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Chen X, Xu J, Guo S, Zhang S, Wang H, Shen P, Shang Y, Tan M, Geng Y. Blood-brain barrier permeability by CT perfusion predicts parenchymal hematoma after recanalization with thrombectomy. J Neuroimaging 2024; 34:241-248. [PMID: 38018876 DOI: 10.1111/jon.13172] [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: 09/18/2023] [Revised: 11/13/2023] [Accepted: 11/13/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND AND PURPOSE Parenchymal hematoma is a dreaded complication of mechanical thrombectomy after acute ischemic stroke. This study evaluated whether blood-brain barrier permeability measurements based on CT perfusion could be used as predictors of parenchymal hematoma after successful recanalization and compared the predictive value of various permeability parameters in patients with acute ischemic stroke. METHODS We enrolled 53 patients with acute ischemic stroke who underwent mechanical thrombectomy and achieved successful recanalization. Each patient underwent CT, CT angiography, and CT perfusion imaging before treatment. We used relative volume transfer constant (rKtrans ) values, relative permeability-surface area product (rP·S), and relative extraction fraction (rE) to evaluate preoperative blood-brain barrier permeability in the delayed perfusion area. RESULTS Overall, 22 patients (37.7%) developed hemorrhagic transformation after surgery, including 10 patients (16.9%) with hemorrhagic infarction and 11 patients (20.8%) with parenchymal hematoma. The rP·S, rKtrans , and rE of the hypoperfusion area in the parenchymal hematoma group were significantly higher than those in the hemorrhagic infarction and no-hemorrhage transformation groups (p < .01). We found that rE and rP·S were superior to rKtrans in predicting parenchymal hematoma transformation after thrombectomy (P·S area under the curve [AUC] .844 vs. rKtrans AUC .753, z = 2.064, p = .039; rE AUC .907 vs. rKtrans AUC .753, z = 2.399, p = .017). CONCLUSIONS Patients with parenchymal hematoma after mechanical thrombectomy had higher blood-brain barrier permeability in hypoperfusion areas. Among blood-brain barrier permeability measurement parameters, rP·S and rE showed better accuracy for parenchymal hematoma prediction.
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Affiliation(s)
- Xinyi Chen
- Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jie Xu
- Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shunyuan Guo
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
| | - Sheng Zhang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
| | - Huiyuan Wang
- Department of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Panpan Shen
- Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yafei Shang
- Department of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Mingming Tan
- Zhejiang Provincial People's Hospital, Department of Quality Management, Hangzhou, China
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
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Gomez F, El-Ghanem M, Feldstein E, Jagdeo M, Koul P, Nuoman R, Gupta G, Gandhi CD, Amuluru K, Al-Mufti F. Cerebral Ischemic Reperfusion Injury: Preventative and Therapeutic Strategies. Cardiol Rev 2023; 31:287-292. [PMID: 36129330 DOI: 10.1097/crd.0000000000000467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute ischemic stroke is a leading cause of morbidity and mortality in the United States. Treatment goals remain focused on restoring blood flow to compromised areas. However, a major concern arises after reperfusion occurs. Cerebral ischemic reperfusion injury is defined as damage to otherwise salvageable brain tissue occurring with the reestablishment of the vascular supply to that region. The pool of eligible patients for revascularization continues to grow, especially with the recently expanded endovascular therapeutic window. Neurointensivists should understand and manage complications of successful recanalization. In this review, we examine the pathophysiology, diagnosis, and potential management strategies in cerebral ischemic reperfusion injury.
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Affiliation(s)
- Francisco Gomez
- From the Department of Neurology, University of Missouri School of Medicine, Columbia, MO
| | - Mohammad El-Ghanem
- Department of Neuroendovascular Surgery, HCA Houston Healthcare, Houston, TX
| | - Eric Feldstein
- Westchester Medical Center, Maria Fareri Children's Hospital, Valhalla, NY
| | - Matt Jagdeo
- Westchester Medical Center, Maria Fareri Children's Hospital, Valhalla, NY
| | - Prateeka Koul
- Department of Neurology, Northshore-Long Island Jewish Medical Center, Manhasset, NY
| | - Rolla Nuoman
- Westchester Medical Center, Maria Fareri Children's Hospital, Valhalla, NY
| | - Gaurav Gupta
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Chirag D Gandhi
- Westchester Medical Center, Maria Fareri Children's Hospital, Valhalla, NY
| | - Krishna Amuluru
- Department of Neurological Surgery, University of Indiana, Indianapolis, IN
| | - Fawaz Al-Mufti
- Westchester Medical Center, Maria Fareri Children's Hospital, Valhalla, NY
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Predictive Value of CT Perfusion in Hemorrhagic Transformation after Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Brain Sci 2023; 13:brainsci13010156. [PMID: 36672136 PMCID: PMC9856940 DOI: 10.3390/brainsci13010156] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/02/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Background: Existing studies indicate that some computed tomography perfusion (CTP) parameters may predict hemorrhagic transformation (HT) after acute ischemic stroke (AIS), but there is an inconsistency in the conclusions alongside a lack of comprehensive comparison. Objective: To comprehensively evaluate the predictive value of CTP parameters in HT after AIS. Data sources: A systematical literature review of existing studies was conducted up to 1st October 2022 in six mainstream databases that included original data on the CTP parameters of HT and non-HT groups or on the diagnostic performance of relative cerebral blood flow (rCBF), relative permeability-surface area product (rPS), or relative cerebral blood volume (rCBV) in patients with AIS that completed CTP within 24 h of onset. Data Synthesis: Eighteen observational studies were included. HT and non-HT groups had statistically significant differences in CBF, CBV, PS, rCBF, rCBV, and rPS (p < 0.05 for all). The hierarchical summary receiver operating characteristic (HSROC) revealed that rCBF (area under the curve (AUC) = 0.9), rPS (AUC = 0.89), and rCBV (AUC = 0.85) had moderate diagnostic performances in predicting HT. The pooled sensitivity and specificity of rCBF were 0.85 (95% CI, 0.75−0.91) and 0.83 (95% CI, 0.63−0.94), respectively. Conclusions: rCBF, rPS, and rCBV had moderate diagnostic performances in predicting HT, and rCBF had the best pooled sensitivity and specificity.
