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Yu F, Zhang Y, Sun H, Li X, Shan Y, Zheng C, Cui B, Li J, Yang Y, Yang B, Ma Y, Wang Y, Jiao L, Li X, Lu J. In Vivo Classification and Characterization of Carotid Atherosclerotic Lesions with Integrated 18F-FDG PET/MRI. Diagnostics (Basel) 2024; 14:1006. [PMID: 38786304 PMCID: PMC11120206 DOI: 10.3390/diagnostics14101006] [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: 03/22/2024] [Revised: 04/26/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND The aim of this study was to exploit integrated PET/MRI to simultaneously evaluate the morphological, component, and metabolic features of advanced atherosclerotic plaques and explore their incremental value. METHODS In this observational prospective cohort study, patients with advanced plaque in the carotid artery underwent 18F-FDG PET/MRI. Plaque morphological features were measured, and plaque component features were determined via MRI according to AHA lesion-types. Maximum standardized uptake values (SUVmax) and tissue to background ratio (TBR) on PET were calculated. Area under the receiver-operating characteristic curve (AUC) and net reclassification improvement (NRI) were used to compare the incremental contribution of FDG uptake when added to AHA lesion-types for symptomatic plaque classification. RESULTS A total of 280 patients with advanced plaque in the carotid artery were recruited. A total of 402 plaques were confirmed, and 87 of 402 (21.6%) were symptomatic plaques. 18F-FDG PET/MRI was performed a mean of 38 days (range 1-90) after the symptom. Increased stenosis degree (61.5% vs. 50.0%, p < 0.001) and TBR (2.96 vs. 2.32, p < 0.001) were observed in symptomatic plaques compared with asymptomatic plaques. The performance of the combined model (AHA lesion type VI + stenosis degree + TBR) for predicting symptomatic plaques was the best among all models (AUC = 0.789). The improvement of the combined model (AHA lesion type VII + stenosis degree + TBR) over AHA lesion type VII model for predicting symptomatic plaques was the highest (AUC = 0.757/0.454, combined model/AHA lesion type VII model), and the NRI was 50.7%. CONCLUSIONS Integrated PET/MRI could simultaneously evaluate the morphological component and inflammation features of advanced atherosclerotic plaques and provide supplementary optimization information over AHA lesion-types for identifying vulnerable plaques in atherosclerosis subjects to achieve further stratification of stroke risk.
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Affiliation(s)
- Fan Yu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Yue Zhang
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Heyu Sun
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Xiaoran Li
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Yi Shan
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Chong Zheng
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Bixiao Cui
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Jing Li
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
| | - Yang Yang
- Beijing United Imaging Research Institute of Intelligent Imaging, Beijing 100094, China;
| | - Bin Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (B.Y.); (Y.M.); (Y.W.); (L.J.)
- China International Neuroscience Institute (China-INI), Beijing 100053, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (B.Y.); (Y.M.); (Y.W.); (L.J.)
- China International Neuroscience Institute (China-INI), Beijing 100053, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China
| | - Yabing Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (B.Y.); (Y.M.); (Y.W.); (L.J.)
- China International Neuroscience Institute (China-INI), Beijing 100053, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (B.Y.); (Y.M.); (Y.W.); (L.J.)
- China International Neuroscience Institute (China-INI), Beijing 100053, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China
| | - Xiang Li
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Vienna General Hospital, Medical University of Vienna, 1090 Vienna, Austria
- Department of Nuclear Medicine, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing 101149, China
| | - Jie Lu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Changchun Street, No. 45, Beijing 100053, China; (F.Y.); (Y.Z.); (H.S.); (X.L.); (Y.S.); (C.Z.); (B.C.); (J.L.)
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing 100053, China
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McCabe JJ, Walsh C, Gorey S, Harris K, Hervella P, Iglesias-Rey R, Jern C, Li L, Miyamoto N, Montaner J, Pedersen A, Purroy F, Rothwell PM, Sudlow C, Ueno Y, Vicente-Pascual M, Whiteley W, Woodward M, Kelly PJ. Plasma fibrinogen and risk of vascular recurrence after ischaemic stroke: An individual participant and summary-level data meta-analysis of 11 prospective studies. Eur Stroke J 2024:23969873241246489. [PMID: 38600679 DOI: 10.1177/23969873241246489] [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: 04/12/2024] Open
Abstract
INTRODUCTION Inflammation is an emerging target for secondary prevention after stroke and randomised trials of anti-inflammatory therapies are ongoing. Fibrinogen, a putative pro-inflammatory marker, is associated with first stroke, but its association with major adverse cardiovascular events (MACE) after stroke is unclear. MATERIALS AND METHODS We did a systematic review investigating the association between fibrinogen and post-stroke vascular recurrence. Authors were invited to provide individual-participant data (IPD) and where available we did within-study multivariable analyses with adjustment for cardiovascular risk factors and medications. Adjusted summary-level data was extracted from published reports from studies that did not provide IPD. We pooled risk ratios (RR) by random-effects meta-analysis by comparing supra-median with sub-median fibrinogen levels and performed pre-specified subgroup analysis according to timing of phlebotomy after the index event. RESULTS Eleven studies were included (14,002 patients, 42,800 follow-up years), of which seven provided IPD. Fibrinogen was associated with recurrent MACE on unadjusted (RR 1.35, 95% CI 1.17-1.57, supra-median vs sub-median) and adjusted models (RR 1.21, 95% CI 1.06-1.38). Fibrinogen was associated with recurrent stroke on univariate analysis (RR 1.19, 95% CI 1.03-1.39), but not after adjustment (RR 1.11, 95% CI 0.94-1.31). The association with recurrent MACE was consistently observed in patients with post-acute (⩾14 days) fibrinogen measures (RR 1.29, 95% CI 1.16-1.45), but not in those with early phlebotomy (<14 days) (RR 0.98, 95% CI 0.82-1.18) (Pinteraction = 0.01). Similar associations were observed for recurrent stroke. DISCUSSION AND CONCLUSION Fibrinogen was independently associated with recurrence after stroke, but the association was modified by timing of phlebotomy. Fibrinogen measurements might be useful to identify patients who are more likely to derive benefit from anti-inflammatory therapies after stroke.
