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Lun R, Sreekrishnan A, Liu HY, Albers GW. Ischemic core volumes and collateral status have diurnal fluctuations - A retrospective cohort study of 18,137 patients. J Stroke Cerebrovasc Dis 2024; 33:107965. [PMID: 39187216 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 08/12/2024] [Accepted: 08/22/2024] [Indexed: 08/28/2024] Open
Abstract
INTRODUCTION Recent observations suggest that circadian rhythms are implicated in the timing of stroke onset and the speed of infarct progression. We aimed to replicate these observations in a large, multi-center, automated imaging database. METHODS The RAPID Insights database was queried from 02/01/2016 to 01/31/2022 for patients with perfusion imaging and automated detection of an ischemic stroke due to a presumed large vessel occlusion. Exclusion criteria included: patient age ≤25, mismatch volume of <0 cc, and failure to register a positive value on either relative cerebral blood flow (rCBF) reduction of 38% less than normal or total mismatch volume. Imaging time was subdivided into three epochs: Night: 23:00h-06:59h and Day: 07:00h-14:59h, and Evening: 15:00h-22:59h. Perfusion parameters were defined using standard conventions for core volume, penumbra, and collateral circulation (measured via the Hypoperfusion Intensity Ratio, HIR). Statistical significance was tested using a sinusoidal regression analysis. RESULTS A total of 18,137 cases were analyzed. The peak incidence of stroke imaging of patients with LVOs occurred around noon. A sinusoidal pattern was present, with larger ischemic core volumes and higher HIR during the night compared to the day: peak ischemic core volume of 23.4 cc occurred with imaging performed at 3:56 AM (p<0.001) and peak HIR of 0.35 at 3:40 AM (p<0.001). CONCLUSION We found that ischemic core volumes were larger and collateral status worse at nighttime compared to daytime in this large national database. These findings support prior data suggesting that poor collateral recruitment with subsequent larger ischemic stroke volumes may occur at night.
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Affiliation(s)
- Ronda Lun
- Department of Neurology, Stanford Hospital, Palo Alto, CA, United States.
| | - Anirudh Sreekrishnan
- Department of Neurology, Stanford Hospital, Palo Alto, CA, United States; Department of Neurology, University of California, San Francisco, United States.
| | - Hung-Yu Liu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Gregory W Albers
- Department of Neurology, Stanford Hospital, Palo Alto, CA, United States.
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Mergenthaler P, Balami JS, Neuhaus AA, Mottahedin A, Albers GW, Rothwell PM, Saver JL, Young ME, Buchan AM. Stroke in the Time of Circadian Medicine. Circ Res 2024; 134:770-790. [PMID: 38484031 DOI: 10.1161/circresaha.124.323508] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/15/2024] [Indexed: 03/19/2024]
Abstract
Time-of-day significantly influences the severity and incidence of stroke. Evidence has emerged not only for circadian governance over stroke risk factors, but also for important determinants of clinical outcome. In this review, we provide a comprehensive overview of the interplay between chronobiology and cerebrovascular disease. We discuss circadian regulation of pathophysiological mechanisms underlying stroke onset or tolerance as well as in vascular dementia. This includes cell death mechanisms, metabolism, mitochondrial function, and inflammation/immunity. Furthermore, we present clinical evidence supporting the link between disrupted circadian rhythms and increased susceptibility to stroke and dementia. We propose that circadian regulation of biochemical and physiological pathways in the brain increase susceptibility to damage after stroke in sleep and attenuate treatment effectiveness during the active phase. This review underscores the importance of considering circadian biology for understanding the pathology and treatment choice for stroke and vascular dementia and speculates that considering a patient's chronotype may be an important factor in developing precision treatment following stroke.
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Affiliation(s)
- Philipp Mergenthaler
- Center for Stroke Research Berlin (P.M., A.M.B.), Charité - Universitätsmedizin Berlin, Germany
- Department of Neurology with Experimental Neurology (P.M.), Charité - Universitätsmedizin Berlin, Germany
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Joyce S Balami
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Ain A Neuhaus
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, United Kingdom (A.A.N.)
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Amin Mottahedin
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Nuffield Department of Clinical Neurosciences (A.M., P.M.R.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Gregory W Albers
- Department of Neurology, Stanford Hospital, Palo Alto, CA (G.W.A.)
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences (A.M., P.M.R.), University of Oxford, United Kingdom
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences (P.M.R.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, Geffen School of Medicine, University of Los Angeles, CA (J.L.S.)
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Martin E Young
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham (M.E.Y.)
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Alastair M Buchan
- Center for Stroke Research Berlin (P.M., A.M.B.), Charité - Universitätsmedizin Berlin, Germany
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
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McCullar KS, Abbaspour S, Wang W, Aguirre AD, Westover MB, Klerman EB. Timing of diuretic administration effects on urine volume in hospitalized patients. Front Physiol 2024; 14:1208324. [PMID: 38321985 PMCID: PMC10844419 DOI: 10.3389/fphys.2023.1208324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 12/27/2023] [Indexed: 02/08/2024] Open
Abstract
Importance: Some medications have effects that depend on the time of day they are given. Current knowledge of the time-of-day effects of specific medications in hospitalized patients with cardiovascular disease is very limited. In hospitalized patients, increased medication efficiency might reduce dose (and associated side effects) and/or the length of time in the Intensive Care Unit (ICU) or hospital-potentially improving patient outcomes and patient and family quality of life and reducing financial costs. We studied whether the time of day or night patients in Cardiac or Intensive Care Units receive a diuretic affects urine volume. Methods: In this observational study, data were collected from 7,685 patients (63% male, 18 to 98 years old) admitted to one hospital's Acute Care Cardiac units, Cardiac ICUs, Cardiac Surgery ICUs, and/or Non-cardiac ICUs who received intravenous furosemide (a diuretic), had measurements of urine volume, were hospitalized for ≥3 days between January 2016 to July 2021 and were older than 18 years. The outcomes of interest were urine volume normalized by the most recent (not older than 24 h) weight or body mass index (BMI), (i) in the hour after the time of diuretic administration, and (ii) when no diuretics were administered for the previous 3 h. Results: We identified diuretic medication administration time 23:00-04:59 as a predictor of higher urine volume response. For patients without recent diuretic medication, higher urine volume was predicted 11:00-16:59 and 17:00-22:59. Other factors that affected urine volume response to the diuretic were sex, age, medication dose, creatinine concentration, diagnoses, and hospital unit. Discussion: Time-of-day of medication administration may be a factor associated with increased medication efficiency. Randomized controlled trials should be conducted to quantify the relative effect of modifiable factors, such as time of medication administration, that may affect short- and longer-term outcomes.
