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Goyal M, Hill MD, Ospel JM. Designing clinical trials for bridging cerebroprotection in the era of mechanical thrombectomy: are we missing the point? J Neurointerv Surg 2024:jnis-2024-022009. [PMID: 38937085 DOI: 10.1136/jnis-2024-022009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Johanna M Ospel
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
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Ospel JM, Rex N, Oueidat K, McDonough R, Rinkel L, Baird G, Collins S, Jindal G, Alvin MD, Boxerman J, Barber P, Jayaraman M, Smith W, Amirault-Capuano A, Hill MD, Goyal M, McTaggart R. Infarcts Due to Large Vessel Occlusions Continue to Grow Despite Near-Complete Reperfusion After Endovascular Treatment. J Stroke 2024; 26:260-268. [PMID: 38836273 PMCID: PMC11164585 DOI: 10.5853/jos.2023.02621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 01/09/2024] [Accepted: 02/01/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Infarcts in acute ischemic stroke (AIS) patients may continue to grow even after reperfusion, due to mechanisms such as microvascular obstruction and reperfusion injury. We investigated whether and how much infarcts grow in AIS patients after near-complete (expanded Thrombolysis in Cerebral Infarction [eTICI] 2c/3) reperfusion following endovascular treatment (EVT), and to assess the association of post-reperfusion infarct growth with clinical outcomes. METHODS Data are from a single-center retrospective observational cohort study that included AIS patients undergoing EVT with near-complete reperfusion who received diffusion-weighted magnetic resonance imaging (MRI) within 2 hours post-EVT and 24 hours after EVT. Association of infarct growth between 2 and 24 hours post-EVT and 24-hour National Institutes of Health Stroke Scale (NIHSS) as well as 90-day modified Rankin Scale score was assessed using multivariable logistic regression. RESULTS Ninety-four of 155 (60.6%) patients achieved eTICI 2c/3 and were included in the analysis. Eighty of these 94 (85.1%) patients showed infarct growth between 2 and 24 hours post-reperfusion. Infarct growth ≥5 mL was seen in 39/94 (41.5%) patients, and infarct growth ≥10 mL was seen in 20/94 (21.3%) patients. Median infarct growth between 2 and 24 hours post-reperfusion was 4.5 mL (interquartile range: 0.4-9.2 mL). Post-reperfusion infarct growth was associated with the 24-hour NIHSS in multivariable analysis (odds ratio: 1.16 [95% confidence interval 1.09-1.24], P<0.01). CONCLUSION Infarcts continue to grow after EVT, even if near-complete reperfusion is achieved. Investigating the underlying mechanisms may inform future therapeutic approaches for mitigating the process and help improve patient outcome.
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Affiliation(s)
- Johanna M. Ospel
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nathaniel Rex
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Karim Oueidat
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | | | - Leon Rinkel
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Grayson Baird
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Scott Collins
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Gaurav Jindal
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Matthew D. Alvin
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Jerrold Boxerman
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Phil Barber
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Mahesh Jayaraman
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Wendy Smith
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | | | - Michael D. Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Ryan McTaggart
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
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Xu J, Chen XY, Wang HY, Shang YF, Shen PP, Zhang S, Guo SY, Tan MM, Geng Y. Hemodynamic predictors of early neurological deterioration and clinical outcome after endovascular treatment in large artery occlusion. Heliyon 2024; 10:e24746. [PMID: 38318012 PMCID: PMC10838741 DOI: 10.1016/j.heliyon.2024.e24746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 12/07/2023] [Accepted: 01/12/2024] [Indexed: 02/07/2024] Open
Abstract
Objective Half of the patients with acute large artery occlusion (LAO) have poor outcomes after endovascular treatment (EVT). Early complications such as cerebral edema and symptomatic intracranial hemorrhage (sICH) can lead to early neurological deterioration (END), which correlates with hemodynamics. This study aimed to identify the hemodynamic predictors of END and outcomes in LAO patients after EVT. Methods A total of 76 patients with anterior circulation LAO who underwent EVT and received transcranial Doppler (TCD) monitoring were included. Bilateral middle cerebral artery (MCA) blood flow velocities (BFVs) were measured repeatedly within 1 week. Mean flow velocities (MFV) and MFV index (ipsilateral MFV/contralateral MFV) were calculated. The primary outcome was the incidence of END within 72 h. The secondary outcome was the functional outcome at 90 days-a good outcome was defined as a modified Rankin scale (mRS) score of 0-2, while a poor outcome was defined as an mRS score of 3-6. Results A total of 13 patients (17.1 %) experienced END within 72 h, including 5 (38.5 %) with cerebral edema, 5 (38.5 %) with sICH, and 3 (23.0 %) with infarct progression. Multivariable logistic regression analysis showed that a higher 24 h MFV index was independently associated with END (aOR 10.5; 95 % CI 2.28-48.30, p = 0.003) and a poor 90-day outcome (aOR 5.10; 95 % CI 1.38-18.78, p = 0.014). The area under the receiver operating characteristic (ROC) curve (AUC) of the 24 h MFV index for predicting END was 0.807 (95 % CI 0.700-0.915, p = 0.0005), the sensitivity was 84.6 %, and the specificity was 66.7 %. At the 1-week TCD follow-up, patients who had poor 90-day outcomes showed significantly higher 1-week iMFV [73.5 (58.4-99.0) vs. 57.7 (45.3-76.3), p = 0.004] and MFV index [1.24 (0.98-1.57) vs.1.0 (0.87-1.15) p = 0.007]. A persistent high MFV index (PHMI) was independently associated with a poor outcome (aOR 7.77, 95 % CI 1.81-33.3, p = 0.006). Conclusion TCD monitoring within 24 h after EVT in LAO patients can help predict END, while dynamic follow-up within 1 week is valuable in predicting clinical outcomes.
