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The Assessment of Endovascular Therapies in Ischemic Stroke: Management, Problems and Future Approaches. J Clin Med 2022; 11:jcm11071864. [PMID: 35407472 PMCID: PMC8999747 DOI: 10.3390/jcm11071864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/18/2022] [Accepted: 03/25/2022] [Indexed: 02/06/2023] Open
Abstract
Ischemic stroke accounts for over 80% of all strokes and is one of the leading causes of mortality and permanent disability worldwide. Intravenous administration of recombinant tissue plasminogen activator (rt-PA) is an approved treatment strategy for acute ischemic stroke of large arteries within 4.5 h of onset, and mechanical thrombectomy can be used for large arteries occlusion up to 24 h after onset. Improving diagnostic work up for acute treatment, reducing onset-to-needle time and urgent radiological access angiographic CT images (angioCT) and Magnetic Resonance Imaging (MRI) are real problems for many healthcare systems, which limits the number of patients with good prognosis in real world compared to the results of randomized controlled trials. The applied endovascular procedures demonstrated high efficacy, but some cellular mechanisms, following reperfusion, are still unknown. Changes in the morphology and function of mitochondria associated with reperfusion and ischemia-reperfusion neuronal death are still understudied research fields. Moreover, future research is needed to elucidate the relationship between continuously refined imaging techniques and the variable structure or physical properties of the clot along with vascular permeability and the pleiotropism of ischemic reperfusion lesions in the penumbra, in order to define targeted preventive procedures promoting long-term health benefits.
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Brown GC. Neuronal Loss after Stroke Due to Microglial Phagocytosis of Stressed Neurons. Int J Mol Sci 2021; 22:13442. [PMID: 34948237 PMCID: PMC8707068 DOI: 10.3390/ijms222413442] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/09/2021] [Accepted: 12/10/2021] [Indexed: 11/17/2022] Open
Abstract
After stroke, there is a rapid necrosis of all cells in the infarct, followed by a delayed loss of neurons both in brain areas surrounding the infarct, known as 'selective neuronal loss', and in brain areas remote from, but connected to, the infarct, known as 'secondary neurodegeneration'. Here we review evidence indicating that this delayed loss of neurons after stroke is mediated by the microglial phagocytosis of stressed neurons. After a stroke, neurons are stressed by ongoing ischemia, excitotoxicity and/or inflammation and are known to: (i) release "find-me" signals such as ATP, (ii) expose "eat-me" signals such as phosphatidylserine, and (iii) bind to opsonins, such as complement components C1q and C3b, inducing microglia to phagocytose such neurons. Blocking these factors on neurons, or their phagocytic receptors on microglia, can prevent delayed neuronal loss and behavioral deficits in rodent models of ischemic stroke. Phagocytic receptors on microglia may be attractive treatment targets to prevent delayed neuronal loss after stroke due to the microglial phagocytosis of stressed neurons.
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Affiliation(s)
- Guy C Brown
- Department of Biochemistry, University of Cambridge, Cambridge CB2 1QW, UK
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Goyal M, Ospel JM, Menon B, Almekhlafi M, Jayaraman M, Fiehler J, Psychogios M, Chapot R, van der Lugt A, Liu J, Yang P, Agid R, Hacke W, Walker M, Fischer U, Asdaghi N, McTaggart R, Srivastava P, Nogueira RG, Moret J, Saver JL, Hill MD, Dippel D, Fisher M. Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging. Stroke 2020; 51:3147-3155. [DOI: 10.1161/strokeaha.120.030620] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular treatment is a highly effective therapy for acute ischemic stroke due to large vessel occlusion and has recently revolutionized stroke care. Oftentimes, ischemic core extent on baseline imaging is used to determine endovascular treatment-eligibility. There are, however, 3 fundamental issues with the core concept: First, computed tomography and magnetic resonance imaging, which are mostly used in the acute stroke setting, are not able to precisely determine whether and to what extent brain tissue is infarcted (core) or still viable, due to variability in tissue vulnerability, the phenomenon of selective neuronal loss and lack of a reliable gold standard. Second, treatment decision-making in acute stroke is multifactorial, and as such, the relative importance of single variables, including imaging factors, is reduced. Third, there are often discrepancies between core volume and clinical outcome. This review will address the uncertainty in terminology and proposes a direction towards more clarity. This theoretical exercise needs empirical data that clarify the definitions further and prove its value.
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Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Department of Radiology, University of Calgary, Canada. (M.G., B.M., M.A., M.D.H.)
| | - Johanna M. Ospel
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O., M.P.)
| | - Bijoy Menon
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Department of Radiology, University of Calgary, Canada. (M.G., B.M., M.A., M.D.H.)
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Department of Radiology, University of Calgary, Canada. (M.G., B.M., M.A., M.D.H.)
| | - Mahesh Jayaraman
- Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (M.J., R.M.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (J.F.)
| | - Marios Psychogios
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O., M.P.)
| | - Rene Chapot
- Department of Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany (R.C.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands (A.v.d.L.)
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China (J.L.)
| | - Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China (P.Y.)
| | - Ronit Agid
- Department of Medical Imaging, University of Toronto, Canada (R.A.)
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, Germany (W.H.)
| | - Melanie Walker
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle (M.W.)
| | - Urs Fischer
- Department of Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Switzerland (U.F.)
| | - Negar Asdaghi
- Department of Neurology, University of Miami Miller School of Medicine (N.A.)
| | - Ryan McTaggart
- Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (M.J., R.M.)
| | - Padma Srivastava
- Department of Neurology, All India Institute of Medicine, New Delhi, India (P.S.)
| | - Raul G. Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta (R.G.N.)
| | - Jacques Moret
- The Brain Vascular Center, Baujon University Hospital, Paris, France (J.M.)
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Michael D. Hill
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Department of Radiology, University of Calgary, Canada. (M.G., B.M., M.A., M.D.H.)
| | - Diederik Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands (D.D.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.F.)
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