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Calloni SF, Panni P, Calabrese F, del Poggio A, Roveri L, Squarza S, Pero GC, Paolucci A, Filippi M, Falini A, Anzalone N. Cerebral hyperdensity on CT imaging (CTHD) post-reperfusion treatment in patients with acute cerebral stroke: understanding its clinical meaning. Radiol Med 2022; 127:973-980. [DOI: 10.1007/s11547-022-01525-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 06/30/2022] [Indexed: 11/29/2022]
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5
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van der Steen W, van der Ende NA, van Kranendonk KR, Chalos V, van Oostenbrugge RJ, van Zwam WH, Roos YB, van Doormaal PJ, van Es AC, Lingsma HF, Majoie CB, van der Lugt A, Dippel DW, Roozenbeek B, Boiten J, Albert Vos J, Jansen IG, Mulder MJ, Goldhoorn RJB, Compagne KC, Kappelhof M, Brouwer J, den Hartog SJ, Emmer BJ, Coutinho JM, Schonewille WJ, Albert Vos J, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, Martens JM, Lycklama à Nijeholt GJ, Boiten J, de Bruijn SF, van Dijk LC, van der Worp HB, Lo RH, van Dijk EJ, Boogaarts HD, de Vries J, de Kort PL, van Tuijl J, Peluso JP, Fransen P, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Uyttenboogaart M, Eschgi O, Bokkers RP, Schreuder TH, Heijboer RJ, Keizer K, Yo LS, den Hertog HM, Bulut T, Brouwers PJ, Lycklama GJ, van Walderveen MA, Sprengers ME, Jenniskens SF, van den Berg R, Yoo AJ, Beenen LF, Postma AA, Roosendaal SD, van der Kallen BF, van den Wijngaard IR, Emmer BJ, Martens JM, Yo LS, Vos JA, Bot J, Meijer A, Ghariq E, Bokkers RP, van Proosdij MP, Krietemeijer GM, Peluso JP, Boogaarts HD, Lo R, Dinkelaar W, Auke P, Hammer B, Pegge S, van der Hoorn A, Vinke S, Lycklama à Nijeholt GJ, Boiten J, Vos JA, Hofmeijer J, Martens JM, van der Worp HB, Hofmeijer J, Flach HZ, el Ghannouti N, Sterrenberg M, Pellikaan W, Sprengers R, Elfrink M, Simons M, Vossers M, de Meris J, Vermeulen T, Geerlings A, van Vemde G, Simons T, Messchendorp G, Nicolaij N, Bongenaar H, Bodde K, Kleijn S, Lodico J, Droste H, Wollaert M, Verheesen S, Jeurrissen D, Bos E, Drabbe Y, Sandiman M, Aaldering N, Zweedijk B, Vervoort J, Ponjee E, Romviel S, Kanselaar K, Barning D, Venema E, Geuskens RR, van Straaten T, Ergezen S, Harmsma RR, Muijres D, de Jong A, Berkhemer OA, Boers AM, Huguet J, Groot P, Mens MA, Treurniet KM, Tolhuisen ML, Alves H, Weterings AJ, Kirkels EL, Voogd EJ, Schupp LM, Collette SL, Groot AE, LeCouffe NE, Konduri PR, Prasetya H, Arrarte- Terreros N, Ramos LA, Brown MM, Liebig T, van der Heijden E, Ghannouti N, Fleitour N, Hooijenga I, Puppels C, Pellikaan W, Geerling A, Lindl-Velema A, van Vemde G, de Ridder A, Greebe P, de Bont- Stikkelbroeck J, de Meris J, Haaglanden MC, Janssen K, Licher S, Boodt N, Ros A, Venema E, Slokkers I, Ganpat RJ, Mulder M, Saiedie N, Heshmatollah A, Schipperen S, Vinken S, van Boxtel T, Koets J, Boers M, Santos E, Borst J, Jansen I, Kappelhof M, Lucas M, Geuskens RR, Sales Barros R. Determinants of Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: A Retrospective Cohort Study. Stroke 2022; 53:2818-2827. [PMID: 35674042 PMCID: PMC9389940 DOI: 10.1161/strokeaha.121.036195] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Symptomatic intracranial hemorrhage (sICH) is a serious complication after endovascular treatment for ischemic stroke. We aimed to identify determinants of its occurrence and location.
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Affiliation(s)
- Wouter van der Steen
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nadinda A.M. van der Ende
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Katinka R. van Kranendonk
- Department of Radiology and Nuclear Medicine (K.R.v.K., C.B.L.M.M.), Maastricht University Medical Center, the Netherlands
| | - Vicky Chalos
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Public Health (V.C., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Robert J. van Oostenbrugge
- Amsterdam University Medical Center, University of Amsterdam, the Netherlands. Department of Neurology (R.J.v.O.), Maastricht University Medical Center, the Netherlands
| | - Wim H. van Zwam
- Department of Radiology and Nuclear Medicine (W.H.v.Z.), Maastricht University Medical Center, the Netherlands
| | - Yvo B.W.E.M. Roos
- Department of Neurology (Y.B.W.E.M.R.), Maastricht University Medical Center, the Netherlands
| | - Pieter J. van Doormaal
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C.G.M. van Es
- Department of Radiology, Leiden University Medical Center, the Netherlands (A.C.G.M.v.E.)
