1
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Katyal A, Bhaskar SMM. Value of pre-intervention computed tomography perfusion imaging in the assessment of tissue outcome and long-term clinical prognosis in patients with anterior circulation acute ischemic stroke receiving reperfusion therapy: a systematic review. Acta Radiol 2022; 63:1243-1254. [PMID: 34342497 DOI: 10.1177/02841851211035892] [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] [Indexed: 12/30/2022]
Abstract
BACKGROUND Computed tomography perfusion (CTP) imaging has emerged as an important adjunct to the current armamentarium of acute ischemic stroke (AIS) workflow. However, its adoption in routine clinical practice is far from optimal. PURPOSE To investigate the putative association of CTP imaging biomarkers in the assessment of prognosis in acute ischemic stroke. MATERIAL AND METHODS We performed a systematic review of the literature using MEDLINE, EMBASE, and Cochrane Central Register of Clinical Trials focusing on CTP biomarkers, tissue-based and clinical-based patient outcomes. We included randomized controlled trials, prospective cohort studies, and case-controlled studies published from January 2005 to 28 August 2020. Two independent reviewers conducted the study appraisal, data extraction, and quality assessment of the studies. RESULTS A total of 60 full-text studies were included in the final systematic review analysis. Increasing infarct core volume is associated with reduced odds of achieving functional independence (modified Rankin score 0-2) at 90 days and is correlated with the final infarct volume when reperfusion is achieved. CONCLUSION CTP has value in assessing tissue perfusion status in the hyperacute stroke setting and the long-term clinical prognosis of patients with AIS receiving reperfusion therapy. However, the prognostic use of CTP requires optimization and further validation.
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Affiliation(s)
- Anubhav Katyal
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW, Australia.,University of New South Wales (UNSW), South West Sydney Clinical School, Sydney, NSW, Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW, Australia.,Liverpool Hospital & South West Sydney Local Health District (SWSLHD), Department of Neurology & Neurophysiology, Sydney, NSW, Australia.,NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW, Australia.,Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, NSW, Australia
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2
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Katyal A, Bhaskar SMM. Value of pre-intervention CT perfusion imaging in acute ischemic stroke prognosis. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:774-785. [PMID: 34792033 DOI: 10.5152/dir.2021.20805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Noninvasive imaging plays an important role in acute stroke towards diagnosis and ongoing management of patients. Systemic thrombolysis and endovascular thrombectomy (EVT) are proven treatments currently used in standards of care in acute stroke settings. The role of computed tomography angiography (CTA) in selecting patients with large vessel occlusion for EVT is well established. However, the value of CT perfusion (CTP) imaging in predicting outcomes after stroke remains ambiguous. This article critically evaluates the value of multimodal CT imaging in early diagnosis and prognosis of acute ischemic stroke with a focus on the role of CTP in delineating tissue characteristics, patient selection, and outcomes after reperfusion therapy. Insights on various technical and clinical considerations relevant to CTP applications in acute ischemic stroke, recommendations for existing workflow, and future areas of research are discussed.
