Stroke Cerebrovasc Dis 2014; 23:1056-61. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 08/30/2013] [Accepted: 09/04/2013] [Indexed: 11/26/2022] Open
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Taiyeb AM, Dees WL, Ridha-Albarzanchi MT, Sayes CM, Kraemer DC. In vitroeffects of cilostazol, a phosphodiesterase 3A inhibitor, on mouse oocyte maturation and morphology. Clin Exp Pharmacol Physiol 2014; 41:147-53. [DOI: 10.1111/1440-1681.12193] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 11/01/2013] [Accepted: 11/05/2013] [Indexed: 12/01/2022]
Affiliation(s)
- Ahmed M Taiyeb
- College of Veterinary Medicine and Biomedical Sciences; Texas A&M University; College Station TX USA
- Barz IVF Center for Embryo Research and Infertility Treatment; Erbil Iraq
| | - William L Dees
- College of Veterinary Medicine and Biomedical Sciences; Texas A&M University; College Station TX USA
| | | | - Christie M Sayes
- College of Veterinary Medicine and Biomedical Sciences; Texas A&M University; College Station TX USA
- Nanotoxicology & Nanopharmacology Laboratory; Center for Aerosol & Nanomaterials Engineering; RTI International; Research Triangle NC USA
| | - Duane C Kraemer
- College of Veterinary Medicine and Biomedical Sciences; Texas A&M University; College Station TX USA
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22
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Cilostazol inhibits leukocyte-endothelial cell interactions in murine microvessels after transient bilateral common carotid artery occlusion. Brain Res 2014; 1543:173-8. [PMID: 24309140 DOI: 10.1016/j.brainres.2013.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 11/09/2013] [Accepted: 11/15/2013] [Indexed: 11/20/2022]
Abstract
Leukocyte behavior in the cerebral microvasculature following vessel occlusion has not been fully elucidated. The purpose of this study was to investigate the effects of cilostazol on leukocyte behavior (rolling and adhesion) in murine cerebral microvessels following transient bilateral carotid artery occlusion using intravital fluorescence microscopy. Four groups of mice were assigned: a sham group (n=16); an ischemia (induced by 15-min occlusion of bilateral common carotid arteries) and reperfusion (I/R) group (n=13); I/R+cilostazol (I/R+CZ3 mg/kg) group (I/R after oral administration of cilostazol at 3 mg/kg) (n=8); and I/R+cilostazol (I/R+CZ30 mg/kg) group (I/R after oral administration of cilostazol at 30 mg/kg) (n=12). Leukocytes labeled with 0.05% acridine orange were administered intravenously and their behavior was investigated at 3 and 6 h after reperfusion. Numbers of rolling or adherent leukocytes were expressed as the count per square millimeter per 30s. Numbers of rolling and adherent leukocytes at 3 and 6h after reperfusion were significantly higher in the I/R group than in the sham or I/R+CZ30 mg/kg groups in both pial veins (P<0.05) and pial arteries (P<0.05). Cilostazol (30 mg/kg) inhibited leukocyte-endothelial interactions following cerebral ischemia and reperfusion.
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Omote Y, Deguchi K, Kono S, Liu N, Liu W, Kurata T, Yamashita T, Ikeda Y, Abe K. Neurovascular protection of cilostazol in stroke-prone spontaneous hypertensive rats associated with angiogenesis and pericyte proliferation. J Neurosci Res 2013; 92:369-74. [DOI: 10.1002/jnr.23327] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 09/12/2013] [Accepted: 10/23/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Yoshio Omote
- Department of Neurology, Graduate School of Medicine; Dentistry and Pharmaceutical Sciences, Okayama University; Okayama Japan
| | - Kentaro Deguchi
- Department of Neurology, Graduate School of Medicine; Dentistry and Pharmaceutical Sciences, Okayama University; Okayama Japan
| | - Syoichiro Kono
- Department of Neurology, Graduate School of Medicine; Dentistry and Pharmaceutical Sciences, Okayama University; Okayama Japan
| | - Ning Liu
- Department of Neurology, Graduate School of Medicine; Dentistry and Pharmaceutical Sciences, Okayama University; Okayama Japan
| | - Wentao Liu
- Department of Neurology, Graduate School of Medicine; Dentistry and Pharmaceutical Sciences, Okayama University; Okayama Japan
| | - Tomoko Kurata
- Department of Neurology, Graduate School of Medicine; Dentistry and Pharmaceutical Sciences, Okayama University; Okayama Japan
| | - Toru Yamashita
- Department of Neurology, Graduate School of Medicine; Dentistry and Pharmaceutical Sciences, Okayama University; Okayama Japan
| | - Yoshio Ikeda
- Department of Neurology, Graduate School of Medicine; Dentistry and Pharmaceutical Sciences, Okayama University; Okayama Japan
| | - Koji Abe
- Department of Neurology, Graduate School of Medicine; Dentistry and Pharmaceutical Sciences, Okayama University; Okayama Japan
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Yan BC, Park JH, Shin BN, Ahn JH, Kim IH, Lee JC, Yoo KY, Hwang IK, Choi JH, Park JH, Lee YL, Suh HW, Jun JG, Kwon YG, Kim YM, Kwon SH, Her S, Kim JS, Hyun BH, Kim CK, Cho JH, Lee CH, Won MH. Neuroprotective effect of a new synthetic aspirin-decursinol adduct in experimental animal models of ischemic stroke. PLoS One 2013; 8:e74886. [PMID: 24073226 PMCID: PMC3779249 DOI: 10.1371/journal.pone.0074886] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 08/07/2013] [Indexed: 02/04/2023] Open
Abstract
Stroke is the second leading cause of death. Experimental animal models of cerebral ischemia are widely used for researching mechanisms of ischemic damage and developing new drugs for the prevention and treatment of stroke. The present study aimed to comparatively investigate neuroprotective effects of aspirin (ASA), decursinol (DA) and new synthetic aspirin-decursinol adduct (ASA-DA) against transient focal and global cerebral ischemic damage. We found that treatment with 20 mg/kg, not 10 mg/kg, ASA-DA protected against ischemia-induced neuronal death after transient focal and global ischemic damage, and its neuroprotective effect was much better than that of ASA or DA alone. In addition, 20 mg/kg ASA-DA treatment reduced the ischemia-induced gliosis and maintained antioxidants levels in the corresponding injury regions. In brief, ASA-DA, a new synthetic drug, dramatically protected neurons from ischemic damage, and neuroprotective effects of ASA-DA may be closely related to the attenuation of ischemia-induced gliosis and maintenance of antioxidants.
