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Gajurel BP, Nepal G, Kharel S, Yadav JK, Yadav SK, Shing YK, Goeschl S, Thapaliya S. Safety and efficacy of intravenous thrombolysis in acute ischemic stroke patients with a history of intracranial hemorrhage: A systematic review and meta-analysis. Clin Neurol Neurosurg 2022; 215:107205. [DOI: 10.1016/j.clineuro.2022.107205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 11/03/2022]
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Deng LD, Qi L, Suo Q, Wu SJ, Mamtilahun M, Shi RB, Liu Z, Sun JF, Tang YH, Zhang ZJ, Yang GY, Wang JX. Transcranial focused ultrasound stimulation reduces vasogenic edema after middle cerebral artery occlusion in mice. Neural Regen Res 2022; 17:2058-2063. [PMID: 35142697 PMCID: PMC8848588 DOI: 10.4103/1673-5374.335158] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Blood-brain barrier (BBB) disruption underlies the vasogenic edema and neuronal cell death induced by acute ischemic stroke. Reducing this disruption has therapeutic potential. Transcranial focused ultrasound stimulation has shown neuromodulatory and neuroprotective effects in various brain diseases including ischemic stroke. Ultrasound stimulation can reduce inflammation and promote angiogenesis and neural circuit remodeling. However, its effect on the BBB in the acute phase of ischemic stroke is unknown. In this study of mice subjected to middle cerebral artery occlusion for 90 minutes, low-intensity low-frequency (0.5 MHz) transcranial focused ultrasound stimulation was applied 2, 4, and 8 hours after occlusion. Ultrasound stimulation reduced edema volume, improved neurobehavioral outcomes, improved BBB integrity (enhanced tight junction protein ZO-1 expression and reduced IgG leakage), and reduced secretion of the inflammatory factors tumor necrosis factor-α and activation of matrix metalloproteinase-9 in the ischemic brain. Our results show that low-intensity ultrasound stimulation attenuated BBB disruption and edema formation, which suggests it may have therapeutic use in ischemic brain disease as a protector of BBB integrity.
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Affiliation(s)
- Li-Dong Deng
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Lin Qi
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Qian Suo
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Sheng-Ju Wu
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Muyassar Mamtilahun
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Ru-Bing Shi
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Ze Liu
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jun-Feng Sun
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Yao-Hui Tang
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Zhi-Jun Zhang
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Guo-Yuan Yang
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University; Department of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ji-Xian Wang
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
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Dolatshahi M, Sabahi M, Shahjouei S, Koza E, Abedi V, Zand R. Intravenous thrombolysis in ischemic stroke patients with a prior intracranial hemorrhage: a meta-analysis. Ther Adv Neurol Disord 2022; 15:17562864221074144. [PMID: 35126671 PMCID: PMC8808019 DOI: 10.1177/17562864221074144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/01/2022] [Indexed: 01/01/2023] Open
Abstract
Background: The history of intracranial hemorrhage (ICrH) is considered a contraindication for intravenous thrombolysis (IVT) among patients with acute ischemic stroke (AIS). Objective: This study aimed at comparing the safety of IVT among patients with and without a history of ICrH. Methods: We performed a systematic review of the literature. Data regarding all AIS patients with prior ICrH who received IVT were retrieved. Meta-analysis was performed to compare the rate of symptomatic hemorrhagic transformation (sHT), death within 90 days, and favorable and unfavorable 90-day functional outcomes based on modified Rankin Scale (mRS) among stroke patients with and without prior ICrH. Results: Out of 13,032 reviewed records, 7 studies were included in the systematic review and meta-analysis. Quantitative synthesis of data regarding the rate of sHT (5068 patients) revealed no significant difference between the two groups [odds ratio, OR: 1.55 (0.77, 3.12); p = 0.22]. However, a significantly higher risk of death within 90 days [OR: 3.91 (2.16, 7.08); p < 0.00001] and a significantly higher 90-day poor functional outcomes (mRS, 4–6) [OR: 1.57 (1.07, 2.30); p = 0.02] were observed among patients with prior ICrH. Likewise, the percentage of 90-day good functional outcomes (mRS, 0–1) was lower in the prior ICrH group [OR: 0.54 (0.35, 0.84); p = 0.06]. Subgroup analyses in patients with a history of ICrH (based on both patients’ medical history and imaging confirmation) revealed no significant between-group differences in rates of sHT. Also, sensitivity analysis consisting of only studies using standard-dose IVT showed no difference in sHT rates and 90-day outcomes between the two groups. There was no evidence of heterogeneity (I2 >50%) among included studies. Conclusion: The results of this study indicated that prior history of ICrH does not increase the risk of sHT post-IVT, but it is associated with a higher risk of death and poor functional outcomes in 90 days.
