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Bücke P, Jung S, Kaesmacher J, Goeldlin MB, Horvath T, Prange U, Beyeler M, Fischer U, Arnold M, Seiffge DJ, Meinel TR. Intravenous thrombolysis in patients with recent intake of direct oral anticoagulants: A target trial analysis after the liberalization of institutional guidelines. Eur Stroke J 2024:23969873241252751. [PMID: 38738861 DOI: 10.1177/23969873241252751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
INTRODUCTION This study aimed to report the safety and efficacy of off-label intravenous thrombolysis (IVT) with alteplase after sequentially liberalizing our institutional guidelines allowing IVT for patients under direct oral anticoagulants (DOACs) regardless of plasma levels, time of last intake, and without prior anticoagulation reversal therapy. PATIENTS AND METHODS We utilized the target-trial methodology to emulate hypothetical criteria of a randomized controlled trial in our prospective stroke registry. Consecutive DOAC patients (06/2021-11/2023) otherwise qualifying for IVT were included. Safety and efficacy outcomes (symptomatic intracranial hemorrhage [ICH], any radiological ICH, major bleeding, 90-day mortality, 90-day good functional outcome [mRS 0-2 or return to baseline]) were assessed using inverse-probability-weighted regression-adjustment comparing patients with versus without IVT. RESULTS Ninety eight patients fulfilled the target-trial criteria. IVT was given in 49/98 (50%) patients at a median of 178 (interquartile range 134-285) min after symptom onset with median DOAC plasma level of 77 ng/ml (15 patients had plasma levels > 100 ng/ml; 25/49 [51%] were treated within 12 h after last DOAC ingestion). Endovascular therapy was more frequent in patients without IVT (73% vs 33%). Symptomatic ICH occurred in 0/49 patients receiving IVT and 2/49 patients without IVT (adjusted difference -2.5%; 95% CI -5.9 to 0.8). The rates of any radiological ICH were comparable. Patients receiving IVT were more likely to have good functional outcomes. DISCUSSION AND CONCLUSION After liberalizing our approach for IVT regardless of recent DOAC intake, we did not experience any safety concerns. The association of IVT with better functional outcomes warrants prospective randomized controlled trials.
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Affiliation(s)
- Philipp Bücke
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Simon Jung
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Martina B Goeldlin
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Thomas Horvath
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Ulrike Prange
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Morin Beyeler
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
- Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - David J Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Thomas R Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
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Carré J, Kerforne T, Hauet T, Macchi L. Tissue Injury Protection: The Other Face of Anticoagulant Treatments in the Context of Ischemia and Reperfusion Injury with a Focus on Transplantation. Int J Mol Sci 2023; 24:17491. [PMID: 38139319 PMCID: PMC10743711 DOI: 10.3390/ijms242417491] [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: 11/17/2023] [Revised: 12/06/2023] [Accepted: 12/10/2023] [Indexed: 12/24/2023] Open
Abstract
Organ transplantation has enhanced the length and quality of life of patients suffering from life-threatening organ failure. Donors deceased after brain death (DBDDs) have been a primary source of organs for transplantation for a long time, but the need to find new strategies to face organ shortages has led to the broadening of the criteria for selecting DBDDs and advancing utilization of donors deceased after circulatory death. These new sources of organs come with an elevated risk of procuring organs of suboptimal quality. Whatever the source of organs for transplant, one constant issue is the occurrence of ischemia-reperfusion (IR) injury. The latter results from the variation of oxygen supply during the sequence of ischemia and reperfusion, from organ procurement to the restoration of blood circulation, triggering many deleterious interdependent processes involving biochemical, immune, vascular and coagulation systems. In this review, we focus on the roles of thrombo-inflammation and coagulation as part of IR injury, and we give an overview of the state of the art and perspectives on anticoagulant therapies in the field of transplantation, discussing benefits and risks and proposing a strategic guide to their use during transplantation procedures.
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Affiliation(s)
- Julie Carré
- Service D’Hématologie Biologique, Centre Hospitalo-Universitaire de Poitiers, 86000 Poitiers, France;
- INSERM 1313 Ischémie Reperfusion, Métabolisme, Inflammation Stérile en Transplantation (IRMETIST), Université de Poitiers, 86000 Poitiers, France; (T.K.); (T.H.)
| | - Thomas Kerforne
- INSERM 1313 Ischémie Reperfusion, Métabolisme, Inflammation Stérile en Transplantation (IRMETIST), Université de Poitiers, 86000 Poitiers, France; (T.K.); (T.H.)
- Service D’Anesthésie-Réanimation et Médecine Péri-Opératoire, Centre Hospitalo-Universitaire de Poitiers, 86000 Poitiers, France
- FHU Survival Optimization in Organ Transplantation (SUPORT), 86000 Poitiers, France
| | - Thierry Hauet
- INSERM 1313 Ischémie Reperfusion, Métabolisme, Inflammation Stérile en Transplantation (IRMETIST), Université de Poitiers, 86000 Poitiers, France; (T.K.); (T.H.)
- FHU Survival Optimization in Organ Transplantation (SUPORT), 86000 Poitiers, France
- Service de Biochimie, Centre Hospitalo-Universitaire de Poitiers, 86000 Poitiers, France
| | - Laurent Macchi
- Service D’Hématologie Biologique, Centre Hospitalo-Universitaire de Poitiers, 86000 Poitiers, France;
- INSERM 1313 Ischémie Reperfusion, Métabolisme, Inflammation Stérile en Transplantation (IRMETIST), Université de Poitiers, 86000 Poitiers, France; (T.K.); (T.H.)
- FHU Survival Optimization in Organ Transplantation (SUPORT), 86000 Poitiers, France
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Meinel TR, Wilson D, Gensicke H, Scheitz JF, Ringleb P, Goganau I, Kaesmacher J, Bae HJ, Kim DY, Kermer P, Suzuki K, Kimura K, Macha K, Koga M, Wada S, Altersberger V, Salerno A, Palanikumar L, Zini A, Forlivesi S, Kellert L, Wischmann J, Kristoffersen ES, Beharry J, Barber PA, Hong JB, Cereda C, Schlemm E, Yakushiji Y, Poli S, Leker R, Romoli M, Zedde M, Curtze S, Ikenberg B, Uphaus T, Giannandrea D, Portela PC, Veltkamp R, Ranta A, Arnold M, Fischer U, Cha JK, Wu TY, Purrucker JC, Seiffge DJ. Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants. JAMA Neurol 2023; 80:233-243. [PMID: 36807495 PMCID: PMC9857462 DOI: 10.1001/jamaneurol.2022.4782] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/21/2022] [Indexed: 02/07/2023]
Abstract
Importance International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC). Objective To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion. Design, Setting, and Participants This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021. Exposures Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation. Main Outcomes and Measures The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses. Results Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion. Conclusions and Relevance In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.
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Affiliation(s)
- Thomas R. Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Henrik Gensicke
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Jan F. Scheitz
- Department of Neurology, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research Partner Site Berlin, Germany
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ioana Goganau
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Do Yeon Kim
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Pawel Kermer
- Department of Neurology, Friesland Kliniken, Sande, Germany
- Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kosmas Macha
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Wada
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Valerian Altersberger
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Andrea Zini
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Stefano Forlivesi
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Espen S. Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, Institute of Health and Society (HELSAM), University of Oslo, Oslo, Norway
| | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - P. Alan Barber
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Jae Beom Hong
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Carlo Cereda
- Stroke Center and Department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Yusuke Yakushiji
- Department of Neurology Kansai Medical University, Hirakata, Japan
| | - Sven Poli
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ronen Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Benno Ikenberg
- Department of Neurology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - David Giannandrea
- Division of Neurology and Stroke Unit, Department of Neurology, Gubbio and Città di Castello Hospital, Perugia, Italy
| | - Pere Cardona Portela
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Klinik für Neurologie, Alfried Krupp Krankenhaus, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Capital and Coast District Health Board, Wellington, New Zealand
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J. Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Matrix Metalloproteinases in Cardioembolic Stroke: From Background to Complications. Int J Mol Sci 2023; 24:ijms24043628. [PMID: 36835040 PMCID: PMC9959608 DOI: 10.3390/ijms24043628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/20/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
Matrix metalloproteinases (MMPs) are endopeptidases participating in physiological processes of the brain, maintaining the blood-brain barrier integrity and playing a critical role in cerebral ischemia. In the acute phase of stroke activity, the expression of MMPs increase and is associated with adverse effects, but in the post-stroke phase, MMPs contribute to the process of healing by remodeling tissue lesions. The imbalance between MMPs and their inhibitors results in excessive fibrosis associated with the enhanced risk of atrial fibrillation (AF), which is the main cause of cardioembolic strokes. MMPs activity disturbances were observed in the development of hypertension, diabetes, heart failure and vascular disease enclosed in CHA2DS2VASc score, the scale commonly used to evaluate the risk of thromboembolic complications risk in AF patients. MMPs involved in hemorrhagic complications of stroke and activated by reperfusion therapy may also worsen the stroke outcome. In the present review, we briefly summarize the role of MMPs in the ischemic stroke with particular consideration of the cardioembolic stroke and its complications. Moreover, we discuss the genetic background, regulation pathways, clinical risk factors and impact of MMPs on the clinical outcome.
