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auf dem Brinke K, Kück F, Jamous A, Ernst M, Kunze-Szikszay N, Psychogios MN, Maier IL. The effect of inadvertent systemic hypothermia after mechanical thrombectomy in patients with large-vessel occlusion stroke. Front Neurol 2024; 15:1381872. [PMID: 38903162 PMCID: PMC11188377 DOI: 10.3389/fneur.2024.1381872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 05/08/2024] [Indexed: 06/22/2024] Open
Abstract
Background and aims Postinterventional hypothermia is a frequent complication in patients with large-vessel occlusion strokes (LVOS) after mechanical thrombectomy (MT). This inadvertent hypothermia might potentially have neuroprotective but also adverse effects on patients' outcomes. The aim of the study was to determine the rate of hypothermia in patients with LVOS receiving MT and its influence on functional outcome. Methods We performed a monocentric, retrospective study using a prospectively derived databank, including all LVOS patients receiving MT between 2015 and 2021. Predictive values of postinterventional body temperature and body temperature categories (hyperthermia (≥38°C), normothermia (35°C-37.9°C), and hypothermia (<35°C)) on functional outcome were analyzed using multivariable Bayesian logistic regression models. Favorable outcome was defined as modified Rankin Scale (mRS) ≤3. Results Of the 480 included LVOS patients with MT (46.0% men; mean ± SD age 73 ± 12.9 years), 5 (1.0%) were hyperthermic, 382 (79.6%) normothermic, and 93 (19.4%) hypothermic. Postinterventional hypothermia was significantly associated with unfavorable functional outcome (mRS > 3) after 90 days (OR 2.06, 95% CI 1.01-4.18, p = 0.045). For short-term functional outcome, patients with hypothermia had a higher discharge NIHSS (OR 1.38, 95% CI 1.06 to 1.79, p = 0.015) and a higher change of NIHSS from admission to discharge (OR 1.35, 95% CI 1.03 to 1.76, p = 0.029). Conclusion Approximately a fifth of LVOS patients in this cohort were hypothermic after MT. Hypothermia was an independent predictor of unfavorable functional outcomes. Our findings warrant a prospective trial investigating active warming during MT.
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Affiliation(s)
| | - Fabian Kück
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Ala Jamous
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Marielle Ernst
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Nils Kunze-Szikszay
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Ilko L. Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
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Mergenthaler P, Balami JS, Neuhaus AA, Mottahedin A, Albers GW, Rothwell PM, Saver JL, Young ME, Buchan AM. Stroke in the Time of Circadian Medicine. Circ Res 2024; 134:770-790. [PMID: 38484031 DOI: 10.1161/circresaha.124.323508] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/15/2024] [Indexed: 03/19/2024]
Abstract
Time-of-day significantly influences the severity and incidence of stroke. Evidence has emerged not only for circadian governance over stroke risk factors, but also for important determinants of clinical outcome. In this review, we provide a comprehensive overview of the interplay between chronobiology and cerebrovascular disease. We discuss circadian regulation of pathophysiological mechanisms underlying stroke onset or tolerance as well as in vascular dementia. This includes cell death mechanisms, metabolism, mitochondrial function, and inflammation/immunity. Furthermore, we present clinical evidence supporting the link between disrupted circadian rhythms and increased susceptibility to stroke and dementia. We propose that circadian regulation of biochemical and physiological pathways in the brain increase susceptibility to damage after stroke in sleep and attenuate treatment effectiveness during the active phase. This review underscores the importance of considering circadian biology for understanding the pathology and treatment choice for stroke and vascular dementia and speculates that considering a patient's chronotype may be an important factor in developing precision treatment following stroke.
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Affiliation(s)
- Philipp Mergenthaler
- Center for Stroke Research Berlin (P.M., A.M.B.), Charité - Universitätsmedizin Berlin, Germany
- Department of Neurology with Experimental Neurology (P.M.), Charité - Universitätsmedizin Berlin, Germany
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Joyce S Balami
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Ain A Neuhaus
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, United Kingdom (A.A.N.)
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Amin Mottahedin
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Nuffield Department of Clinical Neurosciences (A.M., P.M.R.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Gregory W Albers
- Department of Neurology, Stanford Hospital, Palo Alto, CA (G.W.A.)
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences (A.M., P.M.R.), University of Oxford, United Kingdom
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences (P.M.R.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, Geffen School of Medicine, University of Los Angeles, CA (J.L.S.)
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Martin E Young
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham (M.E.Y.)
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Alastair M Buchan
- Center for Stroke Research Berlin (P.M., A.M.B.), Charité - Universitätsmedizin Berlin, Germany
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
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Newey C, Skaar JR, O'Hara M, Miao B, Post A, Kelly T. Systematic Literature Review of the Association of Fever and Elevated Temperature with Outcomes in Critically Ill Adult Patients. Ther Hypothermia Temp Manag 2024; 14:10-23. [PMID: 37158862 DOI: 10.1089/ther.2023.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Although most commonly associated with infection, elevated temperature and fever also occur in a variety of critically ill populations. Prior studies have suggested that fever and elevated temperature may be detrimental to critically ill patients and can lead to poor outcomes, but the evidence surrounding the association of fever with outcomes is rapidly evolving. To broadly assess potential associations of elevated temperature and fever with outcomes in critically ill adult patients, we performed a systematic literature review focusing on traumatic brain injury, stroke (ischemic and hemorrhagic), cardiac arrest, sepsis, and general intensive care unit (ICU) patients. Searches were conducted in Embase® and PubMed® from 2016 to 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including dual-screening of abstracts, full texts, and extracted data. In total, 60 studies assessing traumatic brain injury and stroke (24), cardiac arrest (8), sepsis (22), and general ICU (6) patients were included. Mortality, functional, or neurological status and length of stay were the most frequently reported outcomes. Elevated temperature and fever were associated with poor clinical outcomes in patients with traumatic brain injury, stroke, and cardiac arrest but not in patients with sepsis. Although a causal relationship between elevated temperature and poor outcomes cannot be definitively established, the association observed in this systematic literature review supports the concept that management of elevated temperature may factor in avoidance of detrimental outcomes in multiple critically ill populations. The analysis also highlights gaps in our understanding of fever and elevated temperature in critically ill adult patients.
