1
|
Webb AJ, Klerman EB, Mandeville ET. Circadian and Diurnal Regulation of Cerebral Blood Flow. Circ Res 2024; 134:695-710. [PMID: 38484025 PMCID: PMC10942227 DOI: 10.1161/circresaha.123.323049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/30/2024] [Accepted: 02/07/2024] [Indexed: 03/17/2024]
Abstract
Circadian and diurnal variation in cerebral blood flow directly contributes to the diurnal variation in the risk of stroke, either through factors that trigger stroke or due to impaired compensatory mechanisms. Cerebral blood flow results from the integration of systemic hemodynamics, including heart rate, cardiac output, and blood pressure, with cerebrovascular regulatory mechanisms, including cerebrovascular reactivity, autoregulation, and neurovascular coupling. We review the evidence for the circadian and diurnal variation in each of these mechanisms and their integration, from the detailed evidence for mechanisms underlying the nocturnal nadir and morning surge in blood pressure to identifying limited available evidence for circadian and diurnal variation in cerebrovascular compensatory mechanisms. We, thus, identify key systemic hemodynamic factors related to the diurnal variation in the risk of stroke but particularly identify the need for further research focused on cerebrovascular regulatory mechanisms.
Collapse
Affiliation(s)
- Alastair J.S. Webb
- Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom (A.J.S.W.)
| | - Elizabeth B. Klerman
- Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom (A.J.S.W.)
- Department of Neurology, Massachusetts General Hospital, Boston (E.B.K.)
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (E.B.K.)
- Division of Sleep Medicine, Harvard Medical School, Boston, MA (E.B.K.)
| | - Emiri T. Mandeville
- Departments of Radiology and Neurology, Neuroprotection Research Laboratories, Massachusetts General Hospital, Harvard Medical School, Boston (E.T.M.)
| |
Collapse
|
2
|
Gawaz M, Geisler T, Borst O. Current concepts and novel targets for antiplatelet therapy. Nat Rev Cardiol 2023; 20:583-599. [PMID: 37016032 DOI: 10.1038/s41569-023-00854-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/06/2023]
Abstract
Platelets have a crucial role in haemostasis and atherothrombosis. Pharmacological control of platelet hyper-reactivity has become a cornerstone in the prevention of thrombo-ischaemic complications in atherosclerotic diseases. Current antiplatelet therapies substantially improve clinical outcomes in patients with coronary artery disease, but at the cost of increased risk of bleeding. Beyond their role in thrombosis, platelets are known to regulate inflammatory (thrombo-inflammatory) and microcirculatory pathways. Therefore, controlling platelet hyper-reactivity might have implications for both tissue inflammation (myocardial ischaemia) and vascular inflammation (vulnerable plaque formation) to prevent atherosclerosis. In this Review, we summarize the pathophysiological role of platelets in acute myocardial ischaemia, vascular inflammation and atherosclerotic progression. Furthermore, we highlight current clinical concepts of antiplatelet therapy that have contributed to improving patient care and have facilitated more individualized therapy. Finally, we discuss novel therapeutic targets and compounds for antiplatelet therapy that are currently in preclinical development, some of which have a more favourable safety profile than currently approved drugs with regard to bleeding risk. These novel antiplatelet targets might offer new strategies to treat cardiovascular disease.
Collapse
Affiliation(s)
- Meinrad Gawaz
- Department of Cardiology and Angiology, Eberhard Karls University of Tübingen, Tübingen, Germany.
| | - Tobias Geisler
- Department of Cardiology and Angiology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Oliver Borst
- Department of Cardiology and Angiology, Eberhard Karls University of Tübingen, Tübingen, Germany
| |
Collapse
|
3
|
Liu H, Shao T, Yang T, Li D, Wang H, Cheng Y, Zhang T, Zhang J. Comparison of Cilostazol versus Clopidogrel in Addition to Aspirin in Patients with Ischemic Stroke who Underwent Intracranial or Extracranial Artery Stent Implantation. J Atheroscler Thromb 2023; 30:1010-1021. [PMID: 36328566 PMCID: PMC10406684 DOI: 10.5551/jat.63632] [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: 04/18/2022] [Accepted: 09/19/2022] [Indexed: 08/04/2023] Open
Abstract
AIMS The role of cilostazol after intracranial or extracranial artery stent implantation is still unclear. Therefore, we designed this trial to explore the efficacy and safety of cilostazol in this particular population. METHODS In this retrospective study, patients were divided into the cilostazol or clopidogrel group by the antiplatelet therapy received after artery stent implantation. The primary efficacy endpoint was ischemic stroke. Bleeding events and other antiplatelet drug-related adverse reactions (ADRs) were also recorded. Neurological function prognosis was evaluated by the modified Rankin Scale (mRS) after discharge. RESULTS A total of 156 patients were enrolled; 56 underwent intracranial artery stenting, 95 underwent extracranial artery stenting, and 5 underwent intracranial combined with extracranial artery stenting. Any stroke and bleeding events in the hospital of the two groups were comparable (P=0.38, P=0.34, respectively). The incidence of stroke recurrence tended to be lower in the cilostazol group, although not significant (cilostazol vs. clopidogrel, 1.35% vs. 4.88%, P=0.25). There was a significant difference of any bleeding events between the two groups (cilostazol vs. clopidogrel, 5.41% vs. 20.73%, P=0.02). During follow-up, we did not observe an apparent increase of ADRs in the cilostazol group (cilostazol vs. clopidogrel, palpitation 4.05% vs. 2.44%, P=0.58; gastrointestinal discomfort events 8.11% vs. 12.20%, P=0.80). There were no differences between the two groups of neurological function prognosis (P=0.29). CONCLUSIONS Cilostazol-based dual antiplatelet therapy could be recommended as an effective and safe therapy regimen among patients undergoing intracranial or extracranial artery stent implantation.