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Intervention of neuroinflammation in the traumatic brain injury trajectory: In vivo and clinical approaches. Int Immunopharmacol 2022; 108:108902. [DOI: 10.1016/j.intimp.2022.108902] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/25/2022] [Accepted: 05/24/2022] [Indexed: 12/11/2022]
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Direct oral anticoagulant agents attenuate temporary aortic occlusion-induced renal oxidative and inflammatory responses in rats. TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2022; 30:184-191. [PMID: 36168569 PMCID: PMC9473587 DOI: 10.5606/tgkdc.dergisi.2022.22831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 02/04/2022] [Indexed: 11/21/2022]
Abstract
Background
This study aims to investigate the effects of different direct oral anticoagulants on experimental renal injury induced by temporary infrarenal aortic occlusion.
Methods
A total of 35 male Wistar rats (250 to 350 g) were randomly allocated to any of the five groups: sham, ischemia-reperfusion, rivaroxaban, dabigatran, and apixaban groups. Sham group underwent median laparotomy. Ischemia-reperfusion group was given saline gavage for one week. Animals in the other groups received rivaroxaban (3 mg/kg), dabigatran (15 mg/kg), or apixaban (10 mg/kg) daily once for one week via oral gavage. The infrarenal abdominal aorta was clamped for 60 min, and reperfusion was maintained for 120 min in the ischemia-reperfusion, rivaroxaban, dabigatran, and apixaban groups. At the end of reperfusion, kidneys were harvested for biochemical and histopathological analysis.
Results
Renal total antioxidant capacity was reduced, and total oxidant status, interleukin-1 beta, and tumor necrosis factor-alpha were elevated in the ischemia-reperfusion group, compared to the sham group (p<0.005). Histological damage scores were also higher in the ischemia-reperfusion group (p<0.005). Administration of direct oral anticoagulants caused an increase of total antioxidant capacity and reduction of total oxidant status, tumor necrosis factor-alpha, and interleukin-1 beta in the rivaroxaban, dabigatran, and apixaban groups compared to the ischemia-reperfusion group (p<0.005). Histological damage scores were lower in the rivaroxaban and dabigatran groups than the ischemia-reperfusion group scores (p<0.005).
Conclusion
Direct oral anticoagulants reduce aortic clamping-induced renal tissue oxidation and inflammation. Rivaroxaban and dabigatran attenuate ischemia-reperfusion-related histological damage in kidneys.
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Avci S, Gungor H, Kumru AS, Sahin M, Gezer A, Gok U, Kara H, Avcil M. Effects of Apixaban, Rivaroxaban, Dabigatran and Enoxaparin on Histopathology and Laboratory Parameters in Achilles Tendon Injury: An in vivo Study. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2021; 9:205-214. [PMID: 34667466 PMCID: PMC8473998 DOI: 10.4103/sjmms.sjmms_90_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/24/2021] [Accepted: 06/09/2021] [Indexed: 11/04/2022]
Abstract
Objectives To compare the effects of apixaban, rivaroxaban, dabigatran and enoxaparin on histopathology and blood parameters in rats with Achilles tendon injury. Materials and Methods Thirty adult, male Wistar albino rats weighting 220-240 g were randomly divided into five (one control and four treatment) groups and placed in a controlled environment. The Achilles tendon was incised and re-sutured in each rat, after which each group was provided the following treatment for 28 days: a) 2 ml saline to the control group, b) apixaban in 1 ml of saline (10 mg/kg/day) +1 ml of saline, c) rivaroxaban in 1 ml of saline (2 mg/kg/day) +1 ml saline, d) dabigatran in 1 ml of saline (30 mg/kg/day) +1 ml of saline, e) enoxaparin (80 μg/kg/day) + 2 ml of saline. Results Hemogram, biochemical and coagulation parameters differed significantly between the control and treatment groups (P < 0.05). Compared with the control group, in the apixaban group, type I and type III collagen immunoreactivity were severe and moderate, respectively. In the rivaroxaban and dabigatran groups, both type I and type III collagen immunoreactivity were medium and severe, respectively. In the enoxaparin group, type I and type III collagen immunoreactivity were mild and severe, respectively. Conclusion The higher concentration of type I collagen in the apixaban and dabigatran indicates faster tendon healing in these groups, and the higher concentration of the type III collagen in the enoxaparin group indicates slower healing in this group.
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Affiliation(s)
- Sema Avci
- Department of Emergency Medicine, Medical Faculty, Usak University, Usak, Turkey
| | - Huseyin Gungor
- Department of Toxicology and Pharmacology, Faculty of Veterinary Medicine, Sivas Cumhuriyet University, Sivas, Turkey
| | - Alper Serhat Kumru
- Department of Toxicology and Pharmacology, Faculty of Veterinary Medicine, Sivas Cumhuriyet University, Sivas, Turkey
| | - Mahmut Sahin
- Department of Toxicology and Pharmacology, Faculty of Veterinary Medicine, Sivas Cumhuriyet University, Sivas, Turkey
| | - Arzu Gezer
- Department of Geriatrics, Vocational School of Health Services, Ataturk University, Erzurum, Turkey
| | - Uzeyir Gok
- Department of Otorhinolaryngology, Medical Faculty, Amasya University, Amasya, Turkey
| | - Haki Kara
- Department of Toxicology and Pharmacology, Faculty of Veterinary Medicine, Sivas Cumhuriyet University, Sivas, Turkey
| | - Mucahit Avcil
- Department of Emergency Medicine, Medical Faculty, Usak University, Usak, Turkey
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Bieber M, Foerster KI, Haefeli WE, Pham M, Schuhmann MK, Kraft P. Treatment with Edoxaban Attenuates Acute Stroke Severity in Mice by Reducing Blood-Brain Barrier Damage and Inflammation. Int J Mol Sci 2021; 22:ijms22189893. [PMID: 34576055 PMCID: PMC8464921 DOI: 10.3390/ijms22189893] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022] Open
Abstract
Patients with atrial fibrillation and previous ischemic stroke (IS) are at increased risk of cerebrovascular events despite anticoagulation. In these patients, treatment with non-vitamin K oral anticoagulants (NOAC) such as edoxaban reduced the probability and severity of further IS without increasing the risk of major bleeding. However, the detailed protective mechanism of edoxaban has not yet been investigated in a model of ischemia/reperfusion injury. Therefore, in the current study we aimed to assess in a clinically relevant setting whether treatment with edoxaban attenuates stroke severity, and whether edoxaban has an impact on the local cerebral inflammatory response and blood–brain barrier (BBB) function after experimental IS in mice. Focal cerebral ischemia was induced by transient middle cerebral artery occlusion in male mice receiving edoxaban, phenprocoumon or vehicle. Infarct volumes, functional outcome and the occurrence of intracerebral hemorrhage were assessed. BBB damage and the extent of local inflammatory response were determined. Treatment with edoxaban significantly reduced infarct volumes and improved neurological outcome and BBB function on day 1 and attenuated brain tissue inflammation. In summary, our study provides evidence that edoxaban might exert its protective effect in human IS by modulating different key steps of IS pathophysiology, but further studies are warranted.
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Affiliation(s)
- Michael Bieber
- Department of Neurology, University Hospital Würzburg, 97080 Würzburg, Germany; (M.B.); (M.K.S.)
| | - Kathrin I. Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.I.F.); (W.E.H.)
| | - Walter E. Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (K.I.F.); (W.E.H.)
| | - Mirko Pham
- Department of Neuroradiology, University Hospital Würzburg, 97080 Würzburg, Germany;
| | - Michael K. Schuhmann
- Department of Neurology, University Hospital Würzburg, 97080 Würzburg, Germany; (M.B.); (M.K.S.)
| | - Peter Kraft
- Department of Neurology, University Hospital Würzburg, 97080 Würzburg, Germany; (M.B.); (M.K.S.)
