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Wang Z, Liu Z, Li S. Weak Lesion Feature Extraction by Dual-branch Separation and Enhancement Network for Safe Hemorrhagic Transformation Prediction. Comput Med Imaging Graph 2022; 97:102038. [DOI: 10.1016/j.compmedimag.2022.102038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 11/24/2021] [Accepted: 01/13/2022] [Indexed: 11/28/2022]
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2
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Jin S, Cho HJ. Model-free leakage index estimation of the blood-brain barrier using dual dynamic susceptibility contrast MRI acquisition. NMR IN BIOMEDICINE 2021; 34:e4570. [PMID: 34132432 DOI: 10.1002/nbm.4570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/30/2021] [Accepted: 05/23/2021] [Indexed: 06/12/2023]
Abstract
Pharmacokinetic K2 mapping from dynamic susceptibility contrast (DSC)-MRI can be a sensitive technique for evaluating the vascular permeability of the subtly damaged blood-brain barrier (BBB) in ischemic regions. However, the K2 values of ischemic lesions depend upon the selection of the intact BBB reference region. As previous observations suggest that the ΔR2* curve of pre-loaded DSC-MRI is not significantly affected by the extravasation of contrast agent, dual DSC-MRI acquisitions can be performed to derive the BBB leakage index from the voxel-wise reference input function for ischemic regions. This study aims to demonstrate the robustness of such model-free leakage index estimation in ischemic brains. By configuring the relationship between dual ΔR2* curves of the intact contralateral brain, the deviation of the measured ΔR2* curve from the unloaded DSC-MRI with respect to the non-deviated ΔR2* curve in the pre-loaded DSC-MRI can be quantified as the BBB leakage index. Such model-free leakage index values from rats with transient middle carotid artery occlusion (tMCAO) (n = 17) and normal controls (n = 3) were evaluated and compared with conventional K2 values with multiple reference regions. Inter-subject leakage index values were also compared with the corresponding ΔT1 map. Evans-blue-stained images were used to validate the leakage index. For the tMCAO group, leakage index values correlated well with ΔT1 (Pearson's r = 0.828). The hyperintense area on the leakage index map matched well with the corresponding Evans-blue-stained area (Dice correlation = 0.626). The slopes of the scatter-plot from the leakage index (0.97-1.00) were observed to be more robust against changes in the reference region than those from conventional K2 values (0.94-1.07). In a subtly damaged BBB tMCAO model, model-free evaluation of vascular permeability using dual DSC-MRIs would provide a consistent measure of inter-subject vascular permeability.
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Affiliation(s)
- Seokha Jin
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, South Korea
| | - Hyung Joon Cho
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, South Korea
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3
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Bernardo-Castro S, Sousa JA, Brás A, Cecília C, Rodrigues B, Almendra L, Machado C, Santo G, Silva F, Ferreira L, Santana I, Sargento-Freitas J. Pathophysiology of Blood-Brain Barrier Permeability Throughout the Different Stages of Ischemic Stroke and Its Implication on Hemorrhagic Transformation and Recovery. Front Neurol 2020; 11:594672. [PMID: 33362697 PMCID: PMC7756029 DOI: 10.3389/fneur.2020.594672] [Citation(s) in RCA: 176] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/09/2020] [Indexed: 12/25/2022] Open
Abstract
The blood–brain barrier (BBB) is a dynamic interface responsible for maintaining the central nervous system homeostasis. Its unique characteristics allow protecting the brain from unwanted compounds, but its impairment is involved in a vast number of pathological conditions. Disruption of the BBB and increase in its permeability are key in the development of several neurological diseases and have been extensively studied in stroke. Ischemic stroke is the most prevalent type of stroke and is characterized by a myriad of pathological events triggered by an arterial occlusion that can eventually lead to fatal outcomes such as hemorrhagic transformation (HT). BBB permeability seems to follow a multiphasic pattern throughout the different stroke stages that have been associated with distinct biological substrates. In the hyperacute stage, sudden hypoxia damages the BBB, leading to cytotoxic edema and increased permeability; in the acute stage, the neuroinflammatory response aggravates the BBB injury, leading to higher permeability and a consequent risk of HT that can be motivated by reperfusion therapy; in the subacute stage (1–3 weeks), repair mechanisms take place, especially neoangiogenesis. Immature vessels show leaky BBB, but this permeability has been associated with improved clinical recovery. In the chronic stage (>6 weeks), an increase of BBB restoration factors leads the barrier to start decreasing its permeability. Nonetheless, permeability will persist to some degree several weeks after injury. Understanding the mechanisms behind BBB dysregulation and HT pathophysiology could potentially help guide acute stroke care decisions and the development of new therapeutic targets; however, effective translation into clinical practice is still lacking. In this review, we will address the different pathological and physiological repair mechanisms involved in BBB permeability through the different stages of ischemic stroke and their role in the development of HT and stroke recovery.
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Affiliation(s)
| | - João André Sousa
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ana Brás
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carla Cecília
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Bruno Rodrigues
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Luciano Almendra
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cristina Machado
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Gustavo Santo
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Fernando Silva
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Lino Ferreira
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Isabel Santana
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - João Sargento-Freitas
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
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4
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Kamal H, Mehta BK, Ahmed MK, Kavak KS, Zha A, Lail NS, Shirani P, Al-Mufti F, Sawyer RN, Mowla A. Laboratory factors associated with symptomatic hemorrhagic conversion of acute stroke after systemic thrombolysis. J Neurol Sci 2020; 420:117265. [PMID: 33333324 DOI: 10.1016/j.jns.2020.117265] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/13/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Laboratory factors associated with hemorrhagic conversion (HC) after Intravenous thrombolysis with rtPA (IVT) for Acute Ischemic Stroke (AIS) remain nebulous despite advances in our knowledge of AIS. This study aimed to investigate the laboratory factors predisposing to HC in AIS patients receiving IVT. METHODS We retrospectively reviewed the medical records of patients who received IV tPA for AIS at our comprehensive stroke center over a 9.6-year period. Besides age, gender, NIHSS, history of diabetes mellitus (DM), history of atrial fibrillation (Afib), we gathered their laboratory data including International Normalized Ratio (INR), lipid panel, serum albumin, serum creatinine, hemoglobin A1c (HbA1c), and admission blood glucose. Post-thrombolysis brain imagings were reviewed to evaluate for symptomatic ICH (sICH). The mean values of above mentioned laboratory data were compared between the group with sICH and patients with no sICH. Univariate and multivariate logistic regression were performed to evaluate the association of the laboratory findings with presence of sICH. sICH was defined as ICH causing an increase in NIHSS ≥4. RESULTS Of the 794 subjects in this study 51 (6.4%) had sICH. In the univariate analysis, patients who developed sICH had significantly higher NIHSS on admission (14.2 ± 5.4 vs 11.2 ± 6.5, p < .001), LDL-cholesterol (113.3 mg/dl ±36.9 vs. 101.8 mg/dl ± 38.2, p = .032), HbA1c (6.9% ± 2.3 vs. 6.1 ± 1.3, p = .003) and lower levels of Albumin (3.5 g/dl ±0.4 vs. 3.9 g/dl ± 0.5, p < .001). Furthermore, a higher prevalence of history of DM (45% vs. 21.6%, p = .020) and Afib (25.4% vs. 10.4%, p = .028) was found in subjects who developed sICH. There were no significant group differences regarding age, sex, total cholesterol, blood glucose on admission, serum creatinine or INR levels (p > .05). After adjusting for multiple covariates, lower Albumin level and and higher HbA1c were significantly associated with an increased risk for sICH development (p < .05). Chances of sICH increased by 33% for every 1 g/dl below a normal albumin level of 4.0 g/dl (p < .05). CONCLUSION Lower endogenous albumin level and higher HbA1c have shown to predispose to a higher risk of sICH after IVT for AIS and might be good predictors of sICH post IVT.
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Affiliation(s)
- Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America
| | - Bijal K Mehta
- Department of Neurology, Harbor-UCLA Medical Center, Los Angeles, CA, United States of America
| | - Muhammad K Ahmed
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Katelyn S Kavak
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Alicia Zha
- Department of Neurology, University of Texas Health Sciences Center at Houston, Houston, TX, United States of America
| | - Navdeep S Lail
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Peyman Shirani
- Departments of Neurology and Neurosurgery, University of Cincinnati Medical Center, Cincinnati, OH, United States of America
| | - Fawaz Al-Mufti
- Departments of Neurology and Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America
| | - Robert N Sawyer
- Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Ashkan Mowla
- Division of Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, United States of America.
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5
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Elsaid N, Mustafa W, Saied A. Radiological predictors of hemorrhagic transformation after acute ischemic stroke: An evidence-based analysis. Neuroradiol J 2020; 33:118-133. [PMID: 31971093 PMCID: PMC7140299 DOI: 10.1177/1971400919900275] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hemorrhagic transformation (HT) is one of the most common adverse events related to acute ischemic stroke (AIS) that affects the treatment plan and clinical outcome. Identification of a sensitive radiological marker may influence the controversial thrombolytic decision in the setting of AIS and may at a minimum indicate more intensive monitoring or further prophylactic interventions. In this article we summarize possible radiological biomarkers and the role of different radiological modalities including computed tomography (CT), magnetic resonance imaging, angiography, and ultrasound in predicting HT. Different radiological indices of early ischemic changes, large ischemic lesion volume, severe blood flow restriction, blood-brain barrier disruption, poor collaterals and high blood flow velocities have been reported to be associated with higher risk of HT. The current levels of evidence of the available studies highlight the role of the different CT perfusion parameters in predicting HT. Further large standardized studies are recommended to compare the sensitivity and specificity of the different radiological markers combined and delineate the most reliable predictor.
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Affiliation(s)
- Nada Elsaid
- Department of Neurology, University of Mansoura
Faculty of Medicine, Egypt
| | - Wessam Mustafa
- Department of Neurology, University of Mansoura
Faculty of Medicine, Egypt
| | - Ahmed Saied
- Department of Neurology, University of Mansoura
Faculty of Medicine, Egypt
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6
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Li X, Liu H, Zeng W, Liu X, Wen Y, Xiong Q, Yang R. The Value of Whole-Brain Perfusion Parameters Combined with Multiphase Computed Tomography Angiography in Predicting Hemorrhagic Transformation in Ischemic Stroke. J Stroke Cerebrovasc Dis 2020; 29:104690. [PMID: 32067854 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104690] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/18/2020] [Accepted: 01/22/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To explore the value of whole-brain perfusion parameters combined with multiphase computed tomography angiography (MP-CTA) in predicting the hemorrhagic transformation (HT) of ischemic stroke. METHODS A total of 64 patients with ischemic stroke who underwent noncontrast computed tomography, computed tomography perfusion imaging, and computed tomography angiography before treatment from August 2017 to June 2019 were included retrospectively. The perfusion parameters cerebral blood volume (CBV), cerebral blood flow (CBF), time to peak (TTP), mean transit time (MTT), time to maximum (Tmax), and permeability surface (PS) were measured by postprocessing software (Advantage Workstation 4.7 (Revolution, GE Healthcare, USA)), and their ratios between the healthy and affect side relative CBV, relative CBF, relative time to peak (rTTP), relative mean transit time (rMTT), relative Tmax, and relative permeability surface (rPS) were calculated. The differences in perfusion parameters between the HT group and the non-HT group were evaluated. The collateral circulation scores and HT rates were assessed by MP-CTA. Receiver operating characteristic curves were drawn to analyze the diagnostic efficiency of valuable parameters and their correlations with HT. The rate of HT in different treatments were compared. RESULTS The CBV values in the HT group were lower than those in the non-HT group (P < .05), while the TTP, MTT, Tmax, PS, rTTP, rMTT, and rPS values in the HT group were higher than those in the non-HT group (P < .05). PS (r = .63, area under curve = .881) and rPS (r = .52, area under curve = .814) were significantly correlated with HT. The combination of perfusion parameters and the MP-CTA scores can improve the diagnostic efficiency (area under curve = .891). The HT rate in the group with poor collateral (64.29%) was higher than that in the group with good collateral (11.11%). CONCLUSIONS Whole-brain perfusion parameters and MP-CTA scores have important application value in assessing the HT risk of ischemic stroke patients before treatment.
