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Jödicke RA, Huo S, Kränkel N, Piper SK, Ebinger M, Landmesser U, Flöel A, Endres M, Nave AH. The Dynamic of Extracellular Vesicles in Patients With Subacute Stroke: Results of the "Biomarkers and Perfusion-Training-Induced Changes After Stroke" ( BAPTISe) Study. Front Neurol 2021; 12:731013. [PMID: 34819906 PMCID: PMC8606784 DOI: 10.3389/fneur.2021.731013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/17/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Extracellular vesicles (EV) are sub-1 μm bilayer lipid coated particles and have been shown play a role in long-term cardiovascular outcome after ischemic stroke. However, the dynamic change of EV after stroke and their implications for functional outcome have not yet been elucidated. Methods: Serial blood samples from 110 subacute ischemic stroke patients enrolled in the prospective BAPTISe study were analyzed. All patients participated in the PHYS-STROKE trial and received 4-week aerobic training or relaxation sessions. Levels of endothelial-derived (EnV: Annexin V+, CD45-, CD41-, CD31+/CD144+/CD146+), leukocyte-derived (LV: Annexin V+, CD45+, CD41-), monocytic-derived (MoV: Annexin V+, CD41-, CD14+), neuronal-derived (NV: Annexin V+, CD41-, CD45-, CD31-, CD144-, CD146-, CD56+/CD171+/CD271+), and platelet-derived (PV: Annexin V+, CD41+) EV were assessed via fluorescence-activated cell sorting before and after the trial intervention. The levels of EV at baseline were dichotomized at the 75th percentile, with the EV levels at baseline above the 75th percentile classified as "high" otherwise as "low." The dynamic of EV was classified based on the difference between baseline and post intervention, defining increases above the 75th percentile as "high increase" otherwise as "low increase." Associations of baseline levels and change in EV concentrations with Barthel Index (BI) and cardiovascular events in the first 6 months post-stroke were analyzed using mixed model regression analyses and cox regression. Results: Both before and after intervention PV formed the largest population of vesicles followed by NV and EnV. In mixed-model regression analyses, low NV [-8.57 (95% CI -15.53 to -1.57)] and low PV [-6.97 (95% CI -13.92 to -0.01)] at baseline were associated with lower BI in the first 6 months post-stroke. Patients with low increase in NV [8.69 (95% CI 2.08-15.34)] and LV [6.82 (95% CI 0.25-13.4)] were associated with reduced BI in the first 6 months post-stroke. Neither baseline vesicles nor their dynamic were associated with recurrent cardiovascular events. Conclusion: This is the first report analyzing the concentration and the dynamic of EV regarding associations with functional outcome in patients with subacute stroke. Lower levels of PV and NV at baseline were associated with a worse functional outcome in the first 6 months post-stroke. Furthermore, an increase in NV and LV over time was associated with worse BI in the first 6 months post-stroke. Further investigation of the relationship between EV and their dynamic with functional outcome post-stroke are warranted. Clinical Trial Registration: clinicaltrials.gov/, identifier: NCT01954797.
