1
|
Kaufmann JE, Gensicke H, Schaedelin S, Luft AR, Goeggel-Simonetti B, Fischer U, Michel P, Strambo D, Kägi G, Vehoff J, Nedeltchev K, Kahles T, Kellert L, Rosenbaum S, von Rennenberg R, Riegler C, Seiffge D, Sarikaya H, Zietz A, Wischmann J, Polymeris AA, Hänsel M, Globas C, Bonati LH, Brehm A, De Marchis GM, Peters N, Nolte CH, Christensen H, Wegener S, Psychogios MN, Arnold M, Lyrer P, Traenka C, Engelter ST. Toward Individual Treatment in Cervical Artery Dissection: Subgroup Analysis of the TREAT-CAD Randomized Trial. Ann Neurol 2024; 95:886-897. [PMID: 38362818 DOI: 10.1002/ana.26886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/28/2023] [Accepted: 01/23/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE Uncertainty remains regarding antithrombotic treatment in cervical artery dissection. This analysis aimed to explore whether certain patient profiles influence the effects of different types of antithrombotic treatment. METHODS This was a post hoc exploratory analysis based on the per-protocol dataset from TREAT-CAD (NCT02046460), a randomized controlled trial comparing aspirin to anticoagulation in patients with cervical artery dissection. We explored the potential effects of distinct patient profiles on outcomes in participants treated with either aspirin or anticoagulation. Profiles included (1) presenting with ischemia (no/yes), (2) occlusion of the dissected artery (no/yes), (3) early versus delayed treatment start (>median), and (4) intracranial extension of the dissection (no/yes). Outcomes included clinical (stroke, major hemorrhage, death) and magnetic resonance imaging outcomes (new ischemic or hemorrhagic brain lesions) and were assessed for each subgroup in separate logistic models without adjustment for multiple testing. RESULTS All 173 (100%) per-protocol participants were eligible for the analyses. Participants without occlusion had decreased odds of events when treated with anticoagulation (odds ratio [OR] = 0.28, 95% confidence interval [CI] = 0.07-0.86). This effect was more pronounced in participants presenting with cerebral ischemia (n = 118; OR = 0.16, 95% CI = 0.04-0.55). In the latter, those with early treatment (OR = 0.26, 95% CI = 0.07-0.85) or without intracranial extension of the dissection (OR = 0.34, 95% CI = 0.11-0.97) had decreased odds of events when treated with anticoagulation. INTERPRETATION Anticoagulation might be preferable in patients with cervical artery dissection presenting with ischemia and no occlusion or no intracranial extension of the dissection. These findings need confirmation. ANN NEUROL 2024;95:886-897.
Collapse
Affiliation(s)
- Josefin E Kaufmann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Sabine Schaedelin
- Department of Clinical Research, Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas R Luft
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
- Center for Neurology and Rehabilitation, Cereneo, Vitznau, Switzerland
| | - Barbara Goeggel-Simonetti
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
- Department of Neuropediatrics, Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital, Bellinzona, Switzerland
| | - Urs Fischer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Georg Kägi
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
- Department of Neurology and Stroke Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Jochen Vehoff
- Department of Neurology and Stroke Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology and Stroke Center, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Timo Kahles
- Department of Neurology and Stroke Center, Cantonal Hospital Aarau, Aarau, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Sverre Rosenbaum
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Regina von Rennenberg
- Department of Neurology with Experimental Neurology, Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Riegler
- Department of Neurology with Experimental Neurology, Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - David Seiffge
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Hakan Sarikaya
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | | | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Martin Hänsel
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Christoph Globas
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Alex Brehm
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Christian H Nolte
- Department of Neurology with Experimental Neurology, Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Healths at Charité, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Susanne Wegener
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| |
Collapse
|
2
|
von Falkenhausen AS, Wischmann J, Keidel LM, Kellnar AM, Thaler R, Lackermair K, Estner HL, Höglinger G, Massberg S, Kääb S, Kellert L, Sinner MF. Clinical practice of continuous rhythm monitoring after embolic stroke of undetermined source. PLoS One 2024; 19:e0302404. [PMID: 38630693 PMCID: PMC11023399 DOI: 10.1371/journal.pone.0302404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 04/01/2024] [Indexed: 04/19/2024] Open
Abstract
AIMS Embolic stroke of undetermined source (ESUS) accounts for up to 20% of ischemic strokes annually. Undetected atrial fibrillation (AF) is one important potential underlying cause. For AF, oral anticoagulation has evolved as the most preferable means of secondary stroke prevention. To detect unrecognized paroxysmal AF, long-term ECG monitoring is required, and implantable cardiac monitors (ICM) appear most suitable. Yet, ICMs are particularly costly, implantation is invasive, and remote monitoring places a personnel burden on health care providers. Here, we use data from a large cohort of ESUS patients to systematically analyze the effort of ICM remote monitoring for AF diagnosis and the strain on health care providers. METHODS AND RESULTS From a prospective, single-center, observational ESUS registry, we analyzed all ICM-equipped patients post-ESUS (n = 172) between January 1st, 2018, and December 31st, 2019. Through January 2nd, 2023, 48 patients (27.9%) were diagnosed with AF by ICM remote monitoring. During follow-up, a total of 29,180 remote monitoring episodes were transmitted, of which 17,742 were alarms for AF. A systematic estimation of workload revealed that on average, 20.3 trained physician workhours are required to diagnose one patient with AF. CONCLUSION ICM remote monitoring is useful to diagnose AF in cohort of post-ESUS patients. However, the number of ICM alarms is high, even in a cohort at known high risk of AF and in whom AF detection is therapeutically consequential. Improved automated event classification, clear recommendations for ICM interrogation after AF diagnosis, and a careful patient selection for ICM monitoring are warranted.
