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Feng X, Fang H, Ip BYM, Chan KL, Li S, Tian X, Zheng L, Liu Y, Lan L, Liu H, Abrigo J, Ma SH, Fan FSY, Ip VHL, Soo YOY, Mok VCT, Song B, Leung TW, Xu Y, Leng X. Cerebral Hemodynamics Underlying Artery-to-Artery Embolism in Symptomatic Intracranial Atherosclerotic Disease. Transl Stroke Res 2024; 15:572-579. [PMID: 36897543 DOI: 10.1007/s12975-023-01146-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/13/2023] [Accepted: 02/27/2023] [Indexed: 03/11/2023]
Abstract
Artery-to-artery embolism (AAE) is a common stroke mechanism in intracranial atherosclerotic disease (ICAD), associated with a considerable risk of recurrent stroke. We aimed to investigate cerebral hemodynamic features associated with AAE in symptomatic ICAD. Patients with anterior-circulation, symptomatic ICAD confirmed in CT angiography (CTA) were recruited. We classified probable stroke mechanisms as isolated parent artery atherosclerosis occluding penetrating artery, AAE, hypoperfusion, and mixed mechanisms, largely based on infarct topography. CTA-based computational fluid dynamics (CFD) models were built to simulate blood flow across culprit ICAD lesions. Translesional pressure ratio (PR = Pressurepost-stenotic/Pressurepre-stenotic) and wall shear stress ratio (WSSR = WSSstenotic-throat/WSSpre-stenotic) were calculated, to reflect the relative, translesional changes of the two hemodynamic metrics. Low PR (PR ≤ median) and high WSSR (WSSR ≥ 4th quartile) respectively indicated large translesional pressure and elevated WSS upon the lesion. Among 99 symptomatic ICAD patients, 44 had AAE as a probable stroke mechanism, 13 with AAE alone and 31 with coexisting hypoperfusion. High WSSR was independently associated with AAE (adjusted OR = 3.90; P = 0.022) in multivariate logistic regression. There was significant WSSR-PR interaction on the presence of AAE (P for interaction = 0.013): high WSSR was more likely to associate with AAE in those with low PR (P = 0.075), but not in those with normal PR (P = 0.959). Excessively elevated WSS in ICAD might increase the risk of AAE. Such association was more prominent in those with large translesional pressure gradient. Hypoperfusion, commonly coexisting with AAE, might be a therapeutic indicator for secondary stroke prevention in symptomatic ICAD with AAE.
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Affiliation(s)
- Xueyan Feng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hui Fang
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- NHC Key Laboratory of Prevention and Treatment of Cerebrovascular Diseases, Zhengzhou, China
| | - Bonaventure Y M Ip
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ka Lung Chan
- Department of Neurology, the First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shuang Li
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xuan Tian
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lina Zheng
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yuying Liu
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Linfang Lan
- Department of Neurology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Haipeng Liu
- Research Centre for Intelligent Healthcare, Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | - Jill Abrigo
- Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Sze Ho Ma
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Florence S Y Fan
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vincent H L Ip
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yannie O Y Soo
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vincent C T Mok
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Bo Song
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- NHC Key Laboratory of Prevention and Treatment of Cerebrovascular Diseases, Zhengzhou, China
| | - Thomas W Leung
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yuming Xu
- Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
- NHC Key Laboratory of Prevention and Treatment of Cerebrovascular Diseases, Zhengzhou, China.
| | - Xinyi Leng
- Department of Medicine & Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR, China.
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Zhang J, Li W, Zhang K, Huo C, Xu G, Li Z. Blood pressure-cerebral oxygen coupling model: A new approach for stroke risk prediction. JOURNAL OF BIOPHOTONICS 2024; 17:e202300318. [PMID: 37795638 DOI: 10.1002/jbio.202300318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/11/2023] [Accepted: 10/04/2023] [Indexed: 10/06/2023]
Abstract
Stroke is a major cause of death and disability worldwide, but predicting its risk remains challenging. This study aimed to evaluate the cerebral blood flow autoregulation function of subjects with different stroke risk levels and predict their stroke risk. The coupling strength between cerebral oxygen and blood pressure signals was calculated by wavelet analysis and dynamic Bayesian inference and used as a quantitative index of cerebral blood flow autoregulation. A stroke prediction model based on the extreme random tree was constructed using the coupling strength and other data as input features. The results showed that the coupling strength was significantly higher in the high-risk group than the other groups. Moreover, the prediction model achieved an average accuracy of 0.80 across the three groups. The coupling strength of cerebral oxygen and blood pressure can be used as an objective index to predict stroke risk, which has implications for stroke prevention and intervention.
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Affiliation(s)
- Jingsha Zhang
- Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, National Research Center for Rehabilitation Technical Aids, Beijing, China
- Key Laboratory of Neuro-Functional Information and Rehabilitation Engineering of the Ministry of Civil Affairs, Beijing, China
| | - Wenhao Li
- School of Rehabilitation Engineering, Beijing College of Social Administration, Beijing, China
| | - Ke Zhang
- Nanchang City Key Laboratory of Integrated Medical and Industrial Technology, Nanchang University, Nanchang, China
| | - Congcong Huo
- Beijing Advanced Innovation Centre for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Gongcheng Xu
- Beijing Advanced Innovation Centre for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Zengyong Li
- Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, National Research Center for Rehabilitation Technical Aids, Beijing, China
- Key Laboratory of Neuro-Functional Information and Rehabilitation Engineering of the Ministry of Civil Affairs, Beijing, China
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Wu E, Mahdi A, Nickander J, Bruchfeld J, Mellbin L, Haugaa K, Ståhlberg M, Desta L. Enhanced External Counterpulsation for Management of Postacute Sequelae of SARS-CoV-2 Associated Microvascular Angina and Fatigue: An Interventional Pilot Study. Cardiol Res Pract 2023; 2023:6687803. [PMID: 38179014 PMCID: PMC10764650 DOI: 10.1155/2023/6687803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/17/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
Background Postacute sequelae of SARS-CoV-2 infection (PASC) are a novel clinical syndrome characterized in part by endothelial dysfunction. Enhanced external counterpulsation (EECP) produces pulsatile shear stress, which has been associated with improvements in systemic endothelial function. Objective To explore the effects of EECP on symptom burden, physical capacity, mental health, and health-related quality of life (HRQoL) in patients with PASC-associated angina and microvascular dysfunction (MVD). Methods An interventional pilot study was performed, including 10 patients (male = 5, mean age 50.3 years) recruited from a tertiary specialized PASC clinic. Patients with angina and MVD, defined as index of microcirculatory resistance (IMR) ≥25 and/or diagnosed through stress perfusion cardiac magnetic resonance imaging, were included. Patients underwent one modified EECP course (15 one-hour sessions over five weeks). Symptom burden, six-minute walk test, and validated generic self-reported instruments for measuring psychological distress and HRQoL were assessed before and one month after treatment. Results At baseline, most commonly reported PASC symptoms were angina (100%), fatigue (80%), and dyspnea (80%). Other symptoms included palpitations (50%), concentration impairment (50%), muscle pain (30%), and brain fog (30%). Mean IMR was 63.6. After EECP, 6MWD increased (mean 29.5 m, median 21 m) and angina and fatigue improved. Mean depression scores showed reduced symptoms (-0.8). Mean HRQoL scores improved in seven out of eight subscales (+0.2 to 10.5). Conclusions Patients with PASC-associated angina and evidence of MVD experienced subjective and objective benefits from EECP. The treatment was well-tolerated. These findings warrant controlled studies in a larger cohort.
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Affiliation(s)
- Eline Wu
- Division of Cardiology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | - Ali Mahdi
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jannike Nickander
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Judith Bruchfeld
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Linda Mellbin
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Haugaa
- Division of Cardiology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Ståhlberg
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Liyew Desta
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Du J, Peng J, Shen X, Li X, Zhong H, Gao Z, Chen M, Qi L, Xie Q. Enhanced external counterpulsation treatment regulates blood flow and wall shear stress metrics in femoral artery: An in vivo study in healthy subjects. J Biomech 2023; 159:111797. [PMID: 37703718 DOI: 10.1016/j.jbiomech.2023.111797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/25/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023]
Abstract
As a non-invasive assisted circulation therapy, enhanced external counterpulsation (EECP) has demonstrated potential in treatment of lower-extremity arterial disease (LEAD). However, the underlying hemodynamic mechanism remains unclear. This study aimed to conduct the first prospective investigation of the EECP-induced responses of blood flow behavior and wall shear stress (WSS) metrics in the femoral artery. Twelve healthy male volunteers were enrolled. A Doppler ultrasound-basedapproach was introduced for the in vivo determination of blood flow in the common femoral artery (CFA) and superficial femoral artery (SFA) during EECP intervention, with incremental treatment pressures ranging from 10 to 40 kPa. Three-dimensional subject-specific numerical models were developed in 6 subjects to quantitatively assess variations in WSS-derived hemodynamic metrics in the femoral bifurcation. A mesh-independence analysis was performed. Our results indicated that, compared to the pre-EECP condition, both the antegrade and retrograde blood flow volumes in the CFA and SFA were significantly augmented during EECP intervention, while the heart rate remained constant. The time average shear stress (TAWSS) over the entire femoral bifurcation increased by 32.41%, 121.30%, 178.24%, and 214.81% during EECP with treatment pressures of 10 kPa, 20 kPa, 30 kPa, and 40 kPa, respectively. The mean relative resident time (RRT) decreased by 24.53%, 61.01%, 69.81%, and 77.99%, respectively. The percentage of area with low TAWSS in the femoral artery dropped to nearly zero during EECP with a treatment pressure greater than or equal to 30 kPa. We suggest that EECP is an effective and non-invasive approach for regulating blood flow and WSS in lower extremity arteries.
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Affiliation(s)
- Jianhang Du
- Medical Research Center, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518033, China; National Health Commission (NHC) Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou 510080, China.
| | - Junping Peng
- Department of Radiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen 518033, China
| | - Xuelian Shen
- Department of Ultrasound, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen 518033, China
| | - Xiaoling Li
- Community Health Service Management Center, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Huiling Zhong
- Medical Research Center, the Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 518033, China; National Health Commission (NHC) Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou 510080, China
| | - Zhuxuan Gao
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang 110819, China
| | - Muyan Chen
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang 110819, China
| | - Lin Qi
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang 110819, China
| | - Qilian Xie
- Department of Pediatrics, Children's Hospital of Anhui Medical University, Hefei 230051, China
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Li B, Liu Y, Liu J, Sun H, Feng Y, Zhang Z, Zhang L. Cerebral multi-autoregulation model based enhanced external counterpulsation treatment planning for cerebral ischemic stroke. J Cereb Blood Flow Metab 2023; 43:1764-1778. [PMID: 37254770 PMCID: PMC10581230 DOI: 10.1177/0271678x231179542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 03/03/2023] [Accepted: 04/24/2023] [Indexed: 06/01/2023]
Abstract
Enhanced external counterpulsation (EECP) treatment for cerebral ischemic stroke patients with differing severity of stenosis, is subject to uncertainties due to the varying effects of the cerebral autoregulation mechanism on haemodynamics. The current study reports the development of a cerebral multi-autoregulation (MR) mathematical model, based on cerebral arteriole regulation of neurogenic, vascular smooth muscle reflex and shear stress mechanisms which takes into account the severity of stenosis. The model was evaluated by comparison to authentic clinical measurements of cerebral autoregulatory efficiency. Then it was applied to a 0D/3D geometric multi-scale haemodynamic model of a cerebral artery. Haemodynamic indicators were calculated under different pressurization durations of EECP to evaluate the efficacy for different stenosis lesions. Moderate stenosis of 50% to 60% produced excessive time-averaged wall shear stress in the distal area of the stenosis (>7 Pa) during prolonged pressurization and may result in damage to vascular endothelial cells. However, prolonged pressurization did not result in haemodynamic risk for severe stenosis of 70% to 80%, indicating that the duration of pressurization may be extended with increasing severity of stenosis. The current MR model accurately simulated cerebral blood flow and has relevance to the simulation of cerebral haemodynamics in a clinical setting.
