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Zhao E, Barber J, Mathew-Steiner SS, Khanna S, Sen CK, Arciero J. Modeling cerebrovascular responses to assess the impact of the collateral circulation following middle cerebral artery occlusion. Microcirculation 2024; 31:e12849. [PMID: 38354046 PMCID: PMC11014771 DOI: 10.1111/micc.12849] [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: 10/13/2023] [Revised: 01/08/2024] [Accepted: 01/25/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE An improved understanding of the role of the leptomeningeal collateral circulation in blood flow compensation following middle cerebral artery (MCA) occlusion can contribute to more effective treatment development for ischemic stroke. The present study introduces a model of the cerebral circulation to predict cerebral blood flow and tissue oxygenation following MCA occlusion. METHODS The model incorporates flow regulation mechanisms based on changes in pressure, shear stress, and metabolic demand. Oxygen saturation in cerebral vessels and tissue is calculated using a Krogh cylinder model. The model is used to assess the effects of changes in oxygen demand and arterial pressure on cerebral blood flow and oxygenation after MCA occlusion. RESULTS An increase from five to 11 leptomeningeal collateral vessels was shown to increase the oxygen saturation in the region distal to the occlusion by nearly 100%. Post-occlusion, the model also predicted a loss of autoregulation and a decrease in flow to the ischemic territory as oxygen demand was increased; these results were consistent with data from experiments that induced cerebral ischemia. CONCLUSIONS This study highlights the importance of leptomeningeal collaterals following MCA occlusion and reinforces the idea that lower oxygen demand and higher arterial pressure improve conditions of flow and oxygenation.
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Affiliation(s)
- Erin Zhao
- Department of Mathematical Sciences, Indiana University-Purdue University Indianapolis, 402 N. Blackford Street, LD 270, Indianapolis, IN 46202
| | - Jared Barber
- Department of Mathematical Sciences, Indiana University-Purdue University Indianapolis, 402 N. Blackford Street, LD 270, Indianapolis, IN 46202
| | - Shomita S. Mathew-Steiner
- McGowan Institute for Regenerative Medicine, University of Pittsburgh School of Medicine, 450 Technology Drive, Suite 300, Pittsburgh, PA 15219
| | - Savita Khanna
- McGowan Institute for Regenerative Medicine, University of Pittsburgh School of Medicine, 450 Technology Drive, Suite 300, Pittsburgh, PA 15219
| | - Chandan K. Sen
- McGowan Institute for Regenerative Medicine, University of Pittsburgh School of Medicine, 450 Technology Drive, Suite 300, Pittsburgh, PA 15219
| | - Julia Arciero
- Department of Mathematical Sciences, Indiana University-Purdue University Indianapolis, 402 N. Blackford Street, LD 270, Indianapolis, IN 46202
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Savitz SI, Baron JC, Fisher M, Albers GW, Arbe-Barnes S, Boltze J, Broderick J, Broschat KO, Elkind MSV, En’Wezoh D, Furlan AJ, Gorelick PB, Grotta J, Hancock AM, Hess DC, Holt W, Houser G, Hsia AW, Kim WK, Korinek WS, Le Moan N, Liberman M, Lilienfeld S, Luby M, Lynch JK, Mansi C, Simpkins AN, Nadareishvili Z, Nogueira RG, Pryor KE, Sanossian N, Schwamm LH, Selim M, Sheth KN, Spilker J, Solberg Y, Steinberg GK, Stice S, Tymianski M, Wechsler LR, Yoo AJ. Stroke Treatment Academic Industry Roundtable X. Stroke 2019; 50:1026–1031. [DOI: 10.1161/strokeaha.118.023927] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Sean I. Savitz
- From the Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center at Houston, (S.I.S.)
| | - Jean-Claude Baron
- Department of Neurology, Hôpital Sainte-Anne, University Paris Descartes, INSERM U1266, France (J.-C.B.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.F.)
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3
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Saqqur M, Khan K, Derksen C, Alexandrov A, Shuaib A. Transcranial Doppler and Transcranial Color Duplex in Defining Collateral Cerebral Blood Flow. J Neuroimaging 2018; 28:455-476. [DOI: 10.1111/jon.12535] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/18/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- Maher Saqqur
- Division of Neurology, Department of Medicine; University of Alberta; Edmonton AB Canada
- Neuroscience Institute; Hamad General Hospital Doha Qatar
| | - Khurshid Khan
- Division of Neurology, Department of Medicine; University of Alberta; Edmonton AB Canada
| | - Carol Derksen
- Division of Neurology, Department of Medicine; University of Alberta; Edmonton AB Canada
| | - Andrei Alexandrov
- Department of Neurology; University of Tennessee Health Science Center; Memphis TN USA
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine; University of Alberta; Edmonton AB Canada
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5
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Zou C, Hao L, Tian H, Song C, Zhang Y, Zhou H, Liu L. The Effect of Sympathetic Denervation on Cerebral Arteriogenesis After Chronic Cerebral Hypoperfusion. Am J Med Sci 2016; 351:616-22. [PMID: 27238926 DOI: 10.1016/j.amjms.2016.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/01/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To explore the effect of perivascular sympathetic nerve on cerebral collateral arteriogenesis in chronic cerebral hypoperfusion models of rats. MATERIALS AND METHODS Chronic cerebral hypoperfusion model was established by right common carotid artery ligation for 8 weeks, while sympathetic denervation was performed by superior cervical ganglionectomy. The male Sprague-Dawley rats were randomly divided into 4 groups including sham group (n = 21), denervation group (n = 21), artery ligation group (n = 21) and combined group with both artery ligation and denervation (n = 21). After 8 weeks of surgery, the rats in each group were randomly divided into 3 subgroups including subgroup A (n = 7), subgroup B (n = 7) and subgroup C (n = 7). The 3 subgroups were subjected to latex perfusion, permanent right middle cerebral artery occlusion and immunohistochemical staining, respectively. RESULTS The diameters of right leptomeningeal anastomoses in artery ligation group significantly enlarged compared with sham group. When sympathetic denervation was performed in the presence of artery ligation, diameter of collateral vessel decreased, although larger than in sham group. After 8 weeks of permanent right middle cerebral artery occlusion, the cerebral perfusion over the right middle cerebral artery area in combined group was significantly lower than in artery ligation group, although both were higher than in denervation group and sham group. Triphenyltetrazolium chloride staining showed that cerebral infarct volume in combined group was significantly larger than in artery ligation group, and smaller than in denervation group and sham group. Neurologic functional scoring showed that scores in combined group were significantly higher than in artery ligation group, and lower than in denervation group and sham group. Immunohistochemical staining for α-smooth muscle actin showed that compared with sham group, tunica media thickness of right leptomeningeal anastomoses in artery ligation group increased significantly. Thickness in combined group was thinner than in artery ligation group, although thicker than in sham group. CONCLUSIONS Perivascular sympathetic denervation can impair the cerebral collateral arteriogenesis under condition of chronic cerebral hypoperfusion.