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Affiliation(s)
- Xiang Li
- Chongqing Three Gorges Central Hospital, Chongqing, China
| | | | - Wenbing Zeng
- Chongqing Three Gorges Central Hospital, Chongqing, China.
| | - Xinghua Liu
- Chongqing Three Gorges Central Hospital, Chongqing, China
| | - Yun Wen
- Chongqing Three Gorges Central Hospital, Chongqing, China
| | - Qiuxia Xiong
- Chongqing Three Gorges Central Hospital, Chongqing, China
| | - Ran Yang
- Chongqing Three Gorges Central Hospital, Chongqing, China
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7
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Wang T, Hou Y, Bu B, Wang W, Ma T, Liu C, Lin L, Ma L, Lou X, Gao M. Timely Visualization of the Collaterals Formed during Acute Ischemic Stroke with Fe 3 O 4 Nanoparticle-based MR Imaging Probe. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2018; 14:e1800573. [PMID: 29665290 DOI: 10.1002/smll.201800573] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 02/19/2018] [Indexed: 06/08/2023]
Abstract
Ischemic stroke is one of the major leading causes for long-term disability and mortality. Collateral vessels provide an alternative pathway to protect the brain against ischemic injury after arterial occlusion. Aiming at visualizing the collaterals occurring during acute ischemic stroke, an integrin αv β3 -specific Fe3 O4 -Arg-Gly-Asp (RGD) nanoprobe is prepared for magnetic resonance imaging (MRI) of the collaterals. Rat models are constructed by occluding the middle cerebral artery for imaging studies of cerebral ischemia and ischemia-reperfusion on 7.0 Tesla MRI using susceptibility-weighted imaging sequence. To show the binding specificity to the collaterals, the imaging results acquired with the Fe3 O4 -RGD nanoprobe and the Fe3 O4 mother nanoparticles, respectively, are carefully compared. In addition, an RGD blocking experiment is also carried out to support the excellent binding specificity of the Fe3 O4 -RGD nanoprobe. Following the above experiments, cerebral ischemia-reperfusion studies show the collateral dynamics upon reperfusion, which is very important for the prognosis of various revascularization therapies in the clinic. The current study has, for the first time, enabled the direct observation of collaterals in a quasi-real time fashion and further disclosed that the antegrade flow upon reperfusion dominates the blood supply of primary ischemic tissue during the early stage of infarction, which is significantly meaningful for clinical treatment of stroke.
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Affiliation(s)
- Ting Wang
- Department of Radiology, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, P. R. China
| | - Yi Hou
- Key Laboratory of Colloid, Interface and Chemical Thermodynamics, Institute of Chemistry, Chinese Academy of Sciences, Bei Yi Jie 2, Zhong Guan Cun, Beijing, 100190, P. R. China
| | - Bo Bu
- Department of Neurosurgery, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, P. R. China
| | - Wenxin Wang
- Department of Neurosurgery, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, P. R. China
| | - Tiancong Ma
- Key Laboratory of Colloid, Interface and Chemical Thermodynamics, Institute of Chemistry, Chinese Academy of Sciences, Bei Yi Jie 2, Zhong Guan Cun, Beijing, 100190, P. R. China
- School of Chemistry and Chemical Engineering, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Chunyan Liu
- Key Laboratory of Colloid, Interface and Chemical Thermodynamics, Institute of Chemistry, Chinese Academy of Sciences, Bei Yi Jie 2, Zhong Guan Cun, Beijing, 100190, P. R. China
| | - Lan Lin
- Department of Radiology, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, P. R. China
| | - Lin Ma
- Department of Radiology, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, P. R. China
| | - Xin Lou
- Department of Radiology, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, P. R. China
| | - Mingyuan Gao
- Key Laboratory of Colloid, Interface and Chemical Thermodynamics, Institute of Chemistry, Chinese Academy of Sciences, Bei Yi Jie 2, Zhong Guan Cun, Beijing, 100190, P. R. China
- School of Chemistry and Chemical Engineering, University of Chinese Academy of Sciences, Beijing, 100049, China
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8
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Yang B, Li W, Satani N, Nghiem DM, Xi X, Aronowski J, Savitz SI. Protective Effects of Autologous Bone Marrow Mononuclear Cells After Administering t-PA in an Embolic Stroke Model. Transl Stroke Res 2017; 9:135-145. [PMID: 28836238 DOI: 10.1007/s12975-017-0563-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/09/2017] [Accepted: 08/10/2017] [Indexed: 10/19/2022]
Abstract
Tissue plasminogen activator (t-PA) is the only FDA-approved drug for acute ischemic stroke but poses risk for hemorrhagic transformation (HT). Cell therapy has been investigated as a potential therapy to improve recovery after stroke by the modulation of inflammatory responses and the improvement of blood-brain barrier (BBB) integrity, both of which are associated with HT after t-PA. In our present study, we studied the effect of autologous bone marrow mononuclear cells (MNCs) in an embolic stroke model. We administered MNCs in a rat embolic stroke 2 h after administering t-PA. We observed that even though autologous MNCs did not alter the incidence of HT, they decreased the severity of HT and reduced BBB permeability. One possible mechanism could be through the inhibition of MMP3 released by astrocytes via JAK/STAT pathway as shown by our in vitro cell interaction studies.
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Affiliation(s)
- Bing Yang
- Institute for Stroke and Cerebrovascular Disease and Department of Neurology, McGovern Medical School, University of Texas Health Science Center (UTHealth) at Houston, Houston, 77030, TX, USA.
| | - Weilang Li
- Department of Neurology, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Nikunj Satani
- Institute for Stroke and Cerebrovascular Disease and Department of Neurology, McGovern Medical School, University of Texas Health Science Center (UTHealth) at Houston, Houston, 77030, TX, USA
| | - Duyen M Nghiem
- Institute for Stroke and Cerebrovascular Disease and Department of Neurology, McGovern Medical School, University of Texas Health Science Center (UTHealth) at Houston, Houston, 77030, TX, USA
| | - XiaoPei Xi
- Institute for Stroke and Cerebrovascular Disease and Department of Neurology, McGovern Medical School, University of Texas Health Science Center (UTHealth) at Houston, Houston, 77030, TX, USA
| | - Jaroslaw Aronowski
- Institute for Stroke and Cerebrovascular Disease and Department of Neurology, McGovern Medical School, University of Texas Health Science Center (UTHealth) at Houston, Houston, 77030, TX, USA
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease and Department of Neurology, McGovern Medical School, University of Texas Health Science Center (UTHealth) at Houston, Houston, 77030, TX, USA
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9
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Tiwari YV, Lu J, Shen Q, Cerqueira B, Duong TQ. Magnetic resonance imaging of blood-brain barrier permeability in ischemic stroke using diffusion-weighted arterial spin labeling in rats. J Cereb Blood Flow Metab 2017; 37:2706-2715. [PMID: 27742887 PMCID: PMC5536782 DOI: 10.1177/0271678x16673385] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 09/02/2016] [Accepted: 09/13/2016] [Indexed: 12/25/2022]
Abstract
Diffusion-weighted arterial spin labeling magnetic resonance imaging has recently been proposed to quantify the rate of water exchange (Kw) across the blood-brain barrier in humans. This study aimed to evaluate the blood-brain barrier disruption in transient (60 min) ischemic stroke using Kw magnetic resonance imaging with cross-validation by dynamic contrast-enhanced magnetic resonance imaging and Evans blue histology in the same rats. The major findings were: (i) at 90 min after stroke (30 min after reperfusion), group Kw magnetic resonance imaging data showed no significant blood-brain barrier permeability changes, although a few animals showed slightly abnormal Kw. Dynamic contrast-enhanced magnetic resonance imaging confirmed this finding in the same animals. (ii) At two days after stroke, Kw magnetic resonance imaging revealed significant blood-brain barrier disruption. Regions with abnormal Kw showed substantial overlap with regions of hyperintense T2 (vasogenic edema) and hyperperfusion. Dynamic contrast-enhanced magnetic resonance imaging and Evans blue histology confirmed these findings in the same animals. The Kw values in the normal contralesional hemisphere and the ipsilesional ischemic core two days after stroke were: 363 ± 17 and 261 ± 18 min-1, respectively (P < 0.05, n = 9). Kw magnetic resonance imaging is sensitive to blood-brain barrier permeability changes in stroke, consistent with dynamic contrast-enhanced magnetic resonance imaging and Evans blue extravasation. Kw magnetic resonance imaging offers advantages over existing techniques because contrast agent is not needed and repeated measurements can be made for longitudinal monitoring or averaging.
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Affiliation(s)
- Yash V Tiwari
- Research Imaging Institute, University of Texas Health Science Center, San Antonio, TX, USA
- Department of Biomedical Engineering, University of Texas at San Antonio, TX, USA
| | - Jianfei Lu
- Research Imaging Institute, University of Texas Health Science Center, San Antonio, TX, USA
- Department of Anatomy and Embryology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Qiang Shen
- Research Imaging Institute, University of Texas Health Science Center, San Antonio, TX, USA
| | - Bianca Cerqueira
- Research Imaging Institute, University of Texas Health Science Center, San Antonio, TX, USA
- Department of Biomedical Engineering, University of Texas at San Antonio, TX, USA
| | - Timothy Q Duong
- Research Imaging Institute, University of Texas Health Science Center, San Antonio, TX, USA
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10
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Bouts MJ, Tiebosch IA, Rudrapatna US, van der Toorn A, Wu O, Dijkhuizen RM. Prediction of hemorrhagic transformation after experimental ischemic stroke using MRI-based algorithms. J Cereb Blood Flow Metab 2017; 37:3065-3076. [PMID: 28155583 PMCID: PMC5536810 DOI: 10.1177/0271678x16683692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Estimation of hemorrhagic transformation (HT) risk is crucial for treatment decision-making after acute ischemic stroke. We aimed to determine the accuracy of multiparametric MRI-based predictive algorithms in calculating probability of HT after stroke. Spontaneously, hypertensive rats were subjected to embolic stroke and, after 3 h treated with tissue plasminogen activator (Group I: n = 6) or vehicle (Group II: n = 7). Brain MRI measurements of T2, T2*, diffusion, perfusion, and blood-brain barrier permeability were obtained at 2, 24, and 168 h post-stroke. Generalized linear model and random forest (RF) predictive algorithms were developed to calculate the probability of HT and infarction from acute MRI data. Validation against seven-day outcome on MRI and histology revealed that highest accuracy of hemorrhage prediction was achieved with a RF-based model that included spatial brain features (Group I: area under the receiver-operating characteristic curve (AUC) = 0.85 ± 0.14; Group II: AUC = 0.89 ± 0.09), with significant improvement over perfusion- or permeability-based thresholding methods. However, overlap between predicted and actual tissue outcome was significantly lower for hemorrhage prediction models (maximum Dice's Similarity Index (DSI) = 0.20 ± 0.06) than for infarct prediction models (maximum DSI = 0.81 ± 0.06). Multiparametric MRI-based predictive algorithms enable early identification of post-ischemic tissue at risk of HT and may contribute to improved treatment decision-making after acute ischemic stroke.