| | - Hester F. Lingsma
- Department of Public Health (V.C., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Charles B.L.M. Majoie
- Department of Radiology and Nuclear Medicine (K.R.v.K., C.B.L.M.M.), Maastricht University Medical Center, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W.J. Dippel
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Acute Hyperglycemia Exacerbates Hemorrhagic Transformation after Embolic Stroke and Reperfusion with tPA: A Possible Role of TXNIP-NLRP3 Inflammasome. J Stroke Cerebrovasc Dis 2022; 31:106226. [PMID: 34847489 PMCID: PMC8792268 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 11/08/2021] [Accepted: 11/11/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES Acute hyperglycemia (HG) exacerbates reperfusion injury after stroke. Our recent studies showed that acute HG upregulates thioredoxin-interacting protein (TXNIP) expression, which in turn induces inflammation and neurovascular damage in a suture model of ischemic stroke. The aim of the present study was to investigate the effect of acute HG on TXNIP-associated neurovascular damage, in a more clinically relevant murine model of embolic stroke and intravenous tissue plasminogen activator (IV-tPA) reperfusion. MATERIALS AND METHODS HG was induced in adult male mice, by intraperitoneal injection of 20% glucose. This was followed by embolic middle cerebral artery occlusion (eMCAO), with or without IV-tPA (10 mg/kg) given 3 h post embolization. Brain infarction, edema, hemoglobin content, expression of matrix metalloproteinase (MMP-9), vascular endothelial growth factor A (VEGFA), tight junction proteins (claudin-5, occluding, and zonula occludens-1), TXNIP, and NOD-like receptor protein3 (NLRP3)-inflammasome activation were evaluated at 24 h after eMCAO. RESULTS HG alone significantly increased TXNIP in the brain after eMCAO, and this was associated with exacerbated hemorrhagic transformation (HT; as measured by hemoglobin content). IV-tPA in HG conditions showed a trend to decrease infarct volume, but worsened HT after eMCAO, suggesting that HG reduces the therapeutic efficacy of IV-tPA. Further, HG and tPA-reperfusion did not show significant differences in expression of MMP-9, VEGFA, junction proteins, and NLRP3 inflammasome activation between the groups. CONCLUSION The current findings suggest a potential role for TXNIP in the occurrence of HT in hyperglycemic conditions following eMCAO. Further studies are needed to understand the precise role of vascular TXNIP on HG/tPA-induced neurovascular damage after stroke.
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Value of Perfusion CT in the Prediction of Intracerebral Hemorrhage after Endovascular Treatment. Stroke Res Treat 2021; 2021:9933015. [PMID: 34336182 PMCID: PMC8321751 DOI: 10.1155/2021/9933015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 06/29/2021] [Accepted: 07/06/2021] [Indexed: 12/15/2022] Open
Abstract
Background Intracerebral hemorrhage (ICH) is a serious complication of endovascular treatment (EVT) in stroke patients with large vessel occlusion (LVO) and associated with increased morbidity and mortality. Aims Identification of radiological predictors is highly relevant. We investigated the predictive power of computed tomography perfusion (CTP) parameters concerning ICH in patients receiving EVT. Methods 392 patients with anterior circulation LVO with multimodal CT imaging who underwent EVT were analyzed. CTP parameters were visually evaluated for modified ASPECTS regions and compared between patients without ICH, those with hemorrhagic infarction (HI), and those with parenchymal hematoma (PH) according to the ECASS criteria at follow-up imaging and broken down by ASPECTS regions. Results 168 received intravenous thrombolysis (IV-rtPA), and 115 developed subsequent ICH (29.3%), of which 74 were classified as HI and 41 as PH. Patients with HI and PH had lower ASPECTS than patients without ICH and worse functional outcome after 90 days (p < 0.05). In 102 of the 115 patients with ICH, the deep middle cerebral artery (MCA) territory was affected with differences between patients without ICH, those with HI, and those with PH regarding cerebral blood volume (CBV) and blood-brain barrier permeability measured as flow extraction product (FED) relative to the contralateral hemisphere (p < 0.05). Patients with PH showed larger perfusion CT infarct core than patients without ICH (p < 0.01). Conclusion None of the examined CTP parameters was found to be a strong predictor of subsequent ICH. ASPECTS and initial CTP core volume were more reliable and may be useful and even so more practicable to assess the risk of subsequent ICH after EVT.
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Camara R, Matei N, Zhang JH. Evolution of the stroke paradigm: A review of delayed recanalization. J Cereb Blood Flow Metab 2021; 41:945-957. [PMID: 33325765 PMCID: PMC8054720 DOI: 10.1177/0271678x20978861] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
While the time window for reperfusion after ischemic stroke continues to increase, many patients are not candidates for reperfusion under current guidelines that allow for reperfusion within 24 h after last known well time; however, many case studies report favorable outcomes beyond 24 h after symptom onset for both spontaneous and medically induced recanalization. Furthermore, modern imaging allows for identification of penumbra at extended time points, and reperfusion risk factors and complications are becoming better understood. Taken together, continued urgency exists to better understand the pathophysiologic mechanisms and ideal setting of delayed recanalization beyond 24 h after onset of ischemia.
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Affiliation(s)
- Richard Camara
- Departments of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA
| | - Nathanael Matei
- Departments of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA
| | - John H Zhang
- Departments of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA.,Department of Anesthesiology, Loma Linda University, Loma Linda, CA, USA.,Department of Neurosurgery, Loma Linda University, Loma Linda, CA, USA
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Matei N, Camara J, Zhang JH. The Next Step in the Treatment of Stroke. Front Neurol 2021; 11:582605. [PMID: 33551950 PMCID: PMC7862333 DOI: 10.3389/fneur.2020.582605] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/23/2020] [Indexed: 12/12/2022] Open
Abstract
Although many patients do not receive reperfusion therapy because of delayed presentation and/or severity and location of infarct, new reperfusion approaches are expanding the window of intervention. Novel application of neuroprotective agents in combination with the latest methods of reperfusion provide a path to improved stroke intervention outcomes. We examine why neuroprotective agents have failed to translate to the clinic and provide suggestions for new approaches. New developments in recanalization therapy in combination with therapeutics evaluated in parallel animal models of disease will allow for novel, intra-arterial deployment of therapeutic agents over a vastly expanded therapeutic time window and with greater likelihood success. Although the field of neuronal, endothelial, and glial protective therapies has seen numerous large trials, the application of therapies in the context of newly developed reperfusion strategies is still in its infancy. Given modern imaging developments, evaluation of the penumbra will likely play a larger role in the evolving management of stroke. Increasingly more patients will be screened with neuroimaging to identify patients with adequate collateral blood supply allowing for delayed rescue of the penumbra. These patients will be ideal candidates for therapies such as reperfusion dependent therapeutic agents that pair optimally with cutting-edge reperfusion techniques.
