The Efficacy and Safety of Ischemic Stroke Therapies: An Umbrella Review

Investigation of the Impact Factors and Efficacy of N-Butylphthalide (NBP) on Functional Outcomes Following Mechanical Thrombectomy in Stroke Patients

Background

Ischemic stroke was a major cause of mortality and disability worldwide. Mechanical thrombectomy (MT) has improved acute ischemic stroke treatment by restoring blood flow in large vessel occlusions. Yet, reperfusion injury remains a challenge, necessitating adjunctive neuroprotective strategies to enhance recovery. N-butylphthalide (NBP), with its anti-inflammatory and antioxidative properties, may improve functional outcomes post-MT.

Methods

This retrospective study analyzed 120 ischemic stroke patients treated with MT at a single institution from December 2020 to December 2022. Patients were divided into a routine care group (n = 56) and an NBP treatment group (n = 64). Baseline characteristics, comorbidities, and biochemical profiles were assessed. Functional outcomes were measured by the modified Rankin Scale (mRS) at 90 days. Statistical analysis included correlation and logistic regression to identify factors influencing recovery.

Results

Among the NBP group, a significantly higher percentage achieved favorable mRS scores (0-2) compared to the routine care group (62.50% vs 37.50%, P = 0.006). Smoking (OR 0.320, P = 0.021), diabetes (OR 0.246, P = 0.022), and elevated hs-CRP levels (OR 0.407, P = 0.004) were identified as negative predictors of functional recovery. Conversely, NBP treatment significantly improved outcomes (OR 3.248, P = 0.008).

Conclusion

The study supports the potential of NBP as an effective adjunctive therapy in improving recovery following MT in ischemic stroke patients. Modifiable factors such as smoking and diabetes, along with elevated hs-CRP, negatively influence outcomes, highlighting the importance of comprehensive management.

Advancements in the treatment of cerebral ischemia-reperfusion injury: Acupuncture combined with mesenchymal stem cells transplantation

Cerebral ischemia-reperfusion injury (CIRI) constitutes a significant etiology of exacerbated cerebral tissue damage subsequent to intravenous thrombolysis and endovascular mechanical thrombectomy in patients diagnosed with acute ischemic stroke. The treatment of CIRI has been extensively investigated through a multitude of clinical studies. Acupuncture has been demonstrated to be effective in treating CIRI. Recent 5 years studies have identified potential mechanisms of acupuncture, including regulation of autophagy, promotion of angiogenesis, inhibition of inflammation and apoptosis, modulation of cell activation, neuroplasticity regulation, and promotion of nerve regeneration. The transplantation of mesenchymal stem cells (MSCs) can effectively suppress apoptosis, modulate immune responses, and enhance the proliferation and migration of endogenous neural stem cells (NSCs), thereby compensating for the NSCs deficiency following cerebral ischemia/reperfusion injury. The combination of acupuncture and MSCs transplantation demonstrates superiority over individual treatments, significantly enhancing the survival rate of MSCs. Moreover, it facilitates the secretion of various cytokines to promote their homing and differentiation into functional neurons, thereby providing a novel approach for clinical treatment of CIRI.

The D-Dimer/Albumin Ratio as a Novel Biomarker for Predicting the Efficacy of Oral Tirofiban in Patients with Cerebral Infarction