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Affiliation(s)
- Bao Li
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Youjun Liu
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Jincheng Liu
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Hao Sun
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Yili Feng
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Zhe Zhang
- Department of Cardiac Surgery, Peking University Third Hospital, Beijing, China
| | - Liyuan Zhang
- Department of Biomedical Engineering, Faculty of Environment and Life, Beijing University of Technology, Beijing, China
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Lee CH, Chung JW, Guk HS, Hong JM, Rosenson RS, Jeong SK. Cerebral artery signal intensity gradient from Time-of-Flight Magnetic Resonance Angiography and clinical outcome in lenticulostriate infarction: a retrospective cohort study. Front Neurol 2023; 14:1220840. [PMID: 37799283 PMCID: PMC10547899 DOI: 10.3389/fneur.2023.1220840] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/30/2023] [Indexed: 10/07/2023] Open
Abstract
Purpose Lenticulostriate infarction requires further research of arterial hemodynamic factors, as the disease is diagnosed in the absence of major arterial stenosis or cardioembolism. Methods In this multicenter retrospective cohort study, we included patients who were hospitalized for lenticulostriate infarction from January 2015 to March 2021 at three stroke centers in South Korea. We obtained hemodynamic information on cerebral arteries using signal intensity gradient (SIG), an in-vivo approximated wall shear stress (WSS) derived from Time-of-Flight Magnetic Resonance Angiography (TOF-MRA). A favorable outcome was defined as a modified Rankin Scale of 0 to 2 at hospital discharge. Results A total of 294 patients were included, of whom 146 (49.7%) had an unfavorable outcome. The unfavorable outcome group showed significantly lower SIG in both middle cerebral arteries (MCAs) than the favorable group (5.2 ± 1.2 SI/mm vs. 5.9 ± 1.2, p < 0.001), and similar findings were observed in other cerebral arteries. The SIGs in both MCAs were independently associated with favorable outcome, with an odds ratio of 1.42 (95% confidence interval, 1.11-1.80; p = 0.005) for the right MCA and 1.49 (95% CI, 1.15-1.93; p = 0.003) for the left MCA, after adjusting for potential confounders. Similar findings were observed in other cerebral artery SIGs. Conclusion Cerebral artery SIG from TOF-MRA was significantly associated with short-term functional outcomes in patients with lenticulostriate infarction. Further studies are needed to investigate the temporal relationships of SIG in patients with cerebral infarction.
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Affiliation(s)
- Chan-Hyuk Lee
- Department of Neurology, Asan Medical Center, Seoul, Republic of Korea
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyung Seok Guk
- Department of Neurology, Gunsan Medical Center, Gunsan, Republic of Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Robert S. Rosenson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Seul-Ki Jeong
- Seul-Ki Jeong Neurology Clinic, Seoul, Republic of Korea
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Leng X, Leung TW. Collateral Flow in Intracranial Atherosclerotic Disease. Transl Stroke Res 2023; 14:38-52. [PMID: 35672561 DOI: 10.1007/s12975-022-01042-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/27/2022] [Accepted: 05/26/2022] [Indexed: 01/31/2023]
Abstract
Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke and transient ischemic attack (TIA) worldwide. The culprit of ICAD is frequently a high-grade intracranial atherosclerotic stenosis (ICAS) pertaining to the infarct territory, and by then, the ICAS is described as symptomatic. A high-grade ICAS may progressively limit cerebral perfusion downstream, demanding collateral compensation. Collateral circulation refers to the pre-existing and dynamic emergence of vascular channels that maintain and compensate for a failing principal vascular route. Collaterals through the Circle of Willis and leptomeningeal circulation are of utmost importance in this regard. In this article, we first discussed the epidemiology, stroke mechanisms, contemporary therapeutics, and prognosis of symptomatic ICAD. Then, we reviewed the collateral routes in ICAS, factors associated with recruitment and development of the collaterals and diagnostic imaging modalities in assessing the origin and function of collateral circulation. We discussed the associations between collateral circulation and clinical outcomes after acute reperfusion treatment in ICAD-related ischemic strokes with or without large vessel occlusion (LVO). We also conducted a systematic review and meta-analysis on the associations of collateral circulation with the risk of recurrent stroke and the functional outcome in symptomatic ICAS patients on medical treatment as secondary stroke prevention. Finally, we summarized current evidence in these aspects and proposed the future directions.
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Affiliation(s)
- Xinyi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, The Prince of Wales Hospital, Hong Kong SAR, China
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, The Prince of Wales Hospital, Hong Kong SAR, China.
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Noninvasive mechanical auxiliary circulation (NMAC): A general concept and the technological trends. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2022. [DOI: 10.1016/j.medntd.2022.100171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Xiong L, Chen X, Liu J, Wong LKS, Leung TW. Cerebral Augmentation Effect Induced by External Counterpulsation Is Not Related to Impaired Dynamic Cerebral Autoregulation in Ischemic Stroke. Front Neurol 2022; 13:784836. [PMID: 35592467 PMCID: PMC9110640 DOI: 10.3389/fneur.2022.784836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose Dynamic cerebral autoregulation is impaired after ischemic stroke. External counterpulsation (ECP) augments the cerebral blood flow of patients with ischemic stroke by elevation of blood pressure (BP). We aimed to investigate if cerebral augmentation effects during ECP were associated with impaired dynamic cerebral autoregulation in patients after acute ischemic stroke. Methods Forty patients with unilateral ischemic stroke and large artery atherosclerosis in the anterior circulation territory within 7 days from symptom onset and eighteen healthy controls were recruited. We monitored changes in mean flow velocity over both middle cerebral arteries (MCA) by transcranial Doppler (TCD) before, during, and immediately after ECP. Cerebral augmentation index was MCA mean flow velocity increase in percentage during ECP compared with baseline to evaluate the augmentation effects of ECP. Spontaneous arterial BP and cerebral blood flow velocity in both bilateral MCAs were recorded using a servo-controlled plethysmograph and TCD, respectively. Transfer function analysis was used to derive the autoregulatory parameters, including phase difference (PD), and gain. Results The cerebral augmentation index in patients with stroke was significantly higher on both the ipsilateral and contralateral sides than that in controls, while the PD in patients with stroke was significantly lower on both sides than those in controls (all P < 0.05). The cerebral augmentation index did not correlate with PD and gain on either the ipsilateral or contralateral side of patients with stroke or in controls (all P > 0.05). The cerebral augmentation index of patients with stroke was significantly related to mean BP change on the ipsilateral side (R2 = 0.108, P = 0.038). Conclusion The degree of ECP-induced cerebral augmentation effects as measured by the cerebral augmentation index did not correlate with the magnitude of impaired dynamic cerebral autoregulation.
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Affiliation(s)
- Li Xiong
- Clinical Trials Centre, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- *Correspondence: Li Xiong
| | - Xiangyan Chen
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Shatin, Hong Kong SAR, China
- Xiangyan Chen
| | - Jia Liu
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Lawrence Ka Sing Wong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Thomas W. Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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Zhang Y, Chen Z, Mai Z, Zhou W, Wang H, Zhang X, Wei W, Du J, Wu G. Acute Hemodynamic Responses to Enhanced External Counterpulsation in Patients With Coronary Artery Disease. Front Cardiovasc Med 2021; 8:721140. [PMID: 34869627 PMCID: PMC8632772 DOI: 10.3389/fcvm.2021.721140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 10/12/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: Enhanced external counterpulsation is a non-invasive treatment that increases coronary flow in patients with coronary artery disease (CAD). However, the acute responses of vascular and blood flow characteristics in the conduit arteries during and immediately after enhanced external counterpulsation (EECP) need to be verified. Methods: Forty-two patients with CAD and 21 healthy controls were recruited into this study to receive 45 min-EECP. Both common carotid arteries (CCAs), namely, the left carotid (LC) and right carotid (RC), the right brachial (RB), and right femoral (RF) artery were imaged using a Color Doppler ultrasound. The peak systolic velocity (PSV), end-diastolic velocity (EDV), mean inner diameter (ID), resistance index (RI), and mean flow rate (FR) were measured and calculated before, during, and after the 45 min-EECP treatment. Results: During EECP, in the CCAs, the EDV was significantly decreased, while the RI was markedly increased in the two groups (both P < 0.01). However, immediately after EECP, the RI in the RC was significantly lower than that at the baseline in the patients with CAD (P = 0.039). The FR of the LC was markedly increased during EECP only in the CAD patients (P = 0.004). The PSV of the patients with CAD was also significantly reduced during EECP (P = 0.015) and immediately after EECP (P = 0.005) compared with the baseline. Moreover, the ID of the LC, RB, and RF was significantly higher immediately after EECP than that at the baseline (all P < 0.05) in the patients with CAD. In addition, they were also higher than that in the control groups (all P < 0.05). Furthermore, by the subgroup analysis, there were significant differences in the FR, PSV, and RI between females and males during and immediately after EECP (all P < 0.05). Conclusions: Enhanced external counterpulsation creates different responses of vascular and blood flow characteristics in carotid and peripheral arteries, with more significant effects in both the carotid arteries. Additionally, the beneficial effects in ID, blood flow velocity, RI, and FR after 45 min-EECP were shown only in the patients with CAD. More importantly, acute improvement of EECP in the FR of the brachial artery was showed in males, while the FR and RI of the carotid arteries changed in females.
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Affiliation(s)
- Yahui Zhang
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China.,National Health Commission (NHC) Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China.,Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Shenzhen, China
| | - Ziqi Chen
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China.,National Health Commission (NHC) Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Zhouming Mai
- Department of Cardiology, Huizhou Third People's Hospital, Huizhou, China
| | - Wenjuan Zhou
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Hui Wang
- Department of Cardiac Ultrasound, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Xiaodong Zhang
- Department of Physical Education, Nanjing University of Finance and Economics, Nanjing, China
| | - Wenbin Wei
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Jianhang Du
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China.,National Health Commission (NHC) Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China.,Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Shenzhen, China
| | - Guifu Wu
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China.,National Health Commission (NHC) Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China.,Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Shenzhen, China
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11
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Zhang W, Fu W, Yan L, Wang M, Ning B, Mo X, Xiong L, Liu J, Zhang P, Zhong J, Sun L, Fu W. Impaired dynamic cerebral autoregulation in young adults with mild depression. Psychophysiology 2021; 59:e13949. [PMID: 34587299 DOI: 10.1111/psyp.13949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/02/2021] [Accepted: 09/20/2021] [Indexed: 01/02/2023]
Abstract
The incidence of depression is increasing, especially in the young adult population. Impaired cognitive function is one of the characteristics of depression, which may be related to impaired cerebral autoregulation (CA). We investigated the characteristics of CA in young adults with mild depression, as well as its validity for identifying patients with depression. Patients (aged 18-35 years) with Hamilton Depression Rating Scale (HAMD) scores ranging from 8 to 17 and a first episode of mild depression were enrolled in this study. Healthy volunteers were recruited as controls. Noninvasive continuous arterial blood pressure and bilateral middle cerebral artery blood flow velocity were simultaneously recorded from each subject. Transfer function analysis was applied to derive phase difference, gain, coherence and rate of recovery for the assessment of CA. Forty-three patients and 43 healthy controls were enrolled. Phase difference values were significantly compromised in young adults with mild depression and were negatively correlated with HAMD scores. Rate of recovery values estimated from depressed patients was significantly lower. The validity in identifying patients with depression was favorable for the phase difference. The cutoff phase difference value was 29.66. Our findings suggest that dynamic CA was impaired in young patients with mild depression and negatively correlated with HAMD scores. CA represented by phase difference can be used as an objective auxiliary examination of depression, and has clinical diagnostic value for the early identification of patients with depression.
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Affiliation(s)
- Weijun Zhang
- Department of Cerebral Function, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wen Fu
- Department of Rheumatology, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China
| | - Luda Yan
- Shenzhen Bao'an Research Center for Acupuncture and Moxibustion, Shenzhen, China
| | - Mengyu Wang
- School of Rehabilitation Medicine, Henan University of Chinese Medicine, Zhengzhou, China
| | - Baile Ning
- Department of Acupuncture and Moxibustion, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiuyun Mo
- Department of Cerebral Function, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Li Xiong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Jia Liu
- Institute of Advanced Computing and Digital Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Pandeng Zhang
- Institute of Advanced Computing and Digital Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Jingxin Zhong
- Department of Cerebral Function, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lu Sun
- Department of Psychosomatics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wenbin Fu
- Department of Acupuncture and Moxibustion, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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12
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Tian S, Pan W, Peng J, Wang H, Deng B, Liang Y, Li X, Liu H, Wang Y, Luo B, Du J. Hemodynamic Responses in Carotid Bifurcation Induced by Enhanced External Counterpulsation Stimulation in Healthy Controls and Patients With Neurological Disorders. Front Physiol 2021; 12:717080. [PMID: 34531762 PMCID: PMC8438206 DOI: 10.3389/fphys.2021.717080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/21/2021] [Indexed: 12/25/2022] Open
Abstract
Enhanced external counterpulsation is a Food and Drug Administration–approved, non-invasive, assisted circulation therapy for ischemic cardiovascular and cerebrovascular diseases. Previous studies have confirmed that EECP stimulation induces largely different cerebral hemodynamic responses in patients with ischemic stroke and healthy controls. However, the underlying mechanisms remain uncertain. We hypothesize that different blood redistributions at the carotid bifurcation may play a key role. Ten subjects were enrolled in this study, namely, five patients with neurological disorders and five young healthy volunteers as controls. Magnetic resonance angiography (MRA) was performed on the carotid artery. All the subjects received a single session of EECP treatment, with external cuff pressures ranging from 20 to 40 kPa. Vascular ultrasound measurements were taken in the common carotid artery (CCA), external carotid artery (ECA) and internal carotid artery (ICA). Three-dimensional patient-specific numerical models were developed to calculate the WSS-derived hemodynamic factors. The results indicated that EECP increased CCA and ECA blood flow in both groups. The ICA blood flow in the patient group exhibited a mean increase of 6.67% during EECP treatment compared with the pre-EECP condition; a mean decrease of 9.2% was observed in the healthy control group. EECP increased the averaged wall shear stress (AWSS) throughout the carotid bifurcation in the patient group; the ICA AWSS of the healthy group decreased during EECP. In both groups, the oscillatory shear index (OSI) in the ICA increased proportionally with external cuff pressure. In addition, the relative resident time (RRT) was constant or slightly decreased in the CCA and ECA in both groups but increased in the ICA. We suggest that the benefits of EECP to patients with neurological disorders may partly result from blood flow promotion in the ICA and increase in WSS at the carotid bifurcation. In the healthy subjects, the ICA blood flow remained constant during EECP, although the CCA blood flow increased significantly. A relatively low external cuff pressure (20 kPa) is recommended as the optimal treatment pressure for better hemodynamic effects. This study may play an important role in the translation of physiological benefits of EECP treatment in populations with or without neurological disorders.