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Affiliation(s)
- Christopher Newey
- Department of Neurocritical Care, Sanford USD Medical Center, Sioux Falls, South Dakota, USA
| | | | | | | | - Andrew Post
- Trinity Life Sciences, Waltham, Massachusetts, USA
| | - Tim Kelly
- Becton Dickinson, Franklin Lakes, New Jersey, USA
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Dehkharghani S, Vogel A, Jandhyala N, Chung C, Shu L, Frontera J, Yaghi S. Continued Infarction Growth and Penumbral Consumption After Reperfusion in Vaccine-Naive Patients With COVID-19: A Case-Control Study. AJR Am J Roentgenol 2023; 221:517-525. [PMID: 37195793 DOI: 10.2214/ajr.23.29296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND. Neurologic sequelae of SARS-CoV-2 include potentially malignant cerebrovascular events arising from complex hemodynamic, hematologic, and inflammatory processes occurring in concert. OBJECTIVE. This study concerns the hypothesis that despite angiographic reperfusion COVID-19 promotes continued consumption of at-risk tissue volumes after acute ischemic stroke (AIS), yielding critical insights into prognostication and monitoring paradigms in vaccine-naive patients experiencing AIS. METHODS. This retrospective study compared 100 consecutive COVID-19 patients with AIS presenting between March 2020 and April 2021 with a contemporaneous cohort of 282 AIS patients without COVID-19. Reperfusion classes were dichotomized into positive (extended thrombolysis in cerebral ischemia [eTICI] score = 2c-3) and negative (eTICI score < 2c) groups. All patients underwent endovascular therapy after initial CT perfusion imaging (CTP) to document infarction core and total hypoperfusion volumes. RESULTS. Ten COVID-positive (mean age ± SD, 67 ± 12 years; seven men, three women) and 144 COVID-negative patients (mean age, 71 ± 16 years; 76 men, 68 women) undergoing endovascular reperfusion, with antecedent CTP and follow-up imaging, comprised the final dataset. Initial infarction core and total hypoperfusion volumes (mean ± SD) were 1.5 ± 18 mL and 85 ± 100 mL in COVID-negative patients and 30.5 ± 34 mL and 117 ± 80.5 mL in COVID-positive patients, respectively. Final infarction volumes were significantly larger in patients with COVID-19, with median volumes of 77.8 mL versus 18.2 mL among control patients (p = .01), as were normalized measures of infarction growth relative to baseline infarction volume (p = .05). In adjusted logistic parametric regression models, COVID positivity emerged as a significant predictor for continued infarct growth (OR, 5.10 [95% CI, 1.00-25.95]; p = .05). CONCLUSION. These findings support the potentially aggressive clinical course of cerebrovascular events in patients with COVID-19, suggesting greater infarction growth and ongoing consumption of at-risk tissues, even after angiographic reperfusion. CLINICAL IMPACT. SARS-CoV-2 infection may promote continued infarction progression despite angiographic reperfusion in vaccine-naive patients with large-vessel occlusion AIS. The findings carry potential implications for prognostication, treatment selection, and surveillance for infarction growth among revascularized patients in future waves of infection by novel viral strains.
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Affiliation(s)
- Seena Dehkharghani
- Department of Radiology, New York University Langone Medical Center, Center for Biomedical Imaging, 660 1st Ave, 2nd Fl, New York, NY 10016
- Department of Neurology, New York University Langone Health, New York, NY
| | - Andre Vogel
- Department of Radiology, New York University Grossman School of Medicine, New York, NY
| | - Nora Jandhyala
- Department of Radiology, New York University Grossman School of Medicine, New York, NY
| | - Charlotte Chung
- Department of Radiology, New York University Langone Medical Center, Center for Biomedical Imaging, 660 1st Ave, 2nd Fl, New York, NY 10016
| | - Liqi Shu
- Department of Neurology, Brown University, Providence, RI
| | - Jennifer Frontera
- Department of Neurology, New York University Langone Health, New York, NY
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI
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Zhang W, Li F, Zhang C, Lei B, Deng W, Zeng H, Yu Y, Wu J, Peng D, Tian Z, Zhu X, Hu Z, Hong Y, Li W, Ge H, Xu X, Ju D, Yang S, Pan C, Zi W, Wang S. Impact of Body Temperature in Patients With Acute Basilar Artery Occlusion: Analysis of the BASILAR Database. Front Neurol 2022; 13:907410. [PMID: 35720074 PMCID: PMC9205153 DOI: 10.3389/fneur.2022.907410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundA link between body temperature and stroke outcomes has been established but not for acute basilar artery occlusion. We aimed to determine the association between body temperature and clinical outcomes in patients with acute basilar artery occlusion and temperature management range.MethodsWe included patients from the Endovascular Treatment for Acute Basilar Artery Occlusion Study (BASILAR) database with records of both admission body temperature (ABT) and peak body temperature (PBT). ABT was defined as the body temperature first measured at the hospital visit, PBT was defined as the highest temperature within 24 h of treatment, and minus body temperature (MBT) was defined as PBT-ABT. The primary clinical outcome was favorable functional outcome, defined as the proportion of patients with a modified Rankin Scale score of 0–3 at 3 months. Secondary outcomes included 3-month mortality, in-hospital mortality, and symptomatic cerebral hemorrhage.ResultsA total of 664 patients were enrolled in the study; 74.7% were men, with a median age of 65 (interquartile range, 57.25–74) years. In all patients, multivariate analysis indicated that PBT and MBT were independent predictors of favorable functional outcome [odds ratio (OR), 0.57 (95% CI, 0.43–0.77); OR, 0.68 (95% CI, 0.52–0.88), respectively], and higher ABT, PBT, and MBT were associated with an increased 3-month mortality [OR, 1.47 (95% CI, 1.03–2.10), OR, 1.58 (95% CI, 1.28–1.96), OR, 1.35 (95% CI, 1.11–1.65), respectively]. Proportional odds models demonstrated that when ABT, PBT, MBT were in the range of <37.5, <38.9, and −0.6–2.7°C, respectively, the benefit of the endovascular treatment is clearly greater than that of standard medical treatment in terms of favorable functional outcome.ConclusionsBody temperature is an independent predictor of clinical outcome in patients with acute basilar artery occlusion. It is necessary to control the patient body temperature within the appropriate range in clinical settings.Trial RegistrationChinese Clinical Trial Registry ChiCTR1800014759. Registered 03 February 2018. Retrospectively registered.
