1
|
Zaczek R, Traynelis SF, Dingledine R, Koszalka GW, Laskowitz DT. Phase 1 Clinical Results for NP10679, a pH-sensitive GluN2B-selective N-methyl-d-aspartate Receptor Inhibitor. Clin Pharmacol Drug Dev 2023; 12:706-717. [PMID: 36642931 PMCID: PMC10329973 DOI: 10.1002/cpdd.1217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/13/2022] [Indexed: 01/17/2023]
Abstract
NP10679 is a context-dependent and subunit-selective negative allosteric modulator of N-methyl-d-aspartate (NMDA) receptors. It is a more potent inhibitor of GluN2B-containing NMDA receptors at the acidic levels of extracellular pH (eg, 6.9) found in the penumbral regions associated with cerebral ischemia than at physiological pH. This property allows NP10679 to act selectively in ischemic tissue while minimizing the nonselective blockade of NMDA receptors in healthy brain, thereby reducing on-target adverse effects. We report the results of a first-in-human pharmacokinetic and safety phase 1 clinical trial in healthy volunteers receiving single or multiple doses of NP10679 (NCT04007263). We found that NP10679 was well-tolerated and with a half-life of 20 hours, which is amenable to once per day dosing. The only notable side effect in this clinical trial was modest somnolence at higher doses, atypical in that the subject could easily be aroused. The overall results suggest that NP10679 is a candidate for further development for use in acute brain injury, such as ischemic stroke or aneurysmal subarachnoid hemorrhage, as well as for use in neuropsychiatric indications.
Collapse
Affiliation(s)
| | - Stephen F. Traynelis
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, 1510 Clifton Road, Atlanta GA 30322
| | - Ray Dingledine
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, 1510 Clifton Road, Atlanta GA 30322
| | | | - Daniel T. Laskowitz
- Department of Neurology, Duke University, Bryan Research Building, Durham, NC 27701
| |
Collapse
|
2
|
Nazar E, Esmaily H, Yousefi R, Jamali J, Ghandehari K, Hashtarkhani S, Jafari Z, Shakeri MT. A Spatial Variation Analysis of In-Hospital Stroke Mortality Based on Integrated Pre-Hospital and Hospital Data in Mashhad, Iran. ARCHIVES OF IRANIAN MEDICINE 2023; 26:300-309. [PMID: 38310430 PMCID: PMC10685828 DOI: 10.34172/aim.2023.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 05/01/2022] [Indexed: 02/05/2024]
Abstract
BACKGROUND Despite significant advances in the quality and delivery of specialized stroke care, there still persist remarkable spatial variations in emergency medical services (EMS) transport delays, stroke incidence, and its outcomes. Therefore, it is very important to investigate the possible geographical variations of in-hospital stroke mortality and to identify its associated factors. METHODS This historical cohort study included suspected stroke cases transferred to Ghaem Hospital of Mashhad by the EMS from March 2018 to March 2019. Using emergency mission IDs, the pre-hospital emergency data were integrated with the patient medical records in the hospital. We used the Bayesian approach for estimating the model parameters. RESULTS Out of 301 patients (142 (47.2%) females vs. 159 (52.8%) males) with a final diagnosis of stroke, 61 (20.3%) cases had in-hospital mortality. Results from Bayesian spatial log-logistic proportional odds (PO) model showed that age (PO=1.07), access rate to EMS (PO=0.78), arrival time (evening shift vs. day shift, PO=0.09), and sequelae variables (PO=9.20) had a significant association with the odds of in-hospital stroke mortality (P<0.05). Furthermore, the odds of in-hospital stroke mortality were higher in central urban areas compared to suburban areas. CONCLUSION Marked regional variations were found in the odds of in-hospital stroke mortality in Mashhad. There was a direct association between age and odds of in-hospital stroke mortality. Hence, the prognosis of in-hospital stroke mortality could be improved by better control of hypertension, prevention of the occurrence of sequelae, increasing the access rate to EMS, and optimizing shift work schedule.
Collapse
Affiliation(s)
- Eisa Nazar
- Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Mazandaran, Iran
- Orthopedic Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Habibollah Esmaily
- Department of Biostatistics, School of Public Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Razieh Yousefi
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Jamshid Jamali
- Department of Biostatistics, School of Public Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kavian Ghandehari
- Neurocognitive Research Center, Department of Neurology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Soheil Hashtarkhani
- Center for Biomedical Informatics, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, USA
| | - Zahra Jafari
- Clinical Research Development Unit, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Taghi Shakeri
- Department of Biostatistics, School of Public Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| |
Collapse
|
3
|
How can imaging in acute ischemic stroke help us to understand tissue fate in the era of endovascular treatment and cerebroprotection? Neuroradiology 2022; 64:1697-1707. [PMID: 35854136 DOI: 10.1007/s00234-022-03001-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
|
4
|
Stuckey SM, Ong LK, Collins-Praino LE, Turner RJ. Neuroinflammation as a Key Driver of Secondary Neurodegeneration Following Stroke? Int J Mol Sci 2021; 22:ijms222313101. [PMID: 34884906 PMCID: PMC8658328 DOI: 10.3390/ijms222313101] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/25/2021] [Accepted: 12/01/2021] [Indexed: 01/13/2023] Open
Abstract
Ischaemic stroke involves the rapid onset of focal neurological dysfunction, most commonly due to an arterial blockage in a specific region of the brain. Stroke is a leading cause of death and common cause of disability, with over 17 million people worldwide suffering from a stroke each year. It is now well-documented that neuroinflammation and immune mediators play a key role in acute and long-term neuronal tissue damage and healing, not only in the infarct core but also in distal regions. Importantly, in these distal regions, termed sites of secondary neurodegeneration (SND), spikes in neuroinflammation may be seen sometime after the initial stroke onset, but prior to the presence of the neuronal tissue damage within these regions. However, it is key to acknowledge that, despite the mounting information describing neuroinflammation following ischaemic stroke, the exact mechanisms whereby inflammatory cells and their mediators drive stroke-induced neuroinflammation are still not fully understood. As a result, current anti-inflammatory treatments have failed to show efficacy in clinical trials. In this review we discuss the complexities of post-stroke neuroinflammation, specifically how it affects neuronal tissue and post-stroke outcome acutely, chronically, and in sites of SND. We then discuss current and previously assessed anti-inflammatory therapies, with a particular focus on how failed anti-inflammatories may be repurposed to target SND-associated neuroinflammation.
Collapse
Affiliation(s)
- Shannon M. Stuckey
- Discipline of Anatomy and Pathology, School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide 5005, Australia; (S.M.S.); (L.E.C.-P.)
| | - Lin Kooi Ong
- School of Pharmacy, Monash University Malaysia, Subang Jaya 47500, Malaysia;
- School of Biomedical Sciences and Pharmacy and the Priority Research Centre for Stroke and Brain Injury, The University of Newcastle, Callaghan 2308, Australia
| | - Lyndsey E. Collins-Praino
- Discipline of Anatomy and Pathology, School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide 5005, Australia; (S.M.S.); (L.E.C.-P.)
| | - Renée J. Turner
- Discipline of Anatomy and Pathology, School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide 5005, Australia; (S.M.S.); (L.E.C.-P.)
