1
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Pitts JK, Burns DM, Patellos KR. Tenecteplase-associated orolingual angioedema: A case report and literature review. Am J Health Syst Pharm 2024; 81:e220-e225. [PMID: 38270186 DOI: 10.1093/ajhp/zxad334] [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: 12/20/2023] [Indexed: 01/26/2024] Open
Abstract
PURPOSE Orolingual angioedema (OA) secondary to administration of thrombolytic therapy is a rare, but serious, known adverse effect. Despite the lack of robust evidence for their use, C1 esterase inhibitors are recommended by guidelines for the treatment of refractory thrombolytic-associated OA. This report highlights the use of a C1 esterase inhibitor in a patient with tenecteplase-associated OA unresolved by antihistamine and corticosteroid therapy. SUMMARY A 67-year-old white male with a history of hypertension managed with lisinopril presented to the emergency department with acute onset of slurred speech and left-sided hemiparesis. Following workup, an outside hospital's neurology stroke team suspected an acute infarct and determined the patient to be a candidate for tenecteplase. Approximately 1 hour after tenecteplase administration, the patient began complaining of dyspnea and mild oral angioedema. Immediate interventions for OA management included intravenous therapy with dexamethasone 10 mg, diphenhydramine 25 mg, and famotidine 20 mg. After an additional 30 minutes, the patient's OA symptoms continued to progress and a C1 esterase inhibitor (Berinert) was administered. Shortly after administration of the C1 esterase inhibitor, the patient's symptoms continued to worsen, ultimately leading to endotracheal intubation. Following intubation, symptom improvement was noted, and the patient was safely extubated after 30 hours. CONCLUSION Although rare, OA is a potentially life-threatening complication of tenecteplase therapy and requires prompt pharmacological intervention to optimize patient outcomes. Currently, no single agent or treatment algorithm exists that has shown significant efficacy or safety in the setting of thrombolytic-associated OA. Until data are available for C1 esterase inhibitors in this application, these inhibitors should only be considered if there is continued symptom progression after intravenous administration of corticosteroids and antihistamines.
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Affiliation(s)
- Jeffrey K Pitts
- Department of Pharmacy, Licking Memorial Hospital, Newark, OH, USA
| | - Dylan M Burns
- Department of Pharmacy, Licking Memorial Hospital, Newark, OH, USA
| | - Kevin R Patellos
- Department of Pharmacy, Licking Memorial Hospital, Newark, OH, USA
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2
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Arkelius K, Wendt TS, Andersson H, Arnou A, Gottschalk M, Gonzales RJ, Ansar S. LOX-1 and MMP-9 Inhibition Attenuates the Detrimental Effects of Delayed rt-PA Therapy and Improves Outcomes After Acute Ischemic Stroke. Circ Res 2024; 134:954-969. [PMID: 38501247 DOI: 10.1161/circresaha.123.323371] [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: 08/08/2023] [Accepted: 03/06/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Acute ischemic stroke triggers endothelial activation that disrupts vascular integrity and increases hemorrhagic transformation leading to worsened stroke outcomes. rt-PA (recombinant tissue-type plasminogen activator) is an effective treatment; however, its use is limited due to a restricted time window and hemorrhagic transformation risk, which in part may involve activation of MMPs (matrix metalloproteinases) mediated through LOX-1 (lectin-like oxLDL [oxidized low-density lipoprotein] receptor 1). This study's overall aim was to evaluate the therapeutic potential of novel MMP-9 (matrix metalloproteinase 9) ± LOX-1 inhibitors in combination with rt-PA to improve stroke outcomes. METHODS A rat thromboembolic stroke model was utilized to investigate the impact of rt-PA delivered 4 hours poststroke onset as well as selective MMP-9 (JNJ0966) ±LOX-1 (BI-0115) inhibitors given before rt-PA administration. Infarct size, perfusion, and hemorrhagic transformation were evaluated by 9.4-T magnetic resonance imaging, vascular and parenchymal MMP-9 activity via zymography, and neurological function was assessed using sensorimotor function testing. Human brain microvascular endothelial cells were exposed to hypoxia plus glucose deprivation/reperfusion (hypoxia plus glucose deprivation 3 hours/R 24 hours) and treated with ±tPA and ±MMP-9 ±LOX-1 inhibitors. Barrier function was assessed via transendothelial electrical resistance, MMP-9 activity was determined with zymography, and LOX-1 and barrier gene expression/levels were measured using qRT-PCR (quantitative reverse transcription PCR) and Western blot. RESULTS Stroke and subsequent rt-PA treatment increased edema, hemorrhage, MMP-9 activity, LOX-1 expression, and worsened neurological outcomes. LOX-1 inhibition improved neurological function, reduced edema, and improved endothelial barrier integrity. Elevated MMP-9 activity correlated with increased edema, infarct volume, and decreased neurological function. MMP-9 inhibition reduced MMP-9 activity and LOX-1 expression. In human brain microvascular endothelial cells, LOX-1/MMP-9 inhibition differentially attenuated MMP-9 levels, inflammation, and activation following hypoxia plus glucose deprivation/R. CONCLUSIONS Our findings indicate that LOX-1 inhibition and ± MMP-9 inhibition attenuate negative aspects of ischemic stroke with rt-PA therapy, thus resulting in improved neurological function. While no synergistic effect was observed with simultaneous LOX-1 and MMP-9 inhibition, a distinct interaction is evident.
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Affiliation(s)
- Kajsa Arkelius
- Applied Neurovascular Research, Neurosurgery, Department of Clinical Sciences, Lund University, Sweden (K.A., H.A., A.A., S.A.)
| | - Trevor S Wendt
- Department of Basic Medical Sciences, University of Arizona College of Medicine, Phoenix, AZ (T.S.W., R.J.G.)
| | - Henrik Andersson
- Applied Neurovascular Research, Neurosurgery, Department of Clinical Sciences, Lund University, Sweden (K.A., H.A., A.A., S.A.)
| | - Anaële Arnou
- Applied Neurovascular Research, Neurosurgery, Department of Clinical Sciences, Lund University, Sweden (K.A., H.A., A.A., S.A.)
| | | | - Rayna J Gonzales
- Department of Basic Medical Sciences, University of Arizona College of Medicine, Phoenix, AZ (T.S.W., R.J.G.)
| | - Saema Ansar
- Applied Neurovascular Research, Neurosurgery, Department of Clinical Sciences, Lund University, Sweden (K.A., H.A., A.A., S.A.)
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3
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Arrarte Terreros N, Stolp J, Bruggeman AAE, Swijnenburg ISJ, Lopes RR, van Meenen LCC, Groot AED, Kappelhof M, Coutinho JM, Roos YBWEM, Emmer BJ, Beenen LFM, Dippel DWJ, van Zwam WH, van Bavel E, Marquering HA, Majoie CBLM. Thrombus Imaging Characteristics to Predict Early Recanalization in Anterior Circulation Large Vessel Occlusion Stroke. J Cardiovasc Dev Dis 2024; 11:107. [PMID: 38667725 PMCID: PMC11050543 DOI: 10.3390/jcdd11040107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
The early management of transferred patients with a large vessel occlusion (LVO) stroke could be improved by identifying patients who are likely to recanalize early. We aim to predict early recanalization based on patient clinical and thrombus imaging characteristics. We included 81 transferred anterior-circulation LVO patients with an early recanalization, defined as the resolution of the LVO or the migration to a distal location not reachable with endovascular treatment upon repeated radiological imaging. We compared their clinical and imaging characteristics with all (322) transferred patients with a persistent LVO in the MR CLEAN Registry. We measured distance from carotid terminus to thrombus (DT), thrombus length, density, and perviousness on baseline CT images. We built logistic regression models to predict early recanalization. We validated the predictive ability by computing the median area-under-the-curve (AUC) of the receiver operating characteristics curve for 100 5-fold cross-validations. The administration of intravenous thrombolysis (IVT), longer transfer times, more distal occlusions, and shorter, pervious, less dense thrombi were characteristic of early recanalization. After backward elimination, IVT administration, DT and thrombus density remained in the multivariable model, with an AUC of 0.77 (IQR 0.72-0.83). Baseline thrombus imaging characteristics are valuable in predicting early recanalization and can potentially be used to optimize repeated imaging workflow.
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Affiliation(s)
- Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jeffrey Stolp
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Agnetha A. E. Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Isabella S. J. Swijnenburg
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ricardo R. Lopes
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Laura C. C. van Meenen
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Adrien E. D. Groot
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Manon Kappelhof
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Yvo B. W. E. M. Roos
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ludo F. M. Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | | | - Wim H. van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands;
| | - Ed van Bavel
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
| | - Henk A. Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Pontius MHH, Ku CJ, Osmond MJ, Disharoon D, Liu Y, Warnock M, Lawrence DA, Marr DWM, Neeves KB, Shavit JA. Magnetically powered microwheel thrombolysis of occlusive thrombi in zebrafish. Proc Natl Acad Sci U S A 2024; 121:e2315083121. [PMID: 38408253 DOI: 10.1073/pnas.2315083121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/09/2024] [Indexed: 02/28/2024] Open
Abstract
Tissue plasminogen activator (tPA) is the only FDA-approved treatment for ischemic stroke but carries significant risks, including major hemorrhage. Additional options are needed, especially in small vessel thrombi which account for ~25% of ischemic strokes. We have previously shown that tPA-functionalized colloidal microparticles can be assembled into microwheels (µwheels) and manipulated under the control of applied magnetic fields to enable rapid thrombolysis of fibrin gels in microfluidic models of thrombosis. Transparent zebrafish larvae have a highly conserved coagulation cascade that enables studies of hemostasis and thrombosis in the context of intact vasculature, clotting factors, and blood cells. Here, we show that tPA-functionalized µwheels can perform rapid and targeted recanalization in vivo. This effect requires both tPA and µwheels, as minimal to no recanalization is achieved with tPA alone, µwheels alone, or tPA-functionalized microparticles in the absence of a magnetic field. We evaluated tPA-functionalized µwheels in CRISPR-generated plasminogen (plg) heterozygous and homozygous mutants and confirmed that tPA-functionalized µwheels are dose-dependent on plasminogen for lysis. We have found that magnetically powered µwheels as a targeted tPA delivery system are dramatically more efficient at plasmin-mediated thrombolysis than systemic delivery in vivo. Further development of this system in fish and mammalian models could enable a less invasive strategy for alleviating ischemia that is safer than directed thrombectomy or systemic infusion of tPA.
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Affiliation(s)
- M Hao Hao Pontius
- Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109
| | - Chia-Jui Ku
- Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109
| | - Matthew J Osmond
- Department of Chemical and Biological Engineering, Colorado School of Mines, Golden, CO 80401
| | - Dante Disharoon
- Department of Chemical and Biological Engineering, Colorado School of Mines, Golden, CO 80401
| | - Yang Liu
- Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109
| | - Mark Warnock
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Daniel A Lawrence
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109
| | - David W M Marr
- Department of Chemical and Biological Engineering, Colorado School of Mines, Golden, CO 80401
| | - Keith B Neeves
- Department of Bioengineering, University of Colorado, Denver, Aurora, CO 80045
- Department of Pediatrics, University of Colorado, Denver, Aurora, CO 80045
| | - Jordan A Shavit
- Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109
- Department of Human Genetics, University of Michigan, Ann Arbor, MI 48109
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5
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Chen X, Xu X, Li Y, Liu F, Zhang B, Zuo L. Association between fibrinogen-to-albumin ratio and functional prognosis of 3 months in patients with acute ischemic stroke after intravenous thrombolysis. Brain Behav 2024; 14:e3364. [PMID: 38376013 PMCID: PMC10757894 DOI: 10.1002/brb3.3364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 11/24/2023] [Accepted: 11/26/2023] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND The presence of high fibrinogen and low albumin levels in serum is associated with a negative prognosis in acute ischemic stroke (AIS). Fibrinogen-to-albumin ratio (FAR), a new inflammatory biomarker, may provide better prognostic insights in patients with AIS than separate evaluation of fibrinogen or albumin. The objective of this investigation is to examine the correlation between FAR and 3-month functional prognosis after intravenous thrombolysis (IVT) in AIS patients. METHODS The retrospective study recruited AIS patients who received IVT from June 2014 to December 2021. The 3-month functional prognosis was assessed using the Modified Rankin Scale (mRS). A mRS score of ≤2 indicated a good outcome, whereas a mRS score of >2 suggested a poor outcome. RESULTS A total of 591 AIS patients who underwent IVT were included and 147 patients (24.9 %) had a poor outcome. Among the 102 pairs of patients after propensity score matching, there was a significant association between FAR and 3-month prognosis (adjusted OR, 1.19; 95% CI, 1.03-1.38; p = .020). The optimal FAR cutoff value was found to be 7.57, and even after stratifying patients based on this value, we still observed a significant correlation between high FAR level and poor outcome (adjusted OR, 2.08; 95% CI, 1.28-3.40; p = .003). CONCLUSIONS FAR may serve as a prospective biomarker of predicting 3-month prognosis in AIS patients after IVT.
