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Mergenthaler P, Balami JS, Neuhaus AA, Mottahedin A, Albers GW, Rothwell PM, Saver JL, Young ME, Buchan AM. Stroke in the Time of Circadian Medicine. Circ Res 2024; 134:770-790. [PMID: 38484031 DOI: 10.1161/circresaha.124.323508] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/15/2024] [Indexed: 03/19/2024]
Abstract
Time-of-day significantly influences the severity and incidence of stroke. Evidence has emerged not only for circadian governance over stroke risk factors, but also for important determinants of clinical outcome. In this review, we provide a comprehensive overview of the interplay between chronobiology and cerebrovascular disease. We discuss circadian regulation of pathophysiological mechanisms underlying stroke onset or tolerance as well as in vascular dementia. This includes cell death mechanisms, metabolism, mitochondrial function, and inflammation/immunity. Furthermore, we present clinical evidence supporting the link between disrupted circadian rhythms and increased susceptibility to stroke and dementia. We propose that circadian regulation of biochemical and physiological pathways in the brain increase susceptibility to damage after stroke in sleep and attenuate treatment effectiveness during the active phase. This review underscores the importance of considering circadian biology for understanding the pathology and treatment choice for stroke and vascular dementia and speculates that considering a patient's chronotype may be an important factor in developing precision treatment following stroke.
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Affiliation(s)
- Philipp Mergenthaler
- Center for Stroke Research Berlin (P.M., A.M.B.), Charité - Universitätsmedizin Berlin, Germany
- Department of Neurology with Experimental Neurology (P.M.), Charité - Universitätsmedizin Berlin, Germany
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Joyce S Balami
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Ain A Neuhaus
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, United Kingdom (A.A.N.)
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Amin Mottahedin
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Nuffield Department of Clinical Neurosciences (A.M., P.M.R.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Gregory W Albers
- Department of Neurology, Stanford Hospital, Palo Alto, CA (G.W.A.)
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences (A.M., P.M.R.), University of Oxford, United Kingdom
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences (P.M.R.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, Geffen School of Medicine, University of Los Angeles, CA (J.L.S.)
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Martin E Young
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham (M.E.Y.)
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
| | - Alastair M Buchan
- Center for Stroke Research Berlin (P.M., A.M.B.), Charité - Universitätsmedizin Berlin, Germany
- Stroke Research, Radcliffe Department of Medicine (P.M., J.S.B., A.A.N., A.M., A.M.B.), University of Oxford, United Kingdom
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) (P.M., J.S.B., A.A.N., A.M., G.W.A., P.M.R., J.L.S., M.E.Y., A.M.B.)
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2
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Mezuki S, Matsuo R, Irie F, Shono Y, Kuwashiro T, Sugimori H, Wakisaka Y, Ago T, Kamouchi M, Kitazono T. Body temperature in the acute phase and clinical outcomes after acute ischemic stroke. PLoS One 2024; 19:e0296639. [PMID: 38206979 PMCID: PMC10783745 DOI: 10.1371/journal.pone.0296639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/15/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND This study aimed to examine whether post-stroke early body temperature is associated with neurological damage in the acute phase and functional outcomes at three months. METHODS We included 7,177 patients with acute ischemic stroke within 24 h of onset. Axillary temperature was measured daily in the morning for seven days. Mean body temperature was grouped into five quintiles (Q1: 35.1‒36.5°C, Q2: 36.5‒36.7°C, Q3: 36.7‒36.8°C, Q4: 36.8‒37.1°C, and Q5: 37.1‒39.1°C). Clinical outcomes included neurological improvement during hospitalization and poor functional outcome (modified Rankin scale score, 3-6) at three months. A logistic regression analysis was performed to evaluate the association between body temperature and clinical outcomes. RESULTS The patient's mean (SD) age was 70.6 (12.3) years, and 35.7% of patients were women. Mean body temperature was significantly associated with less neurological improvement from Q2 (odds ratios [95% confidence interval], 0.77 [0.65-0.99] vs. Q1) to Q5 (0.33 [0.28-0.40], P for trend <0.001) even after adjusting for potential confounders, including baseline neurological severity, C-reactive protein levels, and post-stroke acute infections. The multivariable-adjusted risk of poor functional outcome linearly increased from Q2 (1.36 [1.03-1.79]) to Q5 (6.44 [5.19-8.96], P for trend <0.001). These associations were maintained even in the analyses excluding patients with acute infectious diseases. Multivariable-adjusted risk of poor functional outcome was higher in patients with early body temperature elevation on days 1-3 and with longer duration with body temperature >37.0°C. CONCLUSIONS Post-stroke early high body temperature is independently associated with unfavorable outcomes following acute ischemic stroke.