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Affiliation(s)
- Wenbin Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Cai Zhang
- Department of Neurology, Daqing Oilfield General Hospital, Daqing, China
| | - Bo Lei
- Department of Cerebrovascular Diseases, Leshan People's Hospital, Leshan, China
| | - Wei Deng
- Department of Neurology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Hongliang Zeng
- Department of Neurology, Ganzhou People's Hospital, Ganzhou, China
| | - Yang Yu
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Junxiong Wu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Daizhou Peng
- Department of Neurology, Qianxinan People's Hospital, Xingyi, China
| | - Zhenxuan Tian
- Department of Neurology, The 404th Hospital of Mianyang, Mianyang, China
| | - Xiurong Zhu
- Department of Neurology, Chongzhou People's Hospital, Chongzhou, China
| | - Zhizhou Hu
- Department of Neurology, Longyan No. 1 Hospital, Longyan, China
| | - Yifan Hong
- Department of Neurology, Shantou Central Hospital, Shantou, China
| | - Wenbo Li
- Department of Neurointervention, Luoyang Central Hospital, Luoyang, China
| | - Hanming Ge
- Department of Neurology, Xi'an Third Hospital, Xi'an, China
| | - Xinwei Xu
- Department of Neurology, Jieyang People's Hospital, Jieyang, China
| | - Dongsheng Ju
- Department of Neurology, Songyuan Jilin Oilfield Hospital, Songyuan, China
| | - Shunyu Yang
- Department of Neurology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Chengde Pan
- Department of Neurology, Banan District People's Hospital, Chongqing, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Wenjie Zi
| | - Shouchun Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
- *Correspondence: Shouchun Wang
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Foda A, Kellner E, Gunawardana A, Gao X, Janz M, Kufner A, Khalil AA, Geran R, Mekle R, Fiebach JB, Galinovic I. Differentiation of Cerebral Neoplasms with Vessel Size Imaging (VSI). Clin Neuroradiol 2022; 32:239-248. [PMID: 34940899 PMCID: PMC8894153 DOI: 10.1007/s00062-021-01129-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 12/03/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Cerebral neoplasms of various histological origins may show comparable appearances on conventional Magnetic Resonance Imaging (MRI). Vessel size imaging (VSI) is an MRI technique that enables noninvasive assessment of microvasculature by providing quantitative estimates of microvessel size and density. In this study, we evaluated the potential of VSI to differentiate between brain tumor types based on their microvascular morphology. METHODS Using a clinical 3T MRI scanner, VSI was performed on 25 patients with cerebral neoplasms, 10 with glioblastoma multiforme (GBM), 8 with primary CNS lymphoma (PCNSL) and 7 with cerebral lung cancer metastasis (MLC). Following the postprocessing of VSI maps, mean vessel diameter (vessel size index, vsi) and microvessel density (Q) were compared across tumors, peritumoral areas, and healthy tissues. RESULTS The MLC tumors have larger and less dense microvasculature compared to PCNSLs in terms of vsi and Q (p = 0.0004 and p < 0.0001, respectively). GBM tumors have higher yet non-significantly different vsi values than PCNSLs (p = 0.065) and non-significant differences in Q. No statistically significant differences in vsi or Q were present between GBMs and MLCs. GBM tumor volume was positively correlated with vsi (r = 0.502, p = 0.0017) and negatively correlated with Q (r = -0.531, p = 0.0007). CONCLUSION Conventional MRI parameters are helpful in differentiating between PCNSLs, GBMs, and MLCs. Additionally incorporating VSI parameters into the diagnostic protocol could help in further differentiating between PCNSLs and metastases and potentially between PCNSLs and GBMs. Future studies in larger patient cohorts are required to establish diagnostic cut-off values for VSI.
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Affiliation(s)
- Asmaa Foda
- International Graduate Program Medical Neurosciences, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Elias Kellner
- Department of Radiology, Medical Physics, University Medical Center Freiburg, Freiburg, Germany
| | - Asanka Gunawardana
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
| | - Xiang Gao
- Department of Radiology, Medical Physics, University Medical Center Freiburg, Freiburg, Germany
| | - Martin Janz
- Department of Hematology, Oncology and Cancer Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Kufner
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ahmed A Khalil
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
- Berlin School of Mind and Brain, Humboldt Universität zu Berlin, Berlin, Germany
- Max Planck Institute for Human Cognitive and Brain Sciences, Berlin, Germany
| | - Rohat Geran
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ralf Mekle
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ivana Galinovic
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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7
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Luo Y, Chen M, Fang J, Dong S, Ma M, Bao J, Feng L, He L. Relationship Between Body Temperature and Early Neurological Deterioration after Endovascular Thrombectomy for Acute Ischemic Stroke with Large Vessel Occlusion. Neurocrit Care 2022; 37:399-409. [PMID: 34981427 DOI: 10.1007/s12028-021-01416-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/30/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Early neurological deterioration (END) after endovascular thrombectomy (EVT) is strongly associated with poor prognosis in patients with large vessel occlusion. The relationship between body temperature and END after EVT is unknown, which we aimed to investigate in this study. METHODS END was defined as an increase of four or more points on the National Institutes of Health Stroke Scale score compared with the baseline assessment within 24 h. Logistic regression and restricted cubic spline models were used to assess the relationship between body temperature and END. RESULTS Among 7741 consecutive patients with ischemic stroke, 406 patients with large vessel occlusion who underwent EVT were enrolled. In total, 88 (21.7%) patients developed END. Logistic regression showed that the maximum body temperature within 24 h (odds ratio [OR] = 1.97 per °C, 95% confidence interval [CI] 1.17-3.32, p = 0.010) was independently associated with END. This association was nonlinear and J shaped (p for nonlinearity = 0.010), and the risk of END increased when the maximum body temperature within 24 h was lower or higher than 37.0 °C. Fever burden is also independently associated with END (OR = 1.06 per °C × hour, 95% CI 1.01-1.11, p = 0.012). In addition, the timing of fever onset was independently associated with END, and the highest risk of END was associated with fever onset within 6 h after EVT (OR = 3.92, 95% CI 1.25-12.27, p = 0.019). CONCLUSIONS In summary, there is a J-shaped association between the maximum body temperature within 24 h after EVT and END. Moreover, the risk of END differed according to the timing of fever onset.