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Affiliation(s)
- Can Zou
- Department of Neurology, No.324 Hospital of PLA, Chongqing, China
| | - Lei Hao
- Department of Neurology, No.324 Hospital of PLA, Chongqing, China
| | - Hong Tian
- Department of Neurology, No.324 Hospital of PLA, Chongqing, China
| | - Chuan Song
- Department of Neurology, No.324 Hospital of PLA, Chongqing, China
| | - Yubo Zhang
- Department of Neurology, No.324 Hospital of PLA, Chongqing, China
| | - Huchuan Zhou
- Department of Neurology, No.324 Hospital of PLA, Chongqing, China
| | - Lei Liu
- Department of Neurology, No.324 Hospital of PLA, Chongqing, China.
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Canavero I, Sherburne HA, Tremble SM, Clark WM, Cipolla MJ. Effects of Acute Stroke Serum on Non-Ischemic Cerebral and Mesenteric Vascular Function. Transl Stroke Res 2016; 7:156-65. [PMID: 26809954 DOI: 10.1007/s12975-016-0449-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/17/2015] [Accepted: 01/08/2016] [Indexed: 02/03/2023]
Abstract
We investigated the effects of circulating factors in serum obtained from patients in the acute phase of different subtypes of ischemic stroke on non-ischemic cerebral and mesenteric arteries, as a potential mechanism involved in influencing regional perfusion and thus clinical evolution. Posterior cerebral arteries (PCAs) and mesentery arteries (MAs) isolated from Wistar Kyoto rats were perfused with serum from acute stroke patients with large vessel disease without (LVD) or with hypertension (LVD + HTN), cardioembolism with hypertension (CE + HTN), or physiologic saline as controls. Myogenic activity and nitric oxide-dependent vasorelaxation were assessed after 2 h of intraluminal exposure to serum. Vascular function was differentially affected by sera. Exposure to LVD serum increased myogenic tone and produced endothelial dysfunction in both PCAs and MAs. However, CE + HTN serum increased tone and decreased smooth muscle sensitivity to NO in vessels from both vascular beds. LVD + HTN serum was associated with reduced smooth muscle sensitivity to NO in vessels from both vascular beds but increased tone only in PCAs. Inflammation and oxidative stress, determined by measurement of high sensitivity C-reactive protein, uric acid, and free 8-isoprostane, were enhanced in all the serum groups. These results demonstrate vasoactive properties of acute stroke serum related to stroke subtypes that could potentially contribute to the pathogenesis of early hemodynamic-based clinical events.
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Affiliation(s)
- Isabella Canavero
- Department of Neurological Sciences, University of Vermont College of Medicine, 149 Beaumont Ave., HSRF 416A, Burlington, VT, 05405, USA
| | - Helene A Sherburne
- Department of Neurological Sciences, University of Vermont College of Medicine, 149 Beaumont Ave., HSRF 416A, Burlington, VT, 05405, USA
| | - Sarah M Tremble
- Department of Neurological Sciences, University of Vermont College of Medicine, 149 Beaumont Ave., HSRF 416A, Burlington, VT, 05405, USA
| | - Wayne M Clark
- Department of Neurology, Oregon Stroke Center, Oregon Health and Science University, Portland, OR, USA
| | - Marilyn J Cipolla
- Department of Neurological Sciences, University of Vermont College of Medicine, 149 Beaumont Ave., HSRF 416A, Burlington, VT, 05405, USA. .,Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont College of Medicine, Burlington, VT, USA. .,Department of Pharmacology, University of Vermont College of Medicine, Burlington, VT, USA.
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Affiliation(s)
- D S Liebeskind
- Neurovascular Imaging Research Core and the UCLA Stroke Center, Los Angeles, CA, USA.
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Tóth M, Little P, Arnberg F, Häggkvist J, Mulder J, Halldin C, Gulyás B, Holmin S. Acute neuroinflammation in a clinically relevant focal cortical ischemic stroke model in rat: longitudinal positron emission tomography and immunofluorescent tracking. Brain Struct Funct 2015; 221:1279-90. [PMID: 25601153 DOI: 10.1007/s00429-014-0970-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 12/14/2014] [Indexed: 01/17/2023]
Abstract
Adequate estimation of neuroinflammatory processes following ischemic stroke is essential for better understanding of disease mechanisms, and for the development of treatment strategies. With the TSPO (18 kDa translocator protein) positron emission tomography (PET) radioligand [(11)C]PBR28, we monitored longitudinally the inflammatory response post-transient cerebral ischemia in rats, using a recently developed rat stroke model that produces isolated focal cortical infarcts with clinical relevance in size and pathophysiology. Six Sprague-Dawley rats were subjected to 90 min transient endovascular occlusion of the M2 segment of the middle cerebral artery (M2CAO). Animals were imaged with a nanoScan(®) PET/MRI system at 1, 4, 7 and 14 days after M2CAO with a bolus injection of [(11)C]PBR28. In the infarct region, we found a significantly increased uptake of [(11)C]PBR28 on day 4, 7 and 14 compared to day 1 as well as compared to the contralateral cortex. No significant increase was detected in the contralateral cortex during the 14 days of imaging. The activation in the infarct region gradually decreased between day 4 and day 14. In an additional group of animals (n = 26), immunofluorescence studies were performed with antibodies for activated microglia/monocytes (Cd11b), phagocytes (Cd68), astrocytes (glial fibrillary acidic protein) and TSPO. The TSPO immunofluorescence signal indicated reactive microgliosis post injury, corresponding to PET findings. The present clinically relevant animal model and TSPO PET ligand appear to be well suited for studies on neuroinflammation after ischemic stroke.
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Affiliation(s)
- Miklós Tóth
- Department of Clinical Neuroscience, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Philip Little
- Department of Clinical Neuroscience, Karolinska Institutet, 171 76, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet, 171 76, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, 171 76, Stockholm, Sweden.,Department of Radiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Jenny Häggkvist
- Department of Clinical Neuroscience, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Jan Mulder
- Science for Life Laboratory, Department of Neuroscience, Karolinska Institutet, 17165, Stockholm, Sweden
| | - Christer Halldin
- Department of Clinical Neuroscience, Karolinska Institutet, 171 76, Stockholm, Sweden.,Imperial College - NTU, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 639798, Singapore
| | - Balázs Gulyás
- Department of Clinical Neuroscience, Karolinska Institutet, 171 76, Stockholm, Sweden. .,Imperial College - NTU, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 639798, Singapore. .,Imperial College London, Faculty of Medicine, Division of Brain Sciences, London, SW7 2AZ, UK.