- Department of Neurology, Klinikum Main-Spessart, 97816 Lohr, Germany
- Correspondence: ; Tel.: +49-9352-505-1501
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Feng T, Hu X, Fukui Y, Tadokoro K, Bian Z, Morihara R, Yamashita T, Abe K. Neuroprotective effects of Scallop-derived plasmalogen in a mouse model of ischemic stroke. Brain Res 2021; 1766:147516. [PMID: 33991494 DOI: 10.1016/j.brainres.2021.147516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 12/28/2022]
Abstract
Scallop-derived plasmalogen (sPlas) has both anti-oxidative and anti-inflammation activities, but its efficacy has not been investigated in ischemic stroke models where oxidative stress, inflammation, and neurovascular unit (NVU) damage accelerates pathophysiological progression. Therefore, in the present study, we aimed to assess the neuroprotective effects of sPlas in ischemic stroke by using a transient middle cerebral artery occlusion (tMCAO) mouse model. After the pretreatment of vehicle or sPlas (10 mg/kg/day) for 14 days, adult male mice were subjected to tMCAO for 60 min, then continuously treated with vehicle or sPlas during reperfusion and for an additional 5 days. The administration of sPlas significantly improved motor deficits (corner and rotarod tests, *p < 0.05 vs vehicle), enhanced serum antioxidative activity (OXY-adsorbent and d-ROMs tests, *p < 0.05 vs vehicle), reduced infarction volume (*p < 0.05 vs vehicle), decreased the expression of two oxidative stress markers, 4-HNE (*p < 0.05 vs vehicle) and 8-OHdG (*p < 0.05 vs vehicle), decreased the expression of pro-inflammatory markers Iba-1 (**p < 0.01 vs vehicle), IL-1β (**p < 0.01 vs vehicle), and TNF-α (**p < 0.01 vs vehicle), and alleviated NVU damage (collagen IV, MMP9, and GFAP/collagen IV, *p < 0.05 vs vehicle). Our present findings are the first to demonstrate the neuroprotective effects of sPlas on acute ischemic stroke mice at 5 d after tMCAO via anti-oxidative stress, anti-inflammation, and improvement of NVU damage, suggesting the potential of sPlas in preventing and treating ischemic stroke.
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Affiliation(s)
- Tian Feng
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan
| | - Xinran Hu
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan
| | - Yusuke Fukui
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan
| | - Koh Tadokoro
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan
| | - Zhihong Bian
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan
| | - Ryuta Morihara
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan
| | - Toru Yamashita
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan
| | - Koji Abe
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan.
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Ye Y, Zhang FT, Wang XY, Tong HX, Zhu YT. Antithrombotic Agents for tPA-Induced Cerebral Hemorrhage: A Systematic Review and Meta-Analysis of Preclinical Studies. J Am Heart Assoc 2020; 9:e017876. [PMID: 33283576 PMCID: PMC7955384 DOI: 10.1161/jaha.120.017876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background tPA (tissue‐type plasminogen activator) remains the only approved drug for acute ischemic stroke, with a potentially serious adverse effect: hemorrhagic transformation. The effects of antithrombotic agents on tPA‐induced hemorrhagic transformation after ischemic stroke are not clearly defined. We performed a systematic review and meta‐analysis in preclinical studies aiming to evaluate the efficacy of antithrombotic agents on tPA‐induced hemorrhagic transformation after ischemic stroke. Methods and Results We conducted a systematic review and meta‐analysis of studies testing antithrombotic agents in animal models of tPA‐induced hemorrhagic transformation. The pooled effects were calculated using random‐effects models, and heterogeneity was explored through meta‐regression and subgroup analyses. Publication bias was assessed using trim and fill method and the Egger test. The efficacy of 18 distinct interventions was described in 22 publications. The pooled data showed a significant improvement in cerebral hemorrhage, infarct size, and neurobehavioral outcome in treated compared with control animals (standardized mean difference, 0.45 [95% CI, 0.11–0.78]; standardized mean difference, 1.18 [95% CI, 0.73–1.64]; and standardized mean difference, 0.91 [95% CI, 0.49–1.32], respectively). Subgroup analysis indicated that quality score, random allocation, control of temperature, anesthetic used, stroke model used, route of drug delivery, time of drug administration, and time of assessment were significant factors that influenced the effects of interventions. Conclusions Administration with antiplatelet agents revealed statistically significant improvement in all the outcomes. Anticoagulant agents showed significant effects in infarct size and neurobehavioral score, but fibrinolytic agents did not show any significant improvement in all the outcomes. The conclusions should be interpreted cautiously given the heterogeneity and publication bias identified in this analysis.
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Affiliation(s)
- Yang Ye
- Department of Integration of Chinese and Western Medicine School of Basic Medical Sciences Peking University Beijing China.,Tasly Microcirculation Research Center Peking University Health Science Center Beijing China
| | - Fu-Tao Zhang
- University of Chinese Academy of Sciences Beijing China.,Northeast Institute of Geography and Agroecology Chinese Academy of Sciences Harbin China.,National Engineering Laboratory for Improving Quality of Arable Land Institute of Agricultural Resources and Regional Planning Chinese Academy of Agricultural Sciences Beijing China
| | - Xiao-Yi Wang
- Department of Integration of Chinese and Western Medicine School of Basic Medical Sciences Peking University Beijing China.,Tasly Microcirculation Research Center Peking University Health Science Center Beijing China
| | - Hong-Xuan Tong
- Institute of Basic Theory for Chinese Medicine China Academy of Chinese Medical Sciences Beijing China
| | - Yu-Tian Zhu
- Department of Urology Peking University Third Hospital Beijing China
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11
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Antithrombin gamma attenuates macrophage/microglial activation and brain damage after transient focal cerebral ischemia in mice. Life Sci 2020; 252:117665. [PMID: 32305521 DOI: 10.1016/j.lfs.2020.117665] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/27/2020] [Accepted: 04/09/2020] [Indexed: 01/09/2023]
Abstract
AIMS Thrombin formation is increased in patients with acute cerebral ischemic stroke, and augments coagulation and inflammation in the brain. Administration of antithrombin (AT) was previously reported to be protective against renal and myocardial ischemic injury. Thus, we hypothesized that treatment with AT would be neuroprotective against cerebral ischemic injury. This study evaluated the effects of AT treatment on ischemic inflammation and brain damage in mice subjected to middle cerebral artery occlusion (MCAO). MAIN METHODS A mouse model of 4-hour MCAO was used to induce ischemic brain injury. Recombinant AT gamma was administered intravenously immediately after reperfusion at 4 h after MCAO. Infarct volume, neurological deficit, and regional cerebral blood flow (rCBF) were measured at 24 h after MCAO. To evaluate the effect of AT gamma on ischemic inflammation, we measured the number of Iba1-positive cells (marker of macrophage/microglial activation) and levels of proinflammatory cytokines. Further, we investigated the direct anti-inflammatory effects of rAT in the J774.1 cell line. KEY FINDINGS Treatment with AT gamma (480 U/kg) reduced infarct volume and neurological deficit, and improved rCBF, in MCAO mice. Moreover, AT gamma treatment decreased the number of Iba1-positive cells and levels of proinflammatory cytokines. In vitro, treatment with thrombin significantly increased proinflammatory cytokine levels, which was significantly reduced by pretreatment with AT gamma. SIGNIFICANCE Treatment with AT showed neuroprotective effects via anticoagulation actions, as well as direct anti-inflammatory effects on macrophage/microglial activation. These data suggest that AT may be a useful new therapeutic option for cerebral ischemia.
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12
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El-Ghafar OAMA, Helal GK, Abo-Youssef AM. Apixaban exhibits anti-arthritic effects by inhibiting activated factor X-mediated JAK2/STAT3 and MAPK phosphorylation pathways. Inflammopharmacology 2020; 28:1253-1267. [PMID: 32141012 DOI: 10.1007/s10787-020-00693-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 02/10/2020] [Indexed: 12/20/2022]
Abstract
Activated factor X (FXa) is strongly linked to various inflammatory events. This study aimed to investigate the effect of FXa on janus kinase2/signal transducers and activators of transcription3 (JAK2/STAT3) and mitogen-activated protein kinase (MAPK) phosphorylation in relation to rheumatoid arthritis (RA). It also extends its scope to explore the possible anti-arthritic effects of apixaban, a selective FXa inhibitor. Rats were allocated into normal control; complete Freund's adjuvant (CFA, 0.4 ml/4 days/12 days); FXa (120 µg/kg/day/3 days) and CFA + FXa groups as well as three treated groups including CFA + apixaban; FXa + apixaban and CFA + FXa + apixaban. Apixaban was administered at a dose of 10 mg/kg/12 h for15 days. By the end of the experimental period, tissue samples were collected for the assessment of phosphorylated (p)-JAK2, STAT3, MAPK, matrixmetalloprotein-1 (MMP-1) and protease-activated receptor 2. Furthermore, Serum interleukin-6 (IL-6), platelet-derived growth factor (PDGF), anti-citrullinated protein antibody (ACPA), 8-hydroxy-2'-deoxyguanosine (8-OHdG), plasma level of FXa and prothrombin time were evaluated. In support, histopathological and macroscopical examinations were performed. FXa activated JAK2, STAT3 and MAPK phosphorylation through activation of PAR 2, PDGF and IL-6 and concomitantly led to a significant elevation in ACPA, MMP-1 and 8-OHdG. Apixaban markedly amended FXa-induced changes. Conclusively, the current study revealed that FXa may have a drastic role in RA progression and pathogenesis at least through stimulation of JAK2/STAT3 and MAPK phosphorylation. Furthermore, apixaban exerted robust arthro-protective effects. These beneficial outcomes could be attributed to its ability to impede JAK2/STAT3 and MAPK activation, as well as to its antioxidant property.