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Affiliation(s)
- Anubhav Katyal
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, Australia; University of New South Wales (UNSW), South Western Sydney Clinical School, NSW, Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, Australia; Department of Neurology - Neurophysiology, Liverpool Hospital - South West Sydney Local Health District (SWSLHD), Sydney, Australia;University of New South Wales (UNSW), South Western Sydney Clinical School, NSW, Australia; Ingham Institute for Applied Medical Research, Stroke - Neurology Research Group, Sydney, Australia; NSW Brain Clot Bank, NSW Health Statewide Biobank and NSW Health Pathology, Sydney, NSW, Australia;Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, Australia
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3
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Zhang XX, Yao FR, Zhu JH, Chen ZG, Shen YP, Qiao YN, Shi HC, Liang JH, Wang XM, Fang Q. Nomogram to predict haemorrhagic transformation after stroke thrombolysis: a combined brain imaging and clinical study. Clin Radiol 2021; 77:e92-e98. [PMID: 34657729 DOI: 10.1016/j.crad.2021.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
AIM To construct a novel nomogram by integrating computed tomography perfusion (CTP) and clinical parameters for individualised prediction of haemorrhagic transformation (HT) in intravenous thrombolysis (IVT)-treated acute ischaemic stroke (AIS) patients. METHODS Anterior circulation AIS patients who underwent IVT at a single centre from January 2018 to June 2020 were reviewed retrospectively. The CTP parameters of two regions of interest (ROI), the entire perfusion lesion areas, and the infract core areas, were assessed. HT was documented by follow-up CT 24 ± 2 h after IVT. Multivariable logistic regression was conducted by including clinical variables and CTP parameters to identify the independent predictors of HT. A nomogram was developed based on the independent predictors. The discriminative value and calibration of the nomogram were tested by concordance indexes (C-indexes) and calibration plots. Internal validation was performed using fivefold cross-validation. RESULTS The nomogram was generated using the complete data from 341 patients. Seven variables were included in the final nomogram, including: the relative cerebral blood volume (rCBV), permeability surface (PS), and relative PS (rPS) in infract core areas, the relative time to maximum (rTmax) and rPS in entire perfusion lesion areas, the National Institutes of Health Stroke Scale (NIHSS), and atrial fibrillation (AF). The C-indexes were 0.815 and 0.817 for the nomogram and internal validation. The calibration plots showed excellent agreement. CONCLUSION This is the first study establishing a nomogram based on CTP and clinical parameters to predict HT after stroke thrombolysis.
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Affiliation(s)
- X-X Zhang
- Department of Neurology, Yancheng Third People's Hospital, Yancheng, 224000, Jiangsu Province, China; Department of Neurology, The First Affiliated Hospital of Soochow University, Soochow, 215000, Jiangsu, China
| | - F-R Yao
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215000, Jiangsu, China
| | - J-H Zhu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Soochow, 215000, Jiangsu, China
| | - Z-G Chen
- Department of Neurology, The First Affiliated Hospital of Soochow University, Soochow, 215000, Jiangsu, China
| | - Y-P Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, 215000, Jiangsu, China
| | - Y-N Qiao
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, 215000, Jiangsu, China
| | - H-C Shi
- Department of Neurology, Yancheng Third People's Hospital, Yancheng, 224000, Jiangsu Province, China
| | - J-H Liang
- Department of Imaging, Medical College of Soochow University, Suzhou, 215000, Jiangsu Province, China
| | - X-M Wang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215000, Jiangsu, China.
| | - Q Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Soochow, 215000, Jiangsu, China.
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4
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Mishra NK, Leigh R, Campbell BCV. Editorial: Intracranial Bleeding After Reperfusion Therapy in Acute Ischemic Stroke. Front Neurol 2021; 12:745993. [PMID: 34531820 PMCID: PMC8438163 DOI: 10.3389/fneur.2021.745993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 07/23/2021] [Indexed: 01/19/2023] Open
Affiliation(s)
- Nishant K Mishra
- Department of Neurology, Division of Stroke and Vascular Neurology, Yale University, New Haven, CT, United States
| | - Richard Leigh
- Department of Neurology, Johns Hopkins University, Baltimore, MD, United States
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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5
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Li C, Hao X, Lin L, Sun C, Yu H, Yao Z, Feng X, Yang Y. Prognostic Value of a New Integrated Parameter-Both Collateral Circulation and Permeability Surface-in Hemorrhagic Transformation of Middle Cerebral Artery Occlusion Acute Ischemic Stroke: Retrospective Cohort Study. Front Aging Neurosci 2021; 13:703734. [PMID: 34512306 PMCID: PMC8424095 DOI: 10.3389/fnagi.2021.703734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/26/2021] [Indexed: 12/03/2022] Open
Abstract