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Affiliation(s)
- Ruben A Jödicke
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Shufan Huo
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Disease, Partner Site Berlin, Berlin, Germany
| | - Nicolle Kränkel
- Klinik für Kardiologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sophie K Piper
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Ulf Landmesser
- Klinik für Kardiologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Agnes Flöel
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, University Medicine Greifswald, Greifswald, Germany.,German Center for Neurodegenerative Diseases, Rostock/Greifswald, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,German Center for Neurodegenerative Disease, Partner Site Berlin, Berlin, Germany
| | - Alexander H Nave
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Disease, Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
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Müller S, Kufner A, Dell'Orco A, Rackoll T, Mekle R, Piper SK, Fiebach JB, Villringer K, Flöel A, Endres M, Ebinger M, Nave AH. Evolution of Blood-Brain Barrier Permeability in Subacute Ischemic Stroke and Associations With Serum Biomarkers and Functional Outcome. Front Neurol 2021; 12:730923. [PMID: 34744972 PMCID: PMC8567961 DOI: 10.3389/fneur.2021.730923] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: In the setting of acute ischemic stroke, increased blood-brain barrier permeability (BBBP) as a sign of injury is believed to be associated with increased risk of poor outcome. Pre-clinical studies show that selected serum biomarkers including C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNFα), matrix metallopeptidases (MMP), and vascular endothelial growth factors (VEGFs) may play a role in BBBP post-stroke. In the subacute phase of stroke, increased BBBP may also be caused by regenerative mechanisms such as vascular remodeling and therefore may improve functional recovery. Our aim was to investigate the evolution of BBBP in ischemic stroke using contrast-enhanced (CE) magnetic resonance imaging (MRI) and to analyze potential associations with blood-derived biomarkers as well as functional recovery in subacute ischemic stroke patients. Methods: This is an exploratory analysis of subacute ischemic stroke patients enrolled in the BAPTISe study nested within the randomized controlled PHYS-STROKE trial (interventions: 4 weeks of aerobic fitness training vs. relaxation). Patients with at least one CE-MRI before (v1) or after (v2) the intervention were eligible for this analysis. The prevalence of increased BBBP was visually assessed on T1-weighted MR-images based on extent of contrast-agent enhancement within the ischemic lesion. The intensity of increased BBBP was assessed semi-quantitatively by normalizing the mean voxel intensity within the region of interest (ROI) to the contralateral hemisphere (“normalized CE-ROI”). Selected serum biomarkers (high-sensitive CRP, IL-6, TNF-α, MMP-9, and VEGF) at v1 (before intervention) were analyzed as continuous and dichotomized variables defined by laboratory cut-off levels. Functional outcome was assessed at 6 months after stroke using the modified Rankin Scale (mRS). Results: Ninety-three patients with a median baseline NIHSS of 9 [IQR 6–12] were included into the analysis. The median time to v1 MRI was 30 days [IQR 18–37], and the median lesion volume on v1 MRI was 4 ml [IQR 1.2–23.4]. Seventy patients (80%) had increased BBBP visible on v1 MRI. After the trial intervention, increased BBBP was still detectable in 52 patients (74%) on v2 MRI. The median time to v2 MRI was 56 days [IQR 46–67]. The presence of increased BBBP on v1 MRI was associated with larger lesion volumes and more severe strokes. Aerobic fitness training did not influence the increase of BBBP evaluated at v2. In linear mixed models, the time from stroke onset to MRI was inversely associated with normalized CE-ROI (coefficient −0.002, Standard Error 0.007, p < 0.01). Selected serum biomarkers were not associated with the presence or evolution of increased BBBP. Multivariable regression analysis did not identify the occurrence or evolution of increased BBBP as an independent predictor of favorable functional outcome post-stroke. Conclusion: In patients with moderate-to-severe subacute stroke, three out of four patients demonstrated increased BBB permeability, which decreased over time. The presence of increased BBBP was associated with larger lesion volumes and more severe strokes. We could not detect an association between selected serum biomarkers of inflammation and an increased BBBP in this cohort. No clear association with favorable functional outcome was observed. Trial registration: NCT01954797.
