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Wang H, Xu C, Xiao Y, Shen P, Guo S, Shang Y, Chen X, Xu J, Li C, Tan M, Zhang S, Geng Y. A dynamic nomogram for predict individual risk of malignant brain edema after endovascular thrombectomy in acute ischemic stroke. Sci Rep 2024; 14:9529. [PMID: 38664433 PMCID: PMC11045849 DOI: 10.1038/s41598-024-60083-w] [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: 01/28/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
The aim of this study was to develop a dynamic nomogram combining clinical and imaging data to predict malignant brain edema (MBE) after endovascular thrombectomy (EVT) in patients with large vessel occlusion stroke (LVOS). We analyzed the data of LVOS patients receiving EVT at our center from October 2018 to February 2023, and divided a 7:3 ratio into the training cohort and internal validation cohort, and we also prospectively collected patients from another stroke center for external validation. MBE was defined as a midline shift or pineal gland shift > 5 mm, as determined by computed tomography (CT) scans obtained within 7 days after EVT. A nomogram was constructed using logistic regression analysis, and its receiver operating characteristic curve (ROC) and calibration were assessed in three cohorts. A total of 432 patients were enrolled in this study, with 247 in the training cohort, 100 in the internal validation cohort, and 85 in the external validation cohort. MBE occurred in 24% (59) in the training cohort, 16% (16) in the internal validation cohort and 14% (12) in the external validation cohort. After adjusting for various confounding factors, we constructed a nomogram including the clot burden score (CBS), baseline neutrophil count, core infarct volume on CTP before EVT, collateral index, and the number of retrieval attempts. The AUCs of the training cohorts were 0.891 (95% CI 0.840-0.942), the Hosmer-Lemeshow test showed good calibration of the nomogram (P = 0.879). And our nomogram performed well in both internal and external validation data. Our nomogram demonstrates promising potential in identifying patients at elevated risk of MBE following EVT for LVOS.
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Affiliation(s)
- Huiyuan Wang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- School of Clinical Medicine, Graduate School, Bengbu Medical College, Bengbu, China
| | - Chenghua Xu
- Department of Neurology, Taizhou First People's Hospital, Taizhou, Zhejiang, China
| | - Yu Xiao
- Department of Neurology, Taizhou First People's Hospital, Taizhou, Zhejiang, China
| | - Panpan Shen
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- Department of the 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, 310014, Zhejiang, China
| | - Yafei Shang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- School of Clinical Medicine, Graduate School, Bengbu Medical College, Bengbu, China
| | - Xinyi Chen
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- Department of the Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jie Xu
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- Department of the Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Chunrong Li
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Mingming Tan
- Department of Quality Management, Zhejiang Provincial People's Hospital, Hangzhou, 310014, Zhejiang, China
| | - Sheng Zhang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China.
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China.
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Zeng Y, Hao L, Chen Y, Liu S, Fan Y, Zhao Z, Wang Y, Chen Q, Li Y. Optimizing intra-arterial hypothermia scheme for acute ischemic stroke in an MCAO/R rat model. Sci Rep 2023; 13:9566. [PMID: 37311853 DOI: 10.1038/s41598-023-35824-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 05/24/2023] [Indexed: 06/15/2023] Open
Abstract
Hypothermia is a promising neuroprotective treatment. This study aims to explore and optimize the intervention scheme of intra-arterial hypothermia (IAH) in a middle cerebral artery occlusion and reperfusion (MCAO/R) rat model. The MCAO/R model was established with a thread that could be retracted 2 h after occlusion. Cold normal saline was injected into the internal carotid artery (ICA) through a microcatheter in different infusion conditions. Grouping followed an orthogonal design (L9[34]) based on three critical factors closely associated with IAH: perfusate temperature (4, 10, 15 °C), infusion flow rate (1/3, 1/2, 2/3 blood flow rate of ICA), and duration (10, 20, 30 min), resulting in 9 subgroups (H1, H2 to H9). A myriad of indexes were monitored, such as vital signs, blood parameters, changes in local ischemic brain tissue temperature (Tb), ipsilateral jugular venous bulb temperature (Tjvb), and the core temperature of the anus (Tcore). After 24 h and 72 h of cerebral ischemia, cerebral infarction volume, cerebral water content, and neurological function were assessed to explore the optimal IAH conditions. The results revealed that the three critical factors were independent predictors for cerebral infarction volume, cerebral water content, and neurological function. The optimal perfusion conditions were 4 °C, 2/3 RICA (0.50 ml/min) for 20 min, and there was a significant correlation between Tb and Tjvb (R = 0.994, P < 0.001). The vital signs, blood routine tests and biochemical indexes showed no significant abnormal changes. These findings revealed that IAH was safe and feasible with the optimized scheme in an MCAO/R rat model.