Collapse
Affiliation(s)
- Aenne Solvejg von Falkenhausen
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Linus M. Keidel
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Antonia M. Kellnar
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
| | - Raffael Thaler
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Heidi L. Estner
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
| | - Günter Höglinger
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | - Stefan Kääb
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Moritz F. Sinner
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| |
Collapse
|
3
|
Masouris I, Wischmann J, Schniepp R, Müller R, Fuhry L, Hamann GF, Trumm C, Liebig T, Kellert L, Schöberl F. Basilar artery occlusion: drip-and-ship versus direct-to-center for mechanical thrombectomy within the Neurovascular Network of Southwest Bavaria (NEVAS). J Neurol 2024; 271:1885-1892. [PMID: 38095722 DOI: 10.1007/s00415-023-12126-x] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Recent clinical trials revealed a substantial clinical benefit for mechanical thrombectomy (MT) in patients with basilar artery occlusion (BAO). While urban areas are sufficiently covered with comprehensive stroke centers and MT expertise, rural areas lack such resources. Structured telemedical stroke networks offer rural hospitals instant consultation by stroke experts, enabling swift administration of intravenous thrombolysis (IVT) on-site and transportation for MT. For BAO patients, data on performance and clinical outcomes in telemedical stroke networks are lacking. METHODS We retrospectively analyzed data from patients with acute BAO eligible for MT: those treated directly in our comprehensive stroke center (direct-to-center/DC) and those treated in rural hospitals that were telemedically consulted by the Neurovascular Network of Southwest Bavaria (NEVAS) and transferred to our center for MT (drip-and-ship, DS). Key time intervals, stroke management performance and functional outcome after 90 days were compared. RESULTS Baseline characteristics, including premorbid status and stroke severity, were comparable. Time from symptom onset to IVT was identical in both groups (118 min). There was a delay of 180 min until recanalization in DS patients, mainly due to patient transport for MT. Procedural treatment time intervals, success of recanalization and complications were comparable. Clinical outcome at 3 months follow-up of DS patients was not inferior to DC patients. CONCLUSION We show for the first time that patients with BAO in rural areas benefit from a structured telemedicine network such as NEVAS, regarding both on-site processing and drip-and-ship for MT. Clinical outcomes are comparable among DS and DC patients.
Collapse
Affiliation(s)
- Ilias Masouris
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany.
| | - J Wischmann
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - R Schniepp
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - R Müller
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | - L Fuhry
- Department of Neurology, Klinikum Ingolstadt, Ingolstadt, Germany
| | - G F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | - C Trumm
- Institute of Neuroradiology, LMU University Hospital, LMU, Munich, Germany
| | - T Liebig
- Institute of Neuroradiology, LMU University Hospital, LMU, Munich, Germany
| | - L Kellert
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - F Schöberl
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| |
Collapse
|
4
|
Masouris I, Kellert L, Pradhan C, Wischmann J, Schniepp R, Müller R, Fuhry L, Hamann GF, Pfefferkorn T, Rémi JM, Schöberl F. Telemedical stroke care significantly improves patient outcome in rural areas: Long-term analysis of the German NEVAS network. Int J Stroke 2024:17474930241234259. [PMID: 38346936 DOI: 10.1177/17474930241234259] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Comprehensive stroke centers (CSC) offer state-of-the-art stroke care in metropolitan centers. However, in rural areas, sufficient stroke expertise is much scarcer. Recently, telemedical stroke networks have offered instant consultation by stroke experts, enabling immediate administration of intravenous thrombolysis (IVT) on-site and decision on thrombectomy. While these immediate decisions are made during the consult, the impact of the network structures on stroke care in spoke hospitals is still not well described. AIMS This study was performed to determine if on-site performance in rural hospitals and patient outcome improve over time through participation and regular medical staff training within a telemedical stroke network. METHODS In this retrospective study, we analyzed data from stroke patients treated in four regional hospitals within the telemedical Neurovascular Network of Southwest Bavaria (NEVAS) between 2014 and 2019. We only included those patients that were treated in the regional hospitals until discharge at home or to neurorehabilitation. Functional outcome (modified Rankin scale) at discharge, mortality rate and periprocedural intracranial hemorrhage served as primary outcome parameters. Door-to-imaging and door-to-needle times were secondary outcome parameters. RESULTS In 2014-2019, 5,379 patients were treated for acute stroke with 477 receiving IVT. Most baseline characteristics were comparable over time. For all stroke patients, door-to-imaging times increased over the years, but significantly improved for potential IVT candidates and those finally treated with IVT. The percentage of patients with door-to-needle time <30 min increased from 10% to 25%. Clinical outcome at discharge improved for all stroke patients treated in the regional hospitals. Particularly for patients treated with IVT, good clinical outcome (modified Rankin scale 0-2) at discharge increased from 2014 to 2019 by 19% and mortality rates dropped from 13% to 5%. CONCLUSIONS 24-h/7-day telemedical support and regular on-site medical staff training within a structured telemedicine stroke network such as NEVAS significantly improve on-site stroke care in rural areas, leading to a considerable benefit in clinical outcome. DATA ACCESS STATEMENT The data that support the findings of this study are available upon reasonable request and in compliance with the local and international ethical guidelines.
Collapse
Affiliation(s)
- Ilias Masouris
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Cauchy Pradhan
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Roman Schniepp
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Robert Müller
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | - Leonard Fuhry
- Department of Neurology, Klinikum Ingolstadt, Ingolstadt, Germany
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | | | - Jan M Rémi
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Florian Schöberl
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
5
|
Wischmann J, Kremer P, Hinske L, Tomasi R, Becker-Pennrich AS, Kellert L. The RAPID-score: Risk Assessment and PredIction of Delirium in acute stroke patients based on very early clinical parameters. Front Neurol 2023; 14:1306520. [PMID: 38162448 PMCID: PMC10756062 DOI: 10.3389/fneur.2023.1306520] [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: 10/03/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024] Open
Abstract
Background and objective Post-stroke delirium (PSD) is a common complication in acute stroke patients, and guidelines recommend routine screening and various preventive and treatment measures. However, there is a substantial lack of standardized approaches in diagnostic and therapeutic management of PSD. Here, we aimed to develop a new pragmatic and easily assessable screening tool to predict PSD based on early parameters, which are already integral to acute stroke diagnostics. Methods We enrolled acute stroke patients admitted to our stroke unit or intensive care unit and developed the scoring system using retrospective single-center patient data. The Confusion Assessment Method for the Intensive Care Unit was used for prospective score validation. Logistic regression models were employed to analyze the association of early clinical and paraclinical parameters with PSD development. Results N = 525 patients (median age: 76 years; 45.7% female) were enrolled, with 29.7% developing PSD during hospitalization. The resulting score comprises 6 items, including medical history, clinical examination findings, and non-contrast computed tomography results at admission. Scores range from -15 to +15 points, with higher values indicating a higher likelihood of PSD, ranging from 4% to 79%. The accuracy was 0.85, and the area under the curve was 0.89. Conclusion The new RAPID (Risk Assessment and PredIction of Delirium in acute stroke patients)-score shows high accuracy in predicting PSD among acute stroke patients and offers precise odds of PSD for each corresponding score value, utilizing routine early clinical and paraclinical parameters. It can identify high-risk populations for clinical study interventions and may be suitable to guide prophylactic PSD measures.