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Affiliation(s)
- Shuai Tian
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China.,Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Sun Yat-sen University, Shenzhen, China
| | - Wei Pan
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China.,Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Sun Yat-sen University, Shenzhen, China
| | - Junping Peng
- Department of Radiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Hui Wang
- Department of Ultrasound, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Bin Deng
- Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Sun Yat-sen University, Shenzhen, China
| | - Yi Liang
- Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Sun Yat-sen University, Shenzhen, China
| | - Xinghua Li
- Medical Imaging Center, Chongming Medical Technology Company, Shenzhen, China
| | - Huahui Liu
- Department of Radiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Yujia Wang
- Department of Ultrasound, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Bin Luo
- Department of Neurosurgery, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Jianhang Du
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China.,Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Sun Yat-sen University, Shenzhen, China.,National Health Commission Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
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13
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Intermittent Sequential Pneumatic Compression Improves Coupling between Cerebral Oxyhaemoglobin and Arterial Blood Pressure in Patients with Cerebral Infarction. BIOLOGY 2021; 10:biology10090869. [PMID: 34571746 PMCID: PMC8470335 DOI: 10.3390/biology10090869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 11/16/2022]
Abstract
This study aims to explore the effect of intermittent sequential pneumatic compression (ISPC) intervention on the coupling relationship between arterial blood pressure (ABP) and changes in oxyhaemoglobin (Δ [O2Hb]). The coupling strength between the two physiological systems was estimated using a coupling function based on dynamic Bayesian inference. The participants were 22 cerebral infarction patients and 20 age- and sex-matched healthy controls. Compared with resting state, the coupling strength from ABP to Δ [O2Hb] oscillations was significantly lower in the bilateral prefrontal cortex (PFC), sensorimotor cortex (SMC), and temporal lobe cortex (TLC) during the ISPC intervention in cerebral infarction patients in interval II. Additionally, the coupling strength was significantly lower in the bilateral SMC in both groups in interval III. These findings indicate that ISPC intervention may facilitate cerebral circulation in the bilateral PFC, SMC, and TLC in cerebral infarction patients. ISPC may promote motor function recovery through its positive influences on motor-related networks. Furthermore, the coupling between Δ [O2Hb] and ABP allows non-invasive assessments of autoregulatory function to quantitatively assess the effect of rehabilitation tasks and to guide therapy in clinical situations.
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14
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Xiong L, Liu D, Wang Y, Wong KS, Fan Y. An Index From Transcranial Doppler Signals for Evaluation of Stroke Rehabilitation Using External Counterpulsation. IEEE Trans Neural Syst Rehabil Eng 2021; 29:1487-1493. [PMID: 34310311 DOI: 10.1109/tnsre.2021.3099203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This study aimed to develop a sensitive index from transcranial Doppler (TCD) signals for quantitatively evaluating the effects of long-term external counterpulsation (ECP) treatment on stroke rehabilitation. We recruited 27 patients with unilateral ischemic stroke and a good acoustic window within 7 days of stroke onset. 15 of them received 35 daily 1-hour ECP treatment (ECP group) and the others underwent conventional therapy without ECP treatment (No-ECP group). We monitored blood flow in middle cerebral arteries on both sides by TCD, and analyzed them via discrete wavelet analysis method. The overall changes of National Institutes of Health Stroke Scale (NIHSS) and Barthel Index were assessed. A 'big-wave' phenomenon was observed in TCD signals of patients in ECP group after 35 days' treatment, with significant fluctuation in frequency interval from 0.010 to 0.034 Hz as main feature. A new index, which was denoted as I , was derived from this phenomenon. The I was significantly higher for patients in ECP group than that for patients in No-ECP group after 35-days' treatment ( 0.01). And the I was positively correlated with NIHSS change in ECP group ( ). The new index could be used as an effective indicator for evaluating enhancement of endothelial metabolism and neurogenic activity after long-term ECP treatment.
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15
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Zhang Y, Mai Z, Du J, Zhou W, Wei W, Wang H, Yao C, Zhang X, Huang H, Wu G. Acute Effect of Enhanced External Counterpulsation on the Carotid Hemodynamic Parameters in Patients With High Cardiovascular Risk Factors. Front Physiol 2021; 12:615443. [PMID: 34220527 PMCID: PMC8247765 DOI: 10.3389/fphys.2021.615443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 05/21/2021] [Indexed: 11/20/2022] Open
Abstract
Purpose Enhanced external counterpulsation (EECP) can improve carotid circulation in patients with coronary artery disease. However, the response of carotid hemodynamic parameters induced by EECP in patients with high cardiovascular risk factors remains to be clarified. This study aimed to investigate the acute effect of EECP on the hemodynamic parameters in the carotid arteries before, during, and immediately after EECP in patients with hypertension, hyperlipidemia, and type 2 diabetes. Methods Eighty-three subjects were recruited into this study to receive 45-min EECP, including patients with simple hypertension (n = 21), hyperlipidemia (n = 23), type 2 diabetes (n = 18), and healthy subjects (n = 21). Hemodynamic parameters in both common carotid arteries (CCAs) were measured and calculated from Doppler ultrasound images. Peak systolic velocity (PSV), end-diastolic velocity (EDV), mean inner diameter (ID), systolic/diastolic flow velocity ratio (VS/VD), flow rate (FR), and resistance index (RI) were monitored before, during, and immediately after 45-min EECP. Results EDV and VS/VD were significantly reduced, while RI of CCAs was significantly increased among four groups during EECP (all P < 0.01). Additionally, the ID of CCAs and the FR of left CCA increased in patients with hyperlipidemia during EECP (P < 0.05). PSV of left CCA was reduced in patients with type 2 diabetes (P < 0.05). Moreover, immediately after EECP, ID was significantly higher in patients with hyperlipidemia. The RI of patients with hypertension and PSV and VS/VD of patients with type 2 diabetes were significantly lower compared with baseline (all P < 0.05). Conclusion EECP created an acute reduction in EDV, PSV, and VS/VD, and an immediate increase in the RI, FR, and ID of CCAs among the four groups. Additionally, a single 45-min session of EECP produced immediate improvement in the ID of patients with hyperlipidemia, the RI of patients with hypertension, and the PSV and VS/VD of patients with type 2 diabetes. The different hemodynamic responses induced by EECP may provide theoretical guidance for making personalized plans in patients with different cardiovascular risk factors.
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Affiliation(s)
- Yahui Zhang
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China.,National Health Commission (NHC) Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China.,Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Shenzhen, China
| | - Zhouming Mai
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Jianhang Du
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China.,Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Shenzhen, China
| | - Wenjuan Zhou
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Wenbin Wei
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Hui Wang
- Department of Cardiac Ultrasound, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Chun Yao
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China.,National Health Commission (NHC) Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Xinxia Zhang
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China.,Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Shenzhen, China
| | - Hui Huang
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China.,Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Shenzhen, China
| | - Guifu Wu
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China.,National Health Commission (NHC) Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China.,Guangdong Innovative Engineering and Technology Research Center for Assisted Circulation, Shenzhen, China
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16
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Leung TW, Wang L, Zou X, Soo Y, Pu Y, Ip HL, Chan A, Au LWC, Fan F, Ma SH, Ip B, Ma K, Lau AYL, Leung H, Hui KF, Li R, Li SH, Fu M, Fong WC, Liu J, Mok V, Wong KSL, Miao Z, Ma N, Yu SCH, Leng X. Plaque morphology in acute symptomatic intracranial atherosclerotic disease. J Neurol Neurosurg Psychiatry 2020; 92:jnnp-2020-325027. [PMID: 33239439 PMCID: PMC7958085 DOI: 10.1136/jnnp-2020-325027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/19/2020] [Accepted: 11/06/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intracranial atherosclerotic disease (ICAD) is globally a major ischaemic stroke subtype with high recurrence. Understanding the morphology of symptomatic ICAD plaques, largely unknown by far, may help identify vulnerable lesions prone to relapse. METHODS We prospectively recruited patients with acute ischaemic stroke or transient ischaemic attack attributed to high-grade ICAD (60%-99% stenosis). Plaque morphological parameters were assessed in three-dimensional rotational angiography, including surface contour, luminal stenosis, plaque length/thickness, upstream shoulder angulation, axial/longitudinal plaque distribution and presence of adjoining branch atheromatous disease (BAD). We compared morphological features of smooth, irregular and ulcerative plaques and correlated them with cerebral ischaemic lesion load downstream in MRI. RESULTS Among 180 recruited patients (median age=60 years; 63.3% male; median stenosis=75%), plaque contour was smooth (51 (28.3%)), irregular (101 (56.1%)) or ulcerative (28 (15.6%)). Surface ulcers were mostly at proximal (46.4%) and middle one-third (35.7%) of the lesions. Most (84.4%) plaques were eccentric, and half had their maximum thickness over the distal end. Ulcerative lesions were thicker (medians 1.6 vs 1.3 mm; p=0.003), had steeper upstream shoulder angulation (56.2° vs 31.0°; p<0.001) and more adjoining BAD (83.3% vs 57.0%; p=0.033) than non-ulcerative plaques. Ulcerative plaques were significantly associated with coexisting acute and chronic infarcts downstream (35.7% vs 12.5%; adjusted OR 4.29, 95% CI 1.65 to 11.14, p=0.003). Sensitivity analyses in patients with anterior-circulation ICAD lesions showed similar results in the associations between the plaque types and infarct load. CONCLUSIONS Ulcerative intracranial atherosclerotic plaques were associated with vulnerable morphological features and had a higher cumulative infarct load downstream.