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Affiliation(s)
- Yaxi Luo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Man Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jinghuan Fang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Shuju Dong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mengmeng Ma
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jiajia Bao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ling Feng
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.
- West China School of Nursing, Sichuan University, Chengdu, China.
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.
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8
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Chen M, Fang J, Wu X, Liu Q, Feng L, He L. Association between hyperpyrexia and poststroke outcomes in patients with recanalization after mechanical thrombectomy: a retrospective cohort study. BMC Neurol 2021; 21:365. [PMID: 34548043 PMCID: PMC8454168 DOI: 10.1186/s12883-021-02400-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 09/14/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Limited data are available for evaluating the relationship between the prognosis and body temperature (BT) in patients treated with mechanical thrombectomy (MT), especially in those with successful recanalization. We aimed to explore the prognostic value of BT in predicting outcomes of stroke recovery at 3 months poststroke. METHODS We retrospectively analyzed the relationship among BT levels as a continuous variable, with fever (BT ≥ 37.5℃) as a binary variable, and obtained several outcomes of interest. Subjects were stratified according to successful recanalization (thrombolysis in cerebral infarction scores of 2b-3) following MT. Functional independence was defined as a modified Rankin scale (mRS) score of 0-2. RESULTS In total, 258 patients were included. The proportion of patients with functional independence was significantly lower among patients with BT ≥ 37.5℃ than among those with BT < 37.5 °C (45.3 % versus 23.0 %; P < 0.001). In the multivariate analysis, hyperpyrexia (especially BT ≥ 38 °C) was significantly associated with poor 3-month outcomes in patients treated with MT. Subgroup analysis was conducted by comparing the successful recanalization group with the non-recanalization group, showing that BT ≥ 37.5 °C was associated with a significantly lower proportion of functional independence in the recanalized patients. Besides, the Kaplan-Meier model showed that the fever group had significantly lower survival rates than the non-fever group during the 3-month follow-up. CONCLUSIONS In patients treated with MT, hyperpyrexia is an independent predictor of poststroke outcomes at 3 months, particularly in those with successful recanalization.
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Affiliation(s)
- Man Chen
- Department of Neurology, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Jinghuan Fang
- Department of Neurology, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Xintong Wu
- Department of Neurology, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Qin Liu
- Department of Neurology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, 610041, Chengdu, China
| | - Ling Feng
- Department of Neurology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, 610041, Chengdu, China.
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, 610041, Chengdu, China.
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9
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Macha K, Schwab S. Endovascular treatment of large vessel occlusion acute ischemic stroke: Is there a place for hypothermia? Eur J Neurol 2021; 28:2469-2470. [PMID: 34008882 DOI: 10.1111/ene.14920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Kosmas Macha
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
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10
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Prognostic significance of early pyrexia in acute intracerebral haemorrhage: The INTERACT2 study. J Neurol Sci 2021; 423:117364. [PMID: 33647734 DOI: 10.1016/j.jns.2021.117364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 01/25/2021] [Accepted: 02/18/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Uncertainty exists over the prognostic significance of pyrexia in acute intracerebral haemorrhage (ICH). We aimed to determine the association of elevated body temperature with clinical and imaging outcomes among participants of the main Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT2). METHODS Post-hoc analyses of INTERACT2, an international open, blinded outcome assessed, randomised trial of 2839 patients with spontaneous ICH (<6 h of onset) and elevated systolic blood pressure (SBP, 150-220 mmHg) randomly assigned to intensive (SBP target <140 mmHg) or guideline-recommended (SBP target < 180 mmHg) BP management. Multivariable logistic regression was used to determine associations of elevated baseline body temperature (<37.5 vs. ≥37.5 °C) and 90-day clinical outcome defined on the modified Rankin scale (mRS). Analysis of covariance determined relations of body temperature and haematoma and perihaematomal oedema (PHE) volumes, at baseline and 24 h post-randomisation. RESULTS Of 2792 participants with data available at admission, 39 (1.4%) patients had elevated body temperature ≥ 37.5 °C. Elevated body temperature was significantly associated with 90-day mortality (adjusted odds ratio 2.44; 95% confidence interval 1.02-5.82; P = .044) but not with major disability alone (mRS scores 3-5) and combination death or major disability (mRS scores 3-6). Elevated body temperature was also associated with larger PHE volume at baseline (10.89 vs. 3.14 cm3, P < .001;) and 24 h (12.43 vs 5.76 cm3, P = .018) but not with haematoma volumes at these time points. CONCLUSION Early pyrexia in mild to moderate ICH is associated with greater mortality and larger PHE volume, suggesting an early inflammatory-mediated reaction. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov (NCT00716079).