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Affiliation(s)
- John J McCabe
- Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- School of Medicine, University College Dublin (UCD), Ireland
- Stroke Service, Department of Geriatric Medicine and Neurology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Cathal Walsh
- Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- Department of Biostatistics, Trinity College Dublin, Ireland
| | - Sarah Gorey
- Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- School of Medicine, University College Dublin (UCD), Ireland
- Stroke Service, Department of Geriatric Medicine and Neurology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Katie Harris
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Pablo Hervella
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Santiago De Compostela, Spain
| | - Ramon Iglesias-Rey
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Santiago De Compostela, Spain
| | - Christina Jern
- Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Department of Laboratory Medicine, Gothenburg, Sweden
- Department of Clinical Genetics and Genomics, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Linxin Li
- Wolfson Centre for the Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Nobukazu Miyamoto
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Joan Montaner
- Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology, Seville, Spain
- Department of Neurology, Virgen Macarena Hospital, Sevilla, Spain
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Annie Pedersen
- Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Department of Laboratory Medicine, Gothenburg, Sweden
- Department of Clinical Genetics and Genomics, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Francisco Purroy
- Department of Neurology, Hospital Universitari Arnau de Vilanova, Lleida, Spain
- Department of Clinical Neurosciences, Institut Reserca Biomèdica Lleida, University of Lleida, Spain
| | - Peter M Rothwell
- Wolfson Centre for the Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Catherine Sudlow
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Yuji Ueno
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Mikel Vicente-Pascual
- Department of Neurology, Hospital Universitari Arnau de Vilanova, Lleida, Spain
- Department of Clinical Neurosciences, Institut Reserca Biomèdica Lleida, University of Lleida, Spain
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mark Woodward
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- George Institute for Global Health, Imperial College London, London, UK
| | - Peter J Kelly
- Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- School of Medicine, University College Dublin (UCD), Ireland
- Stroke Service, Department of Geriatric Medicine and Neurology, Mater Misericordiae University Hospital, Dublin, Ireland
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Zietz A, Gorey S, Kelly PJ, Katan M, McCabe JJ. Targeting inflammation to reduce recurrent stroke. Int J Stroke 2024; 19:379-387. [PMID: 37800305 DOI: 10.1177/17474930231207777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
BACKGROUND Approximately one in four stroke patients suffer from recurrent vascular events, underlying the necessity to improve secondary stroke prevention strategies. Immune mechanisms are causally associated with coronary atherosclerosis. However, stroke is a heterogeneous disease and the relative contribution of inflammation across stroke mechanisms is not well understood. The optimal design of future randomized control trials (RCTs) of anti-inflammatory therapies to prevent recurrence after stroke must be informed by a clear understanding of the prognostic role of inflammation according to stroke subtype and individual patient factors. AIM In this narrative review, we discuss (1) inflammatory pathways in the etiology of ischemic stroke subtypes; (2) the evidence on inflammatory markers and vascular recurrence after stroke; and (3) review RCT evidence of anti-inflammatory agents for vascular prevention. SUMMARY OF REVIEW Experimental work, genetic epidemiological data, and plaque-imaging studies all implicate inflammation in atherosclerotic stroke. However, emerging evidence also suggests that inflammatory mechanisms are also important in other stroke mechanisms. Advanced neuroimaging techniques support the role of neuroinflammation in blood-brain barrier dysfunction in cerebral small vessel disease (cSVD). Systemic inflammatory processes also promote atrial cardiopathy, incident and recurrent atrial fibrillation (AF). Although several inflammatory markers have been associated with recurrence after stroke, interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hsCRP) are presently the most promising markers to identify patients at increased vascular risk. Several RCTs have shown that anti-inflammatory therapies reduce vascular risk, including stroke, in coronary artery disease (CAD). Some, but not all of these trials, selected patients on the basis of elevated hsCRP. Although unproven after stroke, targeting inflammation to reduce recurrence is a compelling strategy and several RCTs are ongoing. CONCLUSION Evidence points toward the importance of inflammation across multiple stroke etiologies and potential benefit of anti-inflammatory targets in secondary stroke prevention. Taking the heterogeneous stroke etiologies into account, the use of serum biomarkers could be useful to identify patients with residual inflammatory risk and perform biomarker-led patient selection for future RCTs.
