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Pinoșanu EA, Pîrșcoveanu D, Albu CV, Burada E, Pîrvu A, Surugiu R, Sandu RE, Serb AF. Rhoa/ROCK, mTOR and Secretome-Based Treatments for Ischemic Stroke: New Perspectives. Curr Issues Mol Biol 2024; 46:3484-3501. [PMID: 38666949 PMCID: PMC11049286 DOI: 10.3390/cimb46040219] [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: 03/18/2024] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Ischemic stroke triggers a complex cascade of cellular and molecular events leading to neuronal damage and tissue injury. This review explores the potential therapeutic avenues targeting cellular signaling pathways implicated in stroke pathophysiology. Specifically, it focuses on the articles that highlight the roles of RhoA/ROCK and mTOR signaling pathways in ischemic brain injury and their therapeutic implications. The RhoA/ROCK pathway modulates various cellular processes, including cytoskeletal dynamics and inflammation, while mTOR signaling regulates cell growth, proliferation, and autophagy. Preclinical studies have demonstrated the neuroprotective effects of targeting these pathways in stroke models, offering insights into potential treatment strategies. However, challenges such as off-target effects and the need for tissue-specific targeting remain. Furthermore, emerging evidence suggests the therapeutic potential of MSC secretome in stroke treatment, highlighting the importance of exploring alternative approaches. Future research directions include elucidating the precise mechanisms of action, optimizing treatment protocols, and translating preclinical findings into clinical practice for improved stroke outcomes.
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Affiliation(s)
- Elena Anca Pinoșanu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania; (E.A.P.); (D.P.); (C.V.A.)
- Doctoral School, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania
| | - Denisa Pîrșcoveanu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania; (E.A.P.); (D.P.); (C.V.A.)
| | - Carmen Valeria Albu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania; (E.A.P.); (D.P.); (C.V.A.)
| | - Emilia Burada
- Department of Physiology, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania;
| | - Andrei Pîrvu
- Dolj County Regional Centre of Medical Genetics, Clinical Emergency County Hospital Craiova, St. Tabaci, No. 1, 200642 Craiova, Romania;
| | - Roxana Surugiu
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania;
| | - Raluca Elena Sandu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania; (E.A.P.); (D.P.); (C.V.A.)
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania;
| | - Alina Florina Serb
- Department of Biochemistry and Pharmacology, Biochemistry Discipline, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Sq., No. 2, 300041 Timisoara, Romania;
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Lin V, Tian C, Wahlster S, Castillo-Pinto C, Mainali S, Johnson NJ. Temperature Control in Acute Brain Injury: An Update. Semin Neurol 2024. [PMID: 38593854 DOI: 10.1055/s-0044-1785647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Temperature control in severe acute brain injury (SABI) is a key component of acute management. This manuscript delves into the complex role of temperature management in SABI, encompassing conditions like traumatic brain injury (TBI), acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (aSAH), and hypoxemic/ischemic brain injury following cardiac arrest. Fever is a common complication in SABI and is linked to worse neurological outcomes due to increased inflammatory responses and intracranial pressure (ICP). Temperature management, particularly hypothermic temperature control (HTC), appears to mitigate these adverse effects primarily by reducing cerebral metabolic demand and dampening inflammatory pathways. However, the effectiveness of HTC varies across different SABI conditions. In the context of post-cardiac arrest, the impact of HTC on neurological outcomes has shown inconsistent results. In cases of TBI, HTC seems promising for reducing ICP, but its influence on long-term outcomes remains uncertain. For AIS, clinical trials have yet to conclusively demonstrate the benefits of HTC, despite encouraging preclinical evidence. This variability in efficacy is also observed in ICH, aSAH, bacterial meningitis, and status epilepticus. In pediatric and neonatal populations, while HTC shows significant benefits in hypoxic-ischemic encephalopathy, its effectiveness in other brain injuries is mixed. Although the theoretical basis for employing temperature control, especially HTC, is strong, the clinical outcomes differ among various SABI subtypes. The current consensus indicates that fever prevention is beneficial across the board, but the application and effectiveness of HTC are more nuanced, underscoring the need for further research to establish optimal temperature management strategies. Here we provide an overview of the clinical evidence surrounding the use of temperature control in various types of SABI.
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Affiliation(s)
- Victor Lin
- Department of Neurology, University of Washington, Seattle, Washington
| | - Cindy Tian
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, Washington
- Department of Neurosurgery, University of Washington, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
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Binda DD, Baker MB, Varghese S, Wang J, Badenes R, Bilotta F, Nozari A. Targeted Temperature Management for Patients with Acute Ischemic Stroke: A Literature Review. J Clin Med 2024; 13:586. [PMID: 38276093 PMCID: PMC10816923 DOI: 10.3390/jcm13020586] [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: 12/16/2023] [Revised: 01/03/2024] [Accepted: 01/11/2024] [Indexed: 01/27/2024] Open
Abstract
Despite significant advances in medical imaging, thrombolytic therapy, and mechanical thrombectomy, acute ischemic strokes (AIS) remain a major cause of mortality and morbidity globally. Targeted temperature management (TTM) has emerged as a potential therapeutic intervention, aiming to mitigate neuronal damage and improve outcomes. This literature review examines the efficacy and challenges of TTM in the context of an AIS. A comprehensive literature search was conducted using databases such as PubMed, Cochrane, Web of Science, and Google Scholar. Studies were selected based on relevance and quality. We identified key factors influencing the effectiveness of TTM such as its timing, depth and duration, and method of application. The review also highlighted challenges associated with TTM, including increased pneumonia rates. The target temperature range was typically between 32 and 36 °C, with the duration of cooling from 24 to 72 h. Early initiation of TTM was associated with better outcomes, with optimal results observed when TTM was started within the first 6 h post-stroke. Emerging evidence indicates that TTM shows considerable potential as an adjunctive treatment for AIS when implemented promptly and with precision, thereby potentially mitigating neuronal damage and enhancing overall patient outcomes. However, its application is complex and requires the careful consideration of various factors.
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Affiliation(s)
- Dhanesh D. Binda
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Maxwell B. Baker
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Shama Varghese
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Jennifer Wang
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Rafael Badenes
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Federico Bilotta
- Department of Anaesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I Teaching Hospital, Sapienza University of Rome, 00185 Rome, Italy;
| | - Ala Nozari
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
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Diprose WK, Rao A, Ghate K, Dyer Z, Campbell D, Almekhlafi M, Barber PA. Penumbral cooling in ischemic stroke with intraarterial, intravenous or active conductive head cooling: A thermal modeling study. J Cereb Blood Flow Metab 2024; 44:66-76. [PMID: 37734834 PMCID: PMC10905634 DOI: 10.1177/0271678x231203025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 09/23/2023]
Abstract
In ischemic stroke, selectively cooling the ischemic penumbra might lead to neuroprotection while avoiding systemic complications. Because penumbral tissue has reduced cerebral blood flow and in vivo brain temperature measurement remains challenging, the effect of different methods of therapeutic hypothermia on penumbral temperature are unknown. We used the COMSOL Multiphysics® software to model a range of cases of therapeutic hypothermia in ischemic stroke. Four ischemic stroke models were developed with ischemic core and/or penumbra volumes between 33-300 mL. Four experiments were performed on each model, including no cooling, and intraarterial, intravenous, and active conductive head cooling. The steady-state temperature of the non-ischemic brain, ischemic penumbra, and ischemic core without cooling was 37.3 °C, 37.5-37.8 °C, and 38.9-39.4 °C respectively. Intraarterial, intravenous and active conductive head cooling reduced non-ischemic brain temperature by 4.3 °C, 2.1 °C, and 0.7-0.8 °C respectively. Intraarterial, intravenous and head cooling reduced the temperature of the ischemic penumbra by 3.9-4.3 °C, 1.9-2.1 °C, and 1.2-3.4 °C respectively. Active conductive head cooling was the only method to selectively reduce penumbral temperature. Clinical studies that measure brain temperature in ischemic stroke patients undergoing therapeutic hypothermia are required to validate these hypothesis-generating findings.
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Affiliation(s)
- William K Diprose
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Avinash Rao
- Department of Engineering, Victoria University of Wellington, Wellington, New Zealand
| | - Kaustubha Ghate
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Zoe Dyer
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Doug Campbell
- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | | | - P Alan Barber
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
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Xu R, Nair SK, Kilgore CB, Xie ME, Jackson CM, Hui F, Gailloud P, McDougall CG, Gonzalez LF, Huang J, Tamargo RJ, Caplan J. Hypothermia is Associated with Improved Neurological Outcomes After Mechanical Thrombectomy. World Neurosurg 2024; 181:e126-e132. [PMID: 37690581 PMCID: PMC11060169 DOI: 10.1016/j.wneu.2023.09.010] [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: 04/12/2023] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Acute ischemic stroke (AIS) is the second leading cause of death globally. Mechanical thrombectomy (MT) has improved patient prognosis but expedient treatment is still necessary to minimize anoxic injury. Lower intraoperative body temperature decreases cerebral oxygen demand, but the role of hypothermia in treatment of AIS with MT is unclear. METHODS We retrospectively reviewed patients undergoing MT for AIS from 2014 to 2020 at our institution. Patient demographics, comorbidities, intraoperative parameters, and outcomes were collected. Maximum body temperature was extracted from minute-by-minute anesthesia readings, and patients with maximal temperature below 36°C were considered hypothermic. Risk factors were assessed by χ2 and multivariate ordinal regression. RESULTS Of 68 patients, 27 (40%) were hypothermic. There was no significant association of hypothermia with patient age, comorbidities, time since last known well, number of passes intraoperatively, favorable revascularization, tissue plasminogen activator use, and immediate postoperative complications. Hypothermic patients exhibited better neurologic outcome at 3-month follow-up (P = 0.02). On multivariate ordinal regression, lower maximum intraoperative body temperature was associated with improved 3-month outcomes (P < 0.001), when adjusting for other factors influencing neurological outcomes. Other significant protective factors included younger age (P = 0.03), better revascularization (P = 0.03), and conscious sedation (P = 0.02). CONCLUSIONS Lower intraoperative body temperature during MT was independently associated with improved neurological outcome in this single center retrospective series. These results may help guide clinicians in employing therapeutic hypothermia during MT to improve long-term neurologic outcomes from AIS, although larger studies are needed.
