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Schmidt-Pogoda A, Kaesmacher J, Bonberg N, Werring N, Strecker JK, Koecke MHM, Beuker C, Gralla J, Meier R, Wiendl H, Minnerup H, Fischer U, Minnerup J. The dilemma of neuroprotection trials in times of successful endovascular recanalization. Front Neurol 2024; 15:1383494. [PMID: 38654740 PMCID: PMC11035835 DOI: 10.3389/fneur.2024.1383494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
Background The "translational roadblock" between successful animal stroke studies and neutral clinical trials is usually attributed to conceptual weaknesses. However, we hypothesized that rodent studies cannot inform the human disease due to intrinsic pathophysiological differences between rodents and humans., i.e., differences in infarct evolution. Methods To verify our hypothesis, we employed a mixed study design and compared findings from meta-analyses of animal studies and a retrospective clinical cohort study. For animal data, we systematically searched pubmed to identify all rodent studies, in which stroke was induced by MCAO and at least two sequential MRI scans were performed for infarct volume assessment within the first two days. For clinical data, we included 107 consecutive stroke patients with large artery occlusion, who received MRI scans upon admission and one or two days later. Results Our preclinical meta-analyses included 50 studies with 676 animals. Untreated animals had a median post-reperfusion infarct volume growth of 74%. Neuroprotective treatments reduced this infarct volume growth to 23%. A retrospective clinical cohort study showed that stroke patients had a median infarct volume growth of only 2% after successful recanalization. Stroke patients with unsuccessful recanalization, by contrast, experienced a meaningful median infarct growth of 148%. Conclusion Our study shows that rodents have a significant post-reperfusion infarct growth, and that this post-reperfusion infarct growth is the target of neuroprotective treatments. Stroke patients with successful recanalization do not have such infarct growth and thus have no target for neuroprotection.
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Affiliation(s)
- Antje Schmidt-Pogoda
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Nadine Bonberg
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Nils Werring
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Jan-Kolja Strecker
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Mailin Hannah Marie Koecke
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Raphael Meier
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Heike Minnerup
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
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Koecke MHM, Strecker J, Straeten FA, Beuker C, Minnerup J, Schmidt‐Pogoda A, Börsch A. Inhibition of leukocyte migration after ischemic stroke by VE-cadherin mutation in a mouse model leads to reduced infarct volumes and improved motor skills. Brain Behav 2024; 14:e3449. [PMID: 38468566 PMCID: PMC10928452 DOI: 10.1002/brb3.3449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 01/28/2024] [Accepted: 02/04/2024] [Indexed: 03/13/2024] Open
Abstract
AIMS To distinguish between the genuine cellular impact of the ischemic cascade by leukocytes and unspecific effects of edema and humoral components, two knock-in mouse lines were utilized. Mouse lines Y731F and Y685F possess point mutations in VE-cadherin, which lead to a selective inhibition of transendothelial leukocyte migration or impaired vascular permeability. METHODS Ischemic stroke was induced by a model of middle cerebral artery occlusion. Analysis contained structural outcomes (infarct volume and extent of brain edema), functional outcomes (survival analysis, rotarod test, and neuroscore), and the extent and spatial distribution of leukocyte migration (heatmaps and fluorescence-activated cell sorting (FACS) analysis). RESULTS Inhibition of transendothelial leukocyte migration as in Y731F mice leads to smaller infarct volumes (52.33 ± 4719 vs. 70.43 ± 6483 mm3 , p = .0252) and improved motor skills (rotarod test: 85.52 ± 13.24 s vs. 43.06 ± 15.32 s, p = .0285). An impaired vascular permeability as in Y685F mice showed no effect on structural or functional outcomes. Both VE-cadherin mutations did not influence the total immune cell count or spatial distribution in ischemic brain parenchyma. CONCLUSION Selective inhibition of transendothelial leukocyte migration by VE-cadherin mutation after ischemic stroke in a mouse model leads to smaller infarct volumes and improved motor skills.
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Affiliation(s)
| | - Jan‐Kolja Strecker
- Department of Neurology with Institute of Translational NeurologyUniversity of MünsterMünsterGermany
| | - Frederike Anne Straeten
- Department of Neurology with Institute of Translational NeurologyUniversity of MünsterMünsterGermany
| | - Carolin Beuker
- Department of Neurology with Institute of Translational NeurologyUniversity of MünsterMünsterGermany
| | - Jens Minnerup
- Department of Neurology with Institute of Translational NeurologyUniversity of MünsterMünsterGermany
| | - Antje Schmidt‐Pogoda
- Department of Neurology with Institute of Translational NeurologyUniversity of MünsterMünsterGermany
| | - Anna‐Lena Börsch
- Department of Neurology with Institute of Translational NeurologyUniversity of MünsterMünsterGermany
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Sporns PB, Kemmling A, Meyer L, Krogias C, Puetz V, Thierfelder KM, Duering M, Lukas C, Kaiser D, Langner S, Brehm A, Rotkopf LT, Kunz WG, Beuker C, Heindel W, Fiehler J, Schramm P, Wiendl H, Minnerup H, Psychogios MN, Minnerup J. Computed tomography hypoperfusion-hypodensity mismatch vs. automated perfusion mismatch to identify stroke patients eligible for thrombolysis. Front Neurol 2023; 14:1320620. [PMID: 38225983 PMCID: PMC10788186 DOI: 10.3389/fneur.2023.1320620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/04/2023] [Indexed: 01/17/2024] Open
Abstract
Background and purpose Automated perfusion imaging can detect stroke patients with unknown time of symptom onset who are eligible for thrombolysis. However, the availability of this technique is limited. We, therefore, established the novel concept of computed tomography (CT) hypoperfusion-hypodensity mismatch, i.e., an ischemic core lesion visible on cerebral perfusion CT without visible hypodensity in the corresponding native cerebral CT. We compared both methods regarding their accuracy in identifying patients suitable for thrombolysis. Methods In a retrospective analysis of the MissPerfeCT observational cohort study, patients were classified as suitable or not for thrombolysis based on established time window and imaging criteria. We calculated predictive values for hypoperfusion-hypodensity mismatch and automated perfusion imaging to compare accuracy in the identification of patients suitable for thrombolysis. Results Of 247 patients, 219 (88.7%) were eligible for thrombolysis and 28 (11.3%) were not eligible for thrombolysis. Of 197 patients who were within 4.5 h of symptom onset, 190 (96.4%) were identified by hypoperfusion-hypodensity mismatch and 88 (44.7%) by automated perfusion mismatch (p < 0.001). Of 22 patients who were beyond 4.5 h of symptom onset but were eligible for thrombolysis, 5 patients (22.7%) were identified by hypoperfusion-hypodensity mismatch. Predictive values for the hypoperfusion-hypodensity mismatch vs. automated perfusion mismatch were as follows: sensitivity, 89.0% vs. 50.2%; specificity, 71.4% vs. 100.0%; positive predictive value, 96.1% vs. 100.0%; and negative predictive value, 45.5% vs. 20.4%. Conclusion The novel method of hypoperfusion-hypodensity mismatch can identify patients suitable for thrombolysis with higher sensitivity and lower specificity than established techniques. Using this simple method might therefore increase the proportion of patients treated with thrombolysis without the use of special automated software.The MissPerfeCT study is a retrospective observational multicenter cohort study and is registered with clinicaltrials.gov (NCT04277728).