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, 171 76, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
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9
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Rizzo P, Mele D, Caliceti C, Pannella M, Fortini C, Clementz AG, Morelli MB, Aquila G, Ameri P, Ferrari R. The role of notch in the cardiovascular system: potential adverse effects of investigational notch inhibitors. Front Oncol 2015; 4:384. [PMID: 25629006 PMCID: PMC4292456 DOI: 10.3389/fonc.2014.00384] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 12/22/2014] [Indexed: 12/17/2022] Open
Abstract
Targeting the Notch pathway is a new promising therapeutic approach for cancer patients. Inhibition of Notch is effective in the oncology setting because it causes a reduction of highly proliferative tumor cells and it inhibits survival of cancer stem cells, which are considered responsible for tumor recurrence and metastasis. Additionally, since Delta-like ligand 4 (Dll4)-activated Notch signaling is a major modulator of angiogenesis, anti-Dll4 agents are being investigated to reduce vascularization of the tumor. Notch plays a major role in the heart during the development and, after birth, in response to cardiac damage. Therefore, agents used to inhibit Notch in the tumors (gamma secretase inhibitors and anti-Dll4 agents) could potentially affect myocardial repair. The past experience with trastuzumab and other tyrosine kinase inhibitors used for cancer therapy demonstrates that the possible cardiotoxicity of agents targeting shared pathways between cancer and heart and the vasculature should be considered. To date, Notch inhibition in cancer patients has resulted only in mild gastrointestinal toxicity. Little is known about the potential long-term cardiotoxicity associated to Notch inhibition in cancer patients. In this review, we will focus on mechanisms through which inhibition of Notch signaling could lead to cardiomyocytes and endothelial dysfunctions. These adverse effects could contrast with the benefits of therapeutic responses in cancer cells during times of increased cardiac stress and/or in the presence of cardiovascular risk factor.
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Affiliation(s)
- Paola Rizzo
- Department of Medical Sciences, University of Ferrara , Ferrara , Italy ; Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara , Ferrara , Italy ; GVM Hospitals , Cotignola , Italy
| | - Donato Mele
- Azienda Ospedaliero-Universitaria di Ferrara , Cona , Italy
| | | | - Micaela Pannella
- Department of Medical Sciences, University of Ferrara , Ferrara , Italy
| | - Cinzia Fortini
- Department of Medical Sciences, University of Ferrara , Ferrara , Italy
| | | | | | - Giorgio Aquila
- Department of Medical Sciences, University of Ferrara , Ferrara , Italy
| | - Pietro Ameri
- Research Center of Cardiovascular Biology, Department of Internal Medicine, University of Genova , Genova , Italy
| | - Roberto Ferrari
- Department of Medical Sciences, University of Ferrara , Ferrara , Italy ; Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara , Ferrara , Italy ; Azienda Ospedaliero-Universitaria di Ferrara , Cona , Italy
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Abstract
PURPOSE OF REVIEW Arterial spin labeling (ASL) is a noninvasive magnetic resonance perfusion imaging method for visualizing and quantifying whole-brain perfusion that does not require exogenous contrast agents. The goal of this review article is to explain the principles of ASL perfusion imaging and review the strengths and limitations of different ASL methods. RECENT FINDINGS There are several different approaches that vary mainly on the basis of the technique that is used to label the inflowing arterial blood. These methods can be used to assess perfusion at brain tissue level or the perfusion territories of the brain feeding arteries. In patients with acute ischemic stroke, ASL can be of clinical value by detecting brain regions with hypoperfusion and perfusion-diffusion mismatch. ASL has been used to detect decreased perfusion, delayed arrival of the arterial blood bolus and assessment of collateral blood flow in patients with extracranial large artery disease and moyamoya disease. SUMMARY Recent evidence indicates that perfusion and territorial perfusion imaging of the brain feeding arteries with ASL can help to assess the extent of hemodynamic compromise and to customize medicinal and surgical treatment, both in patients with acute and with chronic cerebrovascular disease.
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Abstract
Data drive the analyses of any ischemic stroke trial, culminating in the main results and potential next steps. The distinct purpose of a given trial, advancing a novel treatment or examining routine clinical practice, determines the nature of essential data elements. Information gathering for an effective trial depends on ample data, adequate infrastructure, and properly planned statistical analyses. This review highlights the fact that successful future trials will require appropriate expertise that extends far beyond these basic considerations in order to move from identification of basic risk factors that are associated with outcomes to knowledge of pathophysiology and causation of outcomes. Efficient and productive data collection by local and central sites must be complemented by expert core lab adjudications. Source data archiving, including complete DICOM imaging datasets or biological specimens, are needed to maximize the potential for study interpretation and financial investment. Standard terminology, such as common data elements and definitions, enhance study comparisons. Screening logs attest to generalizability of a study. Real-time data transmission and core lab evaluation will be critical to guide adaptive trial design. Despite the overwhelming focus on the intervention in a particular treatment trial, individual pathophysiology must be considered. Understanding individual subject characteristics is a tenet of the coming era of precision stroke care, where the course of a given patient and eventual outcome is paramount. This will require a new approach to data collection in clinical trials.
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Abstract
Numerous acute ischemic stroke trials have recently published detailed results, providing an opportunity to consider the role of collaterals in stroke pathophysiology and their influential effect on patient outcomes. Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke (SENTIS), the largest randomized controlled trial of device therapy to date, tested the potential augmentation of collateral perfusion. SYNTHESIS Expansion, Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE), and Interventional Management of Stroke (IMS) III chronicled the saga of endovascular therapy trialed against medical treatment for acute ischemic stroke. These recent randomized studies, however, largely neglect current device technology available for endovascular therapy as advanced by the TREVO2 and SOLITAIRE™(TM) FR With the Intention For Thrombectomy (SWIFT) studies. Such exhaustive efforts in recent trials have failed to introduce a new treatment for stroke that unequivocally improves patient outcomes. Collateral perfusion is widely recognized to vary across individuals in any population and exerts a dramatic effect on baseline variables including the time course of ischemic injury, stroke severity, imaging findings, and therapeutic opportunities. Similarly, collaterals have been recognized to influence recanalization, reperfusion, hemorrhagic transformation, and subsequent neurological outcomes after stroke. Collateral lessons may be gleaned from these trials, to expand consideration of overall study results and perhaps most importantly, alter ongoing and new trials in development. Detailed analyses of available information on collaterals from these trials demonstrate that collaterals may be more influential than the choice of treatment modality or intervention.