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Affiliation(s)
- Satomi Mezuki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Ryu Matsuo
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Center for Cohort Study, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Fumi Irie
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Center for Cohort Study, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuji Shono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Takahiro Kuwashiro
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cerebrovascular Medicine and Neurology, Kyushu Medical Center, Fukuoka, Japan
| | - Hiroshi Sugimori
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cerebrovascular Medicine and Neurology, Kyushu Medical Center, Fukuoka, Japan
| | - Yoshinobu Wakisaka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Center for Cohort Study, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuro Ago
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Center for Cohort Study, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Kamouchi
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Center for Cohort Study, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Center for Cohort Study, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Diprose WK, Rao A, Ghate K, Dyer Z, Campbell D, Almekhlafi M, Barber PA. Penumbral cooling in ischemic stroke with intraarterial, intravenous or active conductive head cooling: A thermal modeling study. J Cereb Blood Flow Metab 2024; 44:66-76. [PMID: 37734834 PMCID: PMC10905634 DOI: 10.1177/0271678x231203025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 09/23/2023]
Abstract
In ischemic stroke, selectively cooling the ischemic penumbra might lead to neuroprotection while avoiding systemic complications. Because penumbral tissue has reduced cerebral blood flow and in vivo brain temperature measurement remains challenging, the effect of different methods of therapeutic hypothermia on penumbral temperature are unknown. We used the COMSOL Multiphysics® software to model a range of cases of therapeutic hypothermia in ischemic stroke. Four ischemic stroke models were developed with ischemic core and/or penumbra volumes between 33-300 mL. Four experiments were performed on each model, including no cooling, and intraarterial, intravenous, and active conductive head cooling. The steady-state temperature of the non-ischemic brain, ischemic penumbra, and ischemic core without cooling was 37.3 °C, 37.5-37.8 °C, and 38.9-39.4 °C respectively. Intraarterial, intravenous and active conductive head cooling reduced non-ischemic brain temperature by 4.3 °C, 2.1 °C, and 0.7-0.8 °C respectively. Intraarterial, intravenous and head cooling reduced the temperature of the ischemic penumbra by 3.9-4.3 °C, 1.9-2.1 °C, and 1.2-3.4 °C respectively. Active conductive head cooling was the only method to selectively reduce penumbral temperature. Clinical studies that measure brain temperature in ischemic stroke patients undergoing therapeutic hypothermia are required to validate these hypothesis-generating findings.
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Affiliation(s)
- William K Diprose
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Avinash Rao
- Department of Engineering, Victoria University of Wellington, Wellington, New Zealand
| | - Kaustubha Ghate
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Zoe Dyer
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Doug Campbell
- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | | | - P Alan Barber
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
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4
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Wang C. Comment on "Association of clinical factors to functional outcomes in patients with stroke with large-vessel occlusion after endovascular thrombectomy". J Formos Med Assoc 2023; 122:1227-1228. [PMID: 37365100 DOI: 10.1016/j.jfma.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Affiliation(s)
- Chaohui Wang
- Department of General Medicine, Yiwu Central Hospital, Zhejiang 322000, China.