Background Multimodal CT, including CT angiography (CTA) and CT perfusion (CTP), was increasingly used in stroke triage. This study was to determine the relationship between a new integrated parameter—both collateral circulation and relative permeability surface (PS)—and the hemorrhagic transformation (HT) in acute ischemic stroke (AIS) with middle cerebral artery occlusion (MCAO). Methods We retrospectively reviewed consecutive AIS patients with MCAO who underwent baseline CTA/CTP within 4 h of symptom onset and follow-up susceptibility-weighted imaging (SWI) within 3 weeks. Collateral circulation was assessed on the baseline CTA. Baseline CTP data were postprocessed to generate PS parameter. The patients with poor collateral circulation and at the same time with high relative PS were classified as the group of both poor collateral circulation and high relative PS. HT was defined according to European Cooperative Acute Stroke Study II criteria on follow-up SWI imaging. Multivariate logistic regression analysis was performed using HT as an outcome variable. Results The group of patients with both poor collateral circulation and high relative PS was thirteen and thirty-three (52%) developed HT of the final cohort sixty-three AIS patients with MCAO. Multivariate logistic analysis revealed the new integrated parameter—both collateral circulation and relative PS (odds ratio, 16.59; 95% confidence interval, 13.09–19.10; P < 0.001) was independent predictor of HT. The area under the curve was 0.85 (95% confidence interval, 0.81–0.89). The sensitivity was 57%, specificity 97% and positive predictive value 92%, negative predictive value 58%. Conclusions For AIS patients with MCAO, these with poor collateral circulation on CTA and at the same time with high relative PS on CTP were at high risk for HT.
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Affiliation(s)
- Chanchan Li
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaozhu Hao
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Luyi Lin
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chengfeng Sun
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hai Yu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhenwei Yao
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoyuan Feng
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yanmei Yang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
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6
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Ande SR, Grynspan J, Aviv RI, Shankar JJS. Imaging for Predicting Hemorrhagic Transformation of Acute Ischemic Stroke-A Narrative Review. Can Assoc Radiol J 2021; 73:194-202. [PMID: 34154379 DOI: 10.1177/08465371211018369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hemorrhagic transformation is caused by extravasation of blood products from vessels after acute ischemic stroke. It is an undesirable and potentially devastating complication, which occurs in 10%-40% of clinical cases. Hemorrhagic transformation is classified into four subtypes based on European cooperative acute stroke study II. Predicting hemorrhagic complications at presentation can be useful life saving/altering decisions for the patient. Also, understanding the mechanisms of hemorrhagic transformation can lead to new treatments and intervention measures. We highlighted various imaging techniques that have been used to predict hemorrhagic transformation. Specifically, we looked at the usefulness of perfusion and permeability imaging for hemorrhagic transformation. Use of imaging to predict hemorrhagic transformation could change patient management that may lead to the prevention of hemorrhagic transformation before it occurs. We concluded that the current evidence is not strong enough to rely on these imaging parameters for predicting hemorrhagic transformation and more studies are required.
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Affiliation(s)
- Sudharsana Rao Ande
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jonathan Grynspan
- Department of Radiology, Prairie Skies Medical Imaging, Regina, Saskatchewan, Canada
| | - Richard I Aviv
- Department of Radiology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Jai Jai Shiva Shankar
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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7
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Wang Y, He S, Liu X, Li Z, Zhu L, Xiao G, Du X, Du H, Zhang W, Zhang Y, Orgah J, Feng Y, Zhang B, Zhu Y. Galectin-3 Mediated Inflammatory Response Contributes to Neurological Recovery by QiShenYiQi in Subacute Stroke Model. Front Pharmacol 2021; 12:588587. [PMID: 33953667 PMCID: PMC8089377 DOI: 10.3389/fphar.2021.588587] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 01/29/2021] [Indexed: 11/13/2022] Open
Abstract
Effective therapies for stroke are still limited due to its complex pathological manifestations. QiShenYiQi (QSYQ), a component-based Chinese medicine capable of reducing organ injury caused by ischemia/reperfusion, may offer an alternative option for stroke treatment and post-stroke recovery. Recently, we reported a beneficial effect of QSYQ for acute stroke via modulation of the neuroinflammatory response. However, if QSYQ plays a role in subacute stroke remains unknown. The pharmacological action of QSYQ was investigated in experimental stroke rats which underwent 90 min ischemia and 8 days reperfusion in this study. Neurological and locomotive deficits, cerebral infarction, brain edema, and BBB integrity were assessed. TMT-based quantitative proteomics were performed to identify differentially expressed proteins following QSYQ treatment. Immunohistochemistry, western blot analysis, RT-qPCR, and ELISA were used to validate the proteomics data and to reveal the action mechanisms. Therapeutically, treatment with QSYQ (600 mg/kg) for 7 days significantly improved neurological recovery, attenuated infarct volume and brain edema, and alleviated BBB breakdown in the stroke rats. Bioinformatics analysis indicated that protein galectin-3 and its mediated inflammatory response was closely related to the beneficial effect of QSYQ. Specially, QSYQ (600 mg/kg) markedly downregulated the mRNA and protein expression levels of galectin-3, TNF-α, and IL-6 in CI/RI brain as well as serum levels of TNF-α and IL-6. Overall, our findings showed that the effective action of QSYQ against the subacute phase of CI/RI occurs partly via regulating galectin-3 mediated inflammatory reaction.