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Affiliation(s)
- Peter B. Sporns
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Radiology, Westfaelische Wilhelms-University of Münster and University Hospital of Münster, Münster, Germany
| | - André Kemmling
- Department of Radiology, Westfaelische Wilhelms-University of Münster and University Hospital of Münster, Münster, Germany
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Lennart Meyer
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Kolja M. Thierfelder
- Department of Radiology and Institute of Diagnostic and Interventional Radiology, University Medical Center Rostock, Rostock, Germany
| | - Marco Duering
- Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
| | - Carsten Lukas
- Department of Neuroradiology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Daniel Kaiser
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Sönke Langner
- Department of Radiology and Institute of Diagnostic and Interventional Radiology, University Medical Center Rostock, Rostock, Germany
| | - Alex Brehm
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Lukas T. Rotkopf
- Department of Radiology, German Cancer Research Center, Heidelberg, Germany
| | - Wolfgang G. Kunz
- Department of Radiology, University Hospital, LMU Munich, Germany
| | - Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Walter Heindel
- Department of Radiology, Westfaelische Wilhelms-University of Münster and University Hospital of Münster, Münster, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Schramm
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Heike Minnerup
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Marios Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
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Müller-Miny L, Sauer R, Schulte-Mecklenbeck A, Gross CC, Kovac S, Schilling M, Beuker C, Wiendl H, Meyer zu Hörste G. Contactin-associated protein 2 autoantibodies can be associated with multifocal motor-like neuropathy: a case report. Ther Adv Neurol Disord 2023; 16:17562864231189323. [PMID: 37599705 PMCID: PMC10434843 DOI: 10.1177/17562864231189323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/03/2023] [Indexed: 08/22/2023] Open
Abstract
Autoantibodies against contactin-associated protein 2 (CASPR2) are usually associated with autoimmune encephalitis and neuromyotonia. Their association with inflammatory neuropathies has been described in case reports albeit all with distal symmetric manifestation. Here, we report a patient who developed distal arm paresis, dominantly of the right arm, over the course of 1 year. Electroneurography showed a conduction block of motor nerve conduction, nerve ultrasonography a swelling of the right median and ulnar nerve and flow cytometry an increase in natural killer (NK cells) in the blood and natural killer T (NKT) cells in the cerebrospinal fluid (CSF), therefore indicating a multifocal motor neuropathy-like (MMN-like) phenotype. CASPR2 autoantibodies were detected in serum and CSF. Through immunotherapy with intravenous immunoglobulins the patient showed clinical and neurographic improvement. We therefore describe the first association of CASPR2 autoantibodies with a MMN-like clinical manifestation, extending the spectrum of CASPR2-associated diseases.
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Affiliation(s)
- Louisa Müller-Miny
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Raoul Sauer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Catharina C. Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Matthias Schilling
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Gerd Meyer zu Hörste
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Building A1, Münster 48149, Germany
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Beuker C, Köppe J, Feld J, Meyer CL, Dröge P, Ruhnke T, Günster C, Wiendl H, Reinecke H, Minnerup J. Association of age with 1-year outcome in patients with acute ischaemic stroke treated with thrombectomy: real-world analysis in 18 506 patients. J Neurol Neurosurg Psychiatry 2023; 94:631-637. [PMID: 37001983 PMCID: PMC10359560 DOI: 10.1136/jnnp-2022-330506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 03/15/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND To evaluate the association of age with long-term outcome after thrombectomy. METHODS In a retrospective cohort study based on routine healthcare data from Germany between 2010 and 2018, we included 18 506 patients with acute ischaemic stroke treated with mechanical thrombectomy. Association between age and mortality, disability, and level of care at 1 year was assessed. RESULTS The median age was 76 years, 36.3% were aged ≥80 years and 55.8% were women. Patients aged ≥80 compared with those <80 years had a higher mortality (55.4% vs 28.5%; adjusted HR 1.13; 95% CI 1.05 to 1.31), more often had moderate/severe disability (35.5% vs 33.2%, adjusted HR 1.14; 95% CI 1.06 to 1.23) and less frequently had no/slight disability (17.4% vs 41.0%) at 1 year. Older age was associated with a higher likelihood of living in a nursing home (13.4% vs 9.2%, adjusted HR 1.09; 95% CI 0.97 to 1.22) and a lower likelihood of living at home (33.8% vs 62.8%) at 1 year. These associations were also robust when analysed in patients with no disability prior to stroke. Factors most strongly associated with worse 1-year outcomes in elderly patients were chronic limb-threatening ischaemia (67.9% vs 56.4%; HR 1.59, 95% CI 1.38 to 1.82), dementia at baseline (65.2% vs 47.3%; HR 1.29, 95% CI 1.17 to 1.44) and ventilation >48 hours (79.3% vs 52.2%; HR 2.91, 95% CI 2.66 to 3.18). CONCLUSIONS In this large 'real-world' cohort, outcomes after mechanical thrombectomy were strongly associated with age. Of patients aged ≥80 years more than half were dead and less than one-fifth were functionally independent at 1 year. Certain comorbidities and ventilation >48 hours were associated with even worse outcomes.