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Affiliation(s)
- Mark Jrj Bouts
- 1 Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands.,2 Athinoula A Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.,3 Leiden Institute for Brain and Cognition, Institute of Psychology, Leiden University, Leiden, The Netherlands.,4 Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ivo Acw Tiebosch
- 1 Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Umesh S Rudrapatna
- 1 Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annette van der Toorn
- 1 Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ona Wu
- 2 Athinoula A Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Rick M Dijkhuizen
- 1 Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
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11
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Shiraishi K, Wang Z, Kokuryo D, Aoki I, Yokoyama M. A polymeric micelle magnetic resonance imaging (MRI) contrast agent reveals blood–brain barrier (BBB) permeability for macromolecules in cerebral ischemia-reperfusion injury. J Control Release 2017; 253:165-171. [DOI: 10.1016/j.jconrel.2017.03.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/17/2017] [Accepted: 03/11/2017] [Indexed: 01/10/2023]
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12
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Ji B, Zhou F, Han L, Yang J, Fan H, Li S, Li J, Zhang X, Wang X, Chen X, Xu Y. Sodium Tanshinone IIA Sulfonate Enhances Effectiveness Rt-PA Treatment in Acute Ischemic Stroke Patients Associated with Ameliorating Blood-Brain Barrier Damage. Transl Stroke Res 2017; 8:334-340. [PMID: 28243834 PMCID: PMC5493726 DOI: 10.1007/s12975-017-0526-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 12/11/2022]
Abstract
Treatment with sodium tanshinone IIA sulfonate (STS) may ameliorate blood-brain barrier (BBB) damage in acute ischemic stroke patients receiving recombinant tissue plasminogen activator (rt-PA) thrombolysis and improve stroke patients’ outcome. This randomized, single-center, placebo-controlled clinical trial investigated the potential effects and underlying mechanisms of STS. Forty-two acute ischemic stroke patients receiving intravenous rt-PA thrombolysis were randomized to intravenous administration either with STS (60 mg/day) (n = 21) or with equivalent volume of saline as a placebo (n = 21) after randomization for 10 days. Clinical outcomes, computer tomography perfusion (CTP) imaging with permeability-surface area product (PS) maps and serum levels of BBB damage biomarkers, were compared between the two groups. The percentage of patients with excellent functional outcome indicated by a 90-day mRS ≤1 was significantly higher in the STS group than in the placebo group (p = 0.028). For patients with CTP imaging (n = 30), PS in the ipsilateral lesion (p = 0.034) and relative PS (p = 0.013) were significantly lower in the STS group than that in placebo. STS-treated patients also had lower levels of matrix metalloproteinase (MMP)-9 (p = 0.036) and claudin-5 (p = 0.026), but higher levels of tissue inhibitor of metalloproteinase (TIMP)-1 (p = 0.040) than those in the placebo group. Post-stroke STS treatment could improve neurologic functional outcomes for acute ischemic stroke patients following rt-PA treatment by reducing BBB leakage and damage, which might be mechanistically associated with MMP-9 inhibition.
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Affiliation(s)
- Biying Ji
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Fei Zhou
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Lijuan Han
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Jun Yang
- GE Healthcare, Shanghai, People's Republic of China
| | - Haijian Fan
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Shanshan Li
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Jingwei Li
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Xin Zhang
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Xiaoying Wang
- Departments of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Xiangyan Chen
- Departments of Medicine and Therapeutics, Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
| | - Yun Xu
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China.
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Tomsick TA, Foster LD, Liebeskind DS, Hill MD, Carrozella J, Goyal M, von Kummer R, Demchuk AM, Dzialowski I, Puetz V, Jovin T, Morales H, Palesch YY, Broderick J, Khatri P, Yeatts SD. Outcome Differences between Intra-Arterial Iso- and Low-Osmolality Iodinated Radiographic Contrast Media in the Interventional Management of Stroke III Trial. AJNR Am J Neuroradiol 2015; 36:2074-81. [PMID: 26228892 DOI: 10.3174/ajnr.a4421] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 03/03/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Intracarotid arterial infusion of nonionic, low-osmolal iohexol contrast medium has been associated with increased intracranial hemorrhage in a rat middle cerebral artery occlusion model compared with saline infusion. Iso-osmolal iodixanol (290 mOsm/kg H2O) infusion demonstrated smaller infarcts and less intracranial hemorrhage compared with low-osmolal iopamidol and saline. No studies comparing iodinated radiographic contrast media in human stroke have been performed, to our knowledge. We hypothesized that low-osmolal contrast media may be associated with worse outcomes compared with iodixanol in the Interventional Management of Stroke III Trial (IMS III). MATERIALS AND METHODS We reviewed prospective iodinated radiographic contrast media data for 133 M1 occlusions treated with endovascular therapy. We compared 5 prespecified efficacy and safety end points (mRS 0-2 outcome, modified TICI 2b-3 reperfusion, asymptomatic and symptomatic intracranial hemorrhage, and mortality) between those receiving iodixanol (n = 31) or low-osmolal contrast media (n = 102). Variables imbalanced between iodinated radiographic contrast media types or associated with outcome were considered potential covariates for the adjusted models. In addition to the iodinated radiographic contrast media type, final covariates were those selected by using the stepwise method in a logistic regression model. Adjusted relative risks were then estimated by using a log-link regression model. RESULTS Of baseline or endovascular therapy variables potentially linked to outcome, prior antiplatelet agent use was more common and microcatheter iodinated radiographic contrast media injections were fewer with iodixanol. Relative risk point estimates are in favor of iodixanol for the 5 prespecified end points with M1 occlusion. The percentage of risk differences are numerically greater for microcatheter injections with iodixanol. CONCLUSIONS While data favoring the use of iso-osmolal iodixanol for reperfusion of M1 occlusion following IV rtPA are inconclusive, potential pathophysiologic mechanisms suggesting clinical benefit warrant further investigation.
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Affiliation(s)
- T A Tomsick
- From the Department of Radiology (T.A.T., J.C., H.M.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - L D Foster
- Department of Public Health Sciences (L.D.F., Y.Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - D S Liebeskind
- University of California, Los Angeles Stroke Center (D.S.L.), Los Angeles, California
| | - M D Hill
- Department of Radiology and Clinical Neurosciences (M.D.H., M.G.)
| | - J Carrozella
- From the Department of Radiology (T.A.T., J.C., H.M.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - M Goyal
- Department of Radiology and Clinical Neurosciences (M.D.H., M.G.)
| | | | - A M Demchuk
- Calgary Stroke Program (A.M.D.), Department of Clinical Neurosciences/Medicine/Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - I Dzialowski
- Department of Neurology (I.D.), Elblandklinikum Meissen, Academic Teaching Hospital of Universitätsklinikum, Carl Gustav Carus Technische Universität Dresden, Meißen, Germany
| | - V Puetz
- Neurology (V.P.), Dresden University Stroke Center, Universitätsklinikum Carl Gustav Carus Technischen Universität Dresden, Dresden, Germany
| | - T Jovin
- The Stroke Institute (T.J.), University of Pittsburgh Medical Center, Pittsburgh. Pennsylvania
| | - H Morales
- From the Department of Radiology (T.A.T., J.C., H.M.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - Y Y Palesch
- Department of Public Health Sciences (L.D.F., Y.Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - J Broderick
- Department of Neurology (J.B., P.K.), University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - P Khatri
- Department of Neurology (J.B., P.K.), University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - S D Yeatts
- Department of Public Health Sciences (L.D.F., Y.Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
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Choi HS, Ahn SS, Shin NY, Kim J, Kim JH, Lee JE, Lee HY, Heo JH, Lee SK. Permeability Parameters Measured with Dynamic Contrast-Enhanced MRI: Correlation with the Extravasation of Evans Blue in a Rat Model of Transient Cerebral Ischemia. Korean J Radiol 2015; 16:791-7. [PMID: 26175578 PMCID: PMC4499543 DOI: 10.3348/kjr.2015.16.4.791] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 03/16/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The purpose of this study was to correlate permeability parameters measured with dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) using a clinical 3-tesla scanner with extravasation of Evans blue in a rat model with transient cerebral ischemia. MATERIALS AND METHODS Sprague-Dawley rats (n = 13) with transient middle cerebral artery occlusion were imaged using a 3-tesla MRI with an 8-channel wrist coil. DCE-MRI was performed 12 hours, 18 hours, and 36 hours after reperfusion. Permeability parameters (K(trans), ve, and vp) from DCE-MRI were calculated. Evans blue was injected after DCE-MRI and extravasation of Evans blue was correlated as a reference with the integrity of the blood-brain barrier. Correlation analysis was performed between permeability parameters and the extravasation of Evans blue. RESULTS All permeability parameters (K(trans), ve, and vp) showed a linear correlation with extravasation of Evans blue. Among them, K(trans) showed highest values of both the correlation coefficient and the coefficient of determination (0.687 and 0.473 respectively, p < 0.001). CONCLUSION Permeability parameters obtained by DCE-MRI at 3-T are well-correlated with Evans blue extravasation, and K(trans) shows the strongest correlation among the tested parameters.
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Affiliation(s)
- Hyun Seok Choi
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul 137-701, Korea
| | - Sung Soo Ahn
- Department of Radiology, College of Medicine, Yonsei University, Seoul 120-752, Korea
| | - Na-Young Shin
- Department of Radiology, College of Medicine, Yonsei University, Seoul 120-752, Korea
| | - Jinna Kim
- Department of Radiology, College of Medicine, Yonsei University, Seoul 120-752, Korea
| | - Jae Hyung Kim
- Department of Radiology, College of Medicine, Seoul National University, Seoul 110-744, Korea
| | - Jong Eun Lee
- Department of Anatomy, College of Medicine, Yonsei University, Seoul 120-752, Korea
| | - Hye Yeon Lee
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul 137-701, Korea
| | - Ji Hoe Heo
- Department of Neurology, College of Medicine, Yonsei University, Seoul 120-752, Korea
| | - Seung-Koo Lee
- Department of Radiology, College of Medicine, Yonsei University, Seoul 120-752, Korea
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Kim BJ, Kang HG, Kim HJ, Ahn SH, Kim NY, Warach S, Kang DW. Magnetic resonance imaging in acute ischemic stroke treatment. J Stroke 2014; 16:131-45. [PMID: 25328872 PMCID: PMC4200598 DOI: 10.5853/jos.2014.16.3.131] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 09/15/2014] [Accepted: 09/16/2014] [Indexed: 11/11/2022] Open
Abstract
Although intravenous administration of tissue plasminogen activator is the only proven treatment after acute ischemic stroke, there is always a concern of hemorrhagic risk after thrombolysis. Therefore, selection of patients with potential benefits in overcoming potential harms of thrombolysis is of great importance. Despite the practical issues in using magnetic resonance imaging (MRI) for acute stroke treatment, multimodal MRI can provide useful information for accurate diagnosis of stroke, evaluation of the risks and benefits of thrombolysis, and prediction of outcomes. For example, the high sensitivity and specificity of diffusion-weighted image (DWI) can help distinguish acute ischemic stroke from stroke-mimics. Additionally, the lesion mismatch between perfusion-weighted image (PWI) and DWI is thought to represent potential salvageable tissue by reperfusion therapy. However, the optimal threshold to discriminate between benign oligemic areas and the penumbra is still debatable. Signal changes of fluid-attenuated inversion recovery image within DWI lesions may be a surrogate marker for ischemic lesion age and might indicate risks of hemorrhage after thrombolysis. Clot sign on gradient echo image may reflect the nature of clot, and their location, length and morphology may provide predictive information on recanalization by reperfusion therapy. However, previous clinical trials which solely or mainly relied on perfusion-diffusion mismatch for patient selection, failed to show benefits of MRI-based thrombolysis. Therefore, understanding the clinical implication of various useful MRI findings and comprehensively incorporating those variables into therapeutic decision-making may be a more reasonable approach for expanding the indication of acute stroke thrombolysis.