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Affiliation(s)
| | - Gouda Kamel Helal
- Pharmacology and Toxicology Department, Faculty of Pharmacy, Heliopolis University for Sustainable Development, 3 Cairo-Belbeis Desert Rd, Second Al Salam, Cairo, Egypt
| | - Amira M Abo-Youssef
- Pharmacology and Toxicology Department, Faculty of Pharmacy, Beni-Suef University, Beni Suef, Egypt.
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13
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Zhao Y, Wei ZZ, Lee JH, Gu X, Sun J, Dix TA, Wei L, Yu SP. Pharmacological hypothermia induced neurovascular protection after severe stroke of transient middle cerebral artery occlusion in mice. Exp Neurol 2019; 325:113133. [PMID: 31770520 DOI: 10.1016/j.expneurol.2019.113133] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 09/25/2019] [Accepted: 11/22/2019] [Indexed: 12/19/2022]
Abstract
Therapeutic hypothermia is a potential protective strategy after stroke. The present study evaluated the neurovascular protective potential of pharmacological hypothermia induced by the neurotensin receptor 1 agonist HPI-201 after severe ischemic stroke. Adult C57BL/6 mice were subjected to filament insertion-induced occlusion of the middle cerebral artery (60 min MCAO). HPI-201 was i.p. injected 120 min after the onset of MCAO to initiate and maintain the body temperature at 32-33°C for 6 hrs. The infarct volume, cell death, integrity of the blood brain barrier (BBB) and neurovascular unit (NVU), inflammation, and functional outcomes were evaluated. The hypothermic treatment significantly suppressed the infarct volume and neuronal cell death, accompanied with reduced caspase-3 activation and BAX expression while Bcl-2 increased in the peri-infarct region. The cellular integrity of the BBB and NVU was significantly improved and brain edema was attenuated in HPI-201-treated mice compared to stroke controls. The hypothermic treatment decreased the expression of inflammatory factors including tumor necrosis factor-α (TNF-α), MMP-9, interleukin-1β (IL-1β), the M1 microglia markers IL-12 and inducible nitric oxide synthase (iNOS), while increased the M2 marker arginase-1 (Arg-1). Stroke mice received the hypothermic treatment showed lower neurological severity score (NSS), performed significantly better in functional tests, the mortality rate in the hypothermic group was noticeably lower compared with stroke controls. Taken together, HPI-201 induced pharmacological hypothermia is protective for different neurovascular cells after a severely injured brain, mediated by multiple mechanisms.
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Affiliation(s)
- Yingying Zhao
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Zheng Zachory Wei
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA; Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Medical Center, Decatur, GA 30033, USA
| | - Jin Hwan Lee
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Xiaohuan Gu
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jinmei Sun
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Thomas A Dix
- Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston, SC 29401, USA
| | - Ling Wei
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Shan P Yu
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, USA; Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Medical Center, Decatur, GA 30033, USA.
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Maeda M, Tsuboi T, Hayashi T. An Inhibitor of Activated Blood Coagulation Factor X Shows Anti-Endothelial Senescence and Anti-Atherosclerotic Effects. J Vasc Res 2019; 56:181-190. [DOI: 10.1159/000499975] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 03/28/2019] [Indexed: 11/19/2022] Open
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Pétrault M, Ouk T, Pétrault O, Bastide M, Bordet R, Bérézowski V. Safety of oral anticoagulants on experimental brain microbleeding and cognition. Neuropharmacology 2019; 155:162-172. [PMID: 31132437 DOI: 10.1016/j.neuropharm.2019.05.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 12/24/2022]
Abstract
This study aims at determining the ability of clinical-based doses of four oral anticoagulants to transform the onset of a cerebral microhemorrhages (CMH) burden into a symptomatic intracerebral hemorrhage (ICH) in the healthy brain, and precipitate cognitive impairment. Wild-type mice were anticoagulated for 10 days using apixaban, rivaroxaban or dabigatran as direct oral anticoagulants (DOACs), or warfarin as vitamin K-antagonist. Meanwhile, a burden of ∼20 CMHs was induced in the Sylvian territory by intra-carotid injection of cyclodextrin nanoparticles. At bleeding onset, only warfarin provoked deadly hematoma, and dramatically increased mortality (+45%). All the DOACs enhanced CMH burden through a greater number of intermediate-sized microhemorrhages (+80% to +180%). Although silent at onset, both baseline- and anticoagulant-enhanced CMH burdens increased mortality (+11% to +58%) along the following year without statistical difference among groups, and despite cessation of anticoagulation and absence of CMH progression or transformation into ICH. All survivor mice exhibited reduction in visual recognition memory from 9 months. In the healthy brain, DOACs preserve the onset of microhemorrhages from transformation into ICH, and do not precipitate cognitive impairment despite enhancement of CMH burden. High CMH burdens should however be considered for early detection and preventive memory care apart from anticoagulation decisions.
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Affiliation(s)
- Maud Pétrault
- Univ. Lille, Inserm, CHU Lille, U1171, Degenerative and Vascular Cognitive Disorders, F-59000, Lille, France
| | - Thavarak Ouk
- Univ. Lille, Inserm, CHU Lille, U1171, Degenerative and Vascular Cognitive Disorders, F-59000, Lille, France
| | - Olivier Pétrault
- Univ. Lille, Inserm, CHU Lille, U1171, Degenerative and Vascular Cognitive Disorders, F-59000, Lille, France; UArtois, F-62300, Lens, France
| | - Michèle Bastide
- Univ. Lille, Inserm, CHU Lille, U1171, Degenerative and Vascular Cognitive Disorders, F-59000, Lille, France
| | - Régis Bordet
- Univ. Lille, Inserm, CHU Lille, U1171, Degenerative and Vascular Cognitive Disorders, F-59000, Lille, France
| | - Vincent Bérézowski
- Univ. Lille, Inserm, CHU Lille, U1171, Degenerative and Vascular Cognitive Disorders, F-59000, Lille, France; UArtois, F-62300, Lens, France.
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16
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Cathepsin K Knockout Exacerbates Haemorrhagic Transformation Induced by Recombinant Tissue Plasminogen Activator After Focal Cerebral Ischaemia in Mice. Cell Mol Neurobiol 2019; 39:823-831. [PMID: 31065924 DOI: 10.1007/s10571-019-00682-8] [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: 12/22/2018] [Accepted: 04/29/2019] [Indexed: 12/19/2022]
Abstract
Severe haemorrhagic transformation (HT), a common complication of recombinant tissue plasminogen activator (rtPA) treatment, predicts poor clinical outcomes in acute ischaemic stroke. The search for agents to mitigate this effect includes investigating biomolecules involved in neovascularization. This study examines the role of Cathepsin K (Ctsk) in rtPA-induced HT after focal cerebral ischaemia in mice. After knockout of Ctsk, the gene encoding Ctsk, the outcomes of Ctsk+/+ and Ctsk-/- mice were compared 24 h after rtPA-treated cerebral ischaemia with respect to HT severity, neurological deficits, brain oedema, infarct volume, number of apoptotic neurons and activated microglia/macrophage, blood-brain barrier integrity, vascular endothelial growth factor (VEGF) expression and Akt-mTOR pathway activation. We observed that haemoglobin levels, brain oedema and infarct volume were significantly greater and resulted in more severe neurological deficits in Ctsk-/- than in Ctsk+/+ mice. Consistent with our hypothesis, the number of NeuN-positive neurons was lower and the number of TUNEL-positive apoptotic neurons and activated microglia/macrophage was higher in Ctsk-/- than in Ctsk+/+ mice. Ctsk knockout mice exhibited more severe blood-brain barrier (BBB) disruption, with microvascular endothelial cells exhibiting greater VEGF expression and lower ratios of phospo-Akt/Akt and phospo-mTOR/mTOR than in Ctsk+/+ mice. This study is the first to provide molecular insights into Ctsk-regulated HT after cerebral ischaemia, suggesting that Ctsk deficiency may disrupt the BBB via Akt/mTOR/VEGF signalling, resulting in neurological deficits and neuron apoptosis. Ctsk administration has the potential as a novel modality for improving the safety of rtPA treatment following stroke.