- Correspondence: ; Tel.: +61-8-8313-3114
| |
Collapse
|
5
|
Gangadhara S, Siddiqui A, Mokin M. Food and Drug Association Approval Process for Devices Used in Endovascular Treatment of Stroke. Neurology 2021; 97:S194-S200. [PMID: 34785618 DOI: 10.1212/wnl.0000000000012804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 02/24/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article reviews the Food and Drug Administration's (FDA's) process for approval of new medical devices and describes the evolution of endovascular devices used for the treatment of acute ischemic stroke. RECENT FINDINGS Several recent studies have established the benefit of endovascular treatment of acute ischemic stroke from emergent large vessel occlusion. This has led to endovascular treatment becoming the usual care in acute stroke management and has generated greater-than-ever interest in the development of newer and more effective devices. SUMMARY In the United States, the FDA is the regulatory authority that is empowered with the approval and monitoring of new medical devices for widespread use in the population. The FDA categorizes medical devices into 3 classes based mainly on their potential risks to patients and/or users; class I devices pose the least risk and have the least stringent approval process, while class III devices pose the highest risk and undergo the most stringent and time-consuming approval process. There are 4 main pathways to approval: premarket notification, also known as the 510(k) pathway; premarket approval (PMA), de novo, and Humanitarian Device Exemption pathway. These pathways are described in detail in the article. The FDA also mandates postmarketing surveillance to identify any untoward and unexpected long-term complications.
Collapse
Affiliation(s)
- Shreyas Gangadhara
- From the Department of Neurology (S.G.), University of Mississippi Medical Center, Jackson; Department of Neurosurgery (A.S.), University at Buffalo, NY; and Department of Neurosurgery and Brain Repair (M.M.), University of South Florida, Tampa
| | - Adnan Siddiqui
- From the Department of Neurology (S.G.), University of Mississippi Medical Center, Jackson; Department of Neurosurgery (A.S.), University at Buffalo, NY; and Department of Neurosurgery and Brain Repair (M.M.), University of South Florida, Tampa
| | - Maxim Mokin
- From the Department of Neurology (S.G.), University of Mississippi Medical Center, Jackson; Department of Neurosurgery (A.S.), University at Buffalo, NY; and Department of Neurosurgery and Brain Repair (M.M.), University of South Florida, Tampa.
| |
Collapse
|
6
|
Myers SJ, Ruppa KP, Wilson LJ, Tahirovic YA, Lyuboslavsky P, Menaldino DS, Dentmon ZW, Koszalka GW, Zaczek R, Dingledine RJ, Traynelis SF, Liotta DC. A Glutamate N-Methyl-d-Aspartate (NMDA) Receptor Subunit 2B-Selective Inhibitor of NMDA Receptor Function with Enhanced Potency at Acidic pH and Oral Bioavailability for Clinical Use. J Pharmacol Exp Ther 2021; 379:41-52. [PMID: 34493631 DOI: 10.1124/jpet.120.000370] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 04/02/2021] [Indexed: 12/16/2022] Open
Abstract
We describe a clinical candidate molecule from a new series of glutamate N-methyl-d-aspartate receptor subunit 2B-selective inhibitors that shows enhanced inhibition at extracellular acidic pH values relative to physiologic pH. This property should render these compounds more effective inhibitors of N-methyl-d-aspartate receptors at synapses responding to a high frequency of action potentials, since glutamate-containing vesicles are acidic within their lumen. In addition, acidification of penumbral regions around ischemic tissue should also enhance selective drug action for improved neuroprotection. The aryl piperazine we describe here shows strong neuroprotective actions with minimal side effects in preclinical studies. The clinical candidate molecule NP10679 has high oral bioavailability with good brain penetration and is suitable for both intravenous and oral dosing for therapeutic use in humans. SIGNIFICANCE STATEMENT: This study identifies a new series of glutamate N-methyl-d-aspartate (NMDA) receptor subunit 2B-selective negative allosteric modulators with properties appropriate for clinical advancement. The compounds are more potent at acidic pH, associated with ischemic tissue, and this property should increase the therapeutic safety of this class by improving efficacy in affected tissue while sparing NMDA receptor block in healthy brain.
Collapse
Affiliation(s)
- Scott J Myers
- Department of Pharmacology and Chemical Biology (S.J.M, P.L., R.J.D., S.F.T.), Department of Chemistry (L.J.W., Y.A.T., D.S.M., Z.W.D., D.C.L.), Emory University, Atlanta, Georgia; NeurOp Inc., Atlanta, Georgia (S.J.M., K.P.R., L.J.W., Y.A.T, P.L., D.S.M., Z.W.D., G.W.K., R.Z.), and TRPblue Inc., Durham, North Carolina (G.W.K)
| | - Kamalesh P Ruppa
- Department of Pharmacology and Chemical Biology (S.J.M, P.L., R.J.D., S.F.T.), Department of Chemistry (L.J.W., Y.A.T., D.S.M., Z.W.D., D.C.L.), Emory University, Atlanta, Georgia; NeurOp Inc., Atlanta, Georgia (S.J.M., K.P.R., L.J.W., Y.A.T, P.L., D.S.M., Z.W.D., G.W.K., R.Z.), and TRPblue Inc., Durham, North Carolina (G.W.K)
| | - Lawrence J Wilson
