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Dinakis E, O'Donnell JA, Marques FZ. The gut-immune axis during hypertension and cardiovascular diseases. Acta Physiol (Oxf) 2024; 240:e14193. [PMID: 38899764 DOI: 10.1111/apha.14193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/04/2024] [Accepted: 06/06/2024] [Indexed: 06/21/2024]
Abstract
The gut-immune axis is a relatively novel phenomenon that provides mechanistic links between the gut microbiome and the immune system. A growing body of evidence supports it is key in how the gut microbiome contributes to several diseases, including hypertension and cardiovascular diseases (CVDs). Evidence over the past decade supports a causal link of the gut microbiome in hypertension and its complications, including myocardial infarction, atherosclerosis, heart failure, and stroke. Perturbations in gut homeostasis such as dysbiosis (i.e., alterations in gut microbial composition) may trigger immune responses that lead to chronic low-grade inflammation and, ultimately, the development and progression of these conditions. This is unsurprising, as the gut harbors one of the largest numbers of immune cells in the body, yet is a phenomenon not entirely understood in the context of cardiometabolic disorders. In this review, we discuss the role of the gut microbiome, the immune system, and inflammation in the context of hypertension and CVD, and consolidate current evidence of this complex interplay, whilst highlighting gaps in the literature. We focus on diet as one of the major modulators of the gut microbiota, and explain key microbial-derived metabolites (e.g., short-chain fatty acids, trimethylamine N-oxide) as potential mediators of the communication between the gut and peripheral organs such as the heart, arteries, kidneys, and the brain via the immune system. Finally, we explore the dual role of both the gut microbiome and the immune system, and how they work together to not only contribute, but also mitigate hypertension and CVD.
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Affiliation(s)
- Evany Dinakis
- Hypertension Research Laboratory, School of Biological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Joanne A O'Donnell
- Hypertension Research Laboratory, School of Biological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Francine Z Marques
- Hypertension Research Laboratory, School of Biological Sciences, Monash University, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
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Tsai CY, Liao WL, Wu HM, Chang CW, Chen WL, Hsieh CL. Acupuncture improves neurological function and anti-inflammatory effect in patients with acute ischemic stroke: A double-blinded randomized controlled trial. Complement Ther Med 2024; 82:103049. [PMID: 38729273 DOI: 10.1016/j.ctim.2024.103049] [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: 12/27/2023] [Revised: 03/31/2024] [Accepted: 05/06/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND AND PURPOSE Acupuncture exerts an anti-inflammatory effect and is recommended by the World Health Organization as a complementary therapy for stroke. This study investigated the improvement in neurological function outcome in acute-stage intervention of acute ischemic stroke (AIS), and the anti-inflammatory effect of early acupuncture. METHODS Fifty patients with AIS were randomly assigned to either a control group (CG, 25 patients, received sham acupuncture) or treatment group (TG, 25 patients, received acupuncture treatment). Acupuncture intervention was administered twice a week for a total of 8 sessions over 4 consecutive weeks. The primary outcome was the changes in the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and Barthel Index (BI) scores. The secondary outcome was the changes in serum inflammation-related biomarker levels.(ANAIS trial) RESULTS: A total of 35 patients (18 patients in the CG and 17 patients in the TG) completed the trial. The reduction in NIHSS scores was greater in the TG than in the CG between V2 (second assessment administered after acupuncture intervention) and V1 (first assessment administered before acupuncture intervention; 4.33 ± 1.91 vs. 2.68 ± 1.42, p = 0.005) and between V3 (third assessment administered 28 days after last acupuncture intervention) and V1 (6.00 ± 2.53 vs. 3.83 ± 2.31, p = 0.012). The increase in BI scores was greater in the TG than in the CG between V2 and V1 (28.89 ± 15.39 vs. 14.21 ± 19.38, p = 0.016) and between V3 and V1 (39.41 ± 20.98 vs. 25.00 ± 18.47, p = 0.038). Among participants with high inflammation, the increase in serum IL-12p70 level between V2 and V1 was greater in the TG than in the CG (0.20 ± 0.19 vs. -0.14 ± 0.30, pg/mL p = 0.006). CONCLUSIONS Acupuncture improved the neurological function of patients with AIS, and the relationship between acupuncture improving neurological function and anti-inflammatory effect needs further study. In addition, studies with larger sample sizes and longer follow-ups as well as multicenter clinical trials are expected in the future.
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Affiliation(s)
- Chueh-Yi Tsai
- Department of Neurology, Chung Shan Medical University Hospital, Taichung, Taiwan; Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan; Department of Neurology, Nantou Hospital, Ministry of Health and Welfare, Nantou, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
| | - Wen-Ling Liao
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan; Center for Personalized Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Ming Wu
- Department of Neurology, Chung Shan Medical University Hospital, Taichung, Taiwan; Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Chia-Wei Chang
- Department of Neurology, Nantou Hospital, Ministry of Health and Welfare, Nantou, Taiwan
| | - Wei-Liang Chen
- Center for the Neuroscience and Behavioral Medicine, Children's National Research Institute, Children's National Medical Center, Washington D.C, USA; George Washington University, Washington D.C, USA
| | - Ching-Liang Hsieh
- Graduate Institute of Acupuncture Science, China Medical University, Taichung, Taiwan; Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan; Chinese Medicine Research Center, China Medical University, Taichung, Taiwan.
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Meng L, Sun Y, Zhao X, Meng DM, Liu Z, Adams DC, McDonagh DL, Rasmussen M. Effects of phenylephrine on systemic and cerebral circulations in humans: a systematic review with mechanistic explanations. Anaesthesia 2024; 79:71-85. [PMID: 37948131 DOI: 10.1111/anae.16172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 11/12/2023]
Abstract
We conducted a systematic review of the literature reporting phenylephrine-induced changes in blood pressure, cardiac output, cerebral blood flow and cerebral tissue oxygen saturation as measured by near-infrared spectroscopy in humans. We used the proportion change of the group mean values reported by the original studies in our analysis. Phenylephrine elevates blood pressure whilst concurrently inducing a reduction in cardiac output. Furthermore, despite increasing cerebral blood flow, it decreases cerebral tissue oxygen saturation. The extent of phenylephrine's influence on cardiac output (r = -0.54 and p = 0.09 in awake humans; r = -0.55 and p = 0.007 in anaesthetised humans), cerebral blood flow (r = 0.65 and p = 0.002 in awake humans; r = 0.80 and p = 0.003 in anaesthetised humans) and cerebral tissue oxygen saturation (r = -0.72 and p = 0.03 in awake humans; r = -0.24 and p = 0.48 in anaesthetised humans) appears closely linked to the magnitude of phenylephrine-induced blood pressure changes. When comparing the effects of phenylephrine in awake and anaesthetised humans, we found no evidence of a significant difference in cardiac output, cerebral blood flow or cerebral tissue oxygen saturation. There was also no evidence of a significant difference in effect on systemic and cerebral circulations whether phenylephrine was given by bolus or infusion. We explore the underlying mechanisms driving the phenylephrine-induced cardiac output reduction, cerebral blood flow increase and cerebral tissue oxygen saturation decrease. Individualised treatment approaches, close monitoring and consideration of potential risks and benefits remain vital to the safe and effective use of phenylephrine in acute care.
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Affiliation(s)
- L Meng
- Department of Anesthesia, Indiana University School of Medicine, IA, Indianapolis, USA
| | - Y Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - X Zhao
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - D M Meng
- Choate Rosemary Hall School, CT, Wallingford, USA
| | - Z Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, IA, Indianapolis, USA
| | - D C Adams
- Department of Anesthesia, Indiana University School of Medicine, IA, Indianapolis, USA
| | - D L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, Neurology and Neurotherapeutics, UT Southwestern Medical Center, TX, Dallas, USA
| | - M Rasmussen
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
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Hoenle A, Wagner M, Lorenz S, Steinhart H. Impact of COVID-19 lockdown on hospital admissions for epistaxis in Germany. World J Methodol 2023; 13:446-455. [PMID: 38229949 PMCID: PMC10789106 DOI: 10.5662/wjm.v13.i5.446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/30/2023] [Accepted: 09/28/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Reports of a decrease in hospital admissions during the coronavirus disease 2019 (COVID-19) lockdown period have raised concerns about delayed or missed diagnoses and treatments for non-COVID-19-related illnesses.
AIM To investigate the impact of the COVID-19 pandemic-induced lockdown and its end on hospital admissions of patients with epistaxis in Germany.
METHODS A retrospective analysis based on the national database of the Hospital Remuneration System was used to compare hospital admissions during defined time periods between 2019 and 2022 with the lockdown period as the reference period. This was done on a weekly basis before, during, and after the lockdown. An Interrupted Time Series was used as the analysis method.
RESULTS In our analysis, we included 26183 patients. The implementation of the lockdown led to a substantial reduction in the overall occurrence of epistaxis among patients (P < 0.05). This effect was most pronounced in the age group of 0-39 years, where the decrease was highly significant (P < 0.001). However, there was no change observed in patients aged 80 years and older (not significant). With the end of the lockdown period, the overall number of patients, especially in the youngest age group, increased abruptly and significantly (P < 0.01).
CONCLUSION During the lockdown period, there was a decrease in hospital admissions for younger patients with epistaxis, possibly due to the fear of COVID-19 exposure. We also conclude that the severity of epistaxis was not underestimated in the elderly during the pandemic.
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Affiliation(s)
- Adrian Hoenle
- Department of Ear, Nose and Throat, Head and Neck Surgery, Marienhospital Stuttgart, Stuttgart 70199, Germany
| | - Martin Wagner
- Department of Ear, Nose and Throat, Head and Neck Surgery, Marienhospital Stuttgart, Stuttgart 70199, Germany
| | - Stephan Lorenz
- Department of Emergency Medicine, Katharinenhospital Stuttgart, Stuttgart 70174, Germany
| | - Helmut Steinhart
- Department of Ear, Nose and Throat, Head and Neck Surgery, Marienhospital Stuttgart, Stuttgart 70199, Germany
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Nisar T, Tofade T, Lebioda K, Shaulov S, Shapouran S, Abu-Hadid O, Khandelwal P. Association of blood pressure parameters post mechanical thrombectomy in anemic versus non-anemic patients and clinical outcomes. J Clin Neurosci 2023; 118:153-160. [PMID: 37944359 DOI: 10.1016/j.jocn.2023.11.002] [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: 06/01/2023] [Revised: 09/30/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Higher blood pressure (BP) is considered to be detrimental in patients who undergo mechanical thrombectomy (MT), however, the impact of BP post-MT based on comorbidities like anemia has not been well studied. We aim to determine the association of 24-h post-MT BP parameters with clinical outcomes depending on their anemia status. METHODS We conducted a retrospective chart review of patients who underwent MT at a comprehensive stroke center from 1/2015 to 12/2020. Patients were dichotomized into anemic and non-anemic groups based on the World Health Organization's definition of anemia [hemoglobin < 12.0 g/dL in women and < 13.0 g/dL in men]. We performed a multivariable analysis with binary logistic regression with the 24-h post-MT BP parameters as predictors. The outcomes were functional dependence (3-month mRS 3-6), mortality, and an early neurological improvement. RESULTS 220 patients met the inclusion criteria. 158 (71.82 %) patients had functional dependence at 3-months. In the multivariable analysis, the parameters of a higher mean SBP (132.9 ± 11.94 vs.126.52 ± 13.3; OR, 1.05; 95 % CI, 1.02-1.09; P 0.011), a higher mean MAP (93.35 ± 8.44 vs.89.69 ± 10.03; OR,1.06; 95 % CI, 1.01-1.11; P 0.029) and a higher maximum MAP (115.26 ± 11.73 vs.109.37 ± 12.51; OR,1.05; 95 % CI, 1.01-1.08; P 0.023)were significantly associated with functional dependence in non-anemic patients, while a lower mean DBP (65.53 ± 9.73 vs. 71.94 ± 10.16; OR, 0.92; 95 % CI, 0.86-0.98; P 0.007), lower mean MAP (85.7 ± 8.65 vs. 91.38 ± 10; OR, 0.93; 95 % CI, 0.86-0.99; P 0.02), a lower minimum DBP (49.27 ± 10.51 vs. 55.1 ± 11.23; OR, 0.93; 95 % CI, 0.88-0.99; P 0.019), a lower minimum MAP (68.96 ± 9.54 vs. 74.73 ± 10.47; OR, 0.93; 95 % CI, 0.87-0.99; P 0.023) were significantly associated with mortality in patients with anemia, and a lower minimum DBP (54.75 ± 10.42 vs. 59.69 ± 8.87; OR, 0.95; 95 % CI, 0.91-0.99; P 0.012) and a lower minimum MAP (71.92 ± 14.7 vs.75.67 ± 14.17; OR, 0.97; 95 % CI, 0.94-0.99; P 0.047) were significantly associated with an early neurological improvement in non-anemic patients. For patients with anemia, there was no association between 24-hour BP Parameters post-MT and functional dependence and early neurological improvement, and between 24-hour BP Parameters post-MT and mortality in non-anemic patients. CONCLUSION In our study, higher BP parameters were associated with worse outcomes in patients without anemia, however, this effect was not found in patients with anemia. Certain lower BP parameters were associated with higher 3-month mortality in anemic patients; however, this effect was not found in non-anemic patients. Higher BP post-MT can potentially promote perfusion and thus is not associated with worse outcomes in anemic patients post-MT, whereas in non-anemic patients it may potentially lead to reperfusion injury While our study is limited because of size and its retrospective nature, the findings suggest that an individualized approach to tailor the target BP post-MT to a patient's risk factor profile and associated co-morbid conditions to achieve optimization of medical care post-MT and associated co-morbid conditions to achieve optimization of medical care post-MT.