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11
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Pegoli M, Zurlo Z, Bilotta F. Temperature management in acute brain injury: A systematic review of clinical evidence. Clin Neurol Neurosurg 2020; 197:106165. [PMID: 32937217 DOI: 10.1016/j.clineuro.2020.106165] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/09/2020] [Accepted: 08/19/2020] [Indexed: 01/13/2023]
Abstract
Temperature alterations in neurocritical care settings are common and have a striking effect on brain metabolism leading to or exacerbating neuronal injury. Hyperthermia worsens acute brain injury (ABI) patients outcome. However conclusive evidence linking control of temperature to improved outcome is still lacking. This review article report an update -results from clinical studies published between March 2006 and March 2020- on the relationship between hyperthermia or Target Temperature Management and functional outcome or mortality in ABI patients. MATERIALS AND METHODS A systematic search of articles in PubMed and EMBASE database was accomplished. Only complete studies, published in English in peer-reviewed journals were included. RESULTS A total of 63 articles into 5 subchapters are presented: acute ischemic stroke (17), subarachnoid hemorrhage (14), brain trauma (14), intracranial hemorrhage (8), and mixed acute brain injury (10). This evidence confirm and extend the negative impact of hyperthermia in ABI patients on worse functional outcome and higher mortality. In particular "early hyperthermia" in AIS patients seems to have a protective role have as promoting factor of clot lysis but no conclusive evidence is available. Normothermic TTM seems to have a positive effect on TBI patients in a reduced mortality rate compared to hypothermic TTM. CONCLUSIONS Hyperthermia in ABI patients is associated with worse functional outcome and higher mortality. The use of normothermic TTM has an established indication only in TBI; further studies are needed to define the role and the indications of normothermic TTM in ABI patients.
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Affiliation(s)
- M Pegoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy.
| | - Z Zurlo
- Department of Anaesthesia and Intensive Care, University La Sapienza, Rome, Italy
| | - F Bilotta
- Department of Anaesthesia and Intensive Care, University La Sapienza, Rome, Italy
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12
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Dehkharghani S, Yaghi S, Bowen MT, Pisani L, Scher E, Haussen DC, Nogueira RG. Mild fever as a catalyst for consumption of the ischaemic penumbra despite endovascular reperfusion. Brain Commun 2020; 2:fcaa116. [PMID: 33033801 PMCID: PMC7532660 DOI: 10.1093/braincomms/fcaa116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/18/2020] [Accepted: 06/23/2020] [Indexed: 11/26/2022] Open
Abstract
Cerebrovascular ischaemia is potentiated by hyperthermia, and even mild temperature elevation has proved detrimental to ischaemic brain. Infarction progression following endovascular reperfusion relates to multiple patient-specific and procedural variables; however, the potential influence of mild systemic temperature fluctuations is not fully understood. This study aims to assess the relationship between systemic temperatures in the early aftermath of acute ischaemic stroke and the loss of at-risk penumbral tissues, hypothesizing consumption of the ischaemic penumbra as a function of systemic temperatures, irrespective of reperfusion status. A cross-sectional, retrospective evaluation of a single-institution, prospectively collected endovascular therapy registry was conducted. Patients with anterior circulation, large vessel occlusion acute ischaemic stroke who underwent initial CT perfusion, and in whom at least four-hourly systemic temperatures were recorded beginning from presentation and until the time of final imaging outcome were included. Initial CT perfusion core and penumbra volumes and final MRI infarction volumes were computed. Systemic temperature indices including temperature maxima were recorded, and pre-defined temperature thresholds varying between 37°C and 38°C were examined in unadjusted and adjusted regression models which included glucose, collateral status, reperfusion status, CT perfusion-to-reperfusion delay, general anaesthesia and antipyretic exposure. The primary outcome was the relative consumption of the penumbra, reflecting normalized growth of the at-risk tissue volume ≥10%. The final study population comprised 126 acute ischaemic stroke subjects (mean 63 ± 14.5 years, 63% women). The primary outcome of penumbra consumption ≥10% occurred in 51 (40.1%) subjects. No significant differences in baseline characteristics were present between groups, with the exception of presentation glucose (118 ± 26.6 without versus 143.1 ± 61.6 with penumbra consumption, P = 0.009). Significant differences in the likelihood of penumbra consumption relating to systemic temperature maxima were observed [37°C (interquartile range 36.5 − 37.5°C) without versus 37.5°C (interquartile range 36.8 − 38.2°C) with penumbra consumption, P = 0.001]. An increased likelihood of penumbra consumption was observed for temperature maxima in unadjusted (odds ratio 3.57, 95% confidence interval 1.65 − 7.75; P = 0.001) and adjusted (odds ratio 3.06, 95% confidence interval 1.33 − 7.06; P = 0.009) regression models. Significant differences in median penumbra consumption were present at a pre-defined temperature maxima threshold of 37.5°C [4.8 ml (interquartile range 0 − 11.5 ml) versus 21.1 ml (0 − 44.7 ml) for subjects not reaching or reaching the threshold, respectively, P = 0.007]. Mild fever may promote loss of the ischaemic penumbra irrespective of reperfusion, potentially influencing successful salvage of at-risk tissue volumes following acute ischaemic stroke.