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Affiliation(s)
- Nathanael Matei
- Department of Ophthalmology, University of Southern California, Los Angeles, CA, United States
| | - Justin Camara
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States.,Department of Anesthesiology, Loma Linda University, Loma Linda, CA, United States.,Department of Neurosurgery, Loma Linda University, Loma Linda, CA, United States
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Choi JH, Poli S, Chen M, Nguyen TN, Saver JL, Matouk C, Pile-Spellman J. Selective Brain Hypothermia in Acute Ischemic Stroke: Reperfusion Without Reperfusion Injury. Front Neurol 2020; 11:594289. [PMID: 33281733 PMCID: PMC7691595 DOI: 10.3389/fneur.2020.594289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/15/2020] [Indexed: 01/19/2023] Open
Abstract
In acute ischemic stroke, early recanalization of the occluded artery is crucial for best outcome to be achieved. Recanalization aims at restoring blood flow to the ischemic tissue (reperfusion) and is achieved with pharmacological thrombolytic drugs, endovascular thrombectomy (EVT) devices, or both. The introduction of modern endovascular devices has led to tremendous anatomical and clinical success with rates of substantial reperfusion exceeding 80% and proven clinical benefit in patients with anterior circulation large vessel occlusions (LVOs). However, not every successful reperfusion procedure leads to the desired clinical outcome. In fact, the rate of non-disabled outcome at 3 months with current EVT treatment is ~1 out of 4. A constraint upon better outcomes is that reperfusion, though resolving ischemic stress, may not restore the anatomic structures and metabolic functions of ischemic tissue to their baseline states. In fact, ischemia triggers a complex cascade of destructive mechanisms that can sometimes be exacerbated rather than alleviated by reperfusion therapy. Such reperfusion injury may cause infarct progression, intracranial hemorrhage, and unfavorable outcome. Therapeutic hypothermia has been shown to have a favorable impact on the molecular elaboration of ischemic injury, but systemic hypothermia is limited by slow speed of attaining target temperatures and clinical complications. A novel approach is endovascular delivery of hypothermia to cool the affected brain tissue selectively and rapidly with tight local temperature control, features not available with systemic hypothermia devices. In this perspective article, we discuss the possible benefits of adjunctive selective endovascular brain hypothermia during interventional stroke treatment.
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Affiliation(s)
- Jae H. Choi
- Neurovascular Center, Neurological Surgery, P.C., Lake Success, NY, United States
- Hybernia Medical, LLC, New Rochelle, NY, United States
| | - Sven Poli
- Department of Neurology & Stroke, Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Michael Chen
- Stroke Center, Department of Neurosurgery, Rush University Medical Center, Chicago, IL, United States
| | - Thanh N. Nguyen
- Interventional Neurology/Neuroradiology, Boston University School of Medicine, Boston, MA, United States
| | - Jeffrey L. Saver
- Comprehensive Stroke Center and Department of Neurology, University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Charles Matouk
- Neurovascular Surgery, Department of Neurosurgery, Yale University-New Haven Hospital, New Haven, CT, United States
| | - John Pile-Spellman
- Neurovascular Center, Neurological Surgery, P.C., Lake Success, NY, United States
- Hybernia Medical, LLC, New Rochelle, NY, United States
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Whitney E, Khan YR, Alastra A, Schiraldi M, Siddiqi J. Contrast Extravasation Post Thrombectomy in Patients With Acute Cerebral Stroke: A Review and Recommendations for Future Studies. Cureus 2020; 12:e10616. [PMID: 33123430 PMCID: PMC7584332 DOI: 10.7759/cureus.10616] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Mechanical thrombectomy (MT) for cerebral revascularization in acute stroke is now considered standard of care in select patients. Patients are assessed routinely after MT with CT scanning. The phenomenon of contrast staining is well documented in the literature and is posited to be related to increased blood-brain barrier (BBB) permeability of susceptible and/or infarcting brain tissue allowing angiographic contrast to be visualized outside the normal cerebral vasculature. In some cases, this can progress to include frank blood/contrast extravasation or even more seriously lead to intraparenchymal hemorrhage (IPH) with less favorable clinical outcomes. The relationship of this staining phenomenon and how it may have a cause or effect relationship with progression to hemorrhage is unclear. Many studies have been performed trying to better characterize this radiographic finding in terms of accurate diagnosis and potential for influencing prognosis. A literature review included a glaring lack of standardization in the application of terminology and quantitative/qualitative analysis. Dual energy CT (DECT) appears to be the best imaging modality to differentiate blood from contrast, but its application is limited since it is not as available as conventional CT. The possibility that risk factors are associated with progression of mixed density (blood and contrast) extravasations to frank IPH with resultant poorer outcomes is suggested in some studies. Overall, there remains a lack of consensus on how to best interpret this radiographic finding in altering any future stroke treatment(s). Recommendations of how to overcome this are postulated by the authors, which include standardization of terminology, progression toward more DECT use.