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Affiliation(s)
- Yule Wang
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology and Medicine, Tianjin, China.,Pharmaceutical Informatics Institute, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Shuang He
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology and Medicine, Tianjin, China
| | - Xinyan Liu
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology and Medicine, Tianjin, China
| | - Zhixiong Li
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology and Medicine, Tianjin, China
| | - Lin Zhu
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology and Medicine, Tianjin, China
| | - Guangxu Xiao
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology and Medicine, Tianjin, China
| | - Xiaoli Du
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology and Medicine, Tianjin, China.,Inner Mongolia Medical University, Jinshan Economic and Technological Development District, Inner Mongolia, China
| | - Hongxia Du
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology and Medicine, Tianjin, China
| | - Wen Zhang
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,State Key Laboratory of Core Technology in Innovative Chinese Medicine, Beijing, China
| | - Yiqian Zhang
- State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tianjin Tasly Holding Group Co., Ltd., Tianjin, China
| | - John Orgah
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology and Medicine, Tianjin, China
| | - Yuxin Feng
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology and Medicine, Tianjin, China
| | - Boli Zhang
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yan Zhu
- State Key Laboratory of Component-based Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Research and Development Center of TCM, Tianjin International Joint Academy of Biotechnology and Medicine, Tianjin, China
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8
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Hemorrhagic stroke lesion segmentation using a 3D U-Net with squeeze-and-excitation blocks. Comput Med Imaging Graph 2021; 90:101908. [PMID: 33901919 DOI: 10.1016/j.compmedimag.2021.101908] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 11/22/2022]
Abstract
Hemorrhagic stroke is the condition involving the rupture of a vessel inside the brain and is characterized by high mortality rates. Even if the patient survives, stroke can cause temporary or permanent disability depending on how long blood flow has been interrupted. Therefore, it is crucial to act fast to prevent irreversible damage. In this work, a deep learning-based approach to automatically segment hemorrhagic stroke lesions in CT scans is proposed. Our approach is based on a 3D U-Net architecture which incorporates the recently proposed squeeze-and-excitation blocks. Moreover, a restrictive patch sampling is proposed to alleviate the class imbalance problem and also to deal with the issue of intra-ventricular hemorrhage, which has not been considered as a stroke lesion in our study. Moreover, we also analyzed the effect of patch size, the use of different modalities, data augmentation and the incorporation of different loss functions on the segmentation results. All analyses have been performed using a five fold cross-validation strategy on a clinical dataset composed of 76 cases. Obtained results demonstrate that the introduction of squeeze-and-excitation blocks, together with the restrictive patch sampling and symmetric modality augmentation, significantly improved the obtained results, achieving a mean DSC of 0.86±0.074, showing promising automated segmentation results.