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Affiliation(s)
- Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Jeanette Köppe
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Jannik Feld
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Christian Lennart Meyer
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | | | | | | | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
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Beuker C, Werring N, Bonberg N, Strecker JK, Schmidt-Pogoda A, Schwindt W, Stracke P, Schulte-Mecklenbeck A, Gross C, Wiendl H, Minnerup H, Minnerup J. Stroke in Patients with Bacterial Meningitis: A Cohort Study and Meta-Analysis. Ann Neurol 2023; 93:1094-1105. [PMID: 36806294 DOI: 10.1002/ana.26618] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023]
Abstract
OBJECTIVE The purpose of this study was to characterize patients with ischemic stroke due to bacterial meningitis. METHODS In a single-center retrospective study, we analyzed 102 patients with bacterial meningitis of which 19 had an ischemic stroke. Clinical characteristics, cerebrospinal fluid (CSF) analyses, and spatiotemporal distribution of infarcts were assessed. In addition, we searched PubMed from database inception to August 2021 for observational studies on ischemic stroke in patients with bacterial meningitis, and performed a meta-analysis to investigate the frequency and timing of stroke as well as its effect on mortality. RESULTS In our cohort, 15 (78.9%) patients with stroke had an modified Rankin scale (mRS) ≥ $$ \ge $$ 3 at discharge compared to 33 (39.8%) in patients without stroke (p < 0.01). Of 1,692 patients with bacterial meningitis from 15 cohort studies included in our meta-analysis, cerebral infarcts were found in 332 (16%, 95% confidence interval [CI] = 0.13-0.20) patients. The occurrence of stroke was strongly associated with a higher mortality (odds ratio [OR] = 2.38, 95% CI = 1.70-3.34, p < 0.0001). There was no association of any specific causative pathogen with the occurrence of stroke. Infarcts were mainly distributed in territories of arteries located in the vicinity to the infection focus and peaked at 3 to -7 days and at 2 weeks after onset of meningitis. In patients with ischemic stroke, vasculopathy was found in 63.2% and additional intracerebral hemorrhage in 15.8%. INTERPRETATION This study found that ischemic stroke due to bacterial meningitis is caused by cerebral vasculopathy located in the vicinity of the infection focus, and that the time course of infarctions might enable a therapeutic intervention. ANN NEUROL 2023.
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Affiliation(s)
- Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Nils Werring
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Nadine Bonberg
- Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany
| | - Jan-Kolja Strecker
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Antje Schmidt-Pogoda
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Wolfram Schwindt
- Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany
| | - Paul Stracke
- Department of Clinical Radiology, University Hospital of Muenster, Muenster, Germany
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Catharina Gross
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Heike Minnerup
- Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
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Beuker C, Strunk D, Rawal R, Schmidt-Pogoda A, Werring N, Milles L, Ruck T, Wiendl H, Meuth S, Minnerup H, Minnerup J. Primary Angiitis of the CNS: A Systematic Review and Meta-analysis. Neurol Neuroimmunol Neuroinflamm 2021; 8:e1093. [PMID: 34663675 PMCID: PMC10578363 DOI: 10.1212/nxi.0000000000001093] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/11/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVES To facilitate and improve the diagnostic and therapeutic process by systematically reviewing studies on patients with primary angiitis of the CNS (PACNS). METHODS We searched PubMed, looking at the period between 1988 and February 2020. Studies with adult patients with PACNS were included. We extracted and pooled proportions using fixed-effects models. Main outcomes were proportions of patients with certain clinical, imaging, and laboratory characteristics and neurologic outcomes. RESULTS We identified 46 cohort studies including a total of 911 patients (41% biopsy confirmed, 43% angiogram confirmed, and 16% without clear assignment to the diagnostic procedure). The most frequent onset symptoms were focal neurologic signs (63%), headache (51%), and cognitive impairment (41%). Biopsy- compared with angiogram-confirmed cases had higher occurrences of cognitive impairment (55% vs 39%) and seizures (36% vs 16%), whereas focal neurologic signs occurred less often (56% vs 95%). CSF abnormalities were present in 75% vs 65% and MRI abnormalities in 97% vs 98% of patients. Digital subtraction angiography was positive in 33% of biopsy confirmed, and biopsy was positive in 8% of angiogram-confirmed cases. In 2 large cohorts, mortality was 23% and 8%, and the relapse rate was 30% and 34%, during a median follow-up of 19 and 57 months, respectively. There are no randomized trials on the treatment of PACNS. The initial treatment usually includes glucocorticoids and cyclophosphamide. DISCUSSION PACNS is associated with disabling symptoms, frequent relapses, and significant mortality. Differences in symptoms and neuroimaging results and low overlap between biopsy and angiogram suggest that biopsy- and angiogram-confirmed cases represent different histopathologic types of PACNS. The optimal treatment is unknown.