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Affiliation(s)
- Bing Chun Yan
- Institute of Integrative traditional & western Medicine,Medical College, Yangzhou University, Yangzhou, China
| | - Joon Ha Park
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, South Korea
| | - Bich Na Shin
- Department of Physiology, College of Medicine and Institute of Neurodegeneration and Neuroregeneration, Hallym University, Chuncheon, South Korea
| | - Ji Hyeon Ahn
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, South Korea
| | - In Hye Kim
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, South Korea
| | - Jae-Chul Lee
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, South Korea
| | - Ki-Yeon Yoo
- Department of Oral Anatomy, College of Dentistry, Gangneung-Wonju National University, Gangneung, South Korea
| | - In Koo Hwang
- Department of Anatomy and Cell Biology, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, South Korea
| | - Jung Hoon Choi
- Department of Anatomy, College of Veterinary Medicine, Kangwon National University, Chuncheon, South Korea
| | - Jeong Ho Park
- Division of Applied Chemistry and Biotechnology, Hanbat National University, Daejeon, South Korea
| | - Yun Lyul Lee
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, South Korea
| | - Hong-Won Suh
- Department of Pharmacology and Institute of Natural Medicine, College of Medicine Hallym University, Chuncheon, South Korea
| | - Jong-Gab Jun
- Department of Chemistry and Institute of Applied Chemistry, Hallym University, Chuncheon, South Korea
| | - Young-Guen Kwon
- Department of Biochemistry, College of Life Science and Biotechnology, Yonsei University, Seoul, South Korea
| | - Young-Myeong Kim
- Vascular System Research Center and Department of Molecular and Cellular Biochemistry, School of Medicine, Kangwon National University, Chuncheon, South Korea
| | - Seung-Hae Kwon
- Division of Analytical Bio-imaging, Chuncheon Center, Korea Basic Science Institute, Chuncheon, Kangwon, South Korea
| | - Song Her
- Division of Analytical Bio-imaging, Chuncheon Center, Korea Basic Science Institute, Chuncheon, Kangwon, South Korea
| | - Jin Su Kim
- Molecular Imaging Research Center, Korea Institute of Radiological and Medical Sciences, Seoul, South Korea
| | - Byung-Hwa Hyun
- Laboratory Animal Center, OSONG Medical Innovation Foundation, Osong, South Korea
| | - Chul-Kyu Kim
- Laboratory Animal Center, OSONG Medical Innovation Foundation, Osong, South Korea
| | - Jun Hwi Cho
- Department of Emergency Medicine and Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon, South Korea
| | - Choong Hyun Lee
- Department of Anatomy and Physiology, College of Pharmacy, Dankook University, Cheonan, South Korea
- * E-mail: (MHW); (CHL)
| | - Moo-Ho Won
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, South Korea
- * E-mail: (MHW); (CHL)
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Pires PW, Dams Ramos CM, Matin N, Dorrance AM. The effects of hypertension on the cerebral circulation. Am J Physiol Heart Circ Physiol 2013; 304:H1598-614. [PMID: 23585139 DOI: 10.1152/ajpheart.00490.2012] [Citation(s) in RCA: 250] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Maintenance of brain function depends on a constant blood supply. Deficits in cerebral blood flow are linked to cognitive decline, and they have detrimental effects on the outcome of ischemia. Hypertension causes alterations in cerebral artery structure and function that can impair blood flow, particularly during an ischemic insult or during periods of low arterial pressure. This review will focus on the historical discoveries, novel developments, and knowledge gaps in 1) hypertensive cerebral artery remodeling, 2) vascular function with emphasis on myogenic reactivity and endothelium-dependent dilation, and 3) blood-brain barrier function. Hypertensive artery remodeling results in reduction in the lumen diameter and an increase in the wall-to-lumen ratio in most cerebral arteries; this is linked to reduced blood flow postischemia and increased ischemic damage. Many factors that are increased in hypertension stimulate remodeling; these include the renin-angiotensin-aldosterone system and reactive oxygen species levels. Endothelial function, vital for endothelium-mediated dilation and regulation of myogenic reactivity, is impaired in hypertension. This is a consequence of alterations in vasodilator mechanisms involving nitric oxide, epoxyeicosatrienoic acids, and ion channels, including calcium-activated potassium channels and transient receptor potential vanilloid channel 4. Hypertension causes blood-brain barrier breakdown by mechanisms involving inflammation, oxidative stress, and vasoactive circulating molecules. This exposes neurons to cytotoxic molecules, leading to neuronal loss, cognitive decline, and impaired recovery from ischemia. As the population ages and the incidence of hypertension, stroke, and dementia increases, it is imperative that we gain a better understanding of the control of cerebral artery function in health and disease.
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Affiliation(s)
- Paulo W Pires
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI 48824, USA
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