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Affiliation(s)
- Eric Whitney
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Yasir R Khan
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Anthony Alastra
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Michael Schiraldi
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA.,Neurosurgery, Redlands Community Hospital, Redlands, USA
| | - Javed Siddiqi
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA.,Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA.,Neurosurgery, Arrowhead Regional Medical Center, Colton, USA.,Neurosurgery, California University of Science and Medicine, Colton, USA
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12
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Renú A, Blasco J, Laredo C, Llull L, Urra X, Obach V, López-Rueda A, Rudilosso S, Zarco F, González E, Guio JD, Amaro S, Chamorro A. Carotid stent occlusion after emergent stenting in acute ischemic stroke: Incidence, predictors and clinical relevance. Atherosclerosis 2020; 313:8-13. [PMID: 33002751 DOI: 10.1016/j.atherosclerosis.2020.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/02/2020] [Accepted: 09/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Emergent stent placement may be required during neurothrombectomy. Our aim was to investigate the incidence, predictors and clinical relevance of early extracranial carotid stent occlusion following neurothrombectomy. METHODS We retrospectively analyzed a cohort of 761 consecutive neurothrombectomies performed at our center between May 2010 and August 2018, from whom a total of 106 patients had acute internal carotid artery occlusions. Early stent occlusion was defined as complete vessel occlusion within 24 h of neurothrombectomy. Clinical outcome was evaluated at day 90 with the modified Rankin Score scale (mRS). Pretreatment, procedural and outcome variables were recorded and analyzed using logistic regression. RESULTS Carotid stenting was performed in 99 (13%) patients. Of those, 22 (22%) had early stent occlusion at follow-up. Stent occlusion was associated with a lower use of post-stenting angioplasty [adjusted OR (aOR) = 11.2, 95%CI = 2.49-50.78, p = 0.002)], increased residual intrastent stenosis (aOR = 2.1, 95%CI = 1.38-3.06, p < 0.001) and unsuccesful intracranial recanalization (modified TICI score 0-2a) (aOR = 13.5, 95%CI = 1.97-92.24, p = 0.008). Stent occlusion was associated with poor clinical outcome at day 90 (poorer mRS shift, aOR = 3.9, 95%CI = 1.3-11.3, p = 0.014; mRS>2, aOR = 6.3, 95%CI = 1.8-22.7, p = 0.005), and with an increased rate of symptomatic intracranial hemorrhage at 24 h (14% versus 1%, p = 0.033). CONCLUSIONS Early carotid stent occlusion occurred in one out of five neurothrombectomies and was associated with periprocedural factors that included increased residual intrastent stenosis, a lower use of post-stenting angioplasty and unsuccessful intracranial recanalization. Further investigation is warranted for the evaluation of strategies aimed to prevent carotid stent occlusion.
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Affiliation(s)
- Arturo Renú
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Jordi Blasco
- Radiology Department, Hospital Clinic, Barcelona, Spain
| | - Carlos Laredo
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Laura Llull
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Xabier Urra
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Victor Obach
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Elisabet González
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - José David Guio
- Radiology Department, Hospital General Universitario, Ciudad Real, Spain
| | - Sergio Amaro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
| | - Angel Chamorro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
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13
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Laredo C, Renú A, Llull L, Tudela R, López-Rueda A, Urra X, Macías NG, Rudilosso S, Obach V, Amaro S, Chamorro Á. Elevated glucose is associated with hemorrhagic transformation after mechanical thrombectomy in acute ischemic stroke patients with severe pretreatment hypoperfusion. Sci Rep 2020; 10:10588. [PMID: 32601437 PMCID: PMC7324383 DOI: 10.1038/s41598-020-67448-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 05/04/2020] [Indexed: 11/08/2022] Open
Abstract
Several pretreatment variables such as elevated glucose and hypoperfusion severity are related to brain hemorrhage after endovascular treatment of acute stroke. We evaluated whether elevated glucose and severe hypoperfusion have synergistic effects in the promotion of parenchymal hemorrhage (PH) after mechanical thrombectomy (MT). We included 258 patients MT-treated who had a pretreatment computed tomography perfusion (CTP) and a post-treatment follow-up MRI. Severe hypoperfusion was defined as regions with cerebral blood volume (CBV) values < 2.5% of normal brain [very-low CBV (VLCBV)-regions]. Median baseline glucose levels were 119 (IQR = 105-141) mg/dL. Thirty-nine (15%) patients had pretreatment VLCBV-regions, and 42 (16%) developed a PH after MT. In adjusted models, pretreatment glucose levels interacted significantly with VLCBV on the prediction of PH (p-interaction = 0.011). In patients with VLCBV-regions, higher glucose was significantly associated with PH (adjusted-OR = 3.15; 95% CI = 1.08-9.19, p = 0.036), whereas this association was not significant in patients without VLCBV-regions. CBV values measured at pretreatment CTP in coregistered regions that developed PH or infarct at follow-up were not correlated with pretreatment glucose levels, thus suggesting the existence of alternative deleterious mechanisms other than direct glucose-driven hemodynamic impairments. Overall, these results suggest that both severe hypoperfusion and glucose levels should be considered in the evaluation of adjunctive neuroprotective strategies.
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Affiliation(s)
- Carlos Laredo
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Villarroel 170, 08036, Barcelona, Spain
| | - Arturo Renú
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Villarroel 170, 08036, Barcelona, Spain
| | - Laura Llull
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Villarroel 170, 08036, Barcelona, Spain
| | - Raúl Tudela
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Group of Biomedical Imaging of the University of Barcelona, Barcelona, Spain
| | | | - Xabier Urra
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Villarroel 170, 08036, Barcelona, Spain
| | | | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Villarroel 170, 08036, Barcelona, Spain
| | - Víctor Obach
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Villarroel 170, 08036, Barcelona, Spain
| | - Sergio Amaro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Villarroel 170, 08036, Barcelona, Spain.
| | - Ángel Chamorro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Villarroel 170, 08036, Barcelona, Spain.