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Affiliation(s)
- Taha Nisar
- University of South Alabama, Mobile, AL, USA.
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Liu L, Xie X, Pan Y, Wang A, Wei Y, Liu J, Nie X, Liu D, Zhao Z, Wang P, Shen S, Zhong C, Xu T, Wang D, Wang GC, Song D, Ma Y, Zhao J, Jiang Y, Jing J, Meng X, Obst K, Chen CS, Wang D, Wang Y, Zhang Y, Wang Y, He J. Early versus delayed antihypertensive treatment in patients with acute ischaemic stroke: multicentre, open label, randomised, controlled trial. BMJ 2023; 383:e076448. [PMID: 37813418 PMCID: PMC10561001 DOI: 10.1136/bmj-2023-076448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2023] [Indexed: 10/11/2023]
Abstract
OBJECTIVES To compared the effect of early antihypertensive treatment started within 24-48 h of stroke onset versus delaying treatment until day eight on reducing dependency or death. DESIGN Multicentre, randomised, open label trial. SETTING 106 hospitals in China between 13 June 2018 and 10 July 2022. PARTICIPANTS 4810 patients (≥40 years) were enrolled with acute ischaemic stroke within 24-48 h of symptom onset and elevated systolic blood pressure between 140 mm Hg and <220 mm Hg. INTERVENTIONS Patients were randomly assigned to receive antihypertensive treatment immediately after randomisation (aimed at reducing systolic blood pressure by 10%-20% within the first 24 h and a mean blood pressure <140/90 mm Hg within seven days) or to discontinue antihypertensive medications for seven days if they were taking them, and then receive treatment on day 8 (aimed at achieving mean blood pressure <140/90 mm Hg). MAIN OUTCOME MEASURES The primary outcome was the combination of functional dependency or death (modified Rankin scale score ≥3) at 90 days. Intention to treat analyses were conducted. RESULTS 2413 patients were assigned to the early treatment group and 2397 were assigned to the delayed treatment group. Mean systolic blood pressure was reduced by 9.7% (from 162.9 mm Hg to 146.4 mm Hg) in the early treatment group and by 4.9% (from 162.8 mm Hg to 154.3 mm Hg) in the delayed treatment group within 24 h after randomisation (P for group difference <0.001). Mean systolic blood pressure was 139.1 mm Hg in the early treatment group and 150.9 mm Hg in the delayed treatment group on day seven (P for group difference <0.001). Additionally, 54.6% of patients in the early treatment group and 22.4% in the delayed treatment group had blood pressure of less than 140/90 mm Hg (P<0.001 for group difference) on day seven. At day 90, 289 trial participants (12.0%) in the early treatment group, compared with 250 (10.5%) in the delayed treatment group, had died or experienced a dependency (odds ratio 1.18 (95% confidence interval 0.98 to 1.41), P=0.08). No significant differences in recurrent stroke or adverse events were reported between the two groups. CONCLUSIONS Among patients with mild-to-moderate acute ischaemic stroke and systolic blood pressure between 140 mm Hg and <220 mm Hg who did not receive intravenous thrombolytic treatment, early antihypertensive treatment did not reduce the odds of dependency or death at 90 days. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03479554.
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Affiliation(s)
- Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Aili Wang
- Department of Epidemiology, School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
| | - Yufei Wei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jingyi Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ximing Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Dacheng Liu
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zilin Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Penglian Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Suwen Shen
- Department of Epidemiology, School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
- Department of Chronic Non-Communicable Disease Control, The Affiliated Wuxi Center for Disease Control and Prevention of Nanjing Medical University, Wuxi Center for Disease Control and Prevention, Wuxi, China
| | - Chongke Zhong
- Department of Epidemiology, School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
| | - Tan Xu
- Department of Epidemiology, School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
| | - Dali Wang
- Affiliated Hospital of North China University of Science and Technology, Tang-shan, China
| | | | - Denghua Song
- Sinopharm Tongmei General Hospital, Datong, China
| | - Yunsheng Ma
- The First People's Hospital of Keerqin District, Tongliao, China
| | - Jinguo Zhao
- Weihai Wendeng District People' Hospital, Weihai, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Katherine Obst
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
- Tulane University Translational Science Institute, New Orleans, Louisiana, USA
| | - Chung-Shiuan Chen
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
- Tulane University Translational Science Institute, New Orleans, Louisiana, USA
| | - David Wang
- Neurovascular Division, Department of Neurology, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yonghong Zhang
- Department of Epidemiology, School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
- Tulane University Translational Science Institute, New Orleans, Louisiana, USA
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Bawand R, Ghiasian M, Khazaei M, Samadyan M, Moradi A. Effects of blood pressure unawareness and poor adherence to antihypertensive drugs on outcomes of cerebrovascular accidents among patients with their first-ever stroke. J Hypertens 2023; 41:459-469. [PMID: 36728239 DOI: 10.1097/hjh.0000000000003358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIMS Our main target was to investigate the relationship of blood pressure (BP) unawareness and poor antihypertensive drug adherence with the clinical outcomes of the stroke including hospitalization time, degree of disability, and mortality rate. METHODS AND RESULTS In this cross-sectional study, we evaluated 530 eligible patients (male = 313; female = 217), aged 18 years and older who had a proven diagnosis of nontraumatic first-ever stroke and were referred to the Shahid Beheshti Hospital of Hamadan, Iran, during the period from March 2019 to September 2021. The prevalence of BP unawareness was 19.6%, and 31.8% of antihypertensive drug users (14.3% of all studied population) had poor drug adherence, in which, older age, male gender, marriage, rural residence, and smoking were associated with the lack of appropriate drug adherence. There was no significant difference between patients with diverse stroke types (ischemic or hemorrhagic) from the points of BP awareness and adherence to antihypertensive drugs; nevertheless, patients with a positive history of cardiac diseases had a significantly higher awareness of their BP status ( P = 0.037). BP unawareness was associated with poor clinical prognosis, and could significantly increase stroke mortality ( P = 0.001) and disability ( P < 0.001) rates as well as the duration of hospitalization ( P < 0.001). Moreover, those who survived the stroke (modified Rankin Scale < 6) had the highest odds to be aware of their BP status (adjusted odds ratio [AOR] = 2.380 [95% confidence interval [CI] = 1.39-4.07]). Additionally, nonsmokers (AOR = 7.740), urban residents (AOR = 3.314), and literate patients (AOR = 2.092) had the highest odds of having appropriate drug adherence. CONCLUSION Stroke mortality and morbidity rates can be significantly modified by persuading people to monitor their BP regularly and maximize antihypertensive medication adherence. In the meantime, increasing the literacy level in society and reducing the smoking rate can play important roles in achieving these goals.
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Affiliation(s)
| | | | | | | | - Abbas Moradi
- Department of Social Medicine, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
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Obukhova OA, Harbuzova VY, Zavadska MM, Levchenko ZM, Biesiedina АA, Harbuzova YA, Smiianova YO, Smiianov VA. ANALYSIS OF THE BLOOD HYPERCOAGULATION RISK IN PATIENTS WITH ISCHEMIC ATHEROTHROMBOTIC STROKE DEPENDING OF THE VDR GENE POLYMORPHISMS. POLSKI MERKURIUSZ LEKARSKI : ORGAN POLSKIEGO TOWARZYSTWA LEKARSKIEGO 2023; 51:334-338. [PMID: 37756452 DOI: 10.36740/merkur202304106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Aim: of our study was the analysis of the blood hypercoagulation risk in patients with ischemic atherotrombotic stroke depending of the VDR gene polymorphisms. PATIENTS AND METHODS Materials and Methods: Blood of 170 patients with ischemic atherothrombotic stroke (IATS) and 124 healthy individuals (control group) was used for genotyping. Four polymorphisms (FokI, BsmI, ApaI, TaqI) of gene VDR were examined with PCR-RFLP methodology. Statistical analysis was performed by using SPSS-17.0 program. RESULTS Results: Among patients with IATS who are carriers of the f/f genotype, FokI polymorphism of VDR gene by high thrombin time and a decrease in the rate of spontaneous fibrinolysis was registered. In individuals with the B/B genotype homozygous for the polymorphic variant, BsmI had significantly lower mean values of prothrombin and thrombin time and increased the rate of spontaneous fibrinolysis. The homozygotes for the A-allele ApaI polymorphism have 2.7 times higher risk of developing blood hypercoagulation than homozygotes for the a-allele was found. CONCLUSION Conclusions: Biochemical signs of hypercoagulation syndrome among patients with IATS who are carriers of the f/f genotype of the FokI polymorphic variant and among B/B homozygotes of the BsmI polymorphic variant and homozygotes for the A-allele of the AрaI polymorphism of the VDR gene were registered.
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Qaryouti D, Greene-Chandos D. Neurocritical Care Aspects of Ischemic Stroke Management. Crit Care Clin 2022; 39:55-70. [DOI: 10.1016/j.ccc.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Wang R, Liu Y, Yang P, Zhu Z, Shi M, Peng Y, Zhong C, Wang A, Xu T, Peng H, Xu T, Chen J, Zhang Y, He J. Blood Pressure Fluctuation During Hospitalization and Clinical Outcomes Within 3 Months After Ischemic Stroke. Hypertension 2022; 79:2336-2345. [PMID: 35950501 DOI: 10.1161/hypertensionaha.122.19629] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Increased blood pressure (BP) variability is positively associated with the risks of cerebral small-vessel disease, cardiovascular events and death. However, no large clinical trials have been published to demonstrate the effect of BP fluctuations during hospitalization on clinical outcomes after ischemic stroke. METHODS A total of 3972 patients with acute ischemic stroke from 26 participating hospitals were included in this study, and BP fluctuations were calculated using BP data collected during the hospitalization. The primary outcome was composite outcome of death or major disability (modified Rankin Scale score ≥3) within 3 months and secondary outcomes included death, vascular events, and composite outcomes (death or vascular events). RESULTS Compared with the lowest quartile of systolic BP fluctuations, the adjusted odds ratio associated with the highest quartile was 1.33 ([95% CI, 1.05-1.68]; Ptrend=0.011) for primary outcome; the adjusted hazard ratios were 2.89 ([95% CI, 1.58-5.32]; Ptrend<0.001) for death, 1.48 ([95% CI, 0.83-2.65]; Ptrend=0.071) for vascular events, and 2.06 ([95% CI, 1.32-3.23]; Ptrend<0.001) for composite outcome. Similar results were found for diastolic BP. Multivariable adjusted restricted cubic spline analysis showed a linear relationship between systolic BP fluctuations and the primary outcome (P for linearity=0.0009). CONCLUSIONS Larger BP fluctuations during hospitalization were associated with an increased risk of adverse outcomes at 3 months after ischemic stroke onset, independent of mean BP. These findings suggested that BP fluctuation should be a risk factor of adverse outcomes after ischemic stroke, which provided a new insight for BP management strategy.