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Affiliation(s)
- Yuqi Zeng
- Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Lei Hao
- Department of Neurology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China
- Department of Neurology, Second Affiliated Hospital of Xuzhou Medical University, Quanshan District, Xuzhou, 221006, Jiangsu Province, China
| | - Yue Chen
- Department of Neurology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China
| | - Shuyi Liu
- Department of Neurology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China
| | - Yong Fan
- Central Laboratory, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, 350001, China
| | - Zhenhua Zhao
- Department of Neurology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China
| | - Yinzhou Wang
- Department of Neurology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China.
- Fujian Key Laboratory of Medical Analysis, Fujian Academy of Medical Sciences, Fuzhou, 350001, China.
| | - Qi Chen
- Fujian Key Laboratory of Innate Immune Biology, Biomedical Research Center of South China, College of Life Science, Fujian Normal University, Fuzhou, 350000, China.
| | - Yongkun Li
- Department of Neurology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China.
- Fujian Provincial Key Laboratory of Emergency Medicine, Department of Emergency, Fujian Provincial Hospital, Fuzhou, 350001, China.
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He Y, Zuo M, Huang J, Jiang Y, Zhou L, Li G, Chen L, Liu Q, Liang D, Wang Y, Wang L, Zhou Z. A Novel Nomogram for Predicting Malignant Cerebral Edema After Endovascular Thrombectomy in Acute Ischemic Stroke: A Retrospective Cohort Study. World Neurosurg 2023; 173:e548-e558. [PMID: 36842531 DOI: 10.1016/j.wneu.2023.02.091] [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: 02/13/2023] [Accepted: 02/20/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Malignant cerebral edema (MCE) is a common and feared complication after endovascular thrombectomy (EVT) in acute ischemic stroke (AIS). This study aimed to establish a nomogram to predict MCE in anterior circulation large vessel occlusion stroke (LVOS) patients receiving EVT in order to guide the postoperative medical care in the acute phase. METHODS In this retrospective cohort study, 381 patients with anterior circulation LVOS receiving EVT were screened from 636 hospitalized patients with LVOS at 2 stroke medical centers. Clinical baseline data and imaging data were collected within 2-5 days of admission to the hospital. The patients were divided into 2 groups based on whether MCE occurred after EVT. Multivariate logistic regression analysis was used to evaluate the independent risk factors for MCE and to establish a nomogram. RESULTS Sixty-six patients out of 381 (17.32%) developed MCE. The independent risk factors for MCE included admission National Institutes of Health Stroke Scale (NIHSS) ≥16 (odds ratio [OR] 1.851; 95% CI 1.029-3.329; P = 0.038), ASPECT score (OR 0.621; 95% CI 0.519-0.744; P < 0.001), right hemisphere (OR 1.636; 95% CI 0.941-2.843; P = 0.079), collateral circulation (OR 0.155; 95% CI 0.074-0.324; P < 0.001), recanalization (OR 0.223; 95% CI 0.109-0.457; P < 0.001), hematocrit (OR, 0.937; 95% CI: 0.892-0.985; P =0.010), and glucose (OR 1.118; 95% CI 1.023-1.223; P = 0.036), which were adopted as parameters of the nomogram. The receiver operating characteristic curve analysis showed that the area under the curve of the nomogram in predicting MCE was 0.901(95% CI 0.848-0.940; P < 0.001). The Hosmer-Lemeshow test results were not significant (P = 0.685), demonstrating a good calibration of the nomogram. CONCLUSIONS The novel nomogram composed of admission NIHSS, ASPECT scores, right hemisphere, collateral circulation, recanalization, hematocrit, and serum glucose provide a potential predictor for MCE in patients with AIS after EVT.