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Izuma H, Oka F, Ishihara H, Inoue T, Suehiro E, Nomura S, Suzuki M. Thrombolysis with rt-PA under Rivaroxaban Anticoagulation in a Hypertensive Rat Model of Intraluminal Middle Cerebral Artery Occlusion. J Stroke Cerebrovasc Dis 2018; 27:2761-2767. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 05/24/2018] [Accepted: 06/02/2018] [Indexed: 11/24/2022] Open
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18
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Liu M, Zheng Y, Li G. Safety of Recanalization Therapy in Patients with Acute Ischemic Stroke Under Anticoagulation: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2018; 27:2296-2305. [PMID: 30017747 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Intravenous thrombolysis treatment (IVT) and endovascular therapy (EVT) have been proved as fist-line beneficial option for eligible patients who have acute ischemic stroke (AIS) with major safety concern of symptomatic intracranial hemorrhage (sICH). Unfortunately, the emergency management of patients with AIS taking vitamin K antagonists and with international normalized ratio higher than 1.7 or taking new oral anticoagulants (NOACs) represents a great challenge. We aim to comprehensively determine the safety of EVT in patients under prior-stroke anticoagulants and IVT in patients under NOAC use. METHODS Clinical researches published in the Embase, PubMed, and Cochrane Library electronic databases up to December 2017 were identified for analysis. Subgroup and sensitivity analyses were also conducted to evaluate the robustness of the conclusions. RESULTS Overall, 9 studies involving 3885 patients met the inclusion criteria. The rate of sICH (risk ratio [RR] = .94, 95% CI = .61-1.47, P = .799), mortality (P = .495), and recanalization (P = .655) after EVT did not differ between patients under and those who were not under anticoagulants, although patients under anticoagulants were less likely to achieve good functional outcome (P < .001) than those who were not. Moreover, prior NOAC therapy was not significantly associated with increasing sICH in patients with AIS after IVT (RR = .79, 95% CI = .41-1.53, P = .492). CONCLUSIONS Patients under anticoagulation appear to be safe after EVT with relatively lower rate of good outcome; furthermore, prior NOAC therapy was not associated with an increasing sICH rate after IVT. This offered a practical information to select appropriate therapeutic strategies for patients under anticoagulation, although the level of evidence seems to be quite shaky.
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Affiliation(s)
- Mingsu Liu
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Yang Zheng
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Guangqin Li
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China.
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Lyden PD. Can an anticoagulant reduce brain hemorrhage: Invited comment on "Dabigatran reduces endothelial permeability through inhibition of thrombin-induced cytoskeleton reorganization". Thromb Res 2018; 167:S0049-3848(18)30379-7. [PMID: 29935770 DOI: 10.1016/j.thromres.2018.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/08/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Patrick D Lyden
- Department of Neurology, 127 S. San Vicente Blvd, Room A6417, Los Angeles, CA 90048, United States.
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Rivaroxaban does not influence hemorrhagic transformation in a diabetes ischemic stroke and endovascular thrombectomy model. Sci Rep 2018; 8:7408. [PMID: 29743683 PMCID: PMC5943582 DOI: 10.1038/s41598-018-25820-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/30/2018] [Indexed: 12/31/2022] Open
Abstract
Managing endovascular thrombectomy (ET) in diabetic ischemic stroke (IS) with novel anticoagulants is challenging due to putative risk of intracerebral hemorrhage. The study evaluates increased hemorrhagic transformation (HT) risk in Rivaroxaban-treated diabetic rats post ET. Diabetes was induced in male Sprague-Dawley rats by intraperitoneal injection of 60 mg/kg streptozotocin. After 4-weeks, rats were pretreated orally with 30 mg/kg Rivaroxaban/saline; prothrombin time was monitored. IS and ET was induced after 1 h, by thread-induced transient middle cerebral artery occlusion (tMCAO) that mimicked mechanical ET for proximal MCA occlusion at 60 min. After 24 h reperfusion, infarct volumes, HT, blood-brain barrier (BBB) permeability, tight junction at peri-ischemic lesion and matrix metalloproteinase-9 (MMP-9) activity was measured. Diabetic rats seemed to exhibit increased infarct volume and HT at 24 h after ET than normal rats. Infarct volumes and functional outcomes did not differ between Rivaroxaban and diabetic control groups. A significant increase in HT volumes and BBB permeability under Rivaroxaban treatment was not detected. Compared to diabetic control group, neither the occludin expression was remarkably lower in the Rivaroxaban group nor the MMP-9 activity was higher. Together, Rivaroxaban does not increase HT after ET in diabetic rats with proximal MCA occlusion, since Rivaroxaban has fewer effects on post-ischemic BBB permeability.
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Touzé E, Gruel Y, Gouin-Thibault I, De Maistre E, Susen S, Sie P, Derex L. Intravenous thrombolysis for acute ischaemic stroke in patients on direct oral anticoagulants. Eur J Neurol 2018; 25:747-e52. [PMID: 29360254 DOI: 10.1111/ene.13582] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 01/11/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Whereas intravenous thrombolysis (IVT) is allowed for acute ischaemic stroke in patients on vitamin K antagonists with international normalized ratio ≤1.7, there are no similar recommendations for patients on direct oral anticoagulants (DOACs), notably due to the lack of coagulation tests to assess the therapeutic effects. Although the literature is scarce, consisting of small case series and retrospective studies, considering the frequency of this situation the French Vascular Neurology Society and the French Study Group on Haemostasis and Thrombosis have worked on a joint position paper to provide a practical position regarding the emergency management of ischaemic stroke in patients on DOACs. METHOD Based on a review of the literature, the authors wrote a first text that was submitted to a broad panel of members from the two societies. The text was then amended by the authors to address experts' comments and to reach a consensus. RESULTS In patients with normal renal function and who stopped the DOAC for at least 48 h, the management should not differ from that in patients without oral anticoagulant. In patients who are still on DOACs, mechanical thrombectomy is encouraged preferentially when applicable in first line. Otherwise, when specific tests are available, values <50 ng/ml indicate that IVT is allowed. In the absence of specific tests, standard tests (thrombin time, prothrombin time and activated partial thromboplastin time) can be used for dabigatran and rivaroxaban, although interpretation of these tests may be less reliable. In some patients on dabigatran, idarucizumab may be used before IVT. CONCLUSIONS In this expert opinion paper, it is suggested that IVT can be performed in patients selected according to the time elapsed since the drug was last taken, renal function, type of hospital where the patient is admitted and plasma concentration of DOAC.
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Affiliation(s)
- E Touzé
- Normandie Université, UNICAEN, Unité Neurovasculaire, CHU Caen, Caen, France
| | - Y Gruel
- Service d'Hématologie-Hémostase, Centre Régional de Traitement de l'Hémophilie, UMR CNRS 7292, Hôpital Trousseau, CHRU de Tours et Université François Rabelais, Tours, France
| | - I Gouin-Thibault
- Laboratoire d'Hématologie, Hôpital Cochin, UMR_S1140, Université Paris Descartes, Paris, France
| | - E De Maistre
- Laboratoire d'Hématologie-Hémostase, CHU Dijon Bourgogne, Université de Bourgogne, Dijon Cedex, France
| | - S Susen
- Département d'Hématologie et Transfusion, CHRU, Lille, France
| | - P Sie
- Laboratoire d'Hématologie, Hôpital Rangueil, CHU de Toulouse, Université Toulouse 3, Paul Sabatier, Toulouse, France
| | - L Derex
- Unité Neurovasculaire, Hôpital Neurologique, Hospices Civils, Lyon, France
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Kraft P, Schuhmann MK, Dittmeier M, Fluri F, Kleinschnitz C. Pretreatment with rivaroxaban attenuates stroke severity in rats by a dual antithrombotic and anti-inflammatory mechanism. Thromb Haemost 2017; 115:835-43. [DOI: 10.1160/th15-08-0631] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 09/23/2015] [Indexed: 01/03/2023]
Abstract
SummaryStroke outcome is more favourable in patients receiving oral anticoagulants compared with non-anticoagulated patients. The reasons for this “stroke-attenuating” property of oral anticoagulants are largely unknown. This study examined whether prestroke anticoagulation with rivaroxaban, a novel direct factor Xa inhibitor, influences stroke severity, thrombin-mediated intracerebral thrombus formation and pro-inflammatory processes in a rat model of brain ischaemia/reperfusion injury. Male Wistar rats were anticoagulated with rivaroxaban and subjected to 90 minutes of transient middle cerebral artery occlusion. Infarct size, functional outcome and the occurrence of intracranial haemorrhage (ICH) were assessed until day 7. Thrombin generation was determined by measuring the amount of thrombin/antithrombin complex. Intracerebral thrombus formation was evaluated by histology and Western blot. CD68-immunoreactivity and the expression of cytokines and adhesion molecules were investigated to assess postischaemic inflammation. The integrity of the blood–brain barrier was analysed using fluorescein isothiocyanate-dextran. Rats pretreated with rivaroxaban developed significantly smaller strokes and less severe functional deficits compared with controls. Although rivaroxaban strongly reduced thrombin-mediated thrombus formation, this was not accompanied by an increased risk of ICH. In addition, rivaroxaban dampened the inflammatory response in the ischaemic brain by downregulating ICAM-1 expression and the activation of CD68+-immune cells. In contrast, rivaroxaban had no effect on the integrity of the blood–brain barrier after stroke. Here, we identified reduced thrombo-inflammation as a major determinant of the stroke-protective property of rivaroxaban in rats. Further studies are needed to assess the therapeutic potential of novel oral anticoagulants in the acute phase after a stroke.