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Affiliation(s)
- Thomas W Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Li Wang
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xinying Zou
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Yannie Soo
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yuehua Pu
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Hing Lung Ip
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Anne Chan
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lisa Wing Chi Au
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Florence Fan
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Sze Ho Ma
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Bonaventure Ip
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Karen Ma
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Alexander Yuk-Lun Lau
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Howan Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kwok Fai Hui
- Department of Medicine and Geriatrics, The United Christian Hospital, Hong Kong SAR, China
| | - Richard Li
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Siu Hung Li
- Department of Medicine, North District Hospital, Hong Kong SAR, China
| | - Michael Fu
- Department of Medicine and Geriatric, Tuen Mun Hospital, Hong Kong SAR, China
| | - Wing Chi Fong
- Department of Medicine, The Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Jia Liu
- Shenzhen Institutes of Advanced Technology Chinese Academy of Sciences, Shenzhen, Guangdong, China
| | - Vincent Mok
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ka Sing Lawrence Wong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Simon C H Yu
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xinyi Leng
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
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17
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Paliwal P, Sinha AK, Sharma VK. Reversal of the 'reversed Robin Hood syndrome' in severe intracranial stenosis after enhanced external counterpulsation therapy. Eur J Neurol 2020; 27:2371-2372. [PMID: 32748471 DOI: 10.1111/ene.14459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/24/2020] [Accepted: 07/25/2020] [Indexed: 11/25/2022]
Affiliation(s)
- P Paliwal
- Division of Neurology, National University Hospital, Singapore, Singapore
| | - A K Sinha
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - V K Sharma
- Division of Neurology, National University Hospital, Singapore, Singapore.,YLL School of Medicine, National University of Singapore, Singapore, Singapore
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18
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The Hemodynamic Effect of Enhanced External Counterpulsation Treatment on Atherosclerotic Plaque in the Carotid Artery: A Framework of Patient-Specific Computational Fluid Dynamics Analysis. Cardiol Res Pract 2020; 2020:5903790. [PMID: 32411447 PMCID: PMC7210552 DOI: 10.1155/2020/5903790] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/18/2019] [Accepted: 01/21/2020] [Indexed: 01/28/2023] Open
Abstract
Long-term enhanced external counterpulsation (EECP) therapy has been recommended for antiatherogenesis in recent clinical observations and trials. However, the precise mechanism underlying the benefits has not been fully clarified. To quantify the effect of EECP intervention on arterial hemodynamic environment, a framework of numerical assessment was introduced using a parallel computing algorithm. A 3D endothelial surface of the carotid artery with mild atherosclerotic plaque was constructed from images of magnetic resonance angiography (MRA). Physiologic boundary conditions were derived from images of the ultrasound flow velocity spectrum measured at the common carotid artery and before and during EECP intervention. Hemodynamic factors relating to wall shear stress (WSS) and its spatial and temporal fluctuations were calculated and analyzed, which included AWSS, OSI, and AWSSG. Measuring and computational results showed that diastole blood pressure, perfusion, and WSS level in carotid bifurcation were significantly increased during EECP intervention. Mean AWSS level throughout the model increased by 16.9%, while OSI level did not show a significant change during EECP. We thus suggested that long-term EECP treatment might inhibit the initiation and development of atherosclerotic plaque via improving the hemodynamic environment in the carotid artery. Meanwhile, EECP performance induced a 19.6% increase in AWSSG level, and whether it would influence the endothelial functions may need a further study. Moreover, the numerical method proposed in this study was expected to be useful for the instant assessment of clinical application of EECP .
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19
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Fang H, Leng X, Pu Y, Zou X, Pan Y, Song B, Soo YOY, Leung TWH, Wang C, Zhao X, Wang Y, Wang Y, Wong KS, Liu L, Xu Y. Hemodynamic Significance of Middle Cerebral Artery Stenosis Associated With the Severity of Ipsilateral White Matter Changes. Front Neurol 2020; 11:214. [PMID: 32351440 PMCID: PMC7174781 DOI: 10.3389/fneur.2020.00214] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/09/2020] [Indexed: 12/03/2022] Open
Abstract
Background: Previous studies conflicted in the association between intracranial atherosclerotic stenosis (ICAS) and the severity of white matter changes (WMC). Aims: We aimed to investigate the relationships between the severity of luminal stenosis and the hemodynamic significance of middle cerebral artery (MCA) stenosis, and the severity of ipsilateral WMC. Methods: In this cross-sectional study, patients with a recent ischemic stroke or transient ischemic attack and a 50–99% MCA-M1 stenosis in the Chinese Intracranial Atherosclerosis study cohort were analyzed. The post- to pre-stenotic signal intensity ratio (SIR) was obtained in time-of-flight MR angiography (MRA) to represent the hemodynamic significance of MCA-M1 stenosis, with a lower SIR indicating a hemodynamically more severe lesion. The severity of ipsilesional WMC was assessed by an age-related WMC (ARWMC) scale in T2-weighted fluid attenuated inversion recovery MR imaging. The relationships between the degree of MCA-M1 stenosis, SIR, and ipsilesional ARWMC scale were analyzed. The MCA-M1 lesion with a higher percentage of stenosis was chosen for analyses in patients with bilateral MCA-M1 stenoses. Results: Among 180 subjects (mean age, 64 years), a lower SIR of MCA-M1 stenosis (Spearman correlation coefficient, −0.543; p < 0.001), but not the degree of stenosis (p = 0.93), was significantly linearly correlated with a higher ipsilateral ARWMC. Multivariate ordinal logistic regression identified older age (OR = 1.037; 95% CI, 1.008–1.066; p = 0.011) and lower SIR (OR = 0.010; 95% CI, 0.002–0.058; p < 0.001) as independent predictors for more severe ipsilateral WMC. Conclusion: Patients with hemodynamically more severe ICAS are more likely to have more severe ipsilateral WMC. Longitudinal studies with sequential imaging exams may further reveal the impact of hemodynamic significance of ICAS on the development and progression of WMC.
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Affiliation(s)
- Hui Fang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong
| | - Yuehua Pu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xinying Zou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Bo Song
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yannie O Y Soo
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong
| | - Thomas W H Leung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong
| | - Chunxue Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Ka Sing Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuming Xu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Lin S, Xiao-Ming W, Gui-Fu W. Expert consensus on the clinical application of enhanced external counterpulsation in elderly people (2019). Aging Med (Milton) 2020; 3:16-24. [PMID: 32232188 PMCID: PMC7099759 DOI: 10.1002/agm2.12097] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/09/2020] [Accepted: 01/13/2020] [Indexed: 01/07/2023] Open
Abstract
Enhanced external counterpulsation (EECP) is a non-invasive assisted circulation technique and a rich pool of evidence has accumulated for its clinical application in the prevention and management of multiple comorbidities in the elderly population, including angina, heart failure, ischemic cerebrovascular diseases, neurodegenerative diseases, sleep disorder, diabetes and its complications, ischemic eye diseases, sudden hearing loss and erectile dysfunction, as well as various psychological and psychiatric conditions. When applying EECP to elderly patients, emphasis should be placed on issues such as safety assessment, risk management and protocol individualization, as well as the monitoring of efficacy during and after treatment.
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Affiliation(s)
- Shen Lin
- Department of Geriatrics Qilu Hospital of Shandong Univeristy, Key Laboratory of Cardiovascular Disease Proteomics of Shandong Province Ji-nan city China
| | - Wang Xiao-Ming
- Department of Geriatrics Clinical Research Center for Geriatric Diseases Xi Jing Hospital of Air Force Medical University Xi-an city China
| | - Wu Gui-Fu
- Department of Cardiovascular Medicine Research Center for Assisted Circulation Innovative Engineering Technologies The Eighth Affiliated Hospital of Sun Yat-sen University Shen-zhen city China
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21
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Gibbons TD, Zuj KA, Prince CN, Kingston DC, Peterson SD, Hughson RL. Haemodynamic and cerebrovascular effects of intermittent lower-leg compression as countermeasure to orthostatic stress. Exp Physiol 2019; 104:1790-1800. [PMID: 31578774 DOI: 10.1113/ep088077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 09/30/2019] [Indexed: 02/04/2023]
Abstract
NEW FINDINGS What is the central question of this study? Does smartly timed intermittent compression of the lower legs alter cerebral blood velocity and oxygenation during acute orthostatic challenges? What is the main finding and its importance? Intermittent compression timed to the local diastolic phase increased the blood flux through the legs and heart after two different orthostatic stress tests. Cerebral blood velocity improved during the first minute of recovery, and indices of cerebral tissue oxygenation remained elevated for 2 min. These results provide promise for the use of lower-leg active compression as a therapeutic tool for individuals vulnerable to initial orthostatic hypotension and orthostatic stress. ABSTRACT Intermittent compression of the lower legs provides the possibility of improving orthostatic tolerance by actively promoting venous return and improving central haemodynamics. We tested the hypothesis that intermittent compression of 65 mmHg timed to occur only within the local diastolic phase of each cardiac cycle would attenuate the decrease in blood pressure and improve cerebral haemodynamics during the first minute of recovery from two different orthostatic stress tests. Fourteen subjects (seven female) performed four squat-to-stand transitions and four repeats of standing bilateral thigh-cuff occlusion and release (TCR), with intermittent compression of the lower legs applied in half of the trials. Blood flow in the superficial femoral artery, mean arterial pressure, Doppler ultrasound cardiac output, total peripheral resistance, middle cerebral artery blood velocity (MCAv) and cerebral tissue saturation index (TSI%) were monitored. With both orthostatic stress tests, there was a significant compression × time interaction for superficial femoral artery flow (P < 0.001). The hypotensive state was attenuated with intermittent compression despite decreased total peripheral resistance (squat-to-stand, compression × time interaction, P < 0.001; TCR, compression × time interaction, P = 0.002) as a consequence of elevated cardiac output in both tests (P < 0.001). Intermittent compression also increased MCAv (P = 0.001) and TSI% (P < 0.001) during the squat-to-stand transition and during TCR (MCAv and TSI%, compression × time interaction, P < 0.001). Intermittent compression of the lower legs during quiet standing after an active orthostatic challenge augmented local, central and cerebral haemodynamics, providing potential as a therapeutic tool for individuals vulnerable to orthostatic stress.
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Affiliation(s)
- Travis D Gibbons
- Faculty of Applied Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Kathryn A Zuj
- Faculty of Applied Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Chekema N Prince
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON, Canada
| | - David C Kingston
- Faculty of Applied Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Sean D Peterson
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Richard L Hughson
- Schlegel-University of Waterloo Research Institute for Aging, Faculty of Applied Health Sciences, Waterloo, ON, Canada
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22
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Hemodynamic effects of enhanced external counterpulsation on cerebral arteries: a multiscale study. Biomed Eng Online 2019; 18:91. [PMID: 31462269 PMCID: PMC6714389 DOI: 10.1186/s12938-019-0710-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 08/16/2019] [Indexed: 12/01/2022] Open
Abstract
Background Enhanced external counterpulsation (EECP) is an effective method for treating patients with cerebral ischemic stroke, while hemodynamics is the major contributing factor in the treatment of EECP. Different counterpulsation modes have the potential to lead to different acute and long-term hemodynamic changes, resulting in different treatment effects. However, various questions about appropriate counterpulsation modes for optimizing hemodynamic effects remain unanswered in clinical treatment. Methods A zero-dimensional/three-dimensional (0D/3D) geometric multiscale model of the cerebral artery was established to obtain acute hemodynamic indicators, including mean arterial pressure (MAP) and cerebral blood flow (CBF), as well as localized hemodynamic details for the cerebral artery, which includes wall shear stress (WSS) and oscillatory shear index (OSI). Counterpulsation was achieved by applying pressure on calf, thigh and buttock modules in the 0D model. Different counterpulsation modes including various pressure amplitudes and pressurization durations were applied to investigate hemodynamic responses, which impact acute and long-term treatment effects. Both vascular collapse and cerebral autoregulation were considered during counterpulsation. Results Variations of pressure amplitude and pressurization duration have different impacts on hemodynamic effects during EECP treatment. There were small differences in the hemodynamics when similar or different pressure amplitudes were applied to calves, thighs and buttocks. When increasing pressure amplitude was applied to the three body parts, MAP and CBF improved slightly. When pressure amplitude exceeded 200 mmHg, hemodynamic indicators almost never changed, demonstrating consistency with clinical data. However, hemodynamic indicators improved significantly with increasing pressurization duration. For pressurization durations of 0.5, 0.6 and 0.7 s, percentage increases for MAP during counterpulsation were 1.5%, 23.5% and 39.0%, for CBF were 1.2%, 23.4% and 41.6% and for time-averaged WSS were 0.2%, 43.5% and 85.0%, respectively. Conclusions When EECP was applied to patients with cerebral ischemic stroke, pressure amplitude applied to the three parts may remain the same. Patients may not gain much more benefit from EECP treatment by excessively increasing pressure amplitude above 200 mmHg. However, during clinical procedures, pressurization duration could be increased to 0.7 s during the cardiac circle to optimize the hemodynamics for possible superior treatment outcomes.