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Affiliation(s)
- Jie Xu
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Xin-Yi Chen
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Hui-Yuan Wang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- School of Clinical Medicine, Graduate School, Bengbu Medical College, Bengbu, 233030, Anhui, China
| | - Ya-Fei Shang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- School of Clinical Medicine, Graduate School, Bengbu Medical College, Bengbu, 233030, Anhui, China
| | - Pan-Pan Shen
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Sheng Zhang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Shun-Yuan Guo
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Ming-Ming Tan
- Department of Quality Management, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
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Tudor T, Spinazzi EF, Alexander JE, Mandigo GK, Lavine SD, Grinband J, Connolly ES. Progressive microvascular failure in acute ischemic stroke: A systematic review, meta-analysis, and time-course analysis. J Cereb Blood Flow Metab 2024; 44:192-208. [PMID: 38016953 PMCID: PMC10993872 DOI: 10.1177/0271678x231216766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/01/2023] [Accepted: 10/02/2023] [Indexed: 11/30/2023]
Abstract
This systematic review, meta-analysis, and novel time course analysis examines microvascular failure in the treatment of acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT) and/or thrombolytic administration for stroke management. A systematic review and meta-analysis following PRIMSA-2020 guidelines was conducted along with a novel curve-of-best fit analysis to elucidate the time-course of microvascular failure. Scopus and PubMed were searched using relevant keywords to identify studies that examine recanalization and reperfusion assessment of AIS patients following large vessel occlusion. Meta-analysis was conducted using a random-effects model. Curve-of-best-fit analysis of microvascular failure rate was performed with a negative exponential model. Twenty-seven studies with 1151 patients were included. Fourteen studies evaluated patients within a standard stroke onset-to-treatment time window (≤6 hours after last known normal) and thirteen studies had an extended time window (>6 hours). Our analysis yields a 22% event rate of microvascular failure following successful recanalization (95% CI: 16-30%). A negative exponential curve modeled a microvascular failure rate asymptote of 28.5% for standard time window studies, with no convergence of the model for extended time window studies. Progressive microvascular failure is a phenomenon that is increasingly identified in clinical studies of AIS patients undergoing revascularization treatment.
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Affiliation(s)
- Thilan Tudor
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Eleonora F Spinazzi
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Julia E Alexander
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Grace K Mandigo
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Sean D Lavine
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Jack Grinband
- Departments of Psychiatry and Radiology, Columbia University Irving Medical Center, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Fladt J, Guo J, Specht JL, Wang M, Chan LL, Mctaggart R, Buck BH, Aviv R, Swartz RH, Field TS, Tarpley J, Shah R, Goyal M, Tymianski M, Hill MD, Demchuk A, d'Esterre C, Barber P. Infarct Evolution on MR-DWI After Thrombectomy in Acute Stroke Patients Randomized to Nerinetide or Placebo: The REPERFUSE-NA1 Study. Neurology 2024; 102:e207976. [PMID: 38165335 DOI: 10.1212/wnl.0000000000207976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/27/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The neuroprotectant nerinetide has shown promise in reducing infarct volumes in primate models of ischemia reperfusion. We hypothesized that early secondary infarct growth after endovascular therapy (EVT) (1) may be a suitable surrogate biomarker for testing neuroprotective compounds, (2) is feasible to assess in the acute setting using sequential MRI, and (3) can be modified by treatment with nerinetide. METHODS REPERFUSE-NA1 was a prospective, multisite MRI substudy of the randomized controlled trial ESCAPE-NA1 (ClinicalTrials.gov NCT02930018) that involved patients with acute disabling large vessel occlusive stroke undergoing EVT within 12 hours of onset who were randomized to receive intravenous nerinetide or placebo. Patients enrolled in REPERFUSE-NA1 underwent sequential MRI <5 hours post-EVT (day 1) and at 24 hours (day 2). The primary outcome was total diffusion-weighted MRI infarct growth early after EVT, defined as the lesion volume difference between day 2 and day 1. The secondary outcome was region-specific infarct growth in different brain tissue compartments. Statistical analyses were performed using the Mann-Whitney U test and multiple linear regression. RESULTS Sixty-seven of 71 patients included had MRI of sufficient quality. The median infarct