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23
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Kanai Y, Oguro H, Tahara N, Matsuda H, Takayoshi H, Mitaki S, Onoda K, Yamaguchi S. Analysis of Recurrent Stroke Volume and Prognosis between Warfarin and Four Non-Vitamin K Antagonist Oral Anticoagulants' Administration for Secondary Prevention of Stroke. J Stroke Cerebrovasc Dis 2017; 27:338-345. [PMID: 29033229 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 08/27/2017] [Accepted: 09/06/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE We investigated recurrent stroke volume with nonvalvular atrial fibrillation (NVAF) patients treated with non-vitamin K antagonist oral anticoagulants (NOACs) about clinical backgrounds and number of recurrent stroke. METHODS We administered 4 NOACs, dabigatran, rivaroxaban, apixaban, and edoxaban in 101 postcardioembolic strokes with NVAF. In a retrospective study, we measured recurrent stroke volume with magnetic resonance imaging volumetric software and compared them between 10 vitamin K anticoagulant (VKA: warfarin) cases and 13 NOAC cases under anticoagulant therapy. RESULTS Of 101 cases, 31 were started with a VKA and switched to NOACs after 10 recurrent strokes. Other 70 cases were directly started with NOACs and 13 cases with NOACs as first anticoagulants had recurrent stroke. The frequency of recurrent stroke during anticoagulant therapy is not different between the VKA group and the 3 NOACs group. Recurrent stroke volume is significantly larger in the VKA group (26.4 cm3) than in the NOACs group (1.2 cm3). CONCLUSIONS Secondary prevention with NOACs after stroke might be more beneficial than a VKA by reducing recurrent infarct volume.
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Affiliation(s)
- Yukie Kanai
- Department of Neurology, Faculty of Medicine, Shimane University, Izumo City, Shimane, Japan
| | - Hiroaki Oguro
- Department of Neurology, Faculty of Medicine, Shimane University, Izumo City, Shimane, Japan.
| | - Nao Tahara
- Department of Neurology, Faculty of Medicine, Shimane University, Izumo City, Shimane, Japan
| | - Hanako Matsuda
- Department of Neurology, Faculty of Medicine, Shimane University, Izumo City, Shimane, Japan
| | - Hiroyuki Takayoshi
- Department of Neurology, Faculty of Medicine, Shimane University, Izumo City, Shimane, Japan
| | - Shingo Mitaki
- Department of Neurology, Faculty of Medicine, Shimane University, Izumo City, Shimane, Japan
| | - Keiichi Onoda
- Department of Neurology, Faculty of Medicine, Shimane University, Izumo City, Shimane, Japan
| | - Shuhei Yamaguchi
- Department of Neurology, Faculty of Medicine, Shimane University, Izumo City, Shimane, Japan
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24
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Nambiar VK, Dhanya TS, Ajai AV. Successful Revascularization of Acute Middle Cerebral Artery Occlusion by Intravenous Thrombolysis While on Apixaban. Ann Indian Acad Neurol 2017; 20:161-162. [PMID: 28615907 PMCID: PMC5470155 DOI: 10.4103/aian.aian_422_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Vivek K Nambiar
- Division of Stroke, Centre of Neurosciences, Amrita Institute Medical Sciences, Kochi, Kerala, India
| | - T S Dhanya
- Division of Stroke, Centre of Neurosciences, Amrita Institute Medical Sciences, Kochi, Kerala, India
| | - Amrutha V Ajai
- Division of Stroke, Centre of Neurosciences, Amrita Institute Medical Sciences, Kochi, Kerala, India
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25
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Suzuki K, Aoki J, Sakamoto Y, Abe A, Suda S, Okubo S, Nagao T, Kimura K. Low risk of ICH after reperfusion therapy in acute stroke patients treated with direct oral anti-coagulant. J Neurol Sci 2017; 379:207-211. [PMID: 28716241 DOI: 10.1016/j.jns.2017.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 05/16/2017] [Accepted: 06/06/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The safety of intravenous thrombolysis (IVT) and endovascular therapy (EVT) in patients treated with DOAC is unclear. We investigated whether recanalization therapy in patients treated with DOAC is safe. METHODS A nationwide, multicenter, retrospective cohort questionnaire survey was conducted to investigate the: (1) frequency of intracerebral hemorrhage (ICH) after recanalization therapy in patients treated with DOAC; (2) independent factors related to ICH; (3) relationship between last intake time of DOAC and ICH; and (4) comparison of ICH frequency between patients treated with DOAC, vitamin K antagonist (VKA), and no-anticoagulation (no-ACT) (control). RESULTS One hundred eighteen stroke centers returned the questionnaire and 100 patients (56 IVT alone, 29 EVT alone, and 15 both IVT and EVT) on DOAC were registered. The frequency of asymptomatic and symptomatic (≥4-point NIHSS score increase) ICH within 24h in DOAC patients were 18% and 2%, and were not different compared with the VKA and no-ACT groups (p=0.728; and p=0.626). On multivariate analysis, systolic blood pressure (OR, 1.04; p<0.001) and blood glucose (OR, 1.02; p=0.019) were independent factors for ICH. Among the 52 patients with a known last intake time of DOAC, the rate of ICH was higher in patients ≤4h from last intake than those >4h (38% vs. 10%, p=0.033). CONCLUSIONS Risk of ICH after reperfusion therapy in patients treated with DOAC should be low. Systolic blood pressure, glucose level, and DOAC intake time appear to be factors for ICH.
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Affiliation(s)
- Kentaro Suzuki
- Department of Neurological Science, Nippon Medical School Hospital, Tokyo, Japan.
| | - Junya Aoki
- Department of Neurological Science, Nippon Medical School Hospital, Tokyo, Japan
| | - Yuki Sakamoto
- Department of Neurological Science, Nippon Medical School Hospital, Tokyo, Japan
| | - Arata Abe
- Department of Neurological Science, Nippon Medical School Hospital, Tokyo, Japan
| | - Satoshi Suda
- Department of Neurological Science, Nippon Medical School Hospital, Tokyo, Japan
| | - Seiji Okubo
- Department of Neurological Science, Nippon Medical School Hospital, Tokyo, Japan
| | - Takehiko Nagao
- Department of Neurological Science, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurological Science, Nippon Medical School Hospital, Tokyo, Japan
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26
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Foerch C, Schäfer JH, Pfeilschifter W, Bohmann F. [Direct oral anticoagulants and acute stroke : Insights into translational research studies]. DER NERVENARZT 2017; 88:642-651. [PMID: 28188404 DOI: 10.1007/s00115-017-0282-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In recent years a considerable number of translational research studies on intracerebral hemorrhage and ischemic stroke have been published, which are characterized by a particular proximity to practical clinical questions. Animal research has provided insights into the pathophysiological processes and therapy effects, which have so far only been insufficiently investigated in clinical studies. This includes the effectiveness of a rapid reversal of anticoagulation in cases of anticoagulation-associated intracerebral hemorrhage and the safety of thrombolytic treatment in ischemic stroke occurring during treatment with anticoagulants. With the approval of the direct oral anticoagulants these problems have become of particular contemporary relevance. Of course, results from experimental translational studies on stroke cannot be directly translated into clinical routine. Nevertheless, these investigations help to understand the underlying processes and mechanisms and provide proof of concept data for new treatment strategies. This review summarizes the most relevant results in this field of research with a particular focus on practical clinical questions.
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Affiliation(s)
- C Foerch
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland.
| | - J H Schäfer
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
| | - W Pfeilschifter
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
| | - F Bohmann
- Klinik für Neurologie, Goethe-Universität, Schleusenweg 2-16, 60528, Frankfurt am Main, Deutschland
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27
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Xu X, Li C, Wan T, Gu X, Zhu W, Hao J, Bao H, Zuo L, Hu H, Li G. Risk Factors for Hemorrhagic Transformation After Intravenous Thrombolysis in Acute Cerebral Infarction: A Retrospective Single-Center Study. World Neurosurg 2017; 101:155-160. [PMID: 28185970 DOI: 10.1016/j.wneu.2017.01.091] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 01/20/2017] [Accepted: 01/25/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To investigate the risk factors for hemorrhagic transformation (HT) after intravenous thrombolysis using a recombinant tissue plasminogen activator (r-tPA) in acute cerebral infarction. METHODS Patients with acute cerebral infarction receiving r-tPA thrombolysis in Shanghai Eastern Hospital were retrospectively studied. Based on the cranial computed tomography or magnetic resonance imaging examination, after the intravenous thrombolysis, the patients were divided into 2 groups: an HT group and a non-HT group. The information was collected before or after thrombolysis. RESULTS A total of 162 patients were included in the analysis. The age ranged from 25 to 86 years, with an average age of 65.6 ± 10.6 years. The average time from disease onset to thrombolysis was 188 ± 53.1 minutes. Cranial computed tomography or magnetic resonance imaging showed that 20 patients (12.3%) had HT after thrombolysis. Using univariate analysis, history of atrial fibrillation, positive expression of urinary protein, and high National Institutes of Health Stroke Scale (NIHSS) score before thrombolysis, we found that there was a significant difference between the HT and non-HT group (P < 0.05) in the level of mean systolic pressure (MSP) 24 hours after thrombolysis. Multivariate logistic regression analysis indicated that age ≥80 years, MSP ≥140 mm Hg, NIHSS score, and fibrinogen concentration before thrombolysis were risk factors for HT after thrombolysis in patients with acute cerebral infarction. CONCLUSIONS Age, MSP, NIHSS score, and fibrinogen concentration before thrombolysis are risk factors for HT after thrombolysis in acute cerebral infarction. These 4 factors should be carefully taken into account before thrombolysis.