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5
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Chen X, An H, Wu D, Ji X. Research progress of selective brain cooling methods in the prehospital care for stroke patients: A narrative review. Brain Circ 2023; 9:16-20. [PMID: 37151794 PMCID: PMC10158655 DOI: 10.4103/bc.bc_88_22] [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: 11/02/2022] [Revised: 01/14/2023] [Accepted: 01/29/2023] [Indexed: 05/09/2023] Open
Abstract
Over the past four decades, therapeutic hypothermia (TH) has long been suggested as a promising neuroprotective treatment of acute ischemic stroke (AIS). Much attention has focus on keeping the hypothermic benefits and removing side effects of systemic hypothermia. In the past few years, the advent of intravenous thrombolysis and endovascular thrombectomy has taken us into a reperfusion era of AIS treatment. With recent research emphasizing ways to plus neuroprotective treatments to reperfusion therapy, the spotlight is now shifting toward the study of how selective brain hypothermia can offset the drawbacks of systemic hypothermia and be applied in prehospital condition. This mini-review summarizes current brain cooling methods that can be used for inducing selective hypothermia in prehospital care. It will guide the future development of selective cooling methods, extend the application of TH in prehospital care, and provide insights into the prospects of selective hypothermia in AIS.
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Affiliation(s)
- Xi Chen
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Hong An
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- Address for correspondence: Dr. Xunming Ji, Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing 100053, China. E-mail:
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6
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Wang X, Wang X, Ma J, Jia M, Wu L, Li W, Li C, Wu C, Ren C, Chen X, Zhao W, Ji X. Association between the time of day at stroke onset and functional outcome of acute ischemic stroke patients treated with endovascular therapy. J Cereb Blood Flow Metab 2022; 42:2191-2200. [PMID: 35791272 PMCID: PMC9670006 DOI: 10.1177/0271678x221111852] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
To investigate the association between time-of-day of stroke onset and functional outcome in patients with acute ischemic stroke(AIS) treated with endovascular thrombectomy(EVT). AIS patients treated with EVT between January 2013 and December 2018 were recruited and divided them into four 6-h interval groups according to the time-of-day of stroke onset. A total of 438 patients were enrolled, 3-month favorable outcome were achieved in 58.6%, 43.7%, 36.6%, and 30.5% of patients in the 00:00-06:00, 06:00-12:00, 12:00-18:00, and 18:00-24:00 groups, respectively (adjusted OR 0.61, 95% CI 0.40-0.93; p = 0.020). Compared with the 18:00-24:00 interval, patients in the 00:00-06:00 interval (adjusted OR 4.01, 95%CI 1.02-15.80, p = 0.047) and the 06:00-12:00 interval (adjusted OR 3.24, 95% CI 1.09-9.64, p = 0.034) were more likely to achieve favorable outcome. The time-of-day of stroke onset was not associated with 3-month mortality (adjusted p = 0.829), symptomatic intracerebral hemorrhage (sICH, adjusted p = 0.296), or early successful recanalization (adjusted p = 0.074). In conclusion, in AIS patients treated with EVT, those onsets either between 00:00 and 06:00 or between 06:00 and 12:00 appeared to be associated with a higher proportion of favorable outcomes at 3 months, but the time-of-day at stroke onset was not associated with the incidence of sICH, rate of early successful recanalization, or 3-month mortality.