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Sugiyama Y, Yagita Y, Yukami T, Watanabe A, Oyama N, Terasaki Y, Omura-Matsuoka E, Sasaki T, Mochizuki H, Kitagawa K. Granulocyte colony-stimulating factor fails to enhance leptomeningeal collateral growth in spontaneously hypertensive rats. Neurosci Lett 2014; 564:16-20. [PMID: 24508053 DOI: 10.1016/j.neulet.2014.01.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 01/08/2014] [Accepted: 01/25/2014] [Indexed: 10/25/2022]
Abstract
The promotion of collateral artery growth is an attractive approach for the treatment of chronic brain hypoperfusion due to occlusive artery disease. We previously reported that hypertension impaired the collateral artery growth of leptomeningeal anastomoses after brain hypoperfusion. Granulocyte colony-stimulating factor (G-CSF) enhances arteriogenesis in a mouse model via a mechanism involving monocyte/macrophage mobilization. However, the arteriogenic effect of G-CSF in hypertension remains unknown. In the present study, we tested whether G-CSF affected collateral artery growth in both normotensive and hypertensive model rat. Left common carotid artery (CCA) occlusion was performed to induce hypoperfusion in the brains of Wistar rats and spontaneously hypertensive rats (SHR). G-CSF was administered subcutaneously for 5 consecutive days. The superficial angioarchitecture of the leptomeningeal anastomoses and the circle of Willis after CCA occlusion and G-CSF treatment were visualized by latex perfusion. Circulating blood monocytes and CD68-positive cells, which represented the macrophages on the dorsal surface of the brain, were counted. G-CSF enhanced leptomeningeal collateral growth in Wistar rats, but not in SHR. G-CSF increased circulating blood monocytes in both Wistar rats and SHR. The number of CD68-positive cells on the dorsal surface of the brain was increased by G-CSF in Wistar rats, but not in SHR. The increase in macrophage accumulation correlated with the observed arteriogenic effects. In conclusion, G-CSF promotes collateral artery growth in the normotensive model rat, but not in the hypertensive model rat.
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Affiliation(s)
- Yukio Sugiyama
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Yagita
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Toshiro Yukami
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akihiro Watanabe
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Naoki Oyama
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasukazu Terasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Emi Omura-Matsuoka
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazuo Kitagawa
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
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Hartkamp NS, Petersen ET, De Vis JB, Bokkers RPH, Hendrikse J. Mapping of cerebral perfusion territories using territorial arterial spin labeling: techniques and clinical application. NMR IN BIOMEDICINE 2013; 26:901-912. [PMID: 22807022 DOI: 10.1002/nbm.2836] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 06/12/2012] [Accepted: 06/17/2012] [Indexed: 06/01/2023]
Abstract
A knowledge of the exact cerebral perfusion territory which is supplied by any artery is of great importance in the understanding and diagnosis of cerebrovascular disease. The development and optimization of territorial arterial spin labeling (T-ASL) MRI techniques in the past two decades have made it possible to visualize and determine the cerebral perfusion territories in individual patients and, more importantly, to do so without contrast agents or otherwise invasive procedures. This review provides an overview of the development of ASL techniques that aim to visualize the general cerebral perfusion territories or the territory of a specific artery of interest. The first efforts of T-ASL with pulsed, continuous and pseudo-continuous techniques are summarized and subsequent clinical studies using T-ASL are highlighted. In the healthy population, the perfusion territories of the brain-feeding arteries are highly variable. This high variability requires special consideration in specific patient groups, such as patients with cerebrovascular disease, stroke, steno-occlusive disease of the large arteries and arteriovenous malformations. In the past, catheter angiography with selective contrast injection was the only available method to visualize the cerebral perfusion territories in vivo. Several T-ASL methods, sometimes referred to as regional perfusion imaging, are now available that can easily be combined with conventional brain MRI examinations to show the relationship between the cerebral perfusion territories, vascular anatomy and brain infarcts or other pathology. Increased availability of T-ASL techniques on clinical MRI scanners will allow radiologists and other clinicians to gain further knowledge of the relationship between vasculature and patient diagnosis and prognosis. Treatment decisions, such as surgical revascularization, may, in the near future, be guided by information provided by T-ASL MRI in close correlation with structural MRI and quantitative perfusion information.
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Affiliation(s)
- Nolan S Hartkamp
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Chen J, Ji X, Ding Y, Luo Y, Cheng H, Ling F. Role of residual flow on the neuroprotective efficacy of human albumin in the rat with transient cerebral ischemia. Neurol Res 2013; 31:396-401. [DOI: 10.1179/174313209x443973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Hodel J, Leclerc X, Rodallec M, Gerber S, Blanc R, Outteryck O, Benadjaoud S, Rabrait C, Zuber M, Pruvo JP, Zins M. Fluid-attenuated inversion recovery vascular hyperintensities are not visible using 3D CUBE FLAIR sequence. Eur Radiol 2013; 23:1963-9. [DOI: 10.1007/s00330-013-2796-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 01/04/2013] [Accepted: 01/09/2013] [Indexed: 10/27/2022]
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Liebeskind DS, Sanossian N. How well do blood flow imaging and collaterals on angiography predict brain at risk? Neurology 2012; 79:S105-9. [PMID: 23008383 DOI: 10.1212/wnl.0b013e3182695904] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
As endovascular therapy emerges as a principal approach to restore blood flow in the setting of acute stroke, better methods of patient selection need to be developed. Noninvasive studies of blood flow and angiographic results acquired prior to endovascular therapy may help determine areas of brain at risk of infarction and hemorrhagic transformation, both largely determined by the severity of cerebral ischemia. Pathophysiologic measures of collateral flow and perfusion that characterize ischemic severity prior to revascularization may optimize acute stroke decision-making, currently driven by arbitrary time parameters derived from population studies devoid of imaging.
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Affiliation(s)
- David S Liebeskind
- UCLA Stroke Center and Department of Neurology, University of California, Los Angeles, CA, USA.
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18
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Abstract
Collateral circulation and associated potential compensation in downstream perfusion have been recognized long before arterial occlusions were known to cause ischemic stroke. Arterial aspects and the venous capacity of collaterals to offset potentially devastating effects of blocking a cerebral artery have been studied in various animal species and even human populations with stroke, providing a framework for translational research. The time has come for collaterals to move from the periphery to a central position in stroke therapeutics, propelled by the momentum of imaging data and culminating in novel paradigms with respect to time, imaging approaches and treatment strategies. It is time for a concerted focus on collateral perfusion to harness potential therapeutic advances from acute stroke to chronic cerebrovascular disorders.
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Affiliation(s)
- David S Liebeskind
- Department of Neurology, UCLA Stroke Center, Los Angeles, CA 90095, USA.
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Wolff V, Lauer V, Rouyer O, Bataillard M, Marescaux C. [Indications for thrombolysis in ischemic stroke]. Presse Med 2012; 41:504-13. [PMID: 22364805 DOI: 10.1016/j.lpm.2011.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 11/30/2011] [Indexed: 11/26/2022] Open
Abstract
Cerebral MRI with angio-MR are more effective than CT scan for selecting patients with ischemic stroke for thrombolysis. The use of cerebral MRI has to be available 24h a day and everyday as a standardized emergency procedure. Off-label criteria for thrombolysis after acute ischemic stroke are too restritive and have to be revised. In acute ischemic stroke, imaging that shows the collateral circulation within the hypoperfusion area has to be used to estimate the potential of therapeutic revascularization. When there are contraindications for intravenous thrombolysis, the endovascular approach must be argued individually by neurologists and neurointerventionalists together.