volume post-EVT was 12.98 mL (IQR, 5.93-28.08) in the nerinetide group and 10.80 mL (IQR, 3.11-24.45) in the control group (p = 0.59). Patients receiving nerinetide showed a median early secondary infarct growth of 5.92 mL (IQR, 1.09-21.30) compared with 10.80 mL (interquartile range [IQR], 2.54-21.81) in patients with placebo (p = 0.30). Intravenous alteplase modified the effect of nerinetide on region-specific infarct growth in white matter and basal ganglia compartments. In patients with no alteplase, the infarct growth rate was reduced by 120% (standard error [SE], 60%) in the white matter (p = 0.03) and by 340% (SE, 140%) in the basal ganglia (p = 0.02) in the nerinetide group compared with placebo after adjusting for confounders. DISCUSSION This study highlights the potential of using MR imaging as a biomarker to estimate the effect of a neuroprotective agent in acute stroke treatment. Patients with acute large vessel occlusive stroke exhibited appreciable early infarct growth both in the gray matter and the white matter after undergoing EVT. Acknowledging relatively small overall infarct volumes in this study, treatment with nerinetide was associated with slightly reduced percentage infarct growth in the white matter and basal ganglia compared with placebo in patients not receiving intravenous alteplase and had no effect on the total early secondary infarct growth. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov NCT02930018. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for patients with acute large vessel ischemic stroke undergoing EVT, nerinetide did not significantly decrease early post-EVT infarct growth compared with placebo.
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Affiliation(s)
- Joachim Fladt
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Jen Guo
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Jacinta L Specht
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Meng Wang
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Leona L Chan
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Ryan Mctaggart
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Brian H Buck
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Richard Aviv
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Richard H Swartz
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Thalia S Field
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Jason Tarpley
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Ruchir Shah
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Mayank Goyal
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Michael Tymianski
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Michael D Hill
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Andrew Demchuk
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Christopher d'Esterre
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Philip Barber
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
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Staehr C, Aalkjaer C, Matchkov V. The vascular Na,K-ATPase: clinical implications in stroke, migraine, and hypertension. Clin Sci (Lond) 2023; 137:1595-1618. [PMID: 37877226 PMCID: PMC10600256 DOI: 10.1042/cs20220796] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/26/2023]
Abstract
In the vascular wall, the Na,K-ATPase plays an important role in the control of arterial tone. Through cSrc signaling, it contributes to the modulation of Ca2+ sensitivity in vascular smooth muscle cells. This review focuses on the potential implication of Na,K-ATPase-dependent intracellular signaling pathways in severe vascular disorders; ischemic stroke, familial migraine, and arterial hypertension. We propose similarity in the detrimental Na,K-ATPase-dependent signaling seen in these pathological conditions. The review includes a retrospective proteomics analysis investigating temporal changes after ischemic stroke. The analysis revealed that the expression of Na,K-ATPase α isoforms is down-regulated in the days and weeks following reperfusion, while downstream Na,K-ATPase-dependent cSrc kinase is up-regulated. These results are important since previous studies have linked the Na,K-ATPase-dependent cSrc signaling to futile recanalization and vasospasm after stroke. The review also explores a link between the Na,K-ATPase and migraine with aura, as reduced expression or pharmacological inhibition of the Na,K-ATPase leads to cSrc kinase signaling up-regulation and cerebral hypoperfusion. The review discusses the role of an endogenous cardiotonic steroid-like compound, ouabain, which binds to the Na,K-ATPase and initiates the intracellular cSrc signaling, in the pathophysiology of arterial hypertension. Currently, our understanding of the precise control mechanisms governing the Na,K-ATPase/cSrc kinase regulation in the vascular wall is limited. Understanding the role of vascular Na,K-ATPase signaling is essential for developing targeted treatments for cerebrovascular disorders and hypertension, as the Na,K-ATPase is implicated in the pathogenesis of these conditions and may contribute to their comorbidity.