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Affiliation(s)
- Bum Joon Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Goo Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Jin Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Ho Ahn
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Na Young Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Steven Warach
- Seton/University of Texas Southwestern Clinical Research Institute of Austin, TX, USA
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Hemorrhagic transformation after ischemic stroke in animals and humans. J Cereb Blood Flow Metab 2014; 34:185-99. [PMID: 24281743 PMCID: PMC3915212 DOI: 10.1038/jcbfm.2013.203] [Citation(s) in RCA: 379] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/10/2013] [Accepted: 10/28/2013] [Indexed: 01/12/2023]
Abstract
Hemorrhagic transformation (HT) is a common complication of ischemic stroke that is exacerbated by thrombolytic therapy. Methods to better prevent, predict, and treat HT are needed. In this review, we summarize studies of HT in both animals and humans. We propose that early HT (<18 to 24 hours after stroke onset) relates to leukocyte-derived matrix metalloproteinase-9 (MMP-9) and brain-derived MMP-2 that damage the neurovascular unit and promote blood-brain barrier (BBB) disruption. This contrasts to delayed HT (>18 to 24 hours after stroke) that relates to ischemia activation of brain proteases (MMP-2, MMP-3, MMP-9, and endogenous tissue plasminogen activator), neuroinflammation, and factors that promote vascular remodeling (vascular endothelial growth factor and high-moblity-group-box-1). Processes that mediate BBB repair and reduce HT risk are discussed, including transforming growth factor beta signaling in monocytes, Src kinase signaling, MMP inhibitors, and inhibitors of reactive oxygen species. Finally, clinical features associated with HT in patients with stroke are reviewed, including approaches to predict HT by clinical factors, brain imaging, and blood biomarkers. Though remarkable advances in our understanding of HT have been made, additional efforts are needed to translate these discoveries to the clinic and reduce the impact of HT on patients with ischemic stroke.
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18
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Schreiber S, Bueche CZ, Garz C, Braun H. Blood brain barrier breakdown as the starting point of cerebral small vessel disease? - New insights from a rat model. EXPERIMENTAL & TRANSLATIONAL STROKE MEDICINE 2013; 5:4. [PMID: 23497521 PMCID: PMC3618264 DOI: 10.1186/2040-7378-5-4] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 03/05/2013] [Indexed: 01/22/2023]
Abstract
Cerebral small vessel disease (CSVD, cerebral microangiopathy) leads to dementia and stroke-like symptoms. Lacunes, white matter lesions (WML) and microbleeds are the main pathological correlates depicted in in-vivo imaging diagnostics. Early studies described segmental arterial wall disorganizations of small penetrating cerebral arteries as the most pronounced underlying histopathology of lacunes. Luminal narrowing caused by arteriolosclerosis was supposed to result in hypoperfusion with WML and infarcts.We have used the model of spontaneously hypertensive stroke-prone rats (SHRSP) for a longitudinal study to elucidate early histological changes in small cerebral vessels. We suggest that endothelial injuries lead to multiple sites with blood brain barrier (BBB) leakage which cause an ongoing damage of the vessel wall and finally resulting in vessel ruptures and microbleeds. These microbleeds together with reactive small vessel occlusions induce overt cystic infarcts of the surrounding parenchyma. Thus, multiple endothelial leakage sites seem to be the starting point of cerebral microangiopathy. The vascular system reacts with an activated coagulatory state to these early endothelial injuries and by this induces the formation of stases, accumulations of erythrocytes, which represent the earliest detectable histological peculiarity of small vessel disease in SHRSP.In this review we focus on the meaning of the BBB breakdown in CSVD and finally discuss possible consequences for clinicians.
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Affiliation(s)
- Stefanie Schreiber
- Department of Neurology, Otto-von-Guericke-University, Leipziger Strasse 44, Magdeburg, 39120, Germany.
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Lapergue B, Dang BQ, Desilles JP, Ortiz-Munoz G, Delbosc S, Loyau S, Louedec L, Couraud PO, Mazighi M, Michel JB, Meilhac O, Amarenco P. High-density lipoprotein-based therapy reduces the hemorrhagic complications associated with tissue plasminogen activator treatment in experimental stroke. Stroke 2013; 44:699-707. [PMID: 23422087 DOI: 10.1161/strokeaha.112.667832] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE We have previously reported that intravenous injection of high-density lipoproteins (HDLs) was neuroprotective in an embolic stroke model. We hypothesized that HDL vasculoprotective actions on the blood-brain barrier (BBB) may decrease hemorrhagic transformation-associated with tissue plasminogen activator (tPA) administration in acute stroke. METHODS We used tPA alone or in combination with HDLs in vivo in 2 models of focal middle cerebral artery occlusion (MCAO) (embolic and 4-hour monofilament MCAO) and in vitro in a model of BBB. Sprague-Dawley rats were submitted to MCAO, n=12 per group. The rats were then randomly injected with tPA (10 mg/kg) or saline with or without human plasma purified-HDL (10 mg/kg). The therapeutic effects of HDL and BBB integrity were assessed blindly 24 hours later. The integrity of the BBB was also tested using an in vitro model of human cerebral endothelial cells under oxygen-glucose deprivation. RESULTS tPA-treated groups had significantly higher mortality and rate of hemorrhagic transformation at 24 hours in both MCAO models. Cotreatment with HDL significantly reduced stroke-induced mortality versus tPA alone (by 42% in filament MCAO, P=0.009; by 73% in embolic MCAO, P=0.05) and tPA-induced intracerebral parenchymal hematoma (by 92% in filament MCAO, by 100% in embolic MCAO; P<0.0001). This was consistent with an improved BBB integrity. In vitro, HDLs decreased oxygen-glucose deprivation-induced BBB permeability (P<0.05) and vascular endothelial cadherin disorganization. CONCLUSIONS HDL injection decreased tPA-induced hemorrhagic transformation in rat models of MCAO. Both in vivo and in vitro results support the vasculoprotective action of HDLs on BBB under ischemic conditions.
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Affiliation(s)
- Bertrand Lapergue
- Department of Neurology and Stroke Centre, Bichat University Hospital, Paris, France
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20
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Shinoyama M, Nakagawara J, Yoneda H, Suzuki M, Ono H, Kunitsugu I, Kamiyama K, Osato T, Nakamura H. Initial 'TTP Map-Defect' of Computed Tomography Perfusion as a Predictor of Hemorrhagic Transformation of Acute Ischemic Stroke. Cerebrovasc Dis Extra 2013; 3:14-25. [PMID: 23637697 PMCID: PMC3617882 DOI: 10.1159/000346113] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Hemorrhagic transformation (HT) following acute ischemic stroke is a major problem, especially for the indication of reperfusion therapy including intravenous administration of recombinant tissue plasminogen activator (IV rt-PA). The specific predictive factors of HT have not yet been established. The present study evaluated the findings of computed tomography perfusion (CTP) images as predictors of subsequent HT to identify patients with low HT risk for reperfusion therapy such as IV rt-PA. Methods We retrospectively reviewed 68 consecutive stroke patients (41 males; mean age 72.9 years) with steno-occlusive lesions in the major trunk, including 10 patients who underwent IV rt-PA. Each HT was detected on a follow-up T2*-weighted magnetic resonance image until 2 weeks after stroke onset and categorized into four groups [hemorrhagic infarction (HI) type 1 and 2, and parenchymal hematoma (PH) type 1 and 2] according to the European Cooperative Acute Stroke Study (ECASS) classification. We assessed clinical features and radiological findings between the HT and non-HT groups or the PH2 and non-PH2 groups. The efficacy of initial time to peak (TTP) mapping of CTP for predicting HT or PH2 was evaluated. Results Thirty-four patients (50%) developed subsequent HT: 18 (52.9%) had HI and 16 (47.1%) had PH, including 9 PH2 patients (13.2%). IV rt-PA was not significantly associated with HT or PH2 occurrence. Forty of the 68 patients (59%) revealed defect areas on the initial TTP mapping (TTP map-defect), and 34 of these 40 patients (85%) developed secondary HT and 9 patients (22.5%) developed PH2. Initial ‘TTP map-defect’ was significantly associated with the occurrence of HT (p < 0.0001) and PH2 (p = 0.0070). Thirty of the 34 patients (88.2%) in the HT group experienced delayed recanalization of the occluded vessels, in contrast to only 8 of the 34 patients (23.6%) in the non-HT group. All patients of the PH2 group showed recanalization (p = 0.0042). In 40 ‘TTP map-defect’-positive patients, delayed recanalization was associated with the occurrence of HT (p < 0.0001) and PH2 (p = 0.0491). All 28 patients without ‘TTP map-defect’ did not develop HT, including 8 patients (28.6%) with delayed recanalization. Conclusions Initial ‘TTP map-defect’ of CTP could accurately predict HT risk including PH2 risk and identify low-risk patients even in the delayed period.
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Affiliation(s)
- Mizuya Shinoyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan ; Department of Neurosurgery, Yamaguchi University School of Medicine, Yamaguchi, Japan
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Schoknecht K, Shalev H. Blood-brain barrier dysfunction in brain diseases: clinical experience. Epilepsia 2013; 53 Suppl 6:7-13. [PMID: 23134490 DOI: 10.1111/j.1528-1167.2012.03697.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The blood-brain barrier, a unique feature of the cerebral vasculature, is gaining attention as a feature in common neurologic disorders including stroke, traumatic brain injury, epilepsy, and schizophrenia. Although acute blood-brain barrier dysfunction can induce cerebral edema, seizures, or neuropsychiatric symptoms, epileptogenesis and cognitive decline are among the chronic effects. The mechanisms underlying blood-brain barrier dysfunction are diverse and may range from physical endothelial damage in traumatic brain injury to degradation of extracellular matrix proteins via matrix metalloproteinases as part of an inflammatory response. Clinically, blood-brain barrier dysfunction is often detected using contrast-enhanced imaging. However, these techniques do not give any insights into the underlying mechanism. Elucidating the specific pathways of blood-brain barrier dysfunction at different time points and in different brain diseases using novel imaging techniques promises a more accurate blood-brain barrier terminology as well as new treatment options and personalized treatment.
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Affiliation(s)
- Karl Schoknecht
- Institute of Neurophysiology, Charité-University Medicine Berlin, Berlin, Germany.
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Hoffmann A, Bredno J, Wendland MF, Derugin N, Hom J, Schuster T, Zimmer C, Su H, Ohara PT, Young WL, Wintermark M. MRI blood-brain barrier permeability measurements to predict hemorrhagic transformation in a rat model of ischemic stroke. Transl Stroke Res 2012; 3:508-16. [PMID: 24323835 DOI: 10.1007/s12975-012-0212-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 09/03/2012] [Indexed: 10/27/2022]
Abstract
Permeability imaging might add valuable information in the risk assessment of hemorrhagic transformation. This study evaluates the predictive value of blood-brain barrier permeability (BBBP) measurements extracted from dynamic contrast-enhanced MRI for hemorrhagic transformation in ischemic stroke. Spontaneously hypertensive and Wistar rats with 2 h filament occlusion of the right MCA underwent MRI during occlusion, at 4 and 24 h post reperfusion. BBBP was imaged by DCE imaging and quantified by Patlak analysis. Cresyl-violet staining was used to characterize hemorrhage in sacrificed rats at 24 h, immediately following the last imaging study. BBBP changes were evaluated at baseline, 4 and 24 h after reperfusion. Receiver-operating characteristic (ROC) analysis was performed to determine the most accurate BBBP threshold to predict hemorrhagic transformation. In animals showing macroscopic hemorrhage at 24 h, 95th BBBP percentile values ipsilateral were 0.323 [0.260, 0.387], 0.685 [0.385, 0.985], and 0.412 [0.210, 0.613] ml/min·100 g (marginal mean [95%CI]) during occlusion, at 4 and 24 h post reperfusion, respectively. The BBBP values on the infarcted and contralateral side were significantly different at 4 (p = 0.034) and 24 h post reperfusion (p = 0.031). The predictive value of BBBP in terms of macroscopic hemorrhage was highest 4 h after reperfusion (ROC area under the curve = 84 %) with a high negative predictive value (98.3 %) and limited positive predictive value (14.9 %) for a threshold of 0.35 ml/min·100g. Altered BBBP is a necessary but not sufficient condition to cause hemorrhagic transformation in rats with an infarct. Further research is needed to identify those additional risk factors that are required for hemorrhagic transformation to develop in the setting of ischemic stroke.