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Hassan AE, Kotta H, Shariff U, Preston L, Tekle W, Qureshi A. There Is No Association Between the Number of Stent Retriever Passes and the Incidence of Hemorrhagic Transformation for Patients Undergoing Mechanical Thrombectomy. Front Neurol 2019; 10:818. [PMID: 31440198 PMCID: PMC6694295 DOI: 10.3389/fneur.2019.00818] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/16/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Previous research has focused on the association between hemorrhagic transformation (HT) incidence and pre-procedural variables (i.e., baseline variables) rather than the association between HT incidence and endovascular treatment (EVT) procedural variables (e.g., stent retriever passes). Objective: To assess the association, if any, that exists between the number of stent retriever passes per procedure and the incidence of HT for patients undergoing mechanical thrombectomy. Methods: An endovascular database from a comprehensive stroke center was used to collect data on EVT patients treated with Trevo, Solitaire, or Penumbra stent retrievers from the years 2012 to 2017. Statistical analyses were conducted on the stent retriever passes, demographics, morbidities, medication usage, and outcomes and their association with HT. Results: Of the 329 total patients, 46 (14%) had HT. The HT group had an average [SD] of 1.65 [0.67] and range of [1–3] passes per procedure while the non-HT group had an average [SD] of 1.63 [0.86] and range of [1–5] passes per procedure. Admission NIHSS score (p = 0.0003) and the incidence of diabetes mellitus (DM) (p = 0.05) were significantly higher in the HT group. Subdividing HT into symptomatic and asymptomatic ICH groups failed to display significant differences in the distribution of the stent retriever passes (p = 0.969). The number of passes failed to show any association with HT (p = 0.804) while admission NIHSS score was found to have an OR of 1.07 (95%CI: 1.029–1.121, p = 0.001) with HT incidence. Conclusion: No significant association was found between HT incidence and the stent retriever passes. Further multicenter studies are warranted to corroborate our results.
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Affiliation(s)
- Ameer E Hassan
- Department of Neurology and Radiology, University of Texas Rio Grande Valley, Harlingen, TX, United States
| | - Hari Kotta
- Department of Neurology, University of Texas Medical Branch, Galveston, TX, United States
| | - Umar Shariff
- Department of Neurology and Radiology, University of Texas Rio Grande Valley, Harlingen, TX, United States
| | - Laurie Preston
- Department of Neurology and Radiology, University of Texas Rio Grande Valley, Harlingen, TX, United States
| | - Wondwossen Tekle
- Department of Neurology and Radiology, University of Texas Rio Grande Valley, Harlingen, TX, United States
| | - Adnan Qureshi
- Department of Neurology, University of Missouri, Columbia, MO, United States
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15
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Hao Z, Yang C, Xiang L, Wu B, Liu M. Risk factors for intracranial hemorrhage after mechanical thrombectomy: a systematic review and meta-analysis. Expert Rev Neurother 2019; 19:927-935. [PMID: 31200607 DOI: 10.1080/14737175.2019.1632191] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Zilong Hao
- Center of Cerebrovascular Disease, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, P.R. China
| | - Chunsong Yang
- Department of Pharmacy, Evidence-based Pharmacy Center, West China second hospital, Sichuan University, Chengdu, China
| | - Lingbao Xiang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Bo Wu
- Center of Cerebrovascular Disease, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, P.R. China
| | - Ming Liu
- Center of Cerebrovascular Disease, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, P.R. China
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16
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Renú A, Laredo C, Montejo C, Zhao Y, Rudilosso S, Macias N, Llull L, Zarco F, Amaro S, Werner M, Obach V, Macho J, Chamorro A, Urra X. Greater infarct growth limiting effect of mechanical thrombectomy in stroke patients with poor collaterals. J Neurointerv Surg 2019; 11:989-993. [PMID: 30814327 DOI: 10.1136/neurintsurg-2018-014668] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Stroke patients with good collateral circulation achieve the best recovery after mechanical thrombectomy (MT) but strict imaging selection may result in untreated patients that could benefit from MT. We assessed whether the extent of collaterals had modifying effects on the amount of ischemic tissue saved from infarction with MT over best medical treatment (BMT). METHODS This was a single center cohort of consecutive patients (n=339) with proximal occlusions in the carotid territory. Patients were categorized according to a four point category scale on CT angiography as having good (scores 2-3) or poor (scores 0-1) collaterals. The primary outcome measure was the interaction between collaterals and MT on infarct growth. The secondary outcome assessed the treatment effect of MT over BMT on functional status in relation to collateral status. Safety outcomes were mortality and symptomatic intracranial hemorrhage. RESULTS Collaterals had a modifying effect of MT on infarct growth (P=0.004), with a greater reduction in 96 patients with poor collaterals (38.8 mL) than in 243 patients with good collaterals (1.9 mL). There was also a significant (P<0.001) interaction between the effect of MT and functional outcome in relation to collateral status, with more benefits of MT in patients with poor collaterals. MT was associated with lower mortality than BMT in patients with poor collaterals only. CONCLUSION Compared with BMT, the use of MT in the early time window in large vessel stroke results in a more substantial limitation of infarct growth in patients with poor collaterals.
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Affiliation(s)
- Arturo Renú
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Carlos Laredo
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Carmen Montejo
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Yashu Zhao
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Napoleon Macias
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Laura Llull
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Federico Zarco
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Sergio Amaro
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Mariano Werner
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Victor Obach
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Juan Macho
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Angel Chamorro
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Xabier Urra
- Comprehensive Stroke Unit, Hospital Clinic de Barcelona, Barcelona, Spain
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Choi JH, Pile-Spellman J. Reperfusion Changes After Stroke and Practical Approaches for Neuroprotection. Neuroimaging Clin N Am 2019; 28:663-682. [PMID: 30322601 DOI: 10.1016/j.nic.2018.06.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Reperfusion is the first line of care in a growing number of eligible acute ischemic stroke patients. Early reperfusion with thrombolytic drugs and endovascular mechanical devices is associated with improved outcome and lower mortality rates compared with natural history. Reperfusion is not without risk, however, and may result in reperfusion injury, which manifests in hemorrhagic transformation, brain edema, infarct progression, and neurologic worsening. In this article, the functional and structural changes and underlying molecular mechanisms of ischemia and reperfusion are reviewed. The pathways that lead to reperfusion injury and novel neuroprotective strategies with endogenous properties are discussed.