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9
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Arba F, Rinaldi C, Caimano D, Vit F, Busto G, Fainardi E. Blood-Brain Barrier Disruption and Hemorrhagic Transformation in Acute Ischemic Stroke: Systematic Review and Meta-Analysis. Front Neurol 2021; 11:594613. [PMID: 33551955 PMCID: PMC7859439 DOI: 10.3389/fneur.2020.594613] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/07/2020] [Indexed: 01/17/2023] Open
Abstract
Introduction: Hemorrhagic transformation (HT) is a complication of reperfusion therapy for acute ischemic stroke. Blood–brain barrier (BBB) disruption is a crucial step toward HT; however, in clinical studies, there is still uncertainty about this relation. Hence, we conducted a systematic review and meta-analysis to summarize the current evidence. Methods: We performed systematic review and meta-analysis of observational studies from January 1990 to March 2020 about the relation between BBB disruption and HT in patients with acute ischemic stroke with both computed tomography (CT) and magnetic resonance (MR) assessment of BBB. The outcome of interest was HT at follow-up imaging evaluation (within 48 h from symptom onset). We pooled data from available univariate odds ratios (ORs) in random-effects models with DerSimonian–Laird weights and extracted cumulative ORs. Results: We included 30 eligible studies (14 with CT and 16 with MR), N = 2,609 patients, with 88% and 70% of patients included in CT and MR studies treated with acute stroke therapy, respectively. The majority of studies were retrospective and had high or unclear risk of bias. BBB disruption was measured with consistent methodology in CT studies, whereas in MR studies, there was more variability. All CT studies provided a BBB disruption cutoff predictive of HT. Four CT and 10 MR studies were included in the quantitative analysis. We found that BBB disruption was associated with HT with both CT (OR = 3.42; 95%CI = 1.62–7.23) and MR (OR = 9.34; 95%CI = 3.16–27.59). There was a likely publication bias particularly for MR studies. Conclusion: Our results confirm that BBB disruption is associated with HT in both CT and MR studies. Compared with MR, CT has been more uniformly applied in the literature and has resulted in more consistent results. However, more efforts are needed for harmonization of protocols and methodology for implementation of BBB disruption as a neuroradiological marker in clinical practice.
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Affiliation(s)
| | - Chiara Rinaldi
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Danilo Caimano
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Federica Vit
- NEUROFARBA Department, University of Florence, Florence, Italy
| | | | - Enrico Fainardi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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10
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Bernardo-Castro S, Sousa JA, Brás A, Cecília C, Rodrigues B, Almendra L, Machado C, Santo G, Silva F, Ferreira L, Santana I, Sargento-Freitas J. Pathophysiology of Blood-Brain Barrier Permeability Throughout the Different Stages of Ischemic Stroke and Its Implication on Hemorrhagic Transformation and Recovery. Front Neurol 2020; 11:594672. [PMID: 33362697 PMCID: PMC7756029 DOI: 10.3389/fneur.2020.594672] [Citation(s) in RCA: 176] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/09/2020] [Indexed: 12/25/2022] Open
Abstract
The blood–brain barrier (BBB) is a dynamic interface responsible for maintaining the central nervous system homeostasis. Its unique characteristics allow protecting the brain from unwanted compounds, but its impairment is involved in a vast number of pathological conditions. Disruption of the BBB and increase in its permeability are key in the development of several neurological diseases and have been extensively studied in stroke. Ischemic stroke is the most prevalent type of stroke and is characterized by a myriad of pathological events triggered by an arterial occlusion that can eventually lead to fatal outcomes such as hemorrhagic transformation (HT). BBB permeability seems to follow a multiphasic pattern throughout the different stroke stages that have been associated with distinct biological substrates. In the hyperacute stage, sudden hypoxia damages the BBB, leading to cytotoxic edema and increased permeability; in the acute stage, the neuroinflammatory response aggravates the BBB injury, leading to higher permeability and a consequent risk of HT that can be motivated by reperfusion therapy; in the subacute stage (1–3 weeks), repair mechanisms take place, especially neoangiogenesis. Immature vessels show leaky BBB, but this permeability has been associated with improved clinical recovery. In the chronic stage (>6 weeks), an increase of BBB restoration factors leads the barrier to start decreasing its permeability. Nonetheless, permeability will persist to some degree several weeks after injury. Understanding the mechanisms behind BBB dysregulation and HT pathophysiology could potentially help guide acute stroke care decisions and the development of new therapeutic targets; however, effective translation into clinical practice is still lacking. In this review, we will address the different pathological and physiological repair mechanisms involved in BBB permeability through the different stages of ischemic stroke and their role in the development of HT and stroke recovery.