Collapse
Affiliation(s)
- Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Pauline Kremer
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Ludwig Hinske
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
- Institute for Digital Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Roland Tomasi
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Andrea S. Becker-Pennrich
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
- Faculty of Medicine, Pettenkofer School of Public Health, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
6
|
Schmidbauer M, Wischmann J, Dimitriadis K, Kellert L. [Secondary prophylaxis of ischemic stroke]. Inn Med (Heidelb) 2023; 64:1171-1183. [PMID: 37947810 DOI: 10.1007/s00108-023-01615-w] [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] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/12/2023]
Abstract
The secondary prophylaxis of ischemic stroke provides an enormous therapeutic potential due to the high frequency of recurrent thrombembolic events and the exceptional importance of modifiable cardiovascular risk factors for the individual risk of stroke. In this respect, anti-thrombotic, interventional and surgical treatment options must be selected based on the respective etiology. Furthermore, meticulous optimization of risk factors is essential for effective long-term care. Close interdisciplinary and intersectoral collaboration is crucial, especially in the long-term treatment.
Collapse
Affiliation(s)
- Moritz Schmidbauer
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
| | | | | | | |
Collapse
|
7
|
Burbano VG, Wölfer TA, Vlegels N, Quandt F, Zimmermann H, Wischmann J, Kellert L, Liebig T, Dimitriadis K, Saver JL, Tiedt S. Association of the time of day of EVT with clinical outcomes and benefit from successful recanalization after stroke. Ann Clin Transl Neurol 2023; 10:1917-1923. [PMID: 37607113 PMCID: PMC10578882 DOI: 10.1002/acn3.51877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/04/2023] [Indexed: 08/24/2023] Open
Abstract
Experimental and neuroimaging studies suggest an influence of the time of day on acute infarct growth, but whether this could inform patient selection for acute treatments is uncertain. In a multicenter cohort of 9357 stroke patients undergoing endovascular treatment, morning treatment (05:00-10:59) was associated with lowest 90-day mRS scores (adjusted odds ratio, 1.27 [95% CI, 1.08-1.47]; p = 0.004). The association between successful recanalization and outcome was stronger in morning compared to evening-treated patients (pia = 0.046) with treatment benefit persisting until 24 h for morning-treated compared to 11.5 h for evening-treated patients suggesting that the time of day might inform patient selection for EVT.
Collapse
Affiliation(s)
- Vanessa Granja Burbano
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA)MunichGermany
| | - Teresa A. Wölfer
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA)MunichGermany
| | - Naomi Vlegels
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
| | - Fanny Quandt
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Hanna Zimmermann
- Institute of NeuroradiologyLMU University Hospital, LMU MunichMunichGermany
| | | | - Lars Kellert
- Department of NeurologyLMU University Hospital, LMU MunichMunichGermany
| | - Thomas Liebig
- Institute of NeuroradiologyLMU University Hospital, LMU MunichMunichGermany
| | - Konstantinos Dimitriadis
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
- Department of NeurologyLMU University Hospital, LMU MunichMunichGermany
| | - Jeffrey L. Saver
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA)MunichGermany
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA)MunichGermany
| | | |
Collapse
|
8
|
Wischmann J, Pradhan C, Zimmermann H, Keidel L, Tiedt S, Dimitriadis K, Liebig T, Höglinger G, Kellert L. Impact of ongoing intravenous thrombolysis until completion of endovascular treatment in large vessel occlusion stroke patients. Front Neurol 2023; 14:1231530. [PMID: 37602252 PMCID: PMC10437055 DOI: 10.3389/fneur.2023.1231530] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Background Recent studies have implied that ongoing intravenous thrombolysis (IVT) during endovascular treatment (ET) improves functional outcomes in patients who have undergone stroke caused by a large vessel occlusion (LVO). In this study, we investigated the effect of ongoing IVT until completion of ET on procedure duration, first-pass thrombectomy rate, and periprocedural complications. Methods We analyzed patients from the German Stroke Registry-Endovascular Treatment dataset, collected between June 2015 and December 2021. Primary outcomes were modified Rankin Scale (mRS) score after 3 months and achievement of a Thrombolysis In Cerebral Infarction (TICI) score of 2b-3. Secondary parameters included ET duration, first-pass thrombectomy, and periprocedural complications. Results Of the 13,082 patients in the dataset, 1,639 met the study inclusion criteria. A total of n = 317 patients (19.3%) underwent ongoing IVT until completion of ET, while IVT was completed prior to ET in 1,322 patients (80.7%). Ongoing IVT was associated with higher rates of achievement of an mRS score of 0-2 (or a back-to-baseline) after 3 months [odds ratio (OR) 1.53; 95% confidence interval (CI) 1.08-2.17]. Furthermore, ongoing IVT was predictive of achievement of a TICI score of 2b-3 (OR 1.37; 95% CI 1.03-1.83) and of first-pass thrombectomy (OR 2.07; 95% CI 1.51-2.84), while reducing the rate of peri-interventional complications (OR 0.64; 95% CI 0.44-0.94) and reducing ET duration by 24 min [β = -24.35; 95% CI -32.92-(-15.79)]. Conclusion Our findings suggest that ongoing IVT until ET completion has a favorable impact on both clinical and angiographic outcomes, as well as on periprocedural conditions, regardless of the overall time intervals involved. Therefore, rapid ET after IVT should be sought in order to take advantage of the additive effect of ongoing IVT during ET. Future studies should consider IVT timing in the context of ET as a potential confounder and treatment target.
