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Lee TH, Uchiyama S, Kusuma Y, Chiu HC, Navarro JC, Tan KS, Pandian J, Guo L, Wong Y, Venketasubramanian N. A systematic-search-and-review of registered pharmacological therapies investigated to improve neuro-recovery after a stroke. Front Neurol 2024; 15:1346177. [PMID: 38356890 PMCID: PMC10866005 DOI: 10.3389/fneur.2024.1346177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/08/2024] [Indexed: 02/16/2024] Open
Abstract
Background Stroke burden is largely due to long-term impairments requiring prolonged care with loss of productivity. We aimed to identify and assess studies of different registered pharmacological therapies as treatments to improve post-stroke impairments and/or disabilities. Methods We performed a systematic-search-and-review of treatments that have been investigated as recovery-enhancing or recovery-promoting therapies in adult patients with stroke. The treatment must have received registration or market authorization in any country regardless of primary indication. Outcomes included in the review were neurological impairments and functional/disability assessments. "The best available studies" based on study design, study size, and/or date of publication were selected and graded for level of evidence (LOE) by consensus. Results Our systematic search yielded 7,801 citations, and we reviewed 665 full-text papers. Fifty-eight publications were selected as "the best studies" across 25 pharmacological classes: 31 on ischemic stroke, 21 on ischemic or hemorrhagic stroke, 4 on intracerebral hemorrhage, and 2 on subarachnoid hemorrhage (SAH). Twenty-six were systematic reviews/meta-analyses, 29 were randomized clinical trials (RCTs), and three were cohort studies. Only nimodipine for SAH had LOE A of benefit (systematic review and network meta-analysis). Many studies, some of which showed treatment effects, were assessed as LOE C-LD, mainly due to small sample sizes or poor quality. Seven interventions had LOE B-R (systematic review/meta-analysis or RCT) of treatment effects. Conclusion Only one commercially available treatment has LOE A for routine use in stroke. Further studies of putative neuroprotective drugs as adjunctive treatment to revascularization procedures and more confirmatory trials on recovery-promoting therapies will enhance the certainty of their benefit. The decision on their use must be guided by the clinical profile, neurological impairments, and target outcomes based on the available evidence. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=376973, PROSPERO, CRD42022376973.
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Affiliation(s)
- Tsong-Hai Lee
- Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Medical Center, Tokyo, Japan
| | | | - Hou Chang Chiu
- Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
| | | | - Kay Sin Tan
- University of Malaya Medical Center, Kuala Lumpur, Malaysia
| | | | - Liang Guo
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation, Singapore, Singapore
| | - Yoko Wong
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation, Singapore, Singapore
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Vos EM, Geraedts VJ, van der Lugt A, Dippel DWJ, Wermer MJH, Hofmeijer J, van Es ACGM, Roos YBWEM, Peeters-Scholte CMPCD, van den Wijngaard IR. Systematic Review - Combining Neuroprotection With Reperfusion in Acute Ischemic Stroke. Front Neurol 2022; 13:840892. [PMID: 35370911 PMCID: PMC8969766 DOI: 10.3389/fneur.2022.840892] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/17/2022] [Indexed: 12/22/2022] Open
Abstract
Background Clinical trials of neuroprotection in acute ischemic stroke (AIS) have provided disappointing results. Reperfusion may be a necessary condition for positive effects of neuroprotective treatments. This systematic review provides an overview of efficacy of neuroprotective agents in combination with reperfusion therapy in AIS. Methods A literature search was performed on the following databases, namely PubMed, Embase, Web of Science, Cochrane Library, Emcare. All databases were searched up to September 23rd 2021. All randomized controlled trials in which patients were treated with neuroprotective strategies within 12 h of stroke onset in combination with intravenous thrombolysis (IVT), endovascular therapy (EVT), or both were included. Results We screened 1,764 titles/abstracts and included 30 full reports of unique studies with a total of 16,160 patients. In 15 studies neuroprotectants were tested for clinical efficacy, where all patients had to receive reperfusion therapies, either IVT and/or EVT. Heterogeneity in reported outcome measures was observed. Treatment was associated with improved clinical outcome for: 1) uric acid in patients treated with EVT and IVT, 2) nerinetide in patients who underwent EVT without IVT, 3) imatinib in stroke patients treated with IVT with or without EVT, 4) remote ischemic perconditioning and IVT, and 5) high-flow normobaric oxygen treatment after EVT, with or without IVT. Conclusion Studies specifically testing effects of neuroprotective agents in addition to IVT and/or EVT are scarce. Future neuroprotection studies should report standardized functional outcome measures and combine neuroprotective agents with reperfusion therapies in AIS or aim to include prespecified subgroup analyses for treatment with IVT and/or EVT.
