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Medicherla C, Pashun R, Al-Mufti F. Review of Cerebral Collateral Circulation and Insight into Cardiovascular Strategies to Limit Collateral Damage in Ischemic Stroke. Cardiol Rev 2024; 32:188-193. [PMID: 37729598 DOI: 10.1097/crd.0000000000000614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Cerebral collateral circulation is a dynamic and adaptive process by which alternative vascular pathways supply perfusion to ischemic brain tissue in the event of an arterial occlusion. This complicated network of blood vessels that acts as a natural bypass plays a pivotal role in stroke pathophysiology and has become a key area of study given its significance in stroke treatment and patient outcomes. In this review, we will study the factors influencing the formation, recruitment, and endurance of collateral vessels; discuss imaging modalities for quantitative and qualitative assessment of this network; explore the role of collaterals in stroke management; and highlight several cardiovascular strategies to minimize damage to collaterals and optimize stroke outcomes.
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Affiliation(s)
| | - Raymond Pashun
- Department of Cardiology, New York University Langone Health, New York, NY
| | - Fawaz Al-Mufti
- Department of Neurology, Neurosurgery, and Radiology, New York Medical College, Valhalla, NY
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Jung HJ, Ryu JC, Joon Kim B, Kang DW, Kwon SU, Kim JS, Chang JY. Time Window for Induced Hypertension in Acute Small Vessel Occlusive Stroke With Early Neurological Deterioration. Stroke 2024; 55:14-21. [PMID: 38063016 DOI: 10.1161/strokeaha.123.044334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/13/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Therapeutic-induced hypertension treatment (iHTN) is helpful for alleviating early neurological deterioration (END) in acute small vessel occlusive stroke. We examined the time parameters related to iHTN effectiveness in these patients. METHODS We retrospectively reviewed patients with acute small vessel occlusive stroke who underwent iHTN for END, defined as an increase of ≥2 points in total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 point in motor items of NIHSS. The primary outcome was an early neurological improvement (ENI; a decrease of ≥2 points in total NIHSS score or ≥1 point in motor items of NIHSS), and the secondary outcome was any neurological improvement (a decrease of ≥1 point in the total NIHSS score). We conducted a multivariable logistic regression analysis, adjusting for demographics, risk factors, baseline clinical status, and intervention-related variables. We also generated a restricted cubic spline curve for the END-to-iHTN time cutoff. RESULTS Among the 1062 patients with small vessel occlusive stroke screened between 2017 and 2021, 136 patients who received iHTN within 24 hours from END were included. The mean age was 65.1 (±12.0) years, and 61.0% were male. Sixty-five (47.8%) patients showed ENI and 77 (56.6%) patients showed any neurological improvement. END-to-iHTN time was significantly shorter in patients with ENI (150 [49-322] versus 290 [97-545] minutes; P=0.018) or any neurological improvement (150 [50-315] versus 300 [130-573] minutes; P=0.002). A 10-minute increase in the time between END and iHTN decreased the odds of achieving ENI (odds ratio, 0.984 [95% CI, 0.970-0.997]; P=0.019) or any neurological improvement (odds ratio, 0.978 [95% CI, 0.964-0.992]; P=0.002). The restricted cubic spline curve showed that the odds ratio of ENI reached its minimum at ≈3 hours. CONCLUSIONS Among patients with small vessel occlusive stroke with END, a shorter interval between END and the initiation of iHTN was associated with increased odds of achieving neurological improvement. The efficacy of iHTN may be limited to induction within the first 3 hours of END.
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Affiliation(s)
- Hee-Jae Jung
- Department of Neurology, Asan Medical Center (H.-J.J., B.J.K., D.-W.K, S.U.K., J.Y.C.)
| | - Jae-Chan Ryu
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, South Korea (J.-C.R.)
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center (H.-J.J., B.J.K., D.-W.K, S.U.K., J.Y.C.)
- University of Ulsan College of Medicine, Seoul, South Korea (B.J.K., D.-W.K., S.U.K., J.Y.C.)
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center (H.-J.J., B.J.K., D.-W.K, S.U.K., J.Y.C.)
- University of Ulsan College of Medicine, Seoul, South Korea (B.J.K., D.-W.K., S.U.K., J.Y.C.)
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center (H.-J.J., B.J.K., D.-W.K, S.U.K., J.Y.C.)
- University of Ulsan College of Medicine, Seoul, South Korea (B.J.K., D.-W.K., S.U.K., J.Y.C.)
| | - Jong S Kim
- Department of Neurology, Gangneung Asan Hospital (J.S.K.)
| | - Jun Young Chang
- Department of Neurology, Asan Medical Center (H.-J.J., B.J.K., D.-W.K, S.U.K., J.Y.C.)
- University of Ulsan College of Medicine, Seoul, South Korea (B.J.K., D.-W.K., S.U.K., J.Y.C.)
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Nisar T, Tofade T, Lebioda K, Shaulov S, Shapouran S, Abu-Hadid O, Khandelwal P. Association of blood pressure parameters post mechanical thrombectomy in anemic versus non-anemic patients and clinical outcomes. J Clin Neurosci 2023; 118:153-160. [PMID: 37944359 DOI: 10.1016/j.jocn.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/30/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Higher blood pressure (BP) is considered to be detrimental in patients who undergo mechanical thrombectomy (MT), however, the impact of BP post-MT based on comorbidities like anemia has not been well studied. We aim to determine the association of 24-h post-MT BP parameters with clinical outcomes depending on their anemia status. METHODS We conducted a retrospective chart review of patients who underwent MT at a comprehensive stroke center from 1/2015 to 12/2020. Patients were dichotomized into anemic and non-anemic groups based on the World Health Organization's definition of anemia [hemoglobin < 12.0 g/dL in women and < 13.0 g/dL in men]. We performed a multivariable analysis with binary logistic regression with the 24-h post-MT BP parameters as predictors. The outcomes were functional dependence (3-month mRS 3-6), mortality, and an early neurological improvement. RESULTS 220 patients met the inclusion criteria. 158 (71.82 %) patients had functional dependence at 3-months. In the multivariable analysis, the parameters of a higher mean SBP (132.9 ± 11.94 vs.126.52 ± 13.3; OR, 1.05; 95 % CI, 1.02-1.09; P 0.011), a higher mean MAP (93.35 ± 8.44 vs.89.69 ± 10.03; OR,1.06; 95 % CI, 1.01-1.11; P 0.029) and a higher maximum MAP (115.26 ± 11.73 vs.109.37 ± 12.51; OR,1.05; 95 % CI, 1.01-1.08; P 0.023)were significantly associated with functional dependence in non-anemic patients, while a lower mean DBP (65.53 ± 9.73 vs. 71.94 ± 10.16; OR, 0.92; 95 % CI, 0.86-0.98; P 0.007), lower mean MAP (85.7 ± 8.65 vs. 91.38 ± 10; OR, 0.93; 95 % CI, 0.86-0.99; P 0.02), a lower minimum DBP (49.27 ± 10.51 vs. 55.1 ± 11.23; OR, 0.93; 95 % CI, 0.88-0.99; P 0.019), a lower minimum MAP (68.96 ± 9.54 vs. 74.73 ± 10.47; OR, 0.93; 95 % CI, 0.87-0.99; P 0.023) were significantly associated with mortality in patients with anemia, and a lower minimum DBP (54.75 ± 10.42 vs. 59.69 ± 8.87; OR, 0.95; 95 % CI, 0.91-0.99; P 0.012) and a lower minimum MAP (71.92 ± 14.7 vs.75.67 ± 14.17; OR, 0.97; 95 % CI, 0.94-0.99; P 0.047) were significantly associated with an early neurological improvement in non-anemic patients. For patients with anemia, there was no association between 24-hour BP Parameters post-MT and functional dependence and early neurological improvement, and between 24-hour BP Parameters post-MT and mortality in non-anemic patients. CONCLUSION In our study, higher BP parameters were associated with worse outcomes in patients without anemia, however, this effect was not found in patients with anemia. Certain lower BP parameters were associated with higher 3-month mortality in anemic patients; however, this effect was not found in non-anemic patients. Higher BP post-MT can potentially promote perfusion and thus is not associated with worse outcomes in anemic patients post-MT, whereas in non-anemic patients it may potentially lead to reperfusion injury While our study is limited because of size and its retrospective nature, the findings suggest that an individualized approach to tailor the target BP post-MT to a patient's risk factor profile and associated co-morbid conditions to achieve optimization of medical care post-MT and associated co-morbid conditions to achieve optimization of medical care post-MT.
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Affiliation(s)
- Taha Nisar
- University of South Alabama, Mobile, AL, USA.
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De Georgia M, Bowen T, Duncan KR, Chebl AB. Blood pressure management in ischemic stroke patients undergoing mechanical thrombectomy. Neurol Res Pract 2023; 5:12. [PMID: 36991520 PMCID: PMC10061853 DOI: 10.1186/s42466-023-00238-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
The relationship between presenting blood pressure in acute ischemic stroke patients and outcome is complex. Several studies have demonstrated a U-shaped curve with worse outcomes when blood pressure is high or low. The American Heart Association/American Stroke Association guidelines recommend values of blood pressure < 185/110 mmHg in patients treated with intravenous t-PA and "permissive hypertension" up to 220/120 mmHg in those not treated with intravenous t-PA. The optimal blood pressure target is less clear in patients undergoing mechanical thrombectomy. Before thrombectomy, the guidelines recommend a blood pressure < 185/110 mmHg though patients with even lower systolic blood pressures may have better outcomes. During and after thrombectomy, the guidelines recommend a blood pressure < 180/105 mmHg. However, several studies have suggested that during thrombectomy the primary goal should be to prevent significant low blood pressure (e.g., target systolic blood pressure > 140 mmHg or MAP > 70 mmHg). After thrombectomy, the primary goal should be to prevent high blood pressure (e.g., target systolic blood pressure < 160 mmHg or MAP < 90 mmHg). To make more specific recommendations, large, randomized-control studies are needed that address factors such as the baseline blood pressure, timing and degree of revascularization, status of collaterals, and estimated risk of reperfusion injury.