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Affiliation(s)
- Xiahong Xu
- Department of Neurology, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Changsong Li
- Department of Neurology, Shanghai East Hospital, Dalian Medical University, Shanghai, China
| | - Ting Wan
- Department of Neurology, Shanghai East Hospital, Dalian Medical University, Shanghai, China
| | - Xiaobo Gu
- Department of Neurology, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenxia Zhu
- Department of Neurology, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Junjie Hao
- Department of Neurology, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Huan Bao
- Department of Neurology, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lian Zuo
- Department of Neurology, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hui Hu
- Department of Neurology, East Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Gang Li
- Department of Neurology, East Hospital, Tongji University School of Medicine, Shanghai, China.
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28
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Morihara R, Yamashita T, Kono S, Shang J, Nakano Y, Sato K, Hishikawa N, Ohta Y, Heitmeier S, Perzborn E, Abe K. Reduction of intracerebral hemorrhage by rivaroxaban after tPA thrombolysis is associated with downregulation of PAR-1 and PAR-2. J Neurosci Res 2016; 95:1818-1828. [PMID: 28035779 DOI: 10.1002/jnr.24013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 11/18/2016] [Accepted: 12/12/2016] [Indexed: 12/20/2022]
Abstract
This study aimed to assess the risk of intracerebral hemorrhage (ICH) after tissue-type plasminogen activator (tPA) treatment in rivaroxaban compared with warfarin-pretreated male Wistar rat brain after ischemia in relation to activation profiles of protease-activated receptor-1, -2, -3, and -4 (PAR-1, -2, -3, and -4). After pretreatment with warfarin (0.2 mg/kg/day), low-dose rivaroxaban (60 mg/kg/day), high-dose rivaroxaban (120 mg/kg/day), or vehicle for 14 days, transient middle cerebral artery occlusion was induced for 90 min, followed by reperfusion with tPA (10 mg/kg/10 ml). Infarct volume, hemorrhagic volume, immunoglobulin G leakage, and blood parameters were examined. Twenty-four hours after reperfusion, immunohistochemistry for PARs was performed in brain sections. ICH volume was increased in the warfarin-pretreated group compared with the rivaroxaban-treated group. PAR-1, -2, -3, and -4 were widely expressed in the normal brain, and their levels were increased in the ischemic brain, especially in the peri-ischemic lesion. Warfarin pretreatment enhanced the expression of PAR-1 and PAR-2 in the peri-ischemic lesion, whereas rivaroxaban pretreatment did not. The present study shows a lower risk of brain hemorrhage in rivaroxaban-pretreated compared with warfarin-pretreated rats following tPA administration to the ischemic brain. It is suggested that the relative downregulation of PAR-1 and PAR-2 by rivaroxaban compared with warfarin pretreatment might be partly involved in the mechanism of reduced hemorrhagic complications in patients receiving rivaroxaban in clinical trials. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ryuta Morihara
- Departments of Neurology, Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan
| | - Toru Yamashita
- Departments of Neurology, Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan
| | - Syoichiro Kono
- Departments of Neurology, Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan
| | - Jingwei Shang
- Departments of Neurology, Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan
| | - Yumiko Nakano
- Departments of Neurology, Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan
| | - Kota Sato
- Departments of Neurology, Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan
| | - Nozomi Hishikawa
- Departments of Neurology, Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan
| | - Yasuyuki Ohta
- Departments of Neurology, Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan
| | - Stefan Heitmeier
- Bayer Pharma AG, Drug Discovery-Global Therapeutic Research Groups, Cardiovascular Pharmacology, Wuppertal, Germany
| | - Elisabeth Perzborn
- Bayer Pharma AG, Drug Discovery-Global Therapeutic Research Groups, Cardiovascular Pharmacology, Wuppertal, Germany
| | - Koji Abe
- Departments of Neurology, Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan
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29
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Effects of Pretreatment with Warfarin or Rivaroxaban on Neurovascular Unit Dissociation after Tissue Plasminogen Activator Thrombolysis in Ischemic Rat Brain. J Stroke Cerebrovasc Dis 2016; 25:1997-2003. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/20/2016] [Accepted: 04/01/2016] [Indexed: 02/07/2023] Open
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30
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Early introduction of direct oral anticoagulants in cardioembolic stroke patients with non-valvular atrial fibrillation. J Thromb Thrombolysis 2016; 42:393-8. [DOI: 10.1007/s11239-016-1393-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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31
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Seiffge DJ, Hooff RJ, Nolte CH, Béjot Y, Turc G, Ikenberg B, Berge E, Persike M, Dequatre-Ponchelle N, Strbian D, Pfeilschifter W, Zini A, Tveiten A, Næss H, Michel P, Sztajzel R, Luft A, Gensicke H, Traenka C, Hert L, Scheitz JF, De Marchis GM, Bonati LH, Peters N, Charidimou A, Werring DJ, Palm F, Reinhard M, Niesen WD, Nagao T, Pezzini A, Caso V, Nederkoorn PJ, Kägi G, von Hessling A, Padjen V, Cordonnier C, Erdur H, Lyrer PA, Brouns R, Steiner T, Tatlisumak T, Engelter ST. Recanalization Therapies in Acute Ischemic Stroke Patients. Circulation 2015; 132:1261-9. [DOI: 10.1161/circulationaha.115.015484] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 07/23/2015] [Indexed: 12/24/2022]
Abstract
Background—
We explored the safety of intravenous thrombolysis (IVT) or intra-arterial treatment (IAT) in patients with ischemic stroke on non-vitamin K antagonist oral anticoagulants (NOACs, last intake <48 hours) in comparison with patients (1) taking vitamin K antagonists (VKAs) or (2) without previous anticoagulation (no-OAC).
Methods and Results—
This is a multicenter cohort pilot study. Primary outcome measures were (1) occurrence of intracranial hemorrhage (ICH) in 3 categories: any ICH (ICH
any
), symptomatic ICH according to the criteria of the European Cooperative Acute Stroke Study II (ECASS-II) (sICH
ECASS-II
) and the National Institute of Neurological Disorders and Stroke (NINDS) thrombolysis trial (sICH
NINDS
); and (2) death (at 3 months). Cohorts were compared by using propensity score matching. Our NOAC cohort comprised 78 patients treated with IVT/IAT and the comparison groups of 441 VKA patients and 8938 no-OAC patients. The median time from last NOAC intake to IVT/IAT was 13 hours (interquartile range, 8–22 hours). In VKA patients, median pre-IVT/IAT international normalized ratio was 1.3 (interquartile range, 1.1–1.6). ICH
any
was observed in 18.4% NOAC patients versus 26.8% in VKA patients and 17.4% in no-OAC patients. sICH
ECASS-II
and sICH
NINDS
occurred in 2.6%/3.9% NOAC patients, in comparison with 6.5%/9.3% of VKA patients and 5.0%/7.2% of no-OAC patients, respectively. At 3 months, 23.0% of NOAC patients in comparison with 26.9% of VKA patients and 13.9% of no-OAC patients had died. Propensity score matching revealed no statistically significant differences.
Conclusions—
IVT/IAT in selected patients with ischemic stroke under NOAC treatment has a safety profile similar to both IVT/IAT in patients on subtherapeutic VKA treatment or in those without previous anticoagulation. However, further prospective studies are needed, including the impact of specific coagulation tests.