- Department of Pharmacology and Chemical Biology (S.J.M, P.L., R.J.D., S.F.T.), Department of Chemistry (L.J.W., Y.A.T., D.S.M., Z.W.D., D.C.L.), Emory University, Atlanta, Georgia; NeurOp Inc., Atlanta, Georgia (S.J.M., K.P.R., L.J.W., Y.A.T, P.L., D.S.M., Z.W.D., G.W.K., R.Z.), and TRPblue Inc., Durham, North Carolina (G.W.K)
| | - Yesim A Tahirovic
- Department of Pharmacology and Chemical Biology (S.J.M, P.L., R.J.D., S.F.T.), Department of Chemistry (L.J.W., Y.A.T., D.S.M., Z.W.D., D.C.L.), Emory University, Atlanta, Georgia; NeurOp Inc., Atlanta, Georgia (S.J.M., K.P.R., L.J.W., Y.A.T, P.L., D.S.M., Z.W.D., G.W.K., R.Z.), and TRPblue Inc., Durham, North Carolina (G.W.K)
| | - Polina Lyuboslavsky
- Department of Pharmacology and Chemical Biology (S.J.M, P.L., R.J.D., S.F.T.), Department of Chemistry (L.J.W., Y.A.T., D.S.M., Z.W.D., D.C.L.), Emory University, Atlanta, Georgia; NeurOp Inc., Atlanta, Georgia (S.J.M., K.P.R., L.J.W., Y.A.T, P.L., D.S.M., Z.W.D., G.W.K., R.Z.), and TRPblue Inc., Durham, North Carolina (G.W.K)
| | - David S Menaldino
- Department of Pharmacology and Chemical Biology (S.J.M, P.L., R.J.D., S.F.T.), Department of Chemistry (L.J.W., Y.A.T., D.S.M., Z.W.D., D.C.L.), Emory University, Atlanta, Georgia; NeurOp Inc., Atlanta, Georgia (S.J.M., K.P.R., L.J.W., Y.A.T, P.L., D.S.M., Z.W.D., G.W.K., R.Z.), and TRPblue Inc., Durham, North Carolina (G.W.K)
| | - Zackery W Dentmon
- Department of Pharmacology and Chemical Biology (S.J.M, P.L., R.J.D., S.F.T.), Department of Chemistry (L.J.W., Y.A.T., D.S.M., Z.W.D., D.C.L.), Emory University, Atlanta, Georgia; NeurOp Inc., Atlanta, Georgia (S.J.M., K.P.R., L.J.W., Y.A.T, P.L., D.S.M., Z.W.D., G.W.K., R.Z.), and TRPblue Inc., Durham, North Carolina (G.W.K)
| | - George W Koszalka
- Department of Pharmacology and Chemical Biology (S.J.M, P.L., R.J.D., S.F.T.), Department of Chemistry (L.J.W., Y.A.T., D.S.M., Z.W.D., D.C.L.), Emory University, Atlanta, Georgia; NeurOp Inc., Atlanta, Georgia (S.J.M., K.P.R., L.J.W., Y.A.T, P.L., D.S.M., Z.W.D., G.W.K., R.Z.), and TRPblue Inc., Durham, North Carolina (G.W.K)
| | - Robert Zaczek
- Department of Pharmacology and Chemical Biology (S.J.M, P.L., R.J.D., S.F.T.), Department of Chemistry (L.J.W., Y.A.T., D.S.M., Z.W.D., D.C.L.), Emory University, Atlanta, Georgia; NeurOp Inc., Atlanta, Georgia (S.J.M., K.P.R., L.J.W., Y.A.T, P.L., D.S.M., Z.W.D., G.W.K., R.Z.), and TRPblue Inc., Durham, North Carolina (G.W.K)
| | - Raymond J Dingledine
- Department of Pharmacology and Chemical Biology (S.J.M, P.L., R.J.D., S.F.T.), Department of Chemistry (L.J.W., Y.A.T., D.S.M., Z.W.D., D.C.L.), Emory University, Atlanta, Georgia; NeurOp Inc., Atlanta, Georgia (S.J.M., K.P.R., L.J.W., Y.A.T, P.L., D.S.M., Z.W.D., G.W.K., R.Z.), and TRPblue Inc., Durham, North Carolina (G.W.K)
| | - Stephen F Traynelis
- Department of Pharmacology and Chemical Biology (S.J.M, P.L., R.J.D., S.F.T.), Department of Chemistry (L.J.W., Y.A.T., D.S.M., Z.W.D., D.C.L.), Emory University, Atlanta, Georgia; NeurOp Inc., Atlanta, Georgia (S.J.M., K.P.R., L.J.W., Y.A.T, P.L., D.S.M., Z.W.D., G.W.K., R.Z.), and TRPblue Inc., Durham, North Carolina (G.W.K)
| | - Dennis C Liotta
- Department of Pharmacology and Chemical Biology (S.J.M, P.L., R.J.D., S.F.T.), Department of Chemistry (L.J.W., Y.A.T., D.S.M., Z.W.D., D.C.L.), Emory University, Atlanta, Georgia; NeurOp Inc., Atlanta, Georgia (S.J.M., K.P.R., L.J.W., Y.A.T, P.L., D.S.M., Z.W.D., G.W.K., R.Z.), and TRPblue Inc., Durham, North Carolina (G.W.K)
| |
Collapse
|
7
|
Li N, Wu L, Zhao W, Dornbos D, Wu C, Li W, Wu D, Ding J, Ding Y, Xie Y, Ji X. Efficacy and safety of normobaric hyperoxia combined with intravenous thrombolysis on acute ischemic stroke patients. Neurol Res 2021; 43:809-814. [PMID: 34126868 DOI: 10.1080/01616412.2021.1939234] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intravenous thrombolysis elevates the prognostic level of acute ischemic stroke (AIS) patients. Normobaric hyperoxia (NBO) delays the progression of the infarct core and promotes neurological recovery. However, it is uncertain whether NBO can further raise the prognostic level of AIS patients based on intravenous thrombolysis. To explore the efficacy and safety of NBO combined with intravenous thrombolysis on AIS patients. This observational study included anterior circulation stroke patients who received intravenous thrombolysis within 4.5 h after stroke onset. These patients were divided into two groups based on whether or not they received NBO therapy. The baseline data and the prognosis of the two groups were compared. The primary outcome was the proportion of functional independence (modified Rankin Scale 0-2) at 90 days post discharge. A total of 227 patients were included in this study. 125 patients received NBO therapy combined with intravenous thrombolysis, while 102 patients received intravenous thrombolysis only. Overall, the rate of recanalization was 83.3%. Consequently, 101 patients (80.8%) who received NBO combined with intravenous thrombolysis and 63 patients (61.8%) in the control group achieved functional independence (P = 0.002). Multivariable logistic regression analysis showed that NBO combined with intravenous thrombolysis over intravenous thrombolysis alone was associated with 90-day functional independence (OR: 2.318; 95% CI: 1.226-4.381; P = 0.01). This study verified the efficacy and safety of NBO combined with intravenous thrombolysis in AIS patients. Prospective study is needed to further substantiate these findings.