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Affiliation(s)
| | | | | | - Antje Schmidt-Pogoda
- From the Department of Neurology with Institute of Translational Neurology (C.B., D.S., A.S.-P., N.W., H.W., J.M.); Institute of Epidemiology and Social Medicine (R.R., H.M.), University of Münster; Department of Neurology (L.M.), University Hospital Essen, University of Duisburg-Essen; and Department of Neurology (T.R., S.M.), Heinrich-Heine-University, Düsseldorf, Germany
| | - Nils Werring
- From the Department of Neurology with Institute of Translational Neurology (C.B., D.S., A.S.-P., N.W., H.W., J.M.); Institute of Epidemiology and Social Medicine (R.R., H.M.), University of Münster; Department of Neurology (L.M.), University Hospital Essen, University of Duisburg-Essen; and Department of Neurology (T.R., S.M.), Heinrich-Heine-University, Düsseldorf, Germany
| | - Lennart Milles
- From the Department of Neurology with Institute of Translational Neurology (C.B., D.S., A.S.-P., N.W., H.W., J.M.); Institute of Epidemiology and Social Medicine (R.R., H.M.), University of Münster; Department of Neurology (L.M.), University Hospital Essen, University of Duisburg-Essen; and Department of Neurology (T.R., S.M.), Heinrich-Heine-University, Düsseldorf, Germany
| | - Tobias Ruck
- From the Department of Neurology with Institute of Translational Neurology (C.B., D.S., A.S.-P., N.W., H.W., J.M.); Institute of Epidemiology and Social Medicine (R.R., H.M.), University of Münster; Department of Neurology (L.M.), University Hospital Essen, University of Duisburg-Essen; and Department of Neurology (T.R., S.M.), Heinrich-Heine-University, Düsseldorf, Germany
| | - Heinz Wiendl
- From the Department of Neurology with Institute of Translational Neurology (C.B., D.S., A.S.-P., N.W., H.W., J.M.); Institute of Epidemiology and Social Medicine (R.R., H.M.), University of Münster; Department of Neurology (L.M.), University Hospital Essen, University of Duisburg-Essen; and Department of Neurology (T.R., S.M.), Heinrich-Heine-University, Düsseldorf, Germany
| | - Sven Meuth
- From the Department of Neurology with Institute of Translational Neurology (C.B., D.S., A.S.-P., N.W., H.W., J.M.); Institute of Epidemiology and Social Medicine (R.R., H.M.), University of Münster; Department of Neurology (L.M.), University Hospital Essen, University of Duisburg-Essen; and Department of Neurology (T.R., S.M.), Heinrich-Heine-University, Düsseldorf, Germany
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Beuker C, Wankner MC, Thomas C, Strecker JK, Schmidt-Pogoda A, Schwindt W, Schulte-Mecklenbeck A, Gross C, Wiendl H, Barth PJ, Eckert B, Meinel TR, Arnold M, Schaumberg J, Krüger S, Deb-Chatterji M, Magnus T, Röther J, Minnerup J. Characterization of Extracranial Giant Cell Arteritis with Intracranial Involvement and its Rapidly Progressive Subtype. Ann Neurol 2021; 90:118-129. [PMID: 33993547 DOI: 10.1002/ana.26101] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study was to characterize patients with extracranial giant cell arteritis with intracranial involvement. METHODS In a multicenter retrospective study, we included 31 patients with systemic giant cell arteritis (GCA) with intracranial involvement. Clinical characteristics, pattern of arterial involvement, and cytokine profiles were assessed. Patients with GCA without intracranial involvement (n = 17), and with intracranial atherosclerosis (n = 25) served as controls. RESULTS Erythrocyte sedimentation rate (ESR) was elevated in 18 patients (69.2%) with and in 16 patients (100%) without intracranial involvement (p = 0.02). Headache was complained by 15 patients (50.0%) with and 13 patients (76.5%) without intracranial involvement (p = 0.03). Posterior circulation arteries were affected in 26 patients (83.9%), anterior circulation arteries in 17 patients (54.8%), and both territories in 12 patients (38.7%). Patients with GCA had vertebral artery stenosis proximal and, in contrast, patients with atherosclerosis distal to the origin of posterior inferior cerebellar artery (PICA). Among patients with GCA with intracranial involvement, 11 patients (37.9%) had a rapid progressive disease course characterized by short-term recurrent ischemic events. The median modified Rankin Scale (mRS) at follow-up in these patients was 4 (interquartile range [IQR] = 2.0-6.0) and 4 patients (36.4%) died. Vessel wall expression of IL-6 and IL-17 was significantly increased in patients with rapid progressive course. INTERPRETATION Typical characteristics of GCA, headache, and an elevated ESR, are frequently absent in patients with intracranial involvement. However, differentiation of intracranial GCA from atherosclerosis can be facilitated by the typical pattern of vertebral artery stenosis. About one-third of patients with intracranial GCA had a rapid progressive course with poor outcome. IL-17 and IL-6 may represent potential future treatment targets. ANN NEUROL 2021;90:118-129.
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Affiliation(s)
- Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | | | - Christian Thomas
- Institute of Neuropathology, University of Münster, Münster, Germany
| | - Jan-Kolja Strecker
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Antje Schmidt-Pogoda
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Wolfram Schwindt
- Department of Clinical Radiology, University Hospital of Münster, Münster, Germany
| | | | - Catharina Gross
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Peter J Barth
- Institute of Pathology, University of Münster, Münster, Germany
| | - Bernd Eckert
- Department of Neuroradiology, Community Hospital Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Thomas Raphael Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jens Schaumberg
- Department of Neurology, Community Hospital Helios Klinikum Uelzen, Uelzen, Germany
| | - Schulamith Krüger
- Department of Neurology, Community Hospital Helios Klinikum Uelzen, Uelzen, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Magnus
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joachim Röther
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
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9
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Gross CC, Schulte-Mecklenbeck A, Madireddy L, Pawlitzki M, Strippel C, Räuber S, Krämer J, Rolfes L, Ruck T, Beuker C, Schmidt-Pogoda A, Lohmann L, Schneider-Hohendorf T, Hahn T, Schwab N, Minnerup J, Melzer N, Klotz L, Meuth SG, Meyer zu Hörste G, Baranzini SE, Wiendl H. Classification of neurological diseases using multi-dimensional cerebrospinal fluid analysis. Brain 2021; 144:2625-2634. [PMID: 33848319 PMCID: PMC8557345 DOI: 10.1093/brain/awab147] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 12/19/2022] Open
Abstract
Although CSF analysis routinely enables the diagnosis of neurological diseases, it is mainly used for the gross distinction between infectious, autoimmune inflammatory, and degenerative disorders of the CNS. To investigate, whether a multi-dimensional cellular blood and CSF characterization can support the diagnosis of clinically similar neurological diseases, we analysed 546 patients with autoimmune neuroinflammatory, degenerative, or vascular conditions in a cross-sectional retrospective study. By combining feature selection with dimensionality reduction and machine learning approaches we identified pan-disease parameters that were altered across all autoimmune neuroinflammatory CNS diseases and differentiated them from other neurological conditions and inter-autoimmunity classifiers that subdifferentiate variants of CNS-directed autoimmunity. Pan-disease as well as diseases-specific changes formed a continuum, reflecting clinical disease evolution. A validation cohort of 231 independent patients confirmed that combining multiple parameters into composite scores can assist the classification of neurological patients. Overall, we showed that the integrated analysis of blood and CSF parameters improves the differential diagnosis of neurological diseases, thereby facilitating early treatment decisions.