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Affiliation(s)
- Xinxin Chen
- Department of NeurologySchool of MedicineShanghai East HospitalTongji UniversityShanghaiChina
| | - Xiahong Xu
- Department of NeurologySchool of MedicineShanghai East HospitalTongji UniversityShanghaiChina
| | - Ying Li
- Department of NeurologySchool of MedicineShanghai East HospitalTongji UniversityShanghaiChina
| | - Feifeng Liu
- Department of NeurologySchool of MedicineShanghai East HospitalTongji UniversityShanghaiChina
| | - Bei Zhang
- Department of NeurologySchool of MedicineShanghai East HospitalTongji UniversityShanghaiChina
| | - Lian Zuo
- Department of NeurologySchool of MedicineShanghai East HospitalTongji UniversityShanghaiChina
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6
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Brewer PC, Ojo DT, Broughton PX, Imeh-Nathaniel A, Imeh-Nathaniel S, Nathaniel TI. Risk Factors Associated With Exclusion of Obese Patients Ischemic Stroke With a History of Smoking From Thrombolysis Therapy. Clin Appl Thromb Hemost 2024; 30:10760296241246264. [PMID: 38600881 PMCID: PMC11010763 DOI: 10.1177/10760296241246264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 04/12/2024] Open
Abstract
The objective of this study is to determine risk factors that may contribute to exclusion decision from recombinant tissue plasminogen activator (rtPA) in patients with acute ischemic stroke (AIS) with a combined current or history of smoking and obesity. This study was conducted on data from 5469 patients with AIS collected from a regional stroke registry. Risk factors associated with inclusion or exclusion from rtPA were determined using multivariate logistic regression analysis. The adjusted odds ratios and 95% confidence interval for each risk factor were used to predict the increasing odds of an association of a specific risk factor with exclusion from rtPA. In the adjusted analysis, obese patients with AIS with a history of smoking (current and previous) excluded from rtPA were more likely to present with carotid artery stenosis (OR = 0.069, 95% CI 0.011-0.442), diabetes (OR = 0.604, 95% CI 0.366-0.997), higher total cholesterol (OR = 0.975, 95% CI 0.956-0.995), and history of alcohol use (OR = 0.438, 95% CI 0.232-0.828). Higher NIHSS score (OR = 1.051, 95% CI 1.017-1.086), higher triglycerides (OR = 1.004, 95% CI 1.001-1.006), and higher high-density lipoprotein (OR = 1.028, 95% CI 1.000-1.057) were associated with the inclusion for rtPA. Our findings reveal specific risk factors that contribute to the exclusion of patients with AIS with a combined effect of smoking and obesity from rtPA. These findings suggest the need to develop management strategies to improve the use of rtPA for obese patients with AIS with a history of smoking.
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Affiliation(s)
- Philip C. Brewer
- Department of Biomedical Sciences, University of South Carolina, School of Medicine-Greenville, Greenville, SC, USA
| | - Dami T. Ojo
- Department of Biomedical Sciences, University of South Carolina, School of Medicine-Greenville, Greenville, SC, USA
| | - Philip X. Broughton
- Department of Biomedical Sciences, University of South Carolina, School of Medicine-Greenville, Greenville, SC, USA
| | | | | | - Thomas I. Nathaniel
- Department of Biomedical Sciences, University of South Carolina, School of Medicine-Greenville, Greenville, SC, USA
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7
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Pontius MHH, Ku CJ, Osmond M, Disharoon D, Liu Y, Marr DW, Neeves KB, Shavit JA. Magnetically Powered Microwheel Thrombolysis of Occlusive Thrombi in Zebrafish. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.09.11.557256. [PMID: 37745422 PMCID: PMC10515822 DOI: 10.1101/2023.09.11.557256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Tissue plasminogen activator (tPA) is the only FDA approved treatment for ischemic stroke but carries significant risks, including major hemorrhage. Additional options are needed, especially in small vessel thrombi which account for ~25% of ischemic strokes. We have previously shown that tPA-functionalized colloidal microparticles can be assembled into microwheels (µwheels) and manipulated under the control of applied magnetic fields to enable rapid thrombolysis of fibrin gels in microfluidic models of thrombosis. Providing a living microfluidic analog, transparent zebrafish larvae have a highly conserved coagulation cascade that enables studies of hemostasis and thrombosis in the context of intact vasculature, clotting factors, and blood cells. Here we show that tPA-functionalized µwheels can perform rapid and targeted recanalization in vivo. This effect requires both tPA and µwheels, as minimal to no recanalization is achieved with tPA alone, µwheels alone, or tPA-functionalized microparticles in the absence of a magnetic field. We evaluated tPA-µwheels in CRISPR-generated plasminogen (plg) heterozygous and homozygous mutants and confirmed that tPA-µwheels are dose-dependent on plasminogen for lysis. We have found that magnetically powered µwheels as a targeted tPA delivery system are dramatically more efficient at plasmin-mediated thrombolysis than systemic delivery in vivo. Further development of this system in fish and mammalian models could enable a less invasive strategy for alleviating ischemia that is safer than directed thrombectomy or systemic infusion of tPA.
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Affiliation(s)
| | - Chia-Jui Ku
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Matthew Osmond
- Department of Chemical and Biological Engineering, Colorado School of Mines, Golden, CO
| | - Dante Disharoon
- Department of Chemical and Biological Engineering, Colorado School of Mines, Golden, CO
| | - Yang Liu
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - David W.M. Marr
- Department of Chemical and Biological Engineering, Colorado School of Mines, Golden, CO
| | - Keith B. Neeves
- Departments of Bioengineering and Pediatrics, University of Colorado, Denver | Anschutz Medical Campus, Aurora, CO
| | - Jordan A. Shavit
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
- Department of Human Genetics, University of Michigan, Ann Arbor, MI
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Choi YH, Hsu M, Laaker C, Herbath M, Yang H, Cismaru P, Johnson AM, Spellman B, Wigand K, Sandor M, Fabry Z. Dual role of Vascular Endothelial Growth Factor-C (VEGF-C) in post-stroke recovery. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.08.30.555144. [PMID: 37693558 PMCID: PMC10491156 DOI: 10.1101/2023.08.30.555144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Using a mouse model of ischemic stroke, this study characterizes stroke-induced lymphangiogenesis at the cribriform plate (CP). While blocking CP lymphangiogenesis with a VEGFR-3 inhibitor improves stroke outcome, administration of VEGF-C induced larger brain infarcts. Abstract Cerebrospinal fluid (CSF), antigens, and antigen-presenting cells drain from the central nervous system (CNS) into lymphatic vessels near the cribriform plate and dural meningeal lymphatics. However, the pathological roles of these lymphatic vessels surrounding the CNS during stroke are not well understood. Using a mouse model of ischemic stroke, transient middle cerebral artery occlusion (tMCAO), we show that stroke induces lymphangiogenesis near the cribriform plate. Interestingly, lymphangiogenesis is restricted to lymphatic vessels at the cribriform plate and downstream cervical lymph nodes, without affecting the conserved network of lymphatic vessels in the dura. Cribriform plate lymphangiogenesis peaks at day 7 and regresses by day 14 following tMCAO and is regulated by VEGF-C/VEGFR-3. These newly developed lymphangiogenic vessels transport CSF and immune cells to the cervical lymph nodes. Inhibition of VEGF-C/VEGFR-3 signaling using a blocker of VEGFR-3 prevented lymphangiogenesis and led to improved stroke outcomes at earlier time points but had no effects at later time points following stroke. Administration of VEGF-C after tMCAO did not further increase post-stroke lymphangiogenesis, but instead induced larger brain infarcts. The differential roles for VEGFR-3 inhibition and VEGF-C in regulating stroke pathology call into question recent suggestions to use VEGF-C therapeutically for stroke.
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9
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Wu H, Tang Y, Zhang B, Klippel P, Jing Y, Yao J, Jiang X. Miniaturized Stacked Transducer for Intravascular Sonothrombolysis With Internal-Illumination Photoacoustic Imaging Guidance and Clot Characterization. IEEE Trans Biomed Eng 2023; 70:2279-2288. [PMID: 37022249 PMCID: PMC10399617 DOI: 10.1109/tbme.2023.3240725] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Thromboembolism in blood vessels can lead to stroke or heart attack and even sudden death unless brought under control. Sonothrombolysis enhanced by ultrasound contrast agents has shown promising outcome on effective treatment of thromboembolism. Intravascular sonothrombolysis was also reported recently with a potential for effective and safe treatment of deep thrombosis. Despite the promising treatment results, the treatment efficiency for clinical application may not be optimized due to the lack of imaging guidance and clot characterization during the thrombolysis procedure. In this paper, a miniaturized transducer was designed to have an 8-layer PZT-5A stacked with an aperture size of 1.4 × 1.4 mm2 and assembled in a customized two-lumen 10-Fr catheter for intravascular sonothrombolysis. The treatment process was monitored with internal-illumination photoacoustic tomography (II-PAT), a hybrid imaging modality that combines the rich contrast of optical absorption and the deep penetration of ultrasound detection. With intravascular light delivery using a thin optical fiber integrated with the intravascular catheter, II-PAT overcomes the penetration depth limited by strong optical attenuation of tissue. In-vitro PAT-guided sonothrombolysis experiments were carried out with synthetic blood clots embedded in tissue phantom. Clot position, shape, stiffness, and oxygenation level can be estimated by II-PAT at clinically relevant depth of ten centimeters. Our findings have demonstrated the feasibility of the proposed PAT-guided intravascular sonothrombolysis with real-time feedback during the treatment process.
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Amaral S, Duloquin G, Béjot Y. Symptomatic Intracranial Hemorrhage after Ischemic Stroke Treated with Bridging Revascularization Therapy. Life (Basel) 2023; 13:1593. [PMID: 37511968 PMCID: PMC10381185 DOI: 10.3390/life13071593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: bridging revascularization therapy is now the standard of care in patients with ischemic stroke due to large vessel occlusion. This study aimed to determine the frequency of symptomatic intracranial hemorrhage (sICH) related to this treatment, and to assess contributing factors and patients' outcomes. (2) Methods: consecutive ischemic stroke patients treated with bridging therapy were prospectively enrolled. sICH (intracranial hemorrhage with an increase in NIHSS score of ≥4 points) was assessed on imaging at 24 h. The functional status of patients was measured at 6 months using the mRS score; (3) Results: 176 patients were included (mean age 68.7 ± 1.2 years, 52.3% women), among whom 15 (8.5%) had sICH. Patients with sICH had more frequent alcohol abuse (30.1% versus 9.7%, p = 0.023), prestroke use of dual antiplatelet therapy (14.3% versus 1.3%, p = 0.002), higher NIHSS scores at admission (median score 20.5 versus 15, p = 0.01), greater systolic blood pressure upon admission, more frequent vascular intracranial calcifications (p = 0.004), leukoaraiosis (p = 0.001), and intracranial atheroma (p = 0.02), and higher neutrophil-to-lymphocyte ratios (p = 0.02) and neutrophil-to-platelet ratios (p = 0.04). At 6-month follow-up, 9 (60%) patients with sICH died, versus 18% of patients without sICH (p < 0.001). Only 1 (7%) patient with sICH had a good functional outcome, defined as an mRS score of 0 to 2, versus 51% of patients without sICH. (4) Conclusions: one in twelve ischemic stroke patients treated with bridging therapy suffered sICH. Given the observed poor outcomes after sICH, further studies are required to better identify patients at risk to help clinicians in guiding therapeutic strategies.
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Affiliation(s)
- Simon Amaral
- Neurology Department, Dijon University Hospital, 21000 Dijon, France
- Dijon Stroke Registry, EA7460, University of Burgundy, 21078 Dijon, France
| | - Gauthier Duloquin
- Neurology Department, Dijon University Hospital, 21000 Dijon, France
- Dijon Stroke Registry, EA7460, University of Burgundy, 21078 Dijon, France
| | - Yannick Béjot
- Neurology Department, Dijon University Hospital, 21000 Dijon, France
- Dijon Stroke Registry, EA7460, University of Burgundy, 21078 Dijon, France
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11
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Ding J, Lee SJ, Vlahos L, Yuki K, Rada CC, van Unen V, Vuppalapaty M, Chen H, Sura A, McCormick AK, Tomaske M, Alwahabi S, Nguyen H, Nowatzke W, Kim L, Kelly L, Vollrath D, Califano A, Yeh WC, Li Y, Kuo CJ. Therapeutic blood-brain barrier modulation and stroke treatment by a bioengineered FZD 4-selective WNT surrogate in mice. Nat Commun 2023; 14:2947. [PMID: 37268690 PMCID: PMC10238527 DOI: 10.1038/s41467-023-37689-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/27/2023] [Indexed: 06/04/2023] Open
Abstract
Derangements of the blood-brain barrier (BBB) or blood-retinal barrier (BRB) occur in disorders ranging from stroke, cancer, diabetic retinopathy, and Alzheimer's disease. The Norrin/FZD4/TSPAN12 pathway activates WNT/β-catenin signaling, which is essential for BBB and BRB function. However, systemic pharmacologic FZD4 stimulation is hindered by obligate palmitoylation and insolubility of native WNTs and suboptimal properties of the FZD4-selective ligand Norrin. Here, we develop L6-F4-2, a non-lipidated, FZD4-specific surrogate which significantly improves subpicomolar affinity versus native Norrin. In Norrin knockout (NdpKO) mice, L6-F4-2 not only potently reverses neonatal retinal angiogenesis deficits, but also restores BRB and BBB function. In adult C57Bl/6J mice, post-stroke systemic delivery of L6-F4-2 strongly reduces BBB permeability, infarction, and edema, while improving neurologic score and capillary pericyte coverage. Our findings reveal systemic efficacy of a bioengineered FZD4-selective WNT surrogate during ischemic BBB dysfunction, with potential applicability to adult CNS disorders characterized by an aberrant blood-brain barrier.
