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Liu WS, Zhu SF, Guo YL, Huang R, Yang X. Effect of microbubbles on transcranial doppler ultrasound-assisted intracranial recombinant tissue-type plasminogen activator thrombolysis. Vascular 2023; 31:1194-1200. [PMID: 35799413 DOI: 10.1177/17085381221079109] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the effect of microbubbles on the efficacy of transcranial doppler (TCD) ultrasound-assisted thrombolytic therapy of recombinant tissue-type plasminogen activator (rt-PA). METHODS Male New Zealand white rabbits (n = 36) were randomly divided into an rt-PA group (n = 18) and an rt-PA plus microbubble group (n = 18). After the cerebral infarction model was constructed with autologous blood clots, rt-PA and rt-PA plus microbubble intervention were performed, respectively. The hemodynamic changes and infarct size of the two groups were recorded. In addition, the ELISA method was used to detect the level of nitric oxide (NO), superoxide dismutase (SOD), and malondialdehyde (MDA) in the brain tissue of the two-group graph model and high-sensitivity C-reactive protein (hs-CRP) in the serum. RESULTS In the rt-PA group, the recanalization rate was 38.9% and the average infarct size was 11.8%. In the rt-PA plus microbubble group, the recanalization rate was 66.7% and the average infarct size was 8.2%. In addition, the average values for NO, SOD, MDA, and hs-CRP were 16.48 ± 5.39 μmol/L, 730.2 ± 9.86 U/mg, 0.92 ± 0.43 nmol/mg, and 8.56 ± 1.64 mg/L in the rt-PA group, respectively, and the average values were 9.18 ± 3.37 μmol/L, 426.2 ± 6.39 U/mg, 0.73 ± 0.44 nmol/mg, and 5.23 ± 0.94 mg/L in the rt-PA plus microbubble group, respectively. CONCLUSIONS The addition of microbubbles enhanced the effects of TCD-assisted rrt-PA thrombolysis.
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Affiliation(s)
- Wei-Song Liu
- Department of Internal Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Shao-Fen Zhu
- Department of Internal Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yuan-Ling Guo
- Department of Internal Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Rong Huang
- Department of Internal Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xue Yang
- Department of Internal Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
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Bluhmki E, Danays T, Biegert G, Hacke W, Lees KR. Alteplase for Acute Ischemic Stroke in Patients Aged >80 Years: Pooled Analyses of Individual Patient Data. Stroke 2020; 51:2322-2331. [PMID: 32611284 PMCID: PMC7382542 DOI: 10.1161/strokeaha.119.028396] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/18/2020] [Accepted: 04/09/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND/PURPOSE Expert guidelines specify no upper age limit for alteplase for thrombolysis of acute ischemic stroke (AIS) but, until recently, European regulatory criteria restricted its use to patients aged 18 to 80 years. We performed pooled analyses of randomized controlled trial (RCT) and registry data to evaluate the benefit-risk profile of alteplase for AIS among patients aged >80 years to support a regulatory application to lift the upper age restriction. METHODS Individual patient data were evaluated from 7 randomized trials of alteplase (0.9 mg/kg) versus placebo or open control for AIS, and the European SITS-UTMOST registry database. Clinical outcomes, including good functional outcome (score 0-1, modified Rankin Scale day 90 or Oxford Handicap Score day 180), were evaluated in the full RCT and registry populations, and specified age-based subgroups (≤80 or >80 years) who met existing European regulatory criteria for alteplase, excluding upper age restriction. RESULTS Regardless of treatment allocation, 90-day mortality was lower among RCT patients aged ≤80 versus >80 years who otherwise met existing European regulatory criteria (246/2405 [10.2%] versus 307/1028 [29.9%], respectively). Among patients aged >80 years, alteplase versus placebo was associated with a higher proportion of good stroke outcome (modified Rankin Scale score 0-1; 99/518 [19.1%] versus 67/510 [13.1%]; P=0.0109) and similar 90-day mortality (153/518 [29.5%] versus 154/510 [30.2%]; P=0.8382). The odds of a good stroke outcome following alteplase allocation in the full RCT population were independent of age (P=0.7383). Good stroke outcome was reported for almost half (4821/11 169 [43.2%]) of the patients who received alteplase in routine practice. Outcomes in routine practice supported those achieved in RCTs. CONCLUSIONS Alteplase for AIS has a positive benefit-risk profile among patients aged >80 years when administered according to other regulatory criteria. Alteplase for AIS should be evaluated on an individual benefit-risk basis.