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Affiliation(s)
- Angelika Hoffmann
- Department of Radiology, Neuroradiology Division, University of Virginia, Box 800170, Charlottesville, VA, 22908, USA
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Stanimirovic DB, Friedman A. Pathophysiology of the neurovascular unit: disease cause or consequence? J Cereb Blood Flow Metab 2012; 32:1207-21. [PMID: 22395208 PMCID: PMC3390807 DOI: 10.1038/jcbfm.2012.25] [Citation(s) in RCA: 247] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pathophysiology of the neurovascular unit (NVU) is commonly seen in neurological diseases. The typical features of NVU pathophysiology include tissue hypoxia, inflammatory and angiogenic activation, as well as initiation of complex molecular interactions between cellular (brain endothelial cells, astroctyes, pericytes, inflammatory cells, and neurons) and acellular (basal lamina) components of the NVU, jointly resulting in increased blood-brain barrier permeability, brain edema, neurovascular uncoupling, and neuronal dysfunction and damage. The evidence of important role of the brain vascular compartment in disease pathogenesis has elicited the debate whether the primary vascular events may be a cause of the neurological disease, as opposed to a mere participant recruited by a primary neuronal origin of pathology? Whereas some hereditary and acquired cerebral angiopathies could be considered a primary cause of neurological symptoms of the disease, the epidemiological studies showing a high degree of comorbidity among vascular disease and dementias, including Alzheimer's disease, as well as migraine and epilepsy, suggested that primary vascular pathology may be etiological factor causing neuronal dysfunction or degeneration in these diseases. This review focuses on recent hypotheses and evidence, suggesting that pathophysiology of the NVU may be initiating trigger for neuronal pathology and subsequent neurological manifestations of the disease.
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Affiliation(s)
- Danica B Stanimirovic
- Institute for Biological Sciences, National Research Council of Canada, Ottawa, Ontario, Canada.
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Kablau M, Kreisel SH, Sauer T, Binder J, Szabo K, Hennerici MG, Kern R. Predictors and early outcome of hemorrhagic transformation after acute ischemic stroke. Cerebrovasc Dis 2011; 32:334-41. [PMID: 21921596 DOI: 10.1159/000331702] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 08/10/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemorrhagic transformation (HT) after acute ischemic stroke is frequently detected using magnetic resonance imaging (MRI), in particular in patients treated with tissue plasminogen activator (tPA). Knowledge about causes and early clinical consequences of HT mostly arises from computed tomography-based studies. We analyzed potential predictors and early outcome of HT after stroke detected by MRI with T(2)*-weighted gradient echo sequences (T(2)*-MRI). METHODS 122 consecutive stroke patients (mean age 65.5 years, 41% women) who underwent T(2)*-MRI within 6-60 h after stroke onset were included. 25.4% of patients were treated with tPA; the overall detection rate of HT on T(2)*-MRI was 20.5%. Potential predictors of HT, such as age, sex, blood pressure, stroke etiology, prior antithrombotic medication, neurological deficit on admission, tPA treatment, and specific MRI findings, were analyzed. In addition, we evaluated the effect of HT on early outcome: a decrease of >4 points on the National Institute of Health Stroke Scale (NIHSS) on day 5 was considered early improvement, and an increase of >4 points was considered early deterioration. RESULTS The main predictor for occurrence of HT was tPA treatment (48.4 vs. 11.1%; odds ratio 7.50; 95% confidence interval 2.9-19.7; p < 0.001). Furthermore, the development of HT was associated with a severer neurological deficit on admission (mean NIHSS score 9.9 vs. 5.9; p = 0.003), and territorial infarction (88 vs. 58.8%; p = 0.007). 19 patients (15.6%) showed early improvement which was associated with the occurrence of HT (p = 0.011) and tPA treatment (p < 0.001). CONCLUSIONS HT is a frequent finding on T(2)*-MRI in patients with acute ischemic stroke associated with tPA treatment, territorial infarction and severer neurological deficits on admission. However, HT does not cause clinical deterioration; it is rather related to a favorable early outcome likely reflecting early recanalization and better reperfusion in these patients.
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Affiliation(s)
- Micha Kablau
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, Mannheim, Germany.
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Hoffmann A, Bredno J, Wendland MF, Derugin N, Hom J, Schuster T, Su H, Ohara PT, Young WL, Wintermark M. Validation of in vivo magnetic resonance imaging blood-brain barrier permeability measurements by comparison with gold standard histology. Stroke 2011; 42:2054-60. [PMID: 21636816 DOI: 10.1161/strokeaha.110.597997] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We sought to validate the blood-brain barrier permeability measurements extracted from perfusion-weighted MRI through a relatively simple and frequently applied model, the Patlak model, by comparison with gold standard histology in a rat model of ischemic stroke. METHODS Eleven spontaneously hypertensive rats and 11 Wistar rats with unilateral 2-hour filament occlusion of the right middle cerebral artery underwent imaging during occlusion at 4 hours and 24 hours after reperfusion. Blood-brain barrier permeability was imaged by gradient echo imaging after the first pass of the contrast agent bolus and quantified by a Patlak analysis. Blood-brain barrier permeability was shown on histology by the extravasation of Evans blue on fluorescence microscopy sections matching location and orientation of MR images. Cresyl-violet staining was used to detect and characterize hemorrhage. Landmark-based elastic image registration allowed a region-by-region comparison of permeability imaging at 24 hours with Evans blue extravasation and hemorrhage as detected on histological slides obtained immediately after the 24-hour image set. RESULTS Permeability values in the nonischemic tissue (marginal mean ± SE: 0.15 ± 0.019 mL/min 100 g) were significantly lower compared to all permeability values in regions of Evans blue extravasation or hemorrhage. Permeability values in regions of weak Evans blue extravasation (0.23 ± 0.016 mL/min 100 g) were significantly lower compared to permeability values of in regions of strong Evans blue extravasation (0.29 ± 0.020 mL/min 100 g) and macroscopic hemorrhage (0.35 ± 0.049 mL/min 100 g). Permeability values in regions of microscopic hemorrhage (0.26 ± 0.024 mL/min 100 g) only differed significantly from values in regions of nonischemic tissue (0.15 ± 0.019 mL/min 100 g). CONCLUSIONS Areas of increased permeability measured in vivo by imaging coincide with blood-brain barrier disruption and hemorrhage observed on gold standard histology.
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Affiliation(s)
- Angelika Hoffmann
- University of Virginia, Department of Radiology, Neuroradiology Division, Charlottesville, VA 22908, USA
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Sun L, Zhou W, Heiland S, Marti HH, Veltkamp R. A translationally relevant thromboembolic stroke model for the study of secondary hemorrhage after thrombolysis in rats. Brain Res 2010; 1368:346-54. [PMID: 20974110 DOI: 10.1016/j.brainres.2010.10.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2010] [Revised: 10/15/2010] [Accepted: 10/16/2010] [Indexed: 11/26/2022]
Abstract
Secondary hemorrhage after thrombolysis in ischemic stroke is an important complication, which has been difficult to study in preclinical disease models. We have established and characterized a model of thromboembolic middle cerebral artery occlusion in rats. Advantages of this model include a very low rate of spontaneous recanalization and good reperfusion after intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA). In vivo T2* MR imaging and postmortem assays were used for quantification of secondary brain hemorrhage. In our protocol, 12 thrombin-induced autologous blood clots are injected into the internal carotid artery. No spontaneous reperfusion occurs in the first 24h. However, injection of rt-PA 2 or 4h thereafter leads to reperfusion of the MCA territory consistent infarcts, increased blood-brain barrier permeability, and secondary hemorrhage. Remarkably, clinically important factors known to affect the extent and likelihood of secondary hemorrhage such as hypertension and delayed onset of thrombolysis also increase hematoma size in the model. Thus, the model may serve to investigate the pathophysiology of thrombolysis-induced hemorrhage in thromboembolic ischemia as well as potential adjunctive therapies to prevent this complication.
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Affiliation(s)
- Li Sun
- Department of Neurology, Ruprecht-Karls-University Heidelberg, INF 400, 69120, Heidelberg, Germany
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Oxygen therapy reduces secondary hemorrhage after thrombolysis in thromboembolic cerebral ischemia. J Cereb Blood Flow Metab 2010; 30:1651-60. [PMID: 20424638 PMCID: PMC2949252 DOI: 10.1038/jcbfm.2010.50] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hyperbaric oxygen (HBO) and normobaric hyperoxia (NBO) protect the brain parenchyma and the cerebral microcirculation against ischemia. We studied their effect on secondary hemorrhage after thrombolysis in two thromboembolic middle cerebral artery occlusion (MCAO) (tMCAO) models. Beginning 60 minutes after tMCAO with either thrombin-induced thromboemboli (TT) or calcium-induced thromboemboli (CT), spontaneously hypertensive rats (n=96) breathed either air, 100% O(2) (NBO), or 100% O(2) at 3 bar (HBO) for 1 hour. Immediately thereafter, recombinant tissue plasminogen activator (rt-PA, 9 mg/kg) was injected. Although significant reperfusion was observed after thrombolysis in TT-tMCAO, vascular occlusion persisted in CT-tMCAO. In TT-tMCAO, NBO and HBO significantly reduced diffusion-weighted imaging-magnetic resonance imaging (MRI) lesion volume and postischemic blood-brain barrier (BBB) permeability on postcontrast T1-weighted images. NBO and, significantly more potently, HBO reduced macroscopic hemorrhage on T2* MRI and on corresponding postmortem cryosections. Oxygen therapy lowered hemoglobin content and attenuated activation of matrix metalloproteinases in the ischemic hemisphere. In contrast, NBO and HBO failed to reduce infarct size in CT but both decreased BBB damage and microscopic hemorrhagic transformation. Only HBO reduced hemoglobin extravasation in the ischemic hemisphere. In conclusion, NBO and HBO decrease infarct size after thromboembolic ischemia only if recanalization is successful. As NBO and HBO also reduce postthrombolytic intracerebral hemorrhage, combining the two with thrombolysis seems promising.
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Hyperintense acute reperfusion marker on FLAIR is not associated with early haemorrhagic transformation in the elderly. Eur Radiol 2010; 20:2990-6. [PMID: 20652257 DOI: 10.1007/s00330-010-1881-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Revised: 05/29/2010] [Accepted: 06/08/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The hyperintense acute reperfusion marker (HARM) has been described as a predictor for haemorrhagic transformation (HT) in acute ischaemic stroke. We hypothesised that this phenomenon is not present in the elderly. METHODS It was possible to assess 47/84 consecutive patients aged 80 and over with diagnosed ischaemic stroke or transient ischaemic attack (TIA). MRI was performed within 24 h of onset of symptoms with follow-up MRI within a further 48 h. RESULTS Of 47 included patients, 19 showed HARM; it was only seen on follow-up examination. Ten of the 47 patients underwent thrombolysis with recombinant tissue plasminogen activator (rt-PA); 4 of them showed HARM, and 1 of those showed HT. HARM was found in three out of eight patients with haemorrhagic transformation on baseline and/or follow-up MRI. We did not observe an association between HARM and early HT either in the whole group or in the patients who received thrombolysis. CONCLUSION HARM was not associated with HT in the elderly after ischaemic stroke, independent of treatment. While it may indicate dysfunction of the blood-brain barrier (BBB), it does not necessarily amount to HT.