Collapse
Affiliation(s)
- Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Cauchy Pradhan
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany
| | - Hanna Zimmermann
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Linus Keidel
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Steffen Tiedt
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Munich, Germany
| | - Konstantinos Dimitriadis
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Munich, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Günter Höglinger
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
9
|
Wischmann J, Masouris I, Keidel L, Tiedt S, Trumm CG, Zimmermann H, Liebig T, Höglinger G, Kellert L. Periprocedural unfractionated heparin bolus during endovascular treatment in acute ischemic stroke does more harm than good. J Neurointerv Surg 2023:jnis-2023-020551. [PMID: 37665652 DOI: 10.1136/jnis-2023-020551] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/07/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Unfractionated heparin (UFH) bolus is occasionally administered during endovascular treatment (EVT) to reduce thrombotic complications in acute ischemic stroke patients. However, the MR CLEAN-MED trial showed an increase in symptomatic intracranial hemorrhages (sICH) and a non-significant shift towards worse functional outcome with UFH administration. We aimed to analyze the impact of periprocedural UFH bolus in a real-world setting in anterior (ACS) and posterior circulation stroke (PCS) patients. METHODS We analyzed data from the German Stroke Registry-Endovascular Treatment using propensity score matching. Primary outcome was the modified Rankin Scale at 3 months, and secondary outcome measures included mortality, angiographic outcomes, post-EVT National Institute of Health Stroke Scale scores and ICH at 24 hours. RESULTS Among 13,082 patients, 7948 with ACS (UFH bolus use in 15%) and 841 with PCS (UFH bolus use in 16.3%) were included in the propensity score matching analysis. Applying MR CLEAN-MED study criteria, UFH bolus was associated with worse functional outcomes (odds ratio [OR] 1.44; 95% CI 1.06-1.96). Analyzing all ACS and PCS patients, UFH bolus did not provide any net benefit. In ACS patients treated with intravenous thrombolysis (IVT), UFH bolus use was associated with worse functional outcomes (OR 2.40; 95% CI 1.34 to 5.06). CONCLUSION Our findings show transferability of the MR CLEAN-MED results into a real-world setting, confirming a negative effect of periprocedural UFH on functional outcome in this subgroup of patients. Considering all ACS and PCS patients, periprocedural UFH did not provide a net benefit and appears to be harmful, particularly in IVT-treated patients.
Collapse
Affiliation(s)
- Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Ilias Masouris
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Linus Keidel
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Steffen Tiedt
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Munich, Germany
| | - Christoph G Trumm
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Hanna Zimmermann
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Günter Höglinger
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
10
|
Wischmann J, Borowski K, Havla J, Thaler FS, Winkler T, Jung T, Straube A, Masouris I. Case report: Anti septin-5-encephalitis as a treatable cause of cerebellar ataxia and psychiatric symptoms. Front Neurol 2023; 14:1220295. [PMID: 37435157 PMCID: PMC10331165 DOI: 10.3389/fneur.2023.1220295] [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: 05/10/2023] [Accepted: 06/08/2023] [Indexed: 07/13/2023] Open
Abstract
Objectives Anti-septin-5 encephalitis is a rare disease with only few published cases, mainly based on retrospective CSF and serum analyses. Predominant symptoms are cerebellar ataxia and oculomotor abnormalities. Due to the rareness of the disease, treatment recommendations are scarce. Herein, we prospectively describe the clinical course of a female patient with anti-septin-5 encephalitis. Methods We describe diagnostic workup, treatment and follow-up of a 54-year-old patient presenting with vertigo, unsteady gait, lack of drive and behavioral changes. Results Clinical examination revealed severe cerebellar ataxia, saccadic smooth pursuit, upbeat-nystagmus, and dysarthria. Additionally, the patient presented with a depressive syndrome. MRI of the brain and spinal cord were normal. CSF analysis showed lymphocytic pleocytosis (11 cells/μl). Extensive antibody testing revealed anti septin-5 IgG in both CSF and serum without coexisting anti-neuronal antibodies. PET/CT detected no signs of malignancy. Corticosteroids, plasma exchange, and rituximab led to transient clinical improvement followed by relapse. Re-applied treatment with plasma exchange followed by bortezomib resulted in moderate but sustained clinical improvement. Discussion Anti septin-5 encephalitis represents a rare but treatable and therefore relevant differential diagnosis in patients with cerebellar ataxia. Psychiatric symptoms can be observed in anti septin-5 encephalitis. Immunosuppressive treatment including bortezomib is moderately effective.