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Affiliation(s)
- Erich Bluhmki
- ADB Building, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany and Hochschule Biberach, University of Applied Sciences, Germany (E.B.)
| | - Thierry Danays
- The Medical Department, Boehringer Ingelheim France SAS, Reims (T.D.)
| | - Gabriele Biegert
- The Biostatistics and Data Sciences Corp, Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany (G.B.)
| | - Werner Hacke
- The Department of Neurology, University of Heidelberg, Germany (W.H.)
| | - Kennedy R. Lees
- The School of Medicine, Dentistry & Nursing, University of Glasgow, United Kingdom (K.R.L.)
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Azeem MU, Nagy M, Miller MM, Ghasemi M, Mikati A, Silver B, Moonis M, Henninger N. Prevalence of a Multiple Territory Stroke Pattern After Intravenous Thrombolysis. J Stroke Cerebrovasc Dis 2020; 29:104700. [PMID: 32093987 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 12/08/2019] [Accepted: 01/25/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND It has been proposed that the presence of a multiple territory stroke pattern (MTSP) on brain imaging may aid identification of patients with covert atrial fibrillation (AF). However, it is uncertain whether this association holds true among patients treated with intravenous recombinant tissue plasminogen activator (rtPA) because clot fragmentation may affect MTSP prevalence. METHODS/DESIGN Retrospective analysis of 149 acute ischemic stroke patients treated with intravenous rtPA who underwent brain MRI. Presence of multiple acute infarctions on brain MRI that involved more than one vascular territory was considered to denote MTSP. Stroke etiology was categorized as nonembolic, cardioembolic (CES), and embolic stroke of undetermined source (ESUS). RESULTS In the entire cohort, subjects with CES and ESUS had significantly more often an MTSP than subjects with other determined stroke mechanism (P= .007). Although numerically relatively more patients had an MTSP as compared to a non-MTSP among subjects with CES (52% versus 33.9%) and ESUS (44% versus 34.7%), this difference did not reach significance after Bonferroni-adjustment for multiple comparisons (P> .05, each). There was no difference in the prevalence of an MTSP among subjects with known (n = 11/51; 21.6%) versus subsequently diagnosed (n = 1/3; 33.3%) AF (P= .54). CONCLUSIONS Our findings indicate that the known association of multiterritory infarct with AF and ESUS is maintained after thrombolysis. In light of its high specificity, MTSP represents a good marker for AF-related stroke etiology; nevertheless, overall sensitivity for AF was low highlighting that an absent MTSP does not rule out AF.
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Affiliation(s)
- Muhammad Umer Azeem
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Muhammad Nagy
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Malgorzata M Miller
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Mehdi Ghasemi
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Abdul Mikati
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Brian Silver
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Majaz Moonis
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts; Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts.