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Affiliation(s)
- Michael De Georgia
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Theodore Bowen
- Department of Neurology, MetroHealth Medical Center, Cleveland, OH, USA
| | - K Rose Duncan
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Alex Bou Chebl
- Department of Neurology, Henry Ford Medical Center, Detroit, MI, USA
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5
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Time of blood pressure in target range in acute ischemic stroke. J Hypertens 2023; 41:303-309. [PMID: 36583356 DOI: 10.1097/hjh.0000000000003331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the association of blood pressure (BP) time-in-target range (TTR) derived from 24-h ambulatory BP monitoring (ABPM) during the acute phase of ischemic stroke (AIS), with the severity of stroke and its predictive value for the 3 months outcome. METHODS A total of 228 AIS patients (prospective multicenter follow-up study) underwent ABPM every 20 min within 48 h from stroke onset using an automated oscillometric device. Clinical and laboratory findings were recorded. Mean BP parameters, BP variability and TTR for SBP (90-140 mmHg), DBP (60-90 mmHg), and mean arterial pressure (MAP) were calculated. Endpoints were death and disability/death at 3 months. RESULTS A total of 14 942 BP measurements were recorded (∼66 per AIS patient) within 72 h of stroke onset. Patient's 24-h TTR was 34.7 ± 29.9, 64.3 ± 24.2, and 55.3 ± 29.4% for SBP, DBP and MAP, respectively. In patients without prior hypertension, TTR was lower as stroke severity increased for both DBP (P = 0.031) and MAP (P = 0.016). In 175 patients without prior disability, increase in TTR of DBP and MAP associated significantly with a decreased risk of disability/death (hazard ratio 0.96, 95% CI 0.95-0.99, P = 0.007 and hazard ratio 0.97, 95% CI 0.96-0.99, P = 0.007). TTR of SBP in 130-180 mmHg and 110-160 mmHg ranges seems to be related with mortality and disability outcomes, respectively. CONCLUSION TTR can be included for a more detailed description of BP course, according to stroke severity, and for the evaluation of BP predictive role, in addition to mean BP values, derived from ABPM during the acute phase of AIS. CLINICAL TRIAL REGISTRATIONURL http://www.clinicaltrials.gov. Unique identifier: NCT01915862.
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Kargiotis O, Psychogios K, Safouris A, Spiliopoulos S, Karapanayiotides T, Bakola E, Mantatzis M, Dardiotis E, Ellul J, Giannopoulos S, Magoufis G, Tsivgoulis G. Diagnosis and treatment of acute isolated proximal internal carotid artery occlusions: a narrative review. Ther Adv Neurol Disord 2022; 15:17562864221136335. [PMID: 36437850 PMCID: PMC9685148 DOI: 10.1177/17562864221136335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/16/2022] [Indexed: 07/27/2023] Open
Abstract
The clinical manifestations of proximal (extracranial) internal carotid artery occlusions (pICAOs) may range from asymptomatic to acute, large, and devastating ischemic strokes. The etiology and pathophysiology of the occlusion, intracranial collateral status and patient's premorbid status are among the factors determining the clinical presentation and outcome of pICAOs. Rapid and accurate diagnosis is crucial and may be assisted by the combination of carotid and transcranial duplex sonography, or a computed tomography/magnetic resonance angiography (CTA/MRA). It should be noted that with either imaging modalities, the discrimination of a pseudo-occlusion of the extracranial internal carotid artery (ICA) from a true pICAO may not be straightforward. In the absence of randomized data, the management of acute, symptomatic pICAOs remains individualized and relies largely on expert opinion. Administration of intravenous thrombolysis is reasonable and probably beneficial in the settings of acute ischemic stroke with early presentation. Unfortunately, rates of recanalization are rather low and acute interventional reperfusion therapies emerge as a potentially powerful therapeutic option for patients with persistent and severe symptoms. However, none of the pivotal clinical trials on mechanical thrombectomy for acute ischemic stroke randomized patients with isolated extracranial large vessel occlusions. On the contrary, several lines of evidence from non-randomized studies have shown that acute carotid endarterectomy, or endovascular thrombectomy/stenting of the ICA are feasible and safe, and pοtentially beneficial. The heterogeneity in the pathophysiology and clinical presentation of acute pICAOs renders patient selection for an acute interventional treatment a complicated decision-making process. The present narrative review will outline the pathophysiology, clinical presentation, diagnostic challenges, and possible treatment options for pICAOs.
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Affiliation(s)
| | | | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus,
Greece
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
- Aktios Rehabilitation Center, Koropi,
Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional
Radiology Unit, ‘Attikon’ University General Hospital, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of
Medicine, Faculty of Health Sciences, AHEPA University General Hospital,
Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Bakola
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
| | - Michail Mantatzis
- Department of Radiology, Interventional
Neuroradiology Unit, AHEPA University General Hospital, Aristotle University
of Thessaloniki, Thessaloniki, Greece
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital
of Larissa, School of Medicine, University of Thessaly, Larissa,
Greece
| | - John Ellul
- Department of Neurology, University General
Hospital of Patras, Patras, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
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Coliță D, Coliță CI, Hermann DM, Coliță E, Doeppner TR, Udristoiu I, Popa-Wagner A. Therapeutic Use and Chronic Abuse of CNS Stimulants and Anabolic Drugs. Curr Issues Mol Biol 2022; 44:4902-4920. [PMID: 36286048 PMCID: PMC9600088 DOI: 10.3390/cimb44100333] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/29/2022] Open
Abstract
The available evidence suggests that affective disorders, such as depression and anxiety, increase risk for accelerated cognitive decline and late-life dementia in aging individuals. Behavioral neuropsychology studies also showed that cognitive decline is a central feature of aging impacting the quality of life. Motor deficits are common after traumatic brain injuries and stroke, affect subjective well-being, and are linked with reduced quality of life. Currently, restorative therapies that target the brain directly to restore cognitive and motor tasks in aging and disease are available. However, the very same drugs used for therapeutic purposes are employed by athletes as stimulants either to increase performance for fame and financial rewards or as recreational drugs. Unfortunately, most of these drugs have severe side effects and pose a serious threat to the health of athletes. The use of performance-enhancing drugs by children and teenagers has increased tremendously due to the decrease in the age of players in competitive sports and the availability of various stimulants in many forms and shapes. Thus, doping may cause serious health-threatening conditions including, infertility, subdural hematomas, liver and kidney dysfunction, peripheral edema, cardiac hypertrophy, myocardial ischemia, thrombosis, and cardiovascular disease. In this review, we focus on the impact of doping on psychopathological disorders, cognition, and depression. Occasionally, we also refer to chronic use of therapeutic drugs to increase physical performance and highlight the underlying mechanisms. We conclude that raising awareness on the health risks of doping in sport for all shall promote an increased awareness for healthy lifestyles across all generations.
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Affiliation(s)
- Daniela Coliță
- Doctoral School, University of Medicine and Pharmacy “Carol Davila”, 020276 Bucharest, Romania
| | - Cezar-Ivan Coliță
- Doctoral School, University of Medicine and Pharmacy “Carol Davila”, 020276 Bucharest, Romania
- Correspondence: (C.-I.C.); (I.U.); (A.P.-W.)
| | - Dirk M. Hermann
- Chair of Vascular Neurology, Dementia and Ageing, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Eugen Coliță
- Doctoral School, University of Medicine and Pharmacy “Carol Davila”, 020276 Bucharest, Romania
| | - Thorsten R. Doeppner
- Department of Neurology, University Medical Center Göttingen, 37075 Gottingen, Germany
- Department of Neurology, University Hospital Giessen, 35394 Giessen, Germany
| | - Ion Udristoiu
- Department of Psychiatry, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Correspondence: (C.-I.C.); (I.U.); (A.P.-W.)
| | - Aurel Popa-Wagner
- Chair of Vascular Neurology, Dementia and Ageing, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
- Department of Psychiatry, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Correspondence: (C.-I.C.); (I.U.); (A.P.-W.)