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Affiliation(s)
- Jie Ding
- Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Sung-Jin Lee
- Surrozen, Inc. South San Francisco, South San Francisco, CA, 94080, USA
| | - Lukas Vlahos
- Department of Systems Biology, Columbia University, Columbia, NY, 10032, USA
| | - Kanako Yuki
- Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Cara C Rada
- Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Vincent van Unen
- Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA, 94305, USA
- Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | | | - Hui Chen
- Surrozen, Inc. South San Francisco, South San Francisco, CA, 94080, USA
| | - Asmiti Sura
- Surrozen, Inc. South San Francisco, South San Francisco, CA, 94080, USA
| | - Aaron K McCormick
- Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Madeline Tomaske
- Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Samira Alwahabi
- Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Huy Nguyen
- Surrozen, Inc. South San Francisco, South San Francisco, CA, 94080, USA
| | - William Nowatzke
- Surrozen, Inc. South San Francisco, South San Francisco, CA, 94080, USA
| | - Lily Kim
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Lisa Kelly
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Douglas Vollrath
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Andrea Califano
- Department of Systems Biology, Columbia University, Columbia, NY, 10032, USA
| | - Wen-Chen Yeh
- Surrozen, Inc. South San Francisco, South San Francisco, CA, 94080, USA
| | - Yang Li
- Surrozen, Inc. South San Francisco, South San Francisco, CA, 94080, USA
| | - Calvin J Kuo
- Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA, 94305, USA.
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12
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Costru-Tasnic E, Gavriliuc M, Manole E. Serum biomarkers to predict hemorrhagic transformation and ischemic stroke outcomes in a prospective cohort study. J Med Life 2023; 16:908-914. [PMID: 37675160 PMCID: PMC10478654 DOI: 10.25122/jml-2023-0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/11/2023] [Indexed: 09/08/2023] Open
Abstract
Ischemic stroke (IS) remains one of the most frequent causes of death and disability worldwide. Identifying possible prognosis factors for IS outcomes, including hemorrhagic transformation (HT), could improve patients' recovery. This study aimed to investigate the potential prognosis role of non-specific laboratory data at admission and baseline MMP-2 and MMP-9 serum levels in predicting HT risk, discharge, and 3-month follow-up status of IS patients. Data from 150 successive acute cerebral infarction patients were analyzed in a prospective cohort study. The active group included patients who developed HT during hospitalization (55 persons). There were no significant differences in age, gender distribution, time to admission, or time to blood sample collection for MMPs measurement between patients in the active and control groups. IS patients from the active group had a significantly higher rate of AF (atrial fibrillation) in the past (p=0.003), while differences in other factors such as diabetes, hypertension, myocardial infarction, previous stroke, obesity, smoking, and alcohol were not significant. Admission NIHSS score and mRS (modified Rankin Scale) values (at discharge and 90 days) were significantly worse in the active group (p<0.001). Among the analyzed admission laboratory factors (glycemia, lipid profile, coagulation panel, inflammatory reaction parameters, MMP-2, MMP-9), INR presented an inverse correlation, with lower values in the HT cohort (univariate analysis - p=0.01, OR=0.11; multivariate analysis - p=0.03, OR=0.09). Further research on larger cohorts is warranted to determine the specific laboratory biomarkers for predicting hemorrhagic transformation and ischemic stroke outcomes.
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Affiliation(s)
- Elena Costru-Tasnic
- Neurology Department no. 1, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
| | - Mihail Gavriliuc
- Neurology Department no. 1, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
- Diomid Gherman Institute of Neurology and Neurosurgery, Chisinau, Republic of Moldova
| | - Elena Manole
- Neurology Department no. 1, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
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13
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Zeng Z, Christodoulides A, Alves NJ. Real-time tracking of fibrinolysis under constant wall shear and various pulsatile flows in an in-vitro thrombolysis model. Bioeng Transl Med 2023; 8:e10511. [PMID: 37206217 PMCID: PMC10189439 DOI: 10.1002/btm2.10511] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/06/2023] [Accepted: 03/08/2023] [Indexed: 05/21/2023] Open
Abstract
A great need exists for the development of a more representative in-vitro model to efficiently screen novel thrombolytic therapies. We herein report the design, validation, and characterization of a highly reproducible, physiological scale, flowing clot lysis platform with real-time fibrinolysis monitoring to screen thrombolytic drugs utilizing a fluorescein isothiocyanate (FITC)-labeled clot analog. Using this Real-Time Fluorometric Flowing Fibrinolysis assay (RT-FluFF assay), a tPa-dependent degree of thrombolysis was observed both via clot mass loss as well as fluorometrically monitored release of FITC-labeled fibrin degradation products. Percent clot mass loss ranged from 33.6% to 85.9% with fluorescence release rates of 0.53 to 1.17 RFU/min in 40 and 1000 ng/mL tPa conditions, respectively. The platform is easily adapted to produce pulsatile flows. Hemodynamics of human main pulmonary artery were mimicked through matching dimensionless flow parameters calculated using clinical data. Increasing pressure amplitude range (4-40 mmHg) results in a 20% increase of fibrinolysis at 1000 ng/mL tPA. Increasing shear flow rate (205-913 s-1) significantly increases fibrinolysis and mechanical digestion. These findings suggest pulsatile level affects thrombolytic drug activities and the proposed in-vitro clot model offers a versatile testing platform for thrombolytic drug screening.
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Affiliation(s)
- Ziqian Zeng
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Weldon School of Biomedical EngineeringPurdue UniversityWest LafayetteIndianaUSA
| | - Alexei Christodoulides
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Nathan J. Alves
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Weldon School of Biomedical EngineeringPurdue UniversityWest LafayetteIndianaUSA
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14
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Rahman MM, Islam MR, Supti FA, Dhar PS, Shohag S, Ferdous J, Shuvo SK, Akter A, Hossain MS, Sharma R. Exploring the Therapeutic Effect of Neurotrophins and Neuropeptides in Neurodegenerative Diseases: at a Glance. Mol Neurobiol 2023:10.1007/s12035-023-03328-5. [PMID: 37052791 DOI: 10.1007/s12035-023-03328-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/22/2023] [Indexed: 04/14/2023]
Abstract
Neurotrophins and neuropeptides are the essential regulators of peripheral nociceptive nerves that help to induce, sensitize, and maintain pain. Neuropeptide has a neuroprotective impact as it increases trophic support, regulates calcium homeostasis, and reduces excitotoxicity and neuroinflammation. In contrast, neurotrophins target neurons afflicted by ischemia, epilepsy, depression, and eating disorders, among other neuropsychiatric conditions. Neurotrophins are reported to inhibit neuronal death. Strategies maintained for "brain-derived neurotrophic factor (BDNF) therapies" are to upregulate BDNF levels using the delivery of protein and genes or compounds that target BDNF production and boosting BDNF signals by expanding with BDNF mimetics. This review discusses the mechanisms of neurotrophins and neuropeptides against acute neural damage as well as highlighting neuropeptides as a potential therapeutic agent against Parkinson's disease (PD), Huntington's disease (HD), Alzheimer's disease (AD), and Machado-Joseph disease (MJD), the signaling pathways affected by neurotrophins and their receptors in both standard and diseased CNS systems, and future perspectives that can lead to the potent application of neurotrophins and neuropeptides in neurodegenerative diseases (NDs).
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Affiliation(s)
- Md Mominur Rahman
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka, 1207, Bangladesh
| | - Md Rezaul Islam
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka, 1207, Bangladesh
| | - Fatema Akter Supti
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka, 1207, Bangladesh
| | - Puja Sutro Dhar
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka, 1207, Bangladesh
| | - Sheikh Shohag
- Department of Genetic Engineering and Biotechnology, Faculty of Earth and Ocean Science, Bangabandhu Sheikh Mujibur Rahman Maritime University, Mirpur 12, Dhaka, 1216, Bangladesh
| | - Jannatul Ferdous
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka, 1207, Bangladesh
| | - Shakil Khan Shuvo
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka, 1207, Bangladesh
| | - Aklima Akter
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka, 1207, Bangladesh
| | - Md Sarowar Hossain
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka, 1207, Bangladesh
| | - Rohit Sharma
- Department of Rasa Shastra & Bhaishajya Kalpana, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, Uttar Pradesh, India.
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15
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Peng C, Yang F, Peng L, Zhang C, Lin Z, Chen C, Gao H, He J, Jin Z. Temporal trends and outcomes in acute ischaemic stroke patients with a current or historical diagnosis of cancer. Eur J Neurol 2023; 30:951-962. [PMID: 36704907 DOI: 10.1111/ene.15699] [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: 12/06/2022] [Revised: 12/24/2022] [Accepted: 01/12/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE The aim was to evaluate the temporal trends, characteristics and in-hospital outcomes of patients hospitalized with acute ischaemic stroke (AIS) between those with and without current or historical malignancies. METHODS Adult hospitalizations with a primary diagnosis of AIS were identified from the National Inpatient Sample database 2007-2017. Logistic regression was used to compare the differences in the utilization of AIS interventions and in-hospital outcomes. For further analysis, subgroup analyses were performed stratified by cancer subtypes. RESULTS There were 892,862 hospitalizations due to AIS, of which 108,357 (12.14%) had a concurrent diagnosis of current cancer (3.41%) or historical cancer (8.72%). After adjustment for confounders, patients with current malignancy were more likely to have worse clinical outcomes. The presence of historical cancers was not associated with an increase in poor clinical outcomes. Additionally, AIS patients with current malignancy were less likely to receive intravenous thrombolysis (adjusted odds ratio 0.66, 95% confidence interval 0.63-0.71). Amongst the subgroups of AIS patients treated with intravenous thrombolysis or mechanical thrombectomy, outcomes varied by cancer types. Notably, despite these acute stroke interventions, outcome remains poor in AIS patients with lung cancer. CONCLUSIONS Although AIS patients with malignancy generally have worse in-hospital outcomes versus those without, there were considerable variations in these outcomes according to different cancer types and the use of AIS interventions. Finally, treatment of these AIS patients with a current or historical cancer diagnosis should be individualized.
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Affiliation(s)
- Chi Peng
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Fan Yang
- Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University (Army Medical University) and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Chenxu Zhang
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Zhen Lin
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Chenxin Chen
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Huachen Gao
- Department of Plastic Surgery and Burns, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Jia He
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Zhichao Jin
- Department of Health Statistics, Naval Medical University, Shanghai, China
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16
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Zubair AS, Sheth KN. Hemorrhagic Conversion of Acute Ischemic Stroke. Neurotherapeutics 2023; 20:705-711. [PMID: 37085684 PMCID: PMC10275827 DOI: 10.1007/s13311-023-01377-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 04/23/2023] Open
Abstract
Stroke is a leading cause of morbidity and mortality worldwide; a serious complication of ischemic stroke is hemorrhagic transformation. Current treatment of acute ischemic stroke includes endovascular thrombectomy and thrombolytic therapy. Both of these treatment options are linked with increased risks of hemorrhagic conversion. The diagnosis and timely management of patients with hemorrhagic conversion is critically important to patient outcomes. This review aims to discuss hemorrhagic conversion of acute ischemic stroke including discussion of the pathophysiology, review of risk factors, imaging considerations, and treatment of patients with hemorrhagic conversion.
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Affiliation(s)
- Adeel S Zubair
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT, USA
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17
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The efficacy and safety of tenecteplase versus alteplase for acute ischemic stroke: an updated systematic review, pairwise, and network meta-analysis of randomized controlled trials. J Thromb Thrombolysis 2023; 55:322-338. [PMID: 36449231 PMCID: PMC10011306 DOI: 10.1007/s11239-022-02730-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2022] [Indexed: 12/05/2022]
Abstract
Tenecteplase (TNK) is a promising candidate to replace alteplase as the standard of care for acute ischemic stroke (AIS); however, the optimal dosage is still to be investigated. Therefore, we aim to evaluate the safety and efficacy of TNK versus alteplase and to investigate the optimal TNK dosage. A systematic review, pairwise, and network meta-analysis synthesizing randomized controlled trials (RCTs) from WOS, SCOPUS, EMBASE, and PubMed until July 26th, 2022. We used the risk ratio (RR) for dichotomous outcomes presented with the corresponding 95% confidence interval (CI). We registered our protocol in PROSPERO with ID: CRD42022352038. Nine RCTs with a total of 3,707 patients were included. TNK significantly led to complete recanalization (RR: 1.27 with 95% CI [1.02, 1.57], P = 0.03); however, we found no difference regarding early neurological improvement (RR: 1.07 with 95% CI [0.94, 1.21], P = 0.33) and excellent neurological recovery (RR: 1.03 with 95% CI [0.96, 1.10], P = 0.42). Also, TNK was similar to alteplase regarding mortality (RR: 0.99 with 95% CI [0.82, 1.18], P = 0.88), intracranial haemorrhage (RR: 1.00 with 95% CI [0.85, 1.18], P = 0.99), and parenchymal hematoma (RR: 1.13 with 95% CI [0.83, 1.54], P = 0.44). TNK in the dose of 0.25 mg is a viable candidate to displace alteplase as the standard of care in patients with an AIS within 4.5 h of presentation due to its better rate of early neurological recovery and non-inferiority in terms of safety outcomes. However, the evidence regarding TNK's role in AIS presenting after 4.5 h from symptoms onset, wake-up stroke, and minor stroke/TIA is still lacking, necessitating further double-blinded pragmatic RCTs in this regard.