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Affiliation(s)
- Valérie Wolff
- Hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, pôle tête et cou, unité neurovasculaire, 67098 Strasbourg cedex, France.
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20
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Hammer MD, Schwamm L, Starkman S, Schellinger PD, Jovin T, Nogueira R, Burgin WS, Sen S, Diener HC, Watson T, Michel P, Shuaib A, Dillon W, Liebeskind DS. Safety and feasibility of NeuroFlo use in eight- to 24-hour ischemic stroke patients. Int J Stroke 2012; 7:655-61. [PMID: 22264202 DOI: 10.1111/j.1747-4949.2011.00719.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute treatment of ischemic stroke patients presenting more than eight-hours after symptom onset remains limited and largely unproven. Partial aortic occlusion using the NeuroFlo catheter can augment cerebral perfusion in animals. We investigated the safety and feasibility of employing this novel catheter to treat ischemic stroke patients eight-hours to 24 h following symptom onset. METHODS A multicenter, single-arm trial enrolled ischemic stroke patients at nine international academic medical centers. Eligibility included age 18-85 years old, National Institutes of Health stroke scale (NIHSS) score between four and 20, within eight-hours to 24 h after symptom onset, and perfusion-diffusion mismatch confirmed by magnetic resonance imaging. The primary outcome was all adverse events occurring from baseline to 30 days posttreatment. Secondary outcomes included stroke severity on neurological indices through 90 days. This study is registered with ClinicalTrials.gov, number NCT00436592. RESULTS A total of 26 patients were enrolled. Of these, 25 received treatment (one excluded due to aortic morphology); five (20%) died. Favorable neurological outcome at 90 days (modified Rankin score 0-2 vs. 3-6) was associated with lower baseline NIHSS (P < 0·001) and with longer duration from symptom discovery to treatment. There were no symptomatic intracranial hemorrhages or parenchymal hematomas. Asymptomatic intracranial hemorrhage was visible on computed tomography in 32% and only on microbleed in another 20%. CONCLUSIONS Partial aortic occlusion using the NeuroFlo catheter, a novel collateral therapeutic strategy, appears safe and feasible in stroke patients eight-hours to 24 h after symptom onset.
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Affiliation(s)
- M D Hammer
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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21
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Bang OY, Saver JL, Kim SJ, Kim GM, Chung CS, Ovbiagele B, Lee KH, Liebeskind DS. Collateral flow averts hemorrhagic transformation after endovascular therapy for acute ischemic stroke. Stroke 2011; 42:2235-9. [PMID: 21737798 DOI: 10.1161/strokeaha.110.604603] [Citation(s) in RCA: 207] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Collaterals sustain the ischemic penumbra to limit growth of the infarct core before revascularization, yet the impact of baseline collateral flow on hemorrhagic transformation (HT) after endovascular therapy remains unknown. METHODS A collaborative study from 2 stroke centers in distinct geographic regions included 222 consecutive patients who received endovascular therapy for acute cerebral ischemia. The influence of collaterals on HT was analyzed in distinct case scenarios relative to baseline collateral grade at angiography (0 to 1 versus 2 to 4) and recanalization (Thrombolysis in Myocardial Ischemia scale, 0 to 1 versus 2 to 3): good collaterals and successful recanalization (n=98), poor collaterals with successful recanalization (n=43), good collaterals and no recanalization(n=46), and poor collaterals and no recanalization (n=35). RESULTS HT after endovascular therapy occurred in 103 (46.4%) patients; 42 (18.9%) were symptomatic. HT was more frequently observed in patients with poor collaterals and recanalization than in other groups (P=0.048). When revascularization was achieved, patients with poorer collaterals were more likely to have symptomatic worsening with HT (r=-0.181, P=0.032). Multiple logistic regression analysis identified aggressive treatment (OR, 2.558 for Merci clot retrieval; 95% CI, 1.153 to 5.678; OR, 3.618 for combined fibrinolytics and mechanical therapy; 95% CI, 1.551 to 8.437; and OR, 2.085 for intravenous thrombolysis before endovascular therapy; 95% CI, 1.096 to 3.969), poor collaterals and recanalization (OR, 2.666; 95% CI, 1.163 to 6.113), and serum glucose levels (OR, 1.007; 95% CI, 1.000 to 1.014) as independent predictors of HT. CONCLUSIONS Angiographic grade of collateral flow strongly influences the rate of HT after therapeutic recanalization for acute ischemic stroke. Collateral status readily available from baseline angiography may therefore refine therapeutic decision-making in acute cerebral ischemia.
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Affiliation(s)
- Oh Young Bang
- Department of Neurology, UCLA Stroke Center, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
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22
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Sanossian N, Ovbiagele B, Saver JL, Alger JR, Starkman S, Kim D, Ohanian AG, Buck BH, Ali LK, Duckwiler GR, Jahan R, Viñuela F, Liebeskind DS. Leukoaraiosis and collaterals in acute ischemic stroke. J Neuroimaging 2011; 21:232-5. [PMID: 20977524 PMCID: PMC3030936 DOI: 10.1111/j.1552-6569.2010.00512.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND We examined the correlation of angiographic collaterals in acute stroke with the presence, extent, and distribution of white matter changes, so-called Leukoaraiosis, in an effort to determine if Leukoaraiosis indicates chronic cerebral hypoperfusion and/or is associated with the development of cerebral collateral circulation. METHODS Consecutive acute strokes due to large-vessel occlusion on angiography had preprocedure CT or MRI white matter changes graded utilizing the Fazekas scale incorporating deep and periventricular components. Angiographic collaterals evaluated with a 5-point scale were correlated with leukoaraiosis. RESULTS Collaterals were evaluated in 102 cases (51 men, 51 women; mean age 66 (SD 18) years with acute occlusions of the proximal middle cerebral artery (MCA) (47%), distal internal carotid artery (ICA) (28%), distal MCA (9%), basilar (7%), proximal ICA (7%), vertebral (1%), posterior cerebral artery (PCA) (1%), and common carotid artery (CCA) (1%). Collateral grade was well distributed across the scale. Periventricular and deep white matter changes were evident in 34% and 51% of cases, respectively. Collateral grade exhibited no relationship with either the presence or extent of periventricular disease (P= .772, r= .029) or deep white matter changes (P= .559, r=-.059). CONCLUSIONS Leukoaraisosis exhibits no overt relationship with the extent of collaterals measured at angiography in acute ischemic stroke. Chronic small-vessel disease may be a distinct pathophysiologic entity unrelated to arteriogenesis and compensatory aspects of collateral flow.
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Affiliation(s)
- Nerses Sanossian
- Department of Neurology, University of Southern California, CA, USA.