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Bahouth MN, Saylor D, Hillis AE, Gottesman RF. The Impact of Mean Arterial Pressure and Volume Contraction in With Acute Ischemic Stroke. Front Neurol 2022; 13:766305. [PMID: 35345409 PMCID: PMC8957081 DOI: 10.3389/fneur.2022.766305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 01/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose Hydration at the time of stroke may impact functional outcomes. We sought to investigate the relationship between blood pressure, hydration status, and stroke severity in patients with acute ischemic stroke (AIS). Methods We evaluated hydration status, determined by blood urea nitrogen (BUN)/creatinine ratio, in consecutive patients with AIS from a single comprehensive stroke center. Baseline mean arterial pressure (MAP) was analyzed using a linear spline with a knot at 90 mmHg. Baseline stroke severity was defined based on admission NIH Stroke Scale scores (NIHSSS) and MRI diffusion-weighted imaging. Results Among 108 eligible subjects, 55 (51%) presented in a volume contracted state. In adjusted models, in the total sample, for every 10 mmHg higher MAP up to 90 mmHg, NIHSSS was 2.8 points lower (p = 0.053), without further statistically significant association between MAP above 90 and NIHSSS. This relationship was entirely driven by the individuals in a volume contracted state: MAP was not associated with NIHSSS in individuals who were euvolemic. For individuals in a volume contracted state, each 10 mmHg higher MAP, up to 90 mmHg, was associated with 6.9 points lower NIHSSS (95% CI −11.1, −2.6). MAP values above 90 mmHg were not related to NIHSSS in either dehydrated or euvolemic patients. Conclusions Lower MAP contributes to more severe stroke in patients who are volume contracted, but not those who are euvolemic, suggesting that hydration status and blood pressure may jointly contribute to the outcome. Hydration status should be considered when setting blood pressure goals for patients with AIS.
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Affiliation(s)
- Mona N Bahouth
- School of Medicine, Johns Hopkins University, Baltimore, MD, United States.,School of Nursing, Johns Hopkins University, Baltimore, MD, United States
| | - Deanna Saylor
- School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Argye E Hillis
- School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Rebecca F Gottesman
- School of Medicine, Johns Hopkins University, Baltimore, MD, United States.,School of Public Health, Johns Hopkins University, Baltimore, MD, United States
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Simonsen CZ, Bösel J, Rasmussen M. Periprocedural Management During Stroke Thrombectomy. Neurology 2021; 97:S105-S114. [PMID: 34785609 DOI: 10.1212/wnl.0000000000012798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 02/24/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF REVIEW Endovascular therapy (EVT) for acute ischemic stroke caused by large vessel occlusion is a powerful and evidence-based tool to achieve reperfusion and results in improved neurologic outcome. Focus has now shifted toward optimizing the procedure. We reviewed the relevant current literature on periprocedural stroke care such as pretreatment with IV tissue plasminogen activator (tPA), choice of anesthesia, ventilation strategy, and blood pressure management. RECENT FINDINGS IV tPA should not be withheld in a patients with stroke eligible for EVT. A meta-analysis of randomized trials on general anesthesia (GA) vs procedural sedation has shown better neurologic outcomes with protocol-based GA in centers with dedicated neuroanesthesia teams. There are no data from randomized trials on blood pressure control, but according to available evidence, systolic blood pressure should probably be held at >140 mm Hg during the procedure and <160 mm Hg after reperfusion. In ventilated patients, extreme deviations from normoxemia and normocapnia should be avoided. SUMMARY Periprocedural care influences the outcome after EVT for large vessel ischemic stroke. More evidence from prospective ongoing and future studies is urgently needed to identify its optimization.
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Affiliation(s)
- Claus Z Simonsen
- From the Department of Neurology (C.Z.S.) and Department of Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark; and Department of Neurology (J.B.), Klinikum Kassel, Germany.
| | - Julian Bösel
- From the Department of Neurology (C.Z.S.) and Department of Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark; and Department of Neurology (J.B.), Klinikum Kassel, Germany
| | - Mads Rasmussen
- From the Department of Neurology (C.Z.S.) and Department of Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark; and Department of Neurology (J.B.), Klinikum Kassel, Germany
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10
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Davis SM, Donnan GA. Ischemic Penumbra: A Personal View. Cerebrovasc Dis 2021; 50:656-665. [PMID: 34736251 DOI: 10.1159/000519730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/16/2021] [Indexed: 11/19/2022] Open
Abstract
The concept of the ischemic penumbra was defined over 40 years ago by Lindsay Symon and his group and is now an established principle of all acute ischemic stroke therapies. These reperfusion treatments rescue threatened, critically hypoperfused brain tissue and have been proven to improve clinical outcomes. We have been fortunate to have observed and played a small part in the penumbral story from its beginnings in the 1970s to its pivotal position today. Over this period, we have witnessed penumbral imaging evolve from positron emission tomography through to magnetic resonance imaging and now predominantly computed tomography perfusion, with the advent of automated imaging facilitating case selection for reperfusion therapies. We and others have conducted clinical trials using penumbral imaging to extend the time window for intravenous thrombolysis and select patients for thrombectomy. Together with the concept of fast- and slow-growing ischemic infarct patterns, this embeds the penumbral principle in everyday clinical management. The opportunity now exists to make penumbral imaging even more portable, affordable, and more widely available using mobile platforms, novel imaging techniques, digital linkage, and artificial intelligence.
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Affiliation(s)
- Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Victoria, Victoria, Australia
| | - Geoffrey A Donnan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Victoria, Victoria, Australia
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11
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Grotta JC. Fifty Years of Acute Ischemic Stroke Treatment: A Personal History. Cerebrovasc Dis 2021; 50:666-680. [PMID: 34649237 PMCID: PMC8639727 DOI: 10.1159/000519843] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/23/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It has been 50 years since the first explorations of the physiology of cerebral ischemia by measuring cerebral blood flow (CBF), and 25 years since the approval of tissue plasminogen activator for treating acute ischemic stroke. My personal career began and matured during those eras. Here, I provide my perspective on the evolution of acute stroke research and treatment from 1971 to the present, with some in-depth discussion of the National Institutes of Neurologic Disease and Stroke (NINDS) tissue-type plasminogen activator (tPA) stroke trial and development of mobile stroke units. SUMMARY Studies of CBF and metabolism in acute stroke patients revealed graded tissue injury that was dependent on the duration of ischemia. Subsequent animal research unraveled the biochemical cascade of events occurring at the cellular level after cerebral ischemia. After a decade of failed translation, the development of a relatively safe thrombolytic allowed us to achieve reperfusion and apply the lessons from earlier research to achieve positive clinical results. The successful conduct of the NINDS tPA stroke study coupled with positive outcomes from companion tPA studies around the world created the specialty of vascular neurology. This was followed by an avalanche of research in imaging, a focus on enhancing reperfusion through thrombectomy, and improving delivery of faster treatment culminating in mobile stroke units. Key Messages: The last half century has seen the birth and evolution of successful acute stroke treatment. More research is needed in developing new drugs and catheters to build on the advances we have already made with reperfusion and also in evolving our systems of care to get more patients treated more quickly in the prehospital setting. The history of stroke treatment over the last 50 years exemplifies that medical "science" is an evolving discipline worth an entire career's dedication. What was impossible 50 years ago is today's standard of care, what we claim as dogma today will be laughed at a decade from now, and what appears currently impossible will be tomorrow's realities.
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Affiliation(s)
- James C Grotta
- Stroke Research and Mobile Stroke Unit, Memorial Hermann Hospital-Texas Medical Center, Houston, Texas, USA
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12
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Sandset EC, Anderson CS, Bath PM, Christensen H, Fischer U, Gąsecki D, Lal A, Manning LS, Sacco S, Steiner T, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. Eur Stroke J 2021; 6:XLVIII-LXXXIX. [PMID: 34780578 PMCID: PMC8370078 DOI: 10.1177/23969873211012133] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/05/2021] [Indexed: 12/13/2022] Open
Abstract
The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke.The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels >180/105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups. There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.
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Affiliation(s)
- Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- The George Institute China at Peking University Health Science Center, Beijing, PR China
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital & University of Copenhagen, Copenhagen, Denmark
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dariusz Gąsecki
- Department of Adult Neurology, Medical University of Gdańsk, Gdańsk, Poland
| | - Avtar Lal
- Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Lisa S Manning
- Department of Stroke Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Ansari J, Gavins FNE. The impact of thrombo-inflammation on the cerebral microcirculation. Microcirculation 2021; 28:e12689. [PMID: 33638262 DOI: 10.1111/micc.12689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/12/2021] [Accepted: 02/22/2021] [Indexed: 12/16/2022]
Abstract
The intertwined processes of thrombosis and inflammation (termed "thrombo-inflammation") are significant drivers of cerebrovascular diseases, and as such, they represent prime targets for drug discovery programs focusing on treatment and management of cerebrovascular diseases. Most cerebrovascular events result from chronic systemic microcirculatory dysfunction due to underlying conditions, for example, hypertension, diabetes mellitus, coronary artery disease, dyslipidemia, and sickle cell disease. Immune cells especially neutrophils play a critical role in the onset and maintenance of neuroinflammatory responses in the microcirculation. Neutrophils have the ability to drive both inflammatory and anti-inflammatory/pro-resolution effects depending on the underlying vascular state (physiological vs. pathological). In this article, we highlight the pathophysiological role of neutrophils in stroke and discuss ongoing pharmacotherapeutic strategies that are focused on identifying potential therapeutic targets for enhancing neuroprotection, mitigating inflammatory pathways, and enabling resolution.