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Affiliation(s)
| | - João André Sousa
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ana Brás
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carla Cecília
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Bruno Rodrigues
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Luciano Almendra
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cristina Machado
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Gustavo Santo
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Fernando Silva
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Lino Ferreira
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Isabel Santana
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - João Sargento-Freitas
- Stroke Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
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11
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Pan XW, Wang MJ, Gong SS, Sun MH, Wang Y, Zhang YY, Li F, Yu BY, Kou JP. YiQiFuMai Lyophilized Injection ameliorates tPA-induced hemorrhagic transformation by inhibiting cytoskeletal rearrangement associated with ROCK1 and NF-κB signaling pathways. JOURNAL OF ETHNOPHARMACOLOGY 2020; 262:113161. [PMID: 32730882 DOI: 10.1016/j.jep.2020.113161] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/29/2020] [Accepted: 07/02/2020] [Indexed: 06/11/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Thrombolytic therapy with tissue plasminogen activator (tPA) after ischemic stroke exacerbates blood-brain barrier (BBB) breakdown and leads to hemorrhagic transformation (HT). YiQiFuMai Lyophilized Injection (YQFM) is a modern preparation derived from Sheng-mai San (a traditional Chinese medicine). YQFM attenuates the BBB dysfunction induced by cerebral ischemia-reperfusion injury. However, whether YQFM can suppress tPA-induced HT remains unknown. AIM OF THE STUDY We investigated the therapeutic effect of YQFM on tPA-induced HT and explored the underlying mechanisms in vivo and in vitro to improve the safety of tPA use against stroke. METHODS Male C57BL/6J mice were subjected to 45 min of ischemia and 24 h of reperfusion. tPA (10 mg/kg) were infused 2 h after occlusion and YQFM (0.671 g/kg) was injected 2.5 h after occlusion. The in vitro effect of YQFM (100, 200, 400 μg/mL) on tPA (60 μg/mL)-induced dysfunction of the microvascular endothelial barrier in the brain following oxygen-glucose deprivation/reoxygenation (OGD/R) was observed in bEnd.3 cells. RESULTS YQFM suppressed tPA-induced high hemoglobin level in the brain, mortality, neurologic severity score, BBB permeability, expression and activation of matrix metalloproteinase (MMP)-9 and MMP-2, and degradation of tight-junction proteins. Furthermore, YQFM significantly blocked tPA-induced brain microvascular endothelial permeability and phosphorylation of Rho-associated kinase (ROCK)1, myosin light chain (MLC), cofilin and p65 in vivo and in vitro. CONCLUSION YQFM suppressed tPA-induced HT by inhibiting cytoskeletal rearrangement linked with ROCK-cofilin/MLC pathways and inhibiting the nuclear factor-kappa B pathway to ameliorate BBB damage caused by tPA.
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Affiliation(s)
- Xue-Wei Pan
- Jiangsu Key Laboratory of TCM Evaluation and Translational Research, Department of Pharmacology of Chinese Material Medica, School of Traditional Chinese Pharmacy, China Pharmaceutical University, 639 Longmian Road, Nanjing, 211198, PR China.
| | - Mei-Juan Wang
- Jiangsu Key Laboratory of TCM Evaluation and Translational Research, Department of Pharmacology of Chinese Material Medica, School of Traditional Chinese Pharmacy, China Pharmaceutical University, 639 Longmian Road, Nanjing, 211198, PR China.
| | - Shuai-Shuai Gong
- Jiangsu Key Laboratory of TCM Evaluation and Translational Research, Department of Pharmacology of Chinese Material Medica, School of Traditional Chinese Pharmacy, China Pharmaceutical University, 639 Longmian Road, Nanjing, 211198, PR China.