Objective: The efficacy of oral tirofiban in patients with cerebral infarction varies. This study aims to identify novel biomarkers that can predict the efficacy of oral tirofiban in these patients. Materials and methods: A total of 300 patients diagnosed with cerebral infarction via neurosurgery at our hospital from January 2021 to January 2023 were enrolled in this study. Detailed information on their medical history and clinical characteristics was collected, and all the patients were followed up for 90 days. The modified Rankin scale (mRS) and the National Institutes of Health Stroke Scale (NIHSS) were used to evaluate the efficacy of tirofiban. The modified Heidelberg bleeding classification was applied to classify symptomatic intracranial hemorrhage within 48 h after treatment. Results: At 90-days of follow-up, patients with higher mRS scores (Group I) compared to those in lower mRS scores (Group II) exhibited significantly higher levels of platelet count (Group I: 118.55 ± 8.89 10*9/L, Group II: 253.11 ± 13.87 10*9/L, P < .001), neutrophil counts (Group I: 3.38 ± 1.21 10*9/L, Group II: 3.36 ± 1.55 10*9/L, P = .001), D-dimer (Group I: 0.26 ± 0.17 mg/L, Group II: 0.31 ± 0.15 mg/L, P = .007), systemic immune-inflammation index (SII) (Group I: 199.87 ± 103.73, Group II: 258.82 ± 116.67, P < .001), and D-dimer/albumin ratio (DAR) (Group I: 118.55 ± 8.89 10*9 /L, Group II: 253.11 ± 13.87 10*9/L, P < .001). The levels of DAR (OR: 1.047, 95% CIs: 1.032-1.061, P < .001), SII (OR: 1.004, 95% CIs: 1.002-1.007, P < .001), and D-dimer (OR: 8.827, 95% CIs: 1.695-45.984, P = .010) were identified as independent factors affecting the efficacy of tirofiban, showing predictive and diagnostic value in assessing treatment response. Conclusion: Laboratory markers, including DAR, SII and D-dimer, are effective diagnostic indicators for predicting the efficacy of tirofiban in patients with cerebral infarction. These markers provide valuable insight for clinicians in selecting treatment plans, thereby reducing the economic burden for patients with cerebral infarction.

Neuroprotective and vasoprotective effects of herb pair of Zhiqiao-Danggui in ischemic stroke uncovered by LC-MS/MS-based metabolomics approach

Ischemic stroke is the most important cause of disability and death worldwide, but current treatments remain limited. Traditional Chinese medicine (TCM) including the herb pair of Zhiqiao-Danggui (ZD) offers a multifaceted treatment approach through promoting blood circulation, yet its specific anti-ischemic mechanism remains unclear. This study used the photochemically induced thrombosis (PIT) mouse model and the oxygen glucose deprivation/reoxygenation (OGD/R) cell model to explore the therapeutic effect of ZD on ischemic stroke. Mice were treated with high and low doses of ZD extract or positive control. Behavior was assessed using the grid test. The brain tissue was then subjected to infarct volume assessment, histopathology, oxidative stress marker detection, LC/MS metabolomic analysis and qRT-PCR validation. The therapeutic effect of ZD-medicated serum on OGD/R model was tested on cells. Experimental results show that ZD can improve motor function, reduce infarct size, neuronal damage and apoptosis as well as alleviate oxidative stress in mice. ZD-medicated serum promotes endothelial cell proliferation, improves cell survival against OGD/R-induced injury, reduces oxidative damage and protects mitochondrial function. Metabolomics reveals ZD regulation of metabolites in energy metabolism, amino acid metabolism, TCA cycle, and angiogenesis signaling pathways. qRT-PCR results also showed that ZD could attenuate abnormal conduction of angiogenic signals and enhance vessel stability. This study confirmed the neuroprotective and vasoprotective effects of ZD, highlighted its potential in treating ischemic stroke, and provided a scientific basis for the traditional use of ZD.

Causal relationship between hypertension and ischemic stroke: A two-sample Mendelian randomization study

BACKGROUND

Ischemic stroke (IS) is a well-recognized risk factor for human health and has become a major cause of the global burden of disease over the past decades. Determining the correlation between hypertension and IS is important for the prevention of IS. In epidemiologic studies, researches have reported a strong association between hypertension and IS. However, there is a great deal of heterogeneity between these findings, and the strength of the two associations shows very different results in international studies. Here, we used genetic data to methodically assess the association between hypertension and the risk of IS using a Mendelian randomization (MR) framework. This study may provide a more comprehensive theoretical basis for the link between hypertension and IS.

METHODS

We studied three hypertension traits including essential hypertension, gestational hypertension, and preexisting hypertension, in a two-sample MR method. Genetic susceptibility to each type of hypertension was explored for the association with the risk of small-vessel IS in data from the IEU-POENGWAS.