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Affiliation(s)
- Ruirui Wang
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (R.W., P.Y., Z.Z., M.S., C.Z., A.W., Tan Xu, H.P., Y.Z.)
| | - Yang Liu
- Department of Cardiology, First Affiliated Hospital of Soochow University, Suzhou, China (Y.L.).,Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (Y.L., M.S., J.C., J.H.)
| | - Pinni Yang
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (R.W., P.Y., Z.Z., M.S., C.Z., A.W., Tan Xu, H.P., Y.Z.)
| | - Zhengbao Zhu
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (R.W., P.Y., Z.Z., M.S., C.Z., A.W., Tan Xu, H.P., Y.Z.)
| | - Mengyao Shi
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (R.W., P.Y., Z.Z., M.S., C.Z., A.W., Tan Xu, H.P., Y.Z.).,Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (Y.L., M.S., J.C., J.H.)
| | - Yanbo Peng
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Tangshan, China (Y.P.)
| | - Chongke Zhong
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (R.W., P.Y., Z.Z., M.S., C.Z., A.W., Tan Xu, H.P., Y.Z.)
| | - Aili Wang
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (R.W., P.Y., Z.Z., M.S., C.Z., A.W., Tan Xu, H.P., Y.Z.)
| | - Tan Xu
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (R.W., P.Y., Z.Z., M.S., C.Z., A.W., Tan Xu, H.P., Y.Z.)
| | - Hao Peng
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (R.W., P.Y., Z.Z., M.S., C.Z., A.W., Tan Xu, H.P., Y.Z.)
| | - Tian Xu
- Department of Neurology, Affiliated Hospital of Nantong University, China (Tian Xu)
| | - Jing Chen
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (Y.L., M.S., J.C., J.H.).,Department of Medicine, Tulane University School of Medicine, New Orleans, LA (J.C., J.H.)
| | - Yonghong Zhang
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, China (R.W., P.Y., Z.Z., M.S., C.Z., A.W., Tan Xu, H.P., Y.Z.)
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA (Y.L., M.S., J.C., J.H.).,Department of Medicine, Tulane University School of Medicine, New Orleans, LA (J.C., J.H.)
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11
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Chen P, Wu Q, Xie X, Jing J, Gu H, Wang X, Meng X, Liu L, Wang Y, Wang Y. Systolic blood pressure and recurrent stroke in patients with different lesion patterns on diffusion weighted imaging. J Clin Hypertens (Greenwich) 2022; 24:1350-1357. [PMID: 35959564 PMCID: PMC9581100 DOI: 10.1111/jch.14543] [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: 04/25/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 11/28/2022]
Abstract
Little is known about the relationship between baseline systolic blood pressure (SBP) and subsequent clinical events in patients with different lesion patterns on diffusion weighted imaging (DWI). We analyzed the Acute Non‐disabling Cerebrovascular Events (CHANCE) trial dataset. Patients were categorized into negative DW imaging (no detectable lesions), lacunar infarction (single lesion ≤15 mm) and non‐lacunar infarction (single lesion >15 mm or multiple lesions) based on lesion patterns on DWI. The primary outcome was recurrent stroke within 90 days. Cox proportional hazards models were used to assess the association between SBP levels and stroke outcomes in patients with different lesion patterns. A total of 1089 patients were analyzed. We found 258 cases (23.7%) with negative DW imaging, 392 (36.0%) with lacunar infarction and 439 (40.3%) with non‐lacunar infarction. Patients with non‐lacunar infarction had the highest incidence of stroke at 90‐day (P < .001). In non‐lacunar infarction group, compared with SBP < 160 mmHg, patients with SBP ≥ 160 mmHg had significantly higher risk of 90‐day recurrent stroke (20.3% vs. 10.7%; adjusted hazard ratio 1.81, 95% confidence interval 1.09–3.00). No significant association was found between SBP and clinical outcomes in patients with negative DWI and lacunar stroke groups. The result at 1 year was similar as at 90‐day. Therefore, non‐lacunar infarction, the most common lesion pattern in CHANCE study, had the highest risk of recurrent stroke and combined vascular events both in 90 days and 1 year. High baseline SBP was significantly associated with increased risk of short‐ and long‐term recurrent strokes in patients with non‐lacunar infarction.
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Affiliation(s)
- Pan Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Qiong Wu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China.,Department of Neurology, The Second Hospital of Dalian Medical University, Dalian, China
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Hongqiu Gu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Xianwei Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
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12
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Association of 24-hour blood pressure parameters post-thrombectomy with functional outcomes according to collateral status. J Neurol Sci 2022; 441:120369. [DOI: 10.1016/j.jns.2022.120369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/07/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022]
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13
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Saima B, Mikel T, Maria B, Yolanda S, Juan ÁC, Victor VM, Laura P, Montserrat R, Carme GM, Alan M, Joaquín S. Progressive Lacunar Atrokes: A Predictive Score. J Stroke Cerebrovasc Dis 2022; 31:106510. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/01/2022] [Accepted: 04/08/2022] [Indexed: 02/05/2023] Open
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14
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Yuan J, Go LK, Ang XQT, Teo ISZ, Soh FW. Republic of Singapore Air Force Helicopter Search-and-Rescue and Medical Evacuations: A 5-Year Review. Air Med J 2022; 41:350-358. [PMID: 35750441 DOI: 10.1016/j.amj.2022.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
The Republic of Singapore Air Force (RSAF) provides Helicopter Search-and-Rescue (SAR) and Helicopter Medical Evacuation (Heli-Medevac) coverage for the Singapore Aeronautical Search and Rescue Region (ASSR) in the South China Sea, spanning 840,000 km2. This region contains busy international shipping lanes and air traffic routes. Each year, Singapore's Helicopter SAR and Heli-Medevac service is activated multiple times to rescue personnel lost at sea or to evacuate ill and injured ship sailors or passengers to tertiary hospitals in Singapore for stabilization and advanced care. This is a retrospective review on all civilian SAR and Heli-medevac activations by the RSAF over a 5-year period from 2016 to 2020. Case profiles, presenting conditions, in-flight treatment, and patient outcomes are reviewed and discussed. Key operational observations made from RSAF's SAR and Heli-Medevac, as well as lessons learned from these missions, are discussed in this article.
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Affiliation(s)
- Jing Yuan
- Republic of Singapore Air Force, Singapore.
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15
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Krieger P, Zhao A, Croll L, Irvine H, Torres J, Melmed KR, Lord A, Ishida K, Frontera J, Lewis A. Tachycardia is associated with mortality and functional outcome after thrombectomy for acute ischemic stroke. J Stroke Cerebrovasc Dis 2022; 31:106450. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/02/2022] [Accepted: 03/12/2022] [Indexed: 10/18/2022] Open
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16
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Managing high blood pressure in hypertensive patients with an acute ischemic stroke. HIPERTENSION Y RIESGO VASCULAR 2022; 39:157-166. [DOI: 10.1016/j.hipert.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 12/26/2022]
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17
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Bath PM, Song L, Silva GS, Mistry E, Petersen N, Tsivgoulis G, Mazighi M, Bang OY, Sandset EC. Blood Pressure Management for Ischemic Stroke in the First 24 Hours. Stroke 2022; 53:1074-1084. [PMID: 35291822 DOI: 10.1161/strokeaha.121.036143] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High blood pressure (BP) is common after ischemic stroke and associated with a poor functional outcome and increased mortality. The conundrum then arises on whether to lower BP to improve outcome or whether this will worsen cerebral perfusion due to aberrant cerebral autoregulation. A number of large trials of BP lowering have failed to change outcome whether treatment was started prehospital in the community or hospital. Hence, nuances on how to manage high BP are likely, including whether different interventions are needed for different causes, the type and timing of the drug, how quickly BP is lowered, and the collateral effects of the drug, including on cerebral perfusion and platelets. Specific scenarios are also important, including when to lower BP before, during, and after intravenous thrombolysis and endovascular therapy/thrombectomy, when it may be necessary to raise BP, and when antihypertensive drugs taken before stroke should be restarted. This narrative review addresses these and other questions. Although further large trials are ongoing, it is increasingly likely that there is no simple answer. Different subgroups of patients may need to have their BP lowered (eg, before or after thrombolysis), left alone, or elevated.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.)
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (P.M.B.)
| | - Lili Song
- The George Institute China at Peking University Health Science Center, Beijing (L.S.)
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Sydney, Australia (L.S.)
| | - Gisele S Silva
- Neurology, Federal University of São Paulo (UNIFESP) and Hospital Israelita Albert Einstein, Brazil (G.S.S.)
| | - Eva Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (E.M.)
| | - Nils Petersen
- Department of Neurology, Divisions of Vascular Neurology and Neurocritical Care, Yale School of Medicine, New Haven (N.P.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (G.T.)
| | - Mikael Mazighi
- Department of Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris, INSERM 1148, FHU Neurovasc, France (M.M.)
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.)
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Norway (E.C.S.)
- The Norwegian Air Ambulance Foundation, Oslo (E.C.S.)
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Hong JM, Kim DS, Kim M. Hemorrhagic Transformation After Ischemic Stroke: Mechanisms and Management. Front Neurol 2021; 12:703258. [PMID: 34917010 PMCID: PMC8669478 DOI: 10.3389/fneur.2021.703258] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/21/2021] [Indexed: 01/01/2023] Open
Abstract
Symptomatic hemorrhagic transformation (HT) is one of the complications most likely to lead to death in patients with acute ischemic stroke. HT after acute ischemic stroke is diagnosed when certain areas of cerebral infarction appear as cerebral hemorrhage on radiological images. Its mechanisms are usually explained by disruption of the blood-brain barrier and reperfusion injury that causes leakage of peripheral blood cells. In ischemic infarction, HT may be a natural progression of acute ischemic stroke and can be facilitated or enhanced by reperfusion therapy. Therefore, to balance risks and benefits, HT occurrence in acute stroke settings is an important factor to be considered by physicians to determine whether recanalization therapy should be performed. This review aims to illustrate the pathophysiological mechanisms of HT, outline most HT-related factors after reperfusion therapy, and describe prevention strategies for the occurrence and enlargement of HT, such as blood pressure control. Finally, we propose a promising therapeutic approach based on biological research studies that would help clinicians treat such catastrophic complications.
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Affiliation(s)
- Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Da Sol Kim
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Min Kim
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon-si, South Korea
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19
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Nigat AB, Abate MW, Demelash AT, Tibebu NS, Tiruneh CM, Emiru TD, Abdu Yimam M, Nega AD, Yimer YS. Knowledge on Stroke Warning Signs and Associated Factors Among Hypertensive Patients, Northwest Ethiopia: An Institution-Based Cross-Sectional Study. Vasc Health Risk Manag 2021; 17:721-728. [PMID: 34848966 PMCID: PMC8622714 DOI: 10.2147/vhrm.s333394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/05/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Stroke is one of the leading causes of death globally and is a major cause of disability worldwide. It is a preventable and treatable disease by the prevention of modifiable risk factors and early recognition of warning signs, respectively. OBJECTIVE To assess knowledge on stroke warning signs and associated factors among hypertensive patients at South Gondar Zone Comprehensive Specialized Hospital, Northwest Ethiopia, 2020. METHODS An institution-based cross-sectional study was conducted in South Gondar Zone Comprehensive Specialized Hospital from June 1-30, 2020. A systematic random sampling technique was used and data were collected through face to face interviews. Data were entered into Epi data version 4.6.0.0 and exported to SPSS version 25 for cleaning and analysis. Bivariate and multivariable logistic regression analysis was used and variables with p <0.05 in the multivariable analysis were considered as statistically significant. RESULTS Two hundred and fifty-three hypertensive patients completed the questionnaire with a response rate of 100%. Among the total respondents, 15% (95% CI: 10.7, 19.4) of participants had good knowledge of stroke warning signs. Younger age (AOR: 2.82; 95% CI: 1.18, 6.74), urban residence (AOR: 2.9; 95% CI: 1.04, 8.11), being educated (AOR: 2.6; 95% CI: 1.09, 6.23) and having long duration hypertension follow up (AOR: 2.7; 95% CI: 1.25, 5.81) were significantly associated with good knowledge of stroke warning signs. CONCLUSION This study revealed that participants had poor knowledge of stroke warning signs. Younger age, urban residence, being educated and having long duration hypertension follow up were predictors of good stroke warning signs knowledge. Health information dissemination needs to be strengthened for hypertensive patients, particularly for older, rural residents, the non-educated and those having short duration of hypertension follow up.