Collapse
Affiliation(s)
- Na Li
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Renhe Hospital, Beijing, China
| | - Longfei Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - David Dornbos
- Department of Neurological Surgery, Semmes-Murphey Clinic and University of Tennessee Health Science Center, Memphis, TN, USA
| | - Chuanjie Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weili Li
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianping Ding
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yunyan Xie
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
8
|
Perszyk RE, Zheng Z, Banke TG, Zhang J, Xie L, McDaniel MJ, Katzman BM, Pelly SC, Yuan H, Liotta DC, Traynelis SF. The Negative Allosteric Modulator EU1794-4 Reduces Single-Channel Conductance and Ca 2+ Permeability of GluN1/GluN2A N-Methyl-d-Aspartate Receptors. Mol Pharmacol 2021; 99:399-411. [PMID: 33688039 DOI: 10.1124/molpharm.120.000218] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/01/2021] [Indexed: 12/31/2022] Open
Abstract
NMDA receptors are ligand-gated ion channels that mediate a slow, Ca2+-permeable component of excitatory synaptic currents. These receptors are involved in several important brain functions, including learning and memory, and have also been implicated in neuropathological conditions and acute central nervous system injury, which has driven therapeutic interest in their modulation. The EU1794 series of positive and negative allosteric modulators of NMDA receptors has structural determinants of action near the preM1 helix that is involved in channel gating. Here, we describe the effects of the negative allosteric modulator EU1794-4 on GluN1/GluN2A channels studied in excised outside-out patches. Coapplication of EU1794-4 with a maximally effective concentration of glutamate and glycine increases the fraction of time the channel is open by nearly 1.5-fold, yet reduces single-channel conductance by increasing access of the channel to several subconductance levels, which has the net overall effect of reducing the macroscopic current. The lack of voltage-dependence of negative modulation suggests this is unrelated to a channel block mechanism. As seen with other NMDA receptor modulators that reduce channel conductance, EU1794-4 also reduces the Ca2+ permeability relative to monovalent cations of GluN1/GluN2A receptors. We conclude that EU1794-4 is a prototype for a new class of NMDA receptor negative allosteric modulators that reduce both the overall current that flows after receptor activation and the flux of Ca2+ ion relative to monovalent cations. SIGNIFICANCE STATEMENT: NMDA receptors are implicated in many neurological conditions but are challenging to target given their ubiquitous expression. Several newly identified properties of the negative allosteric modulator EU1794-4, including reducing Ca2+ flux through NMDA receptors and attenuating channel conductance, explain why this modulator reduces but does not eliminate NMDA receptor function. A modulator with these properties could have therapeutic advantages for indications in which attenuation of NMDA receptor function is beneficial, such as neurodegenerative disease and acute injury.
Collapse
Affiliation(s)
- Riley E Perszyk
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia (R.E.P., Z.Z., T.G.B., J.Z., L.X., M.J.M., H.Y., S.F.T.) and Department of Chemistry, Emory University, Atlanta, Georgia (B.M.K., S.C.P., D.C.L.)
| | - Zhaoshi Zheng
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia (R.E.P., Z.Z., T.G.B., J.Z., L.X., M.J.M., H.Y., S.F.T.) and Department of Chemistry, Emory University, Atlanta, Georgia (B.M.K., S.C.P., D.C.L.)
| | - Tue G Banke
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia (R.E.P., Z.Z., T.G.B., J.Z., L.X., M.J.M., H.Y., S.F.T.) and Department of Chemistry, Emory University, Atlanta, Georgia (B.M.K., S.C.P., D.C.L.)
| | - Jing Zhang
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia (R.E.P., Z.Z., T.G.B., J.Z., L.X., M.J.M., H.Y., S.F.T.) and Department of Chemistry, Emory University, Atlanta, Georgia (B.M.K., S.C.P., D.C.L.)
| | - Lingling Xie
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia (R.E.P., Z.Z., T.G.B., J.Z., L.X., M.J.M., H.Y., S.F.T.) and Department of Chemistry, Emory University, Atlanta, Georgia (B.M.K., S.C.P., D.C.L.)
| | - Miranda J McDaniel
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia (R.E.P., Z.Z., T.G.B., J.Z., L.X., M.J.M., H.Y., S.F.T.) and Department of Chemistry, Emory University, Atlanta, Georgia (B.M.K., S.C.P., D.C.L.)
| | - Brooke M Katzman
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia (R.E.P., Z.Z., T.G.B., J.Z., L.X., M.J.M., H.Y., S.F.T.) and Department of Chemistry, Emory University, Atlanta, Georgia (B.M.K., S.C.P., D.C.L.)
| | - Stephen C Pelly
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia (R.E.P., Z.Z., T.G.B., J.Z., L.X., M.J.M., H.Y., S.F.T.) and Department of Chemistry, Emory University, Atlanta, Georgia (B.M.K., S.C.P., D.C.L.)
| | - Hongjie Yuan
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia (R.E.P., Z.Z., T.G.B., J.Z., L.X., M.J.M., H.Y., S.F.T.) and Department of Chemistry, Emory University, Atlanta, Georgia (B.M.K., S.C.P., D.C.L.)
| | - Dennis C Liotta
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia (R.E.P., Z.Z., T.G.B., J.Z., L.X., M.J.M., H.Y., S.F.T.) and Department of Chemistry, Emory University, Atlanta, Georgia (B.M.K., S.C.P., D.C.L.)
| | - Stephen F Traynelis
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, Georgia (R.E.P., Z.Z., T.G.B., J.Z., L.X., M.J.M., H.Y., S.F.T.) and Department of Chemistry, Emory University, Atlanta, Georgia (B.M.K., S.C.P., D.C.L.)
| |
Collapse
|
9
|
Paul S, Candelario-Jalil E. Emerging neuroprotective strategies for the treatment of ischemic stroke: An overview of clinical and preclinical studies. Exp Neurol 2020; 335:113518. [PMID: 33144066 DOI: 10.1016/j.expneurol.2020.113518] [Citation(s) in RCA: 291] [Impact Index Per Article: 72.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 12/12/2022]
Abstract
Stroke is the leading cause of disability and thesecond leading cause of death worldwide. With the global population aged 65 and over growing faster than all other age groups, the incidence of stroke is also increasing. In addition, there is a shift in the overall stroke burden towards younger age groups, particularly in low and middle-income countries. Stroke in most cases is caused due to an abrupt blockage of an artery (ischemic stroke), but in some instances stroke may be caused due to bleeding into brain tissue when a blood vessel ruptures (hemorrhagic stroke). Although treatment options for stroke are still limited, with the advancement in recanalization therapy using both pharmacological and mechanical thrombolysis some progress has been made in helping patients recover from ischemic stroke. However, there is still a substantial need for the development of therapeutic agents for neuroprotection in acute ischemic stroke to protect the brain from damage prior to and during recanalization, extend the therapeutic time window for intervention and further improve functional outcome. The current review has assessed the past challenges in developing neuroprotective strategies, evaluated the recent advances in clinical trials, discussed the recent initiative by the National Institute of Neurological Disorders and Stroke in USA for the search of novel neuroprotectants (Stroke Preclinical Assessment Network, SPAN) and identified emerging neuroprotectants being currently evaluated in preclinical studies. The underlying molecular mechanism of each of the neuroprotective strategies have also been summarized, which could assist in the development of future strategies for combinational therapy in stroke treatment.