RESULTS

We observed a strong association between essential hypertension with small-vessel IS. Our evidence from data-driven analyses further suggests that genetic susceptibility to gestational hypertension and preexisting hypertension are associated with the development of small-vessel IS. However, in multivariate analyses, these associations would be explained by congenital hypertension.

CONCLUSIONS

Through our study, we further validated that hypertension is an individual risk factor for IS, with the risk of small-vessel IS increasing approximately 6-fold for every one standard deviation increase in essential hypertension.

Acupuncture for ischemic stroke: where are we now?

Acupuncture is an effective treatment for ischemic stroke (IS) and plays a key role in neurological rehabilitation after IS. Acupuncture can improve the clinical symptoms of various complications after IS, including motor dysfunction, swallowing disorders, speech disorders, cognitive impairment, depression, insomnia, and fatigue. However, the mechanisms underlying the effects of acupuncture in IS remain unclear. Available evidence suggests that acupuncture may exert neuroprotective effects through neuroplasticity (neurogenesis and synaptogenesis), angiogenesis, cell proliferation and apoptosis, and regulation of oxidative stress, inflammation, and immunity. Further studies should be conducted to improve the high-quality evidence-based system of acupuncture intervention for IS, by focusing on the clinical and basic research design, increasing the sample size, standardizing and quantifying the standards of acupuncture operations, using multidisciplinary techniques and methods to systematically explore the key targets of acupuncture intervention for IS, and reveal the efficacy and mechanism of acupuncture in the treatment of IS.

Can the combination of antiplatelet or alteplase thrombolytic therapy with argatroban benefit patients suffering from acute stroke? a systematic review, meta-analysis, and meta-regression

BACKGROUND

The effectiveness of administering argatroban as a treatment approach following antiplatelet therapy or alteplase thrombolytic therapy in patients with acute stroke is presently uncertain. However, it is important to highlight the potential benefits of combining this medication with known thrombolytics or antiplatelet therapy. One notable advantage of argatroban is its short half-life, which helps minimize excessive anticoagulation and risk of bleeding complications in inadvertent cases of hemorrhagic stroke. By conducting a meticulous review and meta-analysis, we aim to further explore the common use of argatroban and examine the plausible advantages of combining this medication with established thrombolytic and antiplatelet therapies.

METHOD

In this study, we performed a rigorous and methodical search for both randomized controlled trials and retrospective analyses. Our main objective was to analyze the impact of argatroban on the occurrence of hemorrhagic events and the mRS scores of 0-2. We utilized a meta-analysis to assess the relative risk (RR) associated with using argatroban versus not using it.

RESULTS

In this study, we analyzed data from 11 different studies, encompassing a total of 8,635 patients. Out of these patients, 3999(46.3%) received argatroban treatment while the remaining 4636(53.7%)did not. The primary outcome of 90-day functional independence (modified Rankin scale (mRS) score≤2) showed that the risk ratio (RR) for patients using argatroban after alteplase thrombolytic therapy compared to those not using argatroban was(RR, 1.00 ([95% CI, 0.92-1.09]; P = 0.97), indicating no statistical significance. However, for patients using argatroban after antiplatelet therapy, was (RR,1.09 [95% CI, 1.04-1.14]; P = 0.0001), which was statistically significant. In terms of hemorrhagic events, the RR for patients using argatroban compared to those not using argatroban was (RR,1.08 [95% CI, 0.88-1.33]; P = 0.46), indicating no statistical significance.

CONCLUSION

The results of this study suggest that further research into combination therapy with argatroban and antiplatelet agents may be warranted, however more rigorous RCTs are needed to definitively evaluate the effects of combination treatment.

Effect of Acupuncture vs Sham Acupuncture on Patients With Poststroke Motor Aphasia: A Randomized Clinical Trial

Importance

Motor aphasia is common among patients with stroke. Acupuncture is recommended as an alternative therapy for poststroke aphasia, but its efficacy remains uncertain.