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Affiliation(s)
- Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Sarah Gorey
- Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- School of Medicine, University College Dublin (UCD), Dublin, Ireland
- Department of Geriatric Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Peter J Kelly
- Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- School of Medicine, University College Dublin (UCD), Dublin, Ireland
- Department of Neurology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - John J McCabe
- Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- School of Medicine, University College Dublin (UCD), Dublin, Ireland
- Department of Geriatric Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
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Rodríguez I, Gramegna LL, Requena M, Rizzuti M, Elosua I, Mayol J, Olivé-Gadea M, Diana F, Rodrigo-Gisbert M, Muchada M, Rivera E, García-Tornel Á, Rizzo F, De Dios M, Rodríguez-Luna D, Piñana C, Pagola J, Hernández D, Juega J, Rodríguez N, Quintana M, Molina C, Ribo M, Tomasello A. Safety and efficacy of early carotid artery stenting in patients with symptomatic stenosis. Interv Neuroradiol 2024:15910199241239204. [PMID: 38515363 DOI: 10.1177/15910199241239204] [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: 03/23/2024] Open
Abstract
BACKGROUND Symptomatic carotid artery stenosis is a significant contributor to ischemic strokes. Carotid artery stenting (CAS) is usually indicated for secondary stroke prevention. This study evaluates the safety and efficacy of CAS performed within a short time frame from symptom onset. METHODS We conducted a single-center, retrospective study of consecutive patients who underwent CAS for symptomatic carotid stenosis within eight days of symptom onset from July 2019 to January 2022. Data on demographics, medical history, procedural details, and follow-up outcomes were analyzed. The primary outcome measure was the recurrence of the stroke within the first month post-procedure. Secondary outcomes included mortality, the rate of intra-procedural complications, and hyperperfusion syndrome. RESULTS We included 93 patients with a mean age of 71.7 ± 11.7 years. The median time from symptom onset to CAS was 96 h. The rate of stroke recurrence was 5.4% in the first month, with a significant association between the number of stents used and increased recurrence risk. Mortality within the first month was 3.2%, with an overall mortality rate of 11.8% after a median follow-up of 19 months. Intra-procedural complications were present in five (5.4%) cases and were related to the number of stents used (p = 0.002) and post-procedural angioplasty (p = 0.045). Hyperperfusion syndrome occurred in 3.2% of cases. CONCLUSION Early CAS within the high-risk window post-symptom onset is a viable secondary stroke prevention strategy in patients with symptomatic carotid artery stenosis. The procedure rate of complication is acceptable, with a low recurrence of stroke. However, further careful selection of patients for this procedural strategy is crucial to optimize outcomes.
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Affiliation(s)
- Isabel Rodríguez
- Interventional Neuroradiology Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Laura Ludovica Gramegna
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Manuel Requena
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | | | - Iker Elosua
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Jordi Mayol
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marta Olivé-Gadea
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Francesco Diana
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marc Rodrigo-Gisbert
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marián Muchada
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Eila Rivera
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Álvaro García-Tornel
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Federica Rizzo
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marta De Dios
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - David Rodríguez-Luna
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Carlos Piñana
- Interventional Radiology, Hospital Clínico Valencia, Barcelona, Spain
| | - Jorge Pagola
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - David Hernández
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jesús Juega
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Noelia Rodríguez
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos Molina
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marc Ribo
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Alejandro Tomasello
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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McCabe JJ, Walsh C, Gorey S, Harris K, Hervella P, Iglesias-Rey R, Jern C, Li L, Miyamoto N, Montaner J, Pedersen A, Purroy FF, Rothwell PM, Sudlow CL, Ueno Y, Vicente-Pascual M, Whiteley WN, Woodward M, Kelly PJ. C-Reactive Protein, Interleukin-6, and Vascular Recurrence According to Stroke Subtype: An Individual Participant Data Meta-Analysis. Neurology 2024; 102:e208016. [PMID: 38165328 DOI: 10.1212/wnl.0000000000208016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/26/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Anti-inflammatory therapies reduce major adverse cardiovascular events (MACE) in coronary artery disease but remain unproven after stroke. Establishing the subtype-specific association between inflammatory markers and recurrence risk is essential for optimal selection of patients in randomized trials (RCTs) of anti-inflammatory therapies for secondary stroke prevention. METHODS Using individual participant data (IPD) identified from a systematic review, we analyzed the association between high-sensitivity C-reactive protein, interleukin-6 (IL-6), and vascular recurrence after ischemic stroke or transient ischemic attack. The prespecified coprimary end points were (1) any recurrent MACE (first major coronary event, recurrent stroke, or vascular death) and (2) any recurrent stroke (ischemic, hemorrhagic, or unspecified) after sample measurement. Analyses were performed stratified by stroke mechanism, per quarter and per biomarker unit increase after loge transformation. We then did study-level meta-analysis with comparable published studies not providing IPD. Preferred Reporting Items for Systematic Review and Meta-Analyses IPD guidelines were followed. RESULTS IPD was obtained from 10 studies (8,420 patients). After adjustment for vascular risk factors and statins/antithrombotic therapy, IL-6 was associated with recurrent MACE in stroke caused by large artery atherosclerosis (LAA) (risk ratio [RR] 2.30, 95% CI 1.21-4.36, p = 0.01), stroke of undetermined cause (UND) (RR 1.78, 1.19-2.66, p = 0.005), and small vessel occlusion (SVO) (RR 1.71, 0.99-2.96, p = 0.053) (quarter 4 [Q4] vs quarter 1 [Q1]). No association was observed for stroke due to cardioembolism or other determined cause. Similar results were seen for recurrent stroke and when analyzed per loge unit increase for MACE (LAA, RR 1.26 [1.06-1.50], p = 0.009; SVO, RR 1.22 [1.01-1.47], p = 0.04; UND, RR 1.18 [1.04-1.34], p = 0.01). High-sensitivity CRP was associated with recurrent MACE in UND stroke only (Q4 vs Q1 RR 1.45 [1.04-2.03], p = 0.03). Findings were consistent on study-level meta-analysis of the IPD results with 2 other comparable studies (20,136 patients). DISCUSSION Our data provide new evidence for the selection of patients in future RCTs of anti-inflammatory therapy in stroke due to large artery atherosclerosis, small vessel occlusion, and undetermined etiology according to inflammatory marker profile.