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Affiliation(s)
- Adane Birhanu Nigat
- Department of Adult Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Moges Wubneh Abate
- Department of Adult Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Agimasie Tigabu Demelash
- Department of Adult Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Nigusie Selomon Tibebu
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Chalie Marew Tiruneh
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Tigabu Desie Emiru
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mehd Abdu Yimam
- Department of Nursing, College of Medicine and Health Sciences, Mizan-Tepi University, Mizan Teferi, Ethiopia
| | - Abebe Dires Nega
- Department of Comprehensive Nursing, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Yohannes Shumet Yimer
- Department of Pharmacy, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
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Gutierrez J, Khasiyev F, Liu M, DeRosa JT, Tom SE, Rundek T, Cheung K, Wright CB, Sacco RL, Elkind MSV. Determinants and Outcomes of Asymptomatic Intracranial Atherosclerotic Stenosis. J Am Coll Cardiol 2021; 78:562-571. [PMID: 34353533 DOI: 10.1016/j.jacc.2021.05.041] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/30/2021] [Accepted: 05/18/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Intracranial atherosclerotic stenosis (ICAS) is one of the most common causes of stroke worldwide and confers a high risk of stroke recurrence, despite aggressive management of risk factors. OBJECTIVES This study identified the role of risk factors and risk of vascular events in subjects with asymptomatic ICAS for improved risk stratification. METHODS Stroke-free participants in the NOMAS (Northern Manhattan Study) trial, prospectively followed since 1993, underwent a brain magnetic resonance angiogram from 2003 to 2008. The study rated stenosis in 11 brain arteries as: 0: no stenosis; 1: <50% or luminal irregularities; 2: 50%-69%; and 3: ≥70% stenosis or flow gap. The study ascertained vascular events during the post-magnetic resonance imaging (MRI) period. Proportional odds regression quantified the association of pre-MRI exposures, and proportional hazard adjusted models were built to identify the risk of events in the post-MRI period. RESULTS The included sample included 1,211 participants from NOMAS (mean age: 71 ± 9 years; 59% women; 65% Hispanic; 45% had any stenosis). Older age (OR: 1.02 per year; 95% CI: 1.01 to 1.04), hypertension duration (OR: 1.01 per year; 95% CI: 1.00 to 1.02), higher number of glucose-lowering drugs (OR: 1.64 per each medication; 95% CI: 1.24 to 2.15), and high-density lipoprotein (OR: 0.96 per mg/dL; 95% CI: 0.92 to 0.99) were associated with ICAS. The highest event risk was noted among participants with ICAS ≥70% (5.5% annual risk of vascular events; HR: 2.1; 95% CI:1.4 to 3.2; compared with those with no ICAS). CONCLUSIONS ICAS is an imaging marker of established atherosclerotic disease in stroke-free subjects, and incidental diagnosis of ICAS should trigger a thorough assessment of vascular health.
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Affiliation(s)
- Jose Gutierrez
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA.
| | - Farid Khasiyev
- Department of Neurology, Saint Louis University, Saint Louis, Missouri, USA
| | - Minghua Liu
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Janet T DeRosa
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sarah E Tom
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA; Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA; Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ken Cheung
- Department of Biostatistics, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York, USA
| | - Clinton B Wright
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Ralph L Sacco
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA; Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA; Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mitchell S V Elkind
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York, USA
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21
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Owjfard M, Taghadosi Z, Bigdeli MR, Safari A, Zarifkar A, Borhani-Haghighi A, Namavar MR. Effect of nicorandil on the spatial arrangement of primary motor cortical neurons in the sub-acute phase of stroke in a rat model. J Chem Neuroanat 2021; 117:102000. [PMID: 34233211 DOI: 10.1016/j.jchemneu.2021.102000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 06/29/2021] [Accepted: 07/01/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Ischemic stroke remains a major cause of disability and death worldwide. The density and the spatial distribution of the primary motor (M1) cortical neurons are important in signal transmission and control the movement-related functions. Recently, the neuroprotective effect of nicorandil in cerebral ischemia was described through its anti-apoptosis, antioxidant and anti-inflammatory properties. This study aimed to determine the effects of nicorandil on the neurobehavioral outcome, infarct size, and density, and spatial distribution of M1 cortical neurons after cerebral ischemia. METHODS Thirty Sprague-Dawley rats were randomly divided into three groups. Sham underwent surgery without middle cerebral artery occlusion (MCAO) and drug. The MCAO and treatment groups after MCAO received saline or nicorandil 2, 24, 48, and 72 h after the induction of brain ischemia. Neurobehavioral tests were performed, brains removed, sectioned, and stained by 2,3,5-triphenyltetrazolium chloride (TTC) to estimate the size of the infarction and Nissl staining to evaluate the numerical density, mean area, and the distribution pattern of M1 cortical neurons, using Voronoi spatial tessellation. RESULTS Although nicorandil treatment significantly decreased the neurological deficits and density of neuronal neighbors, it could not preserve the normal regular spatial distributions of M1 cortical neurons after MCAO. It also could not significantly improve motor function or reduce ischemic lesion size. CONCLUSIONS Treatment using the present dose of nicorandil during sub-acute ischemic stroke could not increase neuronal density or preserve the normal regular spatial distributions after MCAO. However, it had beneficial effects on neurobehavioral and motor function and somewhat reduced ischemic lesion size.
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Affiliation(s)
- Maryam Owjfard
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Animal Sciences and Biotechnology, Faculty of Life Sciences and Biotechnology, Shahid Beheshti University, Tehran, Iran
| | - Zohreh Taghadosi
- Department of Neuroscience, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Reza Bigdeli
- Department of Animal Sciences and Biotechnology, Faculty of Life Sciences and Biotechnology, Shahid Beheshti University, Tehran, Iran; Institute for Cognitive and Brain Science, Shahid Beheshti University, Tehran, Iran
| | - Anahid Safari
- Stem Cells Technology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Asadollah Zarifkar
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mohammad Reza Namavar
- Histomorphometry & Stereology Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Anatomical Sciences, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
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22
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Blood Pressure Control in Acute Stroke: Labetalol or Nicardipine? J Stroke Cerebrovasc Dis 2021; 30:105959. [PMID: 34217067 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/10/2021] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To assess the safety and efficacy of continuous infusion (CIV)-labetalol compared to -nicardipine in controlling blood pressure (BP) in the acute stroke setting. MATERIALS Patients were eligible if they had a diagnosis of an acute stroke and were administered either CIV-labetalol or CIV-nicardipine. Study outcomes were assessed within the first 24 h of the antihypertensive infusion. RESULTS A total of 3,093 patients were included with 3,008 patients in the CIV-nicardipine group and 85 in the CIV-labetalol group. No significant difference was observed in percent time at goal BP between the nicardipine (82%) and labetalol (85%) groups (p = 0.351). There was also no difference in BP variability between nicardipine (37%) and labetalol (39%) groups (p = 0.433). Labetalol was found to have a shorter time to goal BP as compared to nicardipine (24 min vs. 40 min; p = 0.021). While CIV-nicardipine did have a higher incidence of tachycardia compared to labetalol (17% vs. 4%; p <0.001), the incidence of hypotension (13% vs. 15%; p = 0.620) and bradycardia (24% vs. 22%; p = 0.797) were similar. CONCLUSIONS These results indicate that CIV-labetalol and CIV-nicardipine are comparable in safety and efficacy in controlling BP for patients with acute stroke.
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23
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[Prevalence and characteristics of metabolic syndrome in adults admitted to a health care center for ischemic stroke]. NUTR HOSP 2021; 38:267-273. [PMID: 33586993 DOI: 10.20960/nh.03157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Background: Chile has experienced an increase in the prevalence of metabolic syndrome (MS) among the adult population. MS is proposed as a predictor for the occurrence of vascular defects causing ischemic stroke. Objective: to determine the frequency and characteristics of MS in a sample of adults after an ischemic ACV. Methods: a descriptive, cross-sectional study that consisted of reviewing variables related to MS in 180 adult patients admitted to a clinic for an ischemic stroke between the years 2011 and 2017. Weight and height measurements were considered to obtain BMI and nutritional status. Waist circumference (CC), systolic (PAS) and diastolic blood pressure (PAD), total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides (TG), and glycemia were also measured. Results: 62.8 % of the sample had MS. BMI (CI, 28.5-29.9; p = 0.001), CC (CI, 101.3-105.3; p = 0.001), PAS (CI, 147.4-155.7; p = 0.000), PAD (CI, 87.7-93.6; p = 0.000), glycemia (CI, 132.9-159.2; p = 0.000), and TG (CI, 181.2-228.8; p = 0.000) were higher in the group with SM. HDL-cholesterol (CI, 35.5-39.2; p = 0.000) was lower in this same group. Older age (p = 0.007), male gender (p = 0.017), and excess nutritional status (p = 0.000) had a positive association with MS. Of the subjects with MS, there were no differences obtained when comparing the components that define MS between men and women. Conclusion: our findings reveal a high frequency of MS in adults admitted to a clinic for ischemic stroke.
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24
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Catangui EJ. Role of the nurse in the hyperacute care and management of patients following stroke. Nurs Stand 2020; 36:70-75. [PMID: 33369311 DOI: 10.7748/ns.2020.e11469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2020] [Indexed: 11/09/2022]
Abstract
Stroke is a medical emergency that affects millions of people worldwide each year. The first 24-72 hours following a stroke is a critical stage in the patient's management because deterioration can occur during this period. Hyperacute care is a time-sensitive method of managing stroke that has improved the provision of holistic and evidence-based stroke care. This article describes the care and management that patients require in the first 24-72 hours following stroke. It details the evidence-based practice that this involves, and explains the role of the nurse in providing hyperacute care.
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Affiliation(s)
- Elmer Javier Catangui
- Nursing Services, Ministry of National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
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25
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Sladojevic N, Yu B, Liao JK. Regulator of G-Protein Signaling 5 Maintains Brain Endothelial Cell Function in Focal Cerebral Ischemia. J Am Heart Assoc 2020; 9:e017533. [PMID: 32875943 PMCID: PMC7726987 DOI: 10.1161/jaha.120.017533] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Regulator of G‐protein signaling 5 (RGS5) is a negative modulator of G‐protein–coupled receptors. The role of RGS5 in brain endothelial cells is not known. We hypothesized that RGS5 in brain microvascular endothelial cells may be an important mediator of blood‐brain barrier function and stroke severity after focal cerebral ischemia. Methods and Results Using a transient middle cerebral artery occlusion model, we found that mice with global and endothelial‐specific deletion of Rgs5 exhibited larger cerebral infarct size, greater neurological motor deficits, and increased brain edema. In our in vitro models, we observed increased Gq activity and elevated intracellular Ca2+ levels in brain endothelial cells. Furthermore, the loss of endothelial RGS5 leads to decreased endothelial NO synthase expression and phosphorylation, relocalization of endothelial tight junction proteins, and increased cell permeability. Indeed, RGS5 deficiency leads to increased Rho‐associated kinase and myosin light chain kinase activity, which were partially reversed in our in vitro model by pharmacological inhibition of Gq, metabotropic glutamate receptor 1, and ligand‐gated ionotropic glutamate receptor. Conclusions Our findings indicate that endothelial RGS5 plays a novel neuroprotective role in focal cerebral ischemia. Loss of endothelial RGS5 leads to hyperresponsiveness to glutamate signaling pathways, enhanced Rho‐associated kinase– and myosin light chain kinase–mediated actin‐cytoskeleton reorganization, endothelial dysfunction, tight junction protein relocalization, increased blood‐brain barrier permeability, and greater stroke severity. These findings suggest that preservation of endothelial RGS5 may be an important therapeutic strategy for maintaining blood‐brain barrier integrity and limiting the severity of ischemic stroke.