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Affiliation(s)
- Sarah Müller
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Anna Kufner
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie - Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Andrea Dell'Orco
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Torsten Rackoll
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,BIH QUEST - Center for Transforming Biomedical Research, Berlin Institute of Health (BIH), Berlin, Germany.,ExcellenceCluster NeuroCure, Charite-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Ralf Mekle
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Sophie K Piper
- Berlin Institute of Health (BIH), Berlin, Germany.,Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Agnes Flöel
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany.,German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie - Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,ExcellenceCluster NeuroCure, Charite-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Alexander H Nave
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie - Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany
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Kufner A, Khalil AA, Galinovic I, Kellner E, Mekle R, Rackoll T, Boehm-Sturm P, Fiebach JB, Flöel A, Ebinger M, Endres M, Nave AH. Magnetic resonance imaging-based changes in vascular morphology and cerebral perfusion in subacute ischemic stroke. J Cereb Blood Flow Metab 2021; 41:2617-2627. [PMID: 33866849 PMCID: PMC8504415 DOI: 10.1177/0271678x211010071] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
MRI-based vessel size imaging (VSI) allows for in-vivo assessment of cerebral microvasculature and perfusion. This exploratory analysis of vessel size (VS) and density (Q; both assessed via VSI) in the subacute phase of ischemic stroke involved sixty-two patients from the BAPTISe cohort ('Biomarkers And Perfusion--Training-Induced changes after Stroke') nested within a randomized controlled trial (intervention: 4-week training vs. relaxation). Relative VS, Q, cerebral blood volume (rCBV) and -flow (rCBF) were calculated for: ischemic lesion, perilesional tissue, and region corresponding to ischemic lesion on the contralateral side (mirrored lesion). Linear mixed-models detected significantly increased rVS and decreased rQ within the ischemic lesion compared to the mirrored lesion (coefficient[standard error]: 0.2[0.08] p = 0.03 and -1.0[0.3] p = 0.02, respectively); lesion rCBF and rCBV were also significantly reduced. Mixed-models did not identify time-to-MRI, nor training as modifying factors in terms of rVS or rQ up to two months post-stroke. Larger lesion VS was associated with larger lesion volumes (β 34, 95%CI 6.2-62; p = 0.02) and higher baseline NIHSS (β 3.0, 95%CI 0.49-5.3;p = 0.02), but was not predictive of six-month outcome. In summary, VSI can assess the cerebral microvasculature and tissue perfusion in the subacute phases of ischemic stroke, and may carry relevant prognostic value in terms of lesion volume and stroke severity.
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Affiliation(s)
- Anna Kufner
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Ahmed A Khalil
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,School of Mind and Brain, Humboldt Universität zu Berlin, Berlin, Germany.,Department of Neurology, Max Plank Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Ivana Galinovic
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Elias Kellner
- Department of Radiology, Medical Physics, University Medical Center Freiburg, Freiburg, Germany
| | - Ralf Mekle
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Torsten Rackoll
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany.,QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany.,ExcellenceCluster NeuroCure, Charite-Universitätsmedizin Berlin, Berlin, Germany
| | - Philipp Boehm-Sturm
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany.,NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Agnes Flöel
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany.,Department of Neurology, University Medicine Greifswald, Greifswald, Germany.,German Center for Neurodegenerative Diseases, Partner Site Rostock/Greifswald, Greifswald, Germany
| | - Martin Ebinger
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany.,Department of Neurology, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,ExcellenceCluster NeuroCure, Charite-Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - Alexander H Nave
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany
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Kirzinger B, Stroux A, Rackoll T, Endres M, Flöel A, Ebinger M, Nave AH. Elevated Serum Inflammatory Markers in Subacute Stroke Are Associated With Clinical Outcome but Not Modified by Aerobic Fitness Training: Results of the Randomized Controlled PHYS-STROKE Trial. Front Neurol 2021; 12:713018. [PMID: 34512526 PMCID: PMC8426903 DOI: 10.3389/fneur.2021.713018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/28/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Inflammatory markers, such as C-reactive Protein (CRP), Interleukin-6 (IL-6), tumor necrosis factor (TNF)-alpha and fibrinogen, are upregulated following acute stroke. Studies have shown associations of these biomarkers with increased mortality, recurrent vascular risk, and poor functional outcome. It is suggested that physical fitness training may play a role in decreasing long-term inflammatory activity and supports tissue recovery. Aim: We investigated the dynamics of selected inflammatory markers in the subacute phase following stroke and determined if fluctuations are associated with functional recovery up to 6 months. Further, we examined whether exposure to aerobic physical fitness training in the subacute phase influenced serum inflammatory markers over time. Methods: This is an exploratory analysis of patients enrolled in the multicenter randomized-controlled PHYS-STROKE trial. Patients within 45 days of stroke onset were randomized to receive either four weeks of aerobic physical fitness training or relaxation sessions. Generalized estimating equation models were used to investigate the dynamics of inflammatory markers and the associations of exposure to fitness training with serum inflammatory markers over time. Multiple logistic regression models were used to explore associations between inflammatory marker levels at baseline and three months after stroke and outcome at 3- or 6-months. Results: Irrespective of the intervention group, high sensitive CRP (hs-CRP), IL-6, and fibrinogen (but not TNF-alpha) were significantly lower at follow-up visits when compared to baseline (p all ≤ 0.01). In our cohort, exposure to aerobic physical fitness training did not influence levels of inflammatory markers over time. In multivariate logistic regression analyses, increased baseline IL-6 and fibrinogen levels were inversely associated with worse outcome at 3 and 6 months. Increased levels of hs-CRP at 3 months after stroke were associated with impaired outcome at 6 months. We found no independent associations of TNF-alpha levels with investigated outcome parameters. Conclusion: Serum markers of inflammation were elevated after stroke and decreased within 6 months. In our cohort, exposure to aerobic physical fitness training did not modify the dynamics of inflammatory markers over time. Elevated IL-6 and fibrinogen levels in early subacute stroke were associated with worse outcome up to 6-months after stroke. Clinical Trial Registration:ClinicalTrials.gov, NCT01953549.