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Affiliation(s)
- John J McCabe
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Cathal Walsh
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Sarah Gorey
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Katie Harris
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Pablo Hervella
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Ramon Iglesias-Rey
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Christina Jern
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Linxin Li
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Nobukazu Miyamoto
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Joan Montaner
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Annie Pedersen
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Francisco F Purroy
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Peter M Rothwell
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Cathie L Sudlow
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Yuji Ueno
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Mikel Vicente-Pascual
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Will N Whiteley
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Mark Woodward
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
| | - Peter J Kelly
- From the Health Research Board (HRB) Stroke Clinical Trials Network Ireland (SCTNI) (J.J.M., C.W., S.G., P.J.K.), Dublin; School of Medicine (J.J.M., S.G., P.J.K.), University College Dublin (UCD); Stroke Service (J.J.M., S.G.), Department of Geriatric Medicine and Department of Neurology (P.J.K.), Mater Misericordiae University Hospital, Dublin; Health Research Institute and Mathematics Applications Consortium for Science and Industry (MACSI) (C.W.), Department of Mathematics and Statistics, University of Limerick, Ireland; George Institute for Global Health (K.H.), University of New South Wales, Sydney, Australia; Neuroimaging and Biotechnology Laboratory (NOBEL) (P.H., R.I.-R.), Clinical Neuroscience Research Laboratory, Health Research Institute of Santiago de Compostela, Spain; Department of Laboratory Medicine (C.J., A.P.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg; Department of Clinical Genetics and Genomics (C.J., A.P.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Wolfson Centre for the Prevention of Stroke and Dementia (L.L., P.M.R.) and Nuffield Department of Population Health (W.N.W.), University of Oxford, United Kingdom; Department of Neurology (N.M., Y.U.), Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology (J.M.), Hospital Universitari Vall d'Hebron, Barcelona; Institute de Biomedicine of Seville (J.M.), IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Neurology; Virgen Macarena Hospital (J.M.), Neurology, Sevilla; Neurovascular Research Laboratory (J.M.), Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona; Department of Neurology (F.F.P., M.V.-P.), Hospital Universitari Arnau de Vilanova; Department of Clinical Neurosciences (F.F.P., M.V.-P.), Institut Reserca Biomèdica Lleida, University of Lleida, Spain; Centre for Medical Informatics (C.L.S., W.N.W.), Usher Institute of Population Health Sciences and Informatics; Centre for Clinical Brain Sciences (C.L.S.), University of Edinburgh; and George Institute for Global Health (M.W.), Imperial College London, United Kingdom
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Shi X, Tao T, Wang Y, Han Y, Xu X, Yin Q, Wang F, Liu R, Liu X. Heavy macrophage infiltration identified by optical coherence tomography relates to plaque rupture. Ann Clin Transl Neurol 2023; 10:2334-2346. [PMID: 37822283 PMCID: PMC10723231 DOI: 10.1002/acn3.51923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/31/2023] [Accepted: 10/02/2023] [Indexed: 10/13/2023] Open
Abstract
OBJECTIVE Risk stratification plays a critical role in patients with asymptomatic carotid atherosclerotic stenosis. Heavy macrophage infiltration (HMC) is an important factor of plaque destabilization. However, in vivo imaging technologies and screening criteria for HMC remain limited. We aimed to (i) introduce algorithms for in vivo detection of macrophage infiltrations using optical coherence tomography (OCT) and (ii) to investigate the threshold of HMC and its association with plaque vulnerability. METHODS Ex vivo OCT images were co-registered with histopathology in 282 cross-sectional pairs from 19 carotid endarterectomy specimens. Of these, 197 randomly selected pairs were employed to define the parameters, and the remaining 85 pairs were used to evaluate the accuracy of the OCT-based algorithm in detecting macrophage infiltrations. Clinical analysis included 93 patients receiving carotid OCT evaluation. The prevalence and burden of macrophage infiltration were analyzed. Multivariable and subgroup analysis were performed to investigate the association between HMC and plaque rupture. RESULTS The sensitivity and specificity of algorithm for detecting macrophage infiltration were 88.0% and 74.9%, respectively. Of 93 clinical patients, ruptured plaques exhibited higher prevalence of macrophage infiltration than nonruptured plaques (83.7% [36/43] vs 32.0% [16/50], p < 0.001). HMC was identified when the macrophage index was greater than 60.2 (sensitivity = 74.4%, specificity = 84.0%). Multivariable analysis showed that HMC and multiple calcification were independent risk factors for non-lipid-rich plaque rupture. INTERPRETATION This study provides a novel approach and screening criteria for HMC, which might be valuable for atherosclerotic risk stratification.