Collapse
Affiliation(s)
- Johannes Wischmann
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Kathrin Borowski
- Clinical Immunological Laboratory Prof. Dr. med. Winfried Stöcker, Luebeck, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, University Hospital, Ludwig-Maximilians-Universität Munich, Munich, Germany
- Biomedical Center, Medical Faculty, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Franziska S. Thaler
- Institute of Clinical Neuroimmunology, University Hospital, Ludwig-Maximilians-Universität Munich, Munich, Germany
- Biomedical Center, Medical Faculty, Ludwig-Maximilians-Universität Munich, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Tobias Winkler
- Department of Neurology, kbo-Inn-Salzach-Klinikum, Wasserburg am Inn, Germany
| | - Tobias Jung
- Department of Neurology, kbo-Inn-Salzach-Klinikum, Wasserburg am Inn, Germany
| | - Andreas Straube
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Ilias Masouris
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| |
Collapse
|
11
|
Wischmann J, Bartos LM, Brendel M, Albert NL, Forbrig R, Straube A, Masouris I. Translocator protein (TSPO)-PET as diagnostic and monitoring tool in COVID-19 related MRI-negative brainstem encephalitis: a case report. J Neurol 2023; 270:2853-2856. [PMID: 37012466 PMCID: PMC10069725 DOI: 10.1007/s00415-023-11691-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/23/2023] [Accepted: 03/25/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Encephalitis and myelitis have been linked to both COVID-19 vaccination and infection, causing symptoms such as reduced consciousness, mental state alterations and seizures. Remarkably, most cases do not show significant structural alterations on MRI scans, which poses a diagnostic challenge. METHODS We present the diagnostic workup and clinical course of a patient who developed a progressive brainstem syndrome two weeks after COVID-19 vaccination and subsequent infection. We used translocator protein (TSPO)-PET scans for the first time to investigate COVID-related neuroinflammation. RESULTS The patient developed oculomotor disorder, dysarthria, paresthesia in all distal limbs and spastic-atactic gait. CSF analysis revealed mild lymphocytic pleocytosis with normal protein levels. Brain and spinal cord MRI scans were negative, but TSPO/PET scans showed increased microglia activity in the brainstem, which correlated with the clinical course. Steroid treatment led to clinical improvement, but relapse occurred during prednisone taper after four weeks. Plasmapheresis had no significant effect; however, complete remission was achieved with cyclophosphamide and methotrexate, with normal TSPO signal ten months after onset. CONCLUSIONS TSPO-PET can be a valuable tool in the diagnostic and therapeutic monitoring of COVID-19-related encephalitis, particularly in cases where MRI scans are negative. Aggressive immunosuppressive therapy can lead to sustained remission.
Collapse
Affiliation(s)
- Johannes Wischmann
- Department of Neurology, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany.
| | - Laura M Bartos
- Department of Nuclear Medicine, University, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Matthias Brendel
- Department of Nuclear Medicine, University, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Nathalie L Albert
- Department of Nuclear Medicine, University, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Robert Forbrig
- Institute of Neuroradiology, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Andreas Straube
- Department of Neurology, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Ilias Masouris
- Department of Neurology, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
| |
Collapse
|
12
|
Meinel TR, Wilson D, Gensicke H, Scheitz JF, Ringleb P, Goganau I, Kaesmacher J, Bae HJ, Kim DY, Kermer P, Suzuki K, Kimura K, Macha K, Koga M, Wada S, Altersberger V, Salerno A, Palanikumar L, Zini A, Forlivesi S, Kellert L, Wischmann J, Kristoffersen ES, Beharry J, Barber PA, Hong JB, Cereda C, Schlemm E, Yakushiji Y, Poli S, Leker R, Romoli M, Zedde M, Curtze S, Ikenberg B, Uphaus T, Giannandrea D, Portela PC, Veltkamp R, Ranta A, Arnold M, Fischer U, Cha JK, Wu TY, Purrucker JC, Seiffge DJ. Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants. JAMA Neurol 2023; 80:233-243. [PMID: 36807495 PMCID: PMC9857462 DOI: 10.1001/jamaneurol.2022.4782] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/21/2022] [Indexed: 02/07/2023]
Abstract
Importance International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC). Objective To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion. Design, Setting, and Participants This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021. Exposures Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation. Main Outcomes and Measures The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses. Results Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion. Conclusions and Relevance In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.
Collapse
Affiliation(s)
- Thomas R. Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Henrik Gensicke
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Jan F. Scheitz
- Department of Neurology, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research Partner Site Berlin, Germany
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ioana Goganau
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Do Yeon Kim
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Pawel Kermer
- Department of Neurology, Friesland Kliniken, Sande, Germany
- Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kosmas Macha
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Wada
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Valerian Altersberger
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Andrea Zini
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Stefano Forlivesi
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Espen S. Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, Institute of Health and Society (HELSAM), University of Oslo, Oslo, Norway
| | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - P. Alan Barber
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Jae Beom Hong
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Carlo Cereda
- Stroke Center and Department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Yusuke Yakushiji
- Department of Neurology Kansai Medical University, Hirakata, Japan
| | - Sven Poli
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ronen Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Benno Ikenberg
- Department of Neurology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - David Giannandrea
- Division of Neurology and Stroke Unit, Department of Neurology, Gubbio and Città di Castello Hospital, Perugia, Italy
| | - Pere Cardona Portela
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Klinik für Neurologie, Alfried Krupp Krankenhaus, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Capital and Coast District Health Board, Wellington, New Zealand
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J. Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | |
Collapse
|
13
|
von Falkenhausen AS, Feil K, Sinner MF, Schönecker S, Müller J, Wischmann J, Eiffener E, Clauss S, Poli S, Poli K, Zuern CS, Ziemann U, Berrouschot J, Kitsiou A, Schäbitz WR, Dieterich M, Massberg S, Kääb S, Kellert L. Atrial Fibrillation Risk Assessment after Embolic Stroke of Undetermined Source. Ann Neurol 2023; 93:479-488. [PMID: 36373166 DOI: 10.1002/ana.26545] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Approximately 20% of strokes are embolic strokes of undetermined source (ESUS). Undetected atrial fibrillation (AF) remains an important cause. Yet, oral anticoagulation in unselected ESUS patients failed in secondary stroke prevention. Guidance on effective AF detection is lacking. Here, we introduce a novel, non-invasive AF risk assessment after ESUS. METHODS Catch-Up ESUS is an investigator-initiated, observational cohort study conducted between 2018 and 2019 at the Munich University Hospital. Besides clinical characteristics, patients received ≥72 h digital electrocardiogram recordings to generate the rhythm irregularity burden. Uni- and multivariable regression models predicted the primary endpoint of incident AF, ascertained by standardized follow-up including implantable cardiac monitors. Predictors included the novel rhythm irregularity burden constructed from digital electrocardiogram recordings. We independently validated our model in ESUS patients from the University Hospital Tübingen, Germany. RESULTS A total of 297 ESUS patients were followed for 15.6 ± 7.6 months. Incident AF (46 patients, 15.4%) occurred after a median of 105 days (25th to 75th percentile 31-33 days). Secondary outcomes were recurrent stroke in 7.7% and death in 6.1%. Multivariable-adjusted analyses identified the rhythm irregularity burden as the strongest AF-predictor (hazard ratio 3.12, 95% confidence interval 1.62-5.80, p < 0001) while accounting for the known risk factors age, CHA2 DS2 -VASc-Score, and NT-proBNP. Independent validation confirmed the rhythm irregularity burden as the most significant AF-predictor (hazard ratio 2.20, 95% confidence interval 1.45-3.33, p < 0001). INTERPRETATION The novel, non-invasive, electrocardiogram-based rhythm irregularity burden may help adjudicating AF risk after ESUS, and subsequently guide AF-detection after ESUS. Clinical trials need to clarify if high-AF risk patients benefit from tailored secondary stroke prevention. ANN NEUROL 2023;93:479-488.