Collapse
Affiliation(s)
- Hui Liu
- China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
- Department of Pharmacy, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Tengfei Shao
- Department of Pharmacy, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Tao Yang
- Biomedical Informatics Research Lab, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Di Li
- Department of Pharmacy, Wuhan No.1 Hospital, Wuhan, Hubei, China
| | - Huan Wang
- Department of Pharmacy, Wuhan Fourth Hospital,Wuhan,Hubei, China
| | - Yue Cheng
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Tingzheng Zhang
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Jinping Zhang
- China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
- Department of Pharmacy, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| |
Collapse
|
4
|
Cochrane A, Chen C, Stephen J, Rønning OM, Anderson CS, Hankey GJ, Al-Shahi Salman R. Antithrombotic treatment after stroke due to intracerebral haemorrhage. Cochrane Database Syst Rev 2023; 1:CD012144. [PMID: 36700520 PMCID: PMC9878977 DOI: 10.1002/14651858.cd012144.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND This is an update of the Cochrane Review last published in 2017. Survivors of stroke due to intracerebral haemorrhage (ICH) are at risk of major adverse cardiovascular events (MACE). Antithrombotic (antiplatelet or anticoagulant) treatments may lower the risk of ischaemic MACE after ICH, but they may increase the risk of bleeding. OBJECTIVES To determine the overall effectiveness and safety of antithrombotic drugs on MACE and its components for people with ICH. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (5 October 2021). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL: the Cochrane Library 2021, Issue 10), MEDLINE Ovid (from 1948 to October 2021) and Embase Ovid (from 1980 to October 2021). The online registries of clinical trials searched were the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (5 October 2021). We screened the reference lists of included randomised controlled trials (RCTs) for additional, potentially relevant RCTs. SELECTION CRITERIA We selected RCTs in which participants with ICH of any age were allocated to a class of antithrombotic treatment as intervention or comparator. DATA COLLECTION AND ANALYSIS In accordance with standard methodological procedures recommended by Cochrane, two review authors assessed each selected RCT for its risk of bias and extracted data independently. The primary outcome was a composite of MACE, and secondary outcomes included death, individual components of the MACE composite, ICH growth, functional status and cognitive status. We estimated effects using the frequency of outcomes that occurred during the entire duration of follow-up and calculated a risk ratio (RR) for each RCT. We grouped RCTs separately for analysis according to 1) the class(es) of antithrombotic treatment used for the intervention and comparator, and 2) the duration of antithrombotic treatment use (short term versus long term). We pooled the intention-to-treat populations of RCTs using a fixed-effect model for meta-analysis, but used a random-effects model if RCTs differed substantially in their design or there was considerable heterogeneity (I2 ≥ 75%) in their results. We applied GRADE to assess the certainty of the evidence. MAIN RESULTS We identified seven new completed RCTs for this update, resulting in the inclusion of a total of nine RCTs based in secondary care, comprising 1491 participants (average age ranged from 61 to 79 years and the proportion of men ranged from 44% to 67%). The proportion of included RCTs at low risk of bias, by category was: random sequence generation (67%), allocation concealment (67%), performance (22%), detection (78%), attrition (89%), and reporting (78%). For starting versus avoiding short-term prophylactic dose anticoagulation after ICH, no RCT reported MACE. The evidence is very uncertain about the effect of starting short-term prophylactic dose anticoagulation on death (RR 1.00, 95% CI 0.59 to 1.70, P = 1.00; 3 RCTs; very low-certainty evidence), venous thromboembolism (RR 0.84, 95% CI 0.51 to 1.37, P = 0.49; 4 RCTs; very low-certainty evidence), ICH (RR 0.24, 95% CI 0.04 to 1.38, P = 0.11; 2 RCTs; very low-certainty evidence), and independent functional status (RR 2.03, 95% CI 0.78 to 5.25, P = 0.15; 1 RCT; very low-certainty evidence) over 90 days. For starting versus avoiding long-term therapeutic dose oral anticoagulation for atrial fibrillation after ICH, starting long-term therapeutic dose oral anticoagulation probably reduces MACE (RR 0.61, 95% CI 0.40 to 0.94, P = 0.02; 3 RCTs; moderate-certainty evidence) and probably reduces all major occlusive vascular events (RR 0.27, 95% CI 0.14 to 0.53, P = 0.0002; 3 RCTs; moderate-certainty evidence), but probably results in little to no difference in death (RR 1.05, 95% CI 0.62 to 1.78, P = 0.86; 3 RCTs; moderate-certainty evidence), probably increases intracranial haemorrhage (RR 2.43, 95% CI 0.88 to 6.73, P = 0.09; 3 RCTs; moderate-certainty evidence), and may result in little to no difference in independent functional status (RR 0.98, 95% CI 0.78 to 1.24, P = 0.87; 2 RCTs; low-certainty evidence) over one to three years. For starting versus avoiding long-term antiplatelet therapy after ICH, the evidence is uncertain about the effects of starting long-term antiplatelet therapy on MACE (RR 0.89, 95% CI 0.64 to 1.22, P = 0.46; 1 RCT; moderate-certainty evidence), death (RR 1.08, 95% CI 0.76 to 1.53, P = 0.66; 1 RCT; moderate-certainty evidence), all major occlusive vascular events (RR 1.03, 95% CI 0.68 to 1.55, P = 0.90; 1 RCT; moderate-certainty evidence), ICH (RR 0.52, 95% CI 0.27 to 1.03, P = 0.06; 1 RCT; moderate-certainty evidence) and independent functional status (RR 0.95, 95% CI 0.77 to 1.18, P = 0.67; 1 RCT; moderate-certainty evidence) over a median follow-up of two years. For adults within 180 days of non-cardioembolic ischaemic stroke or transient ischaemic attack and a clinical history of prior ICH, there was no evidence of an effect of long-term cilostazol compared to aspirin on MACE (RR 1.33, 95% CI 0.74 to 2.40, P = 0.34; subgroup of 1 RCT; low-certainty evidence), death (RR 1.65, 95% CI 0.55 to 4.91, P = 0.37; subgroup of 1 RCT; low-certainty evidence), or ICH (RR 1.29, 95% CI 0.35 to 4.69, P = 0.70; subgroup of 1 RCT; low-certainty evidence) over a median follow-up of 1.8 years; all major occlusive vascular events and functional status were not reported. AUTHORS' CONCLUSIONS We did not identify beneficial or hazardous effects of short-term prophylactic dose parenteral anticoagulation and long-term oral antiplatelet therapy after ICH on important outcomes. Although there was a significant reduction in MACE and all major occlusive vascular events after long-term treatment with therapeutic dose oral anticoagulation for atrial fibrillation after ICH, the pooled estimates were imprecise, the certainty of evidence was only moderate, and effects on other important outcomes were uncertain. Large RCTs with a low risk of bias are required to resolve the ongoing dilemmas about antithrombotic treatment after ICH.