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Affiliation(s)
- Xuan Shi
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Tao Tao
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Yi Wang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Yunfei Han
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Xiaohui Xu
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Qin Yin
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Fang Wang
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Rui Liu
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Xinfeng Liu
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
- Stroke Center and Department of Neurology, First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
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Maes L, Versweyveld L, Evans NR, McCabe JJ, Kelly P, Van Laere K, Lemmens R. Novel Targets for Molecular Imaging of Inflammatory Processes of Carotid Atherosclerosis: A Systematic Review. Semin Nucl Med 2023:S0001-2998(23)00085-5. [PMID: 37996309 DOI: 10.1053/j.semnuclmed.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/25/2023]
Abstract
Computed tomography angiography (CTA), magnetic resonance angiography (MRA) and 18F-FDG-PET have proven clinical value when evaluating patients with carotid atherosclerosis. In this systematic review, we will focus on the role of novel molecular imaging tracers in that assessment and their potential strengths to stratify stroke risk. We systematically searched PubMed, Embase, the Web of Science Core Collection, and Cochrane Library for articles reporting on molecular imaging to noninvasively detect or characterize inflammation in carotid atherosclerosis. As our focus was on nonclassical novel targets, we omitted reports solely on 18F-FDG and 18F-NaF. We summarized and mapped the selected studies to provide an overview of the current clinical development in molecular imaging in relation to risk factors, imaging and histological findings, diagnostic and prognostic performance. We identified 20 articles in which the utilized tracers to visualize carotid wall inflammation were somatostatin subtype-2- (SST2-) (n = 5), CXC-motif chemokine receptor 4- (CXCR4-) (n = 3), translocator protein- (TSPO-) (n = 2) and aVβ3 integrin-ligands (n = 2) and choline-tracers (n = 2). Tracer uptake correlated with traditional cardiovascular risk factors, that is, age, gender, diabetes, hypercholesterolemia, and hypertension as well as prior cardiovascular disease. We identified discrepancies between tracer uptake and grade of stenosis, plaque calcification, and 18F-FDG uptake, suggesting the importance of alternative characterization of atherosclerosis beyond classical neuroimaging features. Immunohistochemical analysis linked tracer uptake to markers of macrophage infiltration and neovascularization. Symptomatic carotid arteries showed higher uptake compared to asymptomatic (including contralateral, nonculprit) arteries. Some studies demonstrated a potential role of these novel molecular imaging as a specific intermediary (bio)marker for outcome. Several novel tracers show promise for identification of high-risk plaque inflammation. Based on the current evidence we cautiously propose the SST2-ligands and the choline radiotracers as viable candidates for larger prospective longitudinal outcome studies to evaluate their predictive use in clinical practice.
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Affiliation(s)
- Louise Maes
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium; Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium.
| | - Louis Versweyveld
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium; Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium
| | - Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - John J McCabe
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland; School of Medicine, University College Dublin (UCD), Dublin, Ireland; Department of Geriatric Medicine, Mater Misericordiae University Hospital Dublin, Dublin, Ireland
| | - Peter Kelly
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland; School of Medicine, University College Dublin (UCD), Dublin, Ireland; Mater Misericordiae University Hospital Dublin, Stroke Service, Dublin, Ireland
| | - Koen Van Laere
- Division of Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Imaging and Pathology, KULeuven - University of Leuven - Nuclear Medicine and Molecular Imaging, Leuven, Belgium
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium; Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium
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McCabe JJ, Evans NR, Gorey S, Bhakta S, Rudd JHF, Kelly PJ. Imaging Carotid Plaque Inflammation Using Positron Emission Tomography: Emerging Role in Clinical Stroke Care, Research Applications, and Future Directions. Cells 2023; 12:2073. [PMID: 37626883 PMCID: PMC10453446 DOI: 10.3390/cells12162073] [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: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023] Open
Abstract
Atherosclerosis is a chronic systemic inflammatory condition of the vasculature and a leading cause of stroke. Luminal stenosis severity is an important factor in determining vascular risk. Conventional imaging modalities, such as angiography or duplex ultrasonography, are used to quantify stenosis severity and inform clinical care but provide limited information on plaque biology. Inflammatory processes are central to atherosclerotic plaque progression and destabilization. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a validated technique for quantifying plaque inflammation. In this review, we discuss the evolution of FDG-PET as an imaging modality to quantify plaque vulnerability, challenges in standardization of image acquisition and analysis, its potential application to routine clinical care after stroke, and the possible role it will play in future drug discovery.
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Affiliation(s)
- John J. McCabe
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland; (S.G.); (P.J.K.)
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
| | - Nicholas R. Evans
- Department of Clinical Neurosciences, Box 83, Addenbrooke’s Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK; (N.R.E.); (S.B.)
| | - Sarah Gorey
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland; (S.G.); (P.J.K.)
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
| | - Shiv Bhakta
- Department of Clinical Neurosciences, Box 83, Addenbrooke’s Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK; (N.R.E.); (S.B.)
| | - James H. F. Rudd
- Division of Cardiovascular Medicine, Addenbrooke’s Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK;
| | - Peter J. Kelly
- Health Research Board Stroke Clinical Trials Network Ireland, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland; (S.G.); (P.J.K.)