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18
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Nguyen AB, Iqbal O, Block RC, Mousa SA. Prevention and treatment of atherothrombosis: Potential impact of nanotechnology. Vascul Pharmacol 2023; 148:107127. [PMID: 36375733 DOI: 10.1016/j.vph.2022.107127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/29/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
Complications with atherosclerosis can often lead to fatal clot formation and blood vessel occlusion - also known as atherothrombosis. A key component to the development of atherosclerosis and atherothrombosis is the endothelium and its ability to regulate the balance between prothrombotic and antithrombotic activities. Endothelial surface glycocalyx has a critical role in maintenance of vascular integrity. The endothelial glycocalyx, nitric oxide, prostacyclins, heparan sulfate, thrombomodulin, and tissue factor pathway inhibitor all prevent thrombosis, while P-selectin, among many other factors, favors thrombosis. However, endothelial dysfunction gives rise to the acceleration of thrombotic development and eventually the requirement of antithrombotic therapy. Most FDA-approved anticoagulant and antiplatelet therapies today carry a side effect profile of major bleed. Within the past five years, several preclinical studies using different endothelial targets and nanotechnology as a drug delivery method have emerged to target the endothelium and to enhance current antithrombosis without increasing bleed risk. While clinical studies are required, this review illustrates the proof-of-concept of nanotechnology in promoting a greater safety and efficacy profile through multiple in vitro and in vivo studies.
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Affiliation(s)
- Anthony B Nguyen
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, New York 12144, United States of America
| | - Omer Iqbal
- Stritch School of Medicine, Loyola University, Chicago, IL, United States of America
| | - Robert C Block
- University of Rochester, 601 Elmwood Ave, Rochester, NY 14642, United States of America
| | - Shaker A Mousa
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, New York 12144, United States of America.
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19
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Shao H, Chan WCL, Du H, Chen XF, Ma Q, Shao Z. A new machine learning algorithm with high interpretability for improving the safety and efficiency of thrombolysis for stroke patients: A hospital-based pilot study. Digit Health 2023; 9:20552076221149528. [PMID: 36636727 PMCID: PMC9829886 DOI: 10.1177/20552076221149528] [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] [Indexed: 01/04/2023] Open
Abstract
Background Thrombolysis is the first-line treatment for patients with acute ischemic stroke. Previous studies leveraged machine learning to assist neurologists in selecting patients who could benefit the most from thrombolysis. However, when designing the algorithm, most of the previous algorithms traded interpretability for predictive power, making the algorithms hard to be trusted by neurologists and be used in real clinical practice. Methods Our proposed algorithm is an advanced version of classical k-nearest neighbors classification algorithm (KNN). We achieved high interpretability by changing the isotropy in feature space of classical KNN. We leveraged a cohort of 189 patients to prove that our algorithm maintains the interpretability of previous models while in the meantime improving the predictive power when compared with the existing algorithms. The predictive powers of models were assessed by area under the receiver operating characteristic curve (AUC). Results In terms of interpretability, only onset time, diabetes, and baseline National Institutes of Health Stroke Scale (NIHSS) were statistically significant and their contributions to the final prediction were forced to be proportional to their feature importance values by the rescaling formula we defined. In terms of predictive power, our advanced KNN (AUC 0.88) outperformed the classical KNN (AUC 0.75, p = 0.0192 ). Conclusions Our preliminary results show that the advanced KNN achieved high AUC and identified consistent significant clinical features as previous clinical trials/observational studies did. This model shows the potential to assist in thrombolysis patient selection for improving the successful rate of thrombolysis.
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Affiliation(s)
- Huiling Shao
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong,Huiling Shao, Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Room Y934, 9/F, Lee Shau Kee Building, Hung Hom, Kowloon, 999077, Hong Kong.
| | - Wing Chi Lawrence Chan
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Heng Du
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Xiangyan Fiona Chen
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Qilin Ma
- Department of Neurology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Zhiyu Shao
- Department of Neurology, The First Affiliated Hospital of Xiamen University, Xiamen, China
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20
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Seyedaghamiri F, Salimi L, Ghaznavi D, Sokullu E, Rahbarghazi R. Exosomes-based therapy of stroke, an emerging approach toward recovery. Cell Commun Signal 2022; 20:110. [PMID: 35869548 PMCID: PMC9308232 DOI: 10.1186/s12964-022-00919-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/11/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractBased on clinical observations, stroke is touted as one of the specific pathological conditions, affecting an individual’s life worldwide. So far, no effective treatment has been introduced to deal with stroke post-complications. Production and release of several neurotrophic factors by different cells exert positive effects on ischemic areas following stroke. As a correlate, basic and clinical studies have focused on the development and discovery of de novo modalities to introduce these factors timely and in appropriate doses into the affected areas. Exosomes (Exo) are non-sized vesicles released from many cells during pathological and physiological conditions and participate in intercellular communication. These particles transfer several arrays of signaling molecules, like several neurotrophic factors into the acceptor cells and induce specific signaling cascades in the favor of cell bioactivity. This review aimed to highlight the emerging role of exosomes as a therapeutic approach in the regeneration of ischemic areas.
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21
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Ge Y, Zadeh M, Yang C, Candelario-Jalil E, Mohamadzadeh M. Ischemic Stroke Impacts the Gut Microbiome, Ileal Epithelial and Immune Homeostasis. iScience 2022; 25:105437. [PMID: 36388972 PMCID: PMC9650036 DOI: 10.1016/j.isci.2022.105437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/13/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
Ischemic stroke critically impacts neurovascular homeostasis, potentially resulting in neurological disorders. However, the mechanisms through which stroke-induced inflammation modifies the molecular and metabolic circuits, particularly in ileal epithelial cells (iECs), currently remain elusive. Using multiomic approaches, we illustrated that stroke impaired the ileal microbiome and associated metabolites, leading to increased inflammatory signals and altered metabolites, potentially deteriorating the iEC homeostasis. Bulk transcriptomic and metabolomic profiling demonstrated that stroke enhanced fatty acid oxidation while reducing the tricarboxylic acid (TCA) cycle in iECs within the first day after stroke. Intriguingly, single-cell RNA sequencing analysis revealed that stroke dysregulated cell-type-specific gene responses within iECs and reduced frequencies of goblet and tuft cells. Additionally, stroke augmented interleukin-17A+ γδ T cells but decreased CD4+ T cells in the ileum. Collectively, our findings provide a comprehensive overview of stroke-induced intestinal dysbiosis and unveil responsive gene programming within iECs with implications for disease development.
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Affiliation(s)
- Yong Ge
- Department of Microbiology, Immunology & Molecular Genetics, University of Texas Health, San Antonio, TX, USA
- Division of Gastroenterology & Nutrition, Department of Medicine, University of Texas Health, San Antonio, TX, USA
| | - Mojgan Zadeh
- Department of Microbiology, Immunology & Molecular Genetics, University of Texas Health, San Antonio, TX, USA
- Division of Gastroenterology & Nutrition, Department of Medicine, University of Texas Health, San Antonio, TX, USA
| | - Changjun Yang
- Department of Neurosciences, University of Florida, Gainesville, FL, USA
| | | | - Mansour Mohamadzadeh
- Department of Microbiology, Immunology & Molecular Genetics, University of Texas Health, San Antonio, TX, USA
- Division of Gastroenterology & Nutrition, Department of Medicine, University of Texas Health, San Antonio, TX, USA
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22
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Raleigh S, Samson M, Nygaard R, Endorf F, Walter J, Masters T. Bedside Fluorescence Microangiography for Frostbite Diagnosis in the Emergency Department. West J Emerg Med 2022; 23:872-877. [DOI: 10.5811/westjem.2022.8.55020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
Frostbite leads to progressive ischemia eventually causing tissue necrosis if not quickly reversed. Patients with frostbite tend to present to the emergency department (ED) for assessment and treatment. Acute management includes rewarming, pain management, and (when indicated) thrombolytic therapy. Thrombolytic therapy in severe frostbite injury may decrease rates of amputation and improve patient outcomes. Fluorescence microangiography (FMA) has been used to distinguish between perfused and non-perfused tissue. The purpose of this study was to evaluate the potential role of FMA in the acute care of patients with frostbite, specifically its role as a tool to identify perfusion deficit following severe frostbite injury, and to explore its role in time to tissue plasminogen activator (tPA).
Methods: This retrospective analysis included all patients from December 2020–March 2021 who received FMA in a single ED as part of their initial frostbite evaluation. In total, 42 patients presented to the ED with concern for frostbite and were evaluated using FMA.
Results: Mean time from arrival in the ED to FMA was 46.3 minutes. Of the 42 patients, 14 had clinically significant perfusion deficits noted on FMA and received tPA. Mean time to tPA (measured from ED arrival to administration of tPA) for these patients was 117.4 minutes. This is significantly faster than average historical times at our institution of 240-300 minutes.
Conclusion: Bedside FMA provides objective information regarding perfusion deficits and allows for faster decision-making and improved times to tPA. Fluorescence microangiography shows promise for quick and efficient evaluation of perfusion deficits in frostbite-injured patients. This could lead to faster tPA administration and potentially greater rates of tissue salvage after severe frostbite injury.
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Affiliation(s)
- Sarah Raleigh
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Margot Samson
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Rachel Nygaard
- Hennepin County Medical Center, Department of Surgery, Minneapolis, Minnesota
| | - Fredrick Endorf
- Hennepin County Medical Center, Department of Surgery, Minneapolis, Minnesota
| | - Joseph Walter
- Hennepin County Medical Center, Department of Hyperbaric Medicine, Minneapolis, Minnesota
| | - Thomas Masters
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota; Hennepin County Medical Center, Department of Hyperbaric Medicine, Minneapolis, Minnesota
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23
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Shao H, Chen X, Ma Q, Shao Z, Du H, Chan LWC. The feasibility and accuracy of machine learning in improving safety and efficiency of thrombolysis for patients with stroke: Literature review and proposed improvements. Front Neurol 2022; 13:934929. [PMID: 36341121 PMCID: PMC9630915 DOI: 10.3389/fneur.2022.934929] [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: 05/03/2022] [Accepted: 09/28/2022] [Indexed: 11/30/2022] Open
Abstract
In the treatment of ischemic stroke, timely and efficient recanalization of occluded brain arteries can successfully salvage the ischemic brain. Thrombolysis is the first-line treatment for ischemic stroke. Machine learning models have the potential to select patients who could benefit the most from thrombolysis. In this study, we identified 29 related previous machine learning models, reviewed the models on the accuracy and feasibility, and proposed corresponding improvements. Regarding accuracy, lack of long-term outcome, treatment option consideration, and advanced radiological features were found in many previous studies in terms of model conceptualization. Regarding interpretability, most of the previous models chose restrictive models for high interpretability and did not mention processing time consideration. In the future, model conceptualization could be improved based on comprehensive neurological domain knowledge and feasibility needs to be achieved by elaborate computer science algorithms to increase the interpretability of flexible algorithms and shorten the processing time of the pipeline interpreting medical images.
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Affiliation(s)
- Huiling Shao
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Xiangyan Chen
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Qilin Ma
- Department of Neurology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Zhiyu Shao
- Department of Neurology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Heng Du
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Lawrence Wing Chi Chan
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
- *Correspondence: Lawrence Wing Chi Chan
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24
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Huang Y, Jiang J, Ren J, Guo Y, Zhao Q, Zhou J, Li Y, Chen R. A Fibrinogen-Mimicking, Activated-Platelet-Sensitive Nanocoacervate Enhances Thrombus Targeting and Penetration of Tissue Plasminogen Activator for Effective Thrombolytic Therapy. Adv Healthc Mater 2022; 11:e2201265. [PMID: 35864062 DOI: 10.1002/adhm.202201265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/01/2022] [Indexed: 01/27/2023]
Abstract
The development of a fibrinolytic system with long circulation time, high thrombus targeting, efficient thrombus penetration, effective thrombolysis, and minimal hemorrhagic risk remains a major challenge. Herein, inspired by fibrinogen binding to activated platelets in thrombosis, this article reports a fibrinogen-mimicking, activated-platelet-sensitive nanocoacervate to enhance thrombus penetration of tissue plasminogen activator (tPA) for targeted thrombolytic therapy. This biomimetic nanothrombolytic system, denoted as RGD-Chi@tPA, is constructed by "one-pot" coacervation through electrostatic interactions between positively charged arginine-glycine-aspartic acid (RGD)-grafted chitosan (RGD-Chi) and negatively charged tPA. Flow cytometry and confocal laser scanning microscopy measurements show targeting of RGD-Chi@tPA to activated platelets. Controlled tPA release triggered by activated platelets at a thrombus site is demonstrated. Its targeted fibrinolytic and thrombolytic activities are measured in in vitro models. The pharmacokinetic profiles show that RGD-Chi@tPA can significantly prolong circulation time compared to free tPA. In a mouse tail thrombus model, RGD-Chi@tPA displays efficient thrombus targeting and penetration, enabling a complete vascular recanalization as confirmed by the fluorescence imaging, histochemical assay, and laser speckle contrast imager. Consequently, RGD-Chi@tPA induces a substantial enhancement in thrombolysis with minimal hemorrhagic risk compared to free tPA. This simple, effective, and safe platform holds great promise for the development of thrombolytic nanomedicines.