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Aviv RI, d'Esterre CD, Murphy BD, Hopyan JJ, Buck B, Mallia G, Li V, Zhang L, Symons SP, Lee TY. Hemorrhagic transformation of ischemic stroke: prediction with CT perfusion. Radiology 2009; 250:867-77. [PMID: 19244051 DOI: 10.1148/radiol.2503080257] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To determine whether admission computed tomography (CT) perfusion-derived permeability-surface area product (PS) maps differ between patients with hemorrhagic acute stroke and those with nonhemorrhagic acute stroke. MATERIALS AND METHODS This prospective study was institutional review board approved, and all participants gave written informed consent. Forty-one patients who presented with acute stroke within 3 hours after stroke symptom onset underwent two-phase CT perfusion imaging, which enabled PS measurement. Patients were assigned to groups according to whether they had hemorrhage transformation (HT) at follow-up magnetic resonance (MR) imaging and CT and/or whether they received tissue plasminogen activator (TPA) treatment. Clinical, demographic, and CT perfusion variables were compared between the HT and non-HT patient groups. Associations between PS and HT were tested at univariate and multivariate logistic regression analyses and receiver operating characteristic (ROC) analysis. RESULTS HT developed in 23 (56%) patients. Patients with HT had higher National Institutes of Health Stroke Scale (NIHSS) scores (P = .005), poorer outcomes (P = .001), and a higher likelihood of having received TPA (P = .005) compared with patients without HT. Baseline blood flow (P = .17) and blood volume (P = .11) defects and extent of flow reduction (P = .27) were comparable between the two groups. The mean PS for the HT group, 0.49 mL x min(-1) x (100 g)(-1), was significantly higher than that for the non-HT group, 0.09 mL x min(-1) x (100 g)(-1) (P < .0001). PS (odds ratio, 3.5; 95% confidence interval [CI]: 1.69, 7.06; P = .0007) and size of hypoattenuating area at nonenhanced admission CT (odds ratio, 0.4; 95% CI: 0.2, 0.7; P = .002) were the only independent variables associated with HT at stepwise multivariate analysis. The mean area under the ROC curve was 0.918 (95% CI: 0.828, 1.00). The PS threshold of 0.23 mL x min(-1) x (100 g)(-1) had 77% sensitivity and 94% specificity for detection of HT. CONCLUSION Admission PS measurement appears promising for distinguishing patients with acute stroke who are likely from those who are not likely to develop HT. SUPPLEMENTAL MATERIAL http://radiology.rsnajnls.org/cgi/content/full/250/3/867/DC1.
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Affiliation(s)
- Richard I Aviv
- Division of Neuroradiology, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
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Mechanisms and markers for hemorrhagic transformation after stroke. ACTA NEUROCHIRURGICA. SUPPLEMENT 2009; 105:173-8. [PMID: 19066105 DOI: 10.1007/978-3-211-09469-3_34] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Intracerebral hemorrhagic transformation is a multifactorial phenomenon in which ischemic brain tissue converts into a hemorrhagic lesion with blood vessel leakage. Hemorrhagic transformation can significantly contribute to additional brain injury after stroke. Especially threatening are the thrombolytic-induced hemorrhages after reperfusion therapy with tissue plasminogen activator (tPA), the only treatment available for ischemic stroke. In this context, it is important to understand its underlying mechanisms and identify early markers of hemorrhagic transformation, so that we can both search for new treatments as well as predict clinical outcomes in patients. In this review, we discuss the emerging mechanisms for hemorrhagic transformation after stroke, and briefly survey potential molecular, genetic, and neuroimaging markers that might be used for early detection of this challenging clinical problem.
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Copin JC, Gasche Y. Effect of the duration of middle cerebral artery occlusion on the risk of hemorrhagic transformation after tissue plasminogen activator injection in rats. Brain Res 2008; 1243:161-6. [DOI: 10.1016/j.brainres.2008.09.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Revised: 09/12/2008] [Accepted: 09/12/2008] [Indexed: 11/29/2022]
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Henning EC, Latour LL, Hallenbeck JM, Warach S. Reperfusion-associated hemorrhagic transformation in SHR rats: evidence of symptomatic parenchymal hematoma. Stroke 2008; 39:3405-10. [PMID: 18757286 DOI: 10.1161/strokeaha.108.520304] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Symptomatic hemorrhagic transformation (HT) is the most important complicating factor after treatment with intravenous tissue plasminogen activator. In this study, we used multimodal magnetic resonance imaging to investigate the incidence and severity of reperfusion-based HT in spontaneously hypertensive rats after ischemia/reperfusion. METHODS Twenty male spontaneously hypertensive rats were subjected to 30 minutes of middle cerebral artery occlusion via the suture model. Diffusion-weighted, T(2)-weighted, and gradient-echo imaging were performed on days 1, 2, 3, 4, and 7 for longitudinal evaluation of lesion evolution, vasogenic edema, and HT, respectively. Findings on gradient-echo images were classified according to the severity of hemorrhage: no HT; punctate or small petechial hemorrhage (HI-1); confluent petechial hemorrhage (HI-2); hematoma with absent/mild space-occupying effect (PH-1, <or=30% lesion volume); and hematoma with significant space-occupying effect and potential perihematomal edema (PH-2, >30% lesion volume). Histopathologic evaluation of HT was performed after final imaging for comparison with magnetic resonance imaging results. RESULTS Final hemorrhage scores based on severity were as follows: HI-1 23.1%, HI-2 30.8%, PH-1 30.8%, and PH-2 15.4%. Similar to clinical observations, only PH-2 was associated with neurologic deterioration and associated weight loss. CONCLUSIONS This model has a high incidence of parenchymal hematomas (46.2%) and therefore is appropriate for the evaluation of novel therapeutics targeting blood-brain barrier integrity and the reduction of symptomatic HT events (PH-2), as well as those potentially "at risk" for neurologic deterioration (PH-1).
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Affiliation(s)
- Erica C Henning
- Section on Stroke Diagnostics and Therapeutics, Stroke Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD 20892, USA.
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Kastrup A, Gröschel K, Ringer TM, Redecker C, Cordesmeyer R, Witte OW, Terborg C. Early disruption of the blood-brain barrier after thrombolytic therapy predicts hemorrhage in patients with acute stroke. Stroke 2008; 39:2385-7. [PMID: 18556588 DOI: 10.1161/strokeaha.107.505420] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Leaks of the blood-brain barrier can be detected on postcontrast-enhanced T1-weighted MRIs. Although early disruptions of the blood-brain barrier appear to be an important risk factor for tissue plasminogen activator-related hemorrhages in rodents, little is known about their incidence and consequences in human stroke. METHODS This is a retrospective analysis of a prospectively collected stroke database over the past 6 years. In 52 patients, multimodal MRI (including diffusion-weighted, perfusion-weighted, and postcontrast-enhanced T1-weighted MRI to detect blood-brain barrier changes) had been performed immediately before systemic thrombolysis and in 48 patients within a median of 30 minutes (interquartile range: 30 to 60 minutes) after recombinant tissue plasminogen activator treatment. The incidence of symptomatic hemorrhage (SICH), defined as any parenchymal hemorrhage leading to deterioration in the patient's clinical condition, was related to several clinical and imaging variables, including early blood-brain barrier changes. RESULTS Overall, SICH was detected in 9 (9%) patients and among these, 2 died. Although no blood-brain barrier changes were detectable before thrombolysis, 3 of 48 patients (6.25%) had a parenchymal gadolinium enhancement in the areas of initial infarction after tissue plasminogen activator treatment. All 3 patients developed SICHs at sites corresponding to the areas of enhancement. The presence of a parenchymal enhancement was significantly associated with SICH (P<0.01), whereas other clinical and imaging variables did not predict SICH in this series. CONCLUSIONS Early parenchymal enhancement after intravenous tissue plasminogen activator is significantly associated with subsequent SICH and could therefore become a useful imaging sign for the rapid initiation of preventive strategies in the future.
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Delayed matrix metalloproteinase inhibition reduces intracerebral hemorrhage after embolic stroke in rats. Exp Neurol 2008; 213:196-201. [PMID: 18590727 DOI: 10.1016/j.expneurol.2008.05.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Revised: 05/02/2008] [Accepted: 05/29/2008] [Indexed: 11/21/2022]
Abstract
Hemorrhagic transformation (HT) and brain edema are life-threatening complications of recombinant tissue plasminogen activator (rt-PA)-induced reperfusion after ischemic stroke. The risk of HT limits the therapeutic window for reperfusion to 3 h after stroke onset. Pre-treatment with matrix metalloproteinase (MMP) inhibitors reduces HT and cerebral edema in experimental stroke. However, whether a delayed therapeutic intervention would be beneficial is unknown. In this study, 215 male Sprague-Dawley rats were subjected to embolic stroke and 75 rats were included in the final analysis. The animals were treated with the MMP inhibitor p-aminobenzoyl-gly-pro-D-leu-D-ala-hydroxamate before or after 3 or 6 h of ischemia. Animals were monitored for reperfusion and received rt-PA 6 h after ischemia onset. The results at 24 h showed that MMP inhibition 3 h after ischemia significantly decreased the degree of brain edema (17% of hemispheric enlargement in the treated group versus 24% in controls, P=0.018), reduced the risk (OR=0.163; 95% CI: 0.029 to 0.953) and gravity (0.09 versus 0.19 mg of parenchymal hemoglobin, P=0.02) of intracerebral hemorrhage, and improved neurological outcome (20% of the treated animals had a slight deficit; all of the controls had a bad outcome, P<0.05). Delaying MMP inhibition to 6 h after ischemia restricted the beneficial role of the treatment to a reduction in the risk of parenchymal hemorrhage (OR=0.242; 95% CI: 0.060 to 0.989). Our results confirm the involvement of MMPs in HT and support the possibility of extending the therapeutic window for thrombolysis in stroke by administering a broad-spectrum MMP inhibitor after the onset of ischemia.
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Grillon E, Provent P, Montigon O, Segebarth C, Rémy C, Barbier EL. Blood-brain barrier permeability to manganese and to Gd-DOTA in a rat model of transient cerebral ischaemia. NMR IN BIOMEDICINE 2008; 21:427-436. [PMID: 17948222 DOI: 10.1002/nbm.1206] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Loss of integrity of the blood-brain barrier (BBB) and brain swelling is a potentially lethal complication of reperfusion in human stroke. To assess the time course of BBB modifications, we performed angiography, diffusion-weighted imaging, T1-weighted (T1 W) imaging and T1 mapping, and monitored acute changes after middle cerebral artery occlusion and recanalization in rats (n = 27). The animals were grouped according to the duration of occlusion: 30 min (group A, n = 8), 1 h 30 min (group B, n = 9), and 2 h 30 min (group C, n = 10). For 17 animals (four in group A, six in group B, and seven in group C), MnCl2 and dimeglumine gadoterate (Gd-DOTA) were injected at 13 min and 34 min after recanalization, respectively. The 10 remaining animals (control groups) underwent the same acquisition protocols, but no contrast agents were injected. Cell damage was determined 1 h after recanalization on haematoxylin and eosin-stained sections. Our results indicate that in the middle cerebral artery occlusion model in the rat, changes in BBB permeability assessed by contrast agent extravasation occur within the first hour of reperfusion, even after an occlusion period not exceeding 30 min. No differences between BBB permeability to Gd-DOTA and Mn2+ were detected in our experimental conditions. The reduction in apparent diffusion coefficient during occlusion appears to be a good predictor of BBB modifications after reperfusion in this model.