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Affiliation(s)
- Bernadette Kirzinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andrea Stroux
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Torsten Rackoll
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health QUEST Center for Transforming Biomedical Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Klinik Und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases, Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Agnes Flöel
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany.,German Center for Neurodegenerative Diseases, Partner Site Rostock/Greifswald, Greifswald, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Alexander Heinrich Nave
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Klinik Und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
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Rackoll T, Nave AH, Ebinger M, Endres M, Grittner U, Flöel A. Physical Fitness Training in Patients with Subacute Stroke (PHYS-STROKE): Safety analyses of a randomized clinical trial. Int J Stroke 2021; 17:93-100. [PMID: 33724085 PMCID: PMC8739607 DOI: 10.1177/17474930211006286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and aim To report the six-month safety analyses among patients enrolled in the “Physical Fitness Training in Subacute Stroke—PHYS-STROKE” trial and identify underlying risk factors associated with serious adverse events. Methods We performed a pre-specified safety analysis of a multicenter, randomized controlled, endpoint-blinded trial comprising 200 patients with moderate to severe subacute stroke (days 5–45 after stroke) that were randomly assigned (1:1) to receive either aerobic, bodyweight supported, treadmill-based training (n = 105), or relaxation sessions (n = 95, control group). Each intervention session lasted for 25 min, five times weekly for four weeks, in addition to standard rehabilitation therapy. Serious adverse events defined as cerebro- and cardiovascular events, readmission to hospital, and death were assessed during six months of follow-up. Incident rate ratios (IRR) were calculated, and Poisson regression analyses were conducted to identify risk factors for serious adverse events and to test the association with aerobic training. Results Six months after stroke, 50 serious adverse events occurred in the trial with a higher incidence rate (per 100 patient-months) in the training group compared to the relaxation group (6.31 vs. 3.22; IRR 1.70, 95% CI 0.96 to 3.12). The association of aerobic training with serious adverse events incidence rates were modified by diabetes mellitus (IRR for interaction: 7.10, 95% CI 1.56 to 51.24) and by atrial fibrillation (IRR for interaction: 4.37, 95% CI 0.97 to 31.81). Conclusions Safety analysis of the PHYS-STROKE trial found a higher rate of serious adverse events in patients randomized to aerobic training compared to control within six months after stroke. Exploratory analyses found an association between serious adverse events occurrence in the aerobic training group with pre-existing diabetes mellitus and atrial fibrillation which should be further investigated in future trials. Data access statement The raw data and analyses scripts are provided by the authors on a secure online repository for reproduction of reported findings.