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Affiliation(s)
- Seena Dehkharghani
- Department of Radiology, New York University Langone Health, New York, NY, USA
| | - Shadi Yaghi
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Meredith T Bowen
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Leonardo Pisani
- Department of Neurology, Emory University Hospital, Atlanta, GA, USA
| | - Erica Scher
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University Hospital, Atlanta, GA, USA.,Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA 30303, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University Hospital, Atlanta, GA, USA.,Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA 30303, USA
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13
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Ávila-Gómez P, Hervella P, Da Silva-Candal A, Pérez-Mato M, Rodríguez-Yáñez M, López-Dequidt I, Pumar JM, Castillo J, Sobrino T, Iglesias-Rey R, Campos F. Temperature-Induced Changes in Reperfused Stroke: Inflammatory and Thrombolytic Biomarkers. J Clin Med 2020; 9:jcm9072108. [PMID: 32635529 PMCID: PMC7408797 DOI: 10.3390/jcm9072108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 12/14/2022] Open
Abstract
Although hyperthermia is associated with poor outcomes in ischaemic stroke (IS), some studies indicate that high body temperature may benefit reperfusion therapies. We assessed the association of temperature with effective reperfusion (defined as a reduction of ≥8 points in the National Institute of Health Stroke Scale (NIHSS) within the first 24 h) and poor outcome (modified Rankin Scale (mRS) > 2) in 875 retrospectively-included IS patients. We also studied the influence of temperature on thrombolytic (cellular fibronectin (cFn); matrix metalloproteinase 9 (MMP-9)) and inflammatory biomarkers (tumour necrosis factor-alpha (TNF-α), interleukin 6 (IL-6)) and their relationship with effective reperfusion. Our results showed that a higher temperature at 24 but not 6 h after stroke was associated with failed reperfusion (OR: 0.373, p = 0.001), poor outcome (OR: 2.190, p = 0.005) and higher IL-6 levels (OR: 0.958, p < 0.0001). Temperature at 6 h was associated with higher MMP-9 levels (R = 0.697; p < 0.0001) and effective reperfusion, although this last association disappeared after adjusting for confounding factors (OR: 1.178, p = 0.166). Our results suggest that body temperature > 37.5 °C at 24 h, but not at 6 h after stroke, is correlated with reperfusion failure, poor clinical outcome, and infarct size. Mild hyperthermia (36.5–37.5 °C) in the first 6 h window might benefit drug reperfusion therapies by promoting clot lysis.
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Affiliation(s)
- Paulo Ávila-Gómez
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
| | - Pablo Hervella
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
| | - Andrés Da Silva-Candal
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
| | - María Pérez-Mato
- Neuroscience and Cerebrovascular Research Laboratory, Department of Neurology and Stroke Center, La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Universidad Autónoma de Madrid, E28046 Madrid, Spain;
| | - Manuel Rodríguez-Yáñez
- Stroke Unit, Department of Neurology, Health Research Institute of Santiago de Compostela, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain; (M.R.-Y.); (I.L.-D.)
| | - Iria López-Dequidt
- Stroke Unit, Department of Neurology, Health Research Institute of Santiago de Compostela, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain; (M.R.-Y.); (I.L.-D.)
| | - José M. Pumar
- Department of Neuroradiology, Hospital Clínico Universitario, Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain;
| | - José Castillo
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
| | - Tomás Sobrino
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
| | - Ramón Iglesias-Rey
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
- Correspondence: (R.I.-R.); (F.C.); Tel./Fax: +34-981951098 (R.I.-R. & F.C.)
| | - Francisco Campos
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
- Correspondence: (R.I.-R.); (F.C.); Tel./Fax: +34-981951098 (R.I.-R. & F.C.)
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14
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Diprose WK, Liem B, Wang MT, Sutcliffe JA, Brew S, Caldwell JR, McGuinness B, Campbell D, Barber PA. Impact of Body Temperature Before and After Endovascular Thrombectomy for Large Vessel Occlusion Stroke. Stroke 2020; 51:1218-1225. [DOI: 10.1161/strokeaha.119.028160] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background and Purpose—
In ischemic stroke, body temperature is associated with functional outcome. However, the relationship between temperature and outcome may differ in the intraischemic and postischemic phases of stroke. We aimed to determine whether body temperature before or after endovascular thrombectomy (EVT) for large vessel occlusion stroke is associated with clinical outcomes.
Methods—
Consecutive EVT patients were identified from a prospective registry. Temperature measurements within 24 hours of admission were stratified into pre-EVT (preprocedural and intraprocedural) and post-EVT measurements, which served as surrogates for the intraischemic and postischemic phases of large vessel occlusion stroke, respectively. The primary outcome was functional independence, defined as a modified Rankin Scale score of 0, 1, or 2 at 3 months. Secondary outcomes included the ordinal shift of modified Rankin Scale scores at 3 months, symptomatic intracerebral hemorrhage, and mortality at 3 months.
Results—
Four hundred thirty-two participants were included (59% men, mean±SD age 65.6±15.7 years). Multivariable logistic regression demonstrated that higher median pre-EVT temperature (per 1°C increase) was an independent predictor of reduced functional independence (odds ratio [OR], 0.66 [95% CI, 0.46–0.94];
P
=0.02), poorer modified Rankin Scale scores (common OR, 1.42 [95% CI, 1.08–1.85];
P
=0.01), and increased mortality (OR, 1.65 [95% CI, 1.02–2.69];
P
=0.04). Peak post-EVT temperature (per 1°C increase) was a significant predictor of elevated modified Rankin Scale scores (common OR, 1.39 [95% CI, 1.03–1.90];
P
=0.03) and higher mortality (OR, 1.66 [95% CI, 1.04–2.67];
P
=0.03).
Conclusions—
In patients with large vessel occlusion stroke treated with EVT, higher body temperatures during both the intraischemic and postischemic phases were associated with poorer clinical outcomes. Future research investigating the maintenance of normothermia or therapeutic hypothermia in patients needing to be transferred from primary to EVT-capable stroke centers could be considered.
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Affiliation(s)
- William K. Diprose
- From the Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand (W.K.D., M.T.M.W., P.A.B.)