- Neurovascular Unit for Applied Translational and Therapeutics Research, Catherine McAuley Centre, Nelson Street, D07 KX5K Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
- Stroke Service, Department of Medicine for the Elderly, Mater Misericordiae University Hospital, Eccles Street, D07 R2WY Dublin, Ireland
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9
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Zheng Y, Lim MJR, Tan BYQ, Chan BPL, Paliwal P, Jonathan OJY, Bharatendu C, Chan ACY, Yeo LLL, Vijayan J, Hong CS, Chee YH, Wong LYH, Chen J, Chong VYF, Dong Y, Tan CH, Sunny S, Teoh HL, Sinha AK, Sharma VK. Role of plaque inflammation in symptomatic carotid stenosis. Front Neurol 2023; 14:1086465. [PMID: 36761341 PMCID: PMC9902904 DOI: 10.3389/fneur.2023.1086465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/09/2023] [Indexed: 01/25/2023] Open
Abstract
Objective Prior studies have shown that plaque inflammation on FDG-PET and the symptomatic carotid atheroma inflammation lumen-stenosis (SCAIL) score were associated with recurrent ischemic events, but the findings have thus far not been widely validated. Therefore, we aimed to validate the findings of prior studies. Methods A single-center prospective cohort study that recruited patients with (1) recent TIA or ischemic stroke within the past 30 days, (2) ipsilateral carotid artery stenosis of ≥50%, and (3) were not considered for early carotid revascularization. The (1) maximum standardized uptake value (SUVmax) of the symptomatic carotid plaque, (2) the SCAIL score, and (3) stenosis severity of the symptomatic carotid artery were measured for all patients. The outcomes were (1) a 90-day ipsilateral ischemic stroke and (2) a 90-day ipsilateral symptomatic TIA or major adverse cardiovascular event (MACE). Results Among the 131 patients included in the study, the commonest cardiovascular risk factor was hypertension (95 patients, 72.5%), followed by diabetes mellitus (77 patients, 58.8%) and being a current smoker (64 patients, 48.9%). The median (IQR) duration between the index cerebral ischemic event and recruitment to the study was 1 (0, 2.5) days. The median (IQR) duration between the index cerebral ischemic event and FDG-PET was 5 (4, 7) days. A total of 14 (10.7%) patients had a 90-day stroke, and 41 (31.3%) patients had a 90-day TIA or MACE. On comparison of the predictive performances of the SCAIL score and SUVmax, SUVmax was found to be superior to the SCAIL score for predicting both 90-day ipsilateral ischemic stroke (AUC: SCAIL = 0.79, SUVmax = 0.92; p < 0.001; 95% CI = 0.072, 0.229) and 90-day TIA or MACE (AUC: SCAIL = 0.76, SUVmax = 0.84; p = 0.009; 95% CI = 0.020, 0.143). Conclusion Plaque inflammation as quantified on FDG-PET may serve as a reliable biomarker for risk stratification among patients with ECAD and recent TIA or ischemic stroke. Future studies should evaluate whether patients with significant plaque inflammation as quantified on FDG-PET benefit from carotid revascularization and/or anti-inflammatory therapy.
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Affiliation(s)
- Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mervyn Jun Rui Lim
- Division of Neurosurgery, National University Health System, Singapore, Singapore
| | - Benjamin Yong-Qiang Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore,Division of Neurology, National University Health System, Singapore, Singapore
| | | | | | | | - Chandra Bharatendu
- Division of Neurology, National University Health System, Singapore, Singapore
| | | | | | - Joy Vijayan
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Chiew S. Hong
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Young Heng Chee
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Lily Y. H. Wong
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Jintao Chen
- Division of Neurology, National University Health System, Singapore, Singapore
| | | | - Yanhong Dong
- Alice Lee Centre for Nursing Studies, Singapore, Singapore
| | - Chi Hsien Tan
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Sibi Sunny
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Hock Luen Teoh
- Division of Neurology, National University Health System, Singapore, Singapore
| | - Arvind Kumar Sinha
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Vijay Kumar Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore,Division of Neurology, National University Health System, Singapore, Singapore,*Correspondence: Vijay Kumar Sharma ✉
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10
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Sammartino AM, Falco R, Drera A, Dondi F, Bellini P, Bertagna F, Vizzardi E. "Vascular inflammation and cardiovascular disease: review about the role of PET imaging". Int J Cardiovasc Imaging 2023; 39:433-440. [PMID: 36255543 PMCID: PMC9870832 DOI: 10.1007/s10554-022-02730-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/09/2022] [Indexed: 01/27/2023]
Abstract
Inflammation characterizes all stages of atherothrombosis and provides a critical pathophysiological link between plaque formation and its acute rupture, leading to coronary occlusion and heart attack. In the last 20 years the possibility of quantifying the degree of inflammation of atherosclerotic plaques and, therefore, also of vascular inflammation aroused much interest. 18Fluoro-deoxy-glucose photon-emissions-tomography (18F-FDG-PET) is widely used in oncology for staging and searching metastases; in cardiology, the absorption of 18F-FDG into the arterial wall was observed for the first time incidentally in the aorta of patients undergoing PET imaging for cancer staging. PET/CT imaging with 18F-FDG and 18F-sodium fluoride (18F-NaF) has been shown to assess atherosclerotic disease in its molecular phase, when the process may still be reversible. This approach has several limitations in the clinical practice, due to lack of prospective data to justify their use routinely, but it's desirable to develop further scientific evidence to confirm this technique to detect high-risk patients for cardiovascular events.
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Affiliation(s)
- Antonio Maria Sammartino
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, ASST Spedali Civili, University of Brescia, Brescia, Italy.
| | - Raffaele Falco
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Andrea Drera
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Francesco Dondi
- Nuclear Medicine, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, ASST Spedali Civili Di Brescia, University of Brescia, Brescia, Italy
| | - Pietro Bellini
- Nuclear Medicine, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, ASST Spedali Civili Di Brescia, University of Brescia, Brescia, Italy
| | - Francesco Bertagna
- Nuclear Medicine, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, ASST Spedali Civili Di Brescia, University of Brescia, Brescia, Italy
| | - Enrico Vizzardi
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, ASST Spedali Civili, University of Brescia, Brescia, Italy.