Collapse
Affiliation(s)
| | - Chen Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, Australia
- The George Institute for Global Health, Beijing, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Ole Morten Rønning
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
- Perron Institute for Neurological and Translational Science, Perth, Australia
| | | |
Collapse
|
5
|
Fang R, Hu H, Zhou Y, Wang S, Mei Z, She R, Peng X, Jiang Q, Wang X, Xie L, Lin H, Meng P, Zhang K, Wang W, Xie Y, Liu L, Tong J, Wu D, Luo Y, Liu C, Lu Y, Yu S, Cheng S, Xu L, Fang Z, Shang H, Ge J. Efficacy and safety of naotaifang capsules for hypertensive cerebral small vessel disease: Study protocol for a multicenter, randomized, double-blind, placebo-controlled clinical trial. Front Pharmacol 2023; 13:967457. [PMID: 36686705 PMCID: PMC9853990 DOI: 10.3389/fphar.2022.967457] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 10/31/2022] [Indexed: 01/07/2023] Open
Abstract
Background: Hypertensive cerebral small vessel disease (HT-CSVD) is a cerebrovascular clinical, imaging and pathological syndrome caused by hypertension (HT). The condition manifests with lesions in various vessels including intracranial small/arterioles, capillaries, and small/venules. Hypertensive cerebral small vessel disease has complex and diverse clinical manifestations. For instance, it can present as an acute stroke which progresses to cause cognitive decline, affective disorder, unstable gait, dysphagia, or abnormal urination. Moreover, hypertensive cerebral small vessel disease causes 25-30% of all cases of ischemic strokes and more than 50% of all cases of single or mixed dementias. The 1-year recurrence rate of stroke in cerebral small vessel disease patients with hypertension is 14%. In the early stage of development, the symptoms of hypertensive cerebral small vessel disease are concealed and often ignored by patients and even clinicians. Patients with an advanced hypertensive cerebral small vessel disease manifest with severe physical and mental dysfunction. Therefore, this condition has a substantial economic burden on affected families and society. Naotaifang (NTF) is potentially effective in improving microcirculation and neurofunction in patients with ischemic stroke. In this regard, this multicenter randomized controlled trial (RCT) aims to furtherly evaluate the efficacy and safety of naotaifang capsules on hypertensive cerebral small vessel disease. Methods: This study is a multicenter, randomized, double-blind, placebo-controlled clinical trial. A total of 388 eligible subjects were recruited from the First Hospital of Hunan University of Chinese Medicine, Hunan Academy of Chinese Medicine Affiliated Hospital, the First Hospital of Shaoyang University, the First Traditional Chinese Medicine Hospital of Changde, and Jiangmen Wuyi Hospital of Traditional Chinese Medicine from July 2020 to April 2022. After a 4-week run-in period, all participants were divided into the intervention group (represented by Y-T, N-T) and control group (represented by Y-C, N-C); using a stratified block randomized method based on the presence or absence of brain damage symptoms in hypertensive cerebral small vessel disease (represented by Y and N). The Y-T and N-T groups were administered different doses of naotaifang capsules, whereas Y-C and N-C groups received placebo treatment. These four groups received the treatments for 6 months. The primary outcome included Fazekas scores and dilated Virchow-robin spaces (dVRS) grades on magnetic resonance imaging (MRI). The secondary outcomes included the number of lacunar infarctions (LI) and cerebral microbleeds (CMB) on magnetic resonance imaging, clinical blood pressure (BP) level, traditional Chinese medicine (TCM) syndrome scores, mini-mental state examination (MMSE) scale, and safety outcomes. Fazekas scores, dilated Virchow-robin spaces grades, and the number of lacunar infarctions and cerebral microbleeds on magnetic resonance imaging were tested before enrollment and after 6 months of treatment. The clinical blood pressure level, traditional Chinese medicine syndrome scores, mini-mental state examination scale and safety outcomes were tested before enrollment, after 3-month, 6-month treatment and 12th-month follow-up respectively. Conclusion: The protocol will comfirm whether naotaifang capsules reduce Fazekas scores, dilated Virchow-robin spaces grades, and the number of lacunar infarctions and cerebral microbleeds, clinical blood pressure, increase mini-mental state examination scores, traditional Chinese medicine syndrome scores of Qi deficiency and blood stasis (QDBS), and improve the quality of life of subjects. The consolidated evidence from this study will shed light on the benefits of Chinese herbs for hypertensive cerebral small vessel disease, such as nourishing qi, promoting blood circulation and removing blood stasis, and dredging collaterals. However, additional clinical trials with large samples and long intervention periods will be required for in-depth research. Clinical Trial registration: www.chictr.org.cn, identifier ChiCTR1900024524.