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Affiliation(s)
- Xian Wang
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Xiaoyin Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jin Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Milan Jia
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Longfei Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weili Li
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin Chen
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.,Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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7
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Diprose WK, Morgan CA, Wang MT, Diprose JP, Lin JC, Sheriff S, Campbell D, Barber PA. Active conductive head cooling of normal and infarcted brain: A magnetic resonance spectroscopy imaging study. J Cereb Blood Flow Metab 2022; 42:2058-2065. [PMID: 35707879 PMCID: PMC9580175 DOI: 10.1177/0271678x221107988] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Active conductive head cooling is a simple and non-invasive intervention that may slow infarct growth in ischemic stroke. We investigated the effect of active conductive head cooling on brain temperature using whole brain echo-planar spectroscopic imaging. A cooling cap (WElkins Temperature Regulation System, 2nd Gen) was used to administer cooling for 80 minutes to healthy volunteers and chronic stroke patients. Whole brain echo-planar spectroscopic imaging scans were obtained before and after cooling. Brain temperature was estimated using the Metabolite Imaging and Data Analysis System software package, which allows voxel-level temperature calculations using the chemical shift difference between metabolite (N-acetylaspartate, creatine, choline) and water resonances. Eleven participants (six healthy volunteers, five post-stroke) underwent 80 ± 5 minutes of cooling. The average temperature of the coolant was 1.3 ± 0.5°C below zero. Significant reductions in brain temperature (ΔT = -0.9 ± 0.7°C, P = 0.002), and to a lesser extent, rectal temperature (ΔT = -0.3 ± 0.1°C, P = 0.03) were observed. Exploratory analysis showed that the occipital lobes had the greatest reduction in temperature (ΔT = -1.5 ± 1.2°C, P = 0.002). Regions of infarction had similar temperature reductions to the contralateral normal brain. Future research could investigate the feasibility of head cooling as a potential neuroprotective strategy in patients being considered for acute stroke therapies.
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Affiliation(s)
- William K Diprose
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Catherine A Morgan
- Centre for Advanced MRI, The University of Auckland, Auckland, New Zealand.,School of Psychology and Centre for Brain Research, The University of Auckland, Auckland, New Zealand
| | - Michael Tm Wang
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | | | - Joanne C Lin
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand
| | - Sulaiman Sheriff
- Department of Radiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Doug Campbell
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - P Alan Barber
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Department of Neurology, Auckland City Hospital, Auckland, New Zealand
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8
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Zhang W, Li F, Zhang C, Lei B, Deng W, Zeng H, Yu Y, Wu J, Peng D, Tian Z, Zhu X, Hu Z, Hong Y, Li W, Ge H, Xu X, Ju D, Yang S, Pan C, Zi W, Wang S. Impact of Body Temperature in Patients With Acute Basilar Artery Occlusion: Analysis of the BASILAR Database. Front Neurol 2022; 13:907410. [PMID: 35720074 PMCID: PMC9205153 DOI: 10.3389/fneur.2022.907410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundA link between body temperature and stroke outcomes has been established but not for acute basilar artery occlusion. We aimed to determine the association between body temperature and clinical outcomes in patients with acute basilar artery occlusion and temperature management range.MethodsWe included patients from the Endovascular Treatment for Acute Basilar Artery Occlusion Study (BASILAR) database with records of both admission body temperature (ABT) and peak body temperature (PBT). ABT was defined as the body temperature first measured at the hospital visit, PBT was defined as the highest temperature within 24 h of treatment, and minus body temperature (MBT) was defined as PBT-ABT. The primary clinical outcome was favorable functional outcome, defined as the proportion of patients with a modified Rankin Scale score of 0–3 at 3 months. Secondary outcomes included 3-month mortality, in-hospital mortality, and symptomatic cerebral hemorrhage.ResultsA total of 664 patients were enrolled in the study; 74.7% were men, with a median age of 65 (interquartile range, 57.25–74) years. In all patients, multivariate analysis indicated that PBT and MBT were independent predictors of favorable functional outcome [odds ratio (OR), 0.57 (95% CI, 0.43–0.77); OR, 0.68 (95% CI, 0.52–0.88), respectively], and higher ABT, PBT, and MBT were associated with an increased 3-month mortality [OR, 1.47 (95% CI, 1.03–2.10), OR, 1.58 (95% CI, 1.28–1.96), OR, 1.35 (95% CI, 1.11–1.65), respectively]. Proportional odds models demonstrated that when ABT, PBT, MBT were in the range of <37.5, <38.9, and −0.6–2.7°C, respectively, the benefit of the endovascular treatment is clearly greater than that of standard medical treatment in terms of favorable functional outcome.ConclusionsBody temperature is an independent predictor of clinical outcome in patients with acute basilar artery occlusion. It is necessary to control the patient body temperature within the appropriate range in clinical settings.Trial RegistrationChinese Clinical Trial Registry ChiCTR1800014759. Registered 03 February 2018. Retrospectively registered.