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Affiliation(s)
- Jae H Choi
- Center for Unruptured Brain Aneurysms, Neurological Surgery PC, 1991 Marcus Avenue, Suite 108, Lake Success, NY 11042, USA; Department of Neurology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, USA; Hybernia Medical LLC, 626 RexCorp Plaza, Uniondale, NY 11556, USA.
| | - John Pile-Spellman
- Center for Unruptured Brain Aneurysms, Neurological Surgery PC, 1991 Marcus Avenue, Suite 108, Lake Success, NY 11042, USA; Hybernia Medical LLC, 626 RexCorp Plaza, Uniondale, NY 11556, USA
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18
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Adrenal hormones and circulating leukocyte subtypes in stroke patients treated with reperfusion therapy. Brain Behav Immun 2018; 70:346-353. [PMID: 29548995 DOI: 10.1016/j.bbi.2018.03.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/03/2018] [Accepted: 03/12/2018] [Indexed: 11/23/2022] Open
Abstract
Ischemic stroke sets in motion a dialogue between the central nervous and the immune systems that includes the sympathetic/adrenal system. We investigated the course of immune cells and adrenocortical and adrenomedullary effectors in a cohort of 51 patients with acute stroke receiving reperfusion therapy (intravenous alteplase or mechanical thrombectomy) and its correlation with stroke outcomes and infarct growth. Cortisol increased rapidly and fleetingly after stroke, but 39% of patients who had larger infarctions on admission showed a positive delta cortisol at day 1. It was associated with enhanced infarct growth (p = 0.002) and poor outcome [OR (95% CI) 5.30 (1.30-21.69)], and correlated with less lymphocytes and T cells at follow up. Likewise, fewer circulating lymphocytes, T cells, and Tregs were associated with infarct growth. By contrast, metanephrines did not increase at clinical onset, and decreased over time. Higher levels of NMN correlated with more Treg and B cells. Eventually, complete reperfusion at the end of therapy headed the identification of more circulating Tregs at day 1. Then activation of cortical or medullar compartments of the adrenal gland result in specific signatures on leukocyte subpopulations. Manipulation of the adrenal gland hormone levels warrants further investigation.
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Bourcier R, Alexandre PL, Eugène F, Delasalle-Guyomarch B, Guillon B, Kerleroux B, Saleme S, Marnat G, Boucebci S, Mirza M, Ferré JC, Papagiannaki C, Desal H. Is bridging therapy still required in stroke due to carotid artery terminus occlusions? J Neurointerv Surg 2017; 10:625-628. [PMID: 29146829 DOI: 10.1136/neurintsurg-2017-013398] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Studies comparing endovascular stroke treatment using mechanical thrombectomy (MT) with or without prior IV tissue plasminogen activator (tPa) have included only 30% of internal carotid artery terminus occlusions (ICA-O), a known predictor of recanalization failure with IV tPa. OBJECTIVE To carry out a retrospective multicenter analysis of prospectively collected data of consecutive patients to investigate the impact of intravenous thrombolysis on ICA-O by comparing patients treated with MT alone or bridging therapy (BT). MATERIAL AND METHODS Patients with ICA-O treated with MT alone or BT were retrospectively examined and compared. Demographic data, vascular risk factors, treatment modalities, complications, technical and clinical outcomes were recorded. A propensity score (PS) analysis was used to compare modified Rankin Scale (mRS) score at 3 months and intracerebral hemorrhage (ICH) between groups. RESULTS 141 consecutive patients (60% BT/40% MT) were included between January 2014 and June 2016. Baseline characteristics did not differ between the groups. There was no significant difference in the rate of Thrombolysis in Cerebral Infarction 2b/3, distal emboli, and median number of passes between the groups. There was a significant difference between BT and MT groups in the median time between imaging and groin puncture (median 97 min vs 75, p=0.007), the rate of ICH (44% vs 27%, p=0.05), but not for symptomatic ICH (18% vs 13%, p=0.49). With PS, there was a trend towards a higher rate of ICH (OR=2.3, 95% CI 0.9 to 5.9, p=0.09) in the BT group compared with the MT alone group, with no difference in mRS score ≤2 at 3 months (OR=1.6, 95% CI 0.7 to 3.7, p=0.29). CONCLUSION There was no significant difference in clinical outcomes between patients receiving bridging therapy versus direct thrombectomy. Bridging therapy delayed time to groin puncture and increased ICH rate.
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Affiliation(s)
- Romain Bourcier
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | | | - François Eugène
- Department of Neuroradiology, University Hospital of Rennes, Rennes, France
| | | | - Benoit Guillon
- Stroke Unit, University Hospital of Nantes, Nantes, France
| | | | - Suzana Saleme
- Interventional Neuroradiology, CHU Limoges, Limoges, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Samy Boucebci
- Department of Neuroradiology, University Hospital of Poitiers, Poitiers, France
| | | | | | | | - Hubert Desal
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
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20
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Complete reperfusion is required for maximal benefits of mechanical thrombectomy in stroke patients. Sci Rep 2017; 7:11636. [PMID: 28912596 PMCID: PMC5599658 DOI: 10.1038/s41598-017-11946-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/01/2017] [Indexed: 01/31/2023] Open
Abstract
A mTICI 2b or a mTICI 3 score are currently considered success following mechanical thrombectomy (MT) in acute stroke but is undetermined whether the two scores translate equivalent outcomes. We present a single-center, retrospective cohort of patients with anterior circulation stroke treated with MT and achieving a final mTICI score 2b or 3. A multimodal CT at baseline and a multimodal MRI at 24 hours assessed the growth of the infarct, and the modified Rankin Scale (mRS) assessed functional outcome at 90 days. The primary outcome was the shift analysis of the mRS at day 90 in ordinal regression adjusted for covariates (age, sex, pretreatment NIHSS score, target occlusion, infarct core, pretreatment alteplase), and the collateral score. Infarct growth was explored in a similarly adjusted multiple linear regression model. MT was started within a median of 285 minutes of symptom onset; 51 (41%) patients achieved a mTICI 2b, and 74 (59%), a mTICI 3. mTICI 3 resulted in better mRS score transitions than mTICI 2b (odds ratio 2.018 [95% CI 1.033–3.945], p = 0. 040), and reduced infarct growth (p = 0.002). We conclude that in patients with acute stroke receiving MT, success should be redefined as achieving a mTICI 3 score.