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Affiliation(s)
- Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Collin B Kilgore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael E Xie
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ferdinand Hui
- Division of Neurointerventional Surgery, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Phillipe Gailloud
- Department of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Wechsler LR, Adeoye O, Alemseged F, Bahr-Hosseini M, Deljkich E, Favilla C, Fisher M, Grotta J, Hill MD, Kamel H, Khatri P, Lyden P, Mirza M, Nguyen TN, Samaniego E, Schwamm L, Selim M, Silva G, Yavagal DR, Yenari MA, Zachrison KS, Boltze J, Yaghi S. Most Promising Approaches to Improve Stroke Outcomes: The Stroke Treatment Academic Industry Roundtable XII Workshop. Stroke 2023; 54:3202-3213. [PMID: 37886850 DOI: 10.1161/strokeaha.123.044279] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/20/2023] [Indexed: 10/28/2023]
Abstract
The Stroke Treatment Academic Industry Roundtable XII included a workshop to discuss the most promising approaches to improve outcome from acute stroke. The workshop brought together representatives from academia, industry, and government representatives. The discussion examined approaches in 4 epochs: pre-reperfusion, reperfusion, post-reperfusion, and access to acute stroke interventions. The participants identified areas of priority for developing new and existing treatments and approaches to improve stroke outcomes. Although many advances in acute stroke therapy have been achieved, more work is necessary for reperfusion therapies to benefit the most possible patients. Prioritization of promising approaches should help guide the use of resources and investigator efforts.
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Affiliation(s)
- Lawrence R Wechsler
- University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, PA (L.R.W.)
| | - Opeolu Adeoye
- Washington University School of Medicine, St. Louis, MO (O.A.)
| | | | | | | | | | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | | | | | - Hooman Kamel
- Weill Cornel School of Medicine, New York, NY (H.K.)
| | - Pooja Khatri
- University of Cincinnati Medical Center, OH (P.K.)
| | - Patrick Lyden
- University of Southern California, Los Angeles, CA (P.L.)
| | | | | | | | - Lee Schwamm
- Massachusetts General Hospital, Boston (L.S.)
| | - Magdy Selim
- Beth Israel Deaconess Medical Center, Boston, MA (M.S.)
| | | | | | | | | | - Johannes Boltze
- School of Life Sciences, University of Warwick, Coventry, United Kingdom (J.B.)
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Palà E, Penalba A, Bustamante A, García‐Berrocoso T, Lamana‐Vallverdú M, Meisel C, Meisel A, van der Worp HB, R Macleod M, Kallmünzer B, Schwab S, Montaner J. Blood biomarker changes following therapeutic hypothermia in ischemic stroke. Brain Behav 2023; 13:e3230. [PMID: 37721534 PMCID: PMC10636403 DOI: 10.1002/brb3.3230] [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: 03/25/2023] [Revised: 07/23/2023] [Accepted: 08/09/2023] [Indexed: 09/19/2023] Open
Abstract
INTRODUCTION Therapeutic hypothermia is a promising candidate for stroke treatment although its efficacy has not yet been demonstrated in patients. Changes in blood molecules could act as surrogate markers to evaluate the efficacy and safety of therapeutic cooling. METHODS Blood samples from 54 patients included in the EuroHYP-1 study (27 treated with hypothermia, and 27 controls) were obtained at baseline, 24 ± 2 h, and 72 ± 4 h. The levels of a panel of 27 biomarkers, including matrix metalloproteinases and cardiac and inflammatory markers, were measured. RESULTS Metalloproteinase-3 (MMP-3), fatty-acid-binding protein (FABP), and interleukin-8 (IL-8) increased over time in relation to the hypothermia treatment. Statistically significant correlations between the minimum temperature achieved by each patient in the hypothermia group and the MMP-3 level measured at 72 h, FABP level measured at 24 h, and IL-8 levels measured at 24 and 72 h were found. No differential biomarker levels were observed in patients with poor or favorable outcomes according to modified Rankin Scale scores. CONCLUSION Although the exact roles of MMP3, FABP, and IL-8 in hypothermia-treated stroke patients are not known, further exploration is needed to confirm their roles in brain ischemia.
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Affiliation(s)
- Elena Palà
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
| | - Anna Penalba
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
| | - Alejandro Bustamante
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
- Stroke Unit, Hospital Universitari Germans Trias i PujolBadalonaSpain
| | - Teresa García‐Berrocoso
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
- CSIC/UAB Proteomics LaboratoryInstitute of Biomedical Research of BarcelonaSpanish National Research Council (IIBB‐CSIC/IDIBAPS)BarcelonaSpain
| | - Marcel Lamana‐Vallverdú
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
| | - Christian Meisel
- Institute for Medical ImmunologyCharité–Universitätsmedizin BerlinBerlinGermany
- Department of ImmunologyLabor Berlin–Charité VivantesBerlinGermany
| | - Andreas Meisel
- Department of Neurology and Center for Stroke Research BerlinCharité University Hospital BerlinBerlinGermany
| | - H. Bart van der Worp
- Department of Neurology and NeurosurgeryBrain CenterUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Malcolm R Macleod
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghScotlandUK
| | - Bernd Kallmünzer
- Department of NeurologyUniversitätsklinikum ErlangenErlangenGermany
| | - Stefan Schwab
- Department of NeurologyUniversitätsklinikum ErlangenErlangenGermany
| | - Joan Montaner
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville & Department of NeurologyHospital Universitario Virgen MacarenaSevilleSpain
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Goyal M, Rinkel LA, Ospel JM. A Review on Adjunctive Therapies for Endovascular Treatment in Acute Ischemic Stroke. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:263-271. [PMID: 38025256 PMCID: PMC10657729 DOI: 10.5797/jnet.ra.2023-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 05/24/2023] [Indexed: 12/01/2023]
Abstract
Endovascular treatment (EVT) has revolutionized the management of acute ischemic stroke (AIS), but almost half of patients undergoing EVT do not achieve a good outcome. Adjunctive therapies have been proposed to improve the outcomes of EVT in AIS. This review aims to summarize the current evidence on the use of adjunctive therapies in EVT for AIS, including antithrombotic agents, intra-arterial thrombolytics, cerebroprotective agents, normobaric oxygen, and hypothermia. Several adjunctive therapies have shown promise in improving the outcomes of EVT in AIS, but phase 3 clinical trials are needed to establish clinical efficacy. We summarize the advantages and disadvantages of adjunctive EVT treatments and outline the challenges that each of these therapies will face before being adopted in clinical practice.
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Affiliation(s)
- Mayank Goyal
- Department of Diagnostic Imaging and Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Leon A Rinkel
- Department of Diagnostic Imaging and Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Johanna M Ospel
- Department of Diagnostic Imaging and Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
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Choi JH, Pile-Spellman J, Weinberger J, Poli S. Editorial: Selective brain and heart hypothermia - A path toward targeted organ resuscitation and protection. Front Neurol 2023; 14:1162865. [PMID: 36998777 PMCID: PMC10043490 DOI: 10.3389/fneur.2023.1162865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 02/27/2023] [Indexed: 03/15/2023] Open
Affiliation(s)
- Jae H. Choi
- Neurovascular Center, NSPC Brain and Spine Surgery, Lake Success, NY, United States
- *Correspondence: Jae H. Choi
| | - John Pile-Spellman
- Neurovascular Center, NSPC Brain and Spine Surgery, Lake Success, NY, United States
| | - Judah Weinberger
- Dean's Office, Touro University, NYSCAS, New York, NY, United States
| | - Sven Poli
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University Hospital and Faculty of Medicine, University of Tübingen, Tübingen, Germany
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Morais A, Locascio JJ, Sansing LH, Lamb J, Nagarkatti K, Imai T, van Leyen K, Aronowski J, Koenig JI, Bosetti F, Lyden P, Ayata C. Embracing Heterogeneity in The Multicenter Stroke Preclinical Assessment Network (SPAN) Trial. Stroke 2023; 54:620-631. [PMID: 36601951 PMCID: PMC9870939 DOI: 10.1161/strokeaha.122.040638] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The Stroke Preclinical Assessment Network (SPAN) is a multicenter preclinical trial platform using rodent models of transient focal cerebral ischemia to address translational failure in experimental stroke. In addition to centralized randomization and blinding and large samples, SPAN aimed to introduce heterogeneity to simulate the heterogeneity embodied in clinical trials for robust conclusions. Here, we report the heterogeneity introduced by allowing the 6 SPAN laboratories to vary most of the biological and experimental model variables and the impact of this heterogeneity on middle cerebral artery occlusion (MCAo) performance. We included the modified intention-to-treat population of the control mouse cohort of the first SPAN trial (n=421) and examined the biological and procedural independent variables and their covariance. We then determined their impact on the dependent variables cerebral blood flow drop during MCAo, time to achieve MCAo, and total anesthesia duration using multivariable analyses. We found heterogeneity in biological and procedural independent variables introduced mainly by the site. Consequently, all dependent variables also showed heterogeneity among the sites. Multivariable analyses with the site as a random effect variable revealed filament choice as an independent predictor of cerebral blood flow drop after MCAo. Comorbidity, sex, use of laser Doppler flow to monitor cerebral blood flow, days after trial onset, and maintaining anesthesia throughout the MCAo emerged as independent predictors of time to MCAo. Total anesthesia duration was predicted by most independent variables. We present with high granularity the heterogeneity introduced by the biological and model selections by the testing sites in the first trial of cerebroprotection in rodent transient filament MCAo by SPAN. Rather than trying to homogenize all variables across all sites, we embraced the heterogeneity to better approximate clinical trials. Awareness of the heterogeneity, its sources, and how it impacts the study performance may further improve the study design and statistical modeling for future multicenter preclinical trials.
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Affiliation(s)
- Andreia Morais
- Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA
| | - Joseph J. Locascio
- Department of Biostatistics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Lauren H. Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT USA
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT USA
| | - Jessica Lamb
- Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Los Angeles, CA USA
| | - Karisma Nagarkatti
- Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Los Angeles, CA USA
| | - Takahiko Imai
- Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA
| | - Klaus van Leyen
- Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA
| | - Jaroslaw Aronowski
- Department of Neurology, McGovern Medical School, University of Texas HSC, Houston, TX, USA
| | - James I. Koenig
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD USA
| | - Francesca Bosetti
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD USA
| | - Patrick Lyden
- Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Los Angeles, CA USA
- Department of Neurology, Keck School of Medicine at USC, Los Angeles, CA USA
| | - Cenk Ayata
- Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Chen X, An H, Wu D, Ji X. Research progress of selective brain cooling methods in the prehospital care for stroke patients: A narrative review. Brain Circ 2023; 9:16-20. [PMID: 37151794 PMCID: PMC10158655 DOI: 10.4103/bc.bc_88_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/14/2023] [Accepted: 01/29/2023] [Indexed: 05/09/2023] Open
Abstract
Over the past four decades, therapeutic hypothermia (TH) has long been suggested as a promising neuroprotective treatment of acute ischemic stroke (AIS). Much attention has focus on keeping the hypothermic benefits and removing side effects of systemic hypothermia. In the past few years, the advent of intravenous thrombolysis and endovascular thrombectomy has taken us into a reperfusion era of AIS treatment. With recent research emphasizing ways to plus neuroprotective treatments to reperfusion therapy, the spotlight is now shifting toward the study of how selective brain hypothermia can offset the drawbacks of systemic hypothermia and be applied in prehospital condition. This mini-review summarizes current brain cooling methods that can be used for inducing selective hypothermia in prehospital care. It will guide the future development of selective cooling methods, extend the application of TH in prehospital care, and provide insights into the prospects of selective hypothermia in AIS.