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Affiliation(s)
- Nikola Sladojevic
- Section of Cardiology Department of Medicine University of Chicago Chicago IL
| | - Brian Yu
- Section of Cardiology Department of Medicine University of Chicago Chicago IL
| | - James K Liao
- Section of Cardiology Department of Medicine University of Chicago Chicago IL
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26
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Hurford R, Sekhar A, Hughes TAT, Muir KW. Diagnosis and management of acute ischaemic stroke. Pract Neurol 2020; 20:304-316. [PMID: 32507747 PMCID: PMC7577107 DOI: 10.1136/practneurol-2020-002557] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2020] [Indexed: 12/12/2022]
Abstract
Acute ischaemic stroke is a major public health priority and will become increasingly relevant to neurologists of the future. The cornerstone of effective stroke care continues to be timely reperfusion treatment. This requires early recognition of symptoms by the public and first responders, triage to an appropriate stroke centre and efficient assessment and investigation by the attending stroke team. The aim of treatment is to achieve recanalisation and reperfusion of the ischaemic penumbra with intravenous thrombolysis and/or endovascular thrombectomy in appropriately selected patients. All patients should be admitted directly to an acute stroke unit for close monitoring for early neurological deterioration and prevention of secondary complications. Prompt investigation of the mechanism of stroke allows patients to start appropriate secondary preventative treatment. Future objectives include improving accessibility to endovascular thrombectomy, using advanced imaging to extend therapeutic windows and developing neuroprotective agents to prevent secondary neuronal damage.
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Affiliation(s)
- Robert Hurford
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Alakendu Sekhar
- Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Tom A T Hughes
- Department of Neurology, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
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27
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Li Z, Xiao G, Lyu M, Wang Y, He S, Du H, Wang X, Feng Y, Zhu Y. Shuxuening injection facilitates neurofunctional recovery via down-regulation of G-CSF-mediated granulocyte adhesion and diapedesis pathway in a subacute stroke mouse model. Biomed Pharmacother 2020; 127:110213. [PMID: 32417690 DOI: 10.1016/j.biopha.2020.110213] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/19/2020] [Accepted: 04/28/2020] [Indexed: 01/09/2023] Open
Abstract
Post-stroke neural damage is a serious health concern which does not yet have an effective treatment. We have shown previously that Shuxuening injection (SXNI), a Ginkgo biloba extract-based natural medicine, protects brain after an acute ischemic stroke, but its efficacy for post-stroke recovery is not known. This study was to investigate whether SXNI can improve the prognosis of stroke at a subacute phase. Mice with cerebral ischemia-reperfusion injury (CIRI) were established by middle cerebral artery occlusion (MCAO), and drugs or saline were injected by the tail vein every 12 h after reperfusion. The therapeutic effect of SXNI was evaluated by survival rate, modified neurologic severity scores (mNSS), open-field test, locomotive gait patterns, cerebral infarction volume, brain edema and histopathological changes. Subsequently, a combined method of RNA-seq and Ingenuity® Pathway Analysis (IPA) was performed to identify key targets and pathways of SXNI facilitating the prognosis of stroke in mouse brain. The results of the transcriptome analysis were verified by real time reverse transcription-polymerase chain reaction (RT-PCR), enzyme-linked immunosorbent assay (ELISA), western blot (WB) and immunohistochemistry (IHC). The experimental results showed that in the new subacute stroke model, SXNI markedly improves the survival rate, neurological and motor functions and histopathological changes, and significantly reduces cerebral infarction and edema volume. RNA-seq analysis of subacute stroke mice with or without SXNI (3 mL/kg) indicated 963 differentially expressed genes (DEGs) with a fold change ≥ 1.5 and a P-value ≤ 0.01. IPA analysis of DEGs showed that granulocyte adhesion and diapedesis ranked first in the pathway ranking, and the most critical gene regulated by SXNI was G-csf. Simultaneously, RT-PCR, ELISA, WB and IHC results demonstrated that SXNI not only obviously reduced the mRNA expression levels of key genes G-csf, Sele and Mac-1 in this pathway, but also significantly decreased the protein expression levels of G-CSF in serum and E-selectin and MAC-1 in brain tissues. In summary, our research suggested that SXNI can exert a remarkable neurofunctional therapeutic effect on stroke mice via down-regulating G-CSF to inhibit granulocyte adhesion and diapedesis. This study provides experimental evidence that SXNI may fulfill the need for stroke medicine targeting specifically at the recovery stage.
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Affiliation(s)
- Zhixiong Li
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Beihua South Road, JingHai District, Tianjin, 301617, China; Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology & Medicine, 220 Dongting Road, TEDA, Tianjin, 300457, China
| | - Guangxu Xiao
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Beihua South Road, JingHai District, Tianjin, 301617, China; Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology & Medicine, 220 Dongting Road, TEDA, Tianjin, 300457, China
| | - Ming Lyu
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Beihua South Road, JingHai District, Tianjin, 301617, China; Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology & Medicine, 220 Dongting Road, TEDA, Tianjin, 300457, China; Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Yule Wang
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Beihua South Road, JingHai District, Tianjin, 301617, China; Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology & Medicine, 220 Dongting Road, TEDA, Tianjin, 300457, China
| | - Shuang He
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Beihua South Road, JingHai District, Tianjin, 301617, China; Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology & Medicine, 220 Dongting Road, TEDA, Tianjin, 300457, China
| | - Hongxia Du
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Beihua South Road, JingHai District, Tianjin, 301617, China; Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology & Medicine, 220 Dongting Road, TEDA, Tianjin, 300457, China
| | - Xintong Wang
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Beihua South Road, JingHai District, Tianjin, 301617, China; Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology & Medicine, 220 Dongting Road, TEDA, Tianjin, 300457, China
| | - Yuxin Feng
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Beihua South Road, JingHai District, Tianjin, 301617, China; Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology & Medicine, 220 Dongting Road, TEDA, Tianjin, 300457, China
| | - Yan Zhu
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Beihua South Road, JingHai District, Tianjin, 301617, China; Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology & Medicine, 220 Dongting Road, TEDA, Tianjin, 300457, China.
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28
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Anadani M, Arthur AS, Tsivgoulis G, Simpson KN, Alawieh A, Orabi Y, Goyal N, Alexandrov AV, Maier IL, Psychogios M, Liman J, Brinton D, Swisher CB, Shah S, Inamullah O, Keyrouz S, Kansagra AP, Allen M, Giles JA, Wolfe SQ, Fargen KM, Gory B, De Marini P, Kan P, Nascimento FA, Almallouhi E, Petersen N, Kodali S, Rahman S, Richard S, Spiotta AM. Blood Pressure Goals and Clinical Outcomes after Successful Endovascular Therapy: A Multicenter Study. Ann Neurol 2020; 87:830-839. [DOI: 10.1002/ana.25716] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Mohammad Anadani
- Department of NeurosurgeryMedical University of South Carolina Charleston SC USA
- Department of NeurologyMedical University of South Carolina Charleston SC USA
| | - Adam S. Arthur
- Department of NeurologyMedical University of South Carolina Charleston SC USA
| | - Georgios Tsivgoulis
- Department of NeurosurgeryUniversity of Tennessee Health Science Center Memphis TN USA
| | - Kit N. Simpson
- Department of NeurologyAttikon University Hospital, School of Medicine, National and Kapodistrian University of Athens Athens Greece
| | - Ali Alawieh
- Department of NeurosurgeryMedical University of South Carolina Charleston SC USA
| | - Yser Orabi
- Department of NeurologyMedical University of South Carolina Charleston SC USA
| | - Nitin Goyal
- Department of NeurologyUniversity Medical Center Göttingen Göttingen Germany
| | - Andrei V. Alexandrov
- Department of NeurologyUniversity of Tennessee Health Science Center Memphis TN USA
| | - Ilko L. Maier
- Department of NeurologyUniversity Medical Center Göttingen Göttingen Germany
| | | | - Jan Liman
- Department of NeurologyUniversity Medical Center Göttingen Göttingen Germany
| | - Daniel Brinton
- Department of Healthcare Leadership and ManagementMedical University of South Carolina Charleston SC USA
| | | | - Shreyash Shah
- Department of NeurologyDuke University Hospital Durham NC USA
| | - Ovais Inamullah
- Department of NeurologyDuke University Hospital Durham NC USA
| | - Salah Keyrouz
- Department of NeurologyWashington University School of Medicine St Louis MO USA
| | - Akash P. Kansagra
- Department of NeurologyWashington University School of Medicine St Louis MO USA
| | - Michelle Allen
- Department of NeurologyWashington University School of Medicine St Louis MO USA
| | - James A. Giles
- Department of NeurologyWashington University School of Medicine St Louis MO USA
| | - Stacey Q. Wolfe
- Department of NeurosurgeryWake Forest University Winston‐Salem NC USA
| | - Kyle M. Fargen
- Department of NeurosurgeryWake Forest University Winston‐Salem NC USA
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic NeuroradiologyUniversity Hospital of Nancy Nancy France
| | - Pierre De Marini
- Department of Diagnostic and Therapeutic NeuroradiologyUniversity Hospital of Nancy Nancy France
| | - Peter Kan
- Department of NeurosurgeryBaylor College of Medicine Houston TX USA
| | | | - Eyad Almallouhi
- Department of NeurologyMedical University of South Carolina Charleston SC USA
| | - Nils Petersen
- Department of NeurologyYale New Haven Hospital New Haven CT USA
| | - Sreeja Kodali
- Department of NeurologyYale New Haven Hospital New Haven CT USA
| | - Shareena Rahman
- Department of NeurologyDuke University Hospital Durham NC USA
| | - Sébastien Richard
- Department of NeurologyStroke Unit, University Hospital of Nancy Nancy France
| | - Alejandro M. Spiotta
- Department of NeurosurgeryMedical University of South Carolina Charleston SC USA
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Abstract
Despite thousands of neuroprotectants demonstrating promise in preclinical trials, a neuroprotective therapeutic has yet to be approved for the treatment of acute brain injuries such as stroke or traumatic brain injury. Developing a more detailed understanding of models and populations demonstrating "neurological resilience" in spite of brain injury can give us important insights into new translational therapies. Resilience is the process of active adaptation to a stressor. In the context of neuroprotection, models of preconditioning and unique animal models of extreme physiology (such as hibernating species) reliably demonstrate resilience in the laboratory setting. In the clinical setting, resilience is observed in young patients and can be found in those with specific genetic polymorphisms. These important examples of resilience can help transform and extend the current neuroprotective framework from simply countering the injurious cascade into one that anticipates, monitors, and optimizes patients' physiological responses from the time of injury throughout the process of recovery. This review summarizes the underpinnings of key adaptations common to models of resilience and how this understanding can be applied to new neuroprotective approaches.
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Affiliation(s)
- Neel S Singhal
- Department of Neurology, University of California-San Francisco, 555 South Mission Bay Blvd, San Francisco, CA, 94158, USA.
| | - Chung-Huan Sun
- Department of Neurology, University of California-San Francisco, 555 South Mission Bay Blvd, San Francisco, CA, 94158, USA
| | - Evan M Lee
- Cardiovascular Research Institute, University of California-San Francisco, 555 South Mission Bay Blvd, San Francisco, CA, 94158, USA
- Department of Physiology, University of California-San Francisco, 555 South Mission Bay Blvd, San Francisco, CA, 94158, USA
| | - Dengke K Ma
- Cardiovascular Research Institute, University of California-San Francisco, 555 South Mission Bay Blvd, San Francisco, CA, 94158, USA
- Department of Physiology, University of California-San Francisco, 555 South Mission Bay Blvd, San Francisco, CA, 94158, USA
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30
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Brandler ES, Baksh N. Emergency management of stroke in the era of mechanical thrombectomy. Clin Exp Emerg Med 2019; 6:273-287. [PMID: 31910498 PMCID: PMC6952636 DOI: 10.15441/ceem.18.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 10/24/2018] [Indexed: 01/01/2023] Open
Abstract
Emergency management of stroke has been directed at the delivery of recombinant tissue plasminogen activator (tPA) in a timely fashion. Because of the many limitations attached to the delivery of tPA and the perceived benefits accrued to tPA, its use has been limited. Mechanical thrombectomy, a far superior therapy for the largest and most disabling strokes, large vessel occlusions (LVOs), has changed the way acute strokes are managed. Aside from the rush to deliver tPA, there is now a need to identify LVO and refer those patients with LVO to physicians and facilities capable of delivering urgent thrombectomy. Other parts of emergency department management of stroke are directed at identifying and mitigating risk factors for future strokes and at preventing further damage from occurring. We review here the most recent literature supporting these advances in stroke care and present a framework for understanding the role that emergency physicians play in acute stroke care.