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11
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Rimmele DL, Petersen EL, Schlemm E, Kessner SS, Petersen M, Mayer C, Cheng B, Zeller T, Waldeyer C, Behrendt CA, Gerloff C, Thomalla G. Association of Carotid Plaque and Flow Velocity With White Matter Integrity in a Middle-aged to Elderly Population. Neurology 2022; 99:e2699-e2707. [PMID: 36123124 DOI: 10.1212/wnl.0000000000201297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/10/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES It is uncertain whether there is an association of carotid plaques (CPs) and flow velocities with peak width mean diffusivity (PSMD) and white matter hyperintensities (WMH) independent of shared risk factors. We aimed to study this association controlling for biomarkers of inflammation and cardiac dysfunction and typical cardiovascular risk factors and spatial distribution. METHODS We included participants from the population-based Hamburg City Health Study, recruiting citizens between 45 and 74 years of age. Medical history was obtained from structured interviews and extended laboratory tests, physical examinations, MRI of the head, echocardiography, and abdominal and carotid ultrasound were performed. We performed multivariable regression analysis with PSMD and periventricular, deep, and total volume of WMH (pWMH, dWMH, tWMH) as dependent variables. PSMD was calculated as the difference between the 95th and 5th percentiles of MD values on the white skeleton in standard space. Volumes of WMH were determined by the application of a manually trained k-nearest neighbor segmentation algorithm. WMH measured within a distance of 1 cm from the surface of the lateral ventricles were defined as pWMH and above 1 cm as dWMH. RESULTS Two thousand six hundred twenty-three participants were included. The median age was 65 years, and 56% were women. Their median tWMH was 946 mm3(IQR:419, 2,164), PSMD 2.24 mm2/s × 10-4 (IQR: 2.04, 2.47), peak systolic velocity (PSV) of internal carotid arteries 0.70m/second (IQR:0.60, 0.81), and 35% had CPs. Adjusted for age, sex, high-sensitive CRP, NT-proBNP, and commonly measured cardiovascular risk and systemic hemodynamic factors, both CPs (B = 0.15; CI: 0.04, 0.26; p = 0.006) and low PSV (B = -0.49; CI: -0.87, -0.11; p = 0.012) were significantly associated with a higher tWMH and PSMD. Low PSV (B = -0.48; CI: -0.87, -0.1; p = 0.013) was associated with pWMH and the presence of CP with pWMH (B = 0.15; CI: 0.04, 0.26; p = 0.008) and dWMH (B = 0.42; CI: 0.11, 0.74; p < 0.009). DISCUSSION Low PSV and CP are associated with WMH and PSMD independent of cardiovascular risk factors and biomarkers of inflammation and cardiac dysfunction. This points toward pathophysiologic pathways underlying both large and small vessel disease beyond the common cardiovascular risk profile. TRIAL REGISTRATION INFORMATION The trial was submitted at clinicaltrials.gov, under NCT03934957 on January 4, 2019. The first participant was enrolled in February 2016.
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Affiliation(s)
- David Leander Rimmele
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany.
| | - Elina Larissa Petersen
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Eckhard Schlemm
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Simon S Kessner
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Marvin Petersen
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Carola Mayer
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Bastian Cheng
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Tanja Zeller
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Christoph Waldeyer
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Christian-Alexander Behrendt
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Christian Gerloff
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
| | - Götz Thomalla
- From the Department of Neurology (D.L.R., E.S., S.S.K., M.P., C.M., B.C., C.G., G.T.) and Epidemiological Study Center (E.L.P.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Cardiology (T.Z., C.W.) and Vascular Medicine (C.-A.B.), University Heart and Vascular Center UKE Hamburg; and German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck (T.Z., C.W.), Germany
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12
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Advances in Noninvasive Carotid Wall Imaging with Ultrasound: A Narrative Review. J Clin Med 2022; 11:jcm11206196. [PMID: 36294515 PMCID: PMC9604731 DOI: 10.3390/jcm11206196] [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: 09/22/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022] Open
Abstract
Carotid atherosclerosis is a major cause for stroke, with significant associated disease burden morbidity and mortality in Western societies. Diagnosis, grading and follow-up of carotid atherosclerotic disease relies on imaging, specifically ultrasound (US) as the initial modality of choice. Traditionally, the degree of carotid lumen stenosis was considered the sole risk factor to predict brain ischemia. However, modern research has shown that a variety of other imaging biomarkers, such as plaque echogenicity, surface morphology, intraplaque neovascularization and vasa vasorum contribute to the risk for rupture of carotid atheromas with subsequent cerebrovascular events. Furthermore, the majority of embolic strokes of undetermined origin are probably arteriogenic and are associated with nonstenosing atheromas. Therefore, a state-of-the-art US scan of the carotid arteries should take advantage of recent technical developments and should provide detailed information about potential thrombogenic (/) and emboligenic arterial wall features. This manuscript reviews recent advances in ultrasonographic assessment of vulnerable carotid atherosclerotic plaques and highlights the fields of future development in multiparametric arterial wall imaging, in an attempt to convey the most important take-home messages for clinicians performing carotid ultrasound.