Collapse
Affiliation(s)
- Rui Fang
- School of Integrated Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China,Institute of Clinical Pharmacology of Chinese Materia Medica, Hunan Academy of Chinese Medicine, Changsha, Hunan, China
| | - Hua Hu
- Neurology Department, The First Hospital of Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Yue Zhou
- School of Integrated Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Shanshan Wang
- School of Integrated Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Zhigang Mei
- School of Integrated Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Ruining She
- School of Integrated Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Xiwen Peng
- School of Integrated Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Qiling Jiang
- School of Food and Chemical Engineering, Shaoyang University, Shaoyang, Hunan, China
| | - Xiangyuan Wang
- School of Integrated Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Le Xie
- Neurology Department, Hunan Academy of Chinese Medicine Affiliated Hospital (Hunan Provincial Hospital of Integrated Chinese and Western Medicine), Changsha, Hunan, China
| | - Hongyuan Lin
- School of Integrated Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Pan Meng
- School of Integrated Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Kun Zhang
- Radiology Department, The First Hospital of Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Wei Wang
- Health Management Department, The First Hospital of Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Yao Xie
- Neurology Department, Hunan Academy of Chinese Medicine Affiliated Hospital (Hunan Provincial Hospital of Integrated Chinese and Western Medicine), Changsha, Hunan, China
| | - Litao Liu
- School of Food and Chemical Engineering, Shaoyang University, Shaoyang, Hunan, China,Scientific Research Department, The First Affiliated Hospital of Shaoyang University, Shaoyang, Hunan, China
| | - Jiao Tong
- Neurology Department,The First Traditional Chinese Medicine Hospital of Changde (Changde Hospital Affiliated to Hunan University of Chinese Medicine), Changde, Hunan, China
| | - Dahua Wu
- Neurology Department, Hunan Academy of Chinese Medicine Affiliated Hospital (Hunan Provincial Hospital of Integrated Chinese and Western Medicine), Changsha, Hunan, China
| | - Yunhua Luo
- Health Management Department, Hunan Academy of Chinese Medicine Affiliated Hospital (Hunan Provincial Hospital of Integrated Chinese and Western Medicine), Changsha, Hunan, China
| | - Chang Liu
- Neurology Department,The First Traditional Chinese Medicine Hospital of Changde (Changde Hospital Affiliated to Hunan University of Chinese Medicine), Changde, Hunan, China
| | - Yifang Lu
- Health Management Department, The First Affiliated Hospital of Shaoyang University, Shaoyang, Hunan, China
| | - Shangzhen Yu
- Neurology Department, Jiangmen Wuyi Hospital of Traditional Chinese Medicine (Jiangmen Hospital of Traditional Chinese Medicine Affiliated to Jinan University), Jiangmen, Guangdong, China
| | - Shaowu Cheng
- School of Integrated Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Linyong Xu
- School of Life Sciences, Central South University, Changsha, Hunan, China
| | - Zhuyuan Fang
- Jiangsu Province Innovation Center of TCM Hypertension Clinical Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Najing, Jiangsu, China,*Correspondence: Zhuyuan Fang, ; Hongcai Shang, ; Jinwen Ge,
| | - Hongcai Shang
- School of Integrated Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China,Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China,*Correspondence: Zhuyuan Fang, ; Hongcai Shang, ; Jinwen Ge,
| | - Jinwen Ge
- School of Integrated Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China,Institute of Clinical Pharmacology of Chinese Materia Medica, Hunan Academy of Chinese Medicine, Changsha, Hunan, China,*Correspondence: Zhuyuan Fang, ; Hongcai Shang, ; Jinwen Ge,
| |
Collapse
|
6
|
Novel approaches to antiplatelet therapy. Biochem Pharmacol 2022; 206:115297. [DOI: 10.1016/j.bcp.2022.115297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/05/2022] [Accepted: 10/05/2022] [Indexed: 11/20/2022]
|
7
|
Su C, Yang X, Wei S, Zhao R. Association of Cerebral Small Vessel Disease With Gait and Balance Disorders. Front Aging Neurosci 2022; 14:834496. [PMID: 35875801 PMCID: PMC9305071 DOI: 10.3389/fnagi.2022.834496] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/14/2022] [Indexed: 12/27/2022] Open
Abstract
Cerebral small vessel disease (CSVD) is a common cerebrovascular disease and an important cause of gait and balance disorders. Gait and balance disorders can further lead to an increased risk of falls and a decreased quality of life. CSVD can damage gait and balance function by affecting cognitive function or directly disrupting motor pathways, and different CSVD imaging features have different characteristics of gait and balance impairment. In this article, the correlation between different imaging features of sporadic CSVD and gait and balance disorders has been reviewed as follows, which can provide beneficial help for standardized management of CSVD.
Collapse
Affiliation(s)
| | | | | | - Renliang Zhao
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| |
Collapse
|
8
|
Abstract
Despite advances in acute management and prevention of cerebrovascular disease, stroke and vascular cognitive impairment together remain the world's leading cause of death and neurological disability. Hypertension and its consequences are associated with over 50% of ischemic and 70% of hemorrhagic strokes but despite good control of blood pressure (BP), there remains a 10% risk of recurrent cerebrovascular events, and there is no proven strategy to prevent vascular cognitive impairment. Hypertension evolves over the lifespan, from predominant sympathetically driven hypertension with elevated mean BP in early and mid-life to a late-life phenotype of increasing systolic and falling diastolic pressures, associated with increased arterial stiffness and aortic pulsatility. This pattern may partially explain both the increasing incidence of stroke in younger adults as well as late-onset, chronic cerebrovascular injury associated with concurrent systolic hypertension and historic mid-life diastolic hypertension. With increasing arterial stiffness and autonomic dysfunction, BP variability increases, independently predicting the risk of ischemic and intracerebral hemorrhage, and is potentially modifiable beyond control of mean BP. However, the interaction between hypertension and control of cerebral blood flow remains poorly understood. Cerebral small vessel disease is associated with increased pulsatility in large cerebral vessels and reduced reactivity to carbon dioxide, both of which are being targeted in early phase clinical trials. Cerebral arterial pulsatility is mainly dependent upon increased transmission of aortic pulsatility via stiff vessels to the brain, while cerebrovascular reactivity reflects endothelial dysfunction. In contrast, although cerebral autoregulation is critical to adapt cerebral tone to BP fluctuations to maintain cerebral blood flow, its role as a modifiable risk factor for cerebrovascular disease is uncertain. New insights into hypertension-associated cerebrovascular pathophysiology may provide key targets to prevent chronic cerebrovascular disease, acute events, and vascular cognitive impairment.
Collapse
Affiliation(s)
- Alastair J S Webb
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom (A.J.S.W.)