Objective

To investigate the effects of acupuncture on language function, neurological function, and quality of life in patients with poststroke motor aphasia.

Design, Setting, and Participants

This multicenter, sham-controlled, randomized clinical trial was conducted in 3 tertiary hospitals in China from October 21, 2019, to November 13, 2021. Adult patients with poststroke motor aphasia were enrolled. Data analysis was performed from February to April 2023.

Interventions

Eligible participants were randomly allocated (1:1) to manual acupuncture (MA) or sham acupuncture (SA) groups. Both groups underwent language training and conventional treatments.

Main Outcomes and Measures

The primary outcomes were the aphasia quotient (AQ) of the Western Aphasia Battery (WAB) and scores on the Chinese Functional Communication Profile (CFCP) at 6 weeks. Secondary outcomes included WAB subitems, Boston Diagnostic Aphasia Examination, National Institutes of Health Stroke Scale, Stroke-Specific Quality of Life Scale, Stroke and Aphasia Quality of Life Scale-39, and Health Scale of Traditional Chinese Medicine scores at 6 weeks and 6 months after onset. All statistical analyses were performed according to the intention-to-treat principle.

Results

Among 252 randomized patients (198 men [78.6%]; mean [SD] age, 60.7 [7.5] years), 231 were included in the modified intention-to-treat analysis (115 in the MA group and 116 in the SA group). Compared with the SA group, the MA group had significant increases in AQ (difference, 7.99 points; 95% CI, 3.42-12.55 points; P = .001) and CFCP (difference, 23.51 points; 95% CI, 11.10-35.93 points; P < .001) scores at week 6 and showed significant improvements in AQ (difference, 10.34; 95% CI, 5.75-14.93; P < .001) and CFCP (difference, 27.43; 95% CI, 14.75-40.10; P < .001) scores at the end of follow-up.

Conclusions and Relevance

In this randomized clinical trial, patients with poststroke motor aphasia who received 6 weeks of MA compared with those who received SA demonstrated statistically significant improvements in language function, quality of life, and neurological impairment from week 6 of treatment to the end of follow-up at 6 months after onset.

Trial Registration

Chinese Clinical Trial Registry: ChiCTR1900026740.

The role of JAK/STAT signaling pathway in cerebral ischemia-reperfusion injury and the therapeutic effect of traditional Chinese medicine: A narrative review

Cerebral ischemia is a cerebrovascular disease with symptoms caused by insufficient blood or oxygen supply to the brain. When blood supplied is restored after cerebral ischemia, secondary brain injury may occur, which is called cerebral ischemia-reperfusion injury (CIRI). In this process, the Janus kinase/signal transducer and activator of transcription (JAK/STAT) signaling pathway plays an important role. It mediates neuroinflammation and participates in the regulation of physiological activities, such as cell proliferation, differentiation, and apoptosis. After CIRI, M1 microglia is activated and recruited by the damaged tissue. The inflammatory factors are produced by M1 microglia through the JAK/STAT pathway, eventually leading to cell apoptosis. Meanwhile, the JAK2/STAT3 signaling pathway and the expression of lipocalin-2 and caspase-3 could increase. In the pathway, phosphorylated JAK2 and phosphorylated STAT3 function of 2 ways. They not only promote the proliferation of neurons, but also affect the differentiation direction of neural stem cells by further acting on the Notch signaling pathway. Recently, traditional Chinese medicine (TCM) is a key player in CIRI, through JAK2, STAT3, STAT1 and their phosphorylation. Therefore, the review focuses on the JAK/STAT signaling pathway and its relationship with CIRI as well as the influence of the TCM on this pathway. It is aimed at providing the basis for future clinical research on the molecular mechanism of TCM in the treatment of CIRI.