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Affiliation(s)
- Torsten Rackoll
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health QUEST Center for Transforming Biomedical Research Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander H Nave
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| | - Ulrike Grittner
- Berlin Institute of Health (BIH), Berlin, Germany.,Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Agnes Flöel
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, University Medicine Greifswald, Greifswald, Germany
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Nave AH, Rackoll T, Grittner U, Bläsing H, Gorsler A, Nabavi DG, Audebert HJ, Klostermann F, Müller-Werdan U, Steinhagen-Thiessen E, Meisel A, Endres M, Hesse S, Ebinger M, Flöel A. Physical Fitness Training in Patients with Subacute Stroke (PHYS-STROKE): multicentre, randomised controlled, endpoint blinded trial. BMJ 2019; 366:l5101. [PMID: 31533934 PMCID: PMC6749174 DOI: 10.1136/bmj.l5101] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the safety and efficacy of aerobic exercise on activities of daily living in the subacute phase after stroke. DESIGN Multicentre, randomised controlled, endpoint blinded trial. SETTING Seven inpatient rehabilitation sites in Germany (2013-17). PARTICIPANTS 200 adults with subacute stroke (days 5-45 after stroke) with a median National Institutes of Health stroke scale (NIHSS, range 0-42 points, higher values indicating more severe strokes) score of 8 (interquartile range 5-12) were randomly assigned (1:1) to aerobic physical fitness training (n=105) or relaxation sessions (n=95, control group) in addition to standard care. INTERVENTION Participants received either aerobic, bodyweight supported, treadmill based physical fitness training or relaxation sessions, each for 25 minutes, five times weekly for four weeks, in addition to standard rehabilitation therapy. Investigators and endpoint assessors were masked to treatment assignment. MAIN OUTCOME MEASURES The primary outcomes were change in maximal walking speed (m/s) in the 10 m walking test and change in Barthel index scores (range 0-100 points, higher scores indicating less disability) three months after stroke compared with baseline. Safety outcomes were recurrent cardiovascular events, including stroke, hospital readmissions, and death within three months after stroke. Efficacy was tested with analysis of covariance for each primary outcome in the full analysis set. Multiple imputation was used to account for missing values. RESULTS Compared with relaxation, aerobic physical fitness training did not result in a significantly higher mean change in maximal walking speed (adjusted treatment effect 0.1 m/s (95% confidence interval 0.0 to 0.2 m/s), P=0.23) or mean change in Barthel index score (0 (-5 to 5), P=0.99) at three months after stroke. A higher rate of serious adverse events was observed in the aerobic group compared with relaxation group (incidence rate ratio 1.81, 95% confidence interval 0.97 to 3.36). CONCLUSIONS Among moderately to severely affected adults with subacute stroke, aerobic bodyweight supported, treadmill based physical fitness training was not superior to relaxation sessions for maximal walking speed and Barthel index score but did suggest higher rates of adverse events. These results do not appear to support the use of aerobic bodyweight supported fitness training in people with subacute stroke to improve activities of daily living or maximal walking speed and should be considered in future guidelines. TRIAL REGISTRATION ClinicalTrials.gov NCT01953549.
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Affiliation(s)
- Alexander H Nave
- Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research, partner site Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Torsten Rackoll
- Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Kliniken Beelitz, Beelitz-Heilstätten, Germany
| | - Ulrike Grittner
- Berlin Institute of Health, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Darius G Nabavi
- Vivantes Klinikum Neukölln, Klinik für Neurologie, Berlin, Germany
| | - Heinrich J Audebert
- Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Klostermann
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Andreas Meisel
- Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research, partner site Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases, partner site Berlin, Germany
| | - Stefan Hesse
- Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Martin Ebinger
- Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Agnes Flöel
- Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruch-Strasse, 17475 Greifswald, Germany
- German Center for Neurodegenerative Diseases, partner site Rostock/Greifswald, Germany
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7
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Oliveira DMG, Aguiar LT, de Oliveira Limones MV, Gomes AG, da Silva LC, de Morais Faria CDC, Scalzo PL. Aerobic Training Efficacy in Inflammation, Neurotrophins, and Function in Chronic Stroke Persons: A Randomized Controlled Trial Protocol. J Stroke Cerebrovasc Dis 2018; 28:418-424. [PMID: 30420316 DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/10/2018] [Accepted: 10/11/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Neuroinflammation is an important part of stroke pathophysiology and has both detrimental and beneficial effects after stroke. Besides that the enhancement of neurotrophins seems to be related to improvements in stroke recovery. Evidences suggest that exercise plays a role in modulating anti-inflammatory and neurotrophic effects. However, little is known about its impact in stroke survivors, mainly in chronic stroke. The purpose of this study is to investigate the efficacy of moderate-intensity treadmill exercise in changing inflammatory mediators, interleukin-6 (IL-6), soluble tumor necrosis factor receptors I and II (sTNFRI, sTNFRII), interleukin-10 (IL-10), and brain-derived neurotrophic factor (BDNF) levels in chronic stroke patients. The secondary objective is to investigate the effects of training in improve mobility and exercise capacity. METHODS This is a randomized controlled trial. Chronic stroke patients will be randomized to an experimental or control group, and will receive group interventions three times per week, over 12 weeks. The experimental group will receive moderate-intensity (60%-80% of maximum heart rate reserve) treadmill exercise. Control group will perform walking training on the ground (<40% of maximum heart rate reserve). Primary outcomes include IL-6, sTNFRI, sTNFRII, IL-10, and BDNF levels. Secondary outcomes include mobility and exercise capacity. Outcomes will be measured at baseline, postintervention, and at the 4-week follow-up. DISCUSSION The findings of this trial have the potential to provide important insights regarding the effects of an aerobic physical program in the inflammatory process and in the neuronal plasticity in stroke persons and its impact on mobility and exercise capacity.