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom (D.J.W.)
| |
Collapse
|
9
|
Hong S, Lee WJ, Park CY. Comparative Study of Ex Vivo Antiplatelet Activity of Aspirin and Cilostazol in Patients with Diabetes and High Risk of Cardiovascular Disease. Endocrinol Metab (Seoul) 2022; 37:233-242. [PMID: 35381686 PMCID: PMC9081299 DOI: 10.3803/enm.2021.1353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/11/2022] [Accepted: 02/07/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The role of aspirin in primary cardiovascular disease prevention in patients with diabetes remains controversial. However, some studies have suggested beneficial effects of cilostazol on cardiovascular disease in patients with diabetes. We prospectively investigated the antiplatelet effects of cilostazol compared with aspirin in patients with diabetes and cardiovascular risk factors. METHODS We randomly assigned 116 patients with type 2 diabetes and cardiovascular risk factors but no evident cardiovascular disease to receive aspirin at a dose of 100 mg or cilostazol at a dose of 200 mg daily for 14 days. The primary efficacy outcome was antiplatelet effects of aspirin and cilostazol assessed with the VerifyNow system (aspirin response units [ARU]) and PFA-100 (closure time [CT]). Secondary outcomes were changes of clinical laboratory data (ClinicalTrials.gov Identifier: NCT02933788). RESULTS After 14 days, there was greater decrease in ARU in aspirin (-28.9%±9.9%) compared cilostazol (-0.4%±7.1%, P<0.001) and was greater increase in CT in aspirin (99.6%±63.5%) compared cilostazol (25.7%±54.1%, P<0.001). The prevalence of aspirin resistance was 7.5% according to VerifyNow (defined by ARU ≥550) and 18.9% according to PFA-100 (CT <192 seconds). Compared with aspirin, cilostazol treatment was associated with increased high density lipoprotein cholesterol (7.1%±12.7% vs. 4.2%±18.0%, P=0.006) and decreased triglycerides (-9.4%±33.7% vs. 4.4%±17.57%, P=0.016). However, there were no significant changes in total and low density lipoprotein cholesterol, C-reactive protein level, and cluster of differentiation 40 ligand between cilostazol and aspirin groups. CONCLUSION Aspirin showed better antiplatelet effects assessed with VerifyNow and PFA-100 compared with cilostazol. However, there were favorable changes in atherogenic dyslipidemia only in the cilostazol.
Collapse
Affiliation(s)
- Sangmo Hong
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Woo Je Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Cheol-Young Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
10
|
Kamarova M, Baig S, Patel H, Monks K, Wasay M, Ali A, Redgrave J, Majid A, Bell SM. Antiplatelet Use in Ischemic Stroke. Ann Pharmacother 2022; 56:1159-1173. [PMID: 35094598 PMCID: PMC9393649 DOI: 10.1177/10600280211073009] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: A literature review of antiplatelet agents for primary and secondary stroke
prevention, including mechanism of action, cost, and reasons for lack of
benefit. Data sources: Articles were gathered from MEDLINE, Cochrane Reviews, and PubMed databases
(1980-2021). Abstracts from scientific meetings were considered. Search
terms included ischemic stroke, aspirin, clopidogrel, dipyridamole,
ticagrelor, cilostazol, prasugrel, glycoprotein IIb/IIIa inhibitors. Study selection and data extraction: English-language original and review articles were evaluated. Guidelines from
multiple countries were reviewed. Articles were evaluated independently by 2
authors. Data synthesis: An abundance of evidence supports aspirin and clopidogrel use for secondary
stroke prevention. In the acute phase (first 21 days postinitial stroke),
these medications have higher efficacy for preventing further stroke when
combined, but long-term combination therapy is associated with higher
hemorrhage rates. Antiplatelet treatment failure is influenced by poor
adherence and genetic polymorphisms. Antiplatelet agents such as cilostazol
may provide extra benefit over clopidogrel and aspirin, in certain racial
groups, but further research in more diverse ethnic populations is
needed. Relevance to patient care and clinical practice: This review presents the data available on the use of different antiplatelet
agents poststroke. Dual therapy, recurrence after initiation of secondary
preventative therapy, and areas for future research are discussed. Conclusions: Although good evidence exists for the use of certain antiplatelet agents
postischemic stroke, there are considerable opportunities for future
research to investigate personalized therapies. These include screening
patients for platelet polymorphisms that confer antiplatelet resistance and
for randomized trials including more racially diverse populations.
Collapse
Affiliation(s)
- Marharyta Kamarova
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
| | - Sheharyar Baig
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
- Sheffield Institute for Translational
Neuroscience (SITraN), The University of Sheffield, Sheffield, UK
| | - Hamish Patel
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
| | - Kimberley Monks
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
| | - Mohammed Wasay
- Department of Neurology, The Aga Khan
University, Karachi, Pakistan
| | - Ali Ali
- Department of Medicine for the Elderly,
Royal Hallamshire Hospital, Sheffield, UK
| | - Jessica Redgrave
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
| | - Arshad Majid
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
- Sheffield Institute for Translational
Neuroscience (SITraN), The University of Sheffield, Sheffield, UK
| | - Simon M. Bell
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
- Sheffield Institute for Translational
Neuroscience (SITraN), The University of Sheffield, Sheffield, UK
- Simon M. Bell, NIHR Clinical Lecturer in
Neurology, Sheffield Institute for Translational Neuroscience (SITraN), The
University of Sheffield, 385a Glossop Road, Sheffield S10 2HQ, UK.
| |
Collapse
|
11
|
Wang HL, Zhang CL, Qiu YM, Chen AQ, Li YN, Hu B. Dysfunction of the Blood-brain Barrier in Cerebral Microbleeds: from Bedside to Bench. Aging Dis 2021; 12:1898-1919. [PMID: 34881076 PMCID: PMC8612614 DOI: 10.14336/ad.2021.0514] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/14/2021] [Indexed: 02/06/2023] Open
Abstract
Cerebral microbleeds (CMBs) are a disorder of cerebral microvessels that are characterized as small (<10 mm), hypointense, round or ovoid lesions seen on T2*-weighted gradient echo MRI. There is a high prevalence of CMBs in community-dwelling healthy older people. An increasing number of studies have demonstrated the significance of CMBs in stroke, dementia, Parkinson's disease, gait disturbances and late-life depression. Blood-brain barrier (BBB) dysfunction is considered to be the event that initializes CMBs development. However, the pathogenesis of CMBs has not yet been clearly elucidated. In this review, we introduce the pathogenesis of CMBs, hypertensive vasculopathy and cerebral amyloid angiopathy, and review recent research that has advanced our understanding of the mechanisms underlying BBB dysfunction and CMBs presence. CMBs-associated risk factors can exacerbate BBB breakdown through the vulnerability of BBB anatomical and functional changes. Finally, we discuss potential pharmacological approaches to target the BBB as therapy for CMBs.
