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Soni M, Wijeratne T, Ackland DC. A risk score for prediction of symptomatic intracerebral haemorrhage following thrombolysis. Int J Med Inform 2021; 156:104586. [PMID: 34649112 DOI: 10.1016/j.ijmedinf.2021.104586] [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: 05/03/2021] [Revised: 08/29/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous recombinant tissue plasminogen activator (rt-PA) remains the only FDA approved pharmacological therapy for acute ischemic stroke (AIS), but this treatment is associated with symptomatic intracerebral haemorrhage (SICH). The aim of this study was to derive and validate an accurate measure of SICH risk in ischemic stroke patients treated with rt-PA using data readily available from patient clinical records. METHODS Demographics, physiological parameters, and clinical data were obtained from 1,270 ischemic stroke patients treated with thrombolysis at 20 hospitals. This included age, sex, weight, blood pressure, glucose levels, smoking preferences, and presence of previous clinical conditions. Using a bivariate analysis on a training dataset of 890 patients, SICH cases were compared against SICH-free patients and key risk factors associated with SICH were identified. Continuous variables were stratified using k-means clustering, and odds ratios computed for each of the categorical risk factors employed in the risk score. The SICH risk score, which was assessed using an independent validation dataset comprising 380 patients, was defined between 0 and 53, and stratified into 4 categories: very low risk (0-6), low risk (7-12), moderate risk (13-19), and high risk (>20). RESULTS Older age (age > 75 years), higher blood pressure, higher severity of stroke, pre-treatment antithrombotic and history of hypertension and hyperlipidaemia, were shown to be significant risk factors for SICH following rt-PA treatment (p < 0.05). A number of interaction effects with age produced greater overall SICH risk than that of individual variables alone, including age*weight, age*NIHSS, age*diastolic blood pressure, and age*hypertension. The SICH prediction tool demonstrated a C-statistic of 0.75 for continuous risk scoring (0-53) and 0.71 for stratified risk levels. CONCLUSION A novel, computationally efficient risk score utilising data readily available from patient clinical records was shown to predict SICH risk following thrombolysis treatment with high accuracy. This tool may be useful for pre-screening patients for SICH risk to reduce the morbidity and mortality associated with thrombolysis treatment.
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Affiliation(s)
- Mukesh Soni
- Department of Biomedical Engineering, The University of Melbourne, Australia
| | - Tissa Wijeratne
- Department of Medicine and Neurology, AIMSS, Melbourne Medical School, University of Melbourne and Western Health, Sunshine Hospital, St. Albans, Victoria, Australia; School of Psychology & Public Health, Department of Psychology & Counselling, La Trobe University, Bundoora, VIC, Australia; Department of Medicine, Faculty of Medicine, University of Rajarata, Saliyapura, Anuradhapura, Sri Lanka
| | - David C Ackland
- Department of Biomedical Engineering, The University of Melbourne, Australia.
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Tseng YJ, Hu RF, Lee ST, Lin YL, Hsu CL, Lin SW, Liou CW, Lee JD, Peng TI, Lee TH. Risk Factors Associated with Outcomes of Recombinant Tissue Plasminogen Activator Therapy in Patients with Acute Ischemic Stroke. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17020618. [PMID: 31963654 PMCID: PMC7014350 DOI: 10.3390/ijerph17020618] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/07/2020] [Accepted: 01/15/2020] [Indexed: 12/26/2022]
Abstract
Ischemic stroke is the most common type of stroke, and early interventional treatment is associated with favorable outcomes. In the guidelines, thrombolytic therapy using recombinant tissue-type plasminogen activator (rt-PA) is recommended for eligible patients with acute ischemic stroke. However, the risk of hemorrhagic complications limits the use of rt-PA, and the risk factors for poor treatment outcomes need to be identified. To identify the risk factors associated with in-hospital poor outcomes in patients treated with rt-PA, we analyzed the electronic medical records of patients who were diagnosed with acute ischemic stroke and treated for rt-PA at Chang Gung Memorial Hospitals from 2006 to 2016. In-hospital death, intensive care unit (ICU) stay, or prolonged hospitalization were defined as unfavorable treatment outcomes. Medical history variables and laboratory test results were considered variables of interest to determine risk factors. Among 643 eligible patients, 537 (83.5%) and 106 (16.5%) patients had favorable and poor outcomes, respectively. In the multivariable analysis, risk factors associated with poor outcomes were female gender, higher stroke severity index (SSI), higher serum glucose levels, lower mean corpuscular hemoglobin concentration (MCHC), lower platelet counts, and anemia. The risk factors found in this research could help us study the treatment strategy for ischemic stroke.
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Affiliation(s)
- Yi-Ju Tseng
- Department of Information Management, Chang Gung University, Taoyuan 33302, Taiwan; (Y.-J.T.)