Collapse
Affiliation(s)
- Surojit Paul
- Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA.
| | - Eduardo Candelario-Jalil
- Department of Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA
| |
Collapse
|
10
|
Sweid A, Hammoud B, Ramesh S, Wong D, Alexander TD, Weinberg JH, Deprince M, Dougherty J, Maamari DJM, Tjoumakaris S, Zarzour H, Gooch MR, Herial N, Romo V, Hasan DM, Rosenwasser RH, Jabbour P. Acute ischaemic stroke interventions: large vessel occlusion and beyond. Stroke Vasc Neurol 2019; 5:80-85. [PMID: 32411412 PMCID: PMC7213503 DOI: 10.1136/svn-2019-000262] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/29/2019] [Accepted: 11/13/2019] [Indexed: 12/24/2022] Open
Abstract
Care for acute ischaemic stroke is one of the most rapidly evolving fields due to the robust outcomes achieved by mechanical thrombectomy. Large vessel occlusion (LVO) accounts for up to 38% of acute ischaemic stroke and comes with devastating outcomes for patients, families and society in the pre-intervention era. A paradigm shift and a breakthrough brought mechanical thrombectomy back into the spotlight for acute ischaemic stroke; this was because five randomised controlled trials from several countries concluded that mechanical thrombectomy for acute stroke offered overwhelming benefits. This review article will present a comprehensive overview of LVO management, techniques and devices used, and the future of stroke therapy. In addition, we review our institution experience of mechanical thrombectomy for posterior and distal circulation occlusion.
Collapse
Affiliation(s)
- Ahmad Sweid
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Batoul Hammoud
- Endocrinology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sunidhi Ramesh
- Sydney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniella Wong
- Sydney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tyler D Alexander
- Sydney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Maureen Deprince
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jaime Dougherty
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | | | - Hekmat Zarzour
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael R Gooch
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel Herial
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Victor Romo
- Anesthesia, Thomas Jefferson University-Center City Campus, Philadelphia, Pennsylvania, USA
| | - David M Hasan
- Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Robert H Rosenwasser
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| |
Collapse
|
11
|
Liberman AL, Choi HJ, French DD, Prabhakaran S. Is the Cost-Effectiveness of Stroke Thrombolysis Affected by Proportion of Stroke Mimics? Stroke 2019; 50:463-468. [PMID: 30572813 DOI: 10.1161/strokeaha.118.022857] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Differentiating ischemic stroke patients from stroke mimics (SM), nonvascular conditions which simulate stroke, can be challenging in the acute setting. We sought to model the cost-effectiveness of treating suspected acute ischemic stroke patients before a definitive diagnosis could be made. We hypothesized that we would identify threshold proportions of SM among suspected stroke patients arriving to an emergency department above which administration of intravenous thrombolysis was no longer cost-effective. Methods- We constructed a decision-analytic model to examine various emergency department thrombolytic treatment scenarios. The main variables were proportion of SM to true stroke patients, time from symptom onset to treatment, and complication rates. Costs, reimbursement rates, and expected clinical outcomes of ischemic stroke and SM patients were estimated from published data. We report the 90-day incremental cost-effectiveness ratio of administering intravenous thrombolysis compared with no acute treatment from a healthcare sector perspective, as well as the cost-reimbursement ratio from a hospital-level perspective. Cost-effectiveness was defined as a willingness to pay <$100 000 USD per quality adjusted life year gained and high cost-reimbursement ratio was defined as >1.5. Results- There was an increase in incremental cost-effectiveness ratios as the proportion of SM cases increased in the 3-hour time window. The threshold proportion of SM above which the decision to administer thrombolysis was no longer cost-effective was 30%. The threshold proportion of SM above which the decision to administer thrombolysis resulted in high cost-reimbursement ratio was 75%. Results were similar for patients arriving within 0 to 90 minutes of symptom onset as compared with 91 to 180 minutes but were significantly affected by cost of alteplase in sensitivity analyses. Conclusions- We identified thresholds of SM above which thrombolysis was no longer cost-effective from 2 analytic perspectives. Hospitals should monitor SM rates and establish performance metrics to prevent rising acute stroke care costs and avoid potential patient harms.
Collapse
Affiliation(s)
- Ava L Liberman
- From the Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY (A.L.L.)
| | - Ho-Jun Choi
- McCormick School of Engineering and Applied Science, Northwestern University. Evanston, IL (H.-J.C.)
| | - Dustin D French
- Department of Ophthalmology and Center for Healthcare Studies (D.D.F.), Feinberg School of Medicine, Northwestern University, Chicago, IL.,Veterans Affairs Health Services Research and Development Service, Chicago, Illinois (D.D.F.)
| | - Shyam Prabhakaran
- Department of Neurology (S.P.), Feinberg School of Medicine, Northwestern University, Chicago, IL
| |
Collapse
|
12
|
Greenberg K, Hedayat HS, Binning MJ, Veznedaroglu E. Innovations in Care Delivery of Stroke from Emergency Medical Services to the Neurointerventional Operating Room. Neurosurgery 2019; 85:S18-S22. [PMID: 31197327 DOI: 10.1093/neuros/nyz021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 01/28/2019] [Indexed: 01/01/2023] Open
Abstract
Acute ischemic stroke (AIS) and its care is currently one of the most dynamic and evolving illnesses across the globe. Among the most crucial factors in providing the best care to patients are the expedient delivery of thrombolytics and endovascular intervention when indicated. Here, we review our unique model of efficient care centered in our innovative Neurological Emergency Department (Neuro ED). The Neuro ED acts as our hub for EMS communication, imaging, administration of intravenous alteplase, and transition to the Neurointerventional OR. Our structure with its enabling of shortened IV alteplase delivery times and faster door-to-needle (DTN) times may serve as an international model for stroke centers.
Collapse
Affiliation(s)
- Karen Greenberg
- Department of Neurosurgery, Global Neurosciences Institute, Philadelphia, Pennsylvania
| | - Hirad S Hedayat
- Department of Neurosurgery, Global Neurosciences Institute, Philadelphia, Pennsylvania
| | - Mandy J Binning
- Department of Neurosurgery, Global Neurosciences Institute, Philadelphia, Pennsylvania
| | - Erol Veznedaroglu
- Department of Neurosurgery, Global Neurosciences Institute, Philadelphia, Pennsylvania
| |
Collapse
|
13
|
Munich SA, Vakharia K, Levy EI. Overview of Mechanical Thrombectomy Techniques. Neurosurgery 2019; 85:S60-S67. [DOI: 10.1093/neuros/nyz071] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/12/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- Stephan A Munich
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York
| |
Collapse
|
14
|
Direct Aspiration versus Stent Retriever Thrombectomy for Acute Stroke: A Systematic Review and Meta-Analysis in 9127 Patients. J Stroke Cerebrovasc Dis 2019; 28:1329-1337. [PMID: 30772159 DOI: 10.1016/j.jstrokecerebrovasdis.2019.01.034] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/16/2019] [Accepted: 01/29/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The two most common approaches to thrombectomy of emergent large vessel occlusion (direct aspiration and primary stent retriever thrombectomy) have been extensively studied; however, the detailed benefit and risk comparison is largely unknown. OBJECTIVE To conduct a systematic review and meta-analysis to compare radiographic and clinical outcomes between the use of primary stent retrievers and direct aspiration in management of acute ischemic stroke. METHODS PubMed database was searched for studies between September 1, 2012 and December 31, 2017 with acute ischemic stroke patients. RESULTS We identified 64 studies with 6875 patients in the primary stent retriever group and 25 studies with 2252 patients in the aspiration group. Primary aspiration alone, without the need of rescue stent retriever devices within the aspiration cohort, was performed in 65% of 2252 patients. There was no difference in the distribution of emergent large vessel occlusion based on occlusion site, age, baseline National Institutes of Health Stroke Scale, or the use of intravenous tPA (P = .19, .051, .23, and .093, respectively). Successful recanalization rates, defined as thrombolysis in cerebral Infarction 2b/3, were significantly higher in the aspiration group than the primary stent retriever group (89% versus 80%, P < .0001). No significant difference in good clinical outcome, defined as modified Rankin scale 0-2 (aspiration 52% versus stent 48%, P = .13), symptomatic intracerebral hemorrhage (aspiration 5.6% versus stent 7.2%, P = .07), and mortality at 3 months (aspiration 15% versus stent 19%, P = .10). CONCLUSIONS Both aspiration-first (including the subsequent use of stent retriever) and primary stent retriever thrombectomy approaches are equally effective in achieving good clinical outcomes. Our study suggests that direct aspiration with or without subsequent use of stent retriever is a safe and effective alternative to primary stent retriever in acute ischemic stroke.