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Affiliation(s)
- Ethan S Brandler
- Department of Emergency Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Nayeem Baksh
- Department of Emergency Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
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31
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Gomez J, Wolfe S, Sarwal A. Sonographic Demonstration of a Perfusion-Dependent Stroke with Negative MRI and a Flow-Limiting Stenosis. Neurocrit Care 2019; 32:883-888. [PMID: 31664625 DOI: 10.1007/s12028-019-00837-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Jonathan Gomez
- Department of Neurology, Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA.
| | - Stacey Wolfe
- Department of Neurosurgery, Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
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32
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Kim SH, Kim JI, Lee JY, Park CI, Hong JY, Lee SS. Is spontaneous normalization of systolic blood pressure within 24 hours after ischemic stroke onset related with favorable outcomes? PLoS One 2019; 14:e0224293. [PMID: 31639163 PMCID: PMC6804986 DOI: 10.1371/journal.pone.0224293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 10/09/2019] [Indexed: 11/18/2022] Open
Abstract
Background In acute ischemic stroke, blood pressure (BP) tends to rise initially and fall to a baseline level within 24–48 hours. Previous studies reported several different effects of BPs during acute ischemic stroke on clinical outcomes, which was partly due to the different time intervals from stroke onset to BP measurement. Methods All patients with acute ischemic stroke (onset ≤3 hours) who lived independently before the stroke, were consecutively enrolled for a 62-month period. BPs at 0, 12, and 24 hours after admission were collected. A favorable outcome was defined as a modified Rankin Scale (mRS) score 0–2 at discharge. For different standards of BP management, patients were grouped and analyzed according to intravenous (IV) tissue plasminogen activator (tPA) treatment and favorable outcome. Results Among the 446 enrolled patients, 227 patients underwent IV tPA treatment and 216 had mRS score 0–2 at discharge. Patients with favorable outcomes had lower initial NIH Stroke Scale (NIHSS) scores, less frequent progressive neurological deficits, and lower systolic BP (SBP) 12 and 24 hours after admission than patients with unfavorable outcomes, regardless of whether they underwent tPA treatment or not (p <0.05). The BP decreased over a period of 24 hours after admission. In logistic regression analysis, the independent variables associated with favorable outcome were the initial NIHSS score, a progressive neurological deficit, a previous stroke, and the SBP 24 hours after admission in the patients who underwent tPA treatment and the initial NIHSS score and a progressive neurological deficit in the patients who did not undergo tPA treatment (p <0.05). Conclusions The SBPs at 12 and 24 hours after admission were lower in acute stroke patients with favorable outcomes than in the other patients, regardless of whether the patients underwent tPA therapy and the SBP at 24 hours was an independent predictor of favorable outcomes among the patients who underwent tPA treatment.
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Affiliation(s)
- Seo Hyun Kim
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
- * E-mail:
| | - Ji In Kim
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Ji-Yong Lee
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Chan Ik Park
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Jin Yong Hong
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Sung-Soo Lee
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
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33
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Jeong HG, Kim BJ, Kim H, Jung C, Han MK, Liebeskind DS, Bae HJ. Blood Pressure Drop and Penumbral Tissue Loss in Nonrecanalized Emergent Large Vessel Occlusion. Stroke 2019; 50:2677-2684. [DOI: 10.1161/strokeaha.119.025426] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
For patients with emergent large vessel occlusion who may not benefit from timely recanalization treatment, maintaining adequate cerebral perfusion to prevent penumbral tissue loss is a key therapeutic strategy. Cerebral perfusion should be proportional to systemic blood pressure (BP) due to the loss of autoregulation properties in ischemic brain tissue. We hypothesized that acute fluctuations in BP would lead to aggravated penumbral tissue loss in persistent large vessel occlusion.
Methods—
A total of 80 patients with persistent large vessel occlusion of internal carotid artery or middle cerebral artery admitted within 24 hours after onset, and with a baseline, National Institutes of Health Stroke Scale score ≥4-point were included. Baseline and follow-up (median 88 hours) magnetic resonance images were analyzed, and penumbra was defined as the T
max
>6 s region excluding baseline infarction. The hypoperfusion intensity ratio (T
max
>10 s/T
max
>6 s) was calculated within the penumbra. Penumbral tissue loss (%) was defined as the proportion of follow-up infarct in the penumbra. With serial BP measurements in the first 24 hours (median 29, interquartile range 26–35), BP and BP variability parameters, including BP
dropmax
(change from local maxima to minima), were calculated and compared. Generalized linear models were applied to examine the association between BP parameters and the penumbral tissue loss.
Results—
The median penumbral volume was 79.3 mL (interquartile range, 38.2–129.6) and median penumbral tissue loss was 36.7% (interquartile range, 12.0–56.1). In a multivariable analysis, systolic BP (SBP) SBP
dropmax
(β±SE of fourth quartile, 17.82±6.58;
P
value, 0.01) and diastolic BP (DBP) DBP
dropmax
(β±SE of fourth quartile, 14.04±6.38;
P
value, 0.01) were associated with increasing penumbral tissue loss, independently of age, baseline infarction and hypoperfusion intensity ratio. DBP
incmax
, SBP
max
, DBP
max
, SBP
max-min
, DBP
max-min
, and most of the DBP variability indices were associated with penumbral tissue loss.
Conclusions—
BP fluctuations, even a brief and drastic BP drop in the first 24 hours, significantly contributed to penumbral tissue loss irrespective of baseline hypoperfusion.
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Affiliation(s)
- Han-Gil Jeong
- From the Department of Neurology (H.-G.J., B.J.K., H.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Beom Joon Kim
- From the Department of Neurology (H.-G.J., B.J.K., H.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyeran Kim
- From the Department of Neurology (H.-G.J., B.J.K., H.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Cheolkyu Jung
- Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Moon-Ku Han
- From the Department of Neurology (H.-G.J., B.J.K., H.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - David S. Liebeskind
- Neurovascular Imaging Research Core, UCLA Department of Neurology, Los Angeles, CA (D.S.L.)
| | - Hee-Joon Bae
- From the Department of Neurology (H.-G.J., B.J.K., H.K., M.-K.H., H.-J.B.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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34
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Increased interleukin-18 level contributes to the development and severity of ischemic stroke. Aging (Albany NY) 2019; 11:7457-7472. [PMID: 31525735 PMCID: PMC6781996 DOI: 10.18632/aging.102253] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 09/02/2019] [Indexed: 12/17/2022]
Abstract
Although interleukin-18 (IL-18) has been implicated in the pathophysiology of stroke, research findings concerning IL-18 level in stroke have been inconsistent. Thus, we performed a cross-sectional study in patients with first-episode ischemic stroke and then extracted relevant data from databases to validate our results. A total of 252 patients and 259 healthy subjects were recruited, and serum IL-18 level was evaluated in a cross-sectional study. Then, we extracted data and conducted a meta-analysis, including 2,928 patients and 3,739 controls to support our results. A 95% confidence interval for standardized mean difference (SMD) was calculated using a Z test. We found IL-18 was higher in stroke patients than in controls (2.39 ± 0.25 vs. 2.25 ± 0.28, F=8.60, p=0.004) and was negatively associated with the NIHSS scale (r = -0.14, p=0.028). A subsequent meta-analysis confirmed that IL-18 level was higher in stroke patients than in controls (SMD = 2.14, 95% CI = 1.54 ∼ 2.73, P< 0.001). IL-18 level increased with the severity of the stroke (p< 0.01). These findings revealed increased IL-18 level contributed to the development and severity of ischemic stroke, suggesting the potential of this biomarker to become an important reference for the early monitoring of ischemic stroke.
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35
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Liu Y, Manners J, Bittar Y, Chou SHY, Gopalakrishnan V. Towards precision critical care management of blood pressure in hemorrhagic stroke patients using dynamic linear models. PLoS One 2019; 14:e0220283. [PMID: 31381589 PMCID: PMC6681940 DOI: 10.1371/journal.pone.0220283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 07/14/2019] [Indexed: 11/18/2022] Open
Abstract
Finding optimal blood pressure (BP) target and BP treatment after acute ischemic or hemorrhagic strokes is an area of controversy and a significant unmet need in the critical care of stroke victims. Numerous large prospective clinical trials have been done to address this question but have generated neutral or conflicting results. One major limitation that may have contributed to so many neutral or conflicting clinical trial results is the "one-size fit all" approach to BP targets, while the optimal BP target likely varies between individuals. We address this problem with the Acute Intervention Model of Blood Pressure (AIM-BP) framework: an individualized, human interpretable model of BP and its control in the acute care setting. The framework consists of two components: one, a model of BP homeostasis and the various effects that perturb it; and two, a parameter estimator that can learn clinically important model parameters on a patient by patient basis. By estimating the parameters of the AIM-BP model for a given patient, the effectiveness of antihypertensive medication can be quantified separately from the patient's spontaneous BP trends. We hypothesize that the AIM-BP is a sufficient framework for estimating parameters of a homeostasis perturbation model of a stroke patient's BP time course and the AIM-BP parameter estimator can do so as accurately and consistently as a state-of-the-art maximum likelihood estimation method. We demonstrate that this is the case in a proof of concept of the AIM-BP framework, using simulated clinical scenarios modeled on stroke patients from real world intensive care datasets.
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Affiliation(s)
- Yuzhe Liu
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jody Manners
- Department of Neurology, Naval Medical Center Portsmouth, Portsmouth, VA, United States of America
| | - Yazan Bittar
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States of America
| | - Sherry H-Y. Chou
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Vanathi Gopalakrishnan
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States of America
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36
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Anadani M, Orabi MY, Alawieh A, Goyal N, Alexandrov AV, Petersen N, Kodali S, Maier IL, Psychogios MN, Swisher CB, Inamullah O, Kansagra AP, Giles JA, Wolfe SQ, Singh J, Gory B, De Marini P, Kan P, Nascimento FA, Freire LI, Pandhi A, Mitchell H, Kim JT, Fargen KM, Al Kasab S, Liman J, Rahman S, Allen M, Richard S, Spiotta AM. Blood Pressure and Outcome After Mechanical Thrombectomy With Successful Revascularization. Stroke 2019; 50:2448-2454. [PMID: 31318633 DOI: 10.1161/strokeaha.118.024687] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background and Purpose- Successful reperfusion can be achieved in more than two-thirds of patients treated with mechanical thrombectomy. Therefore, it is important to understand the effect of blood pressure (BP) on clinical outcomes after successful reperfusion. In this study, we investigated the relationship between BP on admission and during the first 24 hours after successful reperfusion with clinical outcomes. Methods- This was a multicenter study from 10 comprehensive stroke centers. To ensure homogeneity of the studied cohort, we included only patients with anterior circulation who achieved successful recanalization at the end of procedure. Clinical outcomes included 90-day modified Rankin Scale, symptomatic intracerebral hemorrhage (sICH), mortality, and hemicraniectomy. Results- A total of 1245 patients were included in the study. Mean age was 69±14 years, and 51% of patients were female. Forty-nine percent of patients had good functional outcome at 90-days, and 4.7% suffered sICH. Admission systolic BP (SBP), mean SBP, maximum SBP, SBP SD, and SBP range were associated with higher risk of sICH. In addition, patients in the higher mean SBP groups had higher rates of sICH. Similar results were found for hemicraniectomy. With respect to functional outcome, mean SBP, maximum SBP, and SBP range were inversely associated with the good outcome (modified Rankin Scale score, 0-2). However, the difference in SBP parameters between the poor and good outcome groups was modest. Conclusions- Higher BP within the first 24 hours after successful mechanical thrombectomy was associated with a higher likelihood of sICH, mortality, and requiring hemicraniectomy.