Collapse
Affiliation(s)
- Aenne S von Falkenhausen
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Katharina Feil
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany
| | - Moritz F Sinner
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Sonja Schönecker
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Johanna Müller
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Elodie Eiffener
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Sebastian Clauss
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Center of Experimental Medicine, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Christine S Zuern
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Department of Cardiology, Eberhard-Karls University, Tübingen, Germany.,Cardiology Division, Department of Medicine, University Hospital, and Cardiovascular Research Institute, Basel, Switzerland
| | - Ulf Ziemann
- Department of Neurology and Stroke, University Hospital, Eberhard-Karls University Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Jörg Berrouschot
- Department of Neurology, Klinikum Altenburger Land, Altenburg, Germany
| | - Alkisti Kitsiou
- Department of Neurology, University Hospital, Evangelisches Klinikum Bethel, University of Bielefeld, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Department of Neurology, University Hospital, Evangelisches Klinikum Bethel, University of Bielefeld, Bielefeld, Germany
| | - Marianne Dieterich
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilians University of Munich, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Steffen Massberg
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Stefan Kääb
- Department of Cardiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| |
Collapse
|
14
|
Feil K, Berndt MT, Wunderlich S, Maegerlein C, Bernkopf K, Zimmermann H, Herzberg M, Tiedt S, Küpper C, Wischmann J, Schönecker S, Dimitriadis K, Liebig T, Dieterich M, Zimmer C, Kellert L, Boeckh-Behrens T, Boeckh-Behrens T, Wunderlich S, Ludolph A, Henn KH, Reich A, Nikoubashman O, Wiesmann M, Ernemann U, Poli S, Nolte CH, Siebert E, Zweynert S, Bohner G, Solymosi L, Petzold G, Pfeilschifter W, Keil F, Röther J, Eckert B, Berrouschot J, Bormann A, Alegiani A, Fiehler J, Gerloff C, Thomalla G, Thonke S, Bangard C, Kraemer C, Dichgans M, Psychogios M, Liman J, Petersen M, Stögbauer F, Kraft P, Pham M, Braun M, Hamann GF, Roth C, Gröschel K, Uphaus T, Limmroth V. Endovascular thrombectomy for basilar artery occlusion stroke: Analysis of the German Stroke Registry-Endovascular Treatment. Eur J Neurol 2023; 30:1293-1302. [PMID: 36692229 DOI: 10.1111/ene.15694] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Acute ischemic stroke due to basilar artery occlusion (BAO) causes the most severe strokes and has a poor prognosis. Data regarding efficacy of endovascular thrombectomy in BAO are sparse. Therefore, in this study, we performed an analysis of the therapy of patients with BAO in routine clinical practice. METHODS Patients enrolled between June 2015 and December 2019 in the German Stroke Registry-Endovascular Treatment (GSR-ET) were analyzed. Primary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3), substantial neurological improvement (≥8-point National Institute of Health Stroke Scale [NIHSS] score reduction from admission to discharge or NIHSS score at discharge ≤1), and good functional outcome at 3 months (modified Rankin Scale [mRS] score of 0-2). RESULTS Out of 6635 GSR-ET patients, 640 (9.6%) patients (age 72.2 ± 13.3, 43.3% female) experienced BAO (median [interquartile range] NIHSS score 17 [8, 27]). Successful reperfusion was achieved in 88.4%. Substantial neurological improvement at discharge was reached by 45.5%. At 3-month follow-up, good clinical outcome was observed in 31.1% of patients and the mortality rate was 39.2%. Analysis of mTICI3 versus mTICI2b groups showed considerable better outcome in those with mTICI3 (38.9% vs. 24.4%; p = 0.005). The strongest predictors of good functional outcome were intravenous thrombolysis (IVT) treatment (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.76-5.23) and successful reperfusion (OR 4.92, 95% CI 1.15-21.11), while the effect of time between symptom onset and reperfusion seemed to be small. CONCLUSIONS Acute reperfusion strategies in BAO are common in daily practice and can achieve good rates of successful reperfusion, neurological improvement and good functional outcome. Our data suggest that, in addition to IVT treatment, successful and, in particular, complete reperfusion (mTICI3) strongly predicts good outcome, while time from symptom onset seemed to have a lower impact.