Collapse
|
15
|
Blood-brain barrier permeability assessed by perfusion computed tomography predicts hemorrhagic transformation in acute reperfusion therapy. Neurol Sci 2018; 39:1579-1584. [DOI: 10.1007/s10072-018-3468-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 06/04/2018] [Indexed: 10/14/2022]
|
16
|
Jeong HG, Kim BJ, Choi JC, Hong KS, Yang MH, Jung C, Han MK, Bae HJ. Posttreatment National Institutes of Health Stroke Scale Is Superior to the Initial Score or Thrombolysis in Cerebral Ischemia for 3-Month Outcome. Stroke 2018. [DOI: 10.1161/strokeaha.117.020587] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Han-Gil Jeong
- From the Department of Neurology and Cerebrovascular Center (H.-G.J., B.J.K., M.H.Y., M.-K.H., H.-J.B.) and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Neurology, Jeju National University, Republic of Korea (J.C.C.); and Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea (K.-S.H.)
| | - Beom Joon Kim
- From the Department of Neurology and Cerebrovascular Center (H.-G.J., B.J.K., M.H.Y., M.-K.H., H.-J.B.) and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Neurology, Jeju National University, Republic of Korea (J.C.C.); and Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea (K.-S.H.)
| | - Jay Chol Choi
- From the Department of Neurology and Cerebrovascular Center (H.-G.J., B.J.K., M.H.Y., M.-K.H., H.-J.B.) and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Neurology, Jeju National University, Republic of Korea (J.C.C.); and Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea (K.-S.H.)
| | - Keun-Sik Hong
- From the Department of Neurology and Cerebrovascular Center (H.-G.J., B.J.K., M.H.Y., M.-K.H., H.-J.B.) and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Neurology, Jeju National University, Republic of Korea (J.C.C.); and Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea (K.-S.H.)
| | - Mi Hwa Yang
- From the Department of Neurology and Cerebrovascular Center (H.-G.J., B.J.K., M.H.Y., M.-K.H., H.-J.B.) and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Neurology, Jeju National University, Republic of Korea (J.C.C.); and Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea (K.-S.H.)
| | - Cheolkyu Jung
- From the Department of Neurology and Cerebrovascular Center (H.-G.J., B.J.K., M.H.Y., M.-K.H., H.-J.B.) and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Neurology, Jeju National University, Republic of Korea (J.C.C.); and Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea (K.-S.H.)
| | - Moon-Ku Han
- From the Department of Neurology and Cerebrovascular Center (H.-G.J., B.J.K., M.H.Y., M.-K.H., H.-J.B.) and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Neurology, Jeju National University, Republic of Korea (J.C.C.); and Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea (K.-S.H.)
| | - Hee-Joon Bae
- From the Department of Neurology and Cerebrovascular Center (H.-G.J., B.J.K., M.H.Y., M.-K.H., H.-J.B.) and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Neurology, Jeju National University, Republic of Korea (J.C.C.); and Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea (K.-S.H.)
| |
Collapse
|
17
|
Anaesthesia for neuroradiology: thrombectomy: 'one small step for man, one giant leap for anaesthesia'. Curr Opin Anaesthesiol 2018; 29:568-75. [PMID: 27455043 DOI: 10.1097/aco.0000000000000377] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Endovascular management of acute thrombotic strokes is a new management technique. Anaesthesia will play a key role in the management of these patients. To date there is no established method of managing these patients from an anaesthetic perspective. RECENT FINDINGS In 2015, five landmark studies popularized intra-arterial clot retrieval for ischaemic strokes. Since then there have been a number of small studies investigating the best anaesthetic technique, taking into account patient, technical, and clinical factors. This review summarizes these studies and discusses the different anaesthetic options, with their relative merits and pitfalls. SUMMARY There is a paucity of robust evidence for the best anaesthetic practice in this cohort of patients. Airway protection seems to be an issue in 2.5% of cases. Timing of the procedure is vital, and any delay may be detrimental to neurological outcome. In a survey of neurointerventionalists, the main concern they expressed was the potential delay to revascularization posed by anaesthesia. Patients complain of pain during mechanical clot retrieval if awake. The overall consensus seems to be favouring conscious sedation over general anaesthesia in the acute setting.
Collapse
|
18
|
Tymianski M. Combining Neuroprotection With Endovascular Treatment of Acute Stroke: Is There Hope? Stroke 2017; 48:1700-1705. [PMID: 28487331 DOI: 10.1161/strokeaha.117.017040] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 03/28/2017] [Accepted: 04/03/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Michael Tymianski
- From the Division of Neurosurgery (M.T.) and Krembil Research Institute (M.T.), Toronto Western Hospital, University Health Network, Ontario, Canada; and Department of Surgery, University of Toronto, Ontario, Canada (M.T.).
| |
Collapse
|
19
|
The role of Ca 2+-calmodulin stimulated protein kinase II in ischaemic stroke - A potential target for neuroprotective therapies. Neurochem Int 2017; 107:33-42. [PMID: 28153786 DOI: 10.1016/j.neuint.2017.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/17/2017] [Accepted: 01/24/2017] [Indexed: 01/26/2023]
Abstract
Studies in multiple experimental systems show that Ca2+-calmodulin stimulated protein kinase II (CaMKII) is a major mediator of ischaemia-induced cell death and suggest that CaMKII would be a good target for neuroprotective therapies in acute treatment of stroke. However, as CaMKII regulates many cellular processes in many tissues any clinical treatment involving the inhibition of CaMKII would need to be able to specifically target the functions of ischaemia-activated CaMKII. In this review we summarise new developments in our understanding of the molecular mechanisms involved in ischaemia-induced CaMKII-mediated cell death that have identified ways in which such specificity of CaMKII inhibition after stroke could be achieved. We also review the mechanisms and phases of tissue damage in ischaemic stroke to identify where and when CaMKII-mediated mechanisms may be involved.