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Affiliation(s)
- Wenbin Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Cai Zhang
- Department of Neurology, Daqing Oilfield General Hospital, Daqing, China
| | - Bo Lei
- Department of Cerebrovascular Diseases, Leshan People's Hospital, Leshan, China
| | - Wei Deng
- Department of Neurology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Hongliang Zeng
- Department of Neurology, Ganzhou People's Hospital, Ganzhou, China
| | - Yang Yu
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Junxiong Wu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Daizhou Peng
- Department of Neurology, Qianxinan People's Hospital, Xingyi, China
| | - Zhenxuan Tian
- Department of Neurology, The 404th Hospital of Mianyang, Mianyang, China
| | - Xiurong Zhu
- Department of Neurology, Chongzhou People's Hospital, Chongzhou, China
| | - Zhizhou Hu
- Department of Neurology, Longyan No. 1 Hospital, Longyan, China
| | - Yifan Hong
- Department of Neurology, Shantou Central Hospital, Shantou, China
| | - Wenbo Li
- Department of Neurointervention, Luoyang Central Hospital, Luoyang, China
| | - Hanming Ge
- Department of Neurology, Xi'an Third Hospital, Xi'an, China
| | - Xinwei Xu
- Department of Neurology, Jieyang People's Hospital, Jieyang, China
| | - Dongsheng Ju
- Department of Neurology, Songyuan Jilin Oilfield Hospital, Songyuan, China
| | - Shunyu Yang
- Department of Neurology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Chengde Pan
- Department of Neurology, Banan District People's Hospital, Chongqing, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Wenjie Zi
| | - Shouchun Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
- *Correspondence: Shouchun Wang
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9
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Luo Y, Chen M, Fang J, Dong S, Ma M, Bao J, Feng L, He L. Relationship Between Body Temperature and Early Neurological Deterioration after Endovascular Thrombectomy for Acute Ischemic Stroke with Large Vessel Occlusion. Neurocrit Care 2022; 37:399-409. [PMID: 34981427 DOI: 10.1007/s12028-021-01416-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/30/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Early neurological deterioration (END) after endovascular thrombectomy (EVT) is strongly associated with poor prognosis in patients with large vessel occlusion. The relationship between body temperature and END after EVT is unknown, which we aimed to investigate in this study. METHODS END was defined as an increase of four or more points on the National Institutes of Health Stroke Scale score compared with the baseline assessment within 24 h. Logistic regression and restricted cubic spline models were used to assess the relationship between body temperature and END. RESULTS Among 7741 consecutive patients with ischemic stroke, 406 patients with large vessel occlusion who underwent EVT were enrolled. In total, 88 (21.7%) patients developed END. Logistic regression showed that the maximum body temperature within 24 h (odds ratio [OR] = 1.97 per °C, 95% confidence interval [CI] 1.17-3.32, p = 0.010) was independently associated with END. This association was nonlinear and J shaped (p for nonlinearity = 0.010), and the risk of END increased when the maximum body temperature within 24 h was lower or higher than 37.0 °C. Fever burden is also independently associated with END (OR = 1.06 per °C × hour, 95% CI 1.01-1.11, p = 0.012). In addition, the timing of fever onset was independently associated with END, and the highest risk of END was associated with fever onset within 6 h after EVT (OR = 3.92, 95% CI 1.25-12.27, p = 0.019). CONCLUSIONS In summary, there is a J-shaped association between the maximum body temperature within 24 h after EVT and END. Moreover, the risk of END differed according to the timing of fever onset.