Collapse
Affiliation(s)
- Katharina Feil
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany.,Department of Neurology and Stroke, Eberhard-Karls University Tübingen/Universitätsklinikum Tübingen (UKT), Tübingen, Germany
| | - Maria Teresa Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen Bernkopf
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | | | - Moriz Herzberg
- Institute of Neuroradiology, LMU, Munich, Germany.,Department of Radiology, University Hospital, Würzburg, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Clemens Küpper
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany
| | - Sonja Schönecker
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany
| | - Konstantin Dimitriadis
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | | | - Marianne Dieterich
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.,German Center for Vertigo and Balance Disorders, LMU, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Feil K, Matusevicius M, Herzberg M, Tiedt S, Küpper C, Wischmann J, Schönecker S, Mengel A, Sartor‐Pfeiffer J, Berger K, Dimitriadis K, Liebig T, Dieterich M, Mazya M, Ahmed N, Kellert L. Minor stroke in large vessel occlusion: A matched analysis of patients from the German Stroke Registry-Endovascular Treatment (GSR-ET) and patients from the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Eur J Neurol 2022; 29:1619-1629. [PMID: 35122371 PMCID: PMC9306813 DOI: 10.1111/ene.15272] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 12/16/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Reperfusion treatment in patients presenting with large vessel occlusion (LVO) and minor neurological deficits is still a matter of debate. We aimed to compare minor stroke patients treated with endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) or IVT alone. METHODS Patients enrolled in the German Stroke Registry-Endovascular Treatment (GSR-ET) and the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR) between June 2015 and December 2019 were analyzed. Minor stroke was defined as National Institutes of Health Stroke Scale (NIHSS) score ≤5, and LVO as occlusion of the internal carotid, carotid-T, middle cerebral, basilar, vertebral or posterior cerebral arteries. GSR-ET and SITS-ISTR IVT-treated patients were matched in a 1:1 ratio using propensity-score (PS) matching. The primary outcome was good functional outcome at 3 months (modified Rankin Scale score 0-2). RESULTS A total of 272 GSR-ET patients treated with EVT and IVT (age 68.6 ± 14.0 years, 43.4% female, NIHSS score 4 [interquartile range 2-5]) were compared to 272 IVT-treated SITS-ISTR patients (age 69.4 ± 13.7, 43.4% female, NIHSS score 4 [2-5]). Good functional outcome was seen in 77.0% versus 82.9% (p = 0.119), mortality in 5.9% versus 7.9% (p = 0.413), and intracranial hemorrhage in 8.8% versus 12.5% (p = 0.308) of patients in the GSR-ET versus the SITS-ISTR IVT group, respectively. In a second PS-matched analysis, 624 GSR-ET patients (IVT rate 56.7%) and 624 SITS-ISTR patients (IVT rate 100%), good outcome was more often observed in the SITS-ISTR patients (68.2% vs. 80.9%; p < 0.001), and IVT independently predicted good outcome (odds ratio 2.16, 95% confidence interval 1.43-3.28). CONCLUSIONS Our study suggests similar effectiveness of IVT alone compared to EVT with or without IVT in minor stroke patients. There is an urgent need for randomized controlled trials on this topic.
Collapse
Affiliation(s)
- Katharina Feil
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany,Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Marius Matusevicius
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of Research and EducationKarolinska University HospitalStockholmSweden
| | - Moriz Herzberg
- Institute of NeuroradiologyLMUMunichGermany,Department of RadiologyUniversity HospitalWuerzburgGermany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD)University HospitalLMU MunichMunichGermany
| | - Clemens Küpper
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Johannes Wischmann
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Sonja Schönecker
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Annerose Mengel
- Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Jennifer Sartor‐Pfeiffer
- Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Katharina Berger
- Department of Neurology and EpileptologyEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Konstantin Dimitriadis
- Institute for Stroke and Dementia Research (ISD)University HospitalLMU MunichMunichGermany
| | | | - Marianne Dieterich
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany,Munich Cluster for Systems Neurology (SyNergy)MunichGermany,German Center for Vertigo and Balance DisordersLMUMunichGermany
| | - Michael Mazya
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of NeurologyKarolinska University HospitalStockholmSweden
| | - Niaz Ahmed
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of NeurologyKarolinska University HospitalStockholmSweden
| | - Lars Kellert
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| |
Collapse
|
16
|
Suren C, Lukashova L, Wischmann J, Wulsten D, Wildemann B, Von Eisenhart-Rothe R, Holzmann B, Mayer-Kuckuk P. Abnormal bone architecture in mice expressing MyD88 in cells of the osteoclast lineage. J BIOL REG HOMEOS AG 2019; 33:1105-1111. [PMID: 31332987] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The adapter protein myeloid differentiation primary response gene 88 (MyD88) links the intracellular domains of interleukin receptors 1 and 18, and most Toll-like receptors (TLRs) to interleukin 1 receptor associated kinase (IRAK) signaling and subsequent NF-κB-mediated transcription. Previous work showed that mice with global deficiency of MyD88 (MyD88-/-) have osteopenic cancellous bone along with a reduction in osteoblastic but also osteoclastic surfaces. To further elucidate the role of MyD88 in bone, we utilized mice with osteoclast-restricted MyD88 expression in bone (MyD88OC). Bones of MyD88OC and wild type (wt) mice were examined by microCT analysis. Mechanical properties of bones were tested by three-point bending, and gene expression measured using quantitative real-time polymerase chain reaction. In MyD88OC mice, no osteopenic traits were observed, however, a drastic reduction in geometric parameters was detected. In trabecular bone a loss of connectivity density (-44%, p less than 0.0001) was measured and in cortical bone Imax (-31%, p less than 0.0001), Imin (-20%, p less than 0.001), J (-26%, p less than 0.0001) were reduced. Mechanical testing showed increased load to failure (77%, p less than 0.01) and decreased deflection at failure (-68%, p less than 0.01) of the femur. On the molecular level, relative gene expression analysis showed a (-29%, p less than 0.01) reduction in receptor activator of nuclear factor κ B ligand (RANKL) and no difference in osteoprotegerin (OPG) or RANK. Further, the bone resorption markers cathepsin K (CTSK) and tartrate-resistant acid phosphatase 5 (TRAP) were unchanged. In contrast, the bone formation markers collagen type 1 (COL1A1) and osteocalcin (OC) were decreased by -72% (p less than 0.0001) and -82% (p less than 0.0001), respectively. Together, our data suggests that the function of MyD88 in osteoclasts is sufficient to maintain bone mass, while it fails to preserve bone geometry, likely through dysfunctions in osteoblasts.