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Affiliation(s)
- Junaid Ansari
- Department of Neurology, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA
| | - Felicity N E Gavins
- Department of Life Sciences, The Centre for Inflammation Research and Translational Medicine (CIRTM), Brunel University London, Uxbridge, Middlesex, UK
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de Havenon A, Petersen N, Sultan-Qurraie A, Alexander M, Yaghi S, Park M, Grandhi R, Mistry E. Blood Pressure Management Before, During, and After Endovascular Thrombectomy for Acute Ischemic Stroke. Semin Neurol 2021; 41:46-53. [PMID: 33472269 DOI: 10.1055/s-0040-1722721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
There is an absence of specific evidence or guideline recommendations on blood pressure management for large vessel occlusion stroke patients. Until randomized data are available, the periprocedural blood pressure management of patients undergoing endovascular thrombectomy can be viewed in two phases relative to the achievement of recanalization. In the hyperacute phase, prior to recanalization, hypotension should be avoided to maintain adequate penumbral perfusion. The American Heart Association guidelines should be followed for the upper end of prethrombectomy blood pressure: ≤185/110 mm Hg, unless post-tissue plasminogen activator administration when the goal is <180/105 mm Hg. After successful recanalization (thrombolysis in cerebral infarction [TICI]: 2b-3), we recommend a target of a maximum systolic blood pressure of < 160 mm Hg, while the persistently occluded patients (TICI < 2b) may require more permissive goals up to <180/105 mm Hg. Future research should focus on generating randomized data on optimal blood pressure management both before and after endovascular thrombectomy, to optimize patient outcomes for these divergent clinical scenarios.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, Utah
| | - Nils Petersen
- Department of Neurology, Yale University, New Haven, Connecticut
| | - Ali Sultan-Qurraie
- Department of Neurology, University of Washington, Valley Medical Center, Seattle, Washington
| | | | - Shadi Yaghi
- Department of Neurology, New York University, New York, New York
| | - Min Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Eva Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
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Cantone M, Lanza G, Puglisi V, Vinciguerra L, Mandelli J, Fisicaro F, Pennisi M, Bella R, Ciurleo R, Bramanti A. Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021; 11:brainsci11010070. [PMID: 33430236 PMCID: PMC7825668 DOI: 10.3390/brainsci11010070] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 02/07/2023] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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Affiliation(s)
- Mariagiovanna Cantone
- Department of Neurology, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy
- Department of Neurology IC, Oasi Research Institute—IRCCS, Via Conte Ruggero, 73, 94018 Troina, Italy
- Correspondence: or ; Tel.: +39-095-3782448
| | - Valentina Puglisi
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Luisa Vinciguerra
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Jaime Mandelli
- Department of Neurosurgery, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Manuela Pennisi
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Rita Bella
- Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy;
| | - Rosella Ciurleo
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
| | - Alessia Bramanti
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
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Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021. [PMID: 33430236 DOI: 10.3390/brainsci11010070.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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17
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Abstract
EDITOR'S NOTE The article "Update on Treatment of Acute Ischemic Stroke" by Dr Rabinstein was first published in the February 2017 Cerebrovascular Disease issue of Continuum: Lifelong Learning in Neurology as "Treatment of Acute Ischemic Stroke" and has been updated by Dr Rabinstein for this issue at the request of the Editor-in-Chief. ABSTRACT PURPOSE OF REVIEWThis article provides an update on the state of the art of the treatment of acute ischemic stroke with particular emphasis on the indications for reperfusion therapy.RECENT FINDINGSIn addition to the previously established indications for intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rtPA) within 4.5 hours of stroke symptom onset and endovascular therapy with mechanical thrombectomy for patients with large artery occlusion who can be treated within 6 hours of symptom onset, recent randomized controlled trials have now established new indications for emergency reperfusion in patients with wake-up stroke or delayed presentation (up to 24 hours from last known well in the case of mechanical thrombectomy). Identification of patients who may benefit from acute reperfusion therapy within this extended time window requires screening with perfusion brain imaging or, in the case of IV thrombolysis for wake-up strokes, emergency brain MRI. Collateral status and time to reperfusion remain the primary determinants of outcome.SUMMARYTimely successful reperfusion is the most effective treatment for patients with acute ischemic stroke. Recent evidence supports the expansion of the time window for reperfusion treatment in carefully selected patients.
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Jafari M, Desai A, Damani R. Blood pressure management after mechanical thrombectomy in stroke patients. J Neurol Sci 2020; 418:117140. [PMID: 32961389 DOI: 10.1016/j.jns.2020.117140] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 11/15/2022]
Abstract
Endovascular treatment of acute ischemic stroke (AIS) and mechanical thrombectomy (MT) is proven as a safe and effective novel treatment for emergent large vessel occlusion in the anterior cerebral circulation. However, there are still many unanswered questions on peri and post-procedural management including blood pressure (BP) control. The current guidelines recommend maintaining BP <180/105 mmHg in the first 24 h after MT. However, recent studies suggest that maintaining BP levels at lower levels in the first 24 h after successful revascularization have been associated with favorable functional outcome, reduced mortality rate, and hemorrhagic complications. Not only absolute BP but also its variation in the first 24 h after MT have been associated with neurological outcomes. Evidence on the effect of BP variability (BPV) after MT in AIS even though limited, it does indicate the association of the higher BPV in the first 24 h after MT and poor functional outcomes in AIS. In this review, we will discuss the current literature on BP management in the first 24 h after MT and the impact of BPV in the first 24 h after MT.
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Affiliation(s)
- Mostafa Jafari
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Aaron Desai
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Rahul Damani
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
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Nasi LA, Martins SCO, Gus M, Weiss G, de Almeida AG, Brondani R, Rebello LC, DalPizzol A, Fuchs FD, Valença MJM, Wirth LF, Nunes G, Anderson CS. Early Manipulation of Arterial Blood Pressure in Acute Ischemic Stroke (MAPAS): Results of a Randomized Controlled Trial. Neurocrit Care 2020; 30:372-379. [PMID: 30460598 DOI: 10.1007/s12028-018-0642-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION There is uncertainty over the optimal level of systolic blood pressure (SBP) in the setting of acute ischemic stroke (AIS). The aim of this study was to determine the efficacy of the early manipulation of SBP in non-thrombolised patients. The key hypothesis under investigation was that clinical outcomes vary across ranges of SBP in AIS. METHODS 218 patients were randomized within 12 h of AIS to maintain the SBP during 24 h within three ranges: Group 1 140-160 mmHg, Group 2 161-180 mmHg or Group 3 181-200 mmHg. Vasoactive drugs and fluids were used to achieve these targets. Good outcome was defined as a modified Rankin score 0-2 at 90-days. RESULTS The median SBP in the three groups in 24 h was: 153 mmHg, 163 mmHg, and 178 mmHg, respectively, P < 0.0001. Good clinical outcome did not differ among the different groups (51% vs 52% vs 39%, P = 0.27). Symptomatic intracranial hemorrhage (SICH) was more frequent in the higher SBP range (1% vs 2.7% vs 9.1%, P = 0.048) with similar mortality rates. No patient had acute neurological deterioration related to the SBP reduction in the first 24 h. In our logistic regression analysis, the odds of having good clinical outcome was higher in Group 2 (OR 2.83) after adjusting for important confounders. Regardless of the assigned group, the probability of good outcome was 47% in patients who were manipulated to increase the BP, 42% to decrease and 62% in non-manipulated (P = 0.1). Adverse effects were limited to Group 2 (4%) and Group 3 (7.6%) and were associated with the use of norepinephrine (P = 0.05). CONCLUSIONS Good outcome in 90 days was not significantly different among the 3 blood pressure ranges. After logistic regression analysis, the odds of having good outcome was greater in Group 2 (SBP 161-180 mmHg). SICH occurred more frequently in Group 3 (181-200 mmHg).
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Affiliation(s)
- Luiz Antonio Nasi
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.
| | - Sheila Cristina Ouriques Martins
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Miguel Gus
- Hypertension Group, Cardiology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Gustavo Weiss
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Andrea Garcia de Almeida
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Rosane Brondani
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Letícia Costa Rebello
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Angélica DalPizzol
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Flávio Danni Fuchs
- Hypertension Group, Cardiology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Maria Júlia Monteiro Valença
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Letícia F Wirth
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil
| | - Gerson Nunes
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil
| | - Craig S Anderson
- The George Institute for Global Health, Royal Prince Alfred Hospital, University of New South Wales, Sydney, Australia
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Bang OY, Chung JW, Kim SK, Kim SJ, Lee MJ, Hwang J, Seo WK, Ha YS, Sung SM, Kim EG, Sohn SI, Han MK. Therapeutic-induced hypertension in patients with noncardioembolic acute stroke. Neurology 2019; 93:e1955-e1963. [PMID: 31645472 DOI: 10.1212/wnl.0000000000008520] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 06/06/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To evaluate the safety and efficacy of induced hypertension in patients with acute ischemic stroke. METHODS In this multicenter randomized clinical trial, patients with acute noncardioembolic ischemic stroke within 24 hours of onset who were ineligible for revascularization therapy and those with progressive stroke during hospitalization were randomly assigned (1:1) to the control and intervention groups. In the intervention group, phenylephrine was administered intravenously to increase systolic blood pressure (SBP) up to 200 mm Hg. The primary efficacy endpoint was early neurologic improvement (reduction in NIH Stroke Scale [NIHSS] score of ≥2 points during the first 7 days). The secondary efficacy endpoint was a modified Rankin Scale score of 0 to 2 at 90 days. Safety outcomes included symptomatic intracranial hemorrhage/edema, myocardial infarction, and death. RESULTS In the modified intention-to-treat analyses, 76 and 77 patients were included in the intervention and control groups, respectively. After adjustment for age and initial stroke severity, induced hypertension increased the occurrence of the primary (odds ratio 2.49, 95% confidence interval [CI] 1.25-4.96, p = 0.010) and secondary (odds ratio 2.97, 95% CI 1.32-6.68, p = 0.009) efficacy endpoints. Sixty-seven (88.2%) patients of the intervention group exhibited improvements in NIHSS scores of ≥2 points during induced hypertension (mean SBP 179·7 ± 19.1 mm Hg). Safety outcomes did not significantly differ between groups. CONCLUSION Among patients with noncardioembolic stroke who were ineligible for revascularization therapy and those with progressive stroke, phenylephrine-induced hypertension was safe and resulted in early neurologic improvement and long-term functional independence. CLINICALTRIALSGOV IDENTIFIER NCT01600235. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for patients with acute ischemic stroke, therapeutic-induced hypertension increases the probability of early neurologic improvement.