Collapse
Affiliation(s)
| | | | | | - An-qi Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ya-nan Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| |
Collapse
|
12
|
Effect of Holistic Nursing Intervention Combined with Humanized Nursing Intervention on Activities of Daily Living and Limb Movement Ability of Elderly Patients with Cerebral Hemorrhage after Surgery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:2480551. [PMID: 34721623 PMCID: PMC8556103 DOI: 10.1155/2021/2480551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/03/2021] [Accepted: 10/05/2021] [Indexed: 11/25/2022]
Abstract
Background To improve the nursing status, activities of daily living (ADL), and limb movement ability of elderly patients with cerebral hemorrhage and to actively explore the comprehensive nursing mode that can meet the rehabilitation needs of patients. Methods 128 elderly patients with cerebral hemorrhage admitted to our department (2019.01–2021.01) were included in the study and randomly divided into the reference group and the study group according to the numeration table, with 64 cases in each group. The reference group received routine nursing, while the study group received holistic nursing combined with humanized nursing. Statistical methods were used to analyze the nursing effect of the two intervention models. Results With better scores of the upper limb muscle strength, lower limb muscle strength, and total Fugl-Meyer Assessment (FMA) in both groups after nursing, the scores in the study group after nursing were higher than those in the reference group (P < 0.05). After nursing, the ADL scores of both groups were significantly improved and the score in the study group was better than that in the reference group (P < 0.05). After nursing, the degree of neurological deficit in both groups was significantly better than that before nursing and the degree in the reference group was more serious than that in the study group (P < 0.05). Compared with the reference group, the total infection rate in the study group was lower, while the nursing satisfaction was higher, with statistical significance (P < 0.05). Conclusion The holistic nursing combined with humanized nursing has a remarkable effect on the postoperative intervention of elderly patients with cerebral hemorrhage. It can improve the limb movement function, enhance the ADL, reduce the degree of neurological deficit, improve the quality of life, and enhance the nursing satisfaction of patients after intervention, which is worthy of clinical popularization.
Collapse
|
13
|
Manolis AA, Manolis TA, Melita H, Mikhailidis DP, Manolis AS. Update on Cilostazol: A Critical Review of Its Antithrombotic and Cardiovascular Actions and Its Clinical Applications. J Clin Pharmacol 2021; 62:320-358. [PMID: 34671983 DOI: 10.1002/jcph.1988] [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: 08/31/2021] [Accepted: 10/17/2021] [Indexed: 12/17/2022]
Abstract
Cilostazol, a phosphodiesterase III inhibitor, has vasodilating and antiplatelet properties with a low rate of bleeding complications. It has been used over the past 25 years for improving intermittent claudication in patients with peripheral artery disease (PAD). Cilostazol also has demonstrated efficacy in patients undergoing percutaneous revascularization procedures for both PAD and coronary artery disease. In addition to its antithrombotic and vasodilating actions, cilostazol also inhibits vascular smooth muscle cell proliferation via phosphodiesterase III inhibition, thus mitigating restenosis. Accumulated evidence has shown that cilostazol, due to its "pleiotropic" effects, is a useful, albeit underutilized, agent for both coronary artery disease and PAD. It is also potentially useful after ischemic stroke and is an alternative in those who are allergic or intolerant to classical antithrombotic agents (eg, aspirin or clopidogrel). These issues are herein reviewed together with the pharmacology and pharmacodynamics of cilostazol. Large studies and meta-analyses are presented and evaluated. Current guidelines are also discussed, and the spectrum of cilostazol's actions and therapeutic applications are illustrated.
Collapse
Affiliation(s)
| | | | | | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | |
Collapse
|
14
|
Kitakami K, Kubo Y, Yabuki M, Oomori D, Takahashi T, Igarashi S, Fujiwara S, Yoshida K, Kobayashi M, Terasaki K, Ogasawara K. Five-Year Outcomes of Medical Management Alone for Adult Patients with Ischemic Moyamoya Disease without Cerebral Misery Perfusion. Cerebrovasc Dis 2021; 51:158-164. [PMID: 34518462 DOI: 10.1159/000518725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 07/23/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION No clear guidelines for treating adult patients with ischemic moyamoya disease (MMD) without cerebral hemodynamic compromise such as misery perfusion have been established. Our previous prospective cohort study of adult patients with MMD without misery perfusion who were treated with medical management alone, including an antiplatelet drug, showed a recurrent ischemic event rate of 3% per 2 years. The present prospective study aimed to elucidate the 5-year clinical, cerebral perfusion, and cognitive outcomes of medical management alone for Japanese adult patients with ischemic MMD without cerebral misery perfusion by following the same patients for another 3 years. METHODS In total, 68 patients without recurrent events at a 2-year follow-up were prospectively followed up for another 3 years. Cerebral blood flow (CBF) in the symptomatic cerebral hemisphere was measured using brain perfusion single-photon emission computed tomography at inclusion and at the end of the subsequent 3-year follow-up. Neuropsychological testing was performed at inclusion and at the end of the initial 2- and subsequent 3-year follow-ups. RESULTS During the subsequent 3-year follow-up, 2 patients (3%) developed further ischemic events. In patients without further ischemic events, CBF was significantly greater at the end of the subsequent 3-year follow-up than at inclusion (p = 0.0037), and all neuropsychological test scores improved or remained unchanged at the end of initial 2- and subsequent 3-year follow-ups compared with that at inclusion. CONCLUSION In adult patients receiving medical management alone for ischemic MMD without cerebral misery perfusion, the incidence of further ischemic events was 6% per 5 years and did not change between the initial 2 years after the last is-chemic event and the subsequent 3 years. In patients without further ischemic events, CBF and cognitive function had not deteriorated at 5 years after the last ischemic event.