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Affiliation(s)
- Yaxi Luo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Man Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jinghuan Fang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Shuju Dong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mengmeng Ma
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jiajia Bao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ling Feng
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.
- West China School of Nursing, Sichuan University, Chengdu, China.
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.
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Chen M, Fang J, Wu X, Liu Q, Feng L, He L. Association between hyperpyrexia and poststroke outcomes in patients with recanalization after mechanical thrombectomy: a retrospective cohort study. BMC Neurol 2021; 21:365. [PMID: 34548043 PMCID: PMC8454168 DOI: 10.1186/s12883-021-02400-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 09/14/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Limited data are available for evaluating the relationship between the prognosis and body temperature (BT) in patients treated with mechanical thrombectomy (MT), especially in those with successful recanalization. We aimed to explore the prognostic value of BT in predicting outcomes of stroke recovery at 3 months poststroke. METHODS We retrospectively analyzed the relationship among BT levels as a continuous variable, with fever (BT ≥ 37.5℃) as a binary variable, and obtained several outcomes of interest. Subjects were stratified according to successful recanalization (thrombolysis in cerebral infarction scores of 2b-3) following MT. Functional independence was defined as a modified Rankin scale (mRS) score of 0-2. RESULTS In total, 258 patients were included. The proportion of patients with functional independence was significantly lower among patients with BT ≥ 37.5℃ than among those with BT < 37.5 °C (45.3 % versus 23.0 %; P < 0.001). In the multivariate analysis, hyperpyrexia (especially BT ≥ 38 °C) was significantly associated with poor 3-month outcomes in patients treated with MT. Subgroup analysis was conducted by comparing the successful recanalization group with the non-recanalization group, showing that BT ≥ 37.5 °C was associated with a significantly lower proportion of functional independence in the recanalized patients. Besides, the Kaplan-Meier model showed that the fever group had significantly lower survival rates than the non-fever group during the 3-month follow-up. CONCLUSIONS In patients treated with MT, hyperpyrexia is an independent predictor of poststroke outcomes at 3 months, particularly in those with successful recanalization.
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Affiliation(s)
- Man Chen
- Department of Neurology, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Jinghuan Fang
- Department of Neurology, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Xintong Wu
- Department of Neurology, West China Hospital, Sichuan University, 610041, Chengdu, China
| | - Qin Liu
- Department of Neurology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, 610041, Chengdu, China
| | - Ling Feng
- Department of Neurology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, 610041, Chengdu, China.
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, 610041, Chengdu, China.
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Sou BS, Aglio LS, Zhou J. Anesthetic Management of Acute Ischemic Stroke in the Interventional Neuro-Radiology Suite: State of the Art. Curr Opin Anaesthesiol 2021; 34:476-481. [PMID: 34074884 DOI: 10.1097/aco.0000000000001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review discusses the general anesthetic approach of endovascular stroke therapy and highlights recent advances and considerations for optimal intraoperative management of acute ischemic stroke. RECENT FINDINGS Recent randomized controlled trials have shown no differences in clinical outcomes between monitored anesthesia care with sedation compared with general anesthesia for endovascular stroke therapy. The COVID-19 pandemic has complicated decision-making in the neurointerventional setting. Advances in imaging techniques have extended the window of treatment for endovascular therapy. SUMMARY Optimal time to intervention, hemodynamic stability, novel imaging techniques, and careful consideration of anesthetic plan can impact patient outcomes in reperfusion stroke therapy.