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Affiliation(s)
- Oh Young Bang
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Jong-Won Chung
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Soo-Kyoung Kim
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Suk Jae Kim
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Mi Ji Lee
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jaechun Hwang
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Woo-Keun Seo
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yeon Soo Ha
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Min Sung
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Eung-Gyu Kim
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung-Il Sohn
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
| | - Moon-Ku Han
- From the Department of Neurology (O.Y.B., J.-W.C., M.J.L., W.-K.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Neurology and Institute of Health Science (S.-K.K.), Gyeongsang National University College of Medicine, Jinju; Department of Neurology (S.J.K.), Hana General Hospital, Cheongju; Department of Neurology (J.H.), Kyungpook National University Chilgok Hospital, Daegu; Department of Neurology (Y.S.H.), Wonkwang University, School of Medicine, Iksan; Department of Neurology (S.M.S.), Pusan National University Hospital; Department of Neurology (E.-G.K.), Busan Paik Hospital, Inje University; Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu; and Department of Neurology (M.-K.H.), Seoul National University Bundang Hospital, Seongnam, Korea
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Central Noradrenergic Agonists in the Treatment of Ischemic Stroke-an Overview. Transl Stroke Res 2019; 11:165-184. [PMID: 31327133 DOI: 10.1007/s12975-019-00718-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 02/03/2023]
Abstract
Ischemic stroke is the leading cause of morbidity and mortality with a significant health burden worldwide and few treatment options. Among the short- and long-term effects of ischemic stroke is the cardiovascular sympathetic autonomic dysfunction, presented in part as the by-product of the ischemic damage to the noradrenergic centers of the brain. Unlike high levels in the plasma, the brain may face suboptimal levels of norepinephrine (NE), with adverse effects on the clinical and functional outcomes of ischemic stroke. The intravenous administration of NE and other sympathomimetic agents, in an attempt to increase cerebral perfusion pressure, often aggravates the ischemia-induced rise in blood pressure (BP) with life-threatening consequences for stroke patients, the majority of whom present with hypertension at the time of admission. Unlike the systemic administration, the central administration of NE reduces BP while exerting anti-inflammatory and neuroprotective effects. These characteristics of centrally administered NE, combined with the short latency of response, make it an ideal candidate for use in the acute phase of stroke, followed by the use of centrally acting noradrenergic agonists, such as NE reuptake inhibitors and B2-adrenergic receptor agonists for stroke rehabilitation. In addition, a number of nonpharmacological strategies, such as transcutaneous vagus nerve stimulation (tVNS) and trigeminal nerve stimulation (TNS), have the potential to enhance the central noradrenergic functional activities and improve stroke clinical outcomes. Many factors could influence the efficacy of the noradrenergic treatment in stroke patients. These factors include the type of the noradrenergic agent; the dose, frequency, and duration of administration; the timing of administration in relation to the acute event; and the site and characteristics of the ischemic lesions. Having this knowledge, combined with the better understanding of the regulation of noradrenergic receptors in different parts of the brain, would pave the path for the successful use of the centrally acting noradrenergic agents in the management of ischemic stroke.
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22
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Lee MH, Kim JG, Jeon SB, Kang DW, Kwon SU, Kim JS. Pharmacologically Induced Hypertension Therapy for Acute Stroke Patients. J Stroke 2019; 21:228-230. [PMID: 31161767 PMCID: PMC6549068 DOI: 10.5853/jos.2019.00437] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/09/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Min Hwan Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joong-Goo Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Bum Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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23
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Vitt JR, Trillanes M, Hemphill JC. Management of Blood Pressure During and After Recanalization Therapy for Acute Ischemic Stroke. Front Neurol 2019; 10:138. [PMID: 30846967 PMCID: PMC6394277 DOI: 10.3389/fneur.2019.00138] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 02/04/2019] [Indexed: 12/31/2022] Open
Abstract
Ischemic stroke is a common neurologic condition and can lead to significant long term disability and death. Observational studies have demonstrated worse outcomes in patients presenting with the extremes of blood pressure as well as with hemodynamic variability. Despite these associations, optimal hemodynamic management in the immediate period of ischemic stroke remains an unresolved issue, particularly in the modern era of revascularization therapies. While guidelines exist for BP thresholds during and after thrombolytic therapy, there is substantially less data to guide management during mechanical thrombectomy. Ideal blood pressure targets after attempted recanalization depend both on the degree of reperfusion achieved as well as the extent of infarction present. Following complete reperfusion, lower blood pressure targets may be warranted to prevent reperfusion injury and promote penumbra recovery however prospective clinical trials addressing this issue are warranted.
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Affiliation(s)
- Jeffrey R. Vitt
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Michael Trillanes
- Department of Pharmaceutical Services, University of California, San Francisco, San Francisco, CA, United States
| | - J. Claude Hemphill
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
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24
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Conner AK, Briggs RG, Palejwala AH, Sali G, Sughrue ME. The safety of post-operative elevation of mean arterial blood pressure following brain tumor resection. J Clin Neurosci 2018; 58:156-159. [PMID: 30243597 DOI: 10.1016/j.jocn.2018.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 09/10/2018] [Indexed: 12/23/2022]
Abstract
We demonstrate the safety of artificially elevating the mean arterial blood pressure (MAP) greater than 85 mmHg or 10% above the mean MAP in patients with underlying hypertension during the acute post-operative period in patients undergoing surgery for resection of brain tumors. A retrospective review was undertaken of all patients undergoing surgery by the senior author between 2013 and 2018. Patients who underwent MAP therapy were analyzed for hemorrhagic and cardiac complications. A total of 1162 of 2270 post-operative brain tumor patients underwent MAP therapy after surgery for a minimum of 24 h post-operatively. Of these, 7/1162 (0.6%) patients experienced intra-cavitary hemorrhage within 5 days of surgery. Two of 7 (29%) patients were diagnosed with venous infarction. One of 7 (14%) patients experienced post-operative, intra-cavitary hemorrhage prior to the initiation of MAP therapy. The remaining 4/1162 (0.35%) patients experienced intra-cavitary hemorrhage post-operatively without clear etiology. In assessing cardiac outcomes, 2/1162 patients (0.2%) experienced elevated troponin levels. No patient demonstrated significant cardiac related morbidity or mortality within this cohort. Post-operative MAP therapy with a goal of maintaining MAP greater than 85 mmHg or 10% above the mean MAP in patients with underlying hypertension appears to be a safe intervention in brain tumor patients for at least 24 h in the post-operative period.
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Affiliation(s)
- Andrew K Conner
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Robert G Briggs
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ali H Palejwala
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Goksel Sali
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Michael E Sughrue
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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25
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Leslie-Mazwi T, Chen M, Yi J, Starke RM, Hussain MS, Meyers PM, McTaggart RA, Pride GL, Ansari AS, Abruzzo T, Albani B, Arthur AS, Baxter BW, Bulsara KR, Delgado Almandoz JE, Gandhi CD, Heck D, Hetts SW, Klucznik RP, Jayaraman MV, Lee SK, Mack WJ, Mocco J, Prestigiacomo C, Patsalides A, Rasmussen P, Sunenshine P, Frei D, Fraser JF. Post-thrombectomy management of the ELVO patient: Guidelines from the Society of NeuroInterventional Surgery. J Neurointerv Surg 2017; 9:1258-1266. [PMID: 28963364 DOI: 10.1136/neurintsurg-2017-013270] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/22/2017] [Accepted: 08/06/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Thabele Leslie-Mazwi
- Neurointerventional Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael Chen
- Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Julia Yi
- University Illinois at Chicago, Chicago, Illinois, USA
| | - Robert M Starke
- Department of Neurosurgery and Radiology, University of Miami, Miami, Florida, USA
| | | | | | - Ryan A McTaggart
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - G Lee Pride
- Department of Neuroradiology, University of Texas Southwestern, Dallas, Texas, USA
| | - A Sameer Ansari
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Todd Abruzzo
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Barbara Albani
- Department of Neurointerventional Surgery, Christiana Care Health Systems, Newark, Delaware, USA
| | | | - Blaise W Baxter
- Department of Radiology, Erlanger Medical Center, Chattanooga, Tennessee, USA
| | - Ketan R Bulsara
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Josser E Delgado Almandoz
- Department of Neurointerventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Don Heck
- Department of Radiology, Forsyth Medical Center, Winston Salem, North Carolina, USA
| | - Steven W Hetts
- Department of Radiology, University of California in San Francisco, San Francisco, California, USA
| | - Richard P Klucznik
- Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Mahesh V Jayaraman
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Seon-Kyu Lee
- The University of Chicago, Chicago, Illinois, USA
| | - William J Mack
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - J Mocco
- Mount Sinai School of Medicine, Mount Sinai Health System, New York, New York, USA
| | | | - Athos Patsalides
- New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA
| | - Peter Rasmussen
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Donald Frei
- Swedish Medical Center, Denver, Colorado, USA
| | - Justin F Fraser
- Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
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Challenges in the Anesthetic and Intensive Care Management of Acute Ischemic Stroke. J Neurosurg Anesthesiol 2017; 28:214-32. [PMID: 26368664 DOI: 10.1097/ana.0000000000000225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Acute ischemic stroke (AIS) is a devastating condition with high morbidity and mortality. In the past 2 decades, the treatment of AIS has been revolutionized by the introduction of several interventions supported by class I evidence-care on a stroke unit, intravenous tissue plasminogen activator within 4.5 hours of stroke onset, aspirin commenced within 48 hours of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. There is new class I evidence also demonstrating benefits of endovascular therapy on functional outcomes in those with anterior circulation stroke. In addition, the importance of the careful management of key systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose, has been appreciated. In line with this, the role of anesthesiologists and intensivists in managing AIS has increased. This review highlights the main challenges in the endovascular and intensive care management of AIS that, in part, result from the paucity of research focused on these areas. It also provides guidelines for the management of AIS based upon current evidence, and identifies areas for further research.