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Affiliation(s)
- David J. Seiffge
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Robbert-JanVan Hooff
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Christian H. Nolte
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Yannick Béjot
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Guillaume Turc
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Benno Ikenberg
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Eivind Berge
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Malte Persike
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Nelly Dequatre-Ponchelle
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Daniel Strbian
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Waltraud Pfeilschifter
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Andrea Zini
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Arnstein Tveiten
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Halvor Næss
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Patrik Michel
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Roman Sztajzel
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Andreas Luft
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Henrik Gensicke
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Christopher Traenka
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Lisa Hert
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Jan F. Scheitz
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Gian Marco De Marchis
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Leo H. Bonati
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Nils Peters
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Andreas Charidimou
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - David J. Werring
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Frederick Palm
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Matthias Reinhard
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Wolf-Dirk Niesen
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Takehiko Nagao
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Alessandro Pezzini
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Valeria Caso
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Paul J. Nederkoorn
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Georg Kägi
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Alexander von Hessling
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Visnja Padjen
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Charlotte Cordonnier
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Hebun Erdur
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Philippe A. Lyrer
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Raf Brouns
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Thorsten Steiner
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Turgut Tatlisumak
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
| | - Stefan T. Engelter
- From Stroke Center and Neurology, University Hospital Basel, Switzerland (D.J.S., H.G., C.T., L.H., G.M.D.M., L.H.B., N.P., P.A.L., S.T.E.); Department of Neurology, Universitair Ziekenhuis Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Belgium (R.-J.V.H., R.B.); Department of Neurology and Center for Stroke Research Charité, Berlin, Germany (C.H.N., J.F.S., H.E.); Department of Neurology, University Hospital, Dijon, France (Y.B.); Department of Neurology, Sainte-Anne
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Akiyama H, Uchino K, Hasegawa Y. Characteristics of Symptomatic Intracranial Hemorrhage in Patients Receiving Non-Vitamin K Antagonist Oral Anticoagulant Therapy. PLoS One 2015; 10:e0132900. [PMID: 26171862 PMCID: PMC4501739 DOI: 10.1371/journal.pone.0132900] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/22/2015] [Indexed: 01/18/2023] Open
Abstract
Objectives The first non-vitamin K antagonist oral anticoagulant (NOAC) introduced to the market in Japan was dabigatran in March 2011, and three more NOACs, rivaroxaban, apixaban, and edoxaban, have since become available. Randomized controlled trials of NOACs have revealed that intracranial hemorrhage (ICH) occurs less frequently with NOACs compared with warfarin. However, the absolute incidence of ICH associated with NOACs has increased with greater use of these anticoagulants, and we wanted to explore the incidence, clinical characteristics, and treatment course of patients with NOACs-associated ICH. Methods We retrospectively analyzed the characteristics of symptomatic ICH patients receiving NOACs between March 2011 and September 2014. Results ICH occurred in 6 patients (5 men, 1 woman; mean ± SD age, 72.8 ± 3.2 years). Mean time to onset was 146.2 ± 111.5 days after starting NOACs. Five patients received rivaroxaban and 1 patient received apixaban. None received dabigatran or edoxaban. Notably, no hematoma expansion was observed within 24 h of onset in the absence of infusion of fresh frozen plasma, activated prothrombin complex concentrate, recombinant activated factor VIIa or hemodialysis. When NOAC therapy was initiated, mean HAS-BLED and PANWARDS scores were 1.5 ± 0.5 and 39.5 ± 7.7, respectively. Mean systolic blood pressure was 137.8 ± 15.9 mmHg within 1 month before spontaneous ICH onset. Conclusion Six symptomatic ICHs occurred early in NOAC therapy but hematoma volume was small and did not expand in the absence of infusion of reversal agents or hemodialysis. The occurrence of ICH during NOAC therapy is possible even when there is acceptable mean systolic blood pressure control (137.8 ± 15.9 mmHg) and HAS-BLED score ≤ 2. Even stricter blood pressure lowering and control within the acceptable range may be advisable to prevent ICH during NOAC therapy.
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Affiliation(s)
- Hisanao Akiyama
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Kenji Uchino
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
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Arbit B, Hsu JC. Non-Vitamin K Antagonist Oral Anticoagulant Use in Patients With Atrial Fibrillation and Associated Intracranial Hemorrhage: A Focused Review. Clin Cardiol 2015; 38:684-91. [PMID: 26173428 DOI: 10.1002/clc.22434] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 06/02/2015] [Accepted: 06/08/2015] [Indexed: 12/24/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and predisposes patients to an increased risk of embolic stroke. After nearly 60 years, warfarin is no longer the only effective therapeutic option for patients with AF. Large randomized trials have consistently shown that non-vitamin K oral anticoagulants (NOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban significantly reduce from the risk of intracranial hemorrhage (ICH) compared with warfarin. We provide a focused review regarding the NOACs and ICH in AF patients by summarizing findings of these large clinical trials, mechanisms of lower ICH, reversal strategies with specific agents, and monitoring strategies.
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Affiliation(s)
- Boris Arbit
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California
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Kim HN, Kim TY, Yoon YH, Koh JY. Pyruvate and cilostazol protect cultured rat cortical pericytes against tissue plasminogen activator (tPA)-induced cell death. Brain Res 2015; 1628:317-326. [PMID: 26111647 DOI: 10.1016/j.brainres.2015.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/19/2015] [Accepted: 06/06/2015] [Indexed: 10/23/2022]
Abstract
Since even a brief ischemia can cause permanent brain damage, rapid restoration of blood flow is critical to limiting damage. Although intravenous tPA during the acute stage is the treatment of choice for achieving reperfusion, this treatment is sometimes associated with brain hemorrhage. Agents that reduce tPA-related bleeding risk may help expand its therapeutic window. This study assessed whether zinc dyshomeostasis underlies the toxic effect of tPA on brain vascular pericytes; whether pyruvate, an inhibitor of zinc toxicity, protects pericytes against tPA-induced cell death; and whether cilostazol, which protects pericytes against tPA-induced cell death, affects zinc dyshomeostasis associated with tPA toxicity. Cultured pericytes from newborn rat brains were treated with 10-200 μg/ml tPA for 24 h, inducing cell death in a concentration-dependent manner. tPA-induced cell death was preceded by increases in intracellular free zinc levels, and was substantially attenuated by plasminogen activator inhibitor-1 (PAI-1) or TPEN. Pyruvate completely blocked direct zinc toxicity and tPA-induced pericyte cell death. Both cAMP and cilostazol, a PDE3 inhibitor that attenuates tPA-induced pericyte cell death in vitro and tPA-induced brain hemorrhage in vivo, reduced zinc- and tPA-induced pericyte cell death, suggesting that zinc dyshomeostasis may be targeted by cilostazol in tPA toxicity. These findings show that tPA-induced pericyte cell death may involve zinc dyshomeostasis, and that pyruvate and cilostazol attenuate tPA-induced cell death by reducing the toxic cascade triggered by zinc dyshomeostasis. Since pyruvate is an endogenous metabolite and cilostazol is an FDA-approved drug, in vivo testing of both as protectors against tPA-induced brain hemorrhage may be warranted. This article is part of a Special Issue entitled SI: Neuroprotection.
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Affiliation(s)
- Ha Na Kim
- Neural Injury Research Lab, University of Ulsan College of Medicine, Seoul 138-736, Republic of Korea
| | - Tae-Youn Kim
- Neural Injury Research Lab, University of Ulsan College of Medicine, Seoul 138-736, Republic of Korea
| | - Young Hee Yoon
- Department of Ophthalmology, University of Ulsan College of Medicine, Seoul 138-736, Republic of Korea
| | - Jae-Young Koh
- Neural Injury Research Lab, University of Ulsan College of Medicine, Seoul 138-736, Republic of Korea; Department of Neurology, University of Ulsan College of Medicine, Seoul 138-736, Republic of Korea.
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36
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Łukasik M, Zawilska K, Undas A. Intracranial bleedings in patients on long-term anticoagulant treatment: Benefits from oral thrombin and factor Xa inhibitors in clinical practice. Neurol Neurochir Pol 2015; 49:171-9. [PMID: 26048605 DOI: 10.1016/j.pjnns.2015.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/17/2015] [Accepted: 04/29/2015] [Indexed: 11/27/2022]
Abstract
Dabigatran, a direct thrombin inhibitor and activated factor X inhibitors, rivaroxaban and apixaban, used in the prevention of stroke or systemic embolism in patients with nonvalvular atrial fibrillation (AF), have several advantages over vitamin K antagonists (VKAs). The non-vitamin K oral anticoagulants (NOACs) have been shown to reduce the risk of intracranial bleedings by 50%. The current review summarizes the available data on the epidemiology, mechanisms and treatment of intracranial bleedings observed on oral anticoagulation with the focus on the specificity of NOACs in this context.
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Affiliation(s)
- Maria Łukasik
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland.
| | | | - Anetta Undas
- Institute of Cardiology, Jagiellonian University School of Medicine and John Paul II Hospital, Krakow, Poland.
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Saji N, Kimura K, Aoki J, Uemura J, Sakamoto Y. Intracranial Hemorrhage Caused by Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) – Multicenter Retrospective Cohort Study in Japan –. Circ J 2015; 79:1018-23. [DOI: 10.1253/circj.cj-14-1209] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Naoki Saji
- Department of Stroke Medicine, Kawasaki Medical School
| | - Kazumi Kimura
- Department of Neurological Science, Nippon Medical School Graduate School of Medicine
| | - Junya Aoki
- Department of Neurological Science, Nippon Medical School Graduate School of Medicine
| | | | - Yuki Sakamoto
- Department of Neurological Science, Nippon Medical School Graduate School of Medicine
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