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Affiliation(s)
- Mohammad Anadani
- From the Department of Neurology, Medical University of South Carolina, Charleston (M.A, Y.O, S.A).,Department of Neurology, Washington University School of Medicine, Saint Louis, MO (S.K, J.G, M.A)
| | - Mohamad Y Orabi
- From the Department of Neurology, Medical University of South Carolina, Charleston (M.A, Y.O, S.A)
| | - Ali Alawieh
- Department of Neurosurgery, Medical University of South Carolina, Charleston (A.A, A.S)
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G, A.V.A, A.P, H.M)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G, A.V.A, A.P, H.M)
| | - Nils Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT (N.P, S.K)
| | - Sreeja Kodali
- Department of Neurology, Yale University School of Medicine, New Haven, CT (N.P, S.K).,Department of Neurology, Washington University School of Medicine, Saint Louis, MO (S.K, J.G, M.A)
| | - Ilko L Maier
- Department of Neurology, University Medical Center Göttingen, Germany (I.M, J.L)
| | | | - Christa B Swisher
- Department of Neurology, Duke University Hospital, Durham, NC(O.I, S.R, C.S)
| | - Ovais Inamullah
- Department of Neurology, Duke University Hospital, Durham, NC(O.I, S.R, C.S)
| | - Akash P Kansagra
- Department of Radiology, Washington University School of Medicine, Saint Louis, MO (A.P.K)
| | - James A Giles
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO (S.K, J.G, M.A)
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest University, Winston-Salem, NC (S.W, K.M.F)
| | - Jasmeet Singh
- Department of Radiology, Wake Forest University, Winston-Salem, NC (J.S)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, University Hospital of Nancy, France (B.G, P.D.M., S.R.)
| | - Pierre De Marini
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, University Hospital of Nancy, France (B.G, P.D.M., S.R.)
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX (P.K)
| | | | - Luis Idrovo Freire
- Department of Neurology, Leeds General Infirmary, University of Leeds, United Kingdom (L.I.F)
| | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G, A.V.A, A.P, H.M)
| | - Hunter Mitchell
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G, A.V.A, A.P, H.M)
| | - Joon-Tae Kim
- Department of Neurology (J-T. K), Chonnam National University Hospital Gwangju, South Korea
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest University, Winston-Salem, NC (S.W, K.M.F)
| | - Sami Al Kasab
- From the Department of Neurology, Medical University of South Carolina, Charleston (M.A, Y.O, S.A)
| | - Jan Liman
- Department of Neurology, University Medical Center Göttingen, Germany (I.M, J.L)
| | - Shareena Rahman
- Department of Neurology, Duke University Hospital, Durham, NC(O.I, S.R, C.S).,Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, University Hospital of Nancy, France (B.G, P.D.M., S.R.)
| | | | - Sébastien Richard
- Department of Neurology, Stroke Unit, CIC-P 1433, INSERM U1116, University Hospital of Nancy, France (S.R.)
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston (A.A, A.S)
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37
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Li C, Zhang Y, Xu T, Peng H, Wang D, Xu T, Sun Y, Bu X, Chen CS, Wang A, Wang J, Li Q, Ju Z, Geng D, Zhang J, Chen J, He J. Systolic Blood Pressure Trajectories in the Acute Phase and Clinical Outcomes in 2-Year Follow-up Among Patients With Ischemic Stroke. Am J Hypertens 2019; 32:317-325. [PMID: 30452533 PMCID: PMC6371957 DOI: 10.1093/ajh/hpy174] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/06/2018] [Accepted: 11/12/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Optimal blood pressure (BP) levels during acute ischemic stroke have not been established. We studied associations between systolic BP trajectories during acute phase and subsequent clinical outcomes among patients with ischemic stroke. METHODS A total of 4,036 patients with acute ischemic stroke and elevated BP from the China Antihypertensive Trial in Acute Ischemic Stroke trial were included in this analysis. Three BPs were measured every 2 hours in day 1, every 4 hours during days 2 and 3, and every 8 hours thereafter until hospital discharge or death. Clinical outcomes were assessed at 3, 12, and 24 months. Latent variable mixture modeling was used to identify subgroups that share a similar underlying trajectory of systolic BP during the first 7 days after stroke onset. Logistic regression and Cox proportional hazards models were used to examine the associations between systolic BP trajectories and clinical outcomes during follow-up. RESULTS We identified 5 systolic BP trajectories of high, high-to-moderate-low, moderate-high, moderate-low, and low. Compared to participants in high trajectory, multiple-adjusted odds ratios (95% confidence interval) of all-cause mortality at 3 months for individuals in high-to-moderate-low, moderate-high, moderate-low, and low were 0.34 (0.15-0.77), 0.58 (0.32-1.04), 0.29 (0.15-0.56), and 0.56 (0.26-1.19), respectively. Likewise, the corresponding hazard ratios for all-cause mortality in 24 months were 0.66 (0.44-1.00), 0.74 (0.53-1.05), 0.45 (0.32-0.66), and 0.61 (0.40-0.93), respectively. Similar associations were observed for recurrent stroke and cardiovascular disease, and in both the intervention and control groups. CONCLUSIONS Patients with moderate-low systolic BP during acute ischemic stroke had a lower risk of adverse clinical outcomes.
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Affiliation(s)
- Changwei Li
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, China
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
- Department of Epidemiology & Biostatistics, University of Georgia College of Public Health, GA, USA
| | - Yonghong Zhang
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Medical College of Soochow University, Suzhou, China
| | - Tan Xu
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Medical College of Soochow University, Suzhou, China
| | - Hao Peng
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Medical College of Soochow University, Suzhou, China
| | - Dali Wang
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Hebei, China
| | - Tian Xu
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Medical College of Soochow University, Suzhou, China
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Yingxian Sun
- Department of Cardiology, The First Affiliated Hospital of China Medical University, Liaoning, China
| | - Xiaoqing Bu
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, China
| | - Chung-Shiuan Chen
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Aili Wang
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, School of Public Health, Medical College of Soochow University, Suzhou, China
| | - Jinchao Wang
- Department of Neurology, Yutian County Hospital, Hebei, China
| | - Qunwei Li
- Department of Epidemiology, School of Public Health, Taishan Medical College, Shandong, China
| | - Zhong Ju
- Department of Neurology, Kerqin District First People’s Hospital of Tongliao City, Inner Mongolia, China
| | - Deqin Geng
- Department of Neurology, Affiliated Hospital of Xuzhou Medical College, Jiangsu, China
| | - Jintao Zhang
- Department of Neurology, The 88th Hospital of PLA, Shandong, China
| | - Jing Chen
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Hebei, China
- Tulane University Translational Science Institute, Tulane University, New Orleans, Louisiana, USA
| | - Jiang He
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, China
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
- Tulane University Translational Science Institute, Tulane University, New Orleans, Louisiana, USA
- Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - CATIS investigators
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, China
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38
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Bilirubin and Ischemic Stroke: Rendering the Current Paradigm to Better Understand the Protective Effects of Bilirubin. Mol Neurobiol 2019; 56:5483-5496. [PMID: 30612336 DOI: 10.1007/s12035-018-1440-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/21/2018] [Indexed: 01/14/2023]
Abstract
Novel and innovative methods are critical in fostering new treatments and improving clinical outcomes in patients who suffer from ischemic stroke. Bilirubin has long been considered metabolic waste that can be harmful to the body; however, it is now becoming recognized as one of the body's most potent antioxidant, anti-inflammatory, and neuroprotective molecules. These properties facilitate bilirubin's anti-atherogenic effects to impede and prevent the formation of thrombi in ischemic stroke. These functions allow for protection from neuronal injury during an ischemic state and suggest that elevated bilirubin levels may be linked to a lower rate of morbidity and mortality. Therefore, here we discuss the pathophysiology of stroke and the molecular properties of bilirubin to better understand their beneficial relationship. We outline clinical studies looking at the relationship between serum bilirubin levels and ischemic stroke prevalence. At this time, few studies have rigorously looked at the relationship between bilirubin and ischemic stroke, whether it is positive or negative. Thus, rigorous research is needed to provide evidence supporting the current studies, expand on these studies, and facilitate their translation to bedside therapy for patients who suffer from ischemic stroke.
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39
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Vanaie M, Valiyan Boroujeni M, Motavallipour Abarghuie H, Pourshanazari AA, Rezazadeh H. The Effect of Sneezing on the Reduction of Infarct Volume and the Improvement of Neurological Deficits in Male Rats. Adv Biomed Res 2018; 7:142. [PMID: 30596052 PMCID: PMC6282486 DOI: 10.4103/abr.abr_119_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Sneezing transiently elevates cerebral blood flow. We speculated that induced sneezing, following embolism would restore arterial flow, thereby diminishing infarct volume and improving neurological deficits. Materials and Methods Male rats were subjected to middle cerebral artery occlusion (MCAO) using prepared clots (embolization) and randomized into four equal groups as follows: (1) pre-MCAO-induced sneezing (PRMIS), (2) post-MCAO-induced sneezing (POMIS), and (3) pre- and POMIS (PRPOMIS) and the control group (eight rats per group). In the treatment groups, rats' sneezing episodes were induced before MCAO in PRMIS group or before regaining consciousness from surgical anesthesia in other treatment groups by cutting their whiskers during their anesthesia and subsequently inserted them into the rats' nostrils. Infarct volume was evaluated by 2, 3, 5-triphenyl tetrazolium chloride staining, and neurological deficits and brain edema were assessed by Bederson scale deficit scores 24-h post-MCAO. Results The infarct volume and brain edema reduced and neurological deficits improved in the induced sneezing groups as compared with the MCAO control group. Compared to the control group, the highest improvements in the infarct volume and neurological deficits were seen in the PRPOMIS group, and POMIS group showed the most significant differences concerning the results of both ischemic and nonischemic brain edema. The highest protective effect was observed in the central region of the MCA territory. Conclusions The reduction in ischemia-induced brain injury, brain edema, and neurological deficits by sneezing suggest that brief episodes of acute hypertension after stroke can increase blood flow to the ischemic area and improve recovery.
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Affiliation(s)
- Mahdi Vanaie
- School of Medicine, Medical Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Valiyan Boroujeni
- School of Medicine, Medical Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Ali Asghar Pourshanazari
- School of Medicine, Medical Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Rezazadeh
- Physiology - Pharmacology Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
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40
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Conner AK, Briggs RG, Palejwala AH, Sali G, Sughrue ME. The safety of post-operative elevation of mean arterial blood pressure following brain tumor resection. J Clin Neurosci 2018; 58:156-159. [PMID: 30243597 DOI: 10.1016/j.jocn.2018.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 09/10/2018] [Indexed: 12/23/2022]
Abstract
We demonstrate the safety of artificially elevating the mean arterial blood pressure (MAP) greater than 85 mmHg or 10% above the mean MAP in patients with underlying hypertension during the acute post-operative period in patients undergoing surgery for resection of brain tumors. A retrospective review was undertaken of all patients undergoing surgery by the senior author between 2013 and 2018. Patients who underwent MAP therapy were analyzed for hemorrhagic and cardiac complications. A total of 1162 of 2270 post-operative brain tumor patients underwent MAP therapy after surgery for a minimum of 24 h post-operatively. Of these, 7/1162 (0.6%) patients experienced intra-cavitary hemorrhage within 5 days of surgery. Two of 7 (29%) patients were diagnosed with venous infarction. One of 7 (14%) patients experienced post-operative, intra-cavitary hemorrhage prior to the initiation of MAP therapy. The remaining 4/1162 (0.35%) patients experienced intra-cavitary hemorrhage post-operatively without clear etiology. In assessing cardiac outcomes, 2/1162 patients (0.2%) experienced elevated troponin levels. No patient demonstrated significant cardiac related morbidity or mortality within this cohort. Post-operative MAP therapy with a goal of maintaining MAP greater than 85 mmHg or 10% above the mean MAP in patients with underlying hypertension appears to be a safe intervention in brain tumor patients for at least 24 h in the post-operative period.