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23
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Liu JY, Xiong L, Stinear CM, Leung H, Leung TW, Wong KSL. External counterpulsation enhances neuroplasticity to promote stroke recovery. J Neurol Neurosurg Psychiatry 2019; 90:361-363. [PMID: 29844246 DOI: 10.1136/jnnp-2018-318185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/17/2018] [Accepted: 04/30/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Jing Yi Liu
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Li Xiong
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cathy M Stinear
- Clinical Neuroscience Laboratory, Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Howan Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Thomas W Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ka Sing Lawrence Wong
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
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24
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Buschmann EE, Hillmeister P, Bondke Persson A, Liebeskind DS, Schlich L, Kamenzky R, Busjahn A, Buschmann IR, Bramlage P, Hetzel A, Reinhard M. Short-term external counterpulsation augments cerebral blood flow and tissue oxygenation in chronic cerebrovascular occlusive disease. Eur J Neurol 2018; 25:1326-1332. [PMID: 29924461 PMCID: PMC6221180 DOI: 10.1111/ene.13725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 06/19/2018] [Indexed: 11/30/2022]
Abstract
Background and purpose External counterpulsation improves cerebral perfusion velocity in acute stroke and may stimulate collateral artery growth. However, whether (non‐acute) at‐risk patients with high‐grade carotid artery disease may benefit from counterpulsation needs to be validated. Methods Twenty‐eight patients (71 ± 6.5 years, five women) with asymptomatic unilateral chronic severe internal carotid artery stenosis (>70%) or occlusion were randomized to receive 20 min active counterpulsation followed by sham treatment or vice versa. Cerebral blood flow velocity (CBFV) (measured bilaterally by transcranial middle cerebral artery Doppler), tissue oxygenation index (TOI) (measured over the bilateral prefrontal cortex by near‐infrared spectroscopy) and cerebral hemodynamic parameters, such as relative pulse slope index (RPSI), were monitored. Results Ipsilateral mean CBFV (ΔVmean +3.5 ± 1.2 cm/s) and tissue oxygenation (ΔTOI +2.86 ± 0.8) increased significantly during active counterpulsation compared to baseline, whilst the sham had little effect (ΔVmean +1.13 ± 1.1 cm/s; ΔTOI +1.25 ± 0.65). On contralateral sides, neither counterpulsation nor sham control had any effect on either parameter. During counterpulsation, early dynamic changes in ΔRPSI of the ipsilateral CBFV signal predicted improved tissue oxygenation during counterpulsation (odds ratio 1.179, 95% confidence interval 1.01–1.51), whilst baseline cerebrovascular reactivity to hypercapnia failed to show an association. Conclusions In patients with high‐grade carotid disease, ipsilateral cerebral oxygenation and blood flow velocity are increased by counterpulsation. This is a necessary condition for the stimulation of regenerative collateral artery growth and thus a therapeutic concept for the prevention of cerebral ischaemia. This study provides a rationale for further clinical investigations on the long‐term effects of counterpulsation on cerebral hemodynamics and collateral growth.
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Affiliation(s)
- E E Buschmann
- Department for Cardiology, Center of Internal Medicine, Medical University Graz, Graz, Austria.,Brandenburg School of Medicine, Center for Internal Medicine I, Department for Angiology, Brandenburg an der Havel, Germany.,Department of Cardiology, Charité Universitaetsmedizin Berlin, Campus Virchow, Berlin, Germany
| | - P Hillmeister
- Brandenburg School of Medicine, Center for Internal Medicine I, Department for Angiology, Brandenburg an der Havel, Germany.,Department of Cardiology, Charité Universitaetsmedizin Berlin, Campus Virchow, Berlin, Germany
| | - A Bondke Persson
- Institute of Vegetative Physiology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - D S Liebeskind
- Neurovascular Imaging Research Core and UCLA Stroke Center, Los Angeles, CA, USA
| | - L Schlich
- Department of Neurology, University of Freiburg, Freiburg, Germany
| | - R Kamenzky
- Department of Cardiology, Charité Universitaetsmedizin Berlin, Campus Virchow, Berlin, Germany
| | | | - I R Buschmann
- Brandenburg School of Medicine, Center for Internal Medicine I, Department for Angiology, Brandenburg an der Havel, Germany.,Department of Cardiology, Charité Universitaetsmedizin Berlin, Campus Virchow, Berlin, Germany
| | - P Bramlage
- Brandenburg School of Medicine, Center for Internal Medicine I, Department for Angiology, Brandenburg an der Havel, Germany.,Institute für Pharmakologie und Präventive Medizin, Cloppenburg, Germany
| | - A Hetzel
- Schwarzwaldklinik Neurologie, Bad Krozingen, Germany
| | - M Reinhard
- Department of Neurology, University of Freiburg, Freiburg, Germany.,Department of Neurology and Clinical Neurophysiology, Medical Center Esslingen, Academic Teaching Hospital of the University of Tübingen, Tübingen, Germany
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25
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Liu L, Ding J, Leng X, Pu Y, Huang LA, Xu A, Wong KSL, Wang X, Wang Y. Guidelines for evaluation and management of cerebral collateral circulation in ischaemic stroke 2017. Stroke Vasc Neurol 2018; 3:117-130. [PMID: 30294467 PMCID: PMC6169613 DOI: 10.1136/svn-2017-000135] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/10/2018] [Accepted: 04/12/2018] [Indexed: 12/24/2022] Open
Abstract
Collateral circulation plays a vital role in sustaining blood flow to the ischaemic areas in acute, subacute or chronic phases after an ischaemic stroke or transient ischaemic attack. Good collateral circulation has shown protective effects towards a favourable functional outcome and a lower risk of recurrence in stroke attributed to different aetiologies or undergoing medical or endovascular treatment. Over the past decade, the importance of collateral circulation has attracted more attention and is becoming a hot spot for research. However, the diversity in imaging methods and criteria to evaluate collateral circulation has hindered comparisons of findings from different cohorts and further studies in exploring the clinical relevance of collateral circulation and possible methods to enhance collateral flow. The statement is aimed to update currently available evidence and provide evidence-based recommendations regarding grading methods for collateral circulation, its significance in patients with stroke and methods under investigation to improve collateral flow.
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Affiliation(s)
- Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Ding
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Yuehua Pu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li-An Huang
- Department of Neurology, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Anding Xu
- Department of Neurology, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Ka Sing Lawrence Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Xin Wang
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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26
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The numerical study on specialized treatment strategies of enhanced external counterpulsation for cardiovascular and cerebrovascular disease. Med Biol Eng Comput 2018; 56:1959-1971. [DOI: 10.1007/s11517-018-1834-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 04/19/2018] [Indexed: 12/21/2022]
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Picard F, Panagiotidou P, Wolf-Pütz A, Buschmann I, Buschmann E, Steffen M, Klein RM. Usefulness of Individual Shear Rate Therapy, New Treatment Option for Patients With Symptomatic Coronary Artery Disease. Am J Cardiol 2018; 121:416-422. [PMID: 29274808 DOI: 10.1016/j.amjcard.2017.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/07/2017] [Accepted: 11/13/2017] [Indexed: 01/12/2023]
Abstract
The aim of this study was to elucidate if patients with coronary artery disease (CAD), who fail to respond to revascularization procedures, can improve from individual shear rate therapy (ISRT). The ISRT is an adaptation of the external counterpulsation with lower individual treatment pressures based on Doppler-ultrasound measurements during counterpulsation. In contrast to the external counterpulsation therapy, the ISRT is based on the detection of the individual intra-arterial shear rate. Here we report about the first clinical trial of 31 patients with CAD who were enrolled for 30 sessions of ISRT. To determine the therapeutic effect of ISRT we measured the exercise capacity, the arterial stiffness, the aortic wave reflection, and the 24-hour blood pressure before and after 30 treatment sessions. After 6 weeks of accomplished ISRT the walking distance during the 6-minute walking test extended by 78 m (p = 0.007). The total exercise duration in the exercise stress electrocardiogram increased by 84 seconds (p = 0.012) but not the stress intensity (p = 0.086). The pulse wave velocity decreased by 1.2 m/s (p = 0.004) and demonstrated a decrease in arterial stiffness. Pulse wave analysis results demonstrated a progressive decrease in central blood pressure by 12 mmHg (p = 0.008), in pulse pressure by 9 mmHg (p = 0.005), and in augmentation pressure by 5.3 mmHg (p = 0.004). The 24-hour blood pressure decreased systolic by 15 mmHg (p <0.001) and diastolic by 8 mmHg (p = 0.033). The patients also benefited subjectively followed by New York Heart Association and Canadian Cardiovascular Society classifications. In conclusion, the ISRT is an effective treatment for patients with CAD to improve cardiac fitness, arterial stiffness, and to reduce blood pressure.
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Affiliation(s)
- Frauke Picard
- Department of Cardiology, Augusta Hospital Düsseldorf, Academic Teaching Hospital of the University Faculty of Health, Düsseldorf, Germany.
| | - Petroula Panagiotidou
- Department of Cardiology, Augusta Hospital Düsseldorf, Academic Teaching Hospital of the University Faculty of Health, Düsseldorf, Germany
| | - Ana Wolf-Pütz
- Department of Cardiology, Augusta Hospital Düsseldorf, Academic Teaching Hospital of the University Faculty of Health, Düsseldorf, Germany
| | - Ivo Buschmann
- Department for Cardiology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Berlin, Germany; Medical University Brandenburg (MHB), Center for Internal Medicine, Department for Angiology, Campus Brandenburg Germany, Germany
| | - Eva Buschmann
- Department for Cardiology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Berlin, Germany; Medical University Brandenburg (MHB), Center for Internal Medicine, Department for Angiology, Campus Brandenburg Germany, Germany
| | - Maximilian Steffen
- Department of Cardiology, Augusta Hospital Düsseldorf, Academic Teaching Hospital of the University Faculty of Health, Düsseldorf, Germany
| | - Rolf Michael Klein
- Department of Cardiology, Augusta Hospital Düsseldorf, Academic Teaching Hospital of the University Faculty of Health, Düsseldorf, Germany; Department of Cardiology, University Hospital Witten/Herdecke, Germany
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28
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Flat-head positioning increases cerebral blood flow in anterior circulation acute ischemic stroke. A cluster randomized phase IIb trial. Int J Stroke 2017; 13:600-611. [DOI: 10.1177/1747493017711943] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Whether lying-flat improves blood flow in patients with acute ischemic stroke is unknown. Our aim was to investigate if lying-flat “changes” cerebral blood flow velocities assessed by transcranial Doppler in acute ischemic stroke patients. Methods In a multicenter cluster clinical trial, we randomly assigned patients within 12 h from onset of a neurological deficit due to cerebral ischemia of the anterior circulation to lying-flat or upright head positioning. The primary outcome was a change of 8 cm/s or more in mean cerebral blood flow velocities on transcranial Doppler to the middle cerebral artery at 1 and 24 h post-randomization, adjusted for imbalance in baseline variables. Secondary outcomes included serious adverse events and physical functioning at 90 days. Results Ninety-four of 304 patients screened were recruited. The primary outcome occurred in 11 (26%) of 43 patients in the lying-flat group and in 6 (12%) of 51 in the upright group at 1 h (adjusted odds ratio, 3.81; 95% CI, 1.07 to 13.54), and in 23 (53%) and 18 (36%) patients in these respective groups at 24 h (adjusted odds ratio, 3.04; 95% CI, 1.08 to 8.53). There were no between-group differences in serious adverse events, including pneumonia, heart failure or mortality, nor in functional outcome at 3 months (adjusted common odds ratio, 1.38; 95% CI 0.64 to 3.00). Conclusion The lying-flat head position was associated with a significant increase in cerebral blood flow velocities at one and 24 h within the ipsilateral hemisphere of anterior circulation acute ischemic stroke, without serious safety concerns. Clinical trial registration-URL: http://www.clinicaltrials.gov . Unique identifier: NCT01706094.
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Xiong L, Liu X, Shang T, Smielewski P, Donnelly J, Guo ZN, Yang Y, Leung T, Czosnyka M, Zhang R, Liu J, Wong KS. Impaired cerebral autoregulation: measurement and application to stroke. J Neurol Neurosurg Psychiatry 2017; 88:520-531. [PMID: 28536207 DOI: 10.1136/jnnp-2016-314385] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/05/2017] [Accepted: 01/09/2017] [Indexed: 11/04/2022]
Abstract
Cerebral autoregulation (CA) is a protective mechanism that maintains cerebral blood flow at a relatively constant level despite fluctuations of cerebral perfusion pressure or arterial blood pressure. It is a universal physiological mechanism that may involve myogenic, neural control as well as metabolic regulations of cerebral vasculature in response to changes in pressure or cerebral blood flow. Traditionally, CA has been represented by a sigmoid curve with a wide plateau between about 50 mm Hg and 170 mm Hg of steady-state changes in mean arterial pressure, defined as static CA. With the advent of transcranial Doppler, measurement of cerebral blood flow in response to transient changes in arterial pressure has been used to assess dynamic CA. However, a gold standard for measuring CA is not currently available. Stroke has been the leading cause of long-term adult disability throughout the world. A better understanding of CA and its response to pathological derangements can help assess the severity of stroke, guide management decisions, assess response to interventions and provide prognostic information. The objective of this review is to provide a comprehensive insight about physiology of autoregulation, measurement methodologies and clinical applications in stroke to help build a consensus for what should be included in an internationally agreed protocol for CA testing and monitoring, and to promote its translation into clinical bedside practice for stroke management.