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Schatlo B, Henning EC, Pluta RM, Latour LL, Golpayegani N, Merrill MJ, Lewin N, Chen Y, Oldfield EH. Nitrite does not provide additional protection to thrombolysis in a rat model of stroke with delayed reperfusion. J Cereb Blood Flow Metab 2008; 28:482-9. [PMID: 17684515 DOI: 10.1038/sj.jcbfm.9600542] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
An adjuvant therapy to prolong the therapeutic window for stroke patients is urgently needed. This randomized, blinded, placebo-controlled study investigated adjuvant intravenous sodium nitrite with recombinant tissue plasminogen activator (rtPA) in middle cerebral artery occlusion (MCAO) with 6 and 2 h of ischemia followed by reperfusion in Sprague-Dawley rats (n=59). Quantitative diffusion, T(1)-, T(2)-weighted, and semiquantitative perfusion imaging were performed before and after reperfusion and at 48 h after ischemia to determine the spatiotemporal evolution of stroke. After 48 h animals were killed and examined to evaluate infarct size and evidence of hemorrhagic transformation. Factor VIII immunostaining was performed to assess vessel morphology. Nitrite treatment (6 h group: 37.5 micromol for more than 90 mins; 2 h group: 26.25 and 1.75 micromol for more than 60 mins) did not reduce infarct volume 48 h after MCAO compared with saline-treated placebo groups after 6 or 2 h of MCAO. Stroke progression from baseline to 48 h, based on the apparent diffusion coefficient and relative cerebral blood flow deficits before and after reperfusion and T(2)-weighted hyperintensity at 48 h, did not differ between treated and control animals. These results suggest that nitrite is not a protective adjuvant therapy to delayed rtPA administration after ischemic stroke in rats.
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Affiliation(s)
- Bawarjan Schatlo
- Surgical Neurology Branch, National Institutes of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892, USA
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Abstract
PURPOSE OF REVIEW MRI is increasingly used as the primary imaging modality in acute stroke, since it allows treatment based on individual pathophysiology rather than strict time windows. RECENT FINDINGS PET studies have confirmed that regions with disturbed diffusion frequently indicate irreversible tissue damage, although they may in part be viable. The mismatch between a larger perfusion deficit and a smaller diffusion abnormality contains both critically hypoperfused regions as well as oligemic regions. Although mismatch is thus not perfect, recent prospective trials have convincingly shown that mismatch patients treated with revascularization therapies benefit from reperfusion, while patients without mismatch do not. This is particularly important for patients presenting beyond the first three hours. In addition, several studies have investigated MRI as a tool to assess the risk of thrombolytic treatment. Parameters reflecting severe ischemia, blood-brain barrier damage and preexisting small-vessel disease emerge as risk factors for intracerebral hemorrhage, while microbleeds are not clearly associated with an increased risk. SUMMARY Based on data from prospective trials, the mismatch concept is an acceptable method to identify patients who benefit from recanalization therapies. The concept, however, still needs to be further improved and standard definitions are required before widespread use can be recommended.
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Lin K, Kazmi KS, Law M, Babb J, Peccerelli N, Pramanik BK. Measuring elevated microvascular permeability and predicting hemorrhagic transformation in acute ischemic stroke using first-pass dynamic perfusion CT imaging. AJNR Am J Neuroradiol 2007; 28:1292-8. [PMID: 17698530 PMCID: PMC7977671 DOI: 10.3174/ajnr.a0539] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Hemorrhagic transformation (HT) can be a devastating complication of acute ischemic stroke (AIS). The purpose of this study was to determine whether increased microvascular permeability (PS) of the blood-brain barrier was detected in early AIS by using first-pass dynamic perfusion CT (PCT) and whether PS was significantly higher in infarcts destined for HT. MATERIALS AND METHODS Fifty patients with AIS less than 3 hours old and evaluated by PCT were included. PS color maps were retrospectively generated from PCT data using the Patlak model. One reader analyzed each PS map by drawing 4 circular 10-mm regions of interest on any focal abnormality. The mean of these 4 regions of interest represented the PS of the infarct (PSinfarct). The mean of 4 mirror regions of interest on the nonischemic contralateral hemisphere was also obtained (PScontrol). PSinfarct and PScontrol were compared by using an exact Wilcoxon test. PSinfarct for infarcts that developed HT on follow-up (PSHT) was compared with all of the others (PSNo-HT) using an exact Mann-Whitney test. RESULTS Forty-four infarcts (88%) showed focal PS elevation in the region of infarct. In units of milliliters per 100 milliliters per minute, PSinfarct ranged from 0 to 13 (mean: 3.5+/-3.1) versus PScontrol of 0-0.8 (mean: 0.28+/-0.27; P<.0001). Six infarcts (12%) developed HT, all of which were within the region of PS elevation. PSHT ranged from 5.2 to 13 (mean: 9.8+/-2.9) versus PSNo-HT of 0-5.9 (mean: 2.7+/-2.0; P<.0001). Eighteen infarcts (36%) were treated with recombinant tissue plasminogen activator (rtPA). A significant difference between PSHT and PSNo-HT persisted irrespective of rtPA treatment. CONCLUSIONS Elevated permeability was detectable in AIS by using first-pass PCT and it predicted subsequent HT.
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Affiliation(s)
- K Lin
- Department of Radiology, New York University Medical Center, New York, NY 10029, USA
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Foerch C, Wunderlich MT, Dvorak F, Humpich M, Kahles T, Goertler M, Alvarez-Sabín J, Wallesch CW, Molina CA, Steinmetz H, Sitzer M, Montaner J. Elevated serum S100B levels indicate a higher risk of hemorrhagic transformation after thrombolytic therapy in acute stroke. Stroke 2007; 38:2491-5. [PMID: 17673718 DOI: 10.1161/strokeaha.106.480111] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage constitutes an often fatal sequela of thrombolytic therapy in patients with ischemic stroke. Early blood-brain barrier disruption may play an important role, and the astroglial protein S100B is known to indicate blood-brain barrier dysfunction. We investigated whether elevated pretreatment serum S100B levels predict hemorrhagic transformation (HT) in thrombolyzed patients with stroke. METHODS We retrospectively included 275 patients with ischemic stroke (mean age of 69+/-13 years; 46% female) who had received thrombolytic therapy within 6 hours of symptom onset. S100B levels were determined from pretreatment blood samples. Follow-up brain scans were obtained 24 hours after admission, and HT was classified as either hemorrhagic infarction (1, 2) or parenchymal hemorrhage (1, 2). RESULTS HT occurred in 80 patients (29%; 45 hemorrhagic infarction, 35 parenchymal hemorrhage). Median S100B values were significantly higher in patients with HT (0.14 versus 0.11 mug/L; P=0.017). An S100B value in the highest quintile corresponded to an OR for any HT of 2.87 (95% CI: 1.55 to 5.32; P=0.001) in univariate analysis and of 2.80 (1.40 to 5.62; P=0.004) after adjustment for age, sex, symptom severity, timespan from symptom onset to hospital admission, vascular risk factors, and storage time of serum probes. A pretreatment S100B value above 0.23 mug/L had only a moderate sensitivity (0.46) and specificity (0.82) for predicting severe parenchymal bleeding (parenchymal hemorrhage 2). CONCLUSIONS Elevated S100B serum levels before thrombolytic therapy constitute an independent risk factor for HT in patients with acute stroke. Unfortunately, the diagnostic accuracy of S100B is too low for it to function in this context as a reliable biomarker in clinical practice.
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Affiliation(s)
- Christian Foerch
- Department of Neurology, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
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42
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Lansberg MG, Albers GW, Wijman CAC. Symptomatic intracerebral hemorrhage following thrombolytic therapy for acute ischemic stroke: a review of the risk factors. Cerebrovasc Dis 2007; 24:1-10. [PMID: 17519538 DOI: 10.1159/000103110] [Citation(s) in RCA: 157] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2006] [Accepted: 12/21/2006] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Symptomatic intracerebral hemorrhage (SICH) following thrombolytic therapy for acute ischemic stroke is associated with a high rate of morbidity and mortality. Knowledge of the risk factors associated with SICH following thrombolyitc therapy may provide insight into the pathophysiological mechanisms underlying the development of SICH, lead to the development of treatments that reduce the risk of SICH and have implications for the design of future stroke trials. METHODS Relevant studies were identified through a search in Pubmed. Included studies used multivariate analyses to identify independent risk factors for SICH following thrombolytic therapy. For each variable that was found to have a significant association with SICH, a secondary literature search was conducted to identify additional reports on the specific relationship between that variable and SICH. SUMMARY OF REVIEW Twelve studies met inclusion criteria for the systematic review. Extent of hypoattenuated brain parenchyma on pretreatment CT and elevated serum glucose or history of diabetes were independent risk factors for thrombolysis-associated SICH in six of the twelve studies. Symptom severity was an independent risk factor in three of the studies and advanced age, increased time to treatment, high systolic blood pressure, low platelets, history of congestive heart failure and low plasminogen activator inhibitor levels were found to be independent risk factors for SICH in a single study. Although these data should not alter the current guidelines for the use of rt-PA in acute stroke, they may help develop future strategies aimed at reducing the rate of thrombolysis-associated SICH.
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43
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Neumann-Haefelin T, Hoelig S, Berkefeld J, Fiehler J, Gass A, Humpich M, Kastrup A, Kucinski T, Lecei O, Liebeskind DS, Rother J, Rosso C, Samson Y, Saver JL, Yan B. Leukoaraiosis Is a Risk Factor for Symptomatic Intracerebral Hemorrhage After Thrombolysis for Acute Stroke. Stroke 2006; 37:2463-6. [PMID: 16931786 DOI: 10.1161/01.str.0000239321.53203.ea] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The aim of the study was to evaluate whether leukoaraiosis (LA) is a risk factor for symptomatic intracerebral hemorrhage (sICH) in patients treated with thrombolysis for acute stroke.
Methods—
In this retrospective, multicenter analysis, we evaluated data from acute anterior circulation stroke patients (n=449; <6 hours after symptom onset) treated with thrombolysis. All patients had received standard magnetic resonance imaging evaluation before thrombolysis, including a high-quality T2-weighted sequence. For the analysis, LA in the deep white matter was dichotomized into absent or mild versus moderate or severe (corresponding to Fazekas scores of 0 to 1 versus 2 to 3).
Results—
The rate of sICH was significantly more frequent in patients with moderate to severe LA of the deep white matter (n=12 of 114; 10.5%) than in patients without relevant LA (n=13 of 335; 3.8%), corresponding to an odds ratio of 2.9 (95% CI, 1.29 to 6.59;
P
=0.015). In a logistic-regression analysis (including age, National Institutes of Health Stroke Scale score at presentation, and type of thrombolytic treatment), LA remained a significant independent risk factor (odds ratio, 2.9;
P
=0.03).
Conclusions—
LA of the deep white matter is an independent risk factor for sICH after thrombolytic treatment for acute stroke.
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Affiliation(s)
- Tobias Neumann-Haefelin
- Klinik für Neurologie, ZNN, Klinikum der Goethe-Universität, Schleusenweg 2-16, 60528 Frankfurt, Germany.