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Affiliation(s)
- Christian Staehr
- Department of Biomedicine, Aarhus University, Høegh-Guldbergsgade 10, 8000 Aarhus, Denmark
- Department of Renal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, Aarhus, Denmark
| | - Christian Aalkjaer
- Department of Biomedicine, Aarhus University, Høegh-Guldbergsgade 10, 8000 Aarhus, Denmark
- Danish Cardiovascular Academy, Høegh-Guldbergsgade 10, 8000 Aarhus, Denmark
| | - Vladimir V. Matchkov
- Department of Biomedicine, Aarhus University, Høegh-Guldbergsgade 10, 8000 Aarhus, Denmark
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7
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Malikova H, Kremenova K, Lukavsky J, Holesta M, Lauer D, Koznar B, Weichet J. Early and late infarct growth rate in ischemic stroke patients after successful endovascular treatment in early time window: correlation of imaging and clinical factors with clinical outcome. Quant Imaging Med Surg 2023; 13:5770-5782. [PMID: 37711771 PMCID: PMC10498245 DOI: 10.21037/qims-23-153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/30/2023] [Indexed: 09/16/2023]
Abstract
Background The prospective study assessed infarct growth rate (IGR) in acute ischemic stroke (AIS) with large vessel occlusion (LVO) after recanalization in early time window. Early IGR (EIGR) and late IGR (LIGR) were correlated with imaging and clinical data; we searched for outcome predictors. Methods We included 71 consecutive patients. Subjects underwent computed tomography perfusion (CTP) for ischemic core volume assessment at 99.0 minutes (median) from stroke onset, recanalization was performed at 78.0 minutes (median) from CTP. Final infarct volume (FIV) was measured on 24±2 hours imaging follow-up. EIGR was calculated as the core volume/time between stroke onset and CTP; LIGR was calculated as FIV/time between CTP and imaging follow-up. Twenty-two subjects were assessed as poor outcome, 49 as good outcome. Group differences were tested by Mann-Whitney test and χ2 test. Bayesian logistic regression models were used to predict clinical outcome, Pearson correlations for the log-transformed predictors. Results Subjects with poor outcome were older, median age 78.0 [interquartile range (IQR): 71.8, 83.8] versus 68.0 (IQR: 57.0, 73.0) years; 95% confidence interval (CI): 6.00 to 16.00; P<0.001. Their stroke severity scale was higher, median 19.0 (IQR: 16.0, 20.0) versus 15.5 (IQR: 10.8, 18.0); 95% CI: 1.00 to 6.00; P<0.001. They had higher EIGR, median 23.9 (IQR: 6.4, 104.0) versus 6.7 (IQR: 1.7, 13.0) mL/h; 95% CI: 3.26 to 53.68; P=0.002; and larger core, median 52.5 (IQR: 13.1, 148.5) versus 10.0 (IQR: 1.4, 20.0) mL; 95% CI: 11.00 to 81.00; P<0.001. In subjects with poor outcome, infarct growth continued after thrombectomy with LIGR 2.0 (IQR: 1.2, 9.7) versus 0.3 (IQR: 0.0, 0.7) mL/h; 95% CI: 1.10 to 6.10; P<0.001; resulting in larger FIV, median 186.5 (IQR: 49.3, 280.8) versus 18.5 (IQR: 8.0, 34.0) mL; 95% CI: 55.30 to 214.00; P<0.001. Strong correlations among predictors were found e.g., core and EIGR (r=0.942), LIGR and FIV (r=0.779), core and FIV (r=0.761). Clinical outcome was best predicted using data from later measurements as FIV and LIGR. Conclusions Data from later measurements were more predictive, there was no major benefit to use growth over volume data.
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Affiliation(s)
- Hana Malikova
- Department of Radiology and Nuclear Medicine, Third Faculty of Medicine, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
- Institute of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Karin Kremenova
- Department of Radiology and Nuclear Medicine, Third Faculty of Medicine, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Jiri Lukavsky
- Institute of Psychology, Czech Academy of Sciences, Prague, Czech Republic
| | - Michal Holesta
- Department of Radiology and Nuclear Medicine, Third Faculty of Medicine, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - David Lauer
- Department of Radiology and Nuclear Medicine, Third Faculty of Medicine, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
- Neurology Department, Third Faculty of Medicine, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Boris Koznar
- Cardiology Department, Third Faculty of Medicine, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Jiri Weichet
- Department of Radiology and Nuclear Medicine, Third Faculty of Medicine, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
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8
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Gong GQ, Bilanges B, Allsop B, Masson GR, Roberton V, Askwith T, Oxenford S, Madsen RR, Conduit SE, Bellini D, Fitzek M, Collier M, Najam O, He Z, Wahab B, McLaughlin SH, Chan AWE, Feierberg I, Madin A, Morelli D, Bhamra A, Vinciauskaite V, Anderson KE, Surinova S, Pinotsis N, Lopez-Guadamillas E, Wilcox M, Hooper A, Patel C, Whitehead MA, Bunney TD, Stephens LR, Hawkins PT, Katan M, Yellon DM, Davidson SM, Smith DM, Phillips JB, Angell R, Williams RL, Vanhaesebroeck B. A small-molecule PI3Kα activator for cardioprotection and neuroregeneration. Nature 2023; 618:159-168. [PMID: 37225977 PMCID: PMC7614683 DOI: 10.1038/s41586-023-05972-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 03/17/2023] [Indexed: 05/26/2023]
Abstract
Harnessing the potential beneficial effects of kinase signalling through the generation of direct kinase activators remains an underexplored area of drug development1-5. This also applies to the PI3K signalling pathway, which has been extensively targeted by inhibitors for conditions with PI3K overactivation, such as cancer and immune dysregulation. Here we report the discovery of UCL-TRO-1938 (referred to as 1938 hereon), a small-molecule activator of the PI3Kα isoform, a crucial effector of growth factor signalling. 1938 allosterically activates PI3Kα through a distinct mechanism by enhancing multiple steps of the PI3Kα catalytic cycle and causes both local and global conformational changes in the PI3Kα structure. This compound is selective for PI3Kα over other PI3K isoforms and multiple protein and lipid kinases. It transiently activates PI3K signalling in all rodent and human cells tested, resulting in cellular responses such as proliferation and neurite outgrowth. In rodent models, acute treatment with 1938 provides cardioprotection from ischaemia-reperfusion injury and, after local administration, enhances nerve regeneration following nerve crush. This study identifies a chemical tool to directly probe the PI3Kα signalling pathway and a new approach to modulate PI3K activity, widening the therapeutic potential of targeting these enzymes through short-term activation for tissue protection and regeneration. Our findings illustrate the potential of activating kinases for therapeutic benefit, a currently largely untapped area of drug development.