Collapse
Affiliation(s)
- Kei Kitakami
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Yoshitaka Kubo
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Masahiro Yabuki
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Daisuke Oomori
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Tatsuhiko Takahashi
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Suguru Igarashi
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Shunrou Fujiwara
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Kenji Yoshida
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Masakazu Kobayashi
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Kazunori Terasaki
- Institute for Biomedical Sciences, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| |
Collapse
|
15
|
Wardlaw JM, Debette S, Jokinen H, De Leeuw FE, Pantoni L, Chabriat H, Staals J, Doubal F, Rudilosso S, Eppinger S, Schilling S, Ornello R, Enzinger C, Cordonnier C, Taylor-Rowan M, Lindgren AG. ESO Guideline on covert cerebral small vessel disease. Eur Stroke J 2021; 6:CXI-CLXII. [PMID: 34414301 PMCID: PMC8370079 DOI: 10.1177/23969873211012132] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/02/2021] [Indexed: 12/11/2022] Open
Abstract
'Covert' cerebral small vessel disease (ccSVD) is common on neuroimaging in persons without overt neurological manifestations, and increases the risk of future stroke, cognitive impairment, dependency, and death. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist with clinical decisions about management of ccSVD, specifically white matter hyperintensities and lacunes, to prevent adverse clinical outcomes. The guidelines were developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We prioritised the clinical outcomes of stroke, cognitive decline or dementia, dependency, death, mobility and mood disorders, and interventions of blood pressure lowering, antiplatelet drugs, lipid lowering, lifestyle modifications, glucose lowering and conventional treatments for dementia. We systematically reviewed the literature, assessed the evidence, formulated evidence-based recommendations where feasible, and expert consensus statements. We found little direct evidence, mostly of low quality. We recommend patients with ccSVD and hypertension to have their blood pressure well controlled; lower blood pressure targets may reduce ccSVD progression. We do not recommend antiplatelet drugs such as aspirin in ccSVD. We found little evidence on lipid lowering in ccSVD. Smoking cessation is a health priority. We recommend regular exercise which may benefit cognition, and a healthy diet, good sleep habits, avoiding obesity and stress for general health reasons. In ccSVD, we found no evidence for glucose control in the absence of diabetes or for conventional Alzheimer dementia treatments. Randomised controlled trials with clinical endpoints are a priority for ccSVD.
Collapse
Affiliation(s)
- Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Stephanie Debette
- Bordeaux Population Health Center, University of Bordeaux, INSERM, UM1219, Team VINTAGE
- Department of Neurology, Institute for Neurodegenerative Disease, Bordeaux University Hospital, Bordeaux, France
| | - Hanna Jokinen
- HUS Neurocenter, Division of Neuropsychology, Helsinki University Hospital, University of Helsinki and Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Finland
| | - Frank-Erik De Leeuw
- Radboud University Medical Center, Department of Neurology; Donders Center for Medical Neuroscience, Nijmegen, The Netherlands
| | - Leonardo Pantoni
- Stroke and Dementia Lab, 'Luigi Sacco' Department of Biomedical and Clinical Sciences, University of Milan, Milano, Italy
| | - Hugues Chabriat
- Department of Neurology, Hopital Lariboisiere, APHP, INSERM U 1161, FHU NeuroVasc, University of Paris, Paris, France
| | - Julie Staals
- Department of Neurology, School for Cardiovascular Diseases (CARIM), Maastricht UMC+, AZ Maastricht, the Netherlands
| | - Fergus Doubal
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
- Dept of Medicine for the Elderly, University of Edinburgh, Edinburgh, UK
| | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic, Barcelona, Spain
| | - Sebastian Eppinger
- University Clinic of Neurology, Medical University of Graz, Graz, Austria
| | - Sabrina Schilling
- Bordeaux Population Health Center, University of Bordeaux, INSERM, UM1219, Team VINTAGE
| | - Raffaele Ornello
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Christian Enzinger
- University Clinic of Neurology, Medical University of Graz, Graz, Austria
| | - Charlotte Cordonnier
- Univ. Lille, INSERM, CHU Lille, U1172, LilNCog – Lille Neuroscience & Cognition, Lille, France
| | - Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Arne G Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University; Section of Neurology, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
16
|
Kherallah RY, Khawaja M, Olson M, Angiolillo D, Birnbaum Y. Cilostazol: a Review of Basic Mechanisms and Clinical Uses. Cardiovasc Drugs Ther 2021; 36:777-792. [PMID: 33860901 DOI: 10.1007/s10557-021-07187-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2021] [Indexed: 12/24/2022]
Abstract
Primarily used in the treatment of intermittent claudication, cilostazol is a 2-oxyquinolone derivative that works through the inhibition of phosphodiesterase III and related increases in cyclic adenosine monophosphate (cAMP) levels. However, cilostazol has been implicated in a number of other basic pathways including the inhibition of adenosine reuptake, the inhibition of multidrug resistance protein 4, among others. It has been observed to exhibit antiplatelet, antiproliferative, vasodilatory, and ischemic-reperfusion protective properties. As such, cilostazol has been investigated for clinical use in a variety of settings including intermittent claudication, as an adjunctive for reduction of restenosis after coronary and peripheral endovascular interventions, and in the prevention of secondary stroke, although its widespread implementation for indications other than intermittent claudication has been limited by relatively modest effect sizes and lack of studies in western populations. In this review, we highlight the pleiotropic effects of cilostazol and the evidence for its clinical use.
Collapse
Affiliation(s)
- Riyad Y Kherallah
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Muzamil Khawaja
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Michael Olson
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Dominick Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Yochai Birnbaum
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX, USA.