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Schuhmann MK, Kraft P, Bieber M, Kollikowski AM, Schulze H, Nieswandt B, Pham M, Stegner D, Stoll G. Targeting Platelet GPVI Plus rt-PA Administration but Not α2β1-Mediated Collagen Binding Protects against Ischemic Brain Damage in Mice. Int J Mol Sci 2019; 20:E2019. [PMID: 31022936 DOI: 10.3390/ijms20082019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/09/2019] [Accepted: 04/22/2019] [Indexed: 11/16/2022] Open
Abstract
Platelet collagen interactions at sites of vascular injuries predominantly involve glycoprotein VI (GPVI) and the integrin α2β1. Both proteins are primarily expressed on platelets and megakaryocytes whereas GPVI expression is also shown on endothelial and integrin α2β1 expression on epithelial cells. We recently showed that depletion of GPVI improves stroke outcome without increasing the risk of cerebral hemorrhage. Genetic variants associated with higher platelet surface integrin α2 (ITGA2) receptor levels have frequently been found to correlate with an increased risk of ischemic stroke in patients. However until now, no preclinical stroke study has addressed whether platelet integrin α2β1 contributes to the pathophysiology of ischemia/reperfusion (I/R) injury. Focal cerebral ischemia was induced in C57BL/6 and Itga2-/- mice by a 60 min transient middle cerebral artery occlusion (tMCAO). Additionally, wild-type animals were pretreated with anti-GPVI antibody (JAQ1) or Fab fragments of a function blocking antibody against integrin α2β1 (LEN/B). In anti-GPVI treated animals, intravenous (IV) recombinant tissue plasminogen activator (rt-PA) treatment was applied immediately prior to reperfusion. Stroke outcome, including infarct size and neurological scoring was determined on day 1 after tMCAO. We demonstrate that targeting the integrin α2β1 (pharmacologic; genetic) did neither reduce stroke size nor improve functional outcome on day 1 after tMCAO. In contrast, depletion of platelet GPVI prior to stroke was safe and effective, even when combined with rt-PA treatment. Our results underscore that GPVI, but not ITGA2, is a promising and safe target in the setting of ischemic stroke.
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Touzé E, Gruel Y, Gouin-Thibault I, De Maistre E, Susen S, Sie P, Derex L. Intravenous thrombolysis for acute ischaemic stroke in patients on direct oral anticoagulants. Eur J Neurol 2018; 25:747-e52. [PMID: 29360254 DOI: 10.1111/ene.13582] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [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: 05/07/2017] [Accepted: 01/11/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Whereas intravenous thrombolysis (IVT) is allowed for acute ischaemic stroke in patients on vitamin K antagonists with international normalized ratio ≤1.7, there are no similar recommendations for patients on direct oral anticoagulants (DOACs), notably due to the lack of coagulation tests to assess the therapeutic effects. Although the literature is scarce, consisting of small case series and retrospective studies, considering the frequency of this situation the French Vascular Neurology Society and the French Study Group on Haemostasis and Thrombosis have worked on a joint position paper to provide a practical position regarding the emergency management of ischaemic stroke in patients on DOACs. METHOD Based on a review of the literature, the authors wrote a first text that was submitted to a broad panel of members from the two societies. The text was then amended by the authors to address experts' comments and to reach a consensus. RESULTS In patients with normal renal function and who stopped the DOAC for at least 48 h, the management should not differ from that in patients without oral anticoagulant. In patients who are still on DOACs, mechanical thrombectomy is encouraged preferentially when applicable in first line. Otherwise, when specific tests are available, values <50 ng/ml indicate that IVT is allowed. In the absence of specific tests, standard tests (thrombin time, prothrombin time and activated partial thromboplastin time) can be used for dabigatran and rivaroxaban, although interpretation of these tests may be less reliable. In some patients on dabigatran, idarucizumab may be used before IVT. CONCLUSIONS In this expert opinion paper, it is suggested that IVT can be performed in patients selected according to the time elapsed since the drug was last taken, renal function, type of hospital where the patient is admitted and plasma concentration of DOAC.