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Affiliation(s)
- Li Xiong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Xiuyun Liu
- Department of Clinical Neurosciences, Brain Physics Laboratory, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Ty Shang
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Peter Smielewski
- Department of Clinical Neurosciences, Brain Physics Laboratory, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Joseph Donnelly
- Department of Clinical Neurosciences, Brain Physics Laboratory, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Zhen-Ni Guo
- Department of Neurology, Neuroscience Center, The First Norman Bethune Hospital of Jilin University, Changchun, China
| | - Yi Yang
- Chinese Academy of Sciences, Shenzhen Institutes of Advanced Technology, Shenzhen, China
| | - Thomas Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Marek Czosnyka
- Department of Clinical Neurosciences, Brain Physics Laboratory, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Rong Zhang
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jia Liu
- Chinese Academy of Sciences, Shenzhen Institutes of Advanced Technology, Shenzhen, China
| | - Ka Sing Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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30
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Is Dynamic Cerebral Autoregulation Bilaterally Impaired after Unilateral Acute Ischemic Stroke? J Stroke Cerebrovasc Dis 2017; 26:1081-1087. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/16/2016] [Accepted: 12/24/2016] [Indexed: 11/20/2022] Open
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31
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Xiong L, Tian G, Wang L, Lin W, Chen X, Leung TWH, Soo YOY, Wong LKS. External Counterpulsation Increases Beat-to-Beat Heart Rate Variability in Patients with Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 26:1487-1492. [PMID: 28396189 DOI: 10.1016/j.jstrokecerebrovasdis.2017.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/29/2017] [Accepted: 03/03/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE External counterpulsation (ECP) is a noninvasive method used to augment cerebral perfusion in ischemic stroke. However, the response of beat-to-beat heart rate variability (HRV) in patients with ischemic stroke during ECP remains unknown. METHODS Forty-eight patients with unilateral ischemic stroke at the subacute stage and 14 healthy controls were recruited. Beat-to-beat heart rate before, during, and after ECP was monitored. The frequency components of HRV were calculated using power spectral analysis. Very low frequency (VLF; <.04 Hz), low frequency (LF; .04-.15 Hz), high frequency (HF; .15-.40 Hz), total power spectral density (TP; <.40 Hz), and LF/HF ratio were calculated. RESULTS In stroke patients, although there were no statistical differences in all of the HRV components, the HRV at VLF showed a trend of increase during ECP compared with baseline in the left-sided stroke patients (P = .083). After ECP, the HRV at LF and TP remained higher than baseline in the right-sided stroke patients (LF, 209.4 versus 117.9, P = .050; TP, 1275.6 versus 390.2, P = .017, respectively). Besides, the HRV at TP also increased after ECP compared with baseline in the left-sided stroke patients (563.0 versus 298.3, P = .029). CONCLUSIONS Irrespective of the side of the ischemia, patients showed an increased beat-to-beat HRV after ECP. Additionally, sympathetic and parasympathetic cardiac modulations were increased after ECP in patients after right-sided subacute stroke.
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Affiliation(s)
- Li Xiong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Ge Tian
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Li Wang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Wenhua Lin
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Xiangyan Chen
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Thomas Wai Hong Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Yannie Oi Yan Soo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Lawrence Ka Sing Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China.
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32
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He W, Au-Yeung SYS, Mak M, Leung TWH, Leung H, Wong LKS. The potential synergism by combining external counterpulsation with intermittent theta burst stimulation in post-stroke motor function recovery. Med Hypotheses 2016; 93:140-2. [PMID: 27372874 DOI: 10.1016/j.mehy.2016.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 05/22/2016] [Indexed: 11/16/2022]
Abstract
Upper limb weakness and incoordination is a common disability following ischemic stroke. Previous studies have showed that the single application of external counterpulsation (ECP) and intermittent theta burst stimulation (iTBS) can effectively enhance the cortical motor excitability and facilitate recovery. However, it remains uncertain if sequential application of these therapies would further augment the recovery. We hypothesize a synergistic effect of ECP followed by iTBS to upper limb function may happen through improvements in both cerebral perfusion and neuron excitability.
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Affiliation(s)
- Weijia He
- Division of Neurology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Margaret Mak
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - Thomas Wai Hong Leung
- Division of Neurology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong; Division of Neurology, Prince of Wales Hospital, Shatin, Hong Kong
| | - Howan Leung
- Division of Neurology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong; Division of Neurology, Prince of Wales Hospital, Shatin, Hong Kong
| | - Lawrence Ka Sing Wong
- Division of Neurology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong; Division of Neurology, Prince of Wales Hospital, Shatin, Hong Kong.
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Leng X, Wong KS, Leung TW. The contemporary management of intracranial atherosclerotic disease. Expert Rev Neurother 2016; 16:701-9. [PMID: 27082149 DOI: 10.1080/14737175.2016.1179111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Intracranial atherosclerotic disease is the most common cause of cerebral vasculopathy and an important stroke etiology worldwide, with a higher prevalence in Asian, Hispanic and African ethnicities. Symptomatic intracranial atherosclerotic disease portends a recurrent stroke risk as high as 18% at one year. The key to secondary prevention is an understanding of the underlying stroke mechanism and aggressive control of conventional cardiovascular risks. Contemporary treatment includes antiplatelet therapy, optimal glycemic and blood pressure control, statin therapy and lifestyle modifications. For patients with high-grade (70-99%) symptomatic steno-occlusion, short-term dual antiplatelet therapy with aspirin and clopidogrel followed by life-long single antiplatelet therapy may reduce the recurrent risk. Current evidence does not advocate percutaneous transluminal angioplasty and stenting as an initial treatment. External counterpulsation, encephaloduroarteriosynangiosis and remote limb ischemic preconditioning are treatments under investigation. Future studies should aim at predicting patients prone to recurrence despite of medical therapies and testing the efficacy of emerging therapies.
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Affiliation(s)
- Xinyi Leng
- a Department of Medicine & Therapeutics , The Chinese University of Hong Kong , Hong Kong SAR , China
| | - Ka Sing Wong
- a Department of Medicine & Therapeutics , The Chinese University of Hong Kong , Hong Kong SAR , China
| | - Thomas W Leung
- a Department of Medicine & Therapeutics , The Chinese University of Hong Kong , Hong Kong SAR , China
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Xiong L, Lin W, Han J, Chen X, Leung T, Soo Y, Wong KS. Enhancing cerebral perfusion with external counterpulsation after ischaemic stroke: how long does it last? J Neurol Neurosurg Psychiatry 2016; 87:531-6. [PMID: 25934015 DOI: 10.1136/jnnp-2014-309842] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 04/13/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE External counterpulsation (ECP) is a non-invasive method used to augment cerebral perfusion in ischaemic stroke. We aimed to investigate time-course effects on blood pressure elevation and cerebral blood flow augmentation induced by ECP in ischaemic stroke. METHODS Patients with acute unilateral ischaemic stroke and large artery occlusive disease were recruited to receive 35 daily 1 h ECP treatment sessions. Serial transcranial Doppler monitoring of bilateral middle cerebral arteries was performed on days 3, 5, 7, 10, 14, 21, 28 and 35 after stroke onset. Flow velocity changes before, during and after ECP and continuous beat-to-beat blood pressure data were recorded. The cerebral augmentation index (CAI) is the increase in the percentage of the middle cerebral artery mean flow velocity during ECP compared with baseline. RESULTS The CAI in patients with stroke was significantly higher on the ipsilateral side and on the contralateral side on day 3 (ipsilateral CAI, 9.3%; contralateral CAI, 7.2%), day 5 (7.0%; 6.7%), day 7 (6.8%; 6.0%), day 10 (6.0%; 5.1%), day 14 (4.7%; 2.6%) and day 21 (4.1%; 2.2%) after stroke onset than that in controls (-2.0%) (all p<0.05). There was a significant trend of decreasing CAI on the ipsilateral and contralateral sides over time after a stroke. Differences in the percentage increase in the mean blood pressure did not change significantly over time in patients with stroke. CONCLUSIONS Blood pressure elevation persists throughout ECP treatment, which consists of 35 sessions. However, cerebral blood flow augmentation may last at least 3 weeks and then appears to return to baseline 1 month after acute stroke onset.
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Affiliation(s)
- Li Xiong
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Wenhua Lin
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Jinghao Han
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Xiangyan Chen
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Thomas Leung
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yannie Soo
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Ka Sing Wong
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
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Tian G, Xiong L, Lin W, Han J, Chen X, Leung TWH, Soo YOY, Wong LKS. External Counterpulsation Reduces Beat-to-Beat Blood Pressure Variability When Augmenting Blood Pressure and Cerebral Blood Flow in Ischemic Stroke. J Clin Neurol 2016; 12:308-15. [PMID: 27095525 PMCID: PMC4960215 DOI: 10.3988/jcn.2016.12.3.308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 12/01/2015] [Accepted: 12/02/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND PURPOSE External counterpulsation (ECP) is a noninvasive method used to enhance cerebral perfusion by elevating the blood pressure in ischemic stroke. However, the response of the beat-to-beat blood pressure variability (BPV) in ischemic stroke patients during ECP remains unknown. METHODS We enrolled recent ischemic stroke patients and healthy controls. Changes in the blood flow velocities in bilateral middle cerebral arteries and the continuous beat-to-beat blood pressure before, during, and after ECP were monitored. Power spectral analysis revealed that the BPV included oscillations at very low frequency (VLF; <0.04 Hz), low frequency (LF; 0.04-0.15 Hz), and high frequency (HF; 0.15-0.40 Hz), and the total power spectral density (TP; <0.40 Hz) and LF/HF ratio were calculated. RESULTS We found that ECP significantly increased the systolic and diastolic blood pressures in both stroke patients and controls. ECP decreased markedly the systolic and diastolic BPVs at VLF and LF and the TP, and the diastolic BPV at HF when compared with baseline. The decreases in diastolic and systolic BPV reached 37.56% and 23.20%, respectively, at VLF, 21.15% and 12.19% at LF, 8.76% and 16.59% at HF, and 31.92% and 23.62% for the total TP in stroke patients, which did not differ from those in healthy controls. The change in flow velocity on the contralateral side was positively correlated with the total TP systolic BPV change induced by ECP (r=0.312, p=0.035). CONCLUSIONS ECP reduces the beat-to-beat BPV when increasing the blood pressure and cerebral blood flow velocity in ischemic stroke patients. ECP might be able to improve the clinical outcome by decreasing the beat-to-beat BPV in stroke patients, and this should be explored further in future studies.
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Affiliation(s)
- Ge Tian
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Li Xiong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Wenhua Lin
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Jinghao Han
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Xiangyan Chen
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Thomas Wai Hong Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Yannie Oi Yan Soo
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Lawrence Ka Sing Wong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China.
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Brunser AM, Muñoz Venturelli P, Lavados PM, Gaete J, Martins S, Arima H, Anderson CS, Olavarría VV. Head position and cerebral blood flow in acute ischemic stroke patients: Protocol for the pilot phase, cluster randomized, Head Position in Acute Ischemic Stroke Trial (HeadPoST pilot). Int J Stroke 2016; 11:253-9. [DOI: 10.1177/1747493015620808] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rationale Few proven interventions exist for acute ischemic stroke (AIS), and most are expensive and restricted in applicability. Lying flat ‘head down’ positioning of AIS patients has been shown to increase by as much as 20%, mean cerebral blood flow velocities (CBFV) measured by transcranial Doppler (TCD) but whether this translates into clinical improvement is uncertain. Aim To determine if the lying flat position increases mean CBFV in the affected territory as compared to the sitting up position in AIS patients. Methods and design Head Position in Acute Ischemic Stroke Trial (HeadPoST pilot) is a cluster randomized (clusters being months), assessor-blinded end-point, phase IIb trial, where consecutive adults with anterior circulation AIS within 12 h of symptom onset are positioned to a randomized position for 48 h with TCD performed serially. Study outcomes Primary outcome is mean CBFV on TCD at 1 and 24 h after positioning. Secondary outcomes include: serious adverse events, neurological impairment at seven days, and death and disability at 90 days. Sample size estimates Assuming an increase of 8.3 (SD 11.4) cm/s in average of mean CBFV when tilted from 30° to 0°, 46 clusters are required (92 patients in total) to detect a 20% increase of mean CBFV with 90% power and 5% level of significance. Conclusion HeadPoST pilot is a cluster randomized multicenter clinical trial investigating the effect of head positioning on mean CBFV in anterior circulation AIS.