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Affiliation(s)
- Yu Huang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi Shan Road, Shanghai, 200233, P. R. China.,Department of Chemical Engineering, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - Jingxuan Jiang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi Shan Road, Shanghai, 200233, P. R. China
| | - Jie Ren
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - Yuanyuan Guo
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi Shan Road, Shanghai, 200233, P. R. China
| | - Qianqian Zhao
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi Shan Road, Shanghai, 200233, P. R. China
| | - Jia Zhou
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi Shan Road, Shanghai, 200233, P. R. China
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi Shan Road, Shanghai, 200233, P. R. China
| | - Rongjun Chen
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
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25
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A Nursing Approach to Improving Critical Care Compliance With Vital Signs and Neurological Assessments in Post-IV-Alteplase Stroke Patients. Crit Care Nurs Q 2022; 45:352-358. [PMID: 35980797 DOI: 10.1097/cnq.0000000000000427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ischemic stroke represents 87% of all strokes. As global initiatives move forward with stroke care, health care providers and institutions will be called on to deliver the most current evidence-based care. The American Heart Association/American Stroke Association (AHA/ASA) estimates that 795 000 strokes occur each year; 610 000 are new strokes, and 185 000 are recurrent strokes. Eighty-seven percent are ischemic strokes; the overall mortality rate from stroke was 273 000, which makes stroke the fifth leading cause of death and the leading cause of disability in the United States. Stroke costs the United States an estimated $34 billion each year. This article outlines a nursing intervention regarding the use of intravenous thrombolytic therapy for treating acute ischemic stroke, the risk factors related to IV-alteplase, best-practice protocols, and the nursing role in efforts to deliver safe care. The conclusion reveals the need for health care organizations to explore opportunities, continually inspire innovation at the bedside, highlight nursing's essential contribution to acute stroke care, and encourage publishing improvements in patient care and the nurse practice environment.
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26
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Toul M, Mican J, Slonkova V, Nikitin D, Marek M, Bednar D, Damborsky J, Prokop Z. Hidden Potential of Highly Efficient and Widely Accessible Thrombolytic Staphylokinase. Stroke 2022; 53:3235-3237. [PMID: 36039755 DOI: 10.1161/strokeaha.122.040219] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke burden is substantially increasing but current therapeutic drugs are still far from ideal. Here we highlight the vast potential of staphylokinase as an efficient, fibrin-selective, inexpensive, and evolvable thrombolytic agent. The emphasis is escalated by new recent findings. Staphylokinase nonimmunogenic variant was proven noninferior to alteplase in a clinical trial, with decreased risk of intracranial hemorrhage and the advantage of single bolus administration. Furthermore, our detailed kinetic analysis revealed a new staphylokinase limiting bottleneck whose elimination might provide up to 1000-fold higher activity than the clinically approved alteplase. This knowledge of limitations unlocks new possibilities for improvements that are now achievable by the community of protein engineers who have the required expertise and are ready to transform staphylokinase into a powerful molecule. Collectively, the noninferiority and safety of nonimmunogenic staphylokinase together with the newly identified effectivity limitation make staphylokinase a perfect candidate for further exploration, modification, and advancement to make it the next-generation widely accessible thrombolytic drug effectively treating stroke all around the world, including middle- and low-income countries.
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Affiliation(s)
- Martin Toul
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.).,International Clinical Research Center of St. Anne's University Hospital, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.)
| | - Jan Mican
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.).,International Clinical Research Center of St. Anne's University Hospital, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.)
| | - Veronika Slonkova
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.).,International Clinical Research Center of St. Anne's University Hospital, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.)
| | - Dmitri Nikitin
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.).,International Clinical Research Center of St. Anne's University Hospital, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.)
| | - Martin Marek
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.).,International Clinical Research Center of St. Anne's University Hospital, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.)
| | - David Bednar
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.).,International Clinical Research Center of St. Anne's University Hospital, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.)
| | - Jiri Damborsky
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.).,International Clinical Research Center of St. Anne's University Hospital, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.)
| | - Zbynek Prokop
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.).,International Clinical Research Center of St. Anne's University Hospital, Brno, Czech Republic (M.T., J.M., V.S., D.N., M.M., D.B., J.D., Z.P.)
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27
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Ex Vivo Machine Thrombolysis Reduces Rethrombosis Rates in Salvaged Thrombosed Myocutaneous Flaps in Swine. Plast Reconstr Surg 2022; 150:81-90. [PMID: 35536770 DOI: 10.1097/prs.0000000000009227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is a risk for thrombotic complications (2 to 5 percent) associated with microsurgical reconstruction. Current thrombolytic therapy has a salvage rate between 60 and 70 percent, but it is afflicted by bleeding complications (2 to 6 percent). The use of machine perfusion for delivering thrombolytic agents is a new method that could potentially reduce these complications. In this article, the authors compared flap salvage outcomes comparing machine thrombolysis versus a manual flush with tissue plasminogen activator. METHODS Sixteen bilateral flaps (12 × 9 cm) were dissected from eight female Dutch Landrace pigs (70 kg). Thrombosis was induced in free rectus abdominis flaps by clamping the pedicle's veins for 2 hours. Flaps were either thrombolysed with 2 mg tissue plasminogen activator (1 mg/ml) during 2 hours of machine perfusion (perfusion group; n = 8) or injected intraarterially (manual group; n = 8) before replantation. Near-infrared fluorescence angiography was used to confirm thrombus formation and to assess tissue perfusion; muscle biopsy specimens were analyzed for ischemia/reperfusion injury directly after thrombolysis and 15 hours after replantation. RESULTS A higher incidence of secondary thrombosis was seen in the manual group compared to the perfusion group ( n = 6 versus n = 0, respectively; p < 0.001), resulting in two complete flap failures. Fifteen hours after replantation, mean fluorescence intensities were 13.0 (95 percent CI, 10.1 to 15.8) and 24.6 (95 percent CI, 22.0 to 27.2) in the perfusion and manual group, respectively ( p < 0.001), and mean muscle injury scores were comparable, measuring 7.5 ± 1.5. CONCLUSION Two hours of machine thrombolysis of compromised flaps in a porcine model showed higher salvage rates compared to a manual injection with tissue plasminogen activator and reduced the incidence of secondary thrombosis. CLINICAL RELEVANCE STATEMENT Using machine perfusion systems for ex vivo thrombolysis provides the benefits of local treatment of a composite tissue without the risk of systemic complications and may improve salvage rates and reduce the incidence of secondary thrombosis.
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28
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Vicente-Acosta A, Ceprian M, Sobrino P, Pazos MR, Loría F. Cannabinoids as Glial Cell Modulators in Ischemic Stroke: Implications for Neuroprotection. Front Pharmacol 2022; 13:888222. [PMID: 35721207 PMCID: PMC9199389 DOI: 10.3389/fphar.2022.888222] [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: 03/02/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
Stroke is the second leading cause of death worldwide following coronary heart disease. Despite significant efforts to find effective treatments to reduce neurological damage, many patients suffer from sequelae that impair their quality of life. For this reason, the search for new therapeutic options for the treatment of these patients is a priority. Glial cells, including microglia, astrocytes and oligodendrocytes, participate in crucial processes that allow the correct functioning of the neural tissue, being actively involved in the pathophysiological mechanisms of ischemic stroke. Although the exact mechanisms by which glial cells contribute in the pathophysiological context of stroke are not yet completely understood, they have emerged as potentially therapeutic targets to improve brain recovery. The endocannabinoid system has interesting immunomodulatory and protective effects in glial cells, and the pharmacological modulation of this signaling pathway has revealed potential neuroprotective effects in different neurological diseases. Therefore, here we recapitulate current findings on the potential promising contribution of the endocannabinoid system pharmacological manipulation in glial cells for the treatment of ischemic stroke.
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Affiliation(s)
- Andrés Vicente-Acosta
- Centro de Biología Molecular Severo Ochoa (CSIC-UAM), Madrid, Spain.,Departamento de Biología Molecular, Universidad Autónoma de Madrid, Madrid, Spain
| | - Maria Ceprian
- ERC Team, PGNM, INSERM U1315, CNRS UMR5261, University of Lyon 1, University of Lyon, Lyon, France
| | - Pilar Sobrino
- Departamento de Neurología, Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
| | - Maria Ruth Pazos
- Laboratorio de Apoyo a la Investigación, Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
| | - Frida Loría
- Laboratorio de Apoyo a la Investigación, Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
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29
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Wu H, Zhang B, Huang CC, Peng C, Zhou Q, Jiang X. Ultrasound-Guided Intravascular Sonothrombolysis With a Dual Mode Ultrasound Catheter: In Vitro Study. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2022; 69:1917-1925. [PMID: 35201986 PMCID: PMC9702596 DOI: 10.1109/tuffc.2022.3153929] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Thromboembolism in vessels often leads to stroke or heart attack and even sudden death unless brought under control. Sonothrombolysis based on ultrasound contrast agents has shown promising outcome in effective treatment of thromboembolism. Intravascular sonothrombolysis transducer was reported recently for unprecedented sonothrombolysis in vitro. However, it is necessary to provide an imaging guide during thrombolysis in clinical applications for optimal treatment efficiency. In this article, a dual mode ultrasound catheter was developed by combining a 16-MHz high-frequency element (imaging transducer) and a 220-kHz low-frequency element (treatment transducer) for sonothrombolysis in vitro. The treatment transducer was designed with a 20-layer PZT-5A stack with the aperture size of 1.2×1.2 mm2, and the imaging transducer with the aperture size of 1.2×1.2 mm2 was attached in front of the treatment transducer. Both transducers were assembled into a customized 2-lm 10-Fr catheter. In vitro experiment was carried out using a bovine blood clot. Imaging tests were conducted, showing that the backscattering signals can be obtained with a high signal-to-noise ratio (SNR) for the 16-MHz imaging transducer. Sonothrombolysis was performed successfully that the volume of clot was reduced significantly after the 30-min treatment. The size changes of clot were observed clearly using the 16-MHz M-mode imaging during the thrombolysis. The findings suggest that the proposed ultrasound-guided intravascular sonothrombolysis can be enhanced since the position of treatment transducer can be adjusted with the target at the clot due to the imaging guide.
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30
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Sagris M, Tzoumas A, Kokkinidis DG, Tzavellas G, Korosoglou G, Lichtenberg M. Invasive and Pharmacological Treatment of Deep Vein Thrombosis: a Scoping Review. Curr Pharm Des 2022; 28:778-786. [PMID: 35440298 DOI: 10.2174/1381612828666220418084339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/01/2022] [Indexed: 11/22/2022]
Abstract
The annual occurrence of venous thromboembolism (VTE) is 300,000-600,000 cases in the United States and 700,000 in Europe. VTE includes deep venous thrombosis (DVT) of upper or lower extremities, superior and inferior vena cava thrombosis, and pulmonary embolism (PE) as well. The primary treatment of DVT includes oral anticoagulation to prevent the progression of the thrombus and decrease the risk of pulmonary embolism. Depending on the symptoms, more invasive treatments can be applied to target the iliofemoral thrombus and its removal. However, less emphasis is given to acute symptomatology, early recovery of function, quality of life improvement, and the individualized likelihood of developing post-thrombotic syndrome. While invasive therapy has been used to enhance the acute management of iliofemoral DVT, our knowledge about the overall outcomes associated with the invasive treatment of VTE is still limited. In this review, we illustrate the available data on pharmacological and endovascular management of iliofemoral VTE, including therapies such as catheter-directed thrombolysis (CDT), mechanical thrombectomy (PMT), and pharmacomechanical catheter-directed thrombolysis (PCDT).
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Affiliation(s)
- Marios Sagris
- Department of Medicine, General Hospital of Nikaia, Piraeus, Athens, Greece
| | - Andreas Tzoumas
- Department of Medicine, University of Cincinnati Health, Cincinnati, OH
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine/Yale New Haven Hospital, New Haven, CT
| | - Georgios Tzavellas
- Department of Vascular and Endovascular Surgery, Indiana University Health Ball Memorial Hospital
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31
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Calcitriol ameliorates brain injury in the rat model of cerebral ischemia-reperfusion through Nrf2/HO-1 signalling axis: An in silico and in vivo study. J Stroke Cerebrovasc Dis 2022; 31:106331. [PMID: 35306470 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/12/2022] [Accepted: 01/18/2022] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Calcitriol has been revealed to exert neuroprotective effects in ischemic stroke; however, its role and the underlying mechanisms in brain injury induced by ischemia are not well known. The purpose of this study was to determine the neuroprotective effects of calcitriol pretreatment and to assess the possible neuroprotective function of nuclear factor erythroid 2-related factor 2 (Nrf2)/ heme oxygenase-1 (HO-1) signalling pathway against brain ischemia/reperfusion (I/R) injury in the rat models which was followed by a bioinformatics approach. METHODS The experimental I/R model induction was performed in male Wistar rats for 1 h followed by 23 h reperfusion. Calcitriol was administered intraperitoneally for 7 days prior to stroke. Following ischemia induction 24 h later, neurobehavioral deficits and infarction volume were examined. Oxidative stress was assessed by measurement of malondialdehyde (MDA), nitric oxide (NO) and total antioxidant capacity (TAC). The protein and mRNA expression of HO-1 and Nrf2 were determined by western blot and reverse transcription polymerase chain reaction (RT-PCR), respectively. A molecular docking approach was applied to identify the interaction value of Keap1 with calcitriol. RESULTS Our data demonstrated that calcitriol significantly decreased infarction volume and ameliorated neurological deficits in brain I/R. MDA and NO levels were decreased and TAC level was elevated significantly after calcitriol pretreatment. Furthermore, calcitriol upregulated the expression of HO-1 and Nrf2 protein and mRNA in ischemic brain. Molecular modelling demonstrated that calcitriol could interact with the pocket of Keap1 by an appropriate binding energy. CONCLUSIONS The results indicate that calcitriol protects the brain against I/R injury. This effect may pass through inhibition of oxidative stress and Nrf2/HO-1 pathway activation and this may arise by interaction of Keap1 and calcitriol.