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Affiliation(s)
- Yuxuan He
- Department of Neurology, School of Medicine, Chongqing University, Chongqing, China; Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Meng Zuo
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jialu Huang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ying Jiang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Linke Zhou
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Guangjian Li
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Lin Chen
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Qu Liu
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Dingwen Liang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yu Wang
- Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Li Wang
- Department of Neurology, Zigong Third People's Hospital, Zigong, Sichuang, China
| | - Zhenhua Zhou
- Department of Neurology, School of Medicine, Chongqing University, Chongqing, China; Department of Neurology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
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Shao Y, Chen X, Wang H, Shang Y, Xu J, Zhang J, Wang P, Geng Y. Large mismatch profile predicts rapidly progressing brain edema in acute anterior circulation large vessel occlusion patients undergoing endovascular thrombectomy. Front Neurol 2023; 13:982911. [PMID: 36686510 PMCID: PMC9846046 DOI: 10.3389/fneur.2022.982911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023] Open
Abstract
Background Brain edema is a severe complication in patients with large vessel occlusion (LVO) that can reduce the effectiveness of endovascular therapy (EVT). This study aimed to investigate the association of the perfusion profile at baseline computed tomography (CT) perfusion with rapidly progressing brain edema (RPBE) after EVT in patients with acute anterior LVO. Methods We retrospectively reviewed consecutive data collected from 149 patients with anterior LVO who underwent EVT at our center. Brain edema was measured by the swelling score (0-6 score), and RPBE was defined as the swelling score increased by more than 2 scores within 24 h after EVT. We investigated the effect of RPBE on poor outcomes [National Institute of Health Stroke Scale (NIHSS) score and modified Rankin scale (mRS) score at discharge, the occurrence of hemorrhagic transformation, and mortality rate in the hospital] using the Mann-Whitney U-test and chi-square test. A multivariate logistic regression model was used to assess the relationship between perfusion imaging parameters and RPBE occurrence. Results Overall, 39 patients (26.2%) experienced RPBE after EVT. At discharge, RPBE was associated with higher NIHSS scores (Z = 3.52, 95% CI 2.0-12.0, P < 0.001) and higher mRS scores (Z = 3.67, 95% CI 0.0-1.0, P < 0.001) including the more frequent occurrence of hemorrhagic transformation (χ2 = 22.17, 95% CI 0.29-0.59, P < 0.001) and higher mortality rates in hospital (χ2 = 9.54, 95% CI 0.06-0.36, P = 0.002). Univariate analysis showed that intravenous thrombolysis, baseline ischemic core volume, and baseline mismatch ratio correlated with RPBE (all P < 0.05). After dividing the mismatch ratio into quartiles and performing a chi-square test between quartiles, we found that the occurrence of RPBE in Q4 (mismatch ratio > 11.3) was significantly lower than that in Q1 (mismatch ratio ≤ 3.0) (P < 0.05). The result of multivariate logistic regression analysis showed that compared with baseline mismatch ratio <5.1, baseline mismatch ratio between 5.1 and 11.3 (OR:3.85, 95% CI 1.06-14.29, P = 0.040), and mismatch ratio >11.3 (OR:5.26, 95% CI 1.28-20.00, P = 0.021) were independent protective factors for RPBE. Conclusion In patients with anterior circulation LVO stroke undergoing successful EVT, a large mismatch ratio at baseline is a protective factor for RPBE, which is associated with poor outcomes.