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23
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Abstract
Collateral circulation in intracranial atherosclerosis has never been systematically characterized. We investigated collaterals in a multicenter trial of symptomatic intracranial atherosclerotic disease. Baseline angiography was reviewed for information on collaterals in stenoses of the internal carotid, middle cerebral, vertebral, and basilar arteries. A battery of angiographic scales was utilized to evaluate lesion site, arterial patency, antegrade flow, downstream territorial perfusion, and collateral circulation, blinded to all other data. Collateral circulation was adequately available for analysis in 287/569 (50%) subjects with proximal arterial stenoses ranging from 50% to 99%. Extent of collaterals was absent or none in 69%, slow or minimal in 10%, more rapid, yet incomplete perfusion of territory in 7%, complete but delayed perfusion in 11%, and rapid, complete collateral perfusion in 4%. Extent of collateral flow correlated with percentage of stenosis (P<0.0001), with more severe stenoses exhibiting greater compensation via collaterals. Overall, collateral grade increased with diminished antegrade flow across the lesion (thrombolysis in myocardial ischemia) and resultant downstream perfusion (thrombolysis in cerebral infarction) (both P<0.001). Our findings provide the initial detailed description of collaterals across a variety of stenoses, suggesting that collateral perfusion is a pivotal component in pathophysiology of intracranial atherosclerosis and implicating the need for further evaluation in ongoing studies.
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Sugiyama Y, Yagita Y, Oyama N, Terasaki Y, Omura-Matsuoka E, Sasaki T, Kitagawa K. Granulocyte Colony-Stimulating Factor Enhances Arteriogenesis and Ameliorates Cerebral Damage in a Mouse Model of Ischemic Stroke. Stroke 2011; 42:770-5. [PMID: 21257824 DOI: 10.1161/strokeaha.110.597799] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Enhancing collateral artery growth is a potent therapeutic approach to treat cardiovascular ischemic disease from occlusive artery. Granulocyte–macrophage colony-stimulating factor (GM-CSF) has gained attention for its ability to promote arteriogenesis, ameliorating brain damage, by the mechanisms involving monocyte upregulation. However, the recent clinical study testing its efficacy in myocardial ischemia has raised the question about its safety. We tested alternative colony-stimulating factors for their effects on collateral artery growth and brain protection.
Methods—
Brain hypoperfusion was produced by occluding the left common carotid artery in C57/BL6 mice. After the surgery, granulocyte colony-stimulating factor, macrophage colony-stimulating factor, or GM-CSF (100 μg/kg/day) was administered daily for 5 days. The angioarchitecture for leptomeningeal anastomoses and the circle of Willis were visualized after the colony-stimulating factor treatment. Circulating blood monocytes and Mac-2-positive cells in the dorsal surface of the brain were determined. A set of animals underwent subsequent ipsilateral middle cerebral artery occlusion and infarct volume was assessed.
Results—
Granulocyte colony-stimulating factor as well as GM-CSF promoted leptomeningeal collateral growth after common carotid artery occlusion. Both granulocyte colony-stimulating factor and GM-CSF increased circulating blood monocytes and Mac-2-positive cells in the dorsal brain surface, suggesting the mechanisms coupled to monocyte upregulation might be shared. Infarct volume after middle cerebral artery occlusion was reduced by granulocyte colony-stimulating factor, similarly to GM-CSF. Macrophage colony-stimulating factor showed none of theses effects.
Conclusions—
Granulocyte colony-stimulating factor enhances collateral artery growth and reduces infarct volume in a mouse model of brain ischemia, similarly to GM-CSF.
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Affiliation(s)
- Yukio Sugiyama
- From the Division of Stroke, Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Yagita
- From the Division of Stroke, Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Naoki Oyama
- From the Division of Stroke, Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasukazu Terasaki
- From the Division of Stroke, Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Emi Omura-Matsuoka
- From the Division of Stroke, Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsutomu Sasaki
- From the Division of Stroke, Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazuo Kitagawa
- From the Division of Stroke, Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
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25
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Bang OY, Saver JL, Kim SJ, Kim GM, Chung CS, Ovbiagele B, Lee KH, Liebeskind DS. Collateral flow predicts response to endovascular therapy for acute ischemic stroke. Stroke 2011; 42:693-9. [PMID: 21233472 DOI: 10.1161/strokeaha.110.595256] [Citation(s) in RCA: 401] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Collaterals sustain the penumbra before recanalization and offset infarct growth, yet the influence of baseline collateral flow on recanalization after endovascular therapy remains relatively unexplored. METHODS We analyzed consecutive patients who received endovascular therapy for acute cerebral ischemia from 2 distinct study populations. We assessed the relationship between pretreatment collateral grade and vascular recanalization (Thrombolysis In Myocardial Ischemia [TIMI] scale). In addition, we assessed infarct growth on serial MRI. RESULTS A total of 222 patients was included, 138 from the United States and 84 from South Korea. Complete revascularization occurred in 14.1% (11 of 78) patients with poor pretreatment collateral grades, whereas it was observed in 25.2% (26 of 103) patients with good collaterals and 41.5% (17 of 41) patients with excellent collaterals (P<0.001). This relationship was consistently observed in both study populations, although the mode of endovascular therapy was different between them. After adjustment for other factors, including mode of endovascular therapy, prior use of intravenous tissue plasminogen activator, and site of occlusion, pretreatment collateral grade was independently associated with recanalization. When revascularization was achieved, greater infarct growth occurred in patients with poor collaterals than in those with good collaterals (P=0.012). CONCLUSIONS Our data indicate that angiographic collateral grade determines the recanalization rate after endovascular revascularization therapy. When therapeutic revascularization was achieved, beneficial effects were not observed in patients with poor collaterals. Angiographic collateral grade may therefore help guide treatment decision-making in acute cerebral ischemia.
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Affiliation(s)
- Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
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26
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Azizyan A, Sanossian N, Mogensen MA, Liebeskind DS. Fluid-attenuated inversion recovery vascular hyperintensities: an important imaging marker for cerebrovascular disease. AJNR Am J Neuroradiol 2010; 32:1771-5. [PMID: 21051516 DOI: 10.3174/ajnr.a2265] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Vascular hyperintensities have been noted on FLAIR sequences obtained in the setting of acute stroke and intracranial steno-occlusive disease. The presence of FVHs likely represents disordered blood flow, often from collaterals distal to arterial occlusion or stenosis. As opposed to other vessel signs seen in arterial insufficiency, FVH is unique in that it does not represent thrombus, but rather sluggish or disordered blood flow through vessels. This review will discuss the diagnostic and prognostic value of FVH and its impact on clinical decision-making.