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Affiliation(s)
- Xi Chen
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Hong An
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- Address for correspondence: Dr. Xunming Ji, Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing 100053, China. E-mail:
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12
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Diprose WK, Morgan CA, Wang MT, Diprose JP, Lin JC, Sheriff S, Campbell D, Barber PA. Active conductive head cooling of normal and infarcted brain: A magnetic resonance spectroscopy imaging study. J Cereb Blood Flow Metab 2022; 42:2058-2065. [PMID: 35707879 PMCID: PMC9580175 DOI: 10.1177/0271678x221107988] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Active conductive head cooling is a simple and non-invasive intervention that may slow infarct growth in ischemic stroke. We investigated the effect of active conductive head cooling on brain temperature using whole brain echo-planar spectroscopic imaging. A cooling cap (WElkins Temperature Regulation System, 2nd Gen) was used to administer cooling for 80 minutes to healthy volunteers and chronic stroke patients. Whole brain echo-planar spectroscopic imaging scans were obtained before and after cooling. Brain temperature was estimated using the Metabolite Imaging and Data Analysis System software package, which allows voxel-level temperature calculations using the chemical shift difference between metabolite (N-acetylaspartate, creatine, choline) and water resonances. Eleven participants (six healthy volunteers, five post-stroke) underwent 80 ± 5 minutes of cooling. The average temperature of the coolant was 1.3 ± 0.5°C below zero. Significant reductions in brain temperature (ΔT = -0.9 ± 0.7°C, P = 0.002), and to a lesser extent, rectal temperature (ΔT = -0.3 ± 0.1°C, P = 0.03) were observed. Exploratory analysis showed that the occipital lobes had the greatest reduction in temperature (ΔT = -1.5 ± 1.2°C, P = 0.002). Regions of infarction had similar temperature reductions to the contralateral normal brain. Future research could investigate the feasibility of head cooling as a potential neuroprotective strategy in patients being considered for acute stroke therapies.
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Affiliation(s)
- William K Diprose
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Catherine A Morgan
- Centre for Advanced MRI, The University of Auckland, Auckland, New Zealand.,School of Psychology and Centre for Brain Research, The University of Auckland, Auckland, New Zealand
| | - Michael Tm Wang
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | | | - Joanne C Lin
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand
| | - Sulaiman Sheriff
- Department of Radiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Doug Campbell
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - P Alan Barber
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Department of Neurology, Auckland City Hospital, Auckland, New Zealand
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13
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Beretta S, Versace A, Fiore G, Piola M, Martini B, Bigiogera V, Coppadoro L, Mariani J, Tinti L, Pirovano S, Monza L, Carone D, Riva M, Padovano G, Galbiati G, Santangelo F, Rasponi M, Padelli F, Giachetti I, Aquino D, Diamanti S, Librizzi L, Bruzzone MG, De Curtis M, Giussani C, Sganzerla EP, Ferrarese C. Selective Cerebrospinal Fluid Hypothermia: Bioengineering Development and In Vivo Study of an Intraventricular Cooling Device (V-COOL). Neurotherapeutics 2022; 19:1942-1950. [PMID: 36129603 PMCID: PMC9723013 DOI: 10.1007/s13311-022-01302-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2022] [Indexed: 12/14/2022] Open
Abstract
Hypothermia is a promising therapeutic strategy for severe vasospasm and other types of non-thrombotic cerebral ischemia, but its clinical application is limited by significant systemic side effects. We aimed to develop an intraventricular device for the controlled cooling of the cerebrospinal fluid, to produce a targeted hypothermia in the affected cerebral hemisphere with a minimal effect on systemic temperature. An intraventricular cooling device (acronym: V-COOL) was developed by in silico modelling, in vitro testing, and in vivo proof-of-concept application in healthy Wistar rats (n = 42). Cerebral cortical temperature, rectal temperature, and intracranial pressure were monitored at increasing flow rate (0.2 to 0.8 mL/min) and duration of application (10 to 60 min). Survival, neurological outcome, and MRI volumetric analysis of the ventricular system were assessed during the first 24 h. The V-COOL prototyping was designed to minimize extra-cranial heat transfer and intra-cranial pressure load. In vivo application of the V-COOL device produced a flow rate-dependent decrease in cerebral cortical temperature, without affecting systemic temperature. The target degree of cerebral cooling (- 3.0 °C) was obtained in 4.48 min at the flow rate of 0.4 mL/min, without significant changes in intracranial pressure. Survival and neurological outcome at 24 h showed no significant difference compared to sham-treated rats. MRI study showed a transient dilation of the ventricular system (+ 38%) in a subset of animals. The V-COOL technology provides an effective, rapid, selective, and safe cerebral cooling to a clinically relevant degree of - 3.0 °C.
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Affiliation(s)
- Simone Beretta
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy.
- Department of Neuroscience, San Gerardo Hospital, ASST Monza, Monza, Italy.
| | - Alessandro Versace
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Gianfranco Fiore
- Department of Electronic, Information and Bioengineering, Politecnico Di Milano, Milan, Italy
| | - Marco Piola
- Department of Electronic, Information and Bioengineering, Politecnico Di Milano, Milan, Italy
| | - Beatrice Martini
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Vittorio Bigiogera
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Lorenzo Coppadoro
- Department of Neuroscience, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Jacopo Mariani
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Lorenzo Tinti
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Silvia Pirovano
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Laura Monza
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Davide Carone
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Matteo Riva
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Giada Padovano
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Gilda Galbiati
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Francesco Santangelo
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Marco Rasponi
- Department of Electronic, Information and Bioengineering, Politecnico Di Milano, Milan, Italy
| | - Francesco Padelli
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Isabella Giachetti
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Domenico Aquino
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Susanna Diamanti
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
- Department of Neuroscience, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Laura Librizzi
- Department of Diagnostics and Technology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Maria Grazia Bruzzone
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marco De Curtis
- Department of Diagnostics and Technology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Carlo Giussani
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
- Department of Neuroscience, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Erik P Sganzerla
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
- Department of Neuroscience, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Carlo Ferrarese
- Laboratory of Experimental Stroke Research, School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy
- Department of Neuroscience, San Gerardo Hospital, ASST Monza, Monza, Italy
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14
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Tiedt S, Buchan AM, Dichgans M, Lizasoain I, Moro MA, Lo EH. The neurovascular unit and systemic biology in stroke - implications for translation and treatment. Nat Rev Neurol 2022; 18:597-612. [PMID: 36085420 DOI: 10.1038/s41582-022-00703-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 12/24/2022]
Abstract
Ischaemic stroke is a leading cause of disability and death for which no acute treatments exist beyond recanalization. The development of novel therapies has been repeatedly hindered by translational failures that have changed the way we think about tissue damage after stroke. What was initially a neuron-centric view has been replaced with the concept of the neurovascular unit (NVU), which encompasses neuronal, glial and vascular compartments, and the biphasic nature of neural-glial-vascular signalling. However, it is now clear that the brain is not the private niche it was traditionally thought to be and that the NVU interacts bidirectionally with systemic biology, such as systemic metabolism, the peripheral immune system and the gut microbiota. Furthermore, these interactions are profoundly modified by internal and external factors, such as ageing, temperature and day-night cycles. In this Review, we propose an extension of the concept of the NVU to include its dynamic interactions with systemic biology. We anticipate that this integrated view will lead to the identification of novel mechanisms of stroke pathophysiology, potentially explain previous translational failures, and improve stroke care by identifying new biomarkers of and treatment targets in stroke.
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Affiliation(s)
- Steffen Tiedt
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA), . .,Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - Alastair M Buchan
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA).,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Martin Dichgans
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA).,Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.,German Center for Neurodegenerative Diseases (DZNE), Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Ignacio Lizasoain
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA).,Department of Pharmacology and Toxicology, Complutense Medical School, Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain
| | - Maria A Moro
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA).,Centro Nacional de Investigaciones Cardiovasculares, CNIC, Madrid, Spain
| | - Eng H Lo
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA), . .,Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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15
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Zhang W, Li F, Zhang C, Lei B, Deng W, Zeng H, Yu Y, Wu J, Peng D, Tian Z, Zhu X, Hu Z, Hong Y, Li W, Ge H, Xu X, Ju D, Yang S, Pan C, Zi W, Wang S. Impact of Body Temperature in Patients With Acute Basilar Artery Occlusion: Analysis of the BASILAR Database. Front Neurol 2022; 13:907410. [PMID: 35720074 PMCID: PMC9205153 DOI: 10.3389/fneur.2022.907410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundA link between body temperature and stroke outcomes has been established but not for acute basilar artery occlusion. We aimed to determine the association between body temperature and clinical outcomes in patients with acute basilar artery occlusion and temperature management range.MethodsWe included patients from the Endovascular Treatment for Acute Basilar Artery Occlusion Study (BASILAR) database with records of both admission body temperature (ABT) and peak body temperature (PBT). ABT was defined as the body temperature first measured at the hospital visit, PBT was defined as the highest temperature within 24 h of treatment, and minus body temperature (MBT) was defined as PBT-ABT. The primary clinical outcome was favorable functional outcome, defined as the proportion of patients with a modified Rankin Scale score of 0–3 at 3 months. Secondary outcomes included 3-month mortality, in-hospital mortality, and symptomatic cerebral hemorrhage.ResultsA total of 664 patients were enrolled in the study; 74.7% were men, with a median age of 65 (interquartile range, 57.25–74) years. In all patients, multivariate analysis indicated that PBT and MBT were independent predictors of favorable functional outcome [odds ratio (OR), 0.57 (95% CI, 0.43–0.77); OR, 0.68 (95% CI, 0.52–0.88), respectively], and higher ABT, PBT, and MBT were associated with an increased 3-month mortality [OR, 1.47 (95% CI, 1.03–2.10), OR, 1.58 (95% CI, 1.28–1.96), OR, 1.35 (95% CI, 1.11–1.65), respectively]. Proportional odds models demonstrated that when ABT, PBT, MBT were in the range of <37.5, <38.9, and −0.6–2.7°C, respectively, the benefit of the endovascular treatment is clearly greater than that of standard medical treatment in terms of favorable functional outcome.ConclusionsBody temperature is an independent predictor of clinical outcome in patients with acute basilar artery occlusion. It is necessary to control the patient body temperature within the appropriate range in clinical settings.Trial RegistrationChinese Clinical Trial Registry ChiCTR1800014759. Registered 03 February 2018. Retrospectively registered.