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32
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Cencer S, Tubergen T, Packard L, Gritters D, LaCroix H, Frye A, Wills N, Zachariah J, Wees N, Khan N, Min J, Dejesus M, Combs J, Khan M. Shorter Intensive Care Unit Stay (12 Hours) Post Thrombolysis Is Safe and Reduces Length of Stay for Minor Stroke Patients. Neurohospitalist 2022; 12:504-507. [DOI: 10.1177/19418744211048014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The current standard of practice for patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator (tPA) requires critical monitoring for 24-hours post-treatment due to the risk of symptomatic intracranial hemorrhage (sICH). This is a costly and resource intensive practice. In this study, we evaluated the safety and efficacy of this standard 24-hour ICU monitoring period compared with a shorter 12-hour ICU monitoring period for minor stroke patients (NIHSS 0-5) treated with tPA only. Stroke mimics and those who underwent thrombectomy were excluded. The primary outcome was length of hospital stay. Secondary outcome measures included sICH, deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days, and favorable functional outcome defined as modified Rankin scale (mRS) of 0-2 at 90 days. Of the 122 patients identified, 77 were in the 24-hour protocol and 45 were in 12-hour protocol. There was significant difference in length of hospital stay for the 24-hour ICU protocol (2.8 days) compared with the 12-hour ICU protocol (1.8 days) ( P < 0.001). Although not statistically significant, the 12-hour group had favorable rates of sICH, 30-day readmission rates, favorable discharge disposition and favorable functional outcome. Rates of DVT, PE and aspiration pneumonia were identical between the groups. Compared with 24-hour ICU monitoring, 12-hour ICU monitoring after thrombolysis for minor acute ischemic stroke was not associated with any increase in adverse outcomes. A randomized trial is needed to verify these findings.
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Affiliation(s)
- Samantha Cencer
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Tricia Tubergen
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Laurel Packard
- Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
| | | | - Hattie LaCroix
- Office of Research, Spectrum Health, Grand Rapids, MI, USA
| | - Angela Frye
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Nicole Wills
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Joseph Zachariah
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Nabil Wees
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Nadeem Khan
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Jiangyong Min
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Michelle Dejesus
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Jordan Combs
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Muhib Khan
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
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33
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Deng LD, Qi L, Suo Q, Wu SJ, Mamtilahun M, Shi RB, Liu Z, Sun JF, Tang YH, Zhang ZJ, Yang GY, Wang JX. Transcranial focused ultrasound stimulation reduces vasogenic edema after middle cerebral artery occlusion in mice. Neural Regen Res 2022; 17:2058-2063. [PMID: 35142697 PMCID: PMC8848588 DOI: 10.4103/1673-5374.335158] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Blood-brain barrier (BBB) disruption underlies the vasogenic edema and neuronal cell death induced by acute ischemic stroke. Reducing this disruption has therapeutic potential. Transcranial focused ultrasound stimulation has shown neuromodulatory and neuroprotective effects in various brain diseases including ischemic stroke. Ultrasound stimulation can reduce inflammation and promote angiogenesis and neural circuit remodeling. However, its effect on the BBB in the acute phase of ischemic stroke is unknown. In this study of mice subjected to middle cerebral artery occlusion for 90 minutes, low-intensity low-frequency (0.5 MHz) transcranial focused ultrasound stimulation was applied 2, 4, and 8 hours after occlusion. Ultrasound stimulation reduced edema volume, improved neurobehavioral outcomes, improved BBB integrity (enhanced tight junction protein ZO-1 expression and reduced IgG leakage), and reduced secretion of the inflammatory factors tumor necrosis factor-α and activation of matrix metalloproteinase-9 in the ischemic brain. Our results show that low-intensity ultrasound stimulation attenuated BBB disruption and edema formation, which suggests it may have therapeutic use in ischemic brain disease as a protector of BBB integrity.
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Affiliation(s)
- Li-Dong Deng
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Lin Qi
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Qian Suo
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Sheng-Ju Wu
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Muyassar Mamtilahun
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Ru-Bing Shi
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Ze Liu
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jun-Feng Sun
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Yao-Hui Tang
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Zhi-Jun Zhang
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Guo-Yuan Yang
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University; Department of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ji-Xian Wang
- Department of Rehabilitation Medicine, Ruijin Hospital, School of Medicine, and Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
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Potla N, Ganti L. Tenecteplase vs. alteplase for acute ischemic stroke: a systematic review. Int J Emerg Med 2022; 15:1. [PMID: 34983359 PMCID: PMC8903524 DOI: 10.1186/s12245-021-00399-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Thrombolysis for acute ischemic stroke (AIS) with alteplase is the currently approved therapy for patients who present within 4.5 h of symptom onset and meet criteria. Recently, there has been interest in the thrombolytic tenecteplase, a modified version of alteplase, due to its lower cost, ease of administration, and studies reporting better outcomes when compared to alteplase. This systematic review compares the efficacy of tenecteplase vs. alteplase with regard to three outcomes: (1) rate of symptomatic hemorrhage, (2) functional outcome at 90 days, and (3) reperfusion grade after thrombectomy to compare the efficacy of both thrombolytics in AIS METHODS: The search was conducted in August 2021 in PubMed, filtered for randomized controlled trials, and studies in English. The main search term was "tenecteplase for acute stroke." RESULTS A total of 6 randomized clinical trials including 1675 patients with AIS was included. No one's study compared alteplase to tenecteplase with all three outcomes after acute ischemic stroke; however, by using a combination of the results, this systematic review summarizes whether tenecteplase outperforms alteplase. CONCLUSIONS The available evidence suggests that tenecteplase appears to be a better thrombolytic agent for acute ischemic stroke when compared to alteplase.
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Affiliation(s)
- Neha Potla
- Unionville-Chadds Ford School District, Kennett Square, PA, USA
| | - Latha Ganti
- Departments of Neurology and Emergency Medicine, University of Central Florida College of Medicine, Orlando, FL, USA. .,Envision Physician Services, Plantation, Florida, FL, USA.
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Adusumilli G, Pederson JM, Hardy N, Kallmes KM, Hutchison K, Kobeissi H, Heiferman DM, Heit JJ. Mechanical Thrombectomy With and Without Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis Using Nested Knowledge. Front Neurol 2022; 12:759759. [PMID: 34975722 PMCID: PMC8719452 DOI: 10.3389/fneur.2021.759759] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/23/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Mechanical thrombectomy (MT) is now the standard-of-care treatment for acute ischemic stroke (AIS) of the anterior circulation and may be performed irrespective of intravenous tissue plasminogen activator (IV-tPA) eligibility prior to the procedure. This study aims to understand better if tPA leads to higher rates of reperfusion and improves functional outcomes in AIS patients after MT and to simultaneously evaluate the functionality and efficiency of a novel semi-automated systematic review platform. Methods: The Nested Knowledge AutoLit semi-automated systematic review platform was utilized to identify randomized control trials published between 2010 and 2021 reporting the use of mechanical thrombectomy and IV-tPA (MT+tPA) vs. MT alone for AIS treatment. The primary outcome was the rate of successful recanalization, defined as thrombolysis in cerebral infarction (TICI) scores ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS) 0-2, 90-day mortality, distal embolization to new territory, and symptomatic intracranial hemorrhage (sICH). A separate random effects model was fit for each outcome measure. Results: We subjectively found Nested Knowledge to be highly streamlined and effective at sourcing the correct literature. Four studies with 1,633 patients, 816 in the MT+tPA arm and 817 in the MT arm, were included in the meta-analysis. In each study, patient populations consisted of only tPA-eligible patients and all imaging and clinical outcomes were adjudicated by an independent and blinded core laboratory. Compared to MT alone, patients treated with MT+tPA had higher odds of eTICI ≥2b (OR = 1.34 [95% CI: 1.10; 1.63]). However, there were no statistically significant differences in the rates of 90-day mRS 0-2 (OR = 0.98 [95% CI: 0.77; 1.24]), 90-day mortality (OR = 0.94 [95% CI: 0.67; 1.32]), distal emboli (OR = 0.94 [95% CI: 0.25; 3.60]), or sICH (OR = 1.17 [95% CI: 0.80; 1.72]). Conclusions: Administering tPA prior to MT may improve the rates of recanalization compared to MT alone in tPA-eligible patients being treated for AIS, but a corresponding improvement in functional and safety outcomes was not present in this review. Further studies looking at the role of tPA before mechanical thrombectomy in different cohorts of patients could better clarify the role of tPA in the treatment protocol for AIS.
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Affiliation(s)
- Gautam Adusumilli
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, United States
| | - John M Pederson
- Nested Knowledge, Inc, St. Paul, MN, United States.,Superior Medical Experts, Inc, St. Paul, MN, United States
| | - Nicole Hardy
- Nested Knowledge, Inc, St. Paul, MN, United States
| | | | | | - Hassan Kobeissi
- Central Michigan University College of Medicine, Mt. Pleasant, MI, United States
| | - Daniel M Heiferman
- Semmes-Murphey Clinic, Department of Neurosurgery, Memphis, TN, United States
| | - Jeremy J Heit
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, United States
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Achar A, Myers R, Ghosh C. Drug Delivery Challenges in Brain Disorders across the Blood-Brain Barrier: Novel Methods and Future Considerations for Improved Therapy. Biomedicines 2021; 9:1834. [PMID: 34944650 PMCID: PMC8698904 DOI: 10.3390/biomedicines9121834] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
Due to the physiological and structural properties of the blood-brain barrier (BBB), the delivery of drugs to the brain poses a unique challenge in patients with central nervous system (CNS) disorders. Several strategies have been investigated to circumvent the barrier for CNS therapeutics such as in epilepsy, stroke, brain cancer and traumatic brain injury. In this review, we summarize current and novel routes of drug interventions, discuss pharmacokinetics and pharmacodynamics at the neurovascular interface, and propose additional factors that may influence drug delivery. At present, both technological and mechanistic tools are devised to assist in overcoming the BBB for more efficient and improved drug bioavailability in the treatment of clinically devastating brain disorders.
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Affiliation(s)
- Aneesha Achar
- Cerebrovascular Research, Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (A.A.); (R.M.)
| | - Rosemary Myers
- Cerebrovascular Research, Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (A.A.); (R.M.)
| | - Chaitali Ghosh
- Cerebrovascular Research, Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (A.A.); (R.M.)
- Department of Biomedical Engineering and Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
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Wu H, Goel LD, Kim H, Zhang B, Kim J, Dayton PA, Xu Z, Jiang X. Dual-Frequency Intravascular Sonothrombolysis: An In Vitro Study. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2021; 68:3599-3607. [PMID: 34370663 PMCID: PMC8645157 DOI: 10.1109/tuffc.2021.3103409] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Thrombo-occlusive disease is one of the leading causes of death worldwide. There has been active research on safe and effective thrombolysis in preclinical and clinical studies. Recently, the dual-frequency transcutaneous sonothrombolysis with contrast agents [microbubbles (MBs)] has been reported to be more efficient in trigging the acoustic cavitation, which leads to a higher lysis rate. Therefore, there is increasing interest in applying dual-frequency technique for more significant efficacy improvement in intravascular sonothrombolysis since a miniaturized intravascular ultrasound transducer typically has a limited power output to fully harness cavitation effects. In this work, we demonstrated this efficacy enhancement by developing a new broadband intravascular transducer and testing dual-frequency sonothromblysis in vitro. A broadband intravascular transducer with a center frequency of 750 kHz and a footprint size of 1.4 mm was designed, fabricated, and characterized. The measured -6-dB fractional bandwidth is 68.1%, and the peak negative pressure is 1.5 MPa under the driving voltage of 80 Vpp. By keeping one frequency component at 750 kHz, the second frequency component was selected from 450 to 650 kHz with an interval of 50 kHz. The in vitro sonothrombolysis tests were conducted with a flow model and the results indicated that the MB-mediated, dual-frequency (750+500 kHz) sonothrombolysis yields an 85% higher lysis rate compared with the single-frequency treatment, and the lysis rate of dual-frequency sonothrombolysis increases with the difference between the two frequency components. These findings suggest a dual-frequency excitation technique for more efficient intravascular sonothrombolysis than conventional single-frequency excitation.