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Affiliation(s)
- A Azizyan
- Keck School of Medicine, University of Southern California, Los Angeles, USA
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27
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Liebeskind DS, Kim D, Starkman S, Changizi K, Ohanian AG, Jahan R, Viñuela F. Collateral failure? Late mechanical thrombectomy after failed intravenous thrombolysis. J Neuroimaging 2010; 20:78-82. [PMID: 18798777 DOI: 10.1111/j.1552-6569.2008.00295.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Collaterals may compensate for reduced blood flow in acute ischemic stroke, yet endurance and quality of collateral perfusion may vary. Collateral sustenance of penumbra may falter after initial recruitment, resulting in progressive ischemia and clinical deficits. Delayed collateral failure may extend the time window for revascularization, even after failed intravenous thrombolysis. CASE DESCRIPTION A 76-year-old woman returned to normal from National Institutes of Health Stroke Scale (NIHSS) score of 18 following intravenous thrombolysis, despite persistent occlusion of the left middle cerebral artery. Subsequent deterioration was successfully reversed with mechanical thrombectomy almost 14 hours after symptom onset. CONCLUSIONS Early clinical improvement or deterioration may reflect collateral perfusion, not necessarily recanalization or reocclusion. The definition of collateral failure must incorporate the expected role and endurance of collaterals. Further investigation of collateral pathophysiology may reveal predictive clinical or imaging features and disclose collateral therapeutic approaches to augment revascularization.
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Affiliation(s)
- David S Liebeskind
- Department of Neurology, UCLA Stroke Center, Los Angeles, California 90095, USA.
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Reperfusion for acute ischemic stroke: arterial revascularization and collateral therapeutics. Curr Opin Neurol 2010; 23:36-45. [PMID: 19926989 DOI: 10.1097/wco.0b013e328334da32] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Reperfusion of the ischemic territory forms the basis of most acute stroke treatments. This overview of the literature relating to reperfusion in acute ischemic stroke published within the last year provides a snapshot of a rapidly evolving aspect of cerebrovascular disease. RECENT FINDINGS Arterial revascularization from systemic thrombolysis to combination endovascular procedures to achieve recanalization has proliferated. Stroke imaging continues to discern features of critical pathophysiology that may influence tissue fate and clinical outcome. Balancing the risk of hemorrhagic transformation against the therapeutic aim to salvage the ischemic penumbra remains a formidable challenge. Collateral therapeutics that enhance perfusion outside the ischemic core present novel dimension to acute stroke therapy, focused on ischemia and not just the clot or plaque. SUMMARY These timely findings illustrate the essential role of reperfusion in acute stroke, delineating aspects of arterial revascularization and collateral therapeutics to be refined in coming years.
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Liebeskind DS. Stroke: the currency of collateral circulation in acute ischemic stroke. Nat Rev Neurol 2010; 5:645-6. [PMID: 19953114 DOI: 10.1038/nrneurol.2009.193] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Symptomatic intracranial arterial stenosis carries one of the highest rates of recurrent stroke (10%-20% per year) despite antithrombotic therapy. Stroke prevention strategies for intracranial atherosclerotic disease follow the guidelines for secondary stroke prevention that target atherogenic risk factors. These include following standard stroke prevention guidelines of weight loss for overweight patients, moderate physical exercise (at least 30 minutes most days), cessation of cigarette smoking, and a low-fat, low-cholesterol diet. Pharmacologic treatments include antiplatelet agents, statins, blood sugar control for diabetics, and antihypertensive medications. Goals may include low-density lipoprotein cholesterol less than 100 mg/dL (< 70 mg/dL in high-risk patients). The absolute blood pressure reduction target is uncertain, but average long-term reductions of 10/5 mm Hg are recommended. Angioplasty with stent placement for the treatment of symptomatic severe intracranial stenosis (>/= 70%) is currently being evaluated in a phase 3 randomized controlled trial. It is unclear whether angioplasty with stent placement is superior to angioplasty alone for the treatment of intracranial stenosis, so both endovascular methods are currently acceptable. Complication and success rates for intracranial angioplasty and stent placement are highly variable, so the widespread application of this procedure is generally not recommended outside of clinical trials and experienced centers.
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Affiliation(s)
- David S Liebeskind
- Department of Neurology, University of California Los Angeles Stroke Center, Los Angeles, CA 90095, USA.
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Augmenting Regional Cerebral Blood Flow Using External-to-Internal Carotid Artery Flow Diversion Method. Ann Biomed Eng 2009; 37:2428-35. [DOI: 10.1007/s10439-009-9782-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2009] [Accepted: 08/18/2009] [Indexed: 12/24/2022]
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Liebeskind DS. Reversing stroke in the 2010s: lessons from Desmoteplase In Acute ischemic Stroke-2 (DIAS-2). Stroke 2009; 40:3156-8. [PMID: 19608990 DOI: 10.1161/strokeaha.109.559682] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David S Liebeskind
- University of California-Los Angeles Stroke Center, Los Angeles, CA 90095, USA.
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34
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Chen J, Cui X, Zacharek A, Ding GL, Shehadah A, Jiang Q, Lu M, Chopp M. Niaspan treatment increases tumor necrosis factor-alpha-converting enzyme and promotes arteriogenesis after stroke. J Cereb Blood Flow Metab 2009; 29:911-20. [PMID: 19223914 PMCID: PMC2782460 DOI: 10.1038/jcbfm.2009.11] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We tested the hypothesis that Niaspan (a prolonged release formulation of niacin) increases tumor necrosis factor-alpha-converting enzyme (TACE) expression and Notch signaling activity and promotes arteriogenesis after stroke. Rats were subjected to middle cerebral artery occlusion and were treated with or without Niaspan. Niaspan significantly elevated local cerebral blood flow, and increased arteriogenesis as indicated by increased arterial diameter and vascular smooth muscle cell (VSMC) proliferation in the ischemic brain after stroke. The increased arteriogenesis significantly correlated with the functional outcome after stroke. Niaspan treatment of stroke upregulated TACE, Notch1, and Notch intracellular domain expression in the ischemic brain. To further investigate the mechanisms of Niaspan-induced arteriogenesis, a primary brain arterial culture was used. Niacin treatment significantly increased arterial sprouting and VSMC migration compared with control nontreated arterial cells. Inhibition of TACE by the TACE inhibitor or knockdown of TACE gene expression in brain arterial culture significantly attenuated Niacin-induced arterial sprouting and VSMC migration. In addition, TACE treatment of arterial culture significantly increased arterial VSMC migration and arterial sprouting. Knockdown of Notch1 marginally decreased arterial sprouting and VSMC migration compared with scrambled control. Niaspan promotes arteriogenesis, which is mediated, in part, by TACE.
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Affiliation(s)
- Jieli Chen
- Department of Neurology, Henry Ford Health Sciences Center, Detroit, Michigan 48202, USA.