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Affiliation(s)
- Yanqi Shao
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xinyi Chen
- Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Huiyuan Wang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,Department of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Yafei Shang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,Department of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Jie Xu
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jinshi Zhang
- Department of Nephrology, Urology and Nephrology Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Peng Wang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yu Geng
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,*Correspondence: Yu Geng ✉
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Scott XO, Chen SH, Hadad R, Yavagal D, Peterson EC, Starke RM, Dietrich WD, Keane RW, de Rivero Vaccari JP. Cohort study on the differential expression of inflammatory and angiogenic factors in thrombi, cerebral and peripheral plasma following acute large vessel occlusion stroke. J Cereb Blood Flow Metab 2022; 42:1827-1839. [PMID: 35673992 PMCID: PMC9536118 DOI: 10.1177/0271678x221106956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/10/2022] [Accepted: 05/20/2022] [Indexed: 11/17/2022]
Abstract
Inflammation plays an important role in the pathogenesis of stroke. The differential expression of inflammatory and angiogenic factors in thrombi and plasma remain undefined. In this observational cohort study, we evaluated angiogenic factors and inflammatory cytokines, in cerebral thrombi, local cerebral plasma (CP), and peripheral plasma (PP) in patients with acute ischemic stroke. Protein analysis of thrombi, CP and PP were used to measure angiogenic and inflammatory proteins using electrochemiluminescence. Our data indicate that VEGF-A, VEGF-C, bFGF, IL-4, IL-13, IL-1β, IL-2, IL-8, IL-16, IL-6 and IL-12p70 were higher in the thrombi of acute ischemic stroke patients than in the CP and PP of stroke patients. Moreover, the protein levels of GM-CSF were lower in the PP than in the CP and the clot. Moreover, VEGF-D, Flt-1, PIGF, TIE-2, IL-5, TNF-β, IL-15, IL-12/IL-23p40, IFN-γ and IL-17A were higher in PP and CP than in thrombi. Our results show that cytokines mediating the inflammatory response and proteins involved in angiogenesis are differentially expressed in thrombi within the cerebral and peripheral circulations. These data highlight the importance of identifying new biomarkers in different compartments of the circulatory system and in thrombi that may be used for the diagnosis and treatment of stroke patients.
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Affiliation(s)
- Xavier O Scott
- Department of Physiology and Biophysics, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Stephanie H Chen
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Roey Hadad
- Department of Physiology and Biophysics, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Dileep Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eric C Peterson
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Robert M Starke
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
| | - W Dalton Dietrich
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Robert W Keane
- Department of Physiology and Biophysics, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan Pablo de Rivero Vaccari
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
- Center for Cognitive Neuroscience and Aging, University of Miami Miller School of Medicine, Miami, FL, USA
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Tan Q, Shen X, Yang H, Xu X, Guo Y, He J, Liu Q, Du X, Wang D, Zhao L. Buffer Coefficient as a Predictor of the Prognosis of Massive Cerebral Infarction. World Neurosurg 2022; 168:e538-e545. [DOI: 10.1016/j.wneu.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/21/2022]
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Gu Y, Zhou C, Piao Z, Yuan H, Jiang H, Wei H, Zhou Y, Nan G, Ji X. Cerebral edema after ischemic stroke: Pathophysiology and underlying mechanisms. Front Neurosci 2022; 16:988283. [PMID: 36061592 PMCID: PMC9434007 DOI: 10.3389/fnins.2022.988283] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/01/2022] [Indexed: 11/30/2022] Open
Abstract
Ischemic stroke is associated with increasing morbidity and has become the main cause of death and disability worldwide. Cerebral edema is a serious complication arising from ischemic stroke. It causes an increase in intracranial pressure, rapid deterioration of neurological symptoms, and formation of cerebral hernia, and is an important risk factor for adverse outcomes after stroke. To date, the detailed mechanism of cerebral edema after stroke remains unclear. This limits advances in prevention and treatment strategies as well as drug development. This review discusses the classification and pathological characteristics of cerebral edema, the possible relationship of the development of cerebral edema after ischemic stroke with aquaporin 4, the SUR1-TRPM4 channel, matrix metalloproteinase 9, microRNA, cerebral venous reflux, inflammatory reactions, and cerebral ischemia/reperfusion injury. It also summarizes research on new therapeutic drugs for post-stroke cerebral edema. Thus, this review provides a reference for further studies and for clinical treatment of cerebral edema after ischemic stroke.