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Regenhardt RW, Das AS, Stapleton CJ, Chandra RV, Rabinov JD, Patel AB, Hirsch JA, Leslie-Mazwi TM. Blood Pressure and Penumbral Sustenance in Stroke from Large Vessel Occlusion. Front Neurol 2017; 8:317. [PMID: 28717354 PMCID: PMC5494536 DOI: 10.3389/fneur.2017.00317] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/16/2017] [Indexed: 12/11/2022] Open
Abstract
The global burden of stroke remains high, and of the various subtypes of stroke, large vessel occlusions (LVOs) account for the largest proportion of stroke-related death and disability. Several randomized controlled trials in 2015 changed the landscape of stroke care worldwide, with endovascular thrombectomy (ET) now the standard of care for all eligible patients. With the proven success of this therapy, there is a renewed focus on penumbral sustenance. In this review, we describe the ischemic penumbra, collateral circulation, autoregulation, and imaging assessment of the penumbra. Blood pressure goals in acute stroke remain controversial, and we review the current data and suggest an approach for induced hypertension in the acute treatment of patients with LVOs. Finally, in addition to reperfusion and enhanced perfusion, efforts focused on developing therapeutic targets that afford neuroprotection and augment neural repair will gain increasing importance. ET has revolutionized stroke care, and future emphasis will be placed on promoting penumbral sustenance, which will increase patient eligibility for this highly effective therapy and reduce overall stroke-related death and disability.
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Affiliation(s)
- Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Alvin S. Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Christopher J. Stapleton
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ronil V. Chandra
- Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, VIC, Australia
| | - James D. Rabinov
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aman B. Patel
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Joshua A. Hirsch
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Thabele M. Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Abstract
PURPOSE OF REVIEW This article provides an update on the state of the art of the emergency treatment of acute ischemic stroke with particular emphasis on the alternatives for reperfusion therapy. RECENT FINDINGS The results of several randomized controlled trials consistently and conclusively demonstrating that previously functional patients with disabling strokes from a proximal intracranial artery occlusion benefit from prompt recanalization with mechanical thrombectomy using a retrievable stent have changed the landscape of acute stroke therapy. Mechanical thrombectomy within 6 hours of symptom onset should now be considered the preferred treatment for these patients along with IV thrombolysis with recombinant tissue plasminogen activator (rtPA) within the first 4.5 hours for all patients who do not have contraindications for systemic thrombolysis. Patients who are ineligible for IV rtPA can also benefit from mechanical thrombectomy. Collateral status and time to reperfusion are the main determinants of outcome. SUMMARY Timely successful reperfusion is the most effective treatment for patients with acute ischemic stroke. Systems of care should be optimized to maximize the number of patients with acute ischemic stroke able to receive reperfusion therapy.
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Ginsberg MD. Expanding the concept of neuroprotection for acute ischemic stroke: The pivotal roles of reperfusion and the collateral circulation. Prog Neurobiol 2016; 145-146:46-77. [PMID: 27637159 DOI: 10.1016/j.pneurobio.2016.09.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/22/2016] [Accepted: 09/10/2016] [Indexed: 12/27/2022]
Abstract
This review surveys the efforts taken to achieve clinically efficacious protection of the ischemic brain and underscores the necessity of expanding our purview to include the essential role of cerebral perfusion and the collateral circulation. We consider the development of quantitative strategies to measure cerebral perfusion at the regional and local levels and the application of these methods to elucidate flow-related thresholds of ischemic viability and to characterize the ischemic penumbra. We stress that the modern concept of neuroprotection must consider perfusion, the necessary substrate upon which ischemic brain survival depends. We survey the major mechanistic approaches to neuroprotection and review clinical neuroprotection trials, focusing on those phase 3 multicenter clinical trials for acute ischemic stroke that have been completed or terminated. We review the evolution of thrombolytic therapies; consider the lessons learned from the initial, negative multicenter trials of endovascular therapy; and emphasize the highly successful positive trials that have finally established a clinical role for endovascular clot removal. As these studies point to the brain's collateral circulation as key to successful reperfusion, we next review the anatomy and pathophysiology of collateral perfusion as it relates to ischemic infarction, as well as the molecular and genetic influences on collateral development. We discuss the current MR and CT-based diagnostic methods for assessing the collateral circulation and the prognostic significance of collaterals in ischemic stroke, and we consider past and possible future therapeutic directions.
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Affiliation(s)
- Myron D Ginsberg
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, United States.
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Scharf EL, Fugate JE, Hocker SE. Extensive Mobile Thrombus of the Internal Carotid Discovered After Intravenous Thrombolysis: What Do I Do Now? Neurohospitalist 2016; 7:96-99. [PMID: 28400904 DOI: 10.1177/1941874416663280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
This case report describes a rare presentation of ischemic stroke secondary to an extensive internal carotid artery thrombus, subsequent therapeutic dilemma, and clinical management. A 58-year-old man was administered intravenous (IV) thrombolysis for right middle cerebral artery territory ischemic stroke symptoms. A computed tomography angiogram of the head and neck following thrombolysis showed a longitudinally extensive internal carotid artery thrombus originating at the region of high-grade calcific stenosis. Mechanical embolectomy was deferred because of risk of clot dislodgement and mild neurological symptoms. Recumbency and hemodynamic augmentation were used acutely to support cerebral perfusion. Anticoagulation was started 24 hours after thrombolysis. Carotid endarterectomy was completed successfully within 1 week of presentation. Clinical outcome was satisfactory with discharge modified Rankin Scale score 0. A longitudinally extensive carotid artery thrombus poses a risk of dislodgement and hemispheric stroke. Optimal management in these cases is not known with certainty. In our case, IV thrombolysis, hemodynamic augmentation, delayed anticoagulation, and carotid endarterectomy resulted in a favorable clinical outcome.
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Abstract
Over the last few decades, the management of acute ischemic stroke has undergone significant advancements with the introduction of intravenous thrombolysis and more recently punctuated by the success of endovascular mechanical thrombectomy trials for large vessel occlusion. These advancements have transformed the practice of neurocritical care. In this review, we present a case-based discussion of common brain reperfusion techniques with an emphasis on complication recognition and management. The article encompasses recent evidence-based recommendations as well as some of our own institutional protocols.
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Xiong L, Lin W, Han J, Chen X, Leung T, Soo Y, Wong KS. Enhancing cerebral perfusion with external counterpulsation after ischaemic stroke: how long does it last? J Neurol Neurosurg Psychiatry 2016; 87:531-6. [PMID: 25934015 DOI: 10.1136/jnnp-2014-309842] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 04/13/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE External counterpulsation (ECP) is a non-invasive method used to augment cerebral perfusion in ischaemic stroke. We aimed to investigate time-course effects on blood pressure elevation and cerebral blood flow augmentation induced by ECP in ischaemic stroke. METHODS Patients with acute unilateral ischaemic stroke and large artery occlusive disease were recruited to receive 35 daily 1 h ECP treatment sessions. Serial transcranial Doppler monitoring of bilateral middle cerebral arteries was performed on days 3, 5, 7, 10, 14, 21, 28 and 35 after stroke onset. Flow velocity changes before, during and after ECP and continuous beat-to-beat blood pressure data were recorded. The cerebral augmentation index (CAI) is the increase in the percentage of the middle cerebral artery mean flow velocity during ECP compared with baseline. RESULTS The CAI in patients with stroke was significantly higher on the ipsilateral side and on the contralateral side on day 3 (ipsilateral CAI, 9.3%; contralateral CAI, 7.2%), day 5 (7.0%; 6.7%), day 7 (6.8%; 6.0%), day 10 (6.0%; 5.1%), day 14 (4.7%; 2.6%) and day 21 (4.1%; 2.2%) after stroke onset than that in controls (-2.0%) (all p<0.05). There was a significant trend of decreasing CAI on the ipsilateral and contralateral sides over time after a stroke. Differences in the percentage increase in the mean blood pressure did not change significantly over time in patients with stroke. CONCLUSIONS Blood pressure elevation persists throughout ECP treatment, which consists of 35 sessions. However, cerebral blood flow augmentation may last at least 3 weeks and then appears to return to baseline 1 month after acute stroke onset.