- Department of Neurology (W.K.D., B.L., P.A.B.), Auckland City Hospital, New Zealand
| | - Bernard Liem
- Department of Neurology (W.K.D., B.L., P.A.B.), Auckland City Hospital, New Zealand
| | - Michael T.M. Wang
- From the Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand (W.K.D., M.T.M.W., P.A.B.)
| | - James A. Sutcliffe
- Department of Radiology (J.A.S., S.B., J.R.C., B.M.), Auckland City Hospital, New Zealand
| | - Stefan Brew
- Department of Radiology (J.A.S., S.B., J.R.C., B.M.), Auckland City Hospital, New Zealand
| | - James R. Caldwell
- Department of Radiology (J.A.S., S.B., J.R.C., B.M.), Auckland City Hospital, New Zealand
| | - Ben McGuinness
- Department of Radiology (J.A.S., S.B., J.R.C., B.M.), Auckland City Hospital, New Zealand
| | - Doug Campbell
- Department of Anaesthesia and Perioperative Medicine (D.C.), Auckland City Hospital, New Zealand
| | - P. Alan Barber
- From the Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand (W.K.D., M.T.M.W., P.A.B.)
- Department of Neurology (W.K.D., B.L., P.A.B.), Auckland City Hospital, New Zealand
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15
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Dehkharghani S, Qiu D. MR Thermometry in Cerebrovascular Disease: Physiologic Basis, Hemodynamic Dependence, and a New Frontier in Stroke Imaging. AJNR Am J Neuroradiol 2020; 41:555-565. [PMID: 32139425 DOI: 10.3174/ajnr.a6455] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/02/2020] [Indexed: 01/20/2023]
Abstract
The remarkable temperature sensitivity of the brain is widely recognized and has been studied for its role in the potentiation of ischemic and other neurologic injuries. Pyrexia frequently complicates large-vessel acute ischemic stroke and develops commonly in critically ill neurologic patients; the profound sensitivity of the brain even to minor intraischemic temperature changes, together with the discovery of brain-to-systemic as well as intracerebral temperature gradients, has thus compelled the exploration of cerebral thermoregulation and uncovered its immutable dependence on cerebral blood flow. A lack of pragmatic and noninvasive tools for spatially and temporally resolved brain thermometry has historically restricted empiric study of cerebral temperature homeostasis; however, MR thermometry (MRT) leveraging temperature-sensitive nuclear magnetic resonance phenomena is well-suited to bridging this long-standing gap. This review aims to introduce the reader to the following: 1) fundamental aspects of cerebral thermoregulation, 2) the physical basis of noninvasive MRT, and 3) the physiologic interdependence of cerebral temperature, perfusion, metabolism, and viability.
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Affiliation(s)
- S Dehkharghani
- From the Department of Radiology (S.D.), New York University Langone Health, New York, New York
| | - D Qiu
- Department of Radiology (D.Q.), Emory University Hospital, Atlanta, Georgia
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16
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Rabinstein AA, Albers GW, Brinjikji W, Koch S. Factors that may contribute to poor outcome despite good reperfusion after acute endovascular stroke therapy. Int J Stroke 2018; 14:23-31. [DOI: 10.1177/1747493018799979] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular therapy with mechanical thrombectomy is a formidable treatment for severe acute ischemic stroke caused by occlusion of a proximal intracranial artery. Its strong beneficial effect is explained by the high rates of very good and excellent reperfusion achieved with current endovascular techniques. However, there is a sizable proportion of patients who do not experience clinical improvement despite successful recanalization of the occluded artery and reperfusion of the ischemic territory. Factors such as baseline reserve, collateral flow, anesthesia and systemic factors have been identified as potential culprits for lack of improvement in the setting of timely and successful revascularization. Older age, baseline disability and perhaps radiological markers of chronic brain injury can affect the prognosis of patients treated with endovascular therapy. Collateral flow is a major determinant of outcome after endovascular therapy and it is manifested by the size of the core in relation to the volume of the salvageable tissue. Parenchymal and vascular imaging can help assess the quality of collateral flow, but the optimal radiological strategy for daily practice (i.e. the optimal combination of rapid availability and diagnostic precision) has not been established. A sizable body of observational evidence indicates that acute hypertension, hyperglycemia and fever are associated with worse outcomes after a stroke even after optimal reperfusion with endovascular therapy. Lastly, current randomized controlled trials in anesthesia for stroke demonstrate similar rates of good functional outcome between general anesthesia and conscious sedation suggesting equipoise exists.
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Affiliation(s)
| | | | | | - Sebastian Koch
- Department of Neurology, University of Miami, Coral Gables, FL, USA
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17
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de Jonge JC, Wallet J, van der Worp HB. Fever worsens outcomes in animal models of ischaemic stroke: A systematic review and meta-analysis. Eur Stroke J 2018; 4:29-38. [PMID: 31165092 PMCID: PMC6533866 DOI: 10.1177/2396987318776421] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/17/2018] [Indexed: 01/05/2023] Open
Abstract
Background Subfebrile temperatures and fever in the first days after stroke are associated with a greater risk of a poor outcome. If this relation is causal, prevention of hyperthermia may improve outcome. Causality can be tested in animal models. We therefore assessed the effects of hyperthermia on outcomes in animal models of ischaemic stroke and explored under which conditions prevention of hyperthermia could be most effective. Methods We performed a systematic review and meta-analysis of data from animal experiments testing the effect of spontaneous or induced hyperthermia on outcome after focal cerebral ischaemia. Our primary outcome measure was infarct size. Normalised mean differences were combined using the random effects model and stratified meta-analysis was used to explore the impact of study characteristics. Results We included 19 publications, reporting on 49 comparisons involving 603 animals. Overall, hyperthermia increased infarct size by 43.4% (95% confidence interval, 29.8-56.9%) and worsened neurobehavioral outcomes by 48.5% (17.2-79.8%). The increase in infarct size was larger with higher temperatures. Hyperthermia was most harmful if present for more than 2 h and when started at the time of artery occlusion rather than later. Conclusion Hyperthermia substantially increased infarct size in animal models of ischaemic stroke, suggesting that the relation between fever and poor outcome observed in patients is at least in part causal. These data provide support to trials testing the effect of the prevention of fever with antipyretic drugs in patients with acute stroke.