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Affiliation(s)
- Andrew K Conner
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Robert G Briggs
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ali H Palejwala
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Goksel Sali
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Michael E Sughrue
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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41
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Early antihypertensive treatment and clinical outcomes in acute ischemic stroke: subgroup analysis by baseline blood pressure. J Hypertens 2018; 36:1372-1381. [PMID: 29389742 PMCID: PMC6368851 DOI: 10.1097/hjh.0000000000001690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND We studied the effect of early antihypertensive treatment on death, major disability, and vascular events among patients with acute ischemic stroke according to their baseline SBP. METHODS We randomly assigned 4071 acute ischemic stroke patients with SBP between 140 and less than 220 mmHg to receive antihypertensive treatment or to discontinue all antihypertensive medications during hospitalization. A composite primary outcome of death and major disability and secondary outcomes were compared between treatment and control stratified by baseline SBP levels of less than 160, 160-179, and at least 180 mmHg. RESULTS At 24 h after randomization, differences in SBP reductions were 8.8, 8.6 and 7.8 mmHg between the antihypertensive treatment and control groups among patients with baseline SBP less than 160, 160-179, and at least 180 mmHg, respectively (P < 0.001 among subgroups). At day 14 or hospital discharge, the primary and secondary outcomes were not significantly different between the treatment and control groups among subgroups. However, there was a significant interaction between antihypertensive treatment and baseline SBP subgroups on death (P = 0.02): odds ratio (95% CI) of 2.42 (0.74-7.89) in patients with baseline SBP less than 60 mmHg and 0.34 (0.11-1.09) in those with baseline SBP at least 180 mmHg. At the 3-month follow-up, the primary and secondary clinical outcomes were not significantly different between the treatment and control groups by baseline SBP levels. CONCLUSION Early antihypertensive treatment had a neutral effect on clinical outcomes among acute ischemic stroke patients with various baseline SBP levels. Future clinical trials are warranted to test BP-lowering effects in acute ischemic stroke patients by baseline SBP levels. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01840072.
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42
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Liu L, Ding J, Leng X, Pu Y, Huang LA, Xu A, Wong KSL, Wang X, Wang Y. Guidelines for evaluation and management of cerebral collateral circulation in ischaemic stroke 2017. Stroke Vasc Neurol 2018; 3:117-130. [PMID: 30294467 PMCID: PMC6169613 DOI: 10.1136/svn-2017-000135] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/10/2018] [Accepted: 04/12/2018] [Indexed: 12/24/2022] Open
Abstract
Collateral circulation plays a vital role in sustaining blood flow to the ischaemic areas in acute, subacute or chronic phases after an ischaemic stroke or transient ischaemic attack. Good collateral circulation has shown protective effects towards a favourable functional outcome and a lower risk of recurrence in stroke attributed to different aetiologies or undergoing medical or endovascular treatment. Over the past decade, the importance of collateral circulation has attracted more attention and is becoming a hot spot for research. However, the diversity in imaging methods and criteria to evaluate collateral circulation has hindered comparisons of findings from different cohorts and further studies in exploring the clinical relevance of collateral circulation and possible methods to enhance collateral flow. The statement is aimed to update currently available evidence and provide evidence-based recommendations regarding grading methods for collateral circulation, its significance in patients with stroke and methods under investigation to improve collateral flow.
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Affiliation(s)
- Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Ding
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Yuehua Pu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li-An Huang
- Department of Neurology, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Anding Xu
- Department of Neurology, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Ka Sing Lawrence Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Xin Wang
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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43
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Chen G, Thakkar M, Robinson C, Doré S. Limb Remote Ischemic Conditioning: Mechanisms, Anesthetics, and the Potential for Expanding Therapeutic Options. Front Neurol 2018; 9:40. [PMID: 29467715 PMCID: PMC5808199 DOI: 10.3389/fneur.2018.00040] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/17/2018] [Indexed: 12/23/2022] Open
Abstract
Novel and innovative approaches are essential in developing new treatments and improving clinical outcomes in patients with ischemic stroke. Remote ischemic conditioning (RIC) is a series of mechanical interruptions in blood flow of a distal organ, following end organ reperfusion, shown to significantly reduce infarct size through inhibition of oxidation and inflammation. Ischemia/reperfusion (I/R) is what ultimately leads to the irreversible brain damage and clinical picture seen in stroke patients. There have been several reports and reviews about the potential of RIC in acute ischemic stroke; however, the focus here is a comprehensive look at the differences in the three types of RIC (remote pre-, per-, and postconditioning). There are some limited uses of preconditioning in acute ischemic stroke due to the unpredictability of the ischemic event; however, it does provide the identification of biomarkers for clinical studies. Remote limb per- and postconditioning offer a more promising treatment during patient care as they can be harnessed during or after the initial ischemic insult. Though further research is needed, it is imperative to discuss the importance of preclinical data in understanding the methods and mechanisms involved in RIC. This understanding will facilitate translation to a clinically feasible paradigm for use in the hospital setting.
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Affiliation(s)
- Gangling Chen
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL, United States.,Department of Pharmacology of Chinese Materia Medica, China Pharmaceutical University, Nanjing, China
| | - Mrugesh Thakkar
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL, United States
| | - Christopher Robinson
- McKnight Brain Institute, University of Florida, Gainesville, FL, United States.,Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Sylvain Doré
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL, United States.,McKnight Brain Institute, University of Florida, Gainesville, FL, United States.,Department of Neurology, University of Florida, Gainesville, FL, United States.,Department of Psychiatry, University of Florida, Gainesville, FL, United States.,Department of Pharmaceutics, University of Florida, Gainesville, FL, United States.,Department of Psychology, University of Florida, Gainesville, FL, United States.,Department of Neuroscience, University of Florida, Gainesville, FL, United States
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44
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Managing high blood pressure during acute ischemic stroke and intracerebral hemorrhage. Curr Opin Neurol 2018; 31:8-13. [DOI: 10.1097/wco.0000000000000508] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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45
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Cytokine MIF Enhances Blood-Brain Barrier Permeability: Impact for Therapy in Ischemic Stroke. Sci Rep 2018; 8:743. [PMID: 29335619 PMCID: PMC5768806 DOI: 10.1038/s41598-017-16927-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 11/19/2017] [Indexed: 01/12/2023] Open
Abstract
Ischemic stroke is a devastating disease with limited therapeutic options. It is very urgent to find a new target for drug development. Here we found that the blood level of MIF in ischemic stroke patients is upregulated. To figure out the pathological role of MIF in ischemic stroke, both in vitro and in vivo studies were conducted. For in vitro studies, primary cortical neuron cultures and adult rat brain endothelial cells (ARBECs) were subjected to oxygen-glucose deprivation (OGD)/reoxygenation. Middle cerebral artery occlusion (MCAo) rodent models were used for in vivo studies. The results show that MIF exerts no direct neuronal toxicity in primary culture but disrupts tight junction in ARBECs. Furthermore, administration of MIF following MCAo shows the deleterious influence on stroke-induced injury by destroying the tight junction of blood-brain barrier and increasing the infarct size. In contrast, administration of MIF antagonist ISO-1 has the profound neuroprotective effect. Our results demonstrate that MIF might be a good drug target for the therapy of stroke.
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El Amki M, Wegener S. Improving Cerebral Blood Flow after Arterial Recanalization: A Novel Therapeutic Strategy in Stroke. Int J Mol Sci 2017; 18:ijms18122669. [PMID: 29232823 PMCID: PMC5751271 DOI: 10.3390/ijms18122669] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 11/30/2017] [Accepted: 12/06/2017] [Indexed: 12/14/2022] Open
Abstract
Ischemic stroke is caused by a disruption in blood supply to a region of the brain. It induces dysfunction of brain cells and networks, resulting in sudden neurological deficits. The cause of stroke is vascular, but the consequences are neurological. Decades of research have focused on finding new strategies to reduce the neural damage after cerebral ischemia. However, despite the incredibly huge investment, all strategies targeting neuroprotection have failed to demonstrate clinical efficacy. Today, treatment for stroke consists of dealing with the cause, attempting to remove the occluding blood clot and recanalize the vessel. However, clinical evidence suggests that the beneficial effect of post-stroke recanalization may be hampered by the occurrence of microvascular reperfusion failure. In short: recanalization is not synonymous with reperfusion. Today, clinicians are confronted with several challenges in acute stroke therapy, even after successful recanalization: (1) induce reperfusion, (2) avoid hemorrhagic transformation (HT), and (3) avoid early or late vascular reocclusion. All these parameters impact the restoration of cerebral blood flow after stroke. Recent advances in understanding the molecular consequences of recanalization and reperfusion may lead to innovative therapeutic strategies for improving reperfusion after stroke. In this review, we will highlight the importance of restoring normal cerebral blood flow after stroke and outline molecular mechanisms involved in blood flow regulation.
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Affiliation(s)
- Mohamad El Amki
- Department of Neurology, University Hospital Zurich and University of Zurich, 8091 Zürich, Switzerland.
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, 8091 Zürich, Switzerland.
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Regenhardt RW, Das AS, Stapleton CJ, Chandra RV, Rabinov JD, Patel AB, Hirsch JA, Leslie-Mazwi TM. Blood Pressure and Penumbral Sustenance in Stroke from Large Vessel Occlusion. Front Neurol 2017; 8:317. [PMID: 28717354 PMCID: PMC5494536 DOI: 10.3389/fneur.2017.00317] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/16/2017] [Indexed: 12/11/2022] Open
Abstract
The global burden of stroke remains high, and of the various subtypes of stroke, large vessel occlusions (LVOs) account for the largest proportion of stroke-related death and disability. Several randomized controlled trials in 2015 changed the landscape of stroke care worldwide, with endovascular thrombectomy (ET) now the standard of care for all eligible patients. With the proven success of this therapy, there is a renewed focus on penumbral sustenance. In this review, we describe the ischemic penumbra, collateral circulation, autoregulation, and imaging assessment of the penumbra. Blood pressure goals in acute stroke remain controversial, and we review the current data and suggest an approach for induced hypertension in the acute treatment of patients with LVOs. Finally, in addition to reperfusion and enhanced perfusion, efforts focused on developing therapeutic targets that afford neuroprotection and augment neural repair will gain increasing importance. ET has revolutionized stroke care, and future emphasis will be placed on promoting penumbral sustenance, which will increase patient eligibility for this highly effective therapy and reduce overall stroke-related death and disability.
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Affiliation(s)
- Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Alvin S. Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Christopher J. Stapleton
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ronil V. Chandra
- Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, VIC, Australia
| | - James D. Rabinov
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aman B. Patel
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Joshua A. Hirsch
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Thabele M. Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Abstract
PURPOSE OF REVIEW This article reviews the clinical evaluation of the patient with acute stroke, including key questions in the focused stroke history, important aspects of the National Institutes of Health Stroke Scale and focused neurologic examination, and the significance of the basic head CT scan in informing a timely treatment decision. RECENT FINDINGS Advances in both stroke treatment and enhanced diagnostics support an evolving paradigm for acute stroke care, ranging from the prehospital setting to the rehabilitative setting. An international emphasis on best practice strategies promotes efficiency and standardization in stroke systems of care. SUMMARY Despite continual changes and augmentations to the field of acute stroke, several fundamentals remain. Central among these is in-depth knowledge of neurovascular anatomy, clinical stroke syndromes, and common mimics, which are foundational to the bedside evaluation of the patient with acute stroke.
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Stone JA, Willey JZ, Keyrouz S, Butera J, McTaggart RA, Cutting S, Silver B, Thompson B, Furie KL, Yaghi S. Therapies for Hemorrhagic Transformation in Acute Ischemic Stroke. Curr Treat Options Neurol 2017; 19:1. [DOI: 10.1007/s11940-017-0438-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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