Collapse
|
20
|
Tsivgoulis G, Safouris A, Krogias C, Arthur AS, Alexandrov AV. Endovascular reperfusion therapies for acute ischemic stroke: dissecting the evidence. Expert Rev Neurother 2016; 16:527-34. [DOI: 10.1586/14737175.2016.1168297] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
21
|
Yuan H, Myers SJ, Wells G, Nicholson KL, Swanger SA, Lyuboslavsky P, Tahirovic YA, Menaldino DS, Ganesh T, Wilson LJ, Liotta DC, Snyder JP, Traynelis SF. Context-dependent GluN2B-selective inhibitors of NMDA receptor function are neuroprotective with minimal side effects. Neuron 2015; 85:1305-1318. [PMID: 25728572 DOI: 10.1016/j.neuron.2015.02.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 01/12/2015] [Accepted: 01/29/2015] [Indexed: 01/09/2023]
Abstract
Stroke remains a significant problem despite decades of work on neuroprotective strategies. NMDA receptor (NMDAR) antagonists are neuroprotective in preclinical models, but have been clinically unsuccessful, in part due to side effects. Here we describe a prototypical GluN2B-selective antagonist with an IC50 value that is 10-fold more potent at acidic pH 6.9 associated with ischemic tissue compared to pH 7.6, a value close to the pH in healthy brain tissue. This should maximize neuroprotection in ischemic tissue while minimizing on-target side effects associated with NMDAR blockade in noninjured brain regions. We have determined the mechanism underlying pH-dependent inhibition and demonstrate the utility of this approach in vivo. We also identify dicarboxylate dimers as a novel proton sensor in proteins. These results provide insight into the molecular basis of pH-dependent neuroprotective NMDAR block, which could be beneficial in a wide range of neurological insults associated with tissue acidification.
Collapse
Affiliation(s)
- Hongjie Yuan
- Department of Pharmacology, Emory University, Atlanta, GA 30322 USA
| | - Scott J Myers
- Department of Pharmacology, Emory University, Atlanta, GA 30322 USA
| | - Gordon Wells
- Department of Chemistry, Emory University, Atlanta, GA 30322 USA
| | - Katherine L Nicholson
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA 23298 USA.,Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, VA 23298 USA
| | - Sharon A Swanger
- Department of Pharmacology, Emory University, Atlanta, GA 30322 USA
| | | | | | | | - Thota Ganesh
- Department of Pharmacology, Emory University, Atlanta, GA 30322 USA
| | | | - Dennis C Liotta
- Department of Chemistry, Emory University, Atlanta, GA 30322 USA
| | - James P Snyder
- Department of Chemistry, Emory University, Atlanta, GA 30322 USA
| | | |
Collapse
|
22
|
Anastasian Z. Anaesthetic management of the patient with acute ischaemic stroke. Br J Anaesth 2014; 113:ii9-ii16. [DOI: 10.1093/bja/aeu372] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
|
23
|
Binning MJ, Sanfillippo G, Rosen W, Dʼambrosio M, Veznedaroglu E, Liebman K, Diaz C, Silva R, Eichorn D, Rubin M. The neurological emergency room and prehospital stroke alert: the whole is greater than the sum of its parts. Neurosurgery 2014; 74:281-5; discussion 285. [PMID: 24276505 DOI: 10.1227/neu.0000000000000259] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Emergency medical services (EMS) prenotification to hospitals regarding the arrival of patients who have had a stroke is recommended to facilitate the workup once the patient arrives. Most hospitals have the patient enter the emergency department (ED) before obtaining a head computed tomography (CT) scan. At Capital Health, prehospital stroke-alert patients are delivered directly to CT and met by a neurological emergency team. The goal of bypassing the ED is to reduce the time to treatment. OBJECTIVE To evaluate (1) door-to-CT and door-to-needle time in patients with an acute stroke who arrive as prehospital stroke alerts and (2) the accuracy of EMS assessment. METHODS A prospective database of all prehospital stroke alert patients was kept and data retrospectively reviewed for patients who were seen between July 2012 and July 2013. RESULTS Between July 2012 and July 2013, 141 prehospital stroke alerts were called to our emergency department, and the patients were stable enough to bypass the ED and go directly to CT. EMS assessment of stroke was accurate 66% of the time, and the diagnosis was neurological 89% of the time. The average time between patient arrival and acquisition of CT imaging was 11.8 minutes. Twenty-six of the 141 patients (18%) received intravenous tissue plasminogen activator. The median time from arrival to intravenous tissue plasminogen activator bolus was 44 minutes. CONCLUSION Trained EMS responders are able to correctly identify patients who are experiencing neurological/neurosurgical emergencies and deliver patients to our comprehensive stroke center in a timely fashion after prenotification. The prehospital stroke alert protocol bypasses the ED, allowing the patient to be met in CT by the neurological ED team, which has proven to decrease door-to-CT and door-to-needle times from our historical means. ABBREVIATIONS ASLS, Advanced Stroke Life SupportDTN, door-to-needleED, emergency departmentEMS, emergency medical servicesEMT, emergency medical technicianIV, intravenousMEND, Miami Emergency Neurological DeficitPHSA, prehospital stroke alerttPA, tissue plasminogen activator.
Collapse
Affiliation(s)
- Mandy J Binning
- Capital Health, Capital Institutes for Neurosciences, Trenton and Pennington, New Jersey
| | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Kim A, Lee JS, Kim JE, Paek YM, Chung K, Park JH, Cho YJ, Hong KS. Trends in yield of a code stroke program for enhancing thrombolysis. J Clin Neurosci 2014; 22:73-8. [PMID: 25282392 DOI: 10.1016/j.jocn.2014.05.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 05/23/2014] [Accepted: 05/27/2014] [Indexed: 11/19/2022]
Abstract
As the benefit of thrombolytic therapy in acute ischemic stroke is time-dependent, a code stroke program needs to be implemented, maintained, and improved with continuous efforts to expedite thrombolytic therapy. We analyzed the long-term yield and efficiency of our code stroke program. Using a prospective single-center registry, we assessed the rates of stroke diagnosis and thrombolysis, door-to-CT scan and door-to-needle times, and annual trends in patients with code stroke activation between May 2007 and December 2011. Of the 791 patients with code stroke activation during the 4.7 year study period, 626 (79.1%) had a stroke, with 461 (58.3%) ischemic strokes and 165 (20.9%) hemorrhagic strokes. Along with an increase of code stroke activation (from 105/year to 236/year) and thrombolytic therapy volumes (from 24/year to 77/year), the rate of thrombolytic therapy among ischemic stroke patients increased from 33.3% to 59.2% (p for trend=0.0001). However, code activations for a non-stroke case also significantly increased (p for trend=0.0001). Door-to-CT scan time (p for trend=0.0011) and proportion of CT scan initiation ⩽ 25 minutes after arrival improved (p for trend=0.0022), and were 18.4 minutes and 76.7%, respectively, in 2011. However, the door-to-needle time and proportion of door-to-needle time ⩽ 60 minutes did not significantly improve, they were (43.3 minutes and 83.1%, respectively, in 2011). Our code stroke program yielded a high rate of detecting thrombolysis candidates and a continuous increase in rates of administration of thrombolytic therapy. These findings support the stroke team members' collaborative effort to treat more patients and to treat patients faster.