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Affiliation(s)
- Brian S Sou
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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12
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Macha K, Schwab S. Endovascular treatment of large vessel occlusion acute ischemic stroke: Is there a place for hypothermia? Eur J Neurol 2021; 28:2469-2470. [PMID: 34008882 DOI: 10.1111/ene.14920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Kosmas Macha
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
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Hartmann C, Winzer S, Pallesen LP, Prakapenia A, Siepmann T, Moustafa H, Theilen H, Barlinn J, Gerber JC, Linn J, Reichmann H, Barlinn K, Puetz V. Inadvertent hypothermia after endovascular therapy is not associated with improved outcome in stroke due to anterior circulation large vessel occlusion. Eur J Neurol 2021; 28:2479-2487. [PMID: 33973292 DOI: 10.1111/ene.14906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Hypothermia may be neuroprotective in acute ischemic stroke. Patients with anterior circulation large vessel occlusion (acLVO) are frequently hypothermic after endovascular therapy (EVT). We sought to determine whether this inadvertent hypothermia is associated with improved outcome. METHODS We extracted data of consecutive patients (January 2016 to May 2019) who received EVT for acLVO from our prospective EVT register of all patients screened for EVT at our tertiary stroke center. We assessed functional outcome at 3 months and performed multivariate analysis to calculate adjusted risk ratios (aRRs) for favorable outcome (modified Rankin Scale scores = 0-2) and mortality across patients who were hypothermic (<36°C) and patients who were normothermic (≥36°C to <37.6°C) after EVT. Moreover, we compared the frequency of complications between these groups. RESULTS Among 837 patients screened, 416 patients received EVT for acLVO and fulfilled inclusion criteria (200 [48.1%] male, mean age = 76 ± 16 years, median National Institutes of Health Stroke Scale score = 16, interquartile range [IQR] = 12-20). Of these, 209 patients (50.2%) were hypothermic (median temperature = 35.2°C, IQR = 34.7-35.7) and 207 patients were normothermic (median temperature = 36.4°C, IQR = 36.1-36.7) after EVT. In multivariate analysis, hypothermia was not associated with favorable outcome (aRR = 0.99, 95% confidence interval [CI] = 0.75-1.31) and mortality (aRR = 1.18, 95% CI = 0.84-1.66). More hypothermic patients suffered from pneumonia (36.4% vs. 25.6%, p = 0.02) and bradyarrhythmia (52.6% vs. 16.4%, p < 0.001), whereas thromboembolic events were distributed evenly (5.7% vs. 6.8%, not significant). CONCLUSIONS Inadvertent hypothermia after EVT for acLVO is not associated with improved functional outcome or reduced mortality but is associated with an increased rate of pneumonia and bradyarrhythmia in patients with acute ischemic stroke.
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Affiliation(s)
- Christian Hartmann
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Simon Winzer
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Lars-Peder Pallesen
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Alexandra Prakapenia
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Haidar Moustafa
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Hermann Theilen
- Department of Anesthesiology, Technische Universität Dresden, Dresden, Germany
| | - Jessica Barlinn
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Johannes C Gerber
- Institute of Neuroradiology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Jennifer Linn
- Institute of Neuroradiology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
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Therapeutic Hypothermia in Critically Ill Patients: The Role of Hypothermia in the Critical Care Toolbox. Crit Care Med 2021; 48:1089-1090. [PMID: 32568908 DOI: 10.1097/ccm.0000000000004389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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Green TL, McNair ND, Hinkle JL, Middleton S, Miller ET, Perrin S, Power M, Southerland AM, Summers DV. Care of the Patient With Acute Ischemic Stroke (Posthyperacute and Prehospital Discharge): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association. Stroke 2021; 52:e179-e197. [PMID: 33691469 DOI: 10.1161/str.0000000000000357] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In 2009, the American Heart Association/American Stroke Association published a comprehensive scientific statement detailing the nursing care of the patient with an acute ischemic stroke through all phases of hospitalization. The purpose of this statement is to provide an update to the 2009 document by summarizing and incorporating current best practice evidence relevant to the provision of nursing and interprofessional care to patients with ischemic stroke and their families during the acute (posthyperacute phase) inpatient admission phase of recovery. Many of the nursing care elements are informed by nurse-led research to embed best practices in the provision and standard of care for patients with stroke. The writing group comprised members of the Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council. A literature review was undertaken to examine the best practices in the care of the patient with acute ischemic stroke. The drafts were circulated and reviewed by all committee members. This statement provides a summary of best practices based on available evidence to guide nurses caring for adult patients with acute ischemic stroke in the hospital posthyperacute/intensive care unit. In many instances, however, knowledge gaps exist, demonstrating the need for continued nurse-led research on care of the patient with acute ischemic stroke.