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Affiliation(s)
- Wenbin Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Cai Zhang
- Department of Neurology, Daqing Oilfield General Hospital, Daqing, China
| | - Bo Lei
- Department of Cerebrovascular Diseases, Leshan People's Hospital, Leshan, China
| | - Wei Deng
- Department of Neurology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Hongliang Zeng
- Department of Neurology, Ganzhou People's Hospital, Ganzhou, China
| | - Yang Yu
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Junxiong Wu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Daizhou Peng
- Department of Neurology, Qianxinan People's Hospital, Xingyi, China
| | - Zhenxuan Tian
- Department of Neurology, The 404th Hospital of Mianyang, Mianyang, China
| | - Xiurong Zhu
- Department of Neurology, Chongzhou People's Hospital, Chongzhou, China
| | - Zhizhou Hu
- Department of Neurology, Longyan No. 1 Hospital, Longyan, China
| | - Yifan Hong
- Department of Neurology, Shantou Central Hospital, Shantou, China
| | - Wenbo Li
- Department of Neurointervention, Luoyang Central Hospital, Luoyang, China
| | - Hanming Ge
- Department of Neurology, Xi'an Third Hospital, Xi'an, China
| | - Xinwei Xu
- Department of Neurology, Jieyang People's Hospital, Jieyang, China
| | - Dongsheng Ju
- Department of Neurology, Songyuan Jilin Oilfield Hospital, Songyuan, China
| | - Shunyu Yang
- Department of Neurology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Chengde Pan
- Department of Neurology, Banan District People's Hospital, Chongqing, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Wenjie Zi
| | - Shouchun Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
- *Correspondence: Shouchun Wang
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16
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Mahajan C, Kapoor I, Prabhakar H. A Narrative Review on Translational Research in Acute Brain Injury. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1744399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractThere has been a constant endeavor to reduce the mortality and morbidity associated with acute brain injury. The associated complex mechanisms involving biomechanics, markers, and neuroprotective drugs/measures have been extensively studied in preclinical studies with an ultimate aim to improve the patients' outcomes. Despite such efforts, only few have been successfully translated into clinical practice. In this review, we shall be discussing the major hurdles in the translation of preclinical results into clinical practice. The need is to choose an appropriate animal model, keeping in mind the species, age, and gender of the animal, choosing suitable outcome measures, ensuring quality of animal trials, and carrying out systematic review and meta-analysis of experimental studies before proceeding to human trials. The interdisciplinary collaboration between the preclinical and clinical scientists will help to design better, meaningful trials which might help a long way in successful translation. Although challenging at this stage, the advent of translational precision medicine will help the integration of mechanism-centric translational medicine and patient-centric precision medicine.
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Affiliation(s)
- Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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17
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Effectiveness of Combined Thrombolysis and Mild Hypothermia Therapy in Acute Cerebral Infarction: A Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:4044826. [PMID: 35469165 PMCID: PMC9034919 DOI: 10.1155/2022/4044826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 03/05/2022] [Accepted: 03/18/2022] [Indexed: 11/18/2022]
Abstract
Objective To evaluate the effectiveness and safety of thrombolytic therapy combined with mild hypothermia in patients with acute cerebral infarction (ACI), based on a meta-analysis of randomized controlled trials (RCTs). Methods PubMed, EMBASE, Cochrane Library, and Chinese National Knowledge Infrastructure Database of Controlled Trials were systematically screened for randomized controlled trials (RCTs) of thrombolytic therapy combined with mild hypothermia in treating ACI from inception to January 2021. Participation and outcomes among intervention enrollees are as follows: P, participants (patients in ACI); I, interventions (thrombolysis in combination with mild hypothermia therapy); C, controls (thrombolysis merely); O, outcomes (main outcomes are the change of NIHSS, glutathione peroxidase, superoxide dismutase, malondialdehyde, inflammatory factor interleukin-1β, tumor necrosis factor-α, and adverse reaction). Following data extraction and quality assessment, a meta-analysis was performed using RevMan 5.3 software. Results A total of 26 RCTs involving 2071 patients were included. Compared to thrombolysis alone, thrombolytic therapy combined with mild hypothermia leads to better therapeutic efficacy [RR = 1.23, 95% CI (1.16, 1.31)], NIHSS [MD = -2.02, 95% CI (-2.55, -1.49)], glutathione peroxidase [MD = 8.71, 95% CI (5.55, 11.87)], superoxide dismutase [MD = 16.52, 95% CI (12.31, 19.74)], malondialdehyde [MD = -1.86, 95% CI (-1.98, -1.75)], interleukin-1β [MD = -3.48, 95% CI (-4.88, -2.08)], tumor necrosis factor-α [MD = -0.46, 95% CI (-3.39, 2.48)], and adverse reaction [RR = 0.87, 95% CI (0.63, 1.20)]. Conclusions Thrombolytic therapy combined with mild hypothermia demonstrates a beneficial role in reducing brain nerve function impairment and inflammatory reactions in ACI subjects analysed in this meta-analysis.
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18
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Abstract
OBJECTIVE Temperature abnormalities are recognized as a marker of human disease, and the therapeutic value of temperature is an attractive treatment target. The objective of this synthetic review is to summarize and critically appraise evidence for active temperature management in critically ill patients. DATA SOURCES We searched MEDLINE for publications relevant to body temperature management (including targeted temperature management and antipyretic therapy) in cardiac arrest, acute ischemic and hemorrhagic stroke, traumatic brain injury, and sepsis. Bibliographies of included articles were also searched to identify additional relevant studies. STUDY SELECTION English-language systematic reviews, meta-analyses, randomized trials, observational studies, and nonhuman data were reviewed, with a focus on the most recent randomized control trial evidence. DATA EXTRACTION Data regarding study methodology, patient population, temperature management strategy, and clinical outcomes were qualitatively assessed. DATA SYNTHESIS Temperature management is common in critically ill patients, and multiple large trials have been conducted to elucidate temperature targets, management strategies, and timing. The strongest data concerning the use of therapeutic hypothermia exist in comatose survivors of cardiac arrest, and recent trials suggest that appropriate postarrest temperature targets between 33°C and 37.5°C are reasonable. Targeted temperature management in other critical illnesses, including acute stroke, traumatic brain injury, and sepsis, has not shown benefit in large clinical trials. Likewise, trials of pharmacologic antipyretic therapy have not demonstrated improved outcomes, although national guidelines do recommend treatment of fever in patients with stroke and traumatic brain injury based on observational evidence associating fever with worse outcomes. CONCLUSIONS Body temperature management in critically ill patients remains an appealing therapy for several illnesses, and additional studies are needed to clarify management strategies and therapeutic pathways.
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19
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Short-duration hypothermia completed prior to reperfusion prevents intracranial pressure elevation following ischaemic stroke in rats. Sci Rep 2021; 11:22354. [PMID: 34785754 PMCID: PMC8595681 DOI: 10.1038/s41598-021-01838-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/01/2021] [Indexed: 11/08/2022] Open
Abstract
Reperfusion therapies re-establish blood flow after arterial occlusion and improve outcome for ischaemic stroke patients. Intracranial pressure (ICP) elevation occurs 18-24 h after experimental stroke. This elevation is prevented by short-duration hypothermia spanning the time of reperfusion. We aimed to determine whether hypothermia-rewarming completed prior to reperfusion, also prevents ICP elevation 24 h post-stroke. Transient middle cerebral artery occlusion was performed on male outbred Wistar rats. Sixty-minute hypothermia to 33 °C, followed by rewarming was induced prior to reperfusion in one group, and after reperfusion in another group. Normothermia controls received identical anaesthesia protocols. ΔICP from pre-stroke to 24 h post-stroke was measured, and infarct volumes were calculated. Rewarming pre-reperfusion prevented ICP elevation (ΔICP = 0.3 ± 3.9 mmHg vs. normothermia ΔICP = 5.2 ± 2.1 mmHg, p = 0.02) and reduced infarct volume (pre-reperfusion = 78.6 ± 23.7 mm3 vs. normothermia = 125.1 ± 44.3 mm3, p = 0.04) 24 h post-stroke. There were no significant differences in ΔICP or infarct volumes between hypothermia groups rewarmed pre- or post-reperfusion. Hypothermia during reperfusion is not necessary for prevention of ICP rise or infarct volume reduction. Short-duration hypothermia may be an applicable early treatment strategy for stroke patients prior to- during-, and after reperfusion therapy.
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20
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Cooling and Sterile Inflammation in an Oxygen-Glucose-Deprivation/Reperfusion Injury Model in BV-2 Microglia. Mediators Inflamm 2021; 2021:8906561. [PMID: 34776788 PMCID: PMC8589512 DOI: 10.1155/2021/8906561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/02/2021] [Indexed: 12/26/2022] Open
Abstract
Objective Cold-inducible RNA-binding protein (CIRBP) has been shown to be involved not only in cooling-induced cellular protection but also as a mediator of sterile inflammation, a critical mechanism of the innate immune response in ischemia/reperfusion (I/R) injury. The role of microglia and its activation in cerebral I/R injury warrants further investigation as both detrimental and regenerative properties have been described. Therefore, we investigated the effects of cooling, specifically viability, activation, and release of damage associated molecular patterns (DAMPs) on oxygen glucose deprivation/reperfusion- (OGD/R-) induced injury in murine BV-2 microglial cells. Methods Murine BV-2 microglial cells were exposed to 2 to 6 h OGD (0.2% O2 in glucose- and serum-free medium) followed by up to 19 h of reperfusion, simulated by restoration of oxygen (21% O2) and nutrients. Cells were maintained at either normothermia (37°C) or cooled to 33.5°C, 1 h after experimental start. Cultured supernatants were harvested after exposure to OGD for analysis of DAMP secretions, including high-mobility group box 1 (HMGB1), heat shock protein 70 (HSP70), and CIRBP, and cytotoxicity was assessed by lactate dehydrogenase releases after exposure to OGD and reperfusion. Intracellular cold-shock proteins CIRBP and RNA-binding motif 3 (RBM3) as well as caspases 9, 8, and 3 were also analyzed via Western blot analysis. Furthermore, inducible nitric oxide synthase (iNOS), ionized calcium-binding adaptor molecule 1 (Iba1), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-1β (IL-1β), interleukin-1α (IL-1α), monocyte chemotactic protein 1 (MCP-1), transforming growth factor β (TGFβ), CIRBP, and RBM3 gene expressions were assessed via reverse transcription polymerase chain reaction, and TNF-α, IL-6, and IL-1β releases into the cultured supernatants were assessed via enzyme-linked immunosorbent assays (ELISA). Results Prolonged exposure to OGD resulted in increased BV-2 necrotic cell death, which was attenuated by cooling. Cooling also significantly induced cold-shock proteins CIRBP and RBM3 gene expressions, with CIRBP expression more rapidly regulated than RBM3 and translatable to significantly increased protein expression. DAMPs including HMGB-1, HSP70, and CIRBP could be detected in cultured supernatants after 6 h of OGD with CIRBP release being significantly attenuated by cooling. Exposure to OGD suppressed cytokine gene expressions of IL-1β, TNF-α, MCP-1, and TGFβ independently of temperature management, whereas cooling led to a significant increase in IL-1α gene expression after 6 h of OGD. In the reperfusion phase, TNF-α and MCP-1 gene expressions were increased, and cooling was associated with significantly lower TGFβ gene expression. Interestingly, cooled Normoxia groups had significant upregulations of microglial activation marker, Iba1, IL-1β, and TNF-α gene expressions. Conclusion BV-2 microglial cells undergo necrotic cell death resulting in DAMP release due to OGD/R-induced injury. Cooling conveyed neuroprotection in OGD/R-injury as observable in increased cell viability as well as induced gene expressions of cold shock proteins. As cooling alone resulted in both upregulation of microglial activation, expression of proinflammatory cytokines, and cold shock protein transcript and protein expression, temperature management might have ambiguous effects in sterile inflammation. However, cooling resulted in a significant decrease of extracellular CIRBP, which has recently been characterized as a novel DAMP and a potent initiator and mediator of inflammation.