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Affiliation(s)
- Jeroen C de Jonge
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Justin Wallet
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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18
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Fleischer CC, Wu J, Qiu D, Park SE, Nahab F, Dehkharghani S. The Brain Thermal Response as a Potential Neuroimaging Biomarker of Cerebrovascular Impairment. AJNR Am J Neuroradiol 2017; 38:2044-2051. [PMID: 28935624 DOI: 10.3174/ajnr.a5380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 07/09/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Brain temperature is critical for homeostasis, relating intimately to cerebral perfusion and metabolism. Cerebral thermometry is historically challenged by the cost and invasiveness of clinical and laboratory methodologies. We propose the use of noninvasive MR thermometry in patients with cerebrovascular disease, hypothesizing the presence of a measurable brain thermal response reflecting the tissue hemodynamic state. MATERIALS AND METHODS Contemporaneous imaging and MR thermometry were performed in 10 patients (32-68 years of age) undergoing acetazolamide challenge for chronic, anterior circulation steno-occlusive disease. Cerebrovascular reactivity was calculated with blood oxygen level-dependent imaging and arterial spin-labeling methods. Brain temperature was calculated pre- and post-acetazolamide using previously established chemical shift thermometry. Mixed-effects models of the voxelwise relationships between the brain thermal response and cerebrovascular reactivity were computed, and the significance of model coefficients was determined with an F test (P < .05). RESULTS We observed significant, voxelwise quadratic relationships between cerebrovascular reactivity from blood oxygen level-dependent imaging and the brain thermal response (x coefficient = 0.052, P < .001; x2coefficient = 0.0068, P < .001) and baseline brain temperatures (x coefficient = 0.59, P = .008; x2 coefficient = -0.13, P < .001). A significant linear relationship was observed for the brain thermal response with cerebrovascular reactivity from arterial spin-labeling (P = .001). CONCLUSIONS The findings support the presence of a brain thermal response exhibiting complex but significant interactions with tissue hemodynamics, which we posit to reflect a relative balance of heat-producing versus heat-dissipating tissue states. The brain thermal response is a potential noninvasive biomarker for cerebrovascular impairment.
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Affiliation(s)
- C C Fleischer
- From the Department of Biomedical Engineering (C.C.F., S.-E.P.), Emory University and Georgia Institute of Technology, Atlanta, Georgia
- the Departments of Radiology and Imaging Sciences (C.C.F., J.W., D.Q., S.D.)
| | - J Wu
- the Departments of Radiology and Imaging Sciences (C.C.F., J.W., D.Q., S.D.)
| | - D Qiu
- the Departments of Radiology and Imaging Sciences (C.C.F., J.W., D.Q., S.D.)
| | - S-E Park
- From the Department of Biomedical Engineering (C.C.F., S.-E.P.), Emory University and Georgia Institute of Technology, Atlanta, Georgia
| | - F Nahab
- Neurology (F.N., S.D.)
- Pediatrics (F.N.), Emory University School of Medicine, Atlanta, Georgia
| | - S Dehkharghani
- the Departments of Radiology and Imaging Sciences (C.C.F., J.W., D.Q., S.D.)
- Neurology (F.N., S.D.)
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19
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Dehkharghani S, Fleischer CC, Qiu D, Yepes M, Tong F. Cerebral Temperature Dysregulation: MR Thermographic Monitoring in a Nonhuman Primate Study of Acute Ischemic Stroke. AJNR Am J Neuroradiol 2017; 38:712-720. [PMID: 28126752 DOI: 10.3174/ajnr.a5059] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/06/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral thermoregulation remains poorly understood. Temperature dysregulation is deeply implicated in the potentiation of cerebrovascular ischemia. We present a multiphasic, MR thermographic study in a nonhuman primate model of MCA infarction, hypothesizing detectable brain temperature disturbances and brain-systemic temperature decoupling. MATERIALS AND METHODS Three Rhesus Macaque nonhuman primates were sourced for 3-phase MR imaging: 1) baseline MR imaging, 2) 7-hour continuous MR imaging following minimally invasive, endovascular MCA stroke induction, and 3) poststroke day 1 MR imaging follow-up. MR thermometry was achieved by multivoxel spectroscopy (semi-localization by adiabatic selective refocusing) by using the proton resonance frequency chemical shift. The relationship of brain and systemic temperatures with time and infarction volumes was characterized by using a mixed-effects model. RESULTS Following MCA infarction, progressive cerebral hyperthermia was observed in all 3 subjects, significantly outpacing systemic temperature fluctuations. Highly significant associations were observed for systemic, hemispheric, and global brain temperatures (F-statistic, P = .0005 for all regressions) relative to the time from stroke induction. Significant differences in the relationship between temperature and time following stroke onset were detected when comparing systemic temperatures with ipsilateral (P = .007), contralateral (P = .004), and infarction core (P = .003) temperatures following multiple-comparisons correction. Significant associations were observed between infarction volumes and both systemic (P ≤ .01) and ipsilateral (P = .04) brain temperatures, but not contralateral brain temperature (P = .08). CONCLUSIONS Successful physiologic and continuous postischemic cerebral MR thermography was conducted and prescribed in a nonhuman primate infarction model to facilitate translatability. The results confirm hypothesized temperature disturbance and decoupling of physiologic brain-systemic temperature gradients. These findings inform a developing paradigm of brain thermoregulation and the applicability of brain temperature as a neuroimaging biomarker in CNS injury.
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Affiliation(s)
- S Dehkharghani
- From the Departments of Radiology and Imaging Sciences (S.D., D.Q., F.T.)
- Neurology (S.D., M.Y.), Emory University Hospital, Atlanta, Georgia
| | - C C Fleischer
- Department of Biomedical Engineering (C.C.F.), Emory University and Georgia Institute of Technology, Atlanta, Georgia
| | - D Qiu
- From the Departments of Radiology and Imaging Sciences (S.D., D.Q., F.T.)
| | - M Yepes
- Neurology (S.D., M.Y.), Emory University Hospital, Atlanta, Georgia
| | - F Tong
- From the Departments of Radiology and Imaging Sciences (S.D., D.Q., F.T.)
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