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Affiliation(s)
- E Touzé
- Normandie Université, UNICAEN, Unité Neurovasculaire, CHU Caen, Caen, France
| | - Y Gruel
- Service d'Hématologie-Hémostase, Centre Régional de Traitement de l'Hémophilie, UMR CNRS 7292, Hôpital Trousseau, CHRU de Tours et Université François Rabelais, Tours, France
| | - I Gouin-Thibault
- Laboratoire d'Hématologie, Hôpital Cochin, UMR_S1140, Université Paris Descartes, Paris, France
| | - E De Maistre
- Laboratoire d'Hématologie-Hémostase, CHU Dijon Bourgogne, Université de Bourgogne, Dijon Cedex, France
| | - S Susen
- Département d'Hématologie et Transfusion, CHRU, Lille, France
| | - P Sie
- Laboratoire d'Hématologie, Hôpital Rangueil, CHU de Toulouse, Université Toulouse 3, Paul Sabatier, Toulouse, France
| | - L Derex
- Unité Neurovasculaire, Hôpital Neurologique, Hospices Civils, Lyon, France
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Kuntz M, Mysiorek C, Pétrault O, Boucau MC, Aijjou R, Uzbekov R, Bérézowski V. Transient oxygen-glucose deprivation sensitizes brain capillary endothelial cells to rtPA at 4h of reoxygenation. Microvasc Res 2013; 91:44-57. [PMID: 24333620 DOI: 10.1016/j.mvr.2013.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Revised: 11/28/2013] [Accepted: 12/03/2013] [Indexed: 01/11/2023]
Abstract
Thrombolysis treatment of acute ischemic stroke is limited by the pro-edematous and hemorrhagic effects exerted by reperfusion, which disrupts the blood-brain barrier (BBB) capillary endothelium in the infarct core. Most studies of the ischemic BBB overlook the complexity of the penumbral area, where the affected brain cells are still viable following deprivation. Our present objective was to examine in vitro the kinetic impact of reoxygenation on the integrity of ischemic BBB cells after oxygen-glucose deprivation. Through the use of a co-culture of brain capillary endothelial cells and glial cells, we first showed that the transendothelial permeability increase induced by deprivation can occur with both preserved cell viability and interendothelial tight junction network. The subtle and heterogeneous alteration of the tight junctions was observable only through electron microscopy. A complete permeability recovery was then found after reoxygenation, when Vimentin and Actin networks were reordered. However, still sparse ultrastructural alterations of tight junctions suggested an acquired vulnerability. Endothelial cells were then exposed to recombinant tissue-type plasminogen activator (rtPA) to define a temporal profile for the toxic effect of this thrombolytic on transendothelial permeability. Interestingly, the reoxygenated BBB broke down with aggravated tight junction disruption when exposed to rtPA only at 4h after reoxygenation. Moreover, this breakdown was enhanced by 50% when ischemic glial cells were present during the first hours of reoxygenation. Our results suggest that post-stroke reoxygenation enables retrieval of the barrier function of brain capillary endothelium when in a non-necrotic environment, but may sensitize it to rtPA at the 4-hour time point, when both endothelial breakdown mechanisms and glial secretions could be identified and targeted in a therapeutical perspective.
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Affiliation(s)
- Mélanie Kuntz
- Univ Lille Nord de France, UArtois, LBHE, EA 2465, Faculté des Sciences Jean Perrin, rue Jean Souvraz, S.P.18, F-62307 Lens cedex, France; Institut de Médecine Prédictive et de Recherche Thérapeutique, Place de Verdun, F-59045 Lille cedex, France; Institut Fédératif de Recherche 114, Place de Verdun, F-59045 Lille cedex, France.
| | - Caroline Mysiorek
- Univ Lille Nord de France, UArtois, LBHE, EA 2465, Faculté des Sciences Jean Perrin, rue Jean Souvraz, S.P.18, F-62307 Lens cedex, France; Institut de Médecine Prédictive et de Recherche Thérapeutique, Place de Verdun, F-59045 Lille cedex, France; Institut Fédératif de Recherche 114, Place de Verdun, F-59045 Lille cedex, France.