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21
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Omileke D, Pepperall D, Bothwell SW, Mackovski N, Azarpeykan S, Beard DJ, Coupland K, Patabendige A, Spratt NJ. Ultra-Short Duration Hypothermia Prevents Intracranial Pressure Elevation Following Ischaemic Stroke in Rats. Front Neurol 2021; 12:684353. [PMID: 34616350 PMCID: PMC8488292 DOI: 10.3389/fneur.2021.684353] [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: 03/23/2021] [Accepted: 08/19/2021] [Indexed: 11/13/2022] Open
Abstract
There is a transient increase in intracranial pressure (ICP) 18–24 h after ischaemic stroke in rats, which is prevented by short-duration hypothermia using rapid cooling methods. Clinical trials of long-duration hypothermia have been limited by feasibility and associated complications, which may be avoided by short-duration cooling. Animal studies have cooled faster than is achievable in patients. We aimed to determine whether gradual cooling at a rate of 2°C/h to 33°C or 1°C/h to 34.5°C, with a 30 min duration at target temperatures, prevented ICP elevation and reduced infarct volume in rats. Transient middle cerebral artery occlusion was performed, followed by gradual cooling to target temperature. Hypothermia to 33°C prevented significant ICP elevation (hypothermia ΔICP = 1.56 ± 2.26 mmHg vs normothermia ΔICP = 8.93 ± 4.82 mmHg; p = 0.02) and reduced infarct volume (hypothermia = 46.4 ± 12.3 mm3 vs normothermia = 85.0 ± 17.5 mm3; p = 0.01). Hypothermia to 34.5°C did not significantly prevent ICP elevation or reduce infarct volume. We showed that gradual cooling to 33°C, at cooling rates achievable in patients, had the same ICP preventative effect as traditional rapid cooling methods. This suggests that this paradigm could be translated to prevent delayed ICP rise in stroke patients.
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Affiliation(s)
- Daniel Omileke
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Debbie Pepperall
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Steven W Bothwell
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Nikolce Mackovski
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Sara Azarpeykan
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Daniel J Beard
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Kirsten Coupland
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Adjanie Patabendige
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Neil J Spratt
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia.,Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, New Lambton, NSW, Australia
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22
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Neuroprotection in Acute Ischemic Stroke: A Brief Review. Can J Neurol Sci 2021; 49:741-745. [PMID: 34526172 DOI: 10.1017/cjn.2021.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The goal of effective neuroprotection in acute ischemic stroke remains elusive. Despite decades of experimental preclinical and clinical experience with innumerable agents, no strategy has proven to be beneficial in humans. As endovascular therapies mature and approach the limits of speed and efficacy, neuroprotection will become the next frontier of acute stroke care. This review will briefly summarize the history, preclinical and clinical triumphs and failures, and future directions of cerebral neuroprotection.
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23
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Abstract
We search for ischemic stroke treatment knowing we have failed-intensely and often-to translate mechanistic knowledge into treatments that alleviate our patients' functional impairments. Lessons can be derived from our shared failures that may point to new directions and new strategies. First, the principle criticisms of both preclinical and clinical assessments are summarized. Next, previous efforts to develop single-mechanism treatments are reviewed. Finally, new definitions, novel approaches, and different directions are presented. In previous development efforts, the basic science and preclinical assessment of candidate treatments often lacked rigor and sufficiency; the clinical trials may have lacked power, rigor, or rectitude; or most likely both preclinical and clinical investigations were flawed. Single-target agents directed against specific molecular mechanisms proved unsuccessful. The term neuroprotection should be replaced as it has become ambiguous: protection of the entire neurovascular unit may be called cerebral cytoprotection or cerebroprotection. Success in developing cerebroprotection-either as an adjunct to recanalization or as stand-alone treatment-will require new definitions that recognize the importance of differential vulnerability in the neurovascular unit. Recent focus on pleiotropic multi-target agents that act via multiple mechanisms of action to interrupt ischemia at multiple steps may be more fruitful. Examples of pleiotropic treatments include therapeutic hypothermia and 3K3A-APC (activated protein C). Alternatively, the single-target drug NA-1 triggers multiple downstream signaling events. Renewed commitment to scientific rigor is essential, and funding agencies and journals may enforce quality principles of rigor in preclinical science. Appropriate animal models should be selected that are suited to the purpose of the investigation. Before clinical trials, preclinical assessment could include subjects that are aged, of both sexes, and harbor comorbid conditions such as diabetes or hypertension. With these new definitions, novel approaches, and renewed attention to rigor, the prospect for successful cerebroprotective therapy should improve.
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Affiliation(s)
- Patrick D Lyden
- Department of Physiology and Neuroscience, Department of Neurology, Zilkha Neurogenetic Institute, Keck School of Medicine of USC, Los Angeles, CA
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24
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Macha K, Schwab S. Endovascular treatment of large vessel occlusion acute ischemic stroke: Is there a place for hypothermia? Eur J Neurol 2021; 28:2469-2470. [PMID: 34008882 DOI: 10.1111/ene.14920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Kosmas Macha
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Erlangen, Germany
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25
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Masè M, Micarelli A, Falla M, Regli IB, Strapazzon G. Insight into the use of tympanic temperature during target temperature management in emergency and critical care: a scoping review. J Intensive Care 2021; 9:43. [PMID: 34118993 PMCID: PMC8199814 DOI: 10.1186/s40560-021-00558-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/30/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Target temperature management (TTM) is suggested to reduce brain damage in the presence of global or local ischemia. Prompt TTM application may help to improve outcomes, but it is often hindered by technical problems, mainly related to the portability of cooling devices and temperature monitoring systems. Tympanic temperature (TTy) measurement may represent a practical, non-invasive approach for core temperature monitoring in emergency settings, but its accuracy under different TTM protocols is poorly characterized. The present scoping review aimed to collect the available evidence about TTy monitoring in TTM to describe the technique diffusion in various TTM contexts and its accuracy in comparison with other body sites under different cooling protocols and clinical conditions. METHODS The scoping review was conducted following the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews (PRISMA-ScR). PubMed, Scopus, and Web of Science electronic databases were systematically searched to identify studies conducted in the last 20 years, where TTy was measured in TTM context with specific focus on pre-hospital or in-hospital emergency settings. RESULTS The systematic search identified 35 studies, 12 performing TTy measurements during TTM in healthy subjects, 17 in patients with acute cardiovascular events, and 6 in patients with acute neurological diseases. The studies showed that TTy was able to track temperature changes induced by either local or whole-body cooling approaches in both pre-hospital and in-hospital settings. Direct comparisons to other core temperature measurements from other body sites were available in 22 studies, which showed a faster and larger change of TTy upon TTM compared to other core temperature measurements. Direct brain temperature measurements were available only in 3 studies and showed a good correlation between TTy and brain temperature, although TTy displayed a tendency to overestimate cooling effects compared to brain temperature. CONCLUSIONS TTy was capable to track temperature changes under a variety of TTM protocols and clinical conditions in both pre-hospital and in-hospital settings. Due to the heterogeneity and paucity of comparative temperature data, future studies are needed to fully elucidate the advantages of TTy in emergency settings and its capability to track brain temperature.
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Affiliation(s)
- Michela Masè
- Institute of Mountain Emergency Medicine, Eurac Research, Drususallee/Viale Druso 1, I-39100, Bolzano, Italy.,IRCS-HTA, Bruno Kessler Foundation, Trento, Italy
| | - Alessandro Micarelli
- Institute of Mountain Emergency Medicine, Eurac Research, Drususallee/Viale Druso 1, I-39100, Bolzano, Italy.,ITER Center for Balance and Rehabilitation Research (ICBRR), Rome, Italy
| | - Marika Falla
- Institute of Mountain Emergency Medicine, Eurac Research, Drususallee/Viale Druso 1, I-39100, Bolzano, Italy.,Centre for Mind/Brain Sciences, CIMeC, University of Trento, Rovereto, Italy
| | - Ivo B Regli
- Institute of Mountain Emergency Medicine, Eurac Research, Drususallee/Viale Druso 1, I-39100, Bolzano, Italy.,Department of Anesthesia and Intensive Care, "F. Tappeiner" Hospital, Merano, Italy
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Drususallee/Viale Druso 1, I-39100, Bolzano, Italy.
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26
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Hartmann C, Winzer S, Pallesen LP, Prakapenia A, Siepmann T, Moustafa H, Theilen H, Barlinn J, Gerber JC, Linn J, Reichmann H, Barlinn K, Puetz V. Inadvertent hypothermia after endovascular therapy is not associated with improved outcome in stroke due to anterior circulation large vessel occlusion. Eur J Neurol 2021; 28:2479-2487. [PMID: 33973292 DOI: 10.1111/ene.14906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Hypothermia may be neuroprotective in acute ischemic stroke. Patients with anterior circulation large vessel occlusion (acLVO) are frequently hypothermic after endovascular therapy (EVT). We sought to determine whether this inadvertent hypothermia is associated with improved outcome. METHODS We extracted data of consecutive patients (January 2016 to May 2019) who received EVT for acLVO from our prospective EVT register of all patients screened for EVT at our tertiary stroke center. We assessed functional outcome at 3 months and performed multivariate analysis to calculate adjusted risk ratios (aRRs) for favorable outcome (modified Rankin Scale scores = 0-2) and mortality across patients who were hypothermic (<36°C) and patients who were normothermic (≥36°C to <37.6°C) after EVT. Moreover, we compared the frequency of complications between these groups. RESULTS Among 837 patients screened, 416 patients received EVT for acLVO and fulfilled inclusion criteria (200 [48.1%] male, mean age = 76 ± 16 years, median National Institutes of Health Stroke Scale score = 16, interquartile range [IQR] = 12-20). Of these, 209 patients (50.2%) were hypothermic (median temperature = 35.2°C, IQR = 34.7-35.7) and 207 patients were normothermic (median temperature = 36.4°C, IQR = 36.1-36.7) after EVT. In multivariate analysis, hypothermia was not associated with favorable outcome (aRR = 0.99, 95% confidence interval [CI] = 0.75-1.31) and mortality (aRR = 1.18, 95% CI = 0.84-1.66). More hypothermic patients suffered from pneumonia (36.4% vs. 25.6%, p = 0.02) and bradyarrhythmia (52.6% vs. 16.4%, p < 0.001), whereas thromboembolic events were distributed evenly (5.7% vs. 6.8%, not significant). CONCLUSIONS Inadvertent hypothermia after EVT for acLVO is not associated with improved functional outcome or reduced mortality but is associated with an increased rate of pneumonia and bradyarrhythmia in patients with acute ischemic stroke.