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Affiliation(s)
- Alejandro M Brunser
- Vascular Neurology Program, Neurology Service, Department of Internal Medicine, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | - Paula Muñoz Venturelli
- Vascular Neurology Program, Neurology Service, Department of Internal Medicine, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
- The George Institute for Global Health, University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Pablo M Lavados
- Vascular Neurology Program, Neurology Service, Department of Internal Medicine, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
- Department of Neurological Sciences, Universidad de Chile, Santiago, Chile
| | - Javier Gaete
- Servicio de Neurología, Hospital Clínico Dr. Lautaro Navarro Avaria, Punta Arenas, Chile
| | - Sheila Martins
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Hisatomi Arima
- The George Institute for Global Health, University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Craig S Anderson
- The George Institute for Global Health, University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Verónica V Olavarría
- Vascular Neurology Program, Neurology Service, Department of Internal Medicine, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
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Nam HS, Scalzo F, Leng X, Ip HL, Lee HS, Fan F, Chen X, Soo Y, Miao Z, Liu L, Feldmann E, Leung T, Wong KS, Liebeskind DS. Hemodynamic Impact of Systolic Blood Pressure and Hematocrit Calculated by Computational Fluid Dynamics in Patients with Intracranial Atherosclerosis. J Neuroimaging 2015; 26:331-8. [PMID: 26598796 DOI: 10.1111/jon.12314] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 10/09/2015] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Success in clinical trials of intracranial atherosclerosis (ICAS) is related to accurate identification of high-risk patients. Noninvasive computational fluid dynamics (CFD) of stenotic lesions may enhance therapeutic decision-making. We determined whether physiologic parameters change downstream cerebral hemodynamics in patients with ICAS. METHODS Consecutive ICAS patients who underwent both CT angiography (CTA) and digital subtraction angiography were enrolled. CFD models were made using CTA source images. Inlet boundary conditions were defined using three ranges of systolic blood pressure (BP) (109.2, 158, and 225 mmHg) and hematocrit (27.3, 40.2, and 48.8). Ratios of pressure, shear strain rates (SSR), and flow velocity across the lesion were calculated using CFD simulations. A linear mixed model was used for the statistical analysis of repeated simulations. RESULTS Among the 56 patients, 32 had moderate stenosis (50-69%) and 24 had severe stenosis (70-99%). A linear mixed model revealed that the ratio of pressure was predicted by systolic BP and stenosis group interaction (P = .036). These pressure decreases were associated with systolic BP (P < .001) and stenosis group (P < .001), but not with hematocrit (P = .337). Post-hoc analysis revealed that pressure decreases were more profound in the severe stenosis than the moderate stenosis group when comparing high and low systolic BP (P = .0108). Ratios of SSR and velocity were only associated in the stenosis group. CONCLUSIONS Our study showed that systolic BP along with the degree of stenosis was associated with pressure decreases across stenotic lesions. Physiologic conditions may superimpose further changes in post-stenotic or downstream blood flow.
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Affiliation(s)
- Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Fabien Scalzo
- Neurovascular Imaging Research Core, University of California, Los Angeles, CA
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hing Lung Ip
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Korea
| | - Florence Fan
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xiangyan Chen
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yannie Soo
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Zhongrong Miao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Thomas Leung
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ka Sing Wong
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
| | - David S Liebeskind
- Neurovascular Imaging Research Core, University of California, Los Angeles, CA
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Xiong L, Chen XY, Leung TWH, Wong LKS. Combined external counterpulsation and endovascular stenting treatment for symptomatic vertebrobasilar artery stenosis: two case reports. Oxf Med Case Reports 2015; 2015:333-6. [PMID: 26568838 PMCID: PMC4626627 DOI: 10.1093/omcr/omv049] [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: 11/18/2014] [Revised: 02/25/2015] [Accepted: 02/26/2015] [Indexed: 11/23/2022] Open
Abstract
Symptomatic vertebrobasilar artery (VBA) stenosis has a poor prognosis. Intravascular stents provide a new therapeutic approach, but the long-term outcome of stenting compared with medical outcome is controversial. External counterpulsation (ECP) is a noninvasive method to improve perfusion of vital organs. We report two cases of this combination with ECP treatment in addition to receiving endovascular stenting. Two patients experienced posterior ischemic stroke. Digital subtraction angiography revealed a severe basilar or vertebral artery stenosis. Computed tomographic perfusion revealed significantly decreased perfusion of posterior artery territories. Both of them underwent combined ECP treatment and endovascular stenting of the stenosed basilar or vertebral artery, without recurrent stroke within 30 days after stenting. The two patients were independent (modified Rankin scale ≤2) at the 12-month follow-up time. Combined ECP treatment and endovascular stent placement may be effective and safe for patients with symptomatic VBA stenosis who failed aggressive medical treatment.
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Affiliation(s)
| | | | | | - Lawrence Ka Sing Wong
- Correspondence address. Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China. Tel: +852-2632-3144; Fax: +852-2649-3761; E-mail
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Xiong L, Lin W, Han J, Chen X, Leung TWH, Soo YOY, Wong LKS. A retrospective pilot study of correlation of cerebral augmentation effects of external counterpulsation with functional outcome after acute ischaemic stroke. BMJ Open 2015; 5:e009233. [PMID: 26351195 PMCID: PMC4563223 DOI: 10.1136/bmjopen-2015-009233] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE External counterpulsation (ECP) is a non-invasive method used to augment cerebral blood flow of patients with ischaemic stroke via induced hypertension. We aimed to explore the correlation between the cerebral blood flow augmentation effects induced by ECP and clinical outcome after acute ischaemic stroke. METHODS We retrospectively analysed our ECP registry of patients with ischaemic stroke who were enrolled within 7 days after stroke onset. Bilateral middle cerebral arteries of patients were monitored using transcranial Doppler (TCD). Flow velocity changes before, during and after ECP were, respectively, recorded for 3 min. The cerebral augmentation index (CAI) was the increase in percentage of the middle cerebral artery mean flow velocity during ECP compared with baseline. TCD data were analysed based on the side ipsilateral or contralateral to the infarct. The modified Rankin Scale (mRS) (good outcome: mRS 0∼2; poor outcome: mRS 3∼6) was evaluated 6 months after the index stroke. RESULTS 72 patients were included (mean age, 63.8±10.7 years; 87.5% males). At month 6 after stroke onset, univariate analysis showed that the National Institutes of Health Stroke Scale at recruitment was significantly higher and ECP therapy duration was longer in the poor outcome group, while the ipsilateral CAI was significantly lower in the good outcome group than that in the poor outcome group (3.71±4.94 vs 7.73±7.66, p=0.044). Multivariate logistic regression showed that ipsilateral CAI was independently correlated with an unfavourable functional outcome after adjusting for confounding factors. CONCLUSIONS The higher degree of cerebral blood flow velocity augmentation on the side ipsilateral to the infarct induced by ECP is independently correlated with an unfavourable functional outcome after acute ischaemic stroke.
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Affiliation(s)
- Li Xiong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Wenhua Lin
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Jinghao Han
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Xiangyan Chen
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Thomas Wai Hong Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yannie Oi Yan Soo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Lawrence Ka Sing Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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Guluma KZ, Liebeskind DS, Raman R, Rapp KS, Ernstrom KB, Alexandrov AV, Shahripour RB, Barlinn K, Starkman S, Grunberg ID, Hemmen TM, Meyer BC, Alexandrov AW. Feasibility and Safety of Using External Counterpulsation to Augment Cerebral Blood Flow in Acute Ischemic Stroke-The Counterpulsation to Upgrade Forward Flow in Stroke (CUFFS) Trial. J Stroke Cerebrovasc Dis 2015; 24:2596-604. [PMID: 26347398 DOI: 10.1016/j.jstrokecerebrovasdis.2015.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 06/28/2015] [Accepted: 07/16/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND External counterpulsation (ECP) increases perfusion to a variety of organs and may be helpful for acute stroke. METHODS We conducted a single-blinded, prospective, randomized controlled feasibility and safety trial of ECP for acute middle cerebral artery (MCA) ischemic stroke. Twenty-three patients presenting within 48 hours of symptom onset were randomized into one of two groups. One group was treated with ECP for 1 hour at a pressure of up to 300 mmHg ("full pressure"). During the procedure, we also determined the highest possible pressure that would augment MCA mean flow velocity (MFV) by 15%. The other group was treated with ECP at 75 mmHg ("sham pressure"). Transcranial Doppler MCA flow velocities and National Institutes of Health Stroke Scale (NIHSS) scores of both groups were checked before, during, and after ECP. Outcomes were assessed at 30 days after randomization. RESULTS Although the procedures were feasible to implement, there was a frequent inability to augment MFV by 15% despite maximal pressures in full-pressure patients. In sham-pressure patients, however, MFV frequently increased as shown by increases in peak systolic velocity and end diastolic velocity. In both groups, starting ECP was often associated with contemporaneous improvements in NIHSS stroke scores. There were no between-group differences in NIHSS, modified Rankin Scale Scores, and Barthel Indices, and no device or treatment-related serious adverse events, deaths, intracerebral hemorrhages, or episodes of acute neuro-worsening. CONCLUSIONS ECP was safe and feasible to use in patients with acute ischemic stroke. It was associated with unexpected effects on flow velocity, and contemporaneous improvements in NIHSS score regardless of pressure used, with a possibility that even very low ECP pressures had an effect. Further study is warranted.
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Affiliation(s)
- Kama Z Guluma
- Department of Emergency Medicine, University of California, San Diego, California, USA.
| | - David S Liebeskind
- UCLA Stroke Center, Department of Neurology, University of California, Los Angeles, California, USA
| | - Rema Raman
- Family Medicine and Public Health and Neurosciences, University of California, San Diego, La Jolla, California, USA
| | - Karen S Rapp
- UCSD Stroke and Coordinating Center, University of California, San Diego, La Jolla, California, USA
| | - Karin B Ernstrom
- Family Medicine & Public Health, University of California, San Diego, La Jolla, California, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Reza B Shahripour
- Neurosonology, Comprehensive Stroke Center, University of Alabama, Birmingham, Alabama, USA
| | - Kristian Barlinn
- Department of Neurology, Dresden University Stroke Center, Carl Gustav Carus University Hospital Dresden, Dresden, Germany
| | - Sidney Starkman
- UCLA Stroke Center and Departments of Emergency Medicine and Neurology, University of California, Los Angeles, California, USA
| | - Ileana D Grunberg
- UCLA Stroke Network, University of California, Los Angeles, California, USA
| | - Thomas M Hemmen
- Department of Neurosciences, UCSD Stroke Program, University of California, San Diego, La Jolla, California, USA
| | - Brett C Meyer
- Department of Neurosciences, UCSD Stroke Program, University of California, San Diego, La Jolla, California, USA
| | - Anne W Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Shakouri SK, Razavi Z, Eslamian F, Sadeghi-Bazargani H, Ghaffari S, Babaei-Ghazani A. Effect of Enhanced External Counterpulsation and Cardiac Rehabilitation on Quality of Life, Plasma Nitric Oxide, Endothelin 1 and High Sensitive CRP in Patients With Coronary Artery Disease: A Pilot Study. Ann Rehabil Med 2015; 39:191-8. [PMID: 25932415 PMCID: PMC4414965 DOI: 10.5535/arm.2015.39.2.191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 04/29/2014] [Indexed: 11/29/2022] Open
Abstract
Objective To investigate the effect of enhanced external counterpulsation (EECP) on plasma nitric oxide (NO), Endothelin 1 (ET1), high sensitive C-reactive protein (HSCRP) and quality of life (QoL) in patients with coronary artery disease (CAD). Methods We conducted a pilot randomized clinical trial in order to evaluate plasma NO, ET1, HSCRP and QoL before and after twenty sessions of EECP (group A) and cardiac rehabilitation (CR, group B) in 42 patients with CAD (21 in each group). Results Forty-two patients (33 male and 9 female) were included in the study. The mean age was 58.2±10 years. The mean HSCRP was 1.52±0.7 in the EECP group and it was reduced to 1.27±0.4 after intervention. The reduction in HSCRP was not statistically significant in EECP and CR groups with p=0.33 and p=0.27, respectively. There was not significant improvement of NO, ET1, and QoL in the EECP and CR groups shortly after therapy (p>0.05). Conclusion Although the short-term EECP treatment in CAD patients improved HSCRP, NO, ET1, and QoL compared with the baseline those improvements are not statistically significant. Further studies are necessary with large study groups and more sessions.