Novel PD-L1-Targeted Phenyl-Pyrazolone Derivatives with Antioxidant Properties

Orally-active anticancer small molecules targeting the PD-1/PD-L1 immune checkpoint are actively searched. Phenyl-pyrazolone derivatives with a high affinity for PD-L1 have been designed and characterized. In addition, the phenyl-pyrazolone unit acts as a scavenger of oxygen free radicals, providing antioxidant effects. The mechanism is known for the drug edaravone (1) which is also an aldehyde-reactive molecule. The present study reports the synthesis and functional characterization of new molecules (2-5) with an improved anti-PD-L1 activity. The leading fluorinated molecule 5 emerges as a potent checkpoint inhibitor, avidly binding to PD-L1, inducing its dimerization, blocking PD-1/PD-L1 signaling mediated by phosphatase SHP-2 and reactivating the proliferation of CTLL-2 cells in the presence of PD-L1. In parallel, the compound maintains a significant antioxidant activity, characterized using electron paramagnetic resonance (EPR)-based free radical scavenging assays with the probes DPPH and DMPO. The aldehyde reactivity of the molecules was investigated using 4-hydroxynonenal (4-HNE), which is a major lipid peroxidation product. The formation of drug-HNE adducts, monitored by high resolution mass spectrometry (HRMS), was clearly identified and compared for each compound. The study leads to the selection of compound 5 and the dichlorophenyl-pyrazolone unit as a scaffold for the design of small molecule PD-L1 inhibitors endowed with antioxidant properties.

Co-administration of Nanowired DL-3-n-Butylphthalide (DL-NBP) Together with Mesenchymal Stem Cells, Monoclonal Antibodies to Alpha Synuclein and TDP-43 (TAR DNA-Binding Protein 43) Enhance Superior Neuroprotection in Parkinson's Disease Following Concussive Head Injury

dl-3-n-butylphthalide (dl-NBP) is one of the potent antioxidant compounds that induces profound neuroprotection in stroke and traumatic brain injury. Our previous studies show that dl-NBP reduces brain pathology in Parkinson's disease (PD) following its nanowired delivery together with mesenchymal stem cells (MSCs) exacerbated by concussive head injury (CHI). CHI alone elevates alpha synuclein (ASNC) in brain or cerebrospinal fluid (CSF) associated with elevated TAR DNA-binding protein 43 (TDP-43). TDP-43 protein is also responsible for the pathologies of PD. Thus, it is likely that exacerbation of brain pathology in PD following brain injury may be thwarted using nanowired delivery of monoclonal antibodies (mAb) to ASNC and/or TDP-43. In this review, the co-administration of dl-NBP with MSCs and mAb to ASNC and/or TDP-43 using nanowired delivery in PD and CHI-induced brain pathology is discussed based on our own investigations. Our observations show that co-administration of TiO2 nanowired dl-NBP with MSCs and mAb to ASNC with TDP-43 induced superior neuroprotection in CHI induced exacerbation of brain pathology in PD, not reported earlier.

Efficacy and safety of blood-activating herbs combined with edaravone in the treatment of acute ischemic stroke: A protocol for systematic review and meta-analysis

BACKGROUND

Although the combination of blood-activating herbs and western drugs has shown advantages in the treatment of ischemic stroke, there is no consensus on the safety and efficacy. This study aimed to systematically evaluate the safety and efficacy of the combination of blood-activating herbs with edaravone (EDA) in the treatment of acute ischemic stroke (AIS).

METHODS

We will implement the search strategy in 8 English and Chinese databases: Cochrane Central Register of Controlled Trials, Web of Science, PubMed, China National Knowledge Infrastructure, China Science and Technology Journal Database, Wanfang Database, EMBASE and MEDLINE. The search included relevant clinical randomized controlled trials and quasi-randomized controlled trials that had been registered for publication by November 2022. Literature screening, data extraction and quality assessment will be performed by 2 authors. We will assess the risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method classification will be used to assess the quality of the literature. Meta-analysis was performed using RevMan V.5.4 and STATA 16 software.

RESULTS

This study will provide a comprehensive analysis of the current clinical evidence on the application of blood-activating herbs combined with EDA in the treatment of AIS.

CONCLUSION

This study will clarify the safety and efficacy of the combination of blood-activating herbs with EDA in the treatment of AIS.