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan
- Healthy Aging Research Center, Chang Gung University, Taoyuan 33302, Taiwan
| | - Ru-Fang Hu
- Department of Information Management, Chang Gung University, Taoyuan 33302, Taiwan; (Y.-J.T.)
| | - Shin-Tyng Lee
- Department of Information Management, Chang Gung University, Taoyuan 33302, Taiwan; (Y.-J.T.)
| | - Yu-Li Lin
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan 33302, Taiwan
| | - Chien-Lung Hsu
- Department of Information Management, Chang Gung University, Taoyuan 33302, Taiwan; (Y.-J.T.)
- Healthy Aging Research Center, Chang Gung University, Taoyuan 33302, Taiwan
- Graduate Institute of Business and Management, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Visual Communication Design, Ming-Chi University of Technology, New Taipei City 24301, Taiwan
- Department of Nursing, Taoyuan Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Shih-Wei Lin
- Department of Information Management, Chang Gung University, Taoyuan 33302, Taiwan; (Y.-J.T.)
- Department of Industrial Engineering and Management, Ming-Chi University of Technology, New Taipei City 24301, Taiwan
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chia-Wei Liou
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Jiann-Der Lee
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Tsung-I Peng
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Neurology, Keelung Chang Gung Memorial Hospital, Keelung 20401, Taiwan
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Correspondence: ; Tel.: +886-3-3281200 (ext. 8340)
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Lapchak PA, Boitano PD, Bombien R, Cook DJ, Doyan S, Lara JM, Schubert DR. CNB-001, a pleiotropic drug is efficacious in embolized agyrencephalic New Zealand white rabbits and ischemic gyrencephalic cynomolgus monkeys. Exp Neurol 2018; 313:98-108. [PMID: 30521790 DOI: 10.1016/j.expneurol.2018.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/16/2018] [Accepted: 11/30/2018] [Indexed: 01/10/2023]
Abstract
Ischemic stroke is an acute neurodegenerative disease that is extremely devastating to patients, their families and society. Stroke is inadequately treated even with endovascular procedures and reperfusion therapy. Using an extensive translational screening process, we have developed a pleiotropic cytoprotective agent with the potential to positively impact a large population of brain ischemia patients and revolutionize the process used for the development of new drugs to treat complex brain disorders. In this unique translational study article, we document that the novel curcumin-based compound, CNB-001, when administered as a single intravenous dose, has significant efficacy to attenuate clinically relevant behavioral deficits following ischemic events in agyrencephalic rabbits when administered 1 h post-embolization and reduces infarct growth in gyrencephalic non-human primates, when administered 5 min after initiation of middle cerebral artery occlusion. CNB-001 is safe and does not increase morbidity or mortality in either research species. Mechanistically, CNB-001 inhibits human 5- and 15-lipoxygenase in vitro, and can attenuate ischemia-induced inflammatory markers, and oxidative stress markers, while potentially promoting synaptic plasticity mediated by enhanced brain-derived neurotrophic factor (BDNF).
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Affiliation(s)
- Paul A Lapchak
- Neurocore LLC, Western University of Health Sciences, Pomona, CA 91766, USA.
| | | | | | - Douglas J Cook
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | | | | | - David R Schubert
- Cellular Neurobiology Laboratories, The Salk Institute, La Jolla, CA, USA
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Pannexin1 knockout and blockade reduces ischemic stroke injury in female, but not in male mice. Oncotarget 2018; 8:36973-36983. [PMID: 28445139 PMCID: PMC5514885 DOI: 10.18632/oncotarget.16937] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/22/2017] [Indexed: 01/27/2023] Open
Abstract
The membrane channel Pannexin 1 (Panx1) mediates apoptotic and inflammatory signaling cascades in injured neurons, responses previously shown to be sexually dimorphic under ischemic conditions. We tested the hypothesis that Panx1 plays an underlying role in mediating sex differences in stroke outcome responses. Middle-aged, 8-9 month old male and female wild type and Panx1 KO mice were subjected to permanent middle cerebral artery (MCA) occlusion, and infarct size and astrocyte and microglia activation were assessed 4 days later. The sexually dimorphic nature of Panx1 deletion was also explored by testing the effect of probenecid a known Panx1 blocker to alter stroke volume. Panx1 KO females displayed significantly smaller infarct volumes (~ 50 % reduction) compared to their wild-type counterparts, whereas no such KO effect occurred in males. This sex-specific effect of Panx1 KO was recapitulated by significant reductions in peri-infarct inflammation and astrocyte reactivity, as well as smaller infarct volumes in probenecid treated females, but not males. Finally, females showed overall, higher Panx1 protein levels than males under ischemic conditions. These findings unmask a deleterious role for Panx1 in response to permanent MCA occlusion, that is unique to females, and provide several new frameworks for understanding sex differences in stroke outcome.