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Affiliation(s)
- E. M. Vos
- Department of Neurology, The Hague Medical Center, The Hague, Netherlands
- *Correspondence: E. M. Vos
| | - V. J. Geraedts
- Department of Neurology, The Hague Medical Center, The Hague, Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - A. van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - D. W. J. Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - M. J. H. Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - J. Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands
- Department of Clinical Neurophysiology, Technical Medical Centre, University of Twente, Enschede, Netherlands
| | - A. C. G. M. van Es
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Radiology, The Hague Medical Center, The Hague, Netherlands
| | - Y. B. W. E. M. Roos
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | | | - I. R. van den Wijngaard
- Department of Neurology, The Hague Medical Center, The Hague, Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
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Modrau B, Winder A, Hjort N, Nygård Johansen M, Andersen G, Fiehler J, Vorum H, Forkert ND. Perfusion Changes in Acute Stroke Treated with Theophylline as an Add-on to Thrombolysis : A Randomized Clinical Trial Subgroup Analysis. Clin Neuroradiol 2021; 32:345-352. [PMID: 34259904 PMCID: PMC9187573 DOI: 10.1007/s00062-021-01029-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/28/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Theophylline has been suggested to have a neuroprotective effect in ischemic stroke; however, results from animal stroke models and clinical trials in humans are controversial. The aim of this study was to assess the effect of theophylline on the cerebral perfusion with multiparametric magnetic resonance imaging (MRI). METHODS The relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), and relative mean transit time (rMTT) in the infarct core, penumbra, and unaffected tissue were measured using multi-parametric MRI at baseline and 3‑h follow-up in patients treated with theophylline or placebo as an add-on to thrombolytic therapy. RESULTS No significant differences in mean rCBF, rCBV, and rMTT was found in the penumbra and unaffected tissue between the theophylline group and the control group between baseline and 3‑h follow-up. In the infarct core, mean rCBV increased on average by 0.05 in the theophylline group and decreased by 0.14 in the control group (p < 0.04). Mean rCBF and mean rMTT in the infarct core were similar between the two treatment groups. CONCLUSION The results indicate that theophylline does not change the perfusion in potentially salvageable penumbral tissue but only affects the rCBV in the infarct core. In contrast to the penumbra, the infarct core is unlikely to be salvageable, which might explain why theophylline failed in clinical trials.
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Affiliation(s)
- Boris Modrau
- Department of Neurology, Aalborg University Hospital, Postbox 561, 9100, Aalborg, Denmark.
| | - Anthony Winder
- Departments of Radiology & Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Niels Hjort
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Grethe Andersen
- Department of Neurology and Clinical Medicine, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik Vorum
- Department of Ophthalmology, Aalborg University Hospital, Aalborg, Denmark
| | - Nils D Forkert
- Departments of Radiology & Clinical Neurosciences, University of Calgary, Calgary, Canada
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Modrau B, Winder A, Hjort N, Johansen MN, Andersen G, Fiehler J, Vorum H, Forkert ND. Machine Learning-Based Prediction of Brain Tissue Infarction in Patients With Acute Ischemic Stroke Treated With Theophylline as an Add-On to Thrombolytic Therapy: A Randomized Clinical Trial Subgroup Analysis. Front Neurol 2021; 12:613029. [PMID: 34093387 PMCID: PMC8175622 DOI: 10.3389/fneur.2021.613029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 04/19/2021] [Indexed: 12/03/2022] Open
Abstract
Background and Purpose: The theophylline in acute ischemic stroke trial investigated the neuroprotective effect of theophylline as an add-on to thrombolytic therapy in patients with acute ischemic stroke. The aim of this pre-planned subgroup analysis was to use predictive modeling to virtually test for differences in the follow-up lesion volumes. Materials and Methods: A subgroup of 52 patients from the theophylline in acute ischemic stroke trial with multi-parametric MRI data acquired at baseline and at 24-h follow-up were analyzed. A machine learning model using voxel-by-voxel information from diffusion- and perfusion-weighted MRI and clinical parameters was used to predict the infarct volume for each individual patient and both treatment arms. After training of the two predictive models, two virtual lesion outcomes were available for each patient, one lesion predicted for theophylline treatment and one lesion predicted for placebo treatment. Results: The mean predicted volume of follow-up lesions was 11.4 ml (standard deviation 18.7) for patients virtually treated with theophylline and 11.2 ml (standard deviation 17.3) for patients virtually treated with placebo (p = 0.86). Conclusions: The predicted follow-up brain lesions for each patient were not significantly different for patients virtually treated with theophylline or placebo, as an add-on to thrombolytic therapy. Thus, this study confirmed the lack of neuroprotective effect of theophylline shown in the main clinical trial and is contrary to the results from preclinical stroke models.
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Affiliation(s)
- Boris Modrau
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Anthony Winder
- Departments of Radiology & Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Niels Hjort
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Grethe Andersen
- Department of Neurology and Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik Vorum
- Department of Ophthalmology, Aalborg University Hospital, Aalborg, Denmark
| | - Nils D Forkert
- Departments of Radiology & Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
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