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Affiliation(s)
- Seyed Kazem Shakouri
- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Fariba Eslamian
- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Homayoun Sadeghi-Bazargani
- Injury Epidemiology & Prevention Research Center, Statistics and Epidemiology Department, School of Health & Nutrition, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Arash Babaei-Ghazani
- Department of Physical Medicine and Rehabilitation, Iran University of Medical Sciences, Tehran, Iran
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Rusanen H, Saarinen JT, Sillanpää N. The association of blood pressure and collateral circulation in hyperacute ischemic stroke patients treated with intravenous thrombolysis. Cerebrovasc Dis 2015; 39:130-7. [PMID: 25660943 DOI: 10.1159/000371339] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The integrity of collateral circulation is a major prognostic factor in ischemic stroke. Patients with good collateral status have larger penumbra and respond better to intravenous thrombolytic therapy. High systolic blood pressure is linked with worse clinical outcome in patients with acute ischemic stroke treated with intravenous thrombolytic therapy. We studied the effect of different blood pressure parameters on leptomeningeal collateral circulation in patients treated with intravenous thrombolytic therapy (<3 h) in a retrospective cohort. METHODS Anterior circulation thrombus was detected with computed tomography angiography and blood pressure was measured prior to intravenous thrombolytic therapy in 104 patients. Baseline clinical and imaging information were collected. Group comparisons were performed; Collateral Score (CS) was assessed and entered into logistic regression analysis. RESULTS Fifty-eight patients out of 104 displayed good collateral filling (CS ≥2). Poor CS was associated with more severe strokes according to National Institutes of Health Stroke Scale (NIHSS) at arrival (16 vs. 11, p = 0.005) and at 24 h (15 vs. 3, p < 0.001) after the treatment. Good CS was associated with higher systolic blood pressure (p = 0.03), but not with diastolic blood pressure (p = 0.26), pulse pressure (p = 0.20) or mean arterial pressure (p = 0.07). Good CS was associated with better Alberta Stroke Program Early CT Score (ASPECTS) in 24 h follow-up imaging (p < 0.001) and favorable clinical outcome at three months (mRS ≤2, p < 0.001). Median CS was the highest (CS = 3) when systolic blood pressure was between 170 and 190 mm Hg (p = 0.03). There was no significant difference in the number of patients with good (n = 11) and poor (n = 12) CS who received intravenous antihypertensive medication (p = 0.39) before or during the thrombolytic therapy. In multivariate analysis age (p = 0.02, OR 0.957 per year, 95% CI 0.92-0.99), time from the onset of symptoms to treatment (p = 0.005, OR 1.03 per minute, 95% CI 1.01-1.05), distal clot location (p = 0.02, OR 3.52, 95% CI 1.19-10.35) and systolic blood pressure (p = 0.04, OR 1.03 per unit mm Hg, 95% CI 1.00-1.05) predicted good CS. Higher systolic blood pressure (p = 0.049, OR 0.96 per unit mm Hg, 95% CI 0.93-1.00) and pulse pressure (p = 0.005, OR 0.94 per unit mm Hg, 95% CI 0.90-0.98) predicted unfavorable clinical outcome at three months in multivariate analysis. CONCLUSION Moderately elevated systolic blood pressure is associated with good collateral circulation in patients treated with intravenous thrombolytic therapy. However, there is an inverse association of systolic blood pressure with the three-month clinical outcome. Diastolic blood pressure, mean arterial pressure and pulse pressure are not statistically and significantly associated with collateral status.
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Affiliation(s)
- Harri Rusanen
- Department of Neurology, Oulu University Hospital, Oulu, Finland
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43
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Leung TW, Wang L, Soo YOY, Ip VHL, Chan AYY, Au LWC, Fan FSY, Lau AYL, Leung H, Abrigo J, Wong A, Mok VCT, Ng PW, Tsoi TH, Li SH, Man CBL, Fong WC, Wong KS, Yu SCH. Evolution of intracranial atherosclerotic disease under modern medical therapy. Ann Neurol 2015; 77:478-86. [PMID: 25557926 DOI: 10.1002/ana.24340] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/26/2014] [Accepted: 12/07/2014] [Indexed: 01/05/2023]
Affiliation(s)
- Thomas W. Leung
- Division of Neurology, Department of Medicine and Therapeutics
| | - Lily Wang
- Division of Neurology, Department of Medicine and Therapeutics
| | | | | | - Anne Y. Y. Chan
- Division of Neurology, Department of Medicine and Therapeutics
| | - Lisa W. C. Au
- Division of Neurology, Department of Medicine and Therapeutics
| | | | - Alex Y. L. Lau
- Division of Neurology, Department of Medicine and Therapeutics
| | - Howan Leung
- Division of Neurology, Department of Medicine and Therapeutics
| | - Jill Abrigo
- Department of Diagnostic and Interventional Radiology; Prince of Wales Hospital, Chinese University of Hong Kong
| | - Adrian Wong
- Division of Neurology, Department of Medicine and Therapeutics
| | | | - Ping Wing Ng
- Department of Medicine and Geriatrics; United Christian Hospital
| | - Tak Hong Tsoi
- Department of Medicine; Pamela Youde Nethersole Eastern Hospital
| | - Siu Hung Li
- Department of Medicine; North District Hospital
| | | | - Wing Chi Fong
- Department of Medicine; Queen Elizabeth Hospital; Hong Kong
| | - Ka Sing Wong
- Division of Neurology, Department of Medicine and Therapeutics
| | - Simon C. H. Yu
- Department of Diagnostic and Interventional Radiology; Prince of Wales Hospital, Chinese University of Hong Kong
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44
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Zhu W, Liao R, Chen Y, Liu L, Zhang Y. Effect of enhanced extracorporeal counterpulsation in patients with non-arteritic anterior ischaemic optic neuropathy. Graefes Arch Clin Exp Ophthalmol 2014; 253:127-33. [DOI: 10.1007/s00417-014-2823-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 09/20/2014] [Accepted: 09/30/2014] [Indexed: 11/28/2022] Open
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45
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Bai YY, Gao X, Wang YC, Peng XG, Chang D, Zheng S, Li C, Ju S. Image-guided pro-angiogenic therapy in diabetic stroke mouse models using a multi-modal nanoprobe. Theranostics 2014; 4:787-97. [PMID: 24955140 PMCID: PMC4063977 DOI: 10.7150/thno.9525] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 04/29/2014] [Indexed: 12/18/2022] Open
Abstract
Purpose: The efficacy of pro-angiogenic therapy is difficult to evaluate with current diagnostic modalities. The objectives were to develop a non-invasive imaging strategy to define the temporal characteristics of angiogenesis and to evaluate the response to pro-angiogenic therapy in diabetic stroke mouse models. Methods: A home-made ανβ3 integrin-targeted multi-modal nanoprobe was intravenously injected into mouse models at set time points after photothrombotic stroke. Magnetic resonance imaging (MRI) and near-infrared fluorescence (NIRF) imaging were carried out at 24 h post-injection. Bone marrow-derived endothelial progenitor cells (EPCs) were infused into the mouse models of ischemic stroke to stimulate angiogenesis. Results: The peak signal intensity in the ischemic-angiogenic area of diabetic and wild-type mouse models was achieved on day 10, with significantly lower signal enhancement observed in the diabetic models. Although the signal intensity was significantly higher after EPC treatment in both models, the enhancement was less pronounced in the diabetic animals compared with the wild-type controls. Histological analysis revealed that the microvessel density and expression of β3 integrin were correlated with the signal intensity assessed with MRI and NIRF imaging. Conclusions: The non-invasive imaging method could be used for early and accurate evaluation of the response to pro-angiogenic therapy in diabetic stroke models.
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Abstract
Atherosclerotic disease often involves the intracranial arteries including those encased by cranial bones and dura, and those located in the subarachnoid space. Age, hypertension, and diabetes mellitus are independent risk factors for intracranial atherosclerosis. Intracranial atherosclerosis can result in thromboembolism with or without hypoperfusion leading to transient or permanent cerebral ischaemic events. High rates of recurrent ischaemic stroke and other cardiovascular events mandate early diagnosis and treatment. Present treatment is based on a combination of antiplatelet drugs, optimisation of blood pressure and LDL cholesterol values, and intracranial angioplasty or stent placement, or both, in selected patients.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and CentraCare Health, St Cloud, MN, USA.
| | - Louis R Caplan
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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47
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Liu LP, Xu AD, Wong LKS, Wang DZ, Wang YJ. Chinese consensus statement on the evaluation and intervention of collateral circulation for ischemic stroke. CNS Neurosci Ther 2014; 20:202-8. [PMID: 24495505 PMCID: PMC4233984 DOI: 10.1111/cns.12226] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 12/20/2013] [Accepted: 12/22/2013] [Indexed: 02/06/2023] Open
Abstract
Background Collateral circulation is becoming more significant in the individual management strategy of ischemic stroke, there are more data updated recently. Aim To make the further acknowledgment of the evaluation and how to improving collateral flow, for better treatment selection. Method A panel of experts on stroke providing related statement based on review the results from most up‐to‐date clinical research. Results DSA is the gold standard in evaluating all levels of collaterals. CTA can be used for evaluating leptomeningeal collaterals, MRA for CoW, TCD or TCCS can be used as screening tool for primary evaluation. The treatment modalities include direct interventions, such as Extracranial–Intracranial bypass, and indirect interventions, as External counterpulsation and pressor therapy. The consideration of methodology to augment and improve can be considered on an individual basis. Discussion In this consensus, we interpret the definition, neuroimaging evaluation, intervention and potential strategy on collaterals in the future. Conclusion Assessment of collateral circulation is crucial for selecting therapeutic options, predicting infarction volume and making prognosis after ischemic stroke. Data is still needed to provide therapeutic evidence for many new developed technologies. Until more evidence is available, the clinical significance of applying the new technologies is unclear and perhaps limited.
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Affiliation(s)
- Li-Ping Liu
- Departments of Neurology and Stroke Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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48
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Lin W, Xiong L, Han J, Leung H, Leung T, Soo Y, Chen X, Wong KSL. Increasing pressure of external counterpulsation augments blood pressure but not cerebral blood flow velocity in ischemic stroke. J Clin Neurosci 2013; 21:1148-52. [PMID: 24508283 DOI: 10.1016/j.jocn.2013.09.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 09/04/2013] [Accepted: 09/24/2013] [Indexed: 11/29/2022]
Abstract
External counterpulsation (ECP) is a noninvasive method used to augment cerebral perfusion but the optimal use of ECP in ischemic stroke has not been well documented. We aimed to investigate the effects of ECP treatment pressure on cerebral blood flow and blood pressure (BP). We recruited 38 ischemic stroke patients with large artery occlusive disease and 20 elderly controls. We commenced ECP treatment pressure at 150 mmHg and gradually increased to 187.5, 225 and 262.5 mmHg. Mean cerebral blood flow velocities (CBFV) of bilateral middle cerebral arteries and continuous beat-to-beat BP were recorded before ECP and during each pressure increment for 3 minutes. Patient CBFV data was analyzed based on whether it was ipsilateral or contralateral to the infarct. Mean BP significantly increased from baseline in both stroke and control groups after ECP commenced. BP increased in both groups following raised ECP pressure and reached maximum at 262.5 mmHg (patients 16.9% increase versus controls 16.52%). The ipsilateral CBFV of patients increased 5.15%, 4.35%, 4.55% and 3.52% from baseline under the four pressures, respectively. All were significantly higher than baseline but did not differ among different ECP pressures; contralateral CBFV changed likewise. Control CBFV did not increase under variable pressures of ECP. ECP did increase CBFV of our patients to a roughly equal degree regardless of ECP pressure. Among the four ECP pressures tested, we recommend 150 mmHg as the optimal treatment pressure for ischemic stroke due to higher risks of hypertension-related complications with higher pressures.
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Affiliation(s)
- Wenhua Lin
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Li Xiong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Jinghao Han
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Howan Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Thomas Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Yannie Soo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Xiangyan Chen
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region
| | - Ka Sing Lawrence Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, Hong Kong Special Administrative Region.
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49
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Lin W, Xiong L, Han J, Leung T, Leung H, Chen X, Wong KSL. Hemodynamic effect of external counterpulsation is a different measure of impaired cerebral autoregulation from vasoreactivity to breath-holding. Eur J Neurol 2013; 21:326-31. [DOI: 10.1111/ene.12314] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 10/21/2013] [Indexed: 11/28/2022]
Affiliation(s)
- W. Lin
- Department of Medicine and Therapeutics; Chinese University of Hong Kong; Hong Kong SAR China
| | - L. Xiong
- Department of Medicine and Therapeutics; Chinese University of Hong Kong; Hong Kong SAR China
| | - J. Han
- Department of Medicine and Therapeutics; Chinese University of Hong Kong; Hong Kong SAR China
| | - T. Leung
- Department of Medicine and Therapeutics; Chinese University of Hong Kong; Hong Kong SAR China
| | - H. Leung
- Department of Medicine and Therapeutics; Chinese University of Hong Kong; Hong Kong SAR China
| | - X. Chen
- Department of Medicine and Therapeutics; Chinese University of Hong Kong; Hong Kong SAR China
| | - K. S. L. Wong
- Department of Medicine and Therapeutics; Chinese University of Hong Kong; Hong Kong SAR China
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50
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Enhanced external counterpulsation improves cerebral blood flow following cardiopulmonary resuscitation. Am J Emerg Med 2013; 31:1638-45. [DOI: 10.1016/j.ajem.2013.08.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/15/2013] [Accepted: 08/15/2013] [Indexed: 11/20/2022] Open
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