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Affiliation(s)
- Mahsa Dolatshahi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | - Mohammadmahdi Sabahi
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USANeurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Vida Abedi
- Neuroscience Institute, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, 100 North Academy Avenue, Danville, PA 17822, USA. Neuroscience Institute, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
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Goh S, Tan NHW, Tan CH, Leow AST, Sia CH, Ho AFW, Lim MJR, Yeo LLL, Tan BYQ. Evaluating the safety and efficacy of intravenous thrombolysis for acute ischemic stroke patients with a history of intracerebral hemorrhage: a systematic review and meta-analysis. J Thromb Thrombolysis 2021; 53:485-494. [PMID: 34302590 DOI: 10.1007/s11239-021-02531-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 12/29/2022]
Abstract
Previous intracerebral hemorrhage (ICH) is labelled as a contraindication for the use of intravenous tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS) based on expert opinion. However, there is a paucity of data available regarding the benefits and risks of IV-tPA in this population. Recent small retrospective cohort studies reporting its off-label use suggest it may be beneficial. This study aims to investigate the safety and efficacy of IV-tPA in AIS patients with previous ICH. We performed a systematic review and meta-analysis of studies reporting on IV-tPA use in AIS patients with and without previous ICH. We searched Embase, PubMed and Cochrane Library from inception to 20 April 2021. Outcomes measured included symptomatic ICH (sICH), 3-month modified Rankin Scale (mRS) score, and 3-month mortality. We included seven retrospective cohort studies comprising 5760 AIS patients who had received IV-tPA, of which 134 had previous ICH. There was no significant difference in the odds of sICH (OR 1.57, 95% CI 0.78-3.15, p = 0.21) and 3-month mRS (mRS 0-1: OR 0.78, 95% CI 0.37-1.65, p = 0.52; mRS 0-2: OR 1.07, 95% CI 0.36-3.15, p = 0.90) between patients with and without previous ICH. There was a trend towards higher 3-month mortality in patients with previous ICH (OR 1.69, 95% CI 0.98-2.91, p = 0.06), although this did not reach statistical significance. The use of IV-tPA in AIS patients with previous ICH was not associated with an increased risk of sICH or disability at 3 months. Further larger studies are needed to establish the safety and efficacy of IV-tPA use in this population.
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Affiliation(s)
- Sherill Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Natalie H W Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Choon Han Tan
- Department of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Aloysius S T Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Andrew F W Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Pre-hospital & Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore National Heart Research Institute Singapore, National Heart Centre, Singapore, Singapore
| | - Mervyn J R Lim
- Division of Neurosurgery, Department of General Surgery, National University Hospital, Singapore, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore.
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
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Zhang H, Zhang B, Chen J. The application of the emergency green channel integrated management strategy in intravenous thrombolytic therapy for AIS. Am J Transl Res 2021; 13:7132-7139. [PMID: 34306473 PMCID: PMC8290777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/02/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To apply the emergency green channel integrated management strategy in intravenous thrombolytic therapy for acute ischemic stroke (AIS). METHODS This retrospective study involved a cohort of 82 AIS patients. Among them, 40 patients admitted to the emergency department of our hospital were treated using the emergency green channel integrated management strategy (the green channel group). Meanwhile, 42 AIS patients were rescued in accordance with the traditional grading and zoning treatment principles (the traditional group). The treatment times, the compliance rates of the times between when the patients entered the emergency department and when they underwent the thrombolysis treatment (the door-to-needle time or DNT), the neurological deficit scores, the Barthel index scores, and the ability of daily living scores before and after the treatment were compared between the two groups. RESULTS Compared with the traditional group, the triage times, the DNTs, the thrombolysis times, and the emergency department lengths of stay in the green channel group were significantly shorter (all P<0.001). The DNT compliance rate in the green channel group was significantly higher than it was in the traditional group (P<0.05). The neurological deficit scores in both groups after the treatment were lower than they were before the treatment (both P<0.01). The neurological deficit score in the green channel group after the treatment was lower than the neurological deficit score in the traditional group (P<0.01). The Barthel index and ability of daily living scores in the two groups after the treatment were significantly increased when compared with before the treatment (all P<0.001). The Barthel index and ability of daily living scores in the green channel group after the treatment were higher than they were in the traditional group (both P<0.001). The incidence of complications during the process of thrombolysis in the green channel group was significantly lower when compared with the incidence in the traditional group (P<0.05). CONCLUSION The emergency green channel integrated management strategy is more effective at shortening AIS patients' stays in the emergency department, increasing their DNT compliance rates, and at saving time for their thrombolytic therapy, improving patients' neurological function to a greater extent. It is worthy of clinical application.