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Affiliation(s)
- Li Xiong
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Wenhua Lin
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Jinghao Han
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Xiangyan Chen
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Thomas Leung
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yannie Soo
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Ka Sing Wong
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
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Safety of peripheral administration of phenylephrine in a neurologic intensive care unit: A pilot study. J Crit Care 2016; 34:107-10. [PMID: 27288620 DOI: 10.1016/j.jcrc.2016.04.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 01/28/2016] [Accepted: 04/04/2016] [Indexed: 11/21/2022]
Abstract
Integral to the management of the neurocritically injured patient are the prevention and treatment of hypotension, maintenance of cerebral perfusion pressure, and occasionally blood pressure augmentation. When adequate volume resuscitation fails to meet perfusion needs, vasopressors are often used to restore end-organ perfusion. This has historically necessitated central venous access given well-documented incidence of extravasation injuries associated with peripheral administration of vasopressors. In this pilot study, we report our 6-month experience with peripheral administration of low-concentration phenylephrine (40 μg/mL) in our neurocritical care unit. We were able to administer peripheral phenylephrine, up to a dose of 2 μg/(kg min), for an average of 14.29hours (1-54.3) in 20 patients with only 1 possible minor complication and no major complications. This was achieved by adding additional safety measures in our computerized physician order entry system and additional nurse-driven safety protocols. Thus, with careful monitoring and safety precautions, peripheral administration of phenylephrine at an optimized concentration appears to have an acceptable safety profile for use in the neurocritical care unit up to a mean infusion time of 14hours.
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35
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McManus M, Liebeskind DS. Blood Pressure in Acute Ischemic Stroke. J Clin Neurol 2016; 12:137-46. [PMID: 26833984 PMCID: PMC4828558 DOI: 10.3988/jcn.2016.12.2.137] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 08/14/2015] [Accepted: 08/17/2015] [Indexed: 02/07/2023] Open
Abstract
Hypertension is present in up to 84% of patients presenting with acute stroke, and a smaller proportion of patients have blood pressures that are below typical values in the context of cerebral ischemia. Outcomes are generally worse in those who present with either low or severely elevated blood pressure. Several studies have provided valuable information about malignant trends in blood pressure during the transition from the acute to the subacute phase of stroke. It is not uncommon for practitioners in clinical practice to identify what appear to be pressure-dependent neurologic deficits. Despite physiologic and clinical data suggesting the importance of blood pressure modulation to support cerebral blood flow to ischemic tissue, randomized controlled trials have not yielded robust evidence for this in acute ischemic stroke. We highlight previous studies involving acute-stroke patients that have defined trends in blood pressure and that have evaluated the safety and efficacy of blood-pressure modulation in acute ischemic stroke. This overview reports the current status of this topic from the perspective of a stroke neurologist and provides a framework for future research.
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Affiliation(s)
- Michael McManus
- Neurovascular Imaging Research Core & UCLA Stroke Center, University of California, Los Angeles, CA, USA
| | - David S Liebeskind
- Neurovascular Imaging Research Core & UCLA Stroke Center, University of California, Los Angeles, CA, USA.
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36
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Winship IR. Cerebral collaterals and collateral therapeutics for acute ischemic stroke. Microcirculation 2015; 22:228-36. [PMID: 25351102 DOI: 10.1111/micc.12177] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 10/22/2014] [Indexed: 11/29/2022]
Abstract
Cerebral collaterals are vascular redundancies in the cerebral circulation that can partially maintain blood flow to ischemic tissue when primary conduits are blocked. After occlusion of a cerebral artery, anastomoses connecting the distal segments of the MCA with distal branches of the ACA and PCA (known as leptomeningeal or pial collaterals) allow for partially maintained blood flow in the ischemic penumbra and delay or prevent cell death. However, collateral circulation varies dramatically between individuals, and collateral extent is significant predictor of stroke severity and recanalization rate. Collateral therapeutics attempt to harness these vascular redundancies by enhancing blood flow through pial collaterals to reduce ischemia and brain damage after cerebral arterial occlusion. While therapies to enhance collateral flow remain relatively nascent neuroprotective strategies, experimental therapies including inhaled NO, transient suprarenal aortic occlusion, and electrical stimulation of the parasympathetic sphenopalatine ganglion show promise as collateral therapeutics with the potential to improve treatment of acute ischemic stroke.
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Affiliation(s)
- Ian R Winship
- Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada; Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
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37
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Cerebral Angiography Can Demonstrate Changes in Collateral Flow During Induced Hypertension. Radiol Case Rep 2015; 2:37. [PMID: 27303484 PMCID: PMC4895774 DOI: 10.2484/rcr.2007.v2i4.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A 52-year-old woman with a large left-hemispheric stroke was transferred to our hospital for possible endovascular treatment. The patient underwent a cerebral angiogram at 7 hours after symptom onset with intent to treat and was found to have occlusion of the proximal M1-segment of the left middle cerebral artery (MCA). At that time it was felt that this was a high-risk patient for mechanical clot retrieval and it was decided to treat her with induced hypertension. The diagnostic catheter was left in place in the left internal carotid artery (ICA) and hypertension was induced in the angiography suite by means of an infusion of neosynephrine. Ten minutes after the goal blood pressure levels had been reached, a repeat left ICA injection was performed, which demonstrated more extensive collateralization of the MCA territory from anterior cerebral artery branches. Mean transit times (MTT) for the left ICA circulation improved from 9.5 seconds prior to induced hypertension to 6.0 seconds. The neosynephrine infusion was continued for a total of 24 hours and the patient showed neurological improvement. We suggest that induced hypertension led to the improved collateralization to the left MCA as evidenced by the improved MTT and augmentation of leptomeningeal collaterals, which in turn led to the patient's clinical improvement.
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38
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Acute Treatment of Blood Pressure After Ischemic Stroke and Intracerebral Hemorrhage. Neurol Clin 2015; 33:361-80. [DOI: 10.1016/j.ncl.2014.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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39
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Nishijima Y, Akamatsu Y, Weinstein PR, Liu J. Collaterals: Implications in cerebral ischemic diseases and therapeutic interventions. Brain Res 2015; 1623:18-29. [PMID: 25770816 DOI: 10.1016/j.brainres.2015.03.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 02/27/2015] [Accepted: 03/03/2015] [Indexed: 02/09/2023]
Abstract
Despite the tremendous progress made in the treatment of cerebrovascular occlusive diseases, many patients suffering from ischemic brain injury still experience dismal outcomes. Although rehabilitation contributes to post-stroke functional recovery, there is no doubt that interventions that promote the restoration of blood supply are proven to minimize ischemic injury and improve recovery. In response to the acutely decreased blood perfusion during arterial occlusion, arteriogenesis, the compensation of blood flow through the collateral circulation during arterial obstructive diseases can act not only in a timely fashion but also much more efficiently compared to angiogenesis, the sprouting of new capillaries, and a mechanism occurring in a delayed fashion while increases the total resistance of the vascular bed of the affected territory. Interestingly, despite the vast differences between the two vascular remodeling mechanisms, some crucial growth factors and cytokines involved in angiogenesis are also required for arteriogenesis. Understanding the mechanisms underlying vascular remodeling after ischemic brain injury is a critical step towards the development of effective therapies for ischemic stroke. The present article will discuss our current views in vascular remodeling acutely after brain ischemia, namely arteriogenesis, and some relevant clinical therapies available on the horizon in augmenting collateral flow that hold promise in treating ischemic brain injury. This article is part of a Special Issue entitled SI: Cell Interactions In Stroke.
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Affiliation(s)
- Yasuo Nishijima
- Department of Neurological Surgery, UCSF, San Francisco, CA 94121, USA; SFVAMC, San Francisco, CA 94121, USA; Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Yosuke Akamatsu
- Department of Neurological Surgery, UCSF, San Francisco, CA 94121, USA; SFVAMC, San Francisco, CA 94121, USA; Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Phillip R Weinstein
- Department of Neurological Surgery, UCSF, San Francisco, CA 94121, USA; SFVAMC, San Francisco, CA 94121, USA
| | - Jialing Liu
- Department of Neurological Surgery, UCSF, San Francisco, CA 94121, USA; SFVAMC, San Francisco, CA 94121, USA.
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40
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Abstract
Stroke is a common and serious disorder and will probably occur with increasing frequency due to an aging of the population. Acute therapies aimed at reversing the effects of acute ischemic stroke are limited to recombinant tissue plasminogen activator administered intravenously within 3 hours of stroke onset. Neuroprotective agents and acute anticoagulation with agents such as heparinoids and heparin are not effective in most cases. Poststroke medical complications such as infection and venous thromboembolism are common but are largely preventable. A variety of medical therapies such as antiplatelet agents, warfarin, statins, and ACE inhibitors can reduce the risk of a recurrent stroke. A key aspect of management for stroke is selection of the proper treatment regimen for each patient.