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Affiliation(s)
- Grace Q Gong
- Cell Signalling, Cancer Institute, University College London, London, UK
| | - Benoit Bilanges
- Cell Signalling, Cancer Institute, University College London, London, UK
| | - Ben Allsop
- Drug Discovery Group, Translational Research Office, University College London, London, UK
| | - Glenn R Masson
- Medical Research Council Laboratory of Molecular Biology, Cambridge, UK
- Division of Cellular Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Victoria Roberton
- UCL Centre for Nerve Engineering, UCL School of Pharmacy, University College London, London, UK
| | - Trevor Askwith
- Drug Discovery Group, Translational Research Office, University College London, London, UK
| | - Sally Oxenford
- Drug Discovery Group, Translational Research Office, University College London, London, UK
| | - Ralitsa R Madsen
- Cell Signalling, Cancer Institute, University College London, London, UK
| | - Sarah E Conduit
- Cell Signalling, Cancer Institute, University College London, London, UK
| | - Dom Bellini
- Medical Research Council Laboratory of Molecular Biology, Cambridge, UK
| | - Martina Fitzek
- Hit Discovery, Discovery Sciences, R&D, AstraZeneca, Alderley Park, Macclesfield, UK
| | - Matt Collier
- Hit Discovery, Discovery Sciences, R&D, AstraZeneca, Alderley Park, Macclesfield, UK
| | - Osman Najam
- The Hatter Cardiovascular Institute, University College London, London, UK
| | - Zhenhe He
- The Hatter Cardiovascular Institute, University College London, London, UK
| | - Ben Wahab
- Medicines Discovery Institute, School of Biosciences, Cardiff University, Cardiff, UK
| | | | - A W Edith Chan
- Wolfson Institute for Biomedical Research, University College London, London, UK
| | | | - Andrew Madin
- Hit Discovery, Discovery Sciences, R&D, AstraZeneca, Cambridge, UK
| | - Daniele Morelli
- Cell Signalling, Cancer Institute, University College London, London, UK
| | - Amandeep Bhamra
- Proteomics Research Translational Technology Platform, Cancer Institute, University College London, London, UK
| | - Vanesa Vinciauskaite
- Division of Cellular Medicine, School of Medicine, University of Dundee, Dundee, UK
| | | | - Silvia Surinova
- Proteomics Research Translational Technology Platform, Cancer Institute, University College London, London, UK
| | - Nikos Pinotsis
- Institute of Structural and Molecular Biology, Birkbeck College, London, UK
| | | | - Matthew Wilcox
- UCL Centre for Nerve Engineering, UCL School of Pharmacy, University College London, London, UK
| | - Alice Hooper
- Drug Discovery Group, Translational Research Office, University College London, London, UK
| | - Chandni Patel
- Drug Discovery Group, Translational Research Office, University College London, London, UK
| | - Maria A Whitehead
- Cell Signalling, Cancer Institute, University College London, London, UK
| | - Tom D Bunney
- Institute of Structural and Molecular Biology, Division of Biosciences, University College London, London, UK
| | | | | | - Matilda Katan
- Institute of Structural and Molecular Biology, Division of Biosciences, University College London, London, UK
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, London, UK
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, London, UK
| | - David M Smith
- Emerging Innovations, Discovery Sciences, R&D, AstraZeneca, Cambridge, UK
| | - James B Phillips
- UCL Centre for Nerve Engineering, UCL School of Pharmacy, University College London, London, UK
| | - Richard Angell
- Drug Discovery Group, Translational Research Office, University College London, London, UK
- Medicines Discovery Institute, School of Biosciences, Cardiff University, Cardiff, UK
| | - Roger L Williams
- Medical Research Council Laboratory of Molecular Biology, Cambridge, UK
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Liu J, Wang J, Wu J, Gu S, Yao Y, Li J, Li Y, Ren H, Luo T. Comparison of two computed tomography perfusion post-processing software to assess infarct volume in patients with acute ischemic stroke. Front Neurosci 2023; 17:1151823. [PMID: 37179549 PMCID: PMC10166848 DOI: 10.3389/fnins.2023.1151823] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/07/2023] [Indexed: 05/15/2023] Open
Abstract
Objectives We used two automated software commonly employed in clinical practice-Olea Sphere (Olea) and Shukun-PerfusionGo (PerfusionGo)-to compare the diagnostic utility and volumetric agreement of computed tomography perfusion (CTP)-predicted final infarct volume (FIV) with true FIV in patients with anterior-circulation acute ischemic stroke (AIS). Methods In all, 122 patients with anterior-circulation AIS who met the inclusion and exclusion criteria were retrospectively enrolled and divided into two groups: intervention group (n = 52) and conservative group (n = 70), according to recanalization of blood vessels and clinical outcome (NIHSS) after different treatments. Patients in both groups underwent one-stop 4D-CT angiography (CTA)/CTP, and the raw CTP data were processed on a workstation using Olea and PerfusionGo post-processing software, to calculate and obtain the ischemic core (IC) and hypoperfusion (IC plus penumbra) volumes, hypoperfusion in the conservative group and IC in the intervention group were used to define the predicted FIV. The ITK-SNAP software was used to manually outline and measure true FIV on the follow-up non-enhanced CT or MRI-DWI images. Intraclass correlation coefficients (ICC), Bland-Altman, and Kappa analysis were used to compare the differences in IC and penumbra volumes calculated by the Olea and PerfusionGo software to investigate the relationship between their predicted FIV and true FIV. Results The IC and penumbra difference between Olea and PerfusionGo within the same group (p < 0.001) was statistically significant. Olea obtained larger IC and smaller penumbra than PerfusionGo. Both software partially overestimated the infarct volume, but Olea significantly overestimated it by a larger percentage. ICC analysis showed that Olea performed better than PerfusionGo (intervention-Olea: ICC 0.633, 95%CI 0.439-0.771; intervention-PerfusionGo: ICC 0.526, 95%CI 0.299-0.696; conservative-Olea: ICC 0.623, 95%CI 0.457-0.747; conservative-PerfusionGo: ICC 0.507, 95%CI 0.312-0.662). Olea and PerfusionGo had the same capacity in accurately diagnosing and classifying patients with infarct volume <70 ml. Conclusion Both software had differences in the evaluation of the IC and penumbra. Olea's predicted FIV was more closely correlated with the true FIV than PerfusionGo's prediction. Accurate assessment of infarction on CTP post-processing software remains challenging. Our results may have important practice implications for the clinical use of perfusion post-processing software.
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Affiliation(s)
- Jiayang Liu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jingjie Wang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiajing Wu
- Department of Radiology, Hospital of PLA Army, Chongqing, China
| | - Sirun Gu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yunzhuo Yao
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yongmei Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Huanhuan Ren
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Tianyou Luo
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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10
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Hoving JW, van Voorst H, Kappelhof M, Tolhuisen M, Treurniet KM, LeCouffe NE, Rinkel LA, Koopman MS, Cavalcante F, Konduri PR, van den Wijngaard IR, Ghariq E, Anton Meijer FJ, Coutinho JM, Marquering HA, Roos YBWEM, Emmer BJ, Majoie CBLM. Infarct Evolution in Patients with Anterior Circulation Large-Vessel Occlusion Randomized to IV Alteplase and Endovascular Treatment versus Endovascular Treatment Alone. AJNR Am J Neuroradiol 2023; 44:434-440. [PMID: 36958803 PMCID: PMC10084906 DOI: 10.3174/ajnr.a7826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/31/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND AND PURPOSE Infarct evolution after endovascular treatment varies widely among patients with stroke and may be affected by baseline characteristics and procedural outcomes. Moreover, IV alteplase and endovascular treatment may influence the relationship of these factors to infarct evolution. We aimed to assess whether the infarct evolution between baseline and follow-up imaging was different for patients who received IVT and EVT versus EVT alone. MATERIALS AND METHODS We included patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN)-NO IV trial with baseline CTP and follow-up imaging. Follow-up infarct volume was segmented on 24-hour or 1-week follow-up DWI or NCCT. Infarct evolution was defined as the follow-up lesion volume: CTP core volume. Substantial infarct growth was defined as an increase in follow-up infarct volume of >10 mL. We assessed whether infarct evolution was different for patients with IV alteplase and endovascular treatment versus endovascular treatment alone and evaluated the association of baseline characteristics and procedural outcomes with infarct evolution using multivariable regression. RESULTS From 228 patients with CTP results available, 145 patients had follow-up imaging and were included in our analysis. For patients with IV alteplase and endovascular treatment versus endovascular treatment alone, the baseline median CTP core volume was 17 (interquartile range = 4-35) mL versus 11 (interquartile range = 6-24) mL. The median follow-up infarct volume was 13 (interquartile range, 4-48) mL versus 17 (interquartile range = 4-50) mL. Collateral status and occlusion location were negatively associated with substantial infarct growth in patients with and without IV alteplase before endovascular treatment. CONCLUSIONS No statistically significant difference in infarct evolution was found in directly admitted patients who received IV alteplase and endovascular treatment within 4.5 hours of symptom onset versus patients who underwent endovascular treatment alone. Collateral status and occlusion location may be useful predictors of infarct evolution prognosis in patients eligible for IV alteplase who underwent endovascular treatment.