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Affiliation(s)
| | - Larissa Tavares Aguiar
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | | | - Aline Gonçalves Gomes
- Neuroscience Programme, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Luana Cristina da Silva
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | | | - Paula Luciana Scalzo
- Department of Morphology, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
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8
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Dromerick AW, Edwardson MA, Edwards DF, Giannetti ML, Barth J, Brady KP, Chan E, Tan MT, Tamboli I, Chia R, Orquiza M, Padilla RM, Cheema AK, Mapstone ME, Fiandaca MS, Federoff HJ, Newport EL. Critical periods after stroke study: translating animal stroke recovery experiments into a clinical trial. Front Hum Neurosci 2015; 9:231. [PMID: 25972803 PMCID: PMC4413691 DOI: 10.3389/fnhum.2015.00231] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 04/10/2015] [Indexed: 12/20/2022] Open
Abstract
Introduction: Seven hundred ninety-five thousand Americans will have a stroke this year, and half will have a chronic hemiparesis. Substantial animal literature suggests that the mammalian brain has much potential to recover from acute injury using mechanisms of neuroplasticity, and that these mechanisms can be accessed using training paradigms and neurotransmitter manipulation. However, most of these findings have not been tested or confirmed in the rehabilitation setting, in large part because of the challenges in translating a conceptually straightforward laboratory experiment into a meaningful and rigorous clinical trial in humans. Through presentation of methods for a Phase II trial, we discuss these issues and describe our approach. Methods: In rodents there is compelling evidence for timing effects in rehabilitation; motor training delivered at certain times after stroke may be more effective than the same training delivered earlier or later, suggesting that there is a critical or sensitive period for strongest rehabilitation training effects. If analogous critical/sensitive periods can be identified after human stroke, then existing clinical resources can be better utilized to promote recovery. The Critical Periods after Stroke Study (CPASS) is a phase II randomized, controlled trial designed to explore whether such a sensitive period exists. We will randomize 64 persons to receive an additional 20 h of upper extremity therapy either immediately upon rehab admission, 2–3 months after stroke onset, 6 months after onset, or to an observation-only control group. The primary outcome measure will be the Action Research Arm Test (ARAT) at 1 year. Blood will be drawn at up to 3 time points for later biomarker studies. Conclusion: CPASS is an example of the translation of rodent motor recovery experiments into the clinical setting; data obtained from this single site randomized controlled trial will be used to finalize the design of a Phase III trial.