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44
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Ding G, Jiang Q, Li L, Zhang L, Gang Zhang Z, Ledbetter KA, Ewing JR, Li Q, Chopp M. Detection of BBB disruption and hemorrhage by Gd-DTPA enhanced MRI after embolic stroke in rat. Brain Res 2006; 1114:195-203. [PMID: 16950236 DOI: 10.1016/j.brainres.2006.07.116] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Revised: 07/10/2006] [Accepted: 07/13/2006] [Indexed: 11/21/2022]
Abstract
Thrombolytic therapy with rtPA increases the risk of hemorrhagic transformation (HT) after cerebral ischemia. We employed contrast enhancement MRI with Gd-DTPA to detect HT in a rat model of embolic stroke treated with rtPA and a glycoprotein IIb/IIIa receptor antagonist, 7E3 F(ab')2, at 4 h after embolic stroke. Male Wistar rats were subjected to embolic stroke and treated with the combination of rtPA and 7E3 F(ab')2 (n=12) or with saline (n=10) at 4 h after onset of stroke. MRI studies were performed immediately and at 24 h after embolization using a 7-T system. Histological measurements were obtained at 48 h. With Gd-DTPA, T1WI images and permeability related MRI parameters (the blood-to-brain transfer constant, Ki, and the distribution volume of mobile protons, Vp) of 15 out of 18 animals showed hyperintensity regions in gross or microscopic HT areas at 24 h, confirmed histologically at 48 h post stroke. Contrast enhancement MRI detected six of seven (86%) animals with gross HT and nine of eleven (82%) animals with microscopic HT at 24 h after ischemia. Two of eighteen animals with HT, had MRI indices of hemorrhage at 3 h post stroke. However, compared to HT data measured histologically at 48 h in embolic stroke rats, the enhanced areas by Gd-DTPA at 24 h were larger, and the patterns (time, intensity and region) did not directly correlate to the subtypes of HT, i.e., gross or microscopic hemorrhage. Contrast enhancement MRI using Gd-DTPA provides a method to detect gross and microscopic HT after stroke in rats.
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Affiliation(s)
- Guangliang Ding
- Department of Neurology, Henry Ford Health Sciences Center, 2799 West Grand Boulevard, Detroit, MI 48202, USA
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45
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Weber R, Ramos-Cabrer P, Hoehn M. Present status of magnetic resonance imaging and spectroscopy in animal stroke models. J Cereb Blood Flow Metab 2006; 26:591-604. [PMID: 16292254 DOI: 10.1038/sj.jcbfm.9600241] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Magnetic resonance imaging (MRI) is based on a wide variety of physical parameters, which, in principle, can all influence the image contrast conditions. As these diverse variables are validated by independent physiological, metabolic, hemodynamic, and histological techniques, a physiological MRI evolves. This imaging modality has been successfully applied to experimental stroke studies, covering a broad range of raised questions. In the present review, we present an overview of possible physiological criteria to be studied by in vivo MRI and magnetic resonance spectroscopy, and critically analyze the present limits and future potential of the imaging technique for experimental stroke investigations. The documented applications cover the spectrum from morphological-structural details of the lesion to hemodynamic and metabolic alterations, inflammatory reaction, evaluation of thrombolytic treatment, studies on recovery of functional brain activation by functional MRI, and, finally, the most recent applications of exploring stem cells for regenerative therapy.
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Affiliation(s)
- Ralph Weber
- In-vivo-NMR-Laboratory, Max-Planck-Institute for Neurological Research, Cologne, Germany
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46
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Knight RA, Nagesh V, Nagaraja TN, Ewing JR, Whitton PA, Bershad E, Fagan SC, Fenstermacher JD. Acute blood-brain barrier opening in experimentally induced focal cerebral ischemia is preferentially identified by quantitative magnetization transfer imaging. Magn Reson Med 2006; 54:822-32. [PMID: 16142716 DOI: 10.1002/mrm.20630] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pathologic changes in brain tissue during and after stroke may lead to injury of the blood-brain barrier (BBB) and subsequent hemorrhagic transformation (HT). In a rat model of HT, the apparent diffusion coefficient of water, cerebral blood flow, relaxation times, T(1) and T(2), and magnetization transfer (MT) related parameters (T(1sat), K(for) and the MT ratio) were repetitively measured during 3 h of focal ischemia and 2 h of reperfusion (n = 8). Areas of BBB opening were identified by sequential assay of the transcapillary influx of Gd-diethylenetriaminepentaacetic acid (Gd-DTPA) by MRI and (14)C-alpha-aminoisobutyric acid (AIB) by quantitative autoradiography. Ischemia-injured regions of interest were identified from the MRI data and divided into those with and without BBB opening. Of the several MRI parameters measured, the T(1sat) in the caudate-putamen and preoptic area during ischemia and the first 2 h of reperfusion correlated best with the regional pattern of BBB opening observed thereafter. These data suggest that an ipsilateral/contralateral T(1sat) ratio > 1.6 demarcates leakage of small molecules such as Gd-DTPA and AIB across the BBB. As to clinical relevance, the quantitation of MT parameters in acute stroke may enable the early detection of areas of BBB opening and potential HT.
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Affiliation(s)
- Robert A Knight
- Department of Neurology, Henry Ford Health Sciences Center, Detroit, MI 48202, USA.
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47
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Rowley HA. Extending the Time Window for Thrombolysis: Evidence from Acute Stroke Trials. Neuroimaging Clin N Am 2005; 15:575-87, x. [PMID: 16360590 DOI: 10.1016/j.nic.2005.08.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Data from intravenous tissue plasminogen activator studies have shown rapidly diminishing clinical benefit beyond 3 hours when noncontrast CT is used for treatment triage. Newer trials, such as the Desmoteplase in Acute Ischemic Stroke trial, have now successfully pushed the time window out to 9 hours using the concept of penumbral imaging and treatment of the perfusion-diffusion mismatch. Advanced imaging with CT or MR imaging protocols is providing a means for rational physiologic selection and outcomes assessment in stroke treatment.
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Affiliation(s)
- Howard A Rowley
- Department of Radiology, University of Wisconsin, Madison, WI 53792, USA.
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48
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Ding G, Nagesh V, Jiang Q, Zhang L, Zhang ZG, Li L, Knight RA, Li Q, Ewing JR, Chopp M. Early Prediction of Gross Hemorrhagic Transformation by Noncontrast Agent MRI Cluster Analysis After Embolic Stroke in Rat. Stroke 2005; 36:1247-52. [PMID: 15879323 DOI: 10.1161/01.str.0000166199.10017.c5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Our goal was to develop magnetic resonance indices, without image contrast agent enhancement, that predict hemorrhagic transformation (HT) in a rat model of embolic stroke.
Methods—
Male Wistar rats subjected to embolic stroke with (n=12) or without (n=10) the combination treatment with recombinant tissue plasminogen activator and an anti–platelet glycoprotein IIb/IIIa antibody 7E3 F(ab′)
2
initiated at 4 hours after onset of stroke were investigated using a 7-T MRI system. Radiofrequency saturation T
1
(T
1sat
) maps with magnetization transfer, apparent diffusion coefficient of water (ADC
w
) maps in 3 directions, and T
2
maps were measured at 2, 24, and 48 hours after embolization. MRI data were analyzed individually and using 2D cluster plots. Histological measurements were obtained at 48 hours.
Results—
Gross hemorrhage was detected at 48 hours in 7 (4 control, 3 treated) of 22 animals. The 2D cluster plot using MRI T
1sat
and ADC
w
maps obtained at 2 hours after stroke predicted all gross HT. The location of gross hemorrhage predicted by the 2D cluster plot was within 0.75 mm of the identifying MRI cluster.
Conclusions—
The 2D MRI cluster plot analysis using T
1sat
and ADC
w
maps acquired at 2 hours after the onset of embolic stroke predicts gross HT.
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Affiliation(s)
- Guangliang Ding
- Department of Neurology, Henry Ford Health Sciences Center, Detroit, MI 48202, USA
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49
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Kim EY, Kim SS, Na DG, Roh HG, Ryoo JW, Kim HK. Sulcal Hyperintensity on Fluid-Attenuated Inversion Recovery Imaging in Acute Ischemic Stroke Patients Treated With Intra-Arterial Thrombolysis. J Comput Assist Tomogr 2005; 29:264-9. [PMID: 15772550 DOI: 10.1097/01.rct.0000155669.05643.49] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the effect of iodinated contrast medium on sulcal hyperintensity on fluid-attenuated inversion recovery (FLAIR) imaging immediately after intra-arterial thrombolysis in patients with acute ischemic stroke and to determine whether it may be associated with subsequent hemorrhagic transformation (HT). METHODS Fourteen consecutive patients with acute ischemic stroke who were treated with intra-arterial thrombolysis were enrolled. All patients underwent noncontrast computed tomography (NCT) and diffusion-weighted (DWI), perfusion-weighted, gradient-recalled echo (GRE), and gadolinium-enhanced T1-weighted magnetic resonance imaging (MRI). Immediate follow-up NCT and MRI (T2-weighted, FLAIR, GRE, DWI, perfusion-weighted, T1-weighted, and gadolinium-enhanced T1-weighted) were obtained and evaluated to determine the presence of sulcal hyperintensity or subarachnoid hemorrhage (SAH). The same follow-up images were obtained on days 1, 3, and 7 and evaluated to determine HT. RESULTS Sulcal hyperintensity was found in 8 (57.1%) of 14 patients and was seen as hyperattenuation on immediate follow-up NCT and as hyperintensity on T1-weighted images in 4 (50%) of 8 patients. It may be suggested that the sulcal hyperattenuation was responsible for the sulcal hyperintensity, considering signal intensity and follow-up imaging. All patients with sulcal hyperintensity showed enhancement in the corresponding gyri on gadolinium-enhanced T1-weighted imaging. Hemorrhagic transformation developed in 5 of 8 patients with sulcal hyperintensity and in 1 of 4 patients without (P = 0.031). CONCLUSIONS In acute ischemic patients treated with intra-arterial thrombolysis, sulcal hyperintensity on FLAIR imaging may be caused by iodinated contrast medium, which should not be considered SAH. Sulcal hyperintensity is significantly associated with subsequent HT.
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Affiliation(s)
- Eung Yeop Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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50
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Latour LL, Kang DW, Ezzeddine MA, Chalela JA, Warach S. Early blood-brain barrier disruption in human focal brain ischemia. Ann Neurol 2004; 56:468-77. [PMID: 15389899 DOI: 10.1002/ana.20199] [Citation(s) in RCA: 351] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Loss of integrity of the blood-brain barrier (BBB) resulting from ischemia/reperfusion is believed to be a precursor to hemorrhagic transformation (HT) and poor outcome. We used a novel magnetic resonance imaging marker to characterize early BBB disruption in human focal brain ischemia and tested for associations with reperfusion, HT, and poor outcome (modified Rankin score >2). BBB disruption was found in 47 of 144 (33%) patients, having a median time from stroke onset to observation of 10.1 hours. Reperfusion was found to be the most powerful independent predictor of early BBB disruption (p = 0.018; odds ratio, 4.09; 95% confidence interval, 1.28-13.1). HT was observed in 22 patients; 16 (72.7%) of those also had early BBB disruption (p < 0.001; odds ratio, 8.11; 95% confidence interval, 2.85-23.1). In addition to baseline severity (National Institutes of Health Stroke Scale score >6), early BBB disruption was found to be an independent predictor of HT. Because the timing of the disruption was early enough to make it relevant to acute thrombolytic therapy, early BBB disruption as defined by this imaging biomarker may be a promising target for adjunctive therapy to reduce the complications associated with thrombolytic therapy, broaden the therapeutic window, and improve clinical outcome.
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Affiliation(s)
- Lawrence L Latour
- Stroke Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20878, USA.
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