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Affiliation(s)
- Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
- Correspondence to: Heinz Wiendl Department of Neurology with Institute of Translational Neurology University and University Hospital Münster; Albert-Schweitzer-Campus 1A1 48149 Münster, Germany E-mail: Correspondence may also be addressed to: Catharina C. Gross E-mail:
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Lohith Madireddy
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Christine Strippel
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Saskia Räuber
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
- Present address: Department of Neurology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Julia Krämer
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Leoni Rolfes
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
- Present address: Department of Neurology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Antje Schmidt-Pogoda
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Lisa Lohmann
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Tilman Schneider-Hohendorf
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Tim Hahn
- Department of Psychiatry, University of Münster, 48149 Münster, Germany
| | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
- Present address: Department of Neurology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Gerd Meyer zu Hörste
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
| | - Sergio E Baranzini
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, 48149 Münster, Germany
- Correspondence to: Heinz Wiendl Department of Neurology with Institute of Translational Neurology University and University Hospital Münster; Albert-Schweitzer-Campus 1A1 48149 Münster, Germany E-mail: Correspondence may also be addressed to: Catharina C. Gross E-mail:
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10
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Beuker C, Strecker JK, Rawal R, Schmidt-Pogoda A, Ruck T, Wiendl H, Klotz L, Schäbitz WR, Sommer CJ, Minnerup H, Meuth SG, Minnerup J. Immune Cell Infiltration into the Brain After Ischemic Stroke in Humans Compared to Mice and Rats: a Systematic Review and Meta-Analysis. Transl Stroke Res 2021; 12:976-990. [PMID: 33496918 PMCID: PMC8557159 DOI: 10.1007/s12975-021-00887-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/14/2022]
Abstract
Although several studies have suggested that anti-inflammatory strategies reduce secondary infarct growth in animal stroke models, clinical studies have not yet demonstrated a clear benefit of immune modulation in patients. Potential reasons include systematic differences of post-ischemic neuroinflammation between humans and rodents. We here performed a systematic review and meta-analysis to summarize and compare the spatial and temporal distribution of immune cell infiltration in human and rodent stroke. Data on spatiotemporal distribution of immune cells (T cells, macrophages, and neutrophils) and infarct volume were extracted. Data from all rodent studies were pooled by means of a random-effect meta-analysis. Overall, 20 human and 188 rodent stroke studies were included in our analyses. In both patients and rodents, the infiltration of macrophages and neutrophils preceded the lymphocytic influx. Macrophages and neutrophils were the predominant immune cells within 72 h after infarction. Although highly heterogeneously across studies, the temporal profile of the poststroke immune response was comparable between patients and rodents. In rodent stroke, the extent of the immune cell infiltration depended on the duration and location of vessel occlusion and on the species. The density of infiltrating immune cells correlated with the infarct volume. In summary, we provide the first systematic analysis and comparison of human and rodent post-ischemic neuroinflammation. Our data suggest that the inflammatory response in rodent stroke models is comparable to that in patients with stroke. However, the overall heterogeneity of the post-ischemic immune response might contribute to the translational failure in stroke research.
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Affiliation(s)
- Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Jan-Kolja Strecker
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Rajesh Rawal
- Institute of Epidemiology and Social Medicine, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Antje Schmidt-Pogoda
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | | | - Clemens J Sommer
- Institute of Neuropathology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Heike Minnerup
- Institute of Epidemiology and Social Medicine, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany.
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11
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Backhaus P, Roll W, Beuker C, Zinnhardt B, Seifert R, Wenning C, Eisenblätter M, Thomas C, Schmidt-Pogoda A, Strunk D, Wagner S, Faust A, Tüttelmann F, Röpke A, Jacobs AH, Stummer W, Wiendl H, Meuth SG, Schäfers M, Grauer O, Minnerup J. Initial experience with [ 18F]DPA-714 TSPO-PET to image inflammation in primary angiitis of the central nervous system. Eur J Nucl Med Mol Imaging 2020; 47:2131-2141. [PMID: 31960097 PMCID: PMC7338821 DOI: 10.1007/s00259-019-04662-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 12/16/2019] [Indexed: 12/16/2022]
Abstract
Purpose Primary angiitis of the central nervous system (PACNS) is a heterogeneous, rare, and poorly understood inflammatory disease. We aimed at non-invasive imaging of activated microglia/macrophages in patients with PACNS by PET-MRI targeting the translocator protein (TSPO) with [18F]DPA-714 to potentially assist differential diagnosis, therapy monitoring, and biopsy planning. Methods In total, nine patients with ischemic stroke and diagnosed or suspected PACNS underwent [18F]DPA-714-PET-MRI. Dynamic PET scanning was performed for 60 min after injection of 233 ± 19 MBq [18F]DPA-714, and MRI was simultaneously acquired. Results In two PACNS patients, [18F]DPA-714 uptake patterns exceeded MRI correlates of infarction, whereas uptake was confined to the infarct in four patients where initial suspicion of PACNS could not be confirmed. About three patients with PACNS or cerebral predominant lymphocytic vasculitis showed no or only faintly increased uptake. Short-term [18F]DPA-714-PET follow-up in a patient with PACNS showed reduced lesional [18F]DPA-714 uptake after anti-inflammatory treatment. Biopsy in the same patient pinpointed the source of tracer uptake to TSPO-expressing immune cells. Conclusions [18F]DPA-714-PET imaging may facilitate the diagnosis and treatment monitoring of PACNS. Further studies are needed to fully understand the potential of TSPO-PET in deciphering the heterogeneity of the disease. Electronic supplementary material The online version of this article (10.1007/s00259-019-04662-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Philipp Backhaus
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany. .,European Institute for Molecular Imaging, University of Münster, Münster, Germany.