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Affiliation(s)
- Alexander W Dromerick
- Department of Rehabilitation Medicine, Center for Brain Plasticity and Recovery, Georgetown University and MedStar National Rehabilitation Hospital Washington, DC, USA ; Department of Neurology, Georgetown University Washington, DC, USA
| | - Matthew A Edwardson
- Department of Rehabilitation Medicine, Center for Brain Plasticity and Recovery, Georgetown University and MedStar National Rehabilitation Hospital Washington, DC, USA ; Department of Neurology, Georgetown University Washington, DC, USA
| | - Dorothy F Edwards
- Department of Kinesiology and Occupational Therapy, University of Wisconsin Madison, WI, USA
| | - Margot L Giannetti
- Department of Rehabilitation Medicine, Center for Brain Plasticity and Recovery, Georgetown University and MedStar National Rehabilitation Hospital Washington, DC, USA
| | - Jessica Barth
- Department of Rehabilitation Medicine, Center for Brain Plasticity and Recovery, Georgetown University and MedStar National Rehabilitation Hospital Washington, DC, USA
| | - Kathaleen P Brady
- Department of Rehabilitation Medicine, Center for Brain Plasticity and Recovery, Georgetown University and MedStar National Rehabilitation Hospital Washington, DC, USA
| | - Evan Chan
- Department of Rehabilitation Medicine, Center for Brain Plasticity and Recovery, Georgetown University and MedStar National Rehabilitation Hospital Washington, DC, USA
| | - Ming T Tan
- Department of Biostatistics, Georgetown University Washington, DC, USA
| | - Irfan Tamboli
- Department of Neuroscience, Georgetown University Washington, DC, USA
| | - Ruth Chia
- Department of Neuroscience, Georgetown University Washington, DC, USA
| | - Michael Orquiza
- Department of Neuroscience, Georgetown University Washington, DC, USA
| | - Robert M Padilla
- Department of Neuroscience, Georgetown University Washington, DC, USA
| | - Amrita K Cheema
- Departments of Oncology and Biochemistry, Georgetown University Washington, DC, USA
| | - Mark E Mapstone
- Department of Neurology, University of Rochester Rochester, NY, USA
| | - Massimo S Fiandaca
- Department of Neurology, Georgetown University Washington, DC, USA ; Department of Neuroscience, Georgetown University Washington, DC, USA
| | - Howard J Federoff
- Department of Neurology, Georgetown University Washington, DC, USA ; Department of Neuroscience, Georgetown University Washington, DC, USA
| | - Elissa L Newport
- Department of Rehabilitation Medicine, Center for Brain Plasticity and Recovery, Georgetown University and MedStar National Rehabilitation Hospital Washington, DC, USA ; Department of Neurology, Georgetown University Washington, DC, USA
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9
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Hsieh YW, Lin KC, Korivi M, Lee TH, Wu CY, Wu KY. The reliability and predictive ability of a biomarker of oxidative DNA damage on functional outcomes after stroke rehabilitation. Int J Mol Sci 2014; 15:6504-16. [PMID: 24743892 PMCID: PMC4013643 DOI: 10.3390/ijms15046504] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 04/02/2014] [Accepted: 04/04/2014] [Indexed: 11/16/2022] Open
Abstract
We evaluated the reliability of 8-hydroxy-2′-deoxyguanosine (8-OHdG), and determined its ability to predict functional outcomes in stroke survivors. The rehabilitation effect on 8-OHdG and functional outcomes were also assessed. Sixty-one stroke patients received a 4-week rehabilitation. Urinary 8-OHdG levels were determined by liquid chromatography–tandem mass spectrometry. The test-retest reliability of 8-OHdG was good (interclass correlation coefficient = 0.76). Upper-limb motor function and muscle power determined by the Fugl-Meyer Assessment (FMA) and Medical Research Council (MRC) scales before rehabilitation showed significant negative correlation with 8-OHdG (r = −0.38, r = −0.30; p < 0.05). After rehabilitation, we found a fair and significant correlation between 8-OHdG and FMA (r = −0.34) and 8-OHdG and pain (r = 0.26, p < 0.05). Baseline 8-OHdG was significantly correlated with post-treatment FMA, MRC, and pain scores (r = −0.34, −0.31, and 0.25; p < 0.05), indicating its ability to predict functional outcomes. 8-OHdG levels were significantly decreased, and functional outcomes were improved after rehabilitation. The exploratory study findings conclude that 8-OHdG is a reliable and promising biomarker of oxidative stress and could be a valid predictor of functional outcomes in patients. Monitoring of behavioral indicators along with biomarkers may have crucial benefits in translational stroke research.
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Affiliation(s)
- Yu-Wei Hsieh
- Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Keh-Chung Lin
- School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei 100, Taiwan.
| | - Mallikarjuna Korivi
- Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Ching-Yi Wu
- Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Kuen-Yuh Wu
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University, Taipei 100, Taiwan.
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