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Affiliation(s)
- Yuhang Gu
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Chen Zhou
- Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
| | - Zhe Piao
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Honghua Yuan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Huimin Jiang
- Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
| | - Huimin Wei
- Advanced Innovation Center for Big Data-Based Precision Medicine, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yifan Zhou
- Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
| | - Guangxian Nan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
- *Correspondence: Guangxian Nan,
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Xunming Ji,
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Ng FC, Churilov L, Yassi N, Kleinig TJ, Thijs V, Wu TY, Shah DG, Dewey HM, Sharma G, Desmond PM, Yan B, Parsons MW, Donnan GA, Davis SM, Mitchell PJ, Leigh R, Campbell BCV. Reduced Severity of Tissue Injury Within the Infarct May Partially Mediate the Benefit of Reperfusion in Ischemic Stroke. Stroke 2022; 53:1915-1923. [PMID: 35135319 DOI: 10.1161/strokeaha.121.036670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Emerging data suggest tissue within the infarct lesion is not homogenously damaged following ischemic stroke but has a gradient of injury. Using blood-brain-barrier (BBB) disruption as a marker of tissue injury, we tested whether therapeutic reperfusion improves clinical outcome by reducing the severity of tissue injury within the infarct in patients with ischemic stroke. METHODS In a pooled analysis of patients treated for anterior circulation large vessel occlusion in the EXTEND-IA TNK (Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke) and EXTEND-IA part-2 (Determining the Optimal Dose of Tenecteplase Before Endovascular Therapy for Ischaemic Stroke) trials, post-treatment BBB permeability at 24 hours was calculated based on the extent of T1-brightening by extravascular gadolinium on T2* perfusion-weighted imaging and measured within the diffusion-weighted-imaging lesion. First, to determine the clinical significance of BBB disruption as a marker of severity of tissue injury, we examined the association between post-treatment BBB permeability and functional outcome. Second, we performed an exploratory (reperfusion, BBB permeability, functional outcome) mediation analysis to estimate the proportion of the reperfusion-outcome relationship that is mediated by change in BBB permeability. RESULTS In the 238 patients analyzed, an increased BBB permeability measured within the infarct at 24 hours was associated with a reduced likelihood of favorable outcome (90-day modified Rankin Scale score of ≤2) after adjusting for age, baseline National Institutes of Health Stroke Scale, premorbid modified Rankin Scale, infarct topography, laterality, thrombolytic agent, sex, parenchymal hematoma, and follow-up infarct volume (adjusted odds ratio, 0.86 [95% CI, 0.75-0.98], P=0.023). Mediation analysis suggested reducing the severity of tissue injury (as estimated by BBB permeability) accounts for 18.2% of the association between reperfusion and favorable outcome, as indicated by a reduction in the regression coefficient of reperfusion after addition of BBB permeability as a covariate. CONCLUSIONS In patients with ischemic stroke, reduced severity of tissue injury within the infarct, as determined by assessing the integrity of the BBB, is independently associated with improved functional outcome. In addition to reducing diffusion-weighted imaging-defined infarct volume, reperfusion may also improve clinical outcome by reducing tissue injury severity within the infarct.
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Affiliation(s)
- Felix C Ng
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,Department of Neurology, Austin Hospital, Austin Health, Heidelberg, Australia (F.C.N., V.T.)
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia. (L.C., V.T., B.C.V.C.).,Melbourne Medical School, The University of Melbourne, Heidelberg, Victoria, Australia (L.C.)
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia (N.Y.)
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Australia (T.J.K.)
| | - Vincent Thijs
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia. (L.C., V.T., B.C.V.C.).,Department of Neurology, Austin Hospital, Austin Health, Heidelberg, Australia (F.C.N., V.T.)
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, New Zealand (T.Y.W.)
| | - Darshan G Shah
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia (D.G.S.)
| | - Helen M Dewey
- Eastern Health and Eastern Health Clinical School, Department of Neurosciences, Monash University, Clayton, Australia (H.M.D.)
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.)
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (P.M.D., B.Y., P.J.M.)
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (P.M.D., B.Y., P.J.M.)
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.)
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.)
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (P.M.D., B.Y., P.J.M.)
| | - Richard Leigh
- Department of Neurology, John Hopkins University, Baltimore, MD (R.L.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia. (L.C., V.T., B.C.V.C.)