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Affiliation(s)
- J W Hoving
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - H van Voorst
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - M Kappelhof
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - M Tolhuisen
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - K M Treurniet
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - N E LeCouffe
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - L A Rinkel
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - M S Koopman
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - F Cavalcante
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - P R Konduri
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - I R van den Wijngaard
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - E Ghariq
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - F J Anton Meijer
- Department of Radiology (F.J.A.M.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - J M Coutinho
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - H A Marquering
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - Y B W E M Roos
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - B J Emmer
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - C B L M Majoie
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
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11
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Bani-Sadr A, Pavie D, Mechtouff L, Cappucci M, Hermier M, Ameli R, Derex L, De Bourguignon C, Cho TH, Eker O, Nighoghossian N, Berthezene Y. Brush sign and collateral supply as potential markers of large infarct growth after successful thrombectomy. Eur Radiol 2023; 33:4502-4509. [PMID: 36633674 DOI: 10.1007/s00330-022-09387-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/13/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To investigate the relationships between brush sign and cerebral collateral status on infarct growth after successful thrombectomy. METHODS HIBISCUS-STROKE cohort includes acute ischemic stroke patients treated with thrombectomy after MRI triage and undergoing a day-6 MRI including FLAIR images to quantify final infarct volume (FIV). Successful reperfusion was defined as a modified thrombolysis in cerebral infarction score ≥ 2B. Infarct growth was calculated by subtracting FIV from baseline ischemic core after co-registration and considered large (LIG) when > 11.6 mL. Brush sign was assessed on T2*-weighted-imaging and collaterals were assessed using the hypoperfusion intensity ratio, which is the volume of Time-To-Tmax (Tmax) ≥ 10 s divided by the volume of Tmax ≥ 6 s. Good collaterals were defined by a hypoperfusion intensity ratio < 0.4. RESULTS One hundred and twenty-nine patients were included, of whom 45 (34.9%) had a brush sign and 63 (48.8%) good collaterals. Brush sign was associated with greater infarct growth (p = 0.01) and larger FIV (p = 0.02). Good collaterals were associated with a smaller baseline ischemic core (p < 0.001), larger penumbra (p = 0.04), and smaller FIV (p < 0.001). Collateral status was not significantly associated with brush sign (p = 0.20) or with infarct growth (p = 0.67). Twenty-eight (22.5%) patients experienced LIG. Univariate regressions indicated that brush sign (odds ratio (OR) = 4.8; 95% confidence interval (CI): [1.9;13.3]; p = 0.004) and hemorrhagic transformation (OR = 1.7; 95%CI: [1.2;2.6]; p = 0.04) were predictive of LIG. In multivariate regression, only the brush sign remained predictive of LIG (OR = 5.2; 95%CI: [1.8-16.6], p = 0.006). CONCLUSIONS Brush sign is a predictor of LIG after successful thrombectomy and cerebral collateral status is not. KEY POINTS • Few predictors of ischemic growth are known in ischemic stroke patients achieving successful mechanical thrombectomy. • Our results suggest that the brush sign-a surrogate marker of severe hypoperfusion-is independently associated with large ischemic growth (> 11.6 mL) after successful thrombectomy whereas cerebral collateral status does not.
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Affiliation(s)
- Alexandre Bani-Sadr
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France. .,CREATIS Laboratory, CNRS UMR 5220, INSERM U 5220, Claude Bernard Lyon I University. 7 Avenue Jean Capelle O, 69100, Villeurbanne, France.