| |
Collapse
|
17
|
Chou PS, Sung PS, Liu CH, Sung YF, Tzeng RC, Yang CP, Lien CH, Po HL, Ho SC, Tsai YT, Chen TS, Wu SL, Hu HH, Chao AC. Prevalence and Effect of Cerebral Small Vessel Disease in Stroke Patients With Aspirin Treatment Failure-A Hospital-Based Stroke Secondary Prevention Registry. Front Neurol 2021; 12:645444. [PMID: 33927682 PMCID: PMC8076747 DOI: 10.3389/fneur.2021.645444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/18/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Breakthrough strokes during treatment with aspirin, termed clinical aspirin treatment failure (ATF), is common in clinical practice. The burden of cerebral small vessel disease (SVD) is associated with an increased recurrent ischemic stroke risk. However, the association between SVD and ATF remains unclear. This study investigated the prevalence and clinical characteristics of SVD in stroke patients with ATF. Methods: Data from a prospective, and multicenter stroke with ATF registry established in 2018 in Taiwan were used, and 300 patients who developed ischemic stroke concurrent with regular use of aspirin were enrolled. White matter lesions (WMLs) and cerebral microbleeds (CMBs) were identified using the Fazekas scale and Microbleed Anatomical Rating Scale, respectively. Demographic data, cardiovascular comorbidities, and index stroke characteristics of patients with different WML and CMB severities were compared. Logistic regression analyses were performed to explore the factors independently associated with outcomes after ATF. Results: The mean patient age was 69.5 ± 11.8 years, and 70.0% of patients were men. Among all patients, periventricular WML (PVWML), deep WML (DWML), and CMB prevalence was 93.3, 90.0, and 52.5%, respectively. Furthermore, 46.0% of the index strokes were small vessel occlusions. Severe PVWMLs and DWMLs were significantly associated with high CMB burdens. Patients with moderate-to-severe PVWMLs and DWMLs were significantly older and had higher cardiovascular comorbidity prevalence than did patients with no or mild WMLs. Moreover, patients with favorable outcomes exhibited significantly low prevalence of severe PVWMLs (p = 0.001) and DWMLs (p = 0.001). After logistic regression was applied, severe WMLs predicted less favorable outcomes independently, compared with those with no to moderate PVWMLs and DWMLs [odds ratio (OR), 0.47; 95% confidence interval (CI), 0.25–0.87 for severe PVWMLs; OR, 0.40; 95% CI, 0.21–0.79 for severe DWMLs]. Conclusions: SVD is common in stroke patients with ATF. PVWMLs and DWMLs are independently associated with functional outcomes in stroke patients with ATF. The burden of SVD should be considered in future antiplatelet strategies for stroke patients after ATF.
Collapse
Affiliation(s)
- Ping-Song Chou
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Hung Liu
- Department of Neurology, Stroke Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yueh-Feng Sung
- Department of Neurology, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Ray-Chang Tzeng
- Department of Neurology, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan
| | - Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan.,Department of Nutrition, Huang-Kuang University, Taichung, Taiwan
| | - Chi-Hsun Lien
- Department of Neurology, Tungs' Taichung Metro Harbor Hospital, Taichung, Taiwan
| | - Helen L Po
- Department of Neurology, Stroke Center, MacKay Memorial Hospital, Taipei, Taiwan
| | - Shang-Chang Ho
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan
| | - Yi-Te Tsai
- Department of Neurology, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
| | - Tsang-Shan Chen
- Department of Neurology, Sin-Lau Hospital, The Presbyterian Church of Taiwan, Tainan, Taiwan
| | - Shey-Lin Wu
- Department of Neurology of Changhua Christian Hospital, Changhua, Taiwan
| | - Han-Hwa Hu
- Department of Neurology, Taipei Medical University-Shaung Ho Hospital, Taipei, Taiwan.,Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - A-Ching Chao
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| |
Collapse
|
18
|
Lin MP, Meschia JF, Gopal N, Barrett KM, Ross OA, Ertekin-Taner N, Brott TG. Cilostazol Versus Aspirin for Secondary Stroke Prevention: Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2021; 30:105581. [PMID: 33388632 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105581] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/06/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Cilostazol has promise as an alternative to aspirin for secondary stroke prevention given its vasodilatory and anti-inflammatory properties in addition to platelet aggregation inhibition. We aimed to conduct a systematic review and meta-analysis to estimate the efficacy and safety of cilostazol compared to aspirin for stroke prevention in patients with previous stroke or transient ischemic attack (TIA). MATERIALS AND METHODS We searched PubMed and the Cochrane Central Register of Controlled Trials from 1996 to 2019. Randomized clinical trials that compared cilostazol to aspirin and reported the endpoints of ischemic stroke, intracranial hemorrhage and any bleeding were included. A random-effects estimate was computed based on the Mantel-Haenszel method. The pooled risk estimates with 95% confidence intervals were compared between cilostazol and aspirin. RESULTS The search identified 5 randomized clinical trials comparing cilostazol vs. aspirin for secondary stroke prevention that collectively enrolled 7240 patients, all from Asian countries (3615 received cilostazol and 3625 received aspirin). Pooled results from the random-effects model showed that cilostazol was associated with significantly lower risk of recurrent ischemic stroke (RR 0.68; 95% CI, 0.54 to 0.87), intracranial hemorrhage (RR 0.42; 95% CI, 0.27 to 0.65) and any bleeding (RR 0.71; 95% CI, 0.55 to 0.91). CONCLUSIONS This meta-analysis suggests that cilostazol is more effective than aspirin in preventing recurrent ischemic stroke with lower risk of intracranial hemorrhage and other bleeding. Since all trials to date are from Asian countries, confirmatory trials of cilostazol for secondary stroke prevention in other populations are needed.
Collapse
Affiliation(s)
- Michelle P Lin
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States.
| | - James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| | - Neethu Gopal
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| | - Kevin M Barrett
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| | - Owen A Ross
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, United States
| | - Nilüfer Ertekin-Taner
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States; Department of Neuroscience, Mayo Clinic, Jacksonville, FL, United States
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| |
Collapse
|
19
|
Guo X, Xue Q, Zhao J, Yang Y, Yu Y, Liu D, Liu J, Yang W, Mu L, Zhang P, Wang T, Han H, Liu S, Zhu Y, Wang T, Qu C, Qu C. Clinical diagnostic and therapeutic guidelines of stroke neurorestoration (2020 China version). JOURNAL OF NEURORESTORATOLOGY 2020. [DOI: 10.26599/jnr.2020.9040026] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Stroke is the main cause of death and disability among Chinese, and neurorestoration is an effective therapeutic strategy for patients with stroke. In recent years, many achievements have been made in stroke neurorestoration, but viewpoints for managing stroke vary per discipline. In order to promote standardization of diagnosis and treatment for stroke neurorestoration, the Chinese Association of Neurorestoratology (CANR; Preparatory) and China Committee of International Association of Neurorestoratology (IANR-China Committee) organized professional experts in the field to integrate fragmented neurorestorative methods and establish clinical diagnostic and therapeutic guidelines for stroke neurorestoration. This guideline includes the diagnosis and staging of stroke and therapeutic recommendations for neurorestoration at different stages of stroke in order to improve survival and quality of life of stroke patients.
Collapse
|