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38
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Wnuk A, Przepiórska K, Pietrzak BA, Kajta M. Posttreatment Strategy Against Hypoxia and Ischemia Based on Selective Targeting of Nonnuclear Estrogen Receptors with PaPE-1. Neurotox Res 2021; 39:2029-2041. [PMID: 34797527 PMCID: PMC8639538 DOI: 10.1007/s12640-021-00441-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 02/06/2023]
Abstract
Newly synthesized Pathway Preferential Estrogen-1 (PaPE-1) selectively activates membrane estrogen receptors (mERs), namely, mERα and mERβ, and has been shown to evoke neuroprotection; however, its effectiveness in protecting brain tissue against hypoxia and ischemia has not been verified in a posttreatment paradigm. This is the first study showing that a 6-h delayed posttreatment with PaPE-1 inhibited hypoxia/ischemia-induced neuronal death, as indicated by neutral red uptake in mouse primary cell cultures in vitro. The effect was accompanied by substantial decreases in neurotoxicity and neurodegeneration in terms of LDH release and Fluoro-Jade C staining of damaged cells, respectively. The mechanisms of the neuroprotective action of PaPE-1 also involved apoptosis inhibition demonstrated by normalization of both mitochondrial membrane potential and expression levels of apoptosis-related genes and proteins such as Fas, Fasl, Bcl2, FAS, FASL, BCL2, BAX, and GSK3β. Furthermore, PaPE-1-evoked neuroprotection was mediated through a reduction in ROS formation and restoration of cellular metabolic activity that had become dysregulated due to hypoxia and ischemia. These data provide evidence that targeting membrane non-GPER estrogen receptors with PaPE-1 is an effective therapy that protects brain neurons from hypoxic/ischemic damage, even when applied with a 6-h delay from injury onset.
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Affiliation(s)
- A Wnuk
- Maj Institute of Pharmacology, Polish Academy of Sciences, Department of Pharmacology, Laboratory of Neuropharmacology and Epigenetics, Smętna Street 12, 31-343, Krakow, Poland.
| | - K Przepiórska
- Maj Institute of Pharmacology, Polish Academy of Sciences, Department of Pharmacology, Laboratory of Neuropharmacology and Epigenetics, Smętna Street 12, 31-343, Krakow, Poland
| | - B A Pietrzak
- Maj Institute of Pharmacology, Polish Academy of Sciences, Department of Pharmacology, Laboratory of Neuropharmacology and Epigenetics, Smętna Street 12, 31-343, Krakow, Poland
| | - M Kajta
- Maj Institute of Pharmacology, Polish Academy of Sciences, Department of Pharmacology, Laboratory of Neuropharmacology and Epigenetics, Smętna Street 12, 31-343, Krakow, Poland.
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Haque O, Pendexter CA, Wilks BT, Hafiz EOA, Markmann JF, Uygun K, Yeh H, Tessier SN. The effect of blood cells retained in rat livers during static cold storage on viability outcomes during normothermic machine perfusion. Sci Rep 2021; 11:23128. [PMID: 34848781 PMCID: PMC8633375 DOI: 10.1038/s41598-021-02417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/01/2021] [Indexed: 12/03/2022] Open
Abstract
In transplantation, livers are transported to recipients using static cold storage (SCS), whereby livers are exposed to cold ischemic injury that contribute to post-transplant risk factors. We hypothesized that flushing organs during procurement with cold preservation solutions could influence the number of donor blood cells retained in the allograft thereby exacerbating cold ischemic injury. We present the results of rat livers that underwent 24 h SCS after being flushed with a cold University of Wisconsin (UW) solution versus room temperature (RT) lactated ringers (LR) solution. These results were compared to livers that were not flushed prior to SCS and thoroughly flushed livers without SCS. We used viability and injury metrics collected during normothermic machine perfusion (NMP) and the number of retained peripheral cells (RPCs) measured by histology to compare outcomes. Compared to the cold UW flush group, livers flushed with RT LR had lower resistance, lactate, AST, and ALT at 6 h of NMP. The number of RPCs also had significant positive correlations with resistance, lactate, and potassium levels and a negative correlation with energy charge. In conclusion, livers exposed to cold UW flush prior to SCS appear to perform worse during NMP, compared to RT LR flush.
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Affiliation(s)
- Omar Haque
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, 51 Blossom St, Boston, MA, 02114, USA
- Shriners Hospitals for Children, Boston, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Surgery, Division of Transplantation, Center for Transplantation Science, Massachusetts General Hospital, 32 Fruit Street, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Casie A Pendexter
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, 51 Blossom St, Boston, MA, 02114, USA
- Shriners Hospitals for Children, Boston, MA, USA
| | - Benjamin T Wilks
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, 51 Blossom St, Boston, MA, 02114, USA
- Shriners Hospitals for Children, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ehab O A Hafiz
- Department of Electron Microscopy Research, Theodor Bilharz Research Institute, Giza, Egypt
| | - James F Markmann
- Department of Surgery, Division of Transplantation, Center for Transplantation Science, Massachusetts General Hospital, 32 Fruit Street, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, 51 Blossom St, Boston, MA, 02114, USA
- Shriners Hospitals for Children, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Heidi Yeh
- Department of Surgery, Division of Transplantation, Center for Transplantation Science, Massachusetts General Hospital, 32 Fruit Street, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Shannon N Tessier
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, 51 Blossom St, Boston, MA, 02114, USA.
- Shriners Hospitals for Children, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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40
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Lu J, Mei Q, Hou X, Manaenko A, Zhou L, Liebeskind DS, Zhang JH, Li Y, Hu Q. Imaging Acute Stroke: From One-Size-Fit-All to Biomarkers. Front Neurol 2021; 12:697779. [PMID: 34630278 PMCID: PMC8497192 DOI: 10.3389/fneur.2021.697779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/30/2021] [Indexed: 12/27/2022] Open
Abstract
In acute stroke management, time window has been rigidly used as a guide for decades and the reperfusion treatment is only available in the first few limited hours. Recently, imaging-based selection of patients has successfully expanded the treatment window out to 16 and even 24 h in the DEFUSE 3 and DAWN trials, respectively. Recent guidelines recommend the use of imaging techniques to guide therapeutic decision-making and expanded eligibility in acute ischemic stroke. A tissue window is proposed to replace the time window and serve as the surrogate marker for potentially salvageable tissue. This article reviews the evolution of time window, addresses the advantage of a tissue window in precision medicine for ischemic stroke, and discusses both the established and emerging techniques of neuroimaging and their roles in defining a tissue window. We also emphasize the metabolic imaging and molecular imaging of brain pathophysiology, and highlight its potential in patient selection and treatment response prediction in ischemic stroke.
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Affiliation(s)
- Jianfei Lu
- Central Laboratory, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiyong Mei
- Department of Neurosurgery, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Xianhua Hou
- Department of Neurology, Southwest Hospital, Army Medical University, Chongqing, China
| | - Anatol Manaenko
- National Health Commission Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lili Zhou
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - David S Liebeskind
- Neurovascular Imaging Research Core and University of California Los Angeles Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
| | - John H Zhang
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Yao Li
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Qin Hu
- Central Laboratory, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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41
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Advanced Imaging in the Era of Tissue-Based Treatment for Acute Ischemic Stroke—a Practical Review. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00685-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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42
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Chen Z, Li Q, Li R, Zhao H, Li Z, Zhou Y, Bian R, Jin X, Lou M, Bai R. Ensemble learning accurately predicts the potential benefits of thrombolytic therapy in acute ischemic stroke. Quant Imaging Med Surg 2021; 11:3978-3989. [PMID: 34476183 DOI: 10.21037/qims-21-33] [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: 01/08/2021] [Accepted: 04/16/2021] [Indexed: 11/06/2022]
Abstract
Background Finding methods to accurately predict the final infarct volumes for acute ischemic stroke patients with full or no recanalization would significantly help to evaluate the potential benefits of thrombolytic therapy. We proposed such a method by constructing a model of ensemble deep learning and machine learning using diffusion-weighted imaging (DWI) only. Methods The proposed prediction model (named AUNet) combines an adaptive linear ensemble model (ALEM) of machine learning and a deep U-Net network with an accelerated non-local module (U-NL-Net) to learn voxel-wise and spatial features, respectively. Of 40 patients with acute ischemic stroke who received thrombolytic therapy, 17 were fully recanalized, 14 were not recanalized, and nine were partially recanalized. The AUNet was separately trained for full recanalization conditions (AUNetR) and no recanalization (AUNetN) as the best and worst outcomes of thrombolysis, respectively. Results AUNet performed significantly better in predicting the final infarct volumes in both the recanalization and non-recanalization conditions [area under the receiver operating characteristic curve (AUC) =0.898±0.022, recanalization; AUC =0.875±0.036, non-recanalization: Matthew's correlation coefficient (MCC) =0.863±0.033, recanalization; MCC =0.851±0.025, non-recanalization] than the fixed-thresholding method (AUC =0.776±0.021, P<0.0001, recanalization; AUC =0.692±0.023, P<0.0001, non-recanalization: MCC =0.742±0.035, recanalization; MCC =0.671±0.024, non-recanalization), the logistic regression method (AUC =0.797±0.023, P<0.003, recanalization; AUC =0.751±0.030, P<0.003, non-recanalization: MCC =0.762±0.035, recanalization; MCC =0.730±0.031, non-recanalization), and a recently developed convolutional neural network (AUC =0.814±0.013, P<0.003, recanalization; AUC =0.781±0.027, P<0.003, non-recanalization: MCC =792±0.022, recanalization; MCC =0.758±0.016, non-recanalization). The potential benefit of thrombolysis calculated from AUNetR and AUNetN showed large individual differences (from 12.81% to 239.73%). Conclusions AUNet improved predictive accuracy over current state-of-the-art methods. More importantly, the accurate prediction of infarct volumes under different recanalization conditions may provide benefitial information for physicians in selecting suitable patients for thrombolytic therapy.
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Affiliation(s)
- Zhihong Chen
- Institute of Information Science and Electronic Engineering, Zhejiang University, Hangzhou, China
| | - Qingqing Li
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Renyuan Li
- Department of Physical Medicine and Rehabilitation, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Interdisciplinary Institute of Neuroscience and Technology, School of Medicine, Zhejiang University, Hangzhou, China
| | - Han Zhao
- Institute of Information Science and Electronic Engineering, Zhejiang University, Hangzhou, China
| | - Zhaoqing Li
- Interdisciplinary Institute of Neuroscience and Technology, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Biomedical Engineering of Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Ying Zhou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Renxiu Bian
- Department of Physical Medicine and Rehabilitation, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xinyu Jin
- Institute of Information Science and Electronic Engineering, Zhejiang University, Hangzhou, China
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Ruiliang Bai
- Department of Physical Medicine and Rehabilitation, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Interdisciplinary Institute of Neuroscience and Technology, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Biomedical Engineering of Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
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Zhang B, Wu H, Goel L, Kim H, Peng C, Kim J, Dayton PA, Gao Y, Jiang X. Magneto-sonothrombolysis with combination of magnetic microbubbles and nanodroplets. ULTRASONICS 2021; 116:106487. [PMID: 34119875 PMCID: PMC8645658 DOI: 10.1016/j.ultras.2021.106487] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/25/2021] [Accepted: 05/31/2021] [Indexed: 05/07/2023]
Abstract
This paper reports a novel technique using the rotational magnetic field oscillation and low-intensity sub-megahertz ultrasound stimulation of magnetic microbubbles (MMBs) to promote the nanodroplets (NDs) phase transition and improve the permeation of NDs into the blood clot fibrin network to enhance the sonothrombolysis efficiency. In this study, the influence of different treatment methods with a combination of MMBs and NDs on the thrombolysis rate of both unretracted and retracted clots were investigated, including the stable and inertial cavitation, tPA effects, MMBs/NDs concentration ratio, sonication factors (input voltage, duty cycle) and rotational magnetic field factors (flux density, frequency). We demonstrated that tPA-mediated magneto-sonothrombolysis in combining NDs with MMBs could significantly enhance in vitro lysis of both unretracted clots (85 ± 8.3%) and retracted clots (57 ± 6.5%) in a flow model with 30 min treatment. The results showed that the combination of MMBs and NDs substantially improves in vitro lysis of blood clots with an unprecedented lysis rate.
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Affiliation(s)
- Bohua Zhang
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC 27695, USA
| | - Huaiyu Wu
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC 27695, USA
| | - Leela Goel
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC 27695, USA; The Joint Department of Biomedical Engineering, The University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, NC 27599, USA
| | - Howuk Kim
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC 27695, USA
| | - Chang Peng
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC 27695, USA
| | - Jinwook Kim
- The Joint Department of Biomedical Engineering, The University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, NC 27599, USA
| | - Paul A Dayton
- The Joint Department of Biomedical Engineering, The University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, NC 27599, USA
| | - Yu Gao
- Institute of Advanced Materials, Nanjing University of Posts and Telecommunications, Nanjing 210023, China
| | - Xiaoning Jiang
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC 27695, USA.