Collapse
Affiliation(s)
- Ahro Kim
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea
| | - Ji Sung Lee
- Biostatistical Consulting Unit, Soonchunhyang University Medical Center, Seoul, Republic of Korea
| | - Ji Eun Kim
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea
| | - Young Min Paek
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea
| | - Kyuyoon Chung
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea
| | - Ji-Hyeon Park
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, 2240 Daewha-dong, Ilsanseo-gu, Goyang City, Gyeonggi-do 411-706, Republic of Korea.
| |
Collapse
|
25
|
Mokin M, Khalessi AA, Mocco J, Lanzino G, Dumont TM, Hanel RA, Lopes DK, Fessler RD, Ringer AJ, Bendok BR, Veznedaroglu E, Siddiqui AH, Hopkins LN, Levy EI. Endovascular treatment of acute ischemic stroke: the end or just the beginning? Neurosurg Focus 2014; 36:E5. [PMID: 24380482 DOI: 10.3171/2013.10.focus13374] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Various endovascular intraarterial approaches are available for treating patients with acute ischemic stroke who present with severe neurological deficits. Three recent randomized trials-Interventional Management of Stroke (IMS) III, Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE), and Synthesis Expansion: A Randomized Controlled Trial on Intra-Arterial Versus Intravenous Thrombolysis in Acute Ischemic Stroke (SYNTHESIS Expansion)-evaluated the efficacy of endovascular treatment of acute ischemic stroke and, after failing to demonstrate any significant clinical benefit of endovascular therapies, raised concerns and questions in the medical community regarding the future of endovascular treatment for acute ischemic stroke. In this paper, the authors review the evolution of endovascular treatment strategies for the treatment of acute stroke and provide their interpretation of findings and potential limitations of the three recently published randomized trials. The authors discuss the advantage of stent-retriever technology over earlier endovascular approaches and review the current status and future directions of endovascular acute stroke studies based on lessons learned from previous trials.
Collapse
|
26
|
Patel MD, Brice JH, Moss C, Suchindran CM, Evenson KR, Rose KM, Rosamond WD. An evaluation of emergency medical services stroke protocols and scene times. PREHOSP EMERG CARE 2013; 18:15-21. [PMID: 24028711 DOI: 10.3109/10903127.2013.825354] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute stroke patients require immediate medical attention. Therefore, American Stroke Association guidelines recommend that for suspected stroke cases, emergency medical services (EMS) personnel spend less than 15 minutes on-scene at least 90% of the time. However, not all EMS providers include specific scene time limits in their stroke patient care protocols. OBJECTIVE We sought to determine whether having a protocol with a specific scene time limit was associated with less time EMS spent on scene. Methods. Stroke protocols from the 100 EMS systems in North Carolina were collected and abstracted for scene time instructions. Suspected stroke events occurring in 2009 were analyzed using data from the North Carolina Prehospital Medical Information System. Scene time was defined as the time from EMS arrival at the scene to departure with the patient. Quantile regression was used to estimate how the 90th percentile of the scene time distribution varied by systems with protocol instructions limiting scene time, adjusting for system patient volume and metropolitan status. RESULTS In 2009, 23 EMS systems in North Carolina had no instructions regarding scene time; 73 had general instructions to minimize scene time; and 4 had a specific limit for scene time (i.e., 10 or 15 min). Among 9,723 eligible suspected stroke events, mean scene time was 15.9 minutes (standard deviation 6.9 min) and median scene time was 15.0 minutes (90th percentile 24.3 min). In adjusted quantile regression models, the estimated reduction in the 90th percentile scene time, comparing protocols with a specific time limit to no instructions, was 2.2 minutes (95% confidence interval 1.3, 3.1 min). The difference in 90th percentile scene time between general and absent instructions was not statistically different (0.7 min [95% confidence interval -0.1, 1.4 min]). CONCLUSION Protocols with specific scene time limits were associated with EMS crews spending less time at the scene while general instructions were not. These findings suggest EMS systems can modestly improve scene times for stroke by specifying a time limit in their protocols.
Collapse
Affiliation(s)
- Mehul D Patel
- Received May 15, 2013 from the Departments of Epidemiology (MDP, KRE, WDR) and Biostatistics (CMS), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the Department of Emergency Medicine (JHB, CM), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and SRA International (KMR), Durham, North Carolina. Revision received June 14, 2013; accepted for publication June 20, 2013
| | | | | | | | | | | | | |
Collapse
|
27
|
Hamann GF. [Mechanical recanalization. There is one last chance! Against]. DER NERVENARZT 2013; 84:1004-6. [PMID: 23860627 DOI: 10.1007/s00115-013-3853-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- G F Hamann
- Neurologische Klinik, Dr. Horst Schmidt Klinik GmbH, Ludwig Erhard Str. 100, 65199, Wiesbaden, Deutschland.
| |
Collapse
|
28
|
Affiliation(s)
- Jeffrey L Saver
- University of California Los Angeles Stroke Center, 710 Westwood Plaza, Los Angeles, CA 90095, USA.
| |
Collapse
|
29
|
Abstract
BACKGROUND Age-adjusted stroke mortality rates in Israel are higher among Arabs compared with Jews; therefore, knowledge of stroke signs and prevention strategies is especially important in the Arab population. Data on stroke knowledge among Arabs in Israel are lacking. AIM We aimed to examine knowledge, perceptions and thoughts of stroke among Arab-Muslim Israelis. METHODS A complementary mixed method design was used. Ninety-nine Arab Muslims living in Israel, older than 40 years, with no history of stroke, were personally interviewed. Knowledge of stroke was assessed using quantitative analysis by a semi-structured interview. Information on perceptions and thoughts evoked by stroke was analyzed using qualitative analysis by the constant comparative method. Rates of reported knowledge-related variables were presented. RESULTS Mean (SD) age of participants was 50.1 (8.0) years, 52.5% were women. Most of the participants (84.8%) knew the causes of stroke but only 29.3% mentioned sudden weakness or paralysis in one side of the body as a warning sign and other warning signs were even less known. The main known risk factor was hypertension (43.3%). Although knowledge of stroke prevention was poor, 89% were interested in learning about stroke and its prevention. The qualitative findings showed that stroke evokes negative thoughts of mental and physical burden and is associated with death, disability, dependence and depression. CONCLUSION Levels of stroke knowledge among Arab-Muslim Israelis are low to moderate. Healthcare professionals should assist high risk populations in controlling and treating risk factors in order to reduce mortality and disability following a stroke.
Collapse
Affiliation(s)
- Michal Itzhaki
- Nursing Department, School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | | |
Collapse
|