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Affiliation(s)
- Hui Zhang
- Department of Nursing, Tongling Vocational and Technical CollegeTongling, Anhui Province, China
| | - Bin Zhang
- Stroke Center, Tongling People’s HospitalTongling, Anhui Province, China
| | - Jie Chen
- Stroke Center, Tongling People’s HospitalTongling, Anhui Province, China
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Tsivgoulis G, Kargiotis O, De Marchis G, Kohrmann M, Sandset EC, Karapanayiotides T, de Sousa DA, Sarraj A, Safouris A, Psychogios K, Vadikolias K, Leys D, Schellinger PD, Alexandrov AV. Off-label use of intravenous thrombolysis for acute ischemic stroke: a critical appraisal of randomized and real-world evidence. Ther Adv Neurol Disord 2021; 14:1756286421997368. [PMID: 33737956 PMCID: PMC7934037 DOI: 10.1177/1756286421997368] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
Intravenous thrombolysis (IVT) represents the only systemic reperfusion therapy able to reverse neurological deficit in patients with acute ischemic stroke (AIS). Despite its effectiveness in patients with or without large vessel occlusion, it can be offered only to a minority of them, because of the short therapeutic window and additional contraindications derived from stringent but arbitrary inclusion and exclusion criteria used in landmark randomized controlled clinical trials. Many absolute or relative contraindications lead to disparities between the official drug label and guidelines or expert recommendations. Based on recent advances in neuroimaging and evidence from cohort studies, off-label use of IVT is increasingly incorporated into the daily practice of many stroke centers. They relate to extension of therapeutic time windows, and expansion of indications in co-existing conditions originally listed in exclusion criteria, such as use of alternative thrombolytic agents, pre-treatment with antiplatelets, anticoagulants or low molecular weight heparins. In this narrative review, we summarize recent randomized and real-world data on the safety and efficacy of off-label use of IVT for AIS. We also make some practical recommendations to stroke physicians regarding the off-label use of thrombolytic agents in complex and uncommon presentations of AIS or other conditions mimicking acute cerebral ischemia. Finally, we provide guidance on the risks and benefits of IVT in numerous AIS subgroups, where equipoise exists and guidelines and treatment practices vary.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, Iras 39, Gerakas Attikis, Athens 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Gianmarco De Marchis
- Neurology and Stroke Center, Department of Clinical Research, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Martin Kohrmann
- Department of Neurology, Universitätsklinikum Essen, Essen, Germany
| | | | - Theodore Karapanayiotides
- Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Diana Aguiar de Sousa
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Amrou Sarraj
- Department of Neurology, The University of Texas at Houston, Houston, TX, USA
| | - Apostolos Safouris
- Second Department of Neurology, National & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | | | - Konstantinos Vadikolias
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Didier Leys
- Department of Neurology (Stroke Unit), Lille Neuroscience and Cognition, Degenerative and Vascular Cognitive Disorders, University of Lille, INSERM (U-1172), Lille, France
| | - Peter D. Schellinger
- Department of Neurology, Johannes Wesling Medical Center Minden, UK RUB Minden, Germany
| | - Andrei V. Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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Esmael A, Elsherief M, Eltoukhy K. Predictive Value of the Alberta Stroke Program Early CT Score (ASPECTS) in the Outcome of the Acute Ischemic Stroke and Its Correlation with Stroke Subtypes, NIHSS, and Cognitive Impairment. Stroke Res Treat 2021; 2021:5935170. [PMID: 33575025 PMCID: PMC7864728 DOI: 10.1155/2021/5935170] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/03/2020] [Accepted: 01/16/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES This study is aimed at correlating ASPECTS with mortality and morbidity in patients with acute middle cerebral artery territory infarction and at determining the cutoff value of ASPECTS that may predict the outcome. METHODS 150 patients diagnosed with acute middle cerebral artery territory infarction were involved in this study. Risk factors, initial NIHSS, and GCS were determined. An initial or follow-up noncontrast CT brain was done and assessed by ASPECTS. Outcomes were determined by mRS during the follow-up of cases after 3 months. Correlations of ASPECTS and outcome variables were done by Spearman correlation. Logistic regression analysis and ROC curve were done to detect the cutoff value of ASPECTS that predicts unfavorable outcomes. RESULTS The most common subtypes of ischemic strokes were lacunar stroke in 66 patients (44%), cardioembolic stroke in 39 patients (26%), and LAA stroke in 30 cases (20%). The cardioembolic stroke had a statistically significant lower ASPECT score than other types of ischemic strokes (P < 0.05). Spearman correlation showed that lower ASPECTS values (worse outcome) were more in older patients and associated with lower initial GCS. ASPECTS values were inversely correlated with initial NIHSS, inpatient stay, inpatient complications, mortality, and mRS. The ASPECTS cutoff value determined for the prediction of unfavorable outcomes was equal to ≤7. The binary logistic regression analysis detected that patients with ASPECTS ≤ 7 were significantly associated with about fourfold increased risk of poor outcomes (OR 3.95, 95% CI 2.09-11.38, and P < 0.01). CONCLUSIONS ASPECTS is a valuable and appropriate technique for the evaluation of the prognosis in acute ischemic stroke. Patients with high ASPECTS values are more likely to attain favorable outcomes, and the cutoff value of ASPECTS is a strong predictor for unfavorable outcomes. This trial is registered with ClinicalTrials.gov NCT04235920.
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Affiliation(s)
- Ahmed Esmael
- Neurology Department, Faculty of Medicine, Mansoura University, Egypt
| | | | - Khaled Eltoukhy
- Neurology Department, Faculty of Medicine, Mansoura University, Egypt
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The role of long non-coding RNA SNHG12 in neuroprotection following cerebral ischemic injury. Neuroreport 2019; 30:945-952. [DOI: 10.1097/wnr.0000000000001308] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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