| | - Min-Hui Sun
- Jiangsu Key Laboratory of TCM Evaluation and Translational Research, Department of Pharmacology of Chinese Material Medica, School of Traditional Chinese Pharmacy, China Pharmaceutical University, 639 Longmian Road, Nanjing, 211198, PR China.
| | - Yan Wang
- Departments of Neurology, University of California, Davis, School of Medicine and Shriners Hospital, Sacramento, CA, 95817, USA.
| | - Yuan-Yuan Zhang
- Jiangsu Key Laboratory of TCM Evaluation and Translational Research, Department of Pharmacology of Chinese Material Medica, School of Traditional Chinese Pharmacy, China Pharmaceutical University, 639 Longmian Road, Nanjing, 211198, PR China.
| | - Fang Li
- Jiangsu Key Laboratory of TCM Evaluation and Translational Research, Department of Pharmacology of Chinese Material Medica, School of Traditional Chinese Pharmacy, China Pharmaceutical University, 639 Longmian Road, Nanjing, 211198, PR China.
| | - Bo-Yang Yu
- Jiangsu Key Laboratory of TCM Evaluation and Translational Research, Department of Pharmacology of Chinese Material Medica, School of Traditional Chinese Pharmacy, China Pharmaceutical University, 639 Longmian Road, Nanjing, 211198, PR China.
| | - Jun-Ping Kou
- Jiangsu Key Laboratory of TCM Evaluation and Translational Research, Department of Pharmacology of Chinese Material Medica, School of Traditional Chinese Pharmacy, China Pharmaceutical University, 639 Longmian Road, Nanjing, 211198, PR China.
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Yuan T, Chen N, Jin H, Yin H. Increased microvascular permeability and low level of low-density lipoprotein cholesterol predict symptomatic intracerebral hemorrhage in acute ischemic stroke. Sci Prog 2020; 103:36850420924153. [PMID: 32491955 PMCID: PMC10451923 DOI: 10.1177/0036850420924153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Symptomatic intracerebral hemorrhage is a serious potential complication of recombinant tissue-type plasminogen activator thrombolysis in acute ischemic stroke. We investigated the optimal imaging and clinical parameters to predict symptomatic intracerebral hemorrhage in acute ischemic stroke patients after recombinant tissue-type plasminogen activator therapy. We retrospectively reviewed 151 acute ischemic stroke patients with thrombolytic therapy, who were dichotomized into symptomatic intracerebral hemorrhage group and non-symptomatic intracerebral hemorrhage group. They underwent multimodal computed tomography, including the measurement of permeability surface. We compared the clinical and radiological characteristics between symptomatic intracerebral hemorrhage group and non-symptomatic intracerebral hemorrhage group, using univariate analysis. Receiver operating characteristic analysis and multivariate logistic regression analyses were then used to determine symptomatic intracerebral hemorrhage predictors. Of 151 patients, 14 patients (9.27%) developed symptomatic intracerebral hemorrhage on follow-up imaging. Relative permeability surface (infarct permeability surface/contralateral normal permeability surface) (p < 0.05) and baseline low-density lipoprotein cholesterol level (p < 0.05) were both predictors of symptomatic intracerebral hemorrhage. Receiver operating characteristic analysis of relative permeability surface revealed an optimal relative permeability surface threshold of 2.239, with an area under the curve of 0.87 (95% confidence interval, 0.732-1.0). The relative permeability surface was 2.239, the sensitivity for symptomatic intracerebral hemorrhage was 85.7%, the specificity was 94.9%, the positive predictive value was 70.6%, and the negative predictive value was 95.5%. For low-density lipoprotein cholesterol, the optimal threshold was 2.45, with an area under the curve of 0.726 (95% confidence interval, 0.586-0.867), the sensitivity for symptomatic intracerebral hemorrhage was 73.0%, the specificity was 64.3%, the positive predictive value was 67.16%, and the negative predictive value was 79.09%. Our study demonstrated that increased infarct permeability surface and low level of low-density lipoprotein cholesterol can be two predictors of symptomatic intracerebral hemorrhage. Detection of relative permeability surface and low-density lipoprotein cholesterol may help clinicians to identify acute ischemic stroke patients with the higher risk of symptomatic intracerebral hemorrhage; intravenous thrombolytic therapy should be carefully performed for patients with high relative permeability surface and low low-density lipoprotein cholesterol. We may take relative permeability surface and low-density lipoprotein cholesterol into account to refine therapeutic decision-making in acute ischemic stroke.