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Affiliation(s)
- Katie S. McCullar
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, United States
| | - Sara Abbaspour
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, United States
| | - Wei Wang
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, United States
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, United States
| | - Aaron D. Aguirre
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - M. Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Elizabeth B. Klerman
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, United States
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, United States
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Burbano VG, Wölfer TA, Vlegels N, Quandt F, Zimmermann H, Wischmann J, Kellert L, Liebig T, Dimitriadis K, Saver JL, Tiedt S. Association of the time of day of EVT with clinical outcomes and benefit from successful recanalization after stroke. Ann Clin Transl Neurol 2023; 10:1917-1923. [PMID: 37607113 PMCID: PMC10578882 DOI: 10.1002/acn3.51877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/04/2023] [Indexed: 08/24/2023] Open
Abstract
Experimental and neuroimaging studies suggest an influence of the time of day on acute infarct growth, but whether this could inform patient selection for acute treatments is uncertain. In a multicenter cohort of 9357 stroke patients undergoing endovascular treatment, morning treatment (05:00-10:59) was associated with lowest 90-day mRS scores (adjusted odds ratio, 1.27 [95% CI, 1.08-1.47]; p = 0.004). The association between successful recanalization and outcome was stronger in morning compared to evening-treated patients (pia = 0.046) with treatment benefit persisting until 24 h for morning-treated compared to 11.5 h for evening-treated patients suggesting that the time of day might inform patient selection for EVT.
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Affiliation(s)
- Vanessa Granja Burbano
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA)MunichGermany
| | - Teresa A. Wölfer
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA)MunichGermany
| | - Naomi Vlegels
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
| | - Fanny Quandt
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Hanna Zimmermann
- Institute of NeuroradiologyLMU University Hospital, LMU MunichMunichGermany
| | | | - Lars Kellert
- Department of NeurologyLMU University Hospital, LMU MunichMunichGermany
| | - Thomas Liebig
- Institute of NeuroradiologyLMU University Hospital, LMU MunichMunichGermany
| | - Konstantinos Dimitriadis
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
- Department of NeurologyLMU University Hospital, LMU MunichMunichGermany
| | - Jeffrey L. Saver
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA)MunichGermany
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA)MunichGermany
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Seners P, Mlynash M, Sreekrishnan A, Ter Schiphorst A, Arquizan C, Costalat V, Henon H, Bretzner M, Heit JJ, Olivot JM, Lansberg MG, Albers GW. Infarct Core Growth During Interhospital Transfer For Thrombectomy Is Faster At Night. Stroke 2023; 54:2167-2171. [PMID: 37376988 PMCID: PMC10527484 DOI: 10.1161/strokeaha.123.043643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Preclinical stroke models have recently reported faster infarct growth (IG) when ischemia was induced during daytime. Considering the inverse rest-activity cycles of rodents and humans, faster IG during the nighttime has been hypothesized in humans. METHODS We retrospectively evaluated acute ischemic stroke patients with a large vessel occlusion transferred from a primary to 1 of 3 French comprehensive stroke center, with magnetic resonance imaging obtained at both centers before thrombectomy. Interhospital IG rate was calculated as the difference in infarct volumes on the 2 diffusion-weighted imaging, divided by the time elapsed between the 2 magnetic resonance imaging. IG rate was compared between patients transferred during daytime (7:00-22:59) and nighttime (23:00-06:59) in multivariable analysis adjusting for occlusion site, National Institutes of Health Stroke Scale score, infarct topography, and collateral status. RESULTS Out of the 329 patients screened, 225 patients were included. Interhospital transfer occurred during nighttime in 31 (14%) patients and daytime in 194 (86%). Median interhospital IG was faster when occurring at night (4.3 mL/h; interquartile range, 1.2-9.5) as compared to the day (1.4 mL/h; interquartile range, 0.4-3.5; P<0.001). In multivariable analysis, nighttime transfer remained independently associated with IG rate (P<0.05). CONCLUSIONS Interhospital IG appeared faster in patients transferred at night. This has potential implications for the design of neuroprotection trials and acute stroke workflow.
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Affiliation(s)
- Pierre Seners
- Stanford Stroke Center, Stanford University, Palo Alto, USA
- Neurology Department, A. de Rothschild Foundation Hospital, Paris, France
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris, Paris
- CIRCA consortium
| | | | | | | | | | - Vincent Costalat
- Neuroradiology Department, CHRU Gui de Chauliac, Montpellier, France
| | - Hilde Henon
- University of Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France
| | | | - Jeremy J. Heit
- Neuroradiology Department, Stanford University, Palo Alto, CA, USA
| | - Jean-Marc Olivot
- Acute Stroke Unit, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse and Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, France
| | | | - Gregory W. Albers
- Stanford Stroke Center, Stanford University, Palo Alto, USA
- CIRCA consortium
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