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13
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Georgakis MK, Bernhagen J, Heitman LH, Weber C, Dichgans M. Targeting the CCL2-CCR2 axis for atheroprotection. Eur Heart J 2022; 43:1799-1808. [PMID: 35567558 DOI: 10.1093/eurheartj/ehac094] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/22/2021] [Accepted: 02/15/2022] [Indexed: 11/12/2022] Open
Abstract
Decades of research have established atherosclerosis as an inflammatory disease. Only recently though, clinical trials provided proof-of-concept evidence for the efficacy of anti-inflammatory strategies with respect to cardiovascular events, thus offering a new paradigm for lowering residual vascular risk. Efforts to target the inflammasome-interleukin-1β-interleukin-6 pathway have been highly successful, but inter-individual variations in drug response, a lack of reduction in all-cause mortality, and a higher rate of infections also highlight the need for a second generation of anti-inflammatory agents targeting atherosclerosis-specific immune mechanisms while minimizing systemic side effects. CC-motif chemokine ligand 2/monocyte-chemoattractant protein-1 (CCL2/MCP-1) orchestrates inflammatory monocyte trafficking between the bone marrow, circulation, and atherosclerotic plaques by binding to its cognate receptor CCR2. Adding to a strong body of data from experimental atherosclerosis models, a coherent series of recent large-scale genetic and observational epidemiological studies along with data from human atherosclerotic plaques highlight the relevance and therapeutic potential of the CCL2-CCR2 axis in human atherosclerosis. Here, we summarize experimental and human data pinpointing the CCL2-CCR2 pathway as an emerging drug target in cardiovascular disease. Furthermore, we contextualize previous efforts to interfere with this pathway, scrutinize approaches of ligand targeting vs. receptor targeting, and discuss possible pathway-intrinsic opportunities and challenges related to pharmacological targeting of the CCL2-CCR2 axis in human atherosclerotic disease.
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Affiliation(s)
- Marios K Georgakis
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, D-81377 Munich, Germany
- Center of Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Jürgen Bernhagen
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, D-81377 Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Laura H Heitman
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Oncode Institute, Utrecht, The Netherlands
| | - Christian Weber
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians-Universität (LMU) Munich, Germany
- Institute for Genetic and Biomedical Research, UoS of Milan, National Research Council, Milan, Italy
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, D-81377 Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
- German Centre for Neurodegenerative Diseases (DZNE), Munich, Germany
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14
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Živković L, Asare Y, Bernhagen J, Dichgans M, Georgakis MK. Pharmacological Targeting of the CCL2/CCR2 Axis for Atheroprotection: A Meta-Analysis of Preclinical Studies. Arterioscler Thromb Vasc Biol 2022; 42:e131-e144. [PMID: 35387476 DOI: 10.1161/atvbaha.122.317492] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The CCL2 (CC-chemokine ligand 2)/CCR2 (CC-chemokine receptor 2) axis governs monocyte recruitment to atherosclerotic lesions. Genetic and epidemiological studies show strong associations of CCL2 levels with atherosclerotic disease. Still, experimental studies testing pharmacological inhibition of CCL2 or CCR2 in atheroprone mice apply widely different approaches and report variable results, thus halting clinical translation. METHODS We systematically searched the literature for studies employing pharmacological CCL2/CCR2 blockade in atheroprone mice and meta-analyzed their effects on lesion size and morphology. RESULTS In a meta-analysis of 14 studies testing 11 different agents, CCL2/CCR2 blockade attenuated atherosclerotic lesion size in the aortic root or arch (g=-0.75 [-1.17 to -0.32], P=6×10-4; N=171/171 mice in experimental/control group), the carotid (g=-2.39 [-4.23 to -0.55], P=0.01; N=24/25), and the femoral artery (g=-2.38 [-3.50 to -1.26], P=3×10-5; N=10/10). Furthermore, CCL2/CCR2 inhibition reduced intralesional macrophage accumulation and increased smooth muscle cell content and collagen deposition. The effects of CCL2/CCR2 inhibition on lesion size correlated with reductions in plaque macrophage accumulation, in accord with a prominent role of CCL2/CCR2 signaling in monocyte recruitment. Subgroup analyses showed comparable efficacy of different CCL2- and CCR2-inhibitors in reducing lesion size and intralesional macrophages. The quality assessment revealed high risk of detection bias due to lack of blinding during outcome assessment, as well as evidence of attrition and reporting bias. CONCLUSIONS Preclinical evidence suggests that pharmacological targeting of CCL2 or CCR2 might lower atherosclerotic lesion burden, but the majority of existing studies suffer major quality issues that highlight the need for additional high-quality research.
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Affiliation(s)
- Luka Živković
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Germany (L.Ž., Y.A., J.B., M.D., M.K.G.)
| | - Yaw Asare
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Germany (L.Ž., Y.A., J.B., M.D., M.K.G.)
| | - Jürgen Bernhagen
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Germany (L.Ž., Y.A., J.B., M.D., M.K.G.).,Munich Cluster for Systems Neurology (SyNergy), Germany (J.B., M.D.).,Munich Heart Alliance, German Center for Cardiovascular Diseases (DZHK), Germany (J.B.)
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Germany (L.Ž., Y.A., J.B., M.D., M.K.G.).,Munich Cluster for Systems Neurology (SyNergy), Germany (J.B., M.D.).,German Centre for Neurodegenerative Diseases (DZNE), Munich, Germany (M.D.)
| | - Marios K Georgakis
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Germany (L.Ž., Y.A., J.B., M.D., M.K.G.).,Center for Genomic Medicine, Massachusetts General Hospital, Boston (M.K.G.).,Program in Medical and Population Genetics, Broad Institute of Harvard and MIT, Boston, MA (M.K.G.)
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