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Affiliation(s)
- Tingting Yuan
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Naifei Chen
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Hang Jin
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Hongmei Yin
- Department of General Internal Medicine, The First Hospital of Jilin University, Changchun, China
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Suh CH, Jung SC, Cho SJ, Kim D, Lee JB, Woo DC, Oh WY, Lee JG, Kim KW. Perfusion CT for prediction of hemorrhagic transformation in acute ischemic stroke: a systematic review and meta-analysis. Eur Radiol 2019; 29:4077-4087. [PMID: 30617485 DOI: 10.1007/s00330-018-5936-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/13/2018] [Accepted: 11/29/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To investigate the diagnostic performance of perfusion CT for prediction of hemorrhagic transformation in acute ischemic stroke. METHODS A computerized literature search of Ovid MEDLINE and EMBASE was conducted up to October 29, 2018. Search terms included acute ischemic stroke, hemorrhagic transformation, and perfusion CT. Studies assessing the diagnostic performance of perfusion CT for prediction of hemorrhagic transformation in acute ischemic stroke were included. Two reviewers independently evaluated the eligibility of the studies. A bivariate random effects model was used to calculate the pooled sensitivity and pooled specificity. Multiple subgroup analyses were performed. RESULTS Fifteen original articles with a total of 1134 patients were included. High blood-brain barrier permeability and hypoperfusion status derived from perfusion CT are associated with hemorrhagic transformation. The pooled sensitivity and specificity were 84% (95% CI, 71-91%) and 74% (95% CI, 67-81%), respectively. The area under the hierarchical summary receiver operating characteristic curve was 0.84 (95% CI, 0.81-0.87). The Higgins I2 statistic demonstrated that heterogeneity was present in the sensitivity (I2 = 80.21%) and specificity (I2 = 85.94%). CONCLUSION Although various perfusion CT parameters have been used across studies, the current evidence supports the use of perfusion CT to predict hemorrhagic transformation in acute ischemic stroke. KEY POINTS • High blood-brain barrier permeability and hypoperfusion status derived from perfusion CT were associated with hemorrhagic transformation. • Perfusion CT has moderate diagnostic performance for the prediction of hemorrhagic transformation in acute ischemic stroke. • The pooled sensitivity was 84%, and the pooled specificity was 74%.
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Affiliation(s)
- Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Seung Chai Jung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
| | - Se Jin Cho
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Donghyun Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jung Bin Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Dong-Cheol Woo
- Bioimaging Center, Biomedical Research Center, Asan Institute for Life Sciences, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Woo Yong Oh
- Clinical Research Division, National Institute of Food and Drug Safety Evaluation, MFDS, Cheongju, Republic of Korea
| | - Jong Gu Lee
- Clinical Research Division, National Institute of Food and Drug Safety Evaluation, MFDS, Cheongju, Republic of Korea
| | - Kyung Won Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.,Asan Image Metrics, Clinical Trial Center, Asan Institute for Life Sciences, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
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Abstract
The most feared complication after acute ischemic stroke is symptomatic or asymptomatic hemorrhagic conversion. Neuroimaging and clinical criteria are used to predict development of hemorrhage. Seizures after acute ischemic stroke or stroke-like symptoms from seizures are not common but may lead to confusion in the peristroke period, especially if seizures are repetitive or evolve into status epilepticus, which could affect neuroimaging findings. Malignant infarction develops when cytotoxic edema is large enough to lead to herniation and death. Post-stroke neuroimaging prognosticators have been described and should be assessed early so that appropriate treatment is offered before herniation leads to additional tissue injury.
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