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Affiliation(s)
- Christian Hartmann
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Simon Winzer
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Lars-Peder Pallesen
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Alexandra Prakapenia
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Haidar Moustafa
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Hermann Theilen
- Department of Anesthesiology, Technische Universität Dresden, Dresden, Germany
| | - Jessica Barlinn
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Johannes C Gerber
- Institute of Neuroradiology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Jennifer Linn
- Institute of Neuroradiology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
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27
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Lo EH, Albers GW, Dichgans M, Donnan G, Esposito E, Foster R, Howells DW, Huang YG, Ji X, Klerman EB, Lee S, Li W, Liebeskind DS, Lizasoain I, Mandeville ET, Moro MA, Ning M, Ray D, Sakadžić S, Saver JL, Scheer FAJL, Selim M, Tiedt S, Zhang F, Buchan AM. Circadian Biology and Stroke. Stroke 2021; 52:2180-2190. [PMID: 33940951 DOI: 10.1161/strokeaha.120.031742] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Circadian biology modulates almost all aspects of mammalian physiology, disease, and response to therapies. Emerging data suggest that circadian biology may significantly affect the mechanisms of susceptibility, injury, recovery, and the response to therapy in stroke. In this review/perspective, we survey the accumulating literature and attempt to connect molecular, cellular, and physiological pathways in circadian biology to clinical consequences in stroke. Accounting for the complex and multifactorial effects of circadian rhythm may improve translational opportunities for stroke diagnostics and therapeutics.
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Affiliation(s)
- Eng H Lo
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Departments of Radiology (E.H.L., E.E., W.L., E.T.M., S.S., F.Z.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Gregory W Albers
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Neurology, Stanford Stroke Center, Stanford University, Palo Alto (G.W.A., S.L.)
| | - Martin Dichgans
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,German Center for Neurodegenerative Diseases (DZNE, Munich) and Munich Cluster for Systems Neurology (SyNergy), Germany (M.D.).,Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Germany (M.D., S.T.)
| | - Geoffrey Donnan
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Departments of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Australia (G.D.)
| | - Elga Esposito
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Departments of Radiology (E.H.L., E.E., W.L., E.T.M., S.S., F.Z.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Russell Foster
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences (R.F.), University of Oxford, United Kingdom
| | - David W Howells
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Tasmanian School of Medicine, University of Tasmania, Australia (D.W.H.)
| | - Yi-Ge Huang
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Stroke Medicine (Y.H., A.M.B.), University of Oxford, United Kingdom
| | - Xunming Ji
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Beijing Institute for Brain Disorders, China (X.J.)
| | - Elizabeth B Klerman
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Neurology (E.B.K., M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Sarah Lee
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Neurology, Stanford Stroke Center, Stanford University, Palo Alto (G.W.A., S.L.)
| | - Wenlu Li
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Departments of Radiology (E.H.L., E.E., W.L., E.T.M., S.S., F.Z.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - David S Liebeskind
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Neurology, Geffen School of Medicine, University of California Los Angeles (J.L.S., D.S.L.)
| | - Ignacio Lizasoain
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Pharmacology and Toxicology, Complutense Medical School, Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain (I.L.)
| | - Emiri T Mandeville
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Departments of Radiology (E.H.L., E.E., W.L., E.T.M., S.S., F.Z.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Maria A Moro
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Centro Nacional de Investigaciones Cardiovasculares, CNIC, Madrid, Spain (M.A.M.)
| | - MingMing Ning
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Neurology (E.B.K., M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - David Ray
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, and Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, United Kingdom (D.R.)
| | - Sava Sakadžić
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Departments of Radiology (E.H.L., E.E., W.L., E.T.M., S.S., F.Z.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jeffrey L Saver
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Neurology, Geffen School of Medicine, University of California Los Angeles (J.L.S., D.S.L.)
| | - Frank A J L Scheer
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Departments of Medicine and Neurology, Brigham & Women's Hospital (F.A.J.L.S.), Harvard Medical School, Boston
| | - Magdy Selim
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Neurology, Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School, Boston
| | - Steffen Tiedt
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Germany (M.D., S.T.)
| | - Fang Zhang
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Departments of Radiology (E.H.L., E.E., W.L., E.T.M., S.S., F.Z.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Alastair M Buchan
- CIRCA consortium (E.H.L., G.W.A., M.D., G.D., E.E., R.F., D.W.H., Y-G.H., X.J., E.B.K., S.L., W.L., D.S.L., I.L., E.T.M., M.A.M., M.N., D.R., S.S., J.L.S., F.A.J.L.S., M.S., S.T., F.Z., A.M.B.), Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Stroke Medicine (Y.H., A.M.B.), University of Oxford, United Kingdom
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Usui T, Macleod MR, McCann SK, Senior AM, Nakagawa S. Meta-analysis of variation suggests that embracing variability improves both replicability and generalizability in preclinical research. PLoS Biol 2021; 19:e3001009. [PMID: 34010281 PMCID: PMC8168858 DOI: 10.1371/journal.pbio.3001009] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 06/01/2021] [Accepted: 05/04/2021] [Indexed: 01/11/2023] Open
Abstract
The replicability of research results has been a cause of increasing concern to the scientific community. The long-held belief that experimental standardization begets replicability has also been recently challenged, with the observation that the reduction of variability within studies can lead to idiosyncratic, lab-specific results that cannot be replicated. An alternative approach is to, instead, deliberately introduce heterogeneity, known as "heterogenization" of experimental design. Here, we explore a novel perspective in the heterogenization program in a meta-analysis of variability in observed phenotypic outcomes in both control and experimental animal models of ischemic stroke. First, by quantifying interindividual variability across control groups, we illustrate that the amount of heterogeneity in disease state (infarct volume) differs according to methodological approach, for example, in disease induction methods and disease models. We argue that such methods may improve replicability by creating diverse and representative distribution of baseline disease state in the reference group, against which treatment efficacy is assessed. Second, we illustrate how meta-analysis can be used to simultaneously assess efficacy and stability (i.e., mean effect and among-individual variability). We identify treatments that have efficacy and are generalizable to the population level (i.e., low interindividual variability), as well as those where there is high interindividual variability in response; for these, latter treatments translation to a clinical setting may require nuance. We argue that by embracing rather than seeking to minimize variability in phenotypic outcomes, we can motivate the shift toward heterogenization and improve both the replicability and generalizability of preclinical research.
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Affiliation(s)
- Takuji Usui
- Evolution and Ecology Research Centre and School of Biological, Earth and Environmental Sciences, University of New South Wales, Sydney, Australia
- The Charles Perkins Centre and School of Life and Environmental Sciences, The University of Sydney, Sydney, Australia
| | - Malcolm R. Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Sarah K. McCann
- QUEST Center for Transforming Biomedical Research, Berlin Institute of Health (BIH), Berlin, Germany
- Charité—Universitätsmedizin Berlin Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alistair M. Senior
- The Charles Perkins Centre and School of Life and Environmental Sciences, The University of Sydney, Sydney, Australia
| | - Shinichi Nakagawa
- Evolution and Ecology Research Centre and School of Biological, Earth and Environmental Sciences, University of New South Wales, Sydney, Australia
- The Charles Perkins Centre and School of Life and Environmental Sciences, The University of Sydney, Sydney, Australia
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29
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Ahmed N, Lees KR, von Kummer R, Holmin S, Escudero-Martinez I, Bottai M, Jansen O, Wahlgren N. The SITS Open Study: A Prospective, Open Label Blinded Evaluation Study of Thrombectomy in Clinical Practice. Stroke 2021; 52:792-801. [PMID: 33563015 DOI: 10.1161/strokeaha.120.031031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We designed SITS (Safe Implementation of Treatment in Stroke) Open to determine benefit and safety of thrombectomy in clinical practice for large artery occlusion stroke, using selected stent retrievers plus standard care versus standard care alone. METHODS SITS Open was a prospective, open, blinded evaluation, international, multicenter, controlled, nonrandomized registry study. Centers lacking access to thrombectomy contributed controls. Primary end point was categorical shift in modified Rankin Scale score at 3 months in the per protocol (PP) population. Principal secondary outcomes were symptomatic intracranial hemorrhage, functional independency (modified Rankin Scale score 0-2) and death at 3 months. Patients independently evaluated by video-recorded modified Rankin Scale interviews blinded to treatment or center identity by central core laboratory were regarded as PP population. Propensity score matching with covariate adjusted analysis was performed. RESULTS During 2014 to 2017, 293 patients (257 thrombectomy, 36 control) from 26 centers in 10 countries fulfilled intention-to-treat and 200 (170 thrombectomy, 30 control) PP criteria; enrollment of controls was limited by rapid uptake of thrombectomy. In PP analysis, median age was 71 versus 71 years, and baseline National Institutes of Health Stroke Scale 17 versus 17 in the thrombectomy and control arms, respectively. The propensity score matching analysis for PP showed a significant shift for modified Rankin Scale at 3 months favoring the thrombectomy group (odds ratio, 3.8 [95% CI, 1.61-8.95]; P=0.002). Regarding safety, there were 4 cases of symptomatic intracranial hemorrhage in the thrombectomy group (2.4%) and none in the control group. CONCLUSIONS In clinical practice, thrombectomy for patients with large artery occlusion stroke is superior to standard of care in our study. Registration: URL: https://www.clinicaltrials.gov. Unique Identifier: NCT02326428.
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Affiliation(s)
- Niaz Ahmed
- Department of Neurology (N.A.), Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience (N.A., S.H., N.W.), Karolinska Institutet, Stockholm, Sweden
| | - Kennedy R Lees
- School of Medicine, Dentistry and Nursing, University of Glasgow, United Kingdom (K.R.L.)
| | - Rudiger von Kummer
- Department of Diagnostic and Interventional Neuroradiology, University of Dresden, Germany (R.v.K.)
| | - Staffan Holmin
- Department of Neuroradiology (S.H.), Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience (N.A., S.H., N.W.), Karolinska Institutet, Stockholm, Sweden
| | - Irene Escudero-Martinez
- Department of Neurology, University Hospital Virgen del Rocío, Sevilla, Spain (I.E.-M.).,Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Spain (I.E.-M.)
| | - Matteo Bottai
- Institute of Environmental Medicine, Biostatistics (M.B.), Karolinska Institutet, Stockholm, Sweden
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany (O.J.)