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Ng FC, Churilov L, Yassi N, Kleinig TJ, Thijs V, Wu TY, Shah DG, Dewey HM, Sharma G, Desmond PM, Yan B, Parsons MW, Donnan GA, Davis SM, Mitchell PJ, Leigh R, Campbell BCV. Microvascular Dysfunction in Blood-Brain Barrier Disruption and Hypoperfusion Within the Infarct Posttreatment Are Associated With Cerebral Edema. Stroke 2021; 53:1597-1605. [PMID: 34937423 DOI: 10.1161/strokeaha.121.036104] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Factors contributing to cerebral edema in the post-hyperacute period of ischemic stroke (first 24-72 hours) are poorly understood. Blood-brain barrier (BBB) disruption and postischemic hyperperfusion reflect microvascular dysfunction and are associated with hemorrhagic transformation. We investigated the relationships between BBB integrity, cerebral blood flow, and space-occupying cerebral edema in patients who received acute reperfusion therapy. METHODS We performed a pooled analysis of patients treated for anterior circulation large vessel occlusion in the EXTEND-IA TNK and EXTEND-IA TNK part 2 trials who had MRI with dynamic susceptibility contrast-enhanced perfusion-weighted imaging 24 hours after treatment. We investigated the associations between BBB disruption and cerebral blood flow within the infarct with cerebral edema assessed using 2 metrics: first midline shift (MLS) trichotomized as an ordinal scale of negligible (<1 mm), mild (≥1 to <5 mm), or severe (≥5 mm), and second relative hemispheric volume (rHV), defined as the ratio of the 3-dimensional volume of the ischemic hemisphere relative to the contralateral hemisphere. RESULTS Of 238 patients analyzed, 133 (55.9%) had negligible, 93 (39.1%) mild, and 12 (5.0%) severe MLS at 24 hours. The associated median rHV was 1.01 (IQR, 1.00-1.028), 1.03 (IQR, 1.01-1.077), and 1.15 (IQR, 1.08-1.22), respectively. MLS and rHV were associated with poor functional outcome at 90 days (P<0.002). Increased BBB permeability was independently associated with more edema after adjusting for age, occlusion location, reperfusion, parenchymal hematoma, and thrombolytic agent used (MLS cOR, 1.12 [95% CI, 1.03-1.20], P=0.005; rHV β, 0.39 [95% CI, 0.24-0.55], P<0.0001), as was reduced cerebral blood flow (MLS cOR, 0.25 [95% CI, 0.10-0.58], P=0.001; rHV β, -2.95 [95% CI, -4.61 to -11.29], P=0.0006). In subgroup analysis of patients with successful reperfusion (extended Treatment in Cerebral Ischemia 2b-3, n=200), reduced cerebral blood flow remained significantly associated with edema (MLS cOR, 0.37 [95% CI, 0.14-0.98], P=0.045; rHV β, -2.59 [95% CI, -4.32 to -0.86], P=0.004). CONCLUSIONS BBB disruption and persistent hypoperfusion in the infarct after reperfusion treatment is associated with space-occupying cerebral edema. Further studies evaluating microvascular dysfunction during the post-hyperacute period as biomarkers of poststroke edema and potential therapeutic targets are warranted.
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Affiliation(s)
- Felix C Ng
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.).,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia (F.C.N., V.T.)
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.).,Department of Neurology, Austin Hospital, Austin Health, Heidelberg, Australia (L.C., V.T., B.C.V.C.).,Melbourne Medical School, The University of Melbourne, Heidelberg, Australia (L.C.)
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.).,Population Health and Immunity Division. The Walter and Eliza Hall Institute of Medical Research. Parkville, Australia (N.Y.)
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Australia (T.J.K.)
| | - Vincent Thijs
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia (F.C.N., V.T.).,Department of Neurology, Austin Hospital, Austin Health, Heidelberg, Australia (L.C., V.T., B.C.V.C.)
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, New Zealand (T.Y.W.)
| | - Darshan G Shah
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia (D.G.S.)
| | - Helen M Dewey
- Eastern Health and Eastern Health Clinical School, Department of Neurosciences, Monash University, Clayton, Australia (H.M.D.)
| | - Gargan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (P.M.D., B.Y., P.J.M.)
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.).,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (P.M.D., B.Y., P.J.M.)
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (P.M.D., B.Y., P.J.M.)
| | - Richard Leigh
- Department of Neurology, John Hopkins University, Baltimore, MD (R.L.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.).,Department of Neurology, Austin Hospital, Austin Health, Heidelberg, Australia (L.C., V.T., B.C.V.C.)
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