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Molecular Mechanisms of Neuroimmune Crosstalk in the Pathogenesis of Stroke. Int J Mol Sci 2021; 22:ijms22179486. [PMID: 34502395 PMCID: PMC8431165 DOI: 10.3390/ijms22179486] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/26/2021] [Accepted: 08/28/2021] [Indexed: 12/21/2022] Open
Abstract
Stroke disrupts the homeostatic balance within the brain and is associated with a significant accumulation of necrotic cellular debris, fluid, and peripheral immune cells in the central nervous system (CNS). Additionally, cells, antigens, and other factors exit the brain into the periphery via damaged blood–brain barrier cells, glymphatic transport mechanisms, and lymphatic vessels, which dramatically influence the systemic immune response and lead to complex neuroimmune communication. As a result, the immunological response after stroke is a highly dynamic event that involves communication between multiple organ systems and cell types, with significant consequences on not only the initial stroke tissue injury but long-term recovery in the CNS. In this review, we discuss the complex immunological and physiological interactions that occur after stroke with a focus on how the peripheral immune system and CNS communicate to regulate post-stroke brain homeostasis. First, we discuss the post-stroke immune cascade across different contexts as well as homeostatic regulation within the brain. Then, we focus on the lymphatic vessels surrounding the brain and their ability to coordinate both immune response and fluid homeostasis within the brain after stroke. Finally, we discuss how therapeutic manipulation of peripheral systems may provide new mechanisms to treat stroke injury.
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Kim C, Hladik A. Angioedema Secondary to tPA Use in Acute Ischemic Stroke Patient with Hypertension: A Case Report. Clin Pract Cases Emerg Med 2021; 5:159-162. [PMID: 34436994 PMCID: PMC8143845 DOI: 10.5811/cpcem.2021.1.49582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/27/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction A well-documented complication of administering tissue plasminogen activator (tPA) in stroke patients is acute intracranial bleeding. A lesser known but still significant complication is angioedema secondary to tPA administration, which can develop in certain individuals with risk factors such as angiotensin converting enzyme (ACE) inhibitor use and location of the stroke. Knowing the potential for this life-threatening complication and being prepared for its proper management is vital for emergency physicians. Case Report We report a 53-year-old Black female who presented to the emergency department with sudden onset of slurred speech and a facial droop. She was found to have an acute ischemic stroke and tPA was administered. She subsequently developed angioedema. Retrospectively, the patient was found to have risk factors that are thought to predispose patients to tPA-induced angioedema. Conclusion Risk factors associated with angioedema secondary to tPA administration have been documented in patients taking ACE inhibitors, as well as patients who develop strokes in the frontal lobe. While many cases may be mild, some patients may develop life-threatening angioedema. Although this complication does not necessarily contraindicate tPA use, it is prudent for the emergency physician to be vigilant for its development, prepared for its treatment, and to be diligent in assessing the need for control of the patient’s airway.
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Affiliation(s)
- Chris Kim
- Eisenhower Medical Center, Department of Emergency Medicine, Rancho Mirage, California
| | - Andrea Hladik
- Eisenhower Medical Center, Department of Emergency Medicine, Rancho Mirage, California
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46
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Gray M, Ernst J, Ashworth S, Patel R, Couperus K. Stroke or No Stroke: A Case Report of Bilingual Aphasia. Clin Pract Cases Emerg Med 2021; 5:325-327. [PMID: 34437039 PMCID: PMC8373183 DOI: 10.5811/cpcem.2021.4.51206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/06/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Bilingual aphasia is an atypical stroke presentation in the multilingual patient where an isolated aphasia occurs in one language while the other remains unaffected. Case Report A multilingual male presented to the emergency department with expressive aphasia to English but who was still able to speak fluently in French. Receptive English was preserved. While his National Institute of Health Stroke Scale score was technically zero, his pure aphasia component qualified him as an exception. He regained some repetitive English, so fibrinolyitic therapy was not initiated. Conclusion Bilingual aphasia is an indication for fibrinolysis given the impact that a pure aphasic stroke has on quality of life.
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Affiliation(s)
- Matthew Gray
- Madigan Army Medical Center, Department of Emergency Medicine, Joint Base Lewis-McChord, Washington
| | - Jacob Ernst
- Madigan Army Medical Center, Department of Emergency Medicine, Joint Base Lewis-McChord, Washington
| | - Simeon Ashworth
- Madigan Army Medical Center, Department of Emergency Medicine, Joint Base Lewis-McChord, Washington
| | - Ronak Patel
- Madigan Army Medical Center, Department of Emergency Medicine, Joint Base Lewis-McChord, Washington
| | - Kyle Couperus
- Madigan Army Medical Center, Department of Emergency Medicine, Joint Base Lewis-McChord, Washington
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47
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Post-Treatment with Amorfrutin B Evokes PPARγ-Mediated Neuroprotection against Hypoxia and Ischemia. Biomedicines 2021; 9:biomedicines9080854. [PMID: 34440058 PMCID: PMC8389580 DOI: 10.3390/biomedicines9080854] [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: 06/14/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 12/14/2022] Open
Abstract
In this study, we demonstrate for the first time that amorfrutin B, a selective modulator of peroxisome proliferator-activated receptor gamma—PPARγ, can protect brain neurons from hypoxia- and ischemia-induced degeneration when applied at 6 h post-treatment in primary cultures. The neuroprotective effect of amorfrutin B suggests that it promotes mitochondrial integrity and is capable of inhibiting reactive oxygen species—ROS activity and ROS-mediated DNA damage. PPARγ antagonist and Pparg mRNA silencing abolished the neuroprotective effect of amorfrutin B, which points to agonistic action of the compound on the respective receptor. Interestingly, amorfrutin B stimulated the methylation of the Pparg gene, both during hypoxia and ischemia. Amorfrutin B also increased the protein level of PPARγ during hypoxia but decreased the mRNA and protein levels of PPARγ during ischemia. Under ischemic conditions, amorfrutin B-evoked hypermethylation of the Pparg gene is in line with the decrease in the mRNA and protein expression of PPARγ. However, under hypoxic conditions, amorfrutin B-dependent hypermethylation of the Pparg gene does not explain the amorfrutin B-dependent increase in receptor protein expression, which suggests other regulatory mechanisms. Other epigenetic parameters, such as HAT and/or sirtuins activities, were affected by amorfrutin B under hypoxic and ischemic conditions. These properties position the compound among the most promising anti-stroke and wide-window therapeutics.
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48
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Haque O, Raigani S, Rosales I, Carroll C, Coe TM, Baptista S, Yeh H, Uygun K, Delmonico FL, Markmann JF. Thrombolytic Therapy During ex-vivo Normothermic Machine Perfusion of Human Livers Reduces Peribiliary Vascular Plexus Injury. Front Surg 2021; 8:644859. [PMID: 34222314 PMCID: PMC8245781 DOI: 10.3389/fsurg.2021.644859] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/24/2021] [Indexed: 12/29/2022] Open
Abstract
Background: A major limitation in expanding the use of donation after circulatory death (DCD) livers in transplantation is the increased risk of graft failure secondary to ischemic cholangiopathy. Warm ischemia causes thrombosis and injury to the peribiliary vascular plexus (PVP), which is supplied by branches of the hepatic artery, causing higher rates of biliary complications in DCD allografts. Aims/Objectives: We aimed to recondition discarded DCD livers with tissue plasminogen activator (tPA) while on normothermic machine perfusion (NMP) to improve PVP blood flow and reduce biliary injury. Methods: Five discarded DCD human livers underwent 12 h of NMP. Plasminogen was circulated in the base perfusate prior to initiation of perfusion and 1 mg/kg of tPA was administered through the hepatic artery at T = 0.5 h. Two livers were split prior to perfusion (S1, S2), with tPA administered in one lobe, while the other served as a control. The remaining three whole livers (W1-W3) were compared to seven DCD control liver perfusions (C1-C7) with similar hepatocellular and biliary viability criteria. D-dimer levels were measured at T = 1 h to verify efficacy of tPA. Lactate, total bile production, bile pH, and difference in biliary injury scores before and after perfusion were compared between tPA and non-tPA groups using unpaired, Mann-Whitney tests. Results: Average weight-adjusted D-dimer levels were higher in tPA livers in the split and whole-liver model, verifying drug function. There were no differences in perfusion hepatic artery resistance, portal vein resistance, and arterial lactate between tPA livers and non-tPA livers in both the split and whole-liver model. However, when comparing biliary injury between hepatocellular and biliary non-viable whole livers, tPA livers had significantly lower PVP injury scores (0.67 vs. 2.0) and mural stroma (MS) injury scores (1.3 vs. 2.7). Conclusion: This study demonstrates that administration of tPA into DCD livers during NMP can reduce PVP and MS injury. Further studies are necessary to assess the effect of tPA administration on long term biliary complications.
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Affiliation(s)
- Omar Haque
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States.,Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States.,Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, MA, United States.,Shriners Hospitals for Children, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Siavash Raigani
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States.,Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, MA, United States.,Shriners Hospitals for Children, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Ivy Rosales
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States.,Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Cailah Carroll
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States.,Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, MA, United States.,Shriners Hospitals for Children, Boston, MA, United States
| | - Taylor M Coe
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States.,Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, MA, United States.,Shriners Hospitals for Children, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Sofia Baptista
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, MA, United States.,Shriners Hospitals for Children, Boston, MA, United States
| | - Heidi Yeh
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States.,Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Korkut Uygun
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States.,Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, MA, United States.,Shriners Hospitals for Children, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Francis L Delmonico
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,New England Donor Services (NEDS), Waltham, MA, United States
| | - James F Markmann
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States.,Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
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49
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Saleh Velez FG, Ortiz Garcia JG. Management dilemmas in acute ischemic stroke and concomitant acute pulmonary embolism: Case series and literature review. eNeurologicalSci 2021; 23:100341. [PMID: 33997324 PMCID: PMC8102755 DOI: 10.1016/j.ensci.2021.100341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) and acute ischemic stroke (AIS) are common disorders with high morbidity and mortality, rarely presenting simultaneously. There is a paucity of data regarding the management of this uncommon presentation. The treatment of these two entities is complex in the acute phase due to the concomitant need for thrombolysis in AIS and anticoagulation for PE. METHODS We retrospectively reviewed confirmed ischemic stroke cases to identify patients presented with simultaneous PE from June 2018 to May 2019. Additionally, a literature review was performed. Two reviewers assessed the manuscripts' quality, and relevant data regarding clinical course and management was extracted. RESULTS We reviewed 439 patient charts, identifying two cases of concomitant AIS and PE. Additionally, twelve articles (n = 15 subjects) fulfilled our literature review criteria for a total of 17 cases, including ours. Intravenous anticoagulation (70.5%) was the most frequent intervention targeting both disorders. Therapies such as intravenous thrombolysis (23.53% (n = 4)) and mechanical thrombectomy (23.53% (n = 4)) were specific in AIS. Catheter-directed thrombolysis (5.88%) was used for PE. Clinical outcomes were favorable (asymptomatic or mild disable symptoms) in 47.05% (N = 8) of patients, while 41.17% had poor outcomes (severe disable symptoms or death). CONCLUSIONS AIS and PE stand for a challenge when they present simultaneously. The evaluation of risks and benefits of therapies such as intravenous thrombolysis, mechanical thrombectomy, and catheter-directed-thrombolysis in the clinical context is essential. According to our review, the ischemic stroke burden guides systemic anticoagulation decisions over interventional procedures when the hemodynamic status remains unaffected.
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Affiliation(s)
- Faddi G. Saleh Velez
- Department of Neurology, University of Chicago, Chicago, IL, United States of America
| | - Jorge G. Ortiz Garcia
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States of America
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50
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Huang Y, Gu B, Salles-Crawley II, Taylor KA, Yu L, Ren J, Liu X, Emerson M, Longstaff C, Hughes AD, Thom SA, Xu XY, Chen R. Fibrinogen-mimicking, multiarm nanovesicles for human thrombus-specific delivery of tissue plasminogen activator and targeted thrombolytic therapy. SCIENCE ADVANCES 2021; 7:7/23/eabf9033. [PMID: 34078604 PMCID: PMC8172176 DOI: 10.1126/sciadv.abf9033] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 04/14/2021] [Indexed: 05/03/2023]
Abstract
Clinical use of tissue plasminogen activator (tPA) in thrombolytic therapy is limited by its short circulation time and hemorrhagic side effects. Inspired by fibrinogen binding to activated platelets, we report a fibrinogen-mimicking, multiarm nanovesicle for thrombus-specific tPA delivery and targeted thrombolysis. This biomimetic system is based on the lipid nanovesicle coated with polyethylene glycol (PEG) terminally conjugated with a cyclic RGD (cRGD) peptide. Our experiments with human blood demonstrated its highly selective binding to activated platelets and efficient tPA release at a thrombus site under both static and physiological flow conditions. Its clot dissolution time in a microfluidic system was comparable to that of free tPA. Furthermore, we report a purpose-built computational model capable of simulating targeted thrombolysis of the tPA-loaded nanovesicle and with a potential in predicting the dynamics of thrombolysis in physiologically realistic scenarios. This combined experimental and computational work presents a promising platform for development of thrombolytic nanomedicines.
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Affiliation(s)
- Yu Huang
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London, UK
| | - Boram Gu
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London, UK
- School of Chemical Engineering, Chonnam National University, Gwangju, Republic of Korea
| | - Isabelle I Salles-Crawley
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - Kirk A Taylor
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Li Yu
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London, UK
| | - Jie Ren
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London, UK
| | - Xuhan Liu
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London, UK
| | - Michael Emerson
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Colin Longstaff
- Biotherapeutics Section, National Institute for Biological Standards and Control, South Mimms, Herts, UK
| | - Alun D Hughes
- Institute of Cardiovascular Science, University College London, London, UK
- MRC Unit for Lifelong Health and Ageing at University College London, London, UK
| | - Simon A Thom
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Xiao Yun Xu
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London, UK.
| | - Rongjun Chen
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London, UK.
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