Collapse
Affiliation(s)
- C Suren
- Department of Orthopedics, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - L Lukashova
- Hospital for Special Surgery, New York, NY, USA
- present address: School of Dental Medicine, University of Pittsburg, Pittsburg, PA, USA
| | - J Wischmann
- Department of Orthopedics, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - D Wulsten
- Julius Wolff Institute and Berlin-Brandenburg Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - B Wildemann
- Julius Wolff Institute and Berlin-Brandenburg Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Research Division, Department of Trauma Surgery, University Hospital Jena, Jena, Germany
| | - R Von Eisenhart-Rothe
- Department of Orthopedics, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - B Holzmann
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - P Mayer-Kuckuk
- Department of Orthopedics, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
- present address: Institute of Experimental Genetics, Helmholtz Center Munich, Neuherberg, Germany
| |
Collapse
|
17
|
Wischmann J, Lenze F, Thiel A, Bookbinder S, Querido W, Schmidt O, Burgkart R, von Eisenhart-Rothe R, Richter GHS, Pleshko N, Mayer-Kuckuk P. Matrix mineralization controls gene expression in osteoblastic cells. Exp Cell Res 2018; 372:25-34. [PMID: 30193837 DOI: 10.1016/j.yexcr.2018.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/21/2018] [Accepted: 09/04/2018] [Indexed: 12/17/2022]
Abstract
Osteoblasts are adherent cells, and under physiological conditions they attach to both mineralized and non-mineralized osseous surfaces. However, how exactly osteoblasts respond to these different osseous surfaces is largely unknown. Our hypothesis was that the state of matrix mineralization provides a functional signal to osteoblasts. To assess the osteoblast response to mineralized compared to demineralized osseous surfaces, we developed and validated a novel tissue surface model. We demonstrated that with the exception of the absence of mineral, the mineralized and demineralized surfaces were similar in molecular composition as determined, for example, by collagen content and maturity. Subsequently, we used the human osteoblastic cell line MG63 in combination with genome-wide gene set enrichment analysis (GSEA) to record and compare the gene expression signatures on mineralized and demineralized surfaces. Assessment of the 5 most significant gene sets showed on mineralized surfaces an enrichment exclusively of genes sets linked to protein synthesis, while on the demineralized surfaces 3 of the 5 enriched gene sets were associated with the matrix. Focusing on these three gene sets, we observed not only the expected structural components of the bone matrix, but also gene products, such as HMCN1 or NID2, that are likely to act as temporal migration guides. Together, these findings suggest that in osteoblasts mineralized and demineralized osseous surfaces favor intracellular protein production and matrix formation, respectively. Further, they demonstrate that the mineralization state of bone independently controls gene expression in osteoblastic cells.
Collapse
Affiliation(s)
- Johannes Wischmann
- Department of Orthopedics, Klinikum rechts der Isar, Technical University Munich, 81675 Munich, Germany
| | - Florian Lenze
- Department of Orthopedics, Klinikum rechts der Isar, Technical University Munich, 81675 Munich, Germany
| | - Antonia Thiel
- Department of Orthopedics, Klinikum rechts der Isar, Technical University Munich, 81675 Munich, Germany
| | - Sakina Bookbinder
- Department of Bioengineering, Temple University, Philadelphia, PA 19122, USA
| | - William Querido
- Department of Bioengineering, Temple University, Philadelphia, PA 19122, USA
| | - Oxana Schmidt
- Children's Cancer Research Center, Comprehensive Cancer Center Munich, German Translational Cancer Research Consortium and Department of Pediatrics, Klinikum rechts der Isar, Technical University Munich, 81675 Munich, Germany
| | - Rainer Burgkart
- Department of Orthopedics, Klinikum rechts der Isar, Technical University Munich, 81675 Munich, Germany
| | | | - Günther H S Richter
- Children's Cancer Research Center, Comprehensive Cancer Center Munich, German Translational Cancer Research Consortium and Department of Pediatrics, Klinikum rechts der Isar, Technical University Munich, 81675 Munich, Germany
| | - Nancy Pleshko
- Department of Bioengineering, Temple University, Philadelphia, PA 19122, USA
| | - Philipp Mayer-Kuckuk
- Department of Orthopedics, Klinikum rechts der Isar, Technical University Munich, 81675 Munich, Germany.
| |
Collapse
|
18
|
Abstract
Bone formation, for example during bone remodelling or fracture repair, requires mature osteoblasts to deposit bone with remarkable spatial precision. As osteoblast precursors derive either from circulation or resident stem cell pools, they and their progeny are required to migrate within the three-dimensional bone space and to navigate to their destination, i.e. to the site of bone formation. An understanding of this process is emerging based on in vitro and in vivo studies of several vertebrate species. Receptors on the osteoblast surface mediate cell adhesion and polarization, which induces osteoblast migration. Osteoblast migration is then facilitated along gradients of chemoattractants. The latter are secreted or released proteolytically by several cell types interacting with osteoblasts, including osteoclasts and vascular endothelial cells. The positions of these cellular sources of chemoattractants in relation to the position of the osteoblasts provide the migrating osteoblasts with tracks to their destination, and osteoblasts possess the means to follow a track marked by multiple chemoattractant gradients. In addition to chemotactic cues, osteoblasts sense other classes of signals and utilize them as landmarks for navigation. The composition of the osseous surface guides adhesion and hence migration efficiency and can also provide steering through haptotaxis. Further, it is likely that signals received from surface interactions modulate chemotaxis. Besides the nature of the surface, mechanical signals such as fluid flow may also serve as navigation signals for osteoblasts. Alterations in osteoblast migration and navigation might play a role in metabolic bone diseases such as osteoporosis.
Collapse
Affiliation(s)
- Antonia Thiel
- Bone Cell and Imaging Laboratory, Department of Orthopedics, Klinikum rechts der Isar, Ismaninger Straße 22, Technical University Munich, 81675 München, Germany
| | - Marie K Reumann
- Siegfried Weller Institute, BG Hospital, University of Tübingen, Schnarrenbergstraße 95, 72076 Tübingen, Germany
| | - Adele Boskey
- Mineralized Tissue Laboratory, Research Division, Hospital for Special Surgery, 535 E 70th Street, New York, NY 10021, U.S.A
| | - Johannes Wischmann
- Bone Cell and Imaging Laboratory, Department of Orthopedics, Klinikum rechts der Isar, Ismaninger Straße 22, Technical University Munich, 81675 München, Germany
| | - Rüdiger von Eisenhart-Rothe
- Bone Cell and Imaging Laboratory, Department of Orthopedics, Klinikum rechts der Isar, Ismaninger Straße 22, Technical University Munich, 81675 München, Germany
| | - Philipp Mayer-Kuckuk
- Bone Cell and Imaging Laboratory, Department of Orthopedics, Klinikum rechts der Isar, Ismaninger Straße 22, Technical University Munich, 81675 München, Germany
| |
Collapse
|