| | - Nils Wahlgren
- Department of Clinical Neuroscience (N.A., S.H., N.W.), Karolinska Institutet, Stockholm, Sweden
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30
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Liddle LJ, Dirks CA, Fedor BA, Almekhlafi M, Colbourne F. A Systematic Review and Meta-Analysis of Animal Studies Testing Intra-Arterial Chilled Infusates After Ischemic Stroke. Front Neurol 2021; 11:588479. [PMID: 33488495 PMCID: PMC7815528 DOI: 10.3389/fneur.2020.588479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/04/2020] [Indexed: 12/11/2022] Open
Abstract
Background: As not all ischemic stroke patients benefit from currently available treatments, there is considerable need for neuroprotective co-therapies. Therapeutic hypothermia is one such co-therapy, but numerous issues have hampered its clinical use (e.g., pneumonia risk with whole-body cooling). Some problems may be avoided with brain-specific methods, such as intra-arterial selective cooling infusion (IA-SCI) into the arteries supplying the ischemic tissue. Objective: Our research question was about the efficacy of IA-SCI in animal middle cerebral artery occlusion models. We hypothesized that IA-SCI would be beneficial, but translationally-relevant study elements may be missing (e.g., aged animals). Methods: We completed a systematic review of the PubMed database following the PRISMA guidelines on May 21, 2020 for animal studies that administered IA-SCI in the peri-reperfusion period and assessed infarct volume, behavior (primary meta-analytic endpoints), edema, or blood-brain barrier injury (secondary endpoints). Our search terms included: "focal ischemia" and related terms, "IA-SCI" and related terms, and "animal" and related terms. Nineteen studies met inclusion criteria. We adapted a methodological quality scale from 0 to 12 for experimental design assessment (e.g., use of blinding/randomization, a priori sample size calculations). Results: Studies were relatively homogenous (e.g., all studies used young, healthy animals). Some experimental design elements, such as blinding, were common whereas others, such as sample size calculations, were infrequent (median methodological quality score: 5; range: 2-7). Our analyses revealed that IA-SCI provides benefit on all endpoints (mean normalized infarct volume reduction = 23.67%; 95% CI: 19.21-28.12; mean normalized behavioral improvement = 35.56%; 95% CI: 25.91-45.20; mean standardized edema reduction = 0.95; 95% CI: 0.56-1.34). Unfortunately, blood-brain barrier assessments were uncommon and could not be analyzed. However, there was substantial statistical heterogeneity and relatively few studies. Therefore, exploration of heterogeneity via meta-regression using saline infusion parameters, study quality, and ischemic duration was inconclusive. Conclusion: Despite convincing evidence of benefit in ischemic stroke models, additional studies are required to determine the scope of benefit, especially when considering additional elements (e.g., dosing characteristics). As there is interest in using this treatment alongside current ischemic stroke therapies, more relevant animal studies will be critical to inform patient studies.
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Affiliation(s)
- Lane J. Liddle
- Department of Psychology, University of Alberta, Edmonton, AB, Canada
| | | | - Brittany A. Fedor
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | | | - Frederick Colbourne
- Department of Psychology, University of Alberta, Edmonton, AB, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
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31
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Choi JH, Poli S, Chen M, Nguyen TN, Saver JL, Matouk C, Pile-Spellman J. Selective Brain Hypothermia in Acute Ischemic Stroke: Reperfusion Without Reperfusion Injury. Front Neurol 2020; 11:594289. [PMID: 33281733 PMCID: PMC7691595 DOI: 10.3389/fneur.2020.594289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/15/2020] [Indexed: 01/19/2023] Open
Abstract
In acute ischemic stroke, early recanalization of the occluded artery is crucial for best outcome to be achieved. Recanalization aims at restoring blood flow to the ischemic tissue (reperfusion) and is achieved with pharmacological thrombolytic drugs, endovascular thrombectomy (EVT) devices, or both. The introduction of modern endovascular devices has led to tremendous anatomical and clinical success with rates of substantial reperfusion exceeding 80% and proven clinical benefit in patients with anterior circulation large vessel occlusions (LVOs). However, not every successful reperfusion procedure leads to the desired clinical outcome. In fact, the rate of non-disabled outcome at 3 months with current EVT treatment is ~1 out of 4. A constraint upon better outcomes is that reperfusion, though resolving ischemic stress, may not restore the anatomic structures and metabolic functions of ischemic tissue to their baseline states. In fact, ischemia triggers a complex cascade of destructive mechanisms that can sometimes be exacerbated rather than alleviated by reperfusion therapy. Such reperfusion injury may cause infarct progression, intracranial hemorrhage, and unfavorable outcome. Therapeutic hypothermia has been shown to have a favorable impact on the molecular elaboration of ischemic injury, but systemic hypothermia is limited by slow speed of attaining target temperatures and clinical complications. A novel approach is endovascular delivery of hypothermia to cool the affected brain tissue selectively and rapidly with tight local temperature control, features not available with systemic hypothermia devices. In this perspective article, we discuss the possible benefits of adjunctive selective endovascular brain hypothermia during interventional stroke treatment.
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Affiliation(s)
- Jae H. Choi
- Neurovascular Center, Neurological Surgery, P.C., Lake Success, NY, United States
- Hybernia Medical, LLC, New Rochelle, NY, United States
| | - Sven Poli
- Department of Neurology & Stroke, Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Michael Chen
- Stroke Center, Department of Neurosurgery, Rush University Medical Center, Chicago, IL, United States
| | - Thanh N. Nguyen
- Interventional Neurology/Neuroradiology, Boston University School of Medicine, Boston, MA, United States
| | - Jeffrey L. Saver
- Comprehensive Stroke Center and Department of Neurology, University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Charles Matouk
- Neurovascular Surgery, Department of Neurosurgery, Yale University-New Haven Hospital, New Haven, CT, United States
| | - John Pile-Spellman
- Neurovascular Center, Neurological Surgery, P.C., Lake Success, NY, United States
- Hybernia Medical, LLC, New Rochelle, NY, United States
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32
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Li J, Gu Y, Li G, Wang L, Cheng X, Wang M, Zhao M. The Role of Hypothermia in Large Hemispheric Infarction: A Systematic Review and Meta-Analysis. Front Neurol 2020; 11:549872. [PMID: 33192981 PMCID: PMC7653189 DOI: 10.3389/fneur.2020.549872] [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: 04/07/2020] [Accepted: 09/18/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Hypothermia is used in the treatment of large hemispheric infarction (LHI); however, its role in outcomes for LHI patients remains ambiguous. This systematic review and meta-analysis was conducted to evaluate the effect of hypothermia on the outcomes of LHI patients. Methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, China Biological Medicine Database, and clinical trials registers before September 21, 2018, and then scanned the reference lists. Randomized controlled trials that compared hypothermia with normothermia in LHI patients were included. Primary outcomes that we reviewed were mortality and neurological outcome. Adverse events during treatment were defined as secondary outcomes. We performed a meta-analysis to calculate pooled risk ratios (RRs), standardized mean differences (SMDs), and 95% confidence intervals (CIs) using fixed-effect models. Results: Three randomized controlled trials involving 131 participants were included. No statistically significant association was revealed between hypothermia and mortality (RR, 1.12; 95% CI, 0.76-1.65). There was significant association between hypothermia and good neurological outcome as assessed by modified Rankin Scale score (mRS of 0-3) of survivors (RR, 2.09; 95% CI, 1.14-3.82), and with neurological outcome by mRS (SMD, -0.54; 95% CI, -1.07 to -0.01). However, significant associations were found between hypothermia and gastrointestinal bleeding, gastric retention, electrolyte derangement, and shivering. No significant differences were detected in the incidence of developing herniation in the rewarming process, pneumonia, cardiac arrhythmia, hemorrhagic transformation, hyperglycemia, hypotension, acute kidney injury, and venous thrombotic events in LHI patients who underwent hypothermia compared with those who had normothermia. Conclusions: This meta-analysis suggested that hypothermia was not associated with mortality in LHI patients. However, it was associated with the improvement of neurological outcome, but with a higher risk of adverse events during treatment. Future studies are needed to demonstrate the efficacy and safety of hypothermia for LHI. The protocol for this systematic review was obtained from PROSPERO (registration number: CRD42018111761).
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Affiliation(s)
- Jing Li
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Yanghui Gu
- Department of Cardiology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Gang Li
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Lixin Wang
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaobin Cheng
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Min Wang
- Department of Intensive Care Unit, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Min Zhao
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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The Clinical Usefulness of Targeted Temperature Management in Acute Ischemic Stroke with Malignant Trait After Endovascular Thrombectomy. Neurocrit Care 2020; 34:990-999. [PMID: 32812197 DOI: 10.1007/s12028-020-01069-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/27/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND/OBJECTIVE Targeted temperature management (TTM) may be more beneficial after endovascular treatment (EVT) in patients with a large ischemic core. Therefore, we assessed the usefulness of TTM for such patients from a multicenter endovascular registry. METHODS Anterior circulation stroke patients who underwent endovascular recanalization were included; acute ischemic stroke with malignant traits was designated as (1) baseline Alberta Stroke Program Early CT Score (ASPECTS) below 6 and (2) diffusion-weighted imaging (DWI) lesion volume measurement (> 82 ml) or National Institutes of Health Stroke Scale score > 20 and item Ia > 0. TTM (34.5 °C) was maintained for at least 48 h. RESULTS We evaluated baseline demographics, risk factors, EVT parameters, and clinical outcomes between the TTM and non-TTM groups. Among the 548 patients, the TTM group (n = 91) significantly had a lower baseline ASPECTS (p < 0.001) and a higher DWI volume (p < 0.001) than the non-TTM group (n = 457). TTM group had a lower prevalence of favorable outcome (0-2 of modified Rankin Scale at 3 months; p = 0.008) than the non-TTM group. In a subgroup analysis of malignant trait patients (n = 80), TTM patients (n = 28) had more favorable outcome (32.1% vs. 7.7% p = 0.009) and less hemorrhagic transformation (none vs. any hemorrhage, p = 0.007) than non-TTM patients (n = 52). After adjusting for potential outcome predictors, TTM (odds ratio [OR] 4.63; confidence interval [CI] 1.20-17.89; p = 0.026) and hypertension (OR 0.18; CI 0.04-0.74; p = 0.018) were found to be independent determinants. CONCLUSIONS Our data suggest that TTM attenuates impending hemorrhagic transformation and leads to favorable clinical outcomes in EVT patients with malignant trait.
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34
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Ageing as a risk factor for cerebral ischemia: Underlying mechanisms and therapy in animal models and in the clinic. Mech Ageing Dev 2020; 190:111312. [PMID: 32663480 DOI: 10.1016/j.mad.2020.111312] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/24/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022]
Abstract
Age is the only one non-modifiable risk of cerebral ischemia. Advances in stroke medicine and behavioral adaptation to stroke risk factors and comorbidities was successful in decreasing stroke incidence and increasing the number of stroke survivors in western societies. Comorbidities aggravates the outcome after cerebral ischemia. However, due to the increased in number of elderly, the incidence of stroke has increased again paralleled by an increase in the number of stroke survivors, many with severe disabilities, that has led to an increased economic and social burden in society. Animal models of stroke often ignore age and comorbidities frequently associated with senescence. This might explain why drugs working nicely in animal models fail to show efficacy in stroke survivors. Since stroke afflicts mostly the elderly comorbid patients, it is highly desirable to test the efficacy of stroke therapies in an appropriate animal stroke model. Therefore, in this review, we make parallels between animal models of stroke und clinical data and summarize the impact of ageing and age-related comorbidities on stroke outcome.