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Affiliation(s)
- E Clarke Haley
- From the Department of Neurology, University of Virginia Health System, Charlottesville.
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Dong MX, Hu QC, Shen P, Pan JX, Wei YD, Liu YY, Ren YF, Liang ZH, Wang HY, Zhao LB, Xie P. Recombinant Tissue Plasminogen Activator Induces Neurological Side Effects Independent on Thrombolysis in Mechanical Animal Models of Focal Cerebral Infarction: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0158848. [PMID: 27387385 PMCID: PMC4936748 DOI: 10.1371/journal.pone.0158848] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 06/22/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Recombinant tissue plasminogen activator (rtPA) is the only effective drug approved by US FDA to treat ischemic stroke, and it contains pleiotropic effects besides thrombolysis. We performed a meta-analysis to clarify effect of tissue plasminogen activator (tPA) on cerebral infarction besides its thrombolysis property in mechanical animal stroke. METHODS Relevant studies were identified by two reviewers after searching online databases, including Pubmed, Embase, and ScienceDirect, from 1979 to 2016. We identified 6, 65, 17, 12, 16, 12 and 13 comparisons reporting effect of endogenous tPA on infarction volume and effects of rtPA on infarction volume, blood-brain barrier, brain edema, intracerebral hemorrhage, neurological function and mortality rate in all 47 included studies. Standardized mean differences for continuous measures and risk ratio for dichotomous measures were calculated to assess the effects of endogenous tPA and rtPA on cerebral infarction in animals. The quality of included studies was assessed using the Stroke Therapy Academic Industry Roundtable score. Subgroup analysis, meta-regression and sensitivity analysis were performed to explore sources of heterogeneity. Funnel plot, Trim and Fill method and Egger's test were obtained to detect publication bias. RESULTS We found that both endogenous tPA and rtPA had not enlarged infarction volume, or deteriorated neurological function. However, rtPA would disrupt blood-brain barrier, aggravate brain edema, induce intracerebral hemorrhage and increase mortality rate. CONCLUSIONS This meta-analysis reveals rtPA can lead to neurological side effects besides thrombolysis in mechanical animal stroke, which may account for clinical exacerbation for stroke patients that do not achieve vascular recanalization with rtPA.
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Affiliation(s)
- Mei-Xue Dong
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Qing-Chuan Hu
- Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Peng Shen
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun-Xi Pan
- Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - You-Dong Wei
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi-Yun Liu
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi-Fei Ren
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zi-Hong Liang
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hai-Yang Wang
- Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Li-Bo Zhao
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Peng Xie
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Neurobiology, Chongqing, China
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Lapchak PA. Critical early thrombolytic and endovascular reperfusion therapy for acute ischemic stroke victims: a call for adjunct neuroprotection. Transl Stroke Res 2015; 6:345-54. [PMID: 26314402 PMCID: PMC4568436 DOI: 10.1007/s12975-015-0419-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 08/06/2015] [Indexed: 12/28/2022]
Abstract
Today, there is an enormous amount of excitement in the field of stroke victim care due to the recent success of MR. CLEAN, SWIFT PRIME, ESCAPE, EXTEND-IA, and REVASCAT endovascular trials. Successful intravenous (IV) recombinant tissue plasminogen activator (rt-PA) clinical trials [i.e., National Institute of Neurological Disorders and Stroke (NINDS) rt-PA trial, Third European Cooperative Acute Stroke Study (ECASSIII), and Third International Stroke study (IST-3)] also need to be emphasized. In the recent endovascular and thrombolytic trials, there is statistically significant improvement using both the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Score (mRS) scale, but neither approach promotes complete recovery in patients enrolled within any particular NIHSS or mRS score tier. Absolute improvement (mRS 0-2 at 90 days) with endovascular therapy is 13.5-31 %, whereas thrombolytics alone also significantly improve patient functional independence, but to a lesser degree (NINDS rt-PA trial 13 %). This article has 3 main goals: (1) first to emphasize the utility and cost-effectiveness of rt-PA to treat stroke; (2) second to review the recent endovascular trials with respect to efficacy, safety, and cost-effectiveness as a stroke treatment; and (3) to further consider and evaluate strategies to develop novel neuroprotective drugs. A thesis will be put forth so that future stroke trials and therapy development can optimally promote recovery so that stroke victims can return to "normal" life.
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Affiliation(s)
- Paul A Lapchak
- Department of Neurology & Neurosurgery, Cedars-Sinai Medical Center Advanced Healthcare Science Pavilion, 127 S. San Vicente Blvd., Suite 8305, Los Angeles, CA, 90048, USA,
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