| | - Wolfgang Roll
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
| | - Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Bastian Zinnhardt
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany.,European Institute for Molecular Imaging, University of Münster, Münster, Germany
| | - Robert Seifert
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany.,European Institute for Molecular Imaging, University of Münster, Münster, Germany
| | - Christian Wenning
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
| | - Michel Eisenblätter
- Institute of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Antje Schmidt-Pogoda
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Daniel Strunk
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Stefan Wagner
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
| | - Andreas Faust
- European Institute for Molecular Imaging, University of Münster, Münster, Germany
| | - Frank Tüttelmann
- Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Albrecht Röpke
- Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Andreas H Jacobs
- European Institute for Molecular Imaging, University of Münster, Münster, Germany.,Department of Geriatrics, Johanniter Hospital, Evangelische Kliniken, Bonn, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Michael Schäfers
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany.,European Institute for Molecular Imaging, University of Münster, Münster, Germany
| | - Oliver Grauer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
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12
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Schmidt-Pogoda A, Bonberg N, Koecke MHM, Strecker JK, Wellmann J, Bruckmann NM, Beuker C, Schäbitz WR, Meuth SG, Wiendl H, Minnerup H, Minnerup J. Why Most Acute Stroke Studies Are Positive in Animals but Not in Patients: A Systematic Comparison of Preclinical, Early Phase, and Phase 3 Clinical Trials of Neuroprotective Agents. Ann Neurol 2019; 87:40-51. [PMID: 31714631 DOI: 10.1002/ana.25643] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 11/11/2019] [Accepted: 11/11/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To analyze why numerous acute stroke treatments were successful in the laboratory but failed in large clinical trials. METHODS We searched all phase 3 trials of medical treatments for acute ischemic stroke and corresponding early clinical and experimental studies. We compared the overall efficacy and assessed the impact of publication bias and study design on the efficacy. Furthermore, we estimated power and true report probability of experimental studies. RESULTS We identified 50 phase 3 trials with 46,008 subjects, 75 early clinical trials with 12,391 subjects, and 209 experimental studies with >7,141 subjects. Three (6%) phase 3, 24 (32%) early clinical, and 143 (69.08%) experimental studies were positive. The mean treatment effect was 0.76 (95% confidence interval [CI] = 0.70-0.83) in experimental studies, 0.87 (95% CI = 0.71-1.06) in early clinical trials, and 1.00 (95% CI = 0.95-1.06) in phase 3 trials. Funnel plot asymmetry and trim-and-fill revealed a clear publication bias in experimental studies and early clinical trials. Study design and adherence to quality criteria had a considerable impact on estimated effect sizes. The mean power of experimental studies was 17%. Assuming a bias of 30% and pre-study odds of 0.5 to 0.7, this leads to a true report probability of <50%. INTERPRETATION Pivotal study design differences between experimental studies and clinical trials, including different primary end points and time to treatment, publication bias, neglected quality criteria and low power, contribute to the stepwise efficacy decline of stroke treatments from experimental studies to phase 3 clinical trials. Even under conservative estimates, less than half of published positive experimental stroke studies are truly positive. ANN NEUROL 2020;87:40-51.
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Affiliation(s)
- Antje Schmidt-Pogoda
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster
| | - Nadine Bonberg
- Institute of Epidemiology and Social Medicine, University of Münster, Münster
| | | | - Jan-Kolja Strecker
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster
| | - Jürgen Wellmann
- Institute of Epidemiology and Social Medicine, University of Münster, Münster
| | - Nils-Martin Bruckmann
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster
| | - Carolin Beuker
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster
| | | | - Sven G Meuth
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster
| | - Heinz Wiendl
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster
| | - Heike Minnerup
- Institute of Epidemiology and Social Medicine, University of Münster, Münster
| | - Jens Minnerup
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster
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13
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Strunk D, Schmidt-Pogoda A, Beuker C, Milles LS, Korsukewitz C, Meuth SG, Minnerup J. Biomarkers in Vasculitides of the Nervous System. Front Neurol 2019; 10:591. [PMID: 31244756 PMCID: PMC6562258 DOI: 10.3389/fneur.2019.00591] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 05/20/2019] [Indexed: 12/13/2022] Open
Abstract
Besides being affected by the rare and severe primary angiitis of the central nervous system (PACNS) the nervous system is also affected by primary systemic vasculitides (PSV). In contrast to PACNS, PSV affect not only the central but also the peripheral nervous system, resulting in a large array of potential symptoms. Given the high burden of disease, difficulties in distinguishing between differential diagnoses, and incomplete pathophysiological insights, there is an urgent need for additional precise diagnostic tools to enable an earlier diagnosis and initiation of effective treatments. Methods available to date, such as inflammatory markers, antibodies, cerebrospinal fluid (CSF) analysis, imaging, and biopsy, turn out to be insufficient to meet all current challenges. We highlight the use of biomarkers as an approach to extend current knowledge and, ultimately, improve patient management. Biomarkers are considered to be useful for disease diagnosis and monitoring, for predicting response to treatment, and for prognosis in clinical practice, as well as for establishing outcome parameters in clinical trials. In this article, we review the recent literature on biomarkers which have been applied in the context of different types of nervous system vasculitides including PACNS, giant-cell arteritis, Takayasu's arteritis, polyarteritis nodosa, ANCA (anti-neutrophil cytoplasm antibody)-associated vasculitides, cryoglobulinemic vasculitis, IgA vasculitis, and Behçet's disease. Overall, the majority of biomarkers is not specific for vasculitides of the nervous system.