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Renú A, Laredo C, Lopez-Rueda A, Llull L, Tudela R, San-Roman L, Urra X, Blasco J, Macho J, Oleaga L, Chamorro A, Amaro S. Vessel Wall Enhancement and Blood–Cerebrospinal Fluid Barrier Disruption After Mechanical Thrombectomy in Acute Ischemic Stroke. Stroke 2017; 48:651-657. [DOI: 10.1161/strokeaha.116.015648] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/22/2016] [Accepted: 12/19/2016] [Indexed: 01/23/2023]
Abstract
Background and Purpose—
Less than half of acute ischemic stroke patients treated with mechanical thrombectomy obtain permanent clinical benefits. Consequently, there is an urgent need to identify mechanisms implicated in the limited efficacy of early reperfusion. We evaluated the predictors and prognostic significance of vessel wall permeability impairment and its association with blood–cerebrospinal fluid barrier (BCSFB) disruption after acute stroke treated with thrombectomy.
Methods—
A prospective cohort of acute stroke patients treated with stent retrievers was analyzed. Vessel wall permeability impairment was identified as gadolinium vessel wall enhancement (GVE) in a 24- to 48-hour follow-up contrast-enhanced magnetic resonance imaging, and severe BCSFB disruption was defined as subarachnoid hemorrhage or gadolinium sulcal enhancement (present across >10 slices). Infarct volume was evaluated in follow-up magnetic resonance imaging, and clinical outcome was evaluated with the modified Rankin Scale at day 90.
Results—
A total of 60 patients (median National Institutes of Health Stroke Scale score, 18) were analyzed, of whom 28 (47%) received intravenous alteplase before mechanical thrombectomy. Overall, 34 (57%) patients had GVE and 27 (45%) had severe BCSFB disruption. GVE was significantly associated with alteplase use before thrombectomy and with more stent retriever passes, along with the presence of severe BCSFB disruption. GVE was associated with poor clinical outcome, and both GVE and severe BCSFB disruption were associated with increased final infarct volume.
Conclusions—
These findings may support the clinical relevance of direct vessel damage and BCSFB disruption after acute stroke and reinforce the need for further improvements in reperfusion strategies. Further validation in larger cohorts of patients is warranted.
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Affiliation(s)
- Arturo Renú
- From the Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., C.L., L.L., X.U., A.C., S.A.); Radiology Department, Hospital Clinic, Barcelona, Spain (A.L.-R., L.S.-R., J.B., J.M., L.O.); and CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Spain (R.T.)
| | - Carlos Laredo
- From the Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., C.L., L.L., X.U., A.C., S.A.); Radiology Department, Hospital Clinic, Barcelona, Spain (A.L.-R., L.S.-R., J.B., J.M., L.O.); and CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Spain (R.T.)
| | - Antonio Lopez-Rueda
- From the Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., C.L., L.L., X.U., A.C., S.A.); Radiology Department, Hospital Clinic, Barcelona, Spain (A.L.-R., L.S.-R., J.B., J.M., L.O.); and CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Spain (R.T.)
| | - Laura Llull
- From the Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., C.L., L.L., X.U., A.C., S.A.); Radiology Department, Hospital Clinic, Barcelona, Spain (A.L.-R., L.S.-R., J.B., J.M., L.O.); and CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Spain (R.T.)
| | - Raúl Tudela
- From the Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., C.L., L.L., X.U., A.C., S.A.); Radiology Department, Hospital Clinic, Barcelona, Spain (A.L.-R., L.S.-R., J.B., J.M., L.O.); and CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Spain (R.T.)
| | - Luis San-Roman
- From the Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., C.L., L.L., X.U., A.C., S.A.); Radiology Department, Hospital Clinic, Barcelona, Spain (A.L.-R., L.S.-R., J.B., J.M., L.O.); and CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Spain (R.T.)
| | - Xabier Urra
- From the Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., C.L., L.L., X.U., A.C., S.A.); Radiology Department, Hospital Clinic, Barcelona, Spain (A.L.-R., L.S.-R., J.B., J.M., L.O.); and CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Spain (R.T.)
| | - Jordi Blasco
- From the Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., C.L., L.L., X.U., A.C., S.A.); Radiology Department, Hospital Clinic, Barcelona, Spain (A.L.-R., L.S.-R., J.B., J.M., L.O.); and CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Spain (R.T.)
| | - Juan Macho
- From the Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., C.L., L.L., X.U., A.C., S.A.); Radiology Department, Hospital Clinic, Barcelona, Spain (A.L.-R., L.S.-R., J.B., J.M., L.O.); and CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Spain (R.T.)
| | - Laura Oleaga
- From the Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., C.L., L.L., X.U., A.C., S.A.); Radiology Department, Hospital Clinic, Barcelona, Spain (A.L.-R., L.S.-R., J.B., J.M., L.O.); and CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Spain (R.T.)
| | - Angel Chamorro
- From the Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., C.L., L.L., X.U., A.C., S.A.); Radiology Department, Hospital Clinic, Barcelona, Spain (A.L.-R., L.S.-R., J.B., J.M., L.O.); and CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Spain (R.T.)
| | - Sergio Amaro
- From the Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., C.L., L.L., X.U., A.C., S.A.); Radiology Department, Hospital Clinic, Barcelona, Spain (A.L.-R., L.S.-R., J.B., J.M., L.O.); and CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Spain (R.T.)
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