| | - Olivier Pétrault
- Univ Lille Nord de France, UArtois, LBHE, EA 2465, Faculté des Sciences Jean Perrin, rue Jean Souvraz, S.P.18, F-62307 Lens cedex, France; Institut de Médecine Prédictive et de Recherche Thérapeutique, Place de Verdun, F-59045 Lille cedex, France; Institut Fédératif de Recherche 114, Place de Verdun, F-59045 Lille cedex, France.
| | - Marie-Christine Boucau
- Univ Lille Nord de France, UArtois, LBHE, EA 2465, Faculté des Sciences Jean Perrin, rue Jean Souvraz, S.P.18, F-62307 Lens cedex, France; Institut de Médecine Prédictive et de Recherche Thérapeutique, Place de Verdun, F-59045 Lille cedex, France; Institut Fédératif de Recherche 114, Place de Verdun, F-59045 Lille cedex, France.
| | - Rachid Aijjou
- Univ Lille Nord de France, UArtois, LBHE, EA 2465, Faculté des Sciences Jean Perrin, rue Jean Souvraz, S.P.18, F-62307 Lens cedex, France; Institut de Médecine Prédictive et de Recherche Thérapeutique, Place de Verdun, F-59045 Lille cedex, France; Institut Fédératif de Recherche 114, Place de Verdun, F-59045 Lille cedex, France.
| | - Rustem Uzbekov
- Département des Microscopies, Université François Rabelais, F-37100 Tours, France; Faculty of Bioengineering & Bioinformatics, Moscow State University, 119991 Moscow, Russia.
| | - Vincent Bérézowski
- Univ Lille Nord de France, UArtois, LBHE, EA 2465, Faculté des Sciences Jean Perrin, rue Jean Souvraz, S.P.18, F-62307 Lens cedex, France; Institut de Médecine Prédictive et de Recherche Thérapeutique, Place de Verdun, F-59045 Lille cedex, France; Institut Fédératif de Recherche 114, Place de Verdun, F-59045 Lille cedex, France.
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Mandava P, Murthy SB, Munoz M, McGuire D, Simon RP, Alexandrov AV, Albright KC, Boehme AK, Martin-Schild S, Martini S, Kent TA. Explicit consideration of baseline factors to assess recombinant tissue-type plasminogen activator response with respect to race and sex. Stroke 2013; 44:1525-31. [PMID: 23674524 DOI: 10.1161/strokeaha.113.001116] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [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: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Sex and race reportedly influence outcome after recombinant tissue-type plasminogen activator (rtPA). It is, however, unclear whether baseline imbalances (eg, stroke severity) or lack of response to thrombolysis is responsible. We applied balancing methods to test the hypothesis that race and sex influence outcome after rtPA independent of baseline conditions. METHODS We mapped group outcomes from the National Institute of Neurological Disorders and Stroke (NINDS) dataset based on race and sex onto a surrogate-control function to assess differences from expected outcomes at their respective National Institutes of Health Stroke Scale and age. Outcomes were also compared for subjects matched individually on key baseline factors using NINDS and 2 recent datasets from southeastern United States. RESULTS At similar National Institutes of Health Stroke Scale and age, 90-day good outcomes (modified Rankin Score, 0-2) in NINDS were similarly improved after rtPA for white men and women. There was a strong trend for improvement in black men. Conversely, black women treated with rtPA showed response rates no different from the controls. After baseline matching, there were nonsignificant trends in outcomes except for significantly fewer good outcomes in black versus matched white women (37% versus 63%; P=0.027). Pooling the 3 datasets showed a similar trend for poorer short-term outcome for black women (P=0.054; modified Rankin Score, 0-1). CONCLUSIONS Matching for key baseline factors indicated that race and sex influence outcome most strikingly in black women who demonstrated poorest outcomes after rtPA. This finding supports the hypothesis that poor response to rtPA, rather than differences in baseline conditions, contributes to the worse outcome. This finding requires prospective confirmation.
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Affiliation(s)
- Pitchaiah Mandava
- Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine, The Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd (127), Houston, TX 77030, USA.
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