| | - Dylan Pavie
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France
| | - Laura Mechtouff
- Stroke Department, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France.,CarMeN Laboratory, INSERM U1060, Claude Bernard Lyon I University, 59 Bd Pinel, 69500, Bron, France
| | - Matteo Cappucci
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France
| | - Marc Hermier
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France
| | - Roxana Ameli
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France
| | - Laurent Derex
- Stroke Department, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France.,Research On Healthcare Performance (RESHAPE), INSERM U 1290, Claude Bernard Lyon I University. Domaine Rockfeller, 8 Avenue Rockfeller, 69373 Cedex 08, Lyon, France
| | | | - Tae-Hee Cho
- Stroke Department, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France.,CarMeN Laboratory, INSERM U1060, Claude Bernard Lyon I University, 59 Bd Pinel, 69500, Bron, France
| | - Omer Eker
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France.,CREATIS Laboratory, CNRS UMR 5220, INSERM U 5220, Claude Bernard Lyon I University. 7 Avenue Jean Capelle O, 69100, Villeurbanne, France
| | - Norbert Nighoghossian
- Stroke Department, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France.,CarMeN Laboratory, INSERM U1060, Claude Bernard Lyon I University, 59 Bd Pinel, 69500, Bron, France
| | - Yves Berthezene
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France.,CREATIS Laboratory, CNRS UMR 5220, INSERM U 5220, Claude Bernard Lyon I University. 7 Avenue Jean Capelle O, 69100, Villeurbanne, France
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12
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Hernández-Pérez M, Werner M, Remollo S, Martín C, Cortés J, Valls A, Ramos A, Dorado L, Serena J, Munuera J, Puig J, Pérez de la Ossa N, Gomis M, Carbonell J, Castaño C, Muñoz-Narbona L, Palomeras E, Domenech S, Massuet A, Terceño M, Davalos A, Millán M. Early and Delayed Infarct Growth in Patients Undergoing Mechanical Thrombectomy: A Prospective, Serial MRI Study. Stroke 2023; 54:217-225. [PMID: 36325911 DOI: 10.1161/strokeaha.122.039090] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND We studied the evolution over time of diffusion weighted imaging (DWI) lesion volume and the factors involved on early and late infarct growth (EIG and LIG) in stroke patients undergoing endovascular treatment (EVT) according to the final revascularization grade. METHODS This is a prospective cohort of patients with anterior large artery occlusion undergoing EVT arriving at 1 comprehensive stroke center. Magnetic resonance imaging was performed on arrival (pre-EVT), <2 hours after EVT (post-EVT), and on day 5. DWI lesions and perfusion maps were evaluated. Arterial revascularization was assessed according to the modified Thrombolysis in Cerebral Infarction (mTICI) grades. We recorded National Institutes of Health Stroke Scale at arrival and at day 7. EIG was defined as (DWI volume post-EVT-DWI volume pre-EVT), and LIG was defined as (DWI volume at 5d-DWI volume post-EVT). Factors involved in EIG and LIG were tested via multivariable lineal models. RESULTS We included 98 patients (mean age 70, median National Institutes of Health Stroke Scale score 17, final mTICI≥2b 86%). Median EIG and LIG were 48 and 63.3 mL in patients with final mTICI<2b, and 3.6 and 3.9 cc in patients with final mTICI≥2b. Both EIG and LIG were associated with higher National Institutes of Health Stroke Scale at day 7 (ρ=0.667; P<0.01 and ρ=0.614; P<0.01, respectively). In patients with final mTICI≥2b, each 10% increase in the volume of DWI pre-EVT and each extra pass leaded to growths of 9% (95% CI, 7%-10%) and 14% (95% CI, 2%-28%) in the DWI volume post-EVT, respectively. Furthermore, each 10% increase in the volume of DWI post-EVT, each extra pass, and each 10 mL increase in TMax6s post-EVT were associated with growths of 8% (95% CI, 6%-9%), 9% (95% CI, 0%-19%), and 12% (95% CI, 5%-20%) in the volume of DWI post-EVT, respectively. CONCLUSIONS Infarct grows during and after EVT, especially in nonrecanalizers but also to a lesser extent in recanalizers. In recanalizers, number of passes and DWI volume influence EIG, while number of passes, DWI, and hypoperfused volume after the procedure determine LIG.
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Affiliation(s)
- María Hernández-Pérez
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
| | - Mariano Werner
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
| | - Sebastián Remollo
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
| | - Carlota Martín
- Universitat Politècnica de Catalunya, Statistics Faculty, Badalona, Spain (C.M., J.C.)
| | - Jordi Cortés
- Universitat Politècnica de Catalunya, Statistics Faculty, Badalona, Spain (C.M., J.C.)
| | - Adrian Valls
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
| | - Anna Ramos
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
| | - Laura Dorado
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
| | - Joaquin Serena
- Department of Neurology, Stroke Unit, Dr Josep Trueta University Hospital, Girona, Spain (J.S., M.T.)
| | - Josep Munuera
- Diagnostic Imaging, Sant Joan de Dèu Hospital, Esplugues de Llobregat, Barcelona, Spain (J.M.)
| | - Josep Puig
- Department of Radiology, IDIBGI Diagnostic Imaging Institute, Dr Josep Trueta University Hospital, Girona, Spain (J.P.)
| | - Natalia Pérez de la Ossa
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
| | - Meritxell Gomis
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
| | - Jaime Carbonell
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
| | - Carlos Castaño
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
| | - Lucia Muñoz-Narbona
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
| | - Ernest Palomeras
- Department of Medicine, Consorci Sanitari del Maresme, Mataró, Barcelona, Spain (E.P.)
| | - Sira Domenech
- Diagnostic Imaging Institute, Germans Trias i Pujol University Hospital, Spain (S.D., A.M.)
| | - Anna Massuet
- Diagnostic Imaging Institute, Germans Trias i Pujol University Hospital, Spain (S.D., A.M.)
| | - Mikel Terceño
- Department of Neurology, Stroke Unit, Dr Josep Trueta University Hospital, Girona, Spain (J.S., M.T.)
| | - Antoni Davalos
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
| | - Monica Millán
- Department of Neurociences, Germans Trias I Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Spain (M.H.-P., M.W., S.R., A.V., A.R., L.D., N.P.d.l.O., M.G., J.C., C.C., L.M.-N., A.D., M.M.)
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