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35
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Hendrikse J, Petersen ET, Chèze A, Chng SM, Venketasubramanian N, Golay X. Relation between cerebral perfusion territories and location of cerebral infarcts. Stroke 2009; 40:1617-22. [PMID: 19299630 DOI: 10.1161/strokeaha.108.539866] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The perfusion territories of the brain-feeding arteries are difficult to assess in vivo and therefore standard cerebral perfusion territory templates are often used to determine the relation between cerebral infarcts and the feeding vasculature. In the present study, we compared this infarct classification, using standard templates, with the individualized depiction of cerebral perfusion territories on MRI. METHODS The ethics committee of our institution approved the study protocol. A total of 159 patients (92 male, 67 female; mean age, 58.9 years) with first-time clinical symptoms of cerebral ischemia were included in the study. Diffusion-weighted imaging was used for depiction of the area of ischemia and the perfusion territories of the left internal carotid artery, right internal carotid artery, and vertebrobasilar arteries were visualized with territorial arterial spin labeling MRI. Infarct locations with respect to cerebral perfusion territories were evaluated with and without territorial arterial spin labeling MRI images. RESULTS In 92% of the patients, the territorial arterial spin labeling images were of diagnostic quality. One hundred thirty-six patients showed areas of ischemia on diffusion-weighted images. The additional information from the territorial arterial spin labeling images changed the classification in 11% of the cortical or border zone infarcts (6 of 56), whereas no territorial changes were observed in lacunar, periventricular, cerebellar, and brainstem infarcts. CONCLUSIONS The diagnostic information provided by perfusion territory imaging in patients with stroke is valuable for the classification of cortical and border zone infarcts, whereas no change of the textbook-based classification was observed for other infarct types.
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Affiliation(s)
- Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, The Netherlands
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36
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Liebeskind DS. Venous hemodynamics may enhance collateral perfusion and the fibrinolytic milieu in paradoxical embolism. Stroke 2008; 40:e30-1. [PMID: 19095976 DOI: 10.1161/strokeaha.108.541441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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37
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Liebeskind DS. Of mice and men: essential considerations in the translation of collateral therapeutics. Stroke 2008; 39:e187-8; author reply e189. [PMID: 18845798 DOI: 10.1161/strokeaha.108.522888] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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38
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Bang OY, Saver JL, Buck BH, Alger JR, Starkman S, Ovbiagele B, Kim D, Jahan R, Duckwiler GR, Yoon SR, Viñuela F, Liebeskind DS. Impact of collateral flow on tissue fate in acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2008; 79:625-9. [PMID: 18077482 PMCID: PMC2702489 DOI: 10.1136/jnnp.2007.132100] [Citation(s) in RCA: 294] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Collaterals may sustain penumbra prior to recanalisation yet the influence of baseline collateral flow on infarct growth following endovascular therapy remains unknown. METHODS Consecutive patients underwent serial diffusion and perfusion MRI before and after endovascular therapy for acute cerebral ischaemia. We assessed the relationship between MRI diffusion and perfusion lesion indices, angiographic collateral grade and infarct growth. Tmax perfusion lesion maps were generated and diffusion-perfusion mismatch regions were divided into Tmax >or=4 s (severe delay) and Tmax >or=2 but <4 s (mild delay). RESULTS Among 44 patients, collateral grade was poor in 7 (15.9%), intermediate in 20 (45.5%) and good in 17 (38.6%) patients. Although diffusion-perfusion mismatch volume was not different depending on the collateral grade, patients with good collaterals had larger areas of milder perfusion delay than those with poor collaterals (p = 0.005). Among 32 patients who underwent day 3-5 post-treatment MRIs, the degree of pretreatment collateral circulation (r = -0.476, p = 0.006) and volume of diffusion-perfusion mismatch (r = 0.371, p = 0.037) were correlated with infarct growth. Greatest infarct growth occurred in patients with both non-recanalisation and poor collaterals. Multiple regression analysis revealed that pretreatment collateral grade was independently associated with infarct growth. CONCLUSION Our data suggest that angiographic collateral grade and penumbral volume interactively shape tissue fate in patients undergoing endovascular recanalisation therapy. These angiographic and MRI parameters provide complementary information about residual blood flow that may help guide treatment decision making in acute cerebral ischaemia.
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Affiliation(s)
- O Y Bang
- Department of Neurology, Samsung Medical Centre, Sungkyunkwan University, Seoul, South Korea
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Hendrikse J, Petersen ET, van Laar PJ, Golay X. Cerebral Border Zones between Distal End Branches of Intracranial Arteries: MR Imaging. Radiology 2008; 246:572-80. [DOI: 10.1148/radiol.2461062100] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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40
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van Laar PJ, van der Grond J, Hendrikse J. Brain Perfusion Territory Imaging: Methods and Clinical Applications of Selective Arterial Spin-labeling MR Imaging. Radiology 2008; 246:354-64. [PMID: 18227536 DOI: 10.1148/radiol.2462061775] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Peter Jan van Laar
- Department of Radiology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands.
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Hendrikse J, Klijn CJM, van Huffelen AC, Kappelle LJ, van der Grond J. Diagnosing Cerebral Collateral Flow Patterns: Accuracy of Non-Invasive Testing. Cerebrovasc Dis 2008; 25:430-7. [PMID: 18349537 DOI: 10.1159/000121344] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Accepted: 11/02/2007] [Indexed: 11/19/2022] Open
Affiliation(s)
- Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Abstract
Collateral circulation is a fundamental determinant of stroke pathophysiology. Distal arterial embolism and hypoperfusion resulting from severe proximal arterial stenosis may be offset by collateral flow. Collaterals influence whether or not infarction results. The detection and characterization of arterial deoxygenation and other consequences of collateral perfusion depend on neuroimaging techniques. Imaging advances will further the understanding of clinical correlates, including collateral sustenance and collateral failure, and possibly promote the development of collateral therapeutics. Refinements of perfusion imaging protocols may quantify the delay and dispersion of collateral flow more accurately. This review explores the role of collateral flow in acute ischemic stroke and describes the imaging modalities used to investigate phenomena "beyond the clot."
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Affiliation(s)
- David S Liebeskind
- University of California Stroke Center, University of California Medical Center, Los Angeles, CA 90095, USA.
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Abstract
Ischemic stroke remains a significant cause of morbidity and mortality. Current therapeutic options for acute ischemic stroke include intravenous thrombolysis and endovascular approaches for recanalization of proximal arterial occlusion. The rapid identification of underlying stroke etiology or mechanism may facilitate selection criteria for emergent therapy. Hyperacute imaging plays an integral role in the delineation of stroke pathophysiology and the formulation of rational stroke therapy. Hyperacute imaging of ischemic stroke may demonstrate proximal vascular occlusion, compensatory collateral circulation, residual or collateral tissue perfusion, and the differentiation of ischemic core from penumbral regions. Characterization of the ischemic field, including core and penumbra, with various mismatch models on multimodal computed tomography or MRI may refine current therapeutic strategies for cerebral ischemia. The diagnostic and therapeutic role of hyperacute imaging has emerged as a pivotal component in the evaluation and management of ischemic stroke.
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Affiliation(s)
- Scott L Selco
- UCLA Stroke Center and Department of Neurology, 710 Westwood Plaza, Los Angeles, CA 90095, USA
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