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Affiliation(s)
- Mark J Alberts
- Stroke Program, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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41
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Berkowitz AL, Voinescu PE, Feske SK. Clinical reasoning: a 42-year-old man who developed blurred vision and dropped his iPod while jogging. Neurology 2014; 83:e89-94. [PMID: 25135916 DOI: 10.1212/wnl.0000000000000712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Aaron L Berkowitz
- From the Department of Neurology, Brigham and Women's Hospital, Boston, MA.
| | - P Emma Voinescu
- From the Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Steven K Feske
- From the Department of Neurology, Brigham and Women's Hospital, Boston, MA
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42
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Jensen MB, Yoo B, Clarke WR, Davis PH, Adams HR. Blood Pressure as an Independent Prognostic Factor in Acute Ischemic Stroke. Can J Neurol Sci 2014; 33:34-8. [PMID: 16583719 DOI: 10.1017/s0317167100004662] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND PURPOSE Blood pressure is elevated in most patients during acute ischemic stroke, but the prognostic significance of this is unclear as the current data yield conflicting results. METHODS Admission blood pressure from the 1281 patients in the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) was analyzed for prognostic significance as well as the risk of hemorrhagic transformation. We also examined weighted-average blood pressure over seven days, and the impact of a 30% change in blood pressure in 24 hours. Patients with severe hypertension were excluded from the TOAST trial. RESULTS Increasing systolic blood pressure (SBP) on admission, but not diastolic (DBP) or mean arterial pressure (MAP) was predictive of poor outcome, but this effect was not significant after adjustment for other know prognostic factors. Increasing weighted-average SBP and MAP over seven days were predictive for poor outcome, but a 30% change in blood pressure over 24 hours was not. CONCLUSIONS Admission blood pressure is not an independent prognostic factor in acute ischemic stroke, but the weighted-average of SBP and MAP over seven days probably does have predictive value with higher values having a worse prognosis. A prospective trial of blood pressure control during acute stroke is needed.
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Affiliation(s)
- Matt B Jensen
- Stroke Center, University of California, San Diego, CA 92103-8466, USA
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43
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The golden hour Performing an acute ischemic stroke workup. Nurse Pract 2014; 39:22-9; quiz 29-30. [PMID: 25083767 DOI: 10.1097/01.npr.0000452974.46311.0f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Ischemic stroke is a medical emergency resulting from an embolic or thrombotic occlusion of an intracranial artery. The purpose of this article is to provide acute care nurse practitioners a summary of recent updates on the rapid evaluation and workup for patient selection and treatment with I.V. fibrinolysis.
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44
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Abstract
Acute ischemic stroke is the fourth leading cause of death and the leading cause of disability in the United States. Stroke is a medical emergency. The development of stroke systems of care has changed the way practitioners view and treat this devastating disease. Ample evidence has shown that patients presenting early and receiving intravenous thrombolytic therapy have the best chance for significant improvement in functional outcome, particularly if they are transported to specialized stroke centers. Early detection and management of medical and neurologic complications is key at preventing further brain damage in patients with acute ischemic stroke.
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Affiliation(s)
- Nelson J Maldonado
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA
| | - Syed O Kazmi
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA
| | - Jose Ignacio Suarez
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA.
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45
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The intensive care management of acute ischemic stroke: an overview. Intensive Care Med 2014; 40:640-53. [DOI: 10.1007/s00134-014-3266-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/11/2014] [Indexed: 01/21/2023]
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46
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Pfluecke C, Christoph M, Kolschmann S, Tarnowski D, Forkmann M, Jellinghaus S, Poitz DM, Wunderlich C, Strasser RH, Schoen S, Ibrahim K. Intra-aortic balloon pump (IABP) counterpulsation improves cerebral perfusion in patients with decreased left ventricular function. Perfusion 2014; 29:511-6. [DOI: 10.1177/0267659114525218] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The current goal of treatment after acute ischemic stroke is the increase of cerebral blood flow (CBF) in ischemic brain tissue. Intra-aortic balloon pump (IABP) counterpulsation in the setting of cardiogenic shock is able to reduce left ventricular afterload and increase coronary blood flow. The effects of an IABP on CBF have not been sufficiently examined. We hypothesize that the use of an IABP especially enhances cerebral blood flow in patients with pre-existing heart failure. Methods: In this pilot study, 36 subjects were examined to investigate the effect of an IABP on middle cerebral artery (MCA) transcranial Doppler (TCD) flow velocity change and relative CBF augmentation by determining velocity time integral changes (ΔVTI) in a constant caliber of the MCA compared to a baseline measurement without an IABP. Subjects were divided into two groups according to their left ventricular ejection fraction (LVEF): Group 1 LVEF >30% and Group 2 LVEF ≤30%. Results: Both groups showed an increase in CBF using an IABP. Patients with a LVEF ≤30% showed a significantly higher increase of ΔVTI in the MCA under IABP augmentation compared to patients with a LVEF >30% (20.9% ± 3.9% Group 2 vs.10.5% ± 2.2% Group 1, p<0,05). The mean arterial pressure (MAP) increased only marginally in both groups under IABP augmentation. Conclusions: IABP improves cerebral blood flow, particularly in patients with pre-existing heart failure and highly impaired LVEF. Hence, an IABP might be a treatment option to improve cerebral perfusion in selected patients with cerebral misperfusion and simultaneously existing severe heart failure.
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Affiliation(s)
- C Pfluecke
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - M Christoph
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - S Kolschmann
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - D Tarnowski
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - M Forkmann
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - S Jellinghaus
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - DM Poitz
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - C Wunderlich
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - RH Strasser
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - S Schoen
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - K Ibrahim
- University of Technology Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
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47
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Liu LP, Xu AD, Wong LKS, Wang DZ, Wang YJ. Chinese consensus statement on the evaluation and intervention of collateral circulation for ischemic stroke. CNS Neurosci Ther 2014; 20:202-8. [PMID: 24495505 PMCID: PMC4233984 DOI: 10.1111/cns.12226] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 12/20/2013] [Accepted: 12/22/2013] [Indexed: 02/06/2023] Open
Abstract
Background Collateral circulation is becoming more significant in the individual management strategy of ischemic stroke, there are more data updated recently. Aim To make the further acknowledgment of the evaluation and how to improving collateral flow, for better treatment selection. Method A panel of experts on stroke providing related statement based on review the results from most up‐to‐date clinical research. Results DSA is the gold standard in evaluating all levels of collaterals. CTA can be used for evaluating leptomeningeal collaterals, MRA for CoW, TCD or TCCS can be used as screening tool for primary evaluation. The treatment modalities include direct interventions, such as Extracranial–Intracranial bypass, and indirect interventions, as External counterpulsation and pressor therapy. The consideration of methodology to augment and improve can be considered on an individual basis. Discussion In this consensus, we interpret the definition, neuroimaging evaluation, intervention and potential strategy on collaterals in the future. Conclusion Assessment of collateral circulation is crucial for selecting therapeutic options, predicting infarction volume and making prognosis after ischemic stroke. Data is still needed to provide therapeutic evidence for many new developed technologies. Until more evidence is available, the clinical significance of applying the new technologies is unclear and perhaps limited.
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Affiliation(s)
- Li-Ping Liu
- Departments of Neurology and Stroke Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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48
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Menon BK, Goyal M. Endovascular therapy in acute ischemic stroke: where we are, the challenges we face and what the future holds. Expert Rev Cardiovasc Ther 2014; 9:473-84. [DOI: 10.1586/erc.11.35] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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49
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Goodfellow JA, Dawson J, Quinn TJ. Management of blood pressure in acute stroke. Expert Rev Neurother 2014; 13:911-23. [DOI: 10.1586/14737175.2013.814964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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50
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Winship IR, Armitage GA, Ramakrishnan G, Dong B, Todd KG, Shuaib A. Augmenting collateral blood flow during ischemic stroke via transient aortic occlusion. J Cereb Blood Flow Metab 2014; 34:61-71. [PMID: 24045399 PMCID: PMC3887343 DOI: 10.1038/jcbfm.2013.162] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 08/20/2013] [Accepted: 08/23/2013] [Indexed: 11/09/2022]
Abstract
Collateral circulation provides an alternative route for blood flow to reach ischemic tissue during a stroke. Blood flow through the cerebral collaterals is a critical predictor of clinical prognosis after stroke and response to recanalization, but data on collateral dynamics and collateral therapeutics are lacking. Here, we investigate the efficacy of a novel approach to collateral blood flow augmentation to increase collateral circulation by optically recording blood flow in leptomeningeal collaterals in a clinically relevant model of ischemic stroke. Using high-resolution laser speckle contrast imaging (LSCI) during thromboembolic middle cerebral artery occlusion (MCAo), we demonstrate that transiently diverting blood flow from peripheral circulation towards the brain via intra-aortic catheter and balloon induces persistent increases in blood flow through anastomoses between the anterior and middle cerebral arteries. Increased collateral flow restores blood flow in the distal middle cerebral artery segments to baseline levels during aortic occlusion and persists for over 1 hour after removal of the aortic balloon. Given the importance of collateral circulation in predicting stroke outcome and response to treatment, and the potential of collateral flow augmentation as an adjuvant or stand-alone therapy for acute ischemic stroke, this data provide support for further development and translation of collateral therapeutics including transient aortic occlusion.
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Affiliation(s)
- Ian R Winship
- 1] Centre for Neuroscience, University of Alberta, Edmonton, Alberta, Canada [2] Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Glenn A Armitage
- 1] Centre for Neuroscience, University of Alberta, Edmonton, Alberta, Canada [2] Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Gomathi Ramakrishnan
- 1] Centre for Neuroscience, University of Alberta, Edmonton, Alberta, Canada [2] Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Bin Dong
- 1] Centre for Neuroscience, University of Alberta, Edmonton, Alberta, Canada [2] Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Kathryn G Todd
- 1] Centre for Neuroscience, University of Alberta, Edmonton, Alberta, Canada [2] Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Ashfaq Shuaib
- 1] Centre for Neuroscience, University of Alberta, Edmonton, Alberta, Canada [2] Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
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