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35
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Affiliation(s)
- Patrick Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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36
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Liddle LJ, Prokop BJ, Dirks CA, Demchuk A, Almekhlafi M, Colbourne F. Infusion of Cold Saline into the Carotid Artery Does Not Affect Outcome After Intrastriatal Hemorrhage. Ther Hypothermia Temp Manag 2020; 10:171-178. [PMID: 32456561 PMCID: PMC7482714 DOI: 10.1089/ther.2020.0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Localized brain hypothermia (HYPO) can be achieved by infusing cold saline into the carotid artery of animals and patients. Studies suggest that HYPO improves behavioral and histological outcomes in focal ischemia models. Given that ischemic stroke and intracerebral hemorrhage (ICH) share pathophysiological overlap, we tested whether cold saline infusion is safe and neuroprotective when given during collagenase-induced ICH. Eighty-five adult male Sprague-Dawley rats were used. Experiment 1 investigated brain and body temperature changes associated with a cold saline infusion paradigm that was scaled from patients according to brain weight and blood volume (3 mL/20-minute infusion). Experiment 2 determined whether HYPO aggravated bleeding volume. Experiment 3 investigated if cerebral edema or elemental concentrations were altered by HYPO. We also collected core body temperature and activity data through telemetry. Experiment 4 investigated whether behavioral outcomes (e.g., skilled reaching) and tissue loss were influenced by HYPO. Our HYPO protocol decreased the ipsilateral striatal temperature by ∼0.20°C (p < 0.001), with no other effects. HYPO did not affect hematoma volume (p = 0.64), cerebral edema (p = 0.34), or elemental concentrations (p = 0.49) at 24 hours post-ICH. Although ICH caused persistent behavioral impairments, HYPO did not improve behavioral outcomes (measured by a neurological deficit scale, cylinder, and the staircase test; p > 0.05 for all). Brain tissue loss was not different between groups on day 28 post-ICH (p = 0.90). Although cold saline infusion appears to be safe in the acute post-ICH period, there was no evidence that this therapy improved outcome. However, our treatment protocol was relatively mild and additional interventions might help improve efficacy. Finally, our findings may also speak to the safety of this cooling approach in focal ischemia where hemorrhagic transformation is a risk; future studies on this issue are needed.
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Affiliation(s)
- Lane J Liddle
- Department of Psychology, University of Alberta, Edmonton, Canada
| | | | | | | | | | - Frederick Colbourne
- Department of Psychology, University of Alberta, Edmonton, Canada.,Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
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Kuczynski AM, Marzoughi S, Al Sultan AS, Colbourne F, Menon BK, van Es ACGM, Berez AL, Goyal M, Demchuk AM, Almekhlafi MA. Therapeutic Hypothermia in Acute Ischemic Stroke-a Systematic Review and Meta-Analysis. Curr Neurol Neurosci Rep 2020; 20:13. [PMID: 32372297 DOI: 10.1007/s11910-020-01029-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Therapeutic hypothermia (TH) in stroke demonstrates robust neuroprotection in animals but clinical applications remain controversial. We assessed current literature on the efficacy of TH in ischemic stroke. RECENT FINDINGS We conducted a meta-analysis comparing TH versus controls in studies published until June 2019. Controlled studies reporting on ≥ 10 adults with acute ischemic stroke were included. Primary outcome was functional independence (modified Rankin Scale [mRS] ≤ 2). Twelve studies (n = 351 TH, n = 427 controls) were included. Functional independence did not differ between groups (RR 1.17, 95% CI 0.93-1.46, random-effects p = 0.2). Five studies reported individual mRS outcomes and demonstrated a shift toward better outcome with TH (unadjusted cOR 1.57, 95% CI 1.01-2.44, p = 0.05). Overall complications were higher with TH (RR 1.18, 95% CI 1.06-1.32, p < 0.01). We did not observe an overall beneficial effect of TH in this analysis although some studies showed a shift toward better outcome. TH was associated with increased complications.
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Affiliation(s)
| | - Sina Marzoughi
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | | | - Bijoy K Menon
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Calgary, AB, Canada
| | - Adriaan C G M van Es
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | - Mayank Goyal
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Calgary, AB, Canada
| | - Mohammed A Almekhlafi
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Calgary, AB, Canada.
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Diprose WK, Liem B, Wang MT, Sutcliffe JA, Brew S, Caldwell JR, McGuinness B, Campbell D, Barber PA. Impact of Body Temperature Before and After Endovascular Thrombectomy for Large Vessel Occlusion Stroke. Stroke 2020; 51:1218-1225. [DOI: 10.1161/strokeaha.119.028160] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background and Purpose—
In ischemic stroke, body temperature is associated with functional outcome. However, the relationship between temperature and outcome may differ in the intraischemic and postischemic phases of stroke. We aimed to determine whether body temperature before or after endovascular thrombectomy (EVT) for large vessel occlusion stroke is associated with clinical outcomes.
Methods—
Consecutive EVT patients were identified from a prospective registry. Temperature measurements within 24 hours of admission were stratified into pre-EVT (preprocedural and intraprocedural) and post-EVT measurements, which served as surrogates for the intraischemic and postischemic phases of large vessel occlusion stroke, respectively. The primary outcome was functional independence, defined as a modified Rankin Scale score of 0, 1, or 2 at 3 months. Secondary outcomes included the ordinal shift of modified Rankin Scale scores at 3 months, symptomatic intracerebral hemorrhage, and mortality at 3 months.
Results—
Four hundred thirty-two participants were included (59% men, mean±SD age 65.6±15.7 years). Multivariable logistic regression demonstrated that higher median pre-EVT temperature (per 1°C increase) was an independent predictor of reduced functional independence (odds ratio [OR], 0.66 [95% CI, 0.46–0.94];
P
=0.02), poorer modified Rankin Scale scores (common OR, 1.42 [95% CI, 1.08–1.85];
P
=0.01), and increased mortality (OR, 1.65 [95% CI, 1.02–2.69];
P
=0.04). Peak post-EVT temperature (per 1°C increase) was a significant predictor of elevated modified Rankin Scale scores (common OR, 1.39 [95% CI, 1.03–1.90];
P
=0.03) and higher mortality (OR, 1.66 [95% CI, 1.04–2.67];
P
=0.03).
Conclusions—
In patients with large vessel occlusion stroke treated with EVT, higher body temperatures during both the intraischemic and postischemic phases were associated with poorer clinical outcomes. Future research investigating the maintenance of normothermia or therapeutic hypothermia in patients needing to be transferred from primary to EVT-capable stroke centers could be considered.
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Affiliation(s)
- William K. Diprose
- From the Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand (W.K.D., M.T.M.W., P.A.B.)
- Department of Neurology (W.K.D., B.L., P.A.B.), Auckland City Hospital, New Zealand
| | - Bernard Liem
- Department of Neurology (W.K.D., B.L., P.A.B.), Auckland City Hospital, New Zealand
| | - Michael T.M. Wang
- From the Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand (W.K.D., M.T.M.W., P.A.B.)
| | - James A. Sutcliffe
- Department of Radiology (J.A.S., S.B., J.R.C., B.M.), Auckland City Hospital, New Zealand
| | - Stefan Brew
- Department of Radiology (J.A.S., S.B., J.R.C., B.M.), Auckland City Hospital, New Zealand
| | - James R. Caldwell
- Department of Radiology (J.A.S., S.B., J.R.C., B.M.), Auckland City Hospital, New Zealand
| | - Ben McGuinness
- Department of Radiology (J.A.S., S.B., J.R.C., B.M.), Auckland City Hospital, New Zealand
| | - Doug Campbell
- Department of Anaesthesia and Perioperative Medicine (D.C.), Auckland City Hospital, New Zealand
| | - P. Alan Barber
- From the Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand (W.K.D., M.T.M.W., P.A.B.)
- Department of Neurology (W.K.D., B.L., P.A.B.), Auckland City Hospital, New Zealand
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Solar RJ, Mattingly T, Lownie SP, Meerkin D. Neuroprotection by selective endovascular brain cooling - the TwinFlo™ Catheter. EUROINTERVENTION 2020; 15:1291-1296. [PMID: 31113765 DOI: 10.4244/eij-d-19-00316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The neuroprotective effects of hypothermia have been demonstrated in experimental models and clinical trials. Experimental studies indicate that improved efficacy and broadened indications can be achieved with moderate to deep hypothermia. The TwinFlo catheter was designed to provide very rapid, deep and selective brain cooling with faster cooling rates, and temperatures much lower than those which can be achieved by any other hypothermia device and technique. This report describes the experimental in vivo studies and initial clinical experience with the TwinFlo catheter.
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Michalski D, Jungk C, Brenner T, Dietrich M, Nusshag C, Weigand MA, Reuß CJ, Beynon C, Bernhard M. Neurologische Intensivmedizin. Anaesthesist 2020; 69:129-136. [DOI: 10.1007/s00101-019-00643-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Caroff J, King RM, Mitchell JE, Marosfoi M, Licwinko JR, Gray-Edwards HL, Puri AS, Merrill TL, Gounis MJ. Focal cooling of brain parenchyma in a transient large vessel occlusion model: proof-of-concept. J Neurointerv Surg 2019; 12:209-213. [PMID: 31363042 DOI: 10.1136/neurintsurg-2019-015179] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/09/2019] [Accepted: 07/12/2019] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The neuroprotective benefit of therapeutic hypothermia (TH) has been demonstrated, but systemic side effects and time required to achieve effective TH in acute ischemic stroke (AIS) care limits clinical use. We investigate rapid and localized cooling using a novel insulated catheter in an ischemia-reperfusion model. METHODS In phase I (n=4), cold saline was delivered to the canine internal carotid artery via an insulated catheter. Temperature was measured using intracerebral thermocouples. The coolant flow rate was varied to meet a target temperature of 31-32°C in the hemisphere infused. In phase II (n=8), a temporary middle cerebral artery occlusion was created. Five dogs underwent localized TH at the optimal flow rate from phase I, and the remaining animals were untreated controls. Cooling was initiated 5 min before recanalization and continued for an additional 20 min following 45 min of occlusion duration. The outcome was infarct volume and neurological function. RESULTS Ipsilateral tissue cooling rates were 2.2±2.5°C/min at a flow rate of 20-40 mL/min with an observed minimum of 23.8°C. Tissue cooling was localized to the ipsilateral side of the infusion with little impact on temperatures of the core or contralateral hemisphere of the brain. In phase II, animals tolerated TH with minimal systemic impact. Infarct volume in treated animals was 0.2±0.2 cm3, which was smaller than in sham animals (3.8±1.0 cm3) as well as six untreated historical control animals (4.0±2.8 cm3) (p=0.013). CONCLUSIONS Proof-of-concept data show that localised brain TH can be quickly and safely achieved through a novel insulated catheter. The small infarct volumes suggest potential benefit for this approach.
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Affiliation(s)
- Jildaz Caroff
- Interventional Neuroradiology, NEURI Center, Bicêtre Hospital, Le Kremlin- Bicêtre, France
| | - Robert M King
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | | | - Miklos Marosfoi
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | | | - Heather L Gray-Edwards
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ajit S Puri
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Thomas L Merrill
- FocalCool, Mullica Hill, New Jersey, USA.,Department of Mechanical Engineering, Rowan University, Glassboro, NJ, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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