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Xu X, Yuan L, Wang W, Xu J, Yang Q, Zhu Y, Xu Y, Yang K, Ge L, Huang X, Zhou Z. Systemic Inflammatory Response Syndrome and Outcomes in Ischemic Patients Treated with Endovascular Treatment. Clin Interv Aging 2020; 15:2331-2340. [PMID: 33324045 PMCID: PMC7733387 DOI: 10.2147/cia.s281865] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 11/20/2020] [Indexed: 01/04/2023] Open
Abstract
Purpose Knowledge regarding the systemic inflammatory response syndrome (SIRS) associated with emergent large vessel occlusion (ELVO) is still insufficient. We aimed to investigate the occurrence rate, predictors, and clinical outcomes of SIRS in patients with ELVO after endovascular treatment (EVT). Patients and Methods We retrospectively collected EVT data of patients with ELVO from July 2015 to August 2019 in our center. SIRS in the absence of infection was recorded in detail. A favorable outcome was defined as obtaining a 90-day modified Rankin Scale (mRS) score ≤2. Results Among the 256 patients who received EVT, 91 (35.5%) developed SIRS. The patients who developed SIRS had a reduced favorable outcome (OR 4.112 [95% CI 1.705 to 9.920]; p=0.002) and higher mortality (OR 25.336 [95% CI 8.578 to 74.835]; p<0.001) at 90 days. A greater SIRS burden was positively correlated with the NIHSS scores at discharge and mRS scores at 90 days (r=0.265, p=0.011; r=0.245, p=0.019). The development of SIRS was associated with neutrophilic leukocytosis, hyperglycemia, higher NIHSS scores at admission, and worse collateral circulation. Conclusion The patients with SIRS had higher odds of poor functional outcomes and higher mortality at 90 days in the EVT-treatment setting. The severity of the inflammatory response was positively correlated with the clinical outcomes of the patients. Clinically, SIRS was associated with neutrophilic leukocytosis, hyperglycemia, baseline stroke severity, and worse collateral circulation.
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Affiliation(s)
- Xiangjun Xu
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Lili Yuan
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Wenbing Wang
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Junfeng Xu
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Qian Yang
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Yujuan Zhu
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Youqing Xu
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Ke Yang
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Liang Ge
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Xianjun Huang
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Zhiming Zhou
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
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Ageing as a risk factor for cerebral ischemia: Underlying mechanisms and therapy in animal models and in the clinic. Mech Ageing Dev 2020; 190:111312. [PMID: 32663480 DOI: 10.1016/j.mad.2020.111312] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/24/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022]
Abstract
Age is the only one non-modifiable risk of cerebral ischemia. Advances in stroke medicine and behavioral adaptation to stroke risk factors and comorbidities was successful in decreasing stroke incidence and increasing the number of stroke survivors in western societies. Comorbidities aggravates the outcome after cerebral ischemia. However, due to the increased in number of elderly, the incidence of stroke has increased again paralleled by an increase in the number of stroke survivors, many with severe disabilities, that has led to an increased economic and social burden in society. Animal models of stroke often ignore age and comorbidities frequently associated with senescence. This might explain why drugs working nicely in animal models fail to show efficacy in stroke survivors. Since stroke afflicts mostly the elderly comorbid patients, it is highly desirable to test the efficacy of stroke therapies in an appropriate animal stroke model. Therefore, in this review, we make parallels between animal models of stroke und clinical data and summarize the impact of ageing and age-related comorbidities on stroke outcome.
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