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Affiliation(s)
- Daniel Strunk
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Antje Schmidt-Pogoda
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Carolin Beuker
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Lennart S Milles
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Catharina Korsukewitz
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
| | - Jens Minnerup
- Department of Neurology, Institute for Translational Neurology, University of Münster, Münster, Germany
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14
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Schulte‐Mecklenbeck A, Kleffner I, Beuker C, Wirth T, Hartwig M, Schmidt‐Pogoda A, Klotz L, Hansen W, Wiendl H, Meuth SG, Gross CC, Minnerup J. Immunophenotyping of cerebrospinal fluid cells in ischaemic stroke. Eur J Neurol 2019; 26:919-926. [DOI: 10.1111/ene.13909] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 01/08/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | - I. Kleffner
- Department of Neurology University Hospital Knappschaftskrankenhaus Bochum GmbH Bochum
| | - C. Beuker
- Department of Neurology University of Münster Münster
| | - T. Wirth
- Department of Neurology University of Münster Münster
| | - M. Hartwig
- Department of Neurology University of Münster Münster
| | | | - L. Klotz
- Department of Neurology University of Münster Münster
| | - W. Hansen
- Institute of Medical Microbiology University Hospital Essen University Duisburg‐Essen Essen Germany
| | - H. Wiendl
- Department of Neurology University of Münster Münster
| | - S. G. Meuth
- Department of Neurology University of Münster Münster
| | - C. C. Gross
- Department of Neurology University of Münster Münster
| | - J. Minnerup
- Department of Neurology University of Münster Münster
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15
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Strunk D, Schulte-Mecklenbeck A, Golombeck KS, Meyer zu Hörste G, Melzer N, Beuker C, Schmidt A, Wiendl H, Meuth SG, Gross CC, Minnerup J. Immune cell profiling in the cerebrospinal fluid of patients with primary angiitis of the central nervous system reflects the heterogeneity of the disease. J Neuroimmunol 2018; 321:109-116. [DOI: 10.1016/j.jneuroim.2018.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 06/05/2018] [Accepted: 06/05/2018] [Indexed: 10/14/2022]
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16
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Beuker C, Schmidt A, Strunk D, Sporns PB, Wiendl H, Meuth SG, Minnerup J. Primary angiitis of the central nervous system: diagnosis and treatment. Ther Adv Neurol Disord 2018; 11:1756286418785071. [PMID: 30034536 PMCID: PMC6048610 DOI: 10.1177/1756286418785071] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/02/2018] [Indexed: 12/16/2022] Open
Abstract
Primary angiitis of the central nervous system (PACNS) represents a rare
inflammatory disease affecting the brain and spinal cord. Stroke,
encephalopathy, headache and seizures are major clinical manifestations. The
diagnosis of PACNS is based on the combination of clinical presentation, imaging
findings (magnetic resonance imaging and angiography), brain biopsy, and
laboratory and cerebral spinal fluid (CSF) values. PACNS can either be confirmed
by magnetic resonance angiography (MRA)/conventional angiography or tissue
biopsy showing the presence of typical histopathological patterns.
Identification of PACNS mimics is often challenging in clinical practice, but
crucial to avoid far-reaching treatment decisions. In view of the severity of
the disease, with considerable morbidity and mortality, early recognition and
treatment initiation is necessary. Due to the rareness and heterogeneity of the
disease, there is a lack of randomized data on treatment strategies.
Retrospective studies suggest the combined administration of cyclophosphamide
and glucocorticoids as induction therapy. Immunosuppressants such as
azathioprine, methotrexate or mycophenolate mofetil are often applied for
maintenance therapy. In addition, the beneficial effects of two biological
agents (anti-CD20 monoclonal antibody rituximab and tumour necrosis factor-α
blocker) have been reported. Nevertheless, diagnosis and treatment is still a
clinical challenge, and further insights into the immunopathogenesis of PACNS
are required to improve the diagnosis and management of patients. The present
review provides a comprehensive overview of diagnostics, differential diagnoses,
and therapeutic approaches of adult PACNS.
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Affiliation(s)
- Carolin Beuker
- Department of Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, D-48149, Germany
| | - Antje Schmidt
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Daniel Strunk
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Peter B Sporns
- Department of Clinical Radiology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
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17
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Hoffmann F, Kraft A, Heigl F, Mauch E, Koehler J, Harms L, Kümpfel T, Köhler W, Ehrlich S, Bayas A, Weinmann-Menke J, Beuker C, Henn KH, Ayzenberg I, Ellrichmann G, Hellwig K, Klingel R, Fassbender CM, Fritz H, Slowinski T, Weihprecht H, Brand M, Stiegler T, Galle J, Schimrigk S. Tryptophan immunoadsorption during pregnancy and breastfeeding in patients with acute relapse of multiple sclerosis and neuromyelitis optica. Ther Adv Neurol Disord 2018; 11:1756286418774973. [PMID: 29872456 PMCID: PMC5974561 DOI: 10.1177/1756286418774973] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 03/20/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Up to every fourth woman with multiple sclerosis (MS) or neuromyelitis optica spectrum disorder (NMOSD) suffers a clinically relevant relapse during pregnancy. High doses of steroids bear some serious risks, especially within the first trimester of pregnancy. Immunoadsorption (IA) is an effective and more selective treatment option in disabling MS relapse than plasma exchange. Data on the use of IA during pregnancy and breastfeeding are scarce. METHODS In this retrospective multicenter study, we analyzed the safety and efficacy of IA treatment in acute relapses during pregnancy or breastfeeding. The primary outcome parameter - change of acute relapse-related disability after IA - was assessed using Expanded Disability Status Scale (EDSS) and visual acuity (VA) measurements for patients with optic neuritis (ON). RESULTS A total of 24 patients were analyzed, 23 with relapsing-remitting MS, and 1 with NMOSD. Twenty patients were treated with IA during pregnancy. Four patients received IA postnatally during the breastfeeding period. Treatment was started at a mean 22.5 [standard deviation (SD) 13.9] days after onset of relapse. Patients were treated with a series of 5.8 (mean, SD 0.7) IA treatments within 7-10 days. Sixteen patients received IA because of steroid-refractory relapse, eight were treated without preceding steroid pulse therapy. EDSS improved clinically relevant from 3.5 [median, interquartile range (IQR) 2] before IA to 2.5 (median, IQR 1.1) after IA, p < 0.001. In patients with ON, VA improved in four out of five patients. Altogether, in 83% of patients, a rapid and marked improvement of relapse-related symptoms was observed after IA with either a decrease of ⩾1 EDSS grade or improvement in VA ⩾20%. No clinically relevant side effect was reported in 138 IA treatments. CONCLUSIONS Tryptophan-IA was found to be effective and well tolerated in MS/NMOSD relapses, both as an escalation option after insufficient response to steroid pulse therapy and as first-line relapse treatment during pregnancy and breastfeeding.
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Affiliation(s)
- Frank Hoffmann
- Department of Neurology, Martha-Maria Hospital, Halle/Saale, Academic, Hospital of University, Halle-Wittenberg, Röntgenstraße 1, D-06120 Halle (Saale), Germany
| | - Andrea Kraft
- Department of Neurology Martha-Maria Hospital, Halle/Saale, Academic Hospital of University Halle-Wittenberg, Germany
| | - Franz Heigl
- Medical Care Center Kempten-Allgäu, Kempten, Germany
| | - Erich Mauch
- Clinic for Neurology Dietenbronn, Academic Hospital of University of Ulm, Schwendi, Germany
| | - Jürgen Koehler
- Marianne-Strauss-Hospital, Multiple Sclerosis Center Kempfenhausen, Berg, Germany
| | - Lutz Harms
- Departments of Neurology Charité University Medicine Berlin, Germany
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, University Hospital and Biomedical Center, Ludwig-Maximilians University Munich, Munich, Germany
| | - Wolfgang Köhler
- Clinic for Neurology and Neurological Intensive Care Medicine, Hubertusburg Hospital, Wermsdorf, Germany
| | - Sven Ehrlich
- Clinic for Neurology and Neurological Intensive Care Medicine, Hubertusburg Hospital, Wermsdorf, Germany
| | - Antonios Bayas
- Department of Neurology, General Hospital Augsburg, Germany
| | - Julia Weinmann-Menke
- Department of Nephrology, Medical Center of the Johannes-Gutenberg University, Mainz, Germany
| | | | | | - Ilya Ayzenberg
- Department of Neurology, St. Josef Hospital, Ruhr University, Bochum, Germany
| | - Gisa Ellrichmann
- Department of Neurology, St. Josef Hospital, Ruhr University, Bochum, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University, Bochum, Germany
| | | | | | - Harald Fritz
- Department of Anaesthesiology and Intensive Care Medicine, Martha-Maria Hospital, Halle/Saale, Germany
| | - Torsten Slowinski
- Department of Nephrology, Charité University Medicine, Berlin, Germany
| | | | - Marcus Brand
- Department of Nephrology, University of Münster, Germany
| | - Thomas Stiegler
- Clinic of Internal Medicine III, Sana Clinic, Offenbach, Germany
| | - Jan Galle
- Department of Nephrology, General Hospital Lüdenscheid, Märkische Kliniken GmbH, Germany
| | - Sebastian Schimrigk
- Department of Neurology, General Hospital Lüdenscheid, Märkische Kliniken GmbH, Germany
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Pfeuffer S, Beuker C, Ruck T, Lenze F, Wiendl H, Melzer N, Meuth SG. Acute cholecystitis during treatment with alemtuzumab in 3 patients with RRMS. Neurology 2016; 87:2380-2381. [PMID: 27794114 DOI: 10.1212/wnl.0000000000003379] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 08/18/2016] [Indexed: 11/15/2022] Open
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Diederich K, Schmidt A, Beuker C, Strecker JK, Wagner DC, Boltze J, Schäbitz WR, Minnerup J. Granulocyte colony-stimulating factor (G-CSF) treatment in combination with transplantation of bone marrow cells is not superior to G-CSF treatment alone after cortical stroke in spontaneously hypertensive rats. Front Cell Neurosci 2014; 8:411. [PMID: 25538562 PMCID: PMC4255603 DOI: 10.3389/fncel.2014.00411] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 11/12/2014] [Indexed: 12/02/2022] Open
Abstract
Granulocyte-colony stimulating factor (G-CSF) and bone marrow derived mononuclear cells (BM-MNCs) have both been shown to improve functional outcome following experimental stroke. These effects are associated with increased angiogenesis and neurogenesis. In the present study, we aimed to determine synergistic effects of G-CSF and BM-NMC treatment on long-term structural and functional recovery after photothrombotic stroke. To model the etiology of stroke more closely, we used spontaneously hypertensive (SH) rats in our experiment. Bone marrow derived mononuclear cells transplantation was initiated 1 h after the onset of photothrombotic stroke. Repeated G-CSF treatment commenced immediately after BM-MNC treatment followed by daily injections for five consecutive days. The primary endpoint was functional outcome after ischemia. Secondary endpoints included analysis of neurogenesis and angiogenesis as well as determination of infarct size. Granulocyte-colony stimulating factor treated rats, either in combination with BM-MNC or alone showed improved somatosensory but not gross motor function following ischemia. No beneficial effect of BM-MNC monotherapy was found. Infarct volumes were comparable in all groups. In contrast to previous studies, which used healthy animals, post-stroke neurogenesis and angiogenesis were not enhanced by G-CSF. In conclusion, the combination of G-CSF and BM-MNC was not more effective than G-CSF alone. The reduced efficacy of G-CSF treatment and the absence of any beneficial effect of BM-MNC transplantation might be attributed to hypertension-related morbidity.
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Affiliation(s)
- Kai Diederich
- Department of Neurology, University of Münster Münster, Germany
| | - Antje Schmidt
- Department of Neurology, University of Münster Münster, Germany
| | - Carolin Beuker
- Department of Neurology, University of Münster Münster, Germany
| | | | - Daniel-Christoph Wagner
- Fraunhofer Institute for Cell Therapy and Immunology Leipzig, Germany ; Translational Center for Regenerative Medicine, University of Leipzig Leipzig, Germany
| | - Johannes Boltze
- Fraunhofer Institute for Cell Therapy and Immunology Leipzig, Germany ; Translational Center for Regenerative Medicine, University of Leipzig Leipzig, Germany
| | | | - Jens Minnerup
- Department of Neurology, University of Münster Münster, Germany
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