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Sarraj A, Campbell BCV. Does Reperfusion Benefit Patients Without Perfusion Mismatch? Stroke 2024; 55:1326-1328. [PMID: 38572633 DOI: 10.1161/strokeaha.124.046989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Affiliation(s)
- Amrou Sarraj
- Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, OH (A.S.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, VIC, Australia (B.C.V.C.)
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Angelucci F, Veverova K, Katonová A, Vyhnalek M, Hort J. Plasminogen activator inhibitor-1 serum levels in frontotemporal lobar degeneration. J Cell Mol Med 2024; 28:e18013. [PMID: 38386354 PMCID: PMC10902304 DOI: 10.1111/jcmm.18013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/25/2023] [Accepted: 10/17/2023] [Indexed: 02/23/2024] Open
Abstract
Plasminogen activator inhibitor-1 (PAI-1) impedes brain plasmin synthesis. Reduced plasmin activity facilitates cumulation of amyloid beta (Aβ) in Alzheimer's disease (AD). Since plasmin also regulates the synaptic activity, it is possible that altered PAI-1 is present in other neurodegenerative disorders. We investigated whether PAI-1 and its counter-regulatory tissue plasminogen activator (tPA) are altered in serum of patients with dementia due to frontotemporal lobar degeneration (FTLD). Thirty five FTLD patients (21 in mild cognitive impairment stage (MCI) and 14 in dementia stage) and 10 cognitively healthy controls were recruited. Serum tPA and PAI-1 protein levels were measured by anova. Correlation between biochemical and demographic data were explored by measuring Pearson correlation coefficient. Serum PAI-1 levels were elevated in the FTLD dementia group as compared to FTLD MCI and controls. tPA serum levels and PAI-1/tPA ratio did not significantly differ among groups. There was a negative correlation between PAI-1 serum levels and disease severity measured by MMSE score. No correlations of tPA serum levels and PAI-1/tPA ratio with MMSE were found. Increased PAI-1 serum levels may serve as a marker of dementia in FTLD, suggesting that, besides Aβ pathway, the plasmin system may affect cognition through synaptic activity.
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Affiliation(s)
- Francesco Angelucci
- Memory ClinicDepartment of NeurologySecond Faculty of MedicineCharles University and Motol University HospitalPragueCzech Republic
- International Clinical Research CentreSt. Anne's University HospitalBrnoCzech Republic
| | - Katerina Veverova
- Memory ClinicDepartment of NeurologySecond Faculty of MedicineCharles University and Motol University HospitalPragueCzech Republic
| | - Alžbeta Katonová
- Memory ClinicDepartment of NeurologySecond Faculty of MedicineCharles University and Motol University HospitalPragueCzech Republic
| | - Martin Vyhnalek
- Memory ClinicDepartment of NeurologySecond Faculty of MedicineCharles University and Motol University HospitalPragueCzech Republic
| | - Jakub Hort
- Memory ClinicDepartment of NeurologySecond Faculty of MedicineCharles University and Motol University HospitalPragueCzech Republic
- International Clinical Research CentreSt. Anne's University HospitalBrnoCzech Republic
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Li S, Wang X, Jin A, Liu G, Gu H, Li H, Campbell BCV, Fisher M, Yang Y, Wei Y, Wang J, Wang Y, Zhao X, Liu L, Li Z, Meng X, Wang Y. Safety and Efficacy of Reteplase Versus Alteplase for Acute Ischemic Stroke: A Phase 2 Randomized Controlled Trial. Stroke 2024; 55:366-375. [PMID: 38152962 DOI: 10.1161/strokeaha.123.045193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/05/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Reteplase is a more affordable new-generation thrombolytic with a prolonged half-life. We aimed to determine the safety dose range of reteplase for patients with acute ischemic stroke within 4.5 hours of onset. METHODS This is a multicenter, prospective, randomized controlled, open-label, blinded-end point phase 2 clinical trial. Patients with acute ischemic stroke aged between 18 and 80 years who were eligible for standard intravenous thrombolysis were enrolled from 17 centers in China and randomly assigned (1:1:1) to receive intravenous reteplase 12+12 mg, intravenous reteplase 18+18 mg, or intravenous alteplase 0.9 mg/kg. The primary safety outcome was symptomatic intracranial hemorrhage (SITS definition) within 36 hours. The primary efficacy outcome was the proportion of patients with the National Institutes of Health Stroke Scale score of no more than 1 or a decrease of at least 4 points from the baseline at 14 days after thrombolysis. RESULTS Between August 2019 and May 2021, 180 patients were randomly assigned to reteplase 12+12 mg (n=61), reteplase 18+18 mg (n=67), or alteplase (n=52). Four patients did not receive the study agent. Symptomatic intracranial hemorrhage occurred in 3 of 60 (5.0%) in the reteplase 12+12 mg group, 1 of 66 (1.5%) in the reteplase 18+18 mg group, and 1 of 50 (2.0%) in the alteplase group (P=0.53). The primary efficacy outcome in the modified intention-to-treat population occurred in 45 of 60 (75.0%) in the reteplase 12+12 mg group (odds ratio, 0.85 [95% CI, 0.35-2.06]), 48 of 66 (72.7%) in the reteplase 18+18 mg group (odds ratio, 0.75 [95% CI, 0.32-1.78]), and 39 of 50 (78.0%) in alteplase group. CONCLUSIONS Reteplase was well tolerated in patients with acute ischemic stroke within 4.5 hours of onset in China with a similar efficacy profile to alteplase. The efficacy and appropriate dosage of reteplase for patients with acute ischemic stroke need prospective validation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04028518.
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Affiliation(s)
- Shuya Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Xuechun Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Aoming Jin
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Gaifen Liu
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Hongqiu Gu
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Hao Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, VIC, Australia (B.C.V.C.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | - Yi Yang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China (Y.Y.)
| | - Yan Wei
- Department of Neurology, Halison International Peace Hospital of Hengshui City, China (Y.W.)
| | - Junhai Wang
- Department of Neurology, Sinopharm Tongmei General Hospital, Datong, China (J.W.)
| | - Yilong Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Xingquan Zhao
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Liping Liu
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Zixiao Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Xia Meng
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Yongjun Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
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Tsuchida T, Hayakawa M, Kumano O. Characterization and Usefulness of Clot-Fibrinolysis Waveform Analysis in Critical Care Patients with Enhanced or Suppressed Fibrinolysis. Thromb Haemost 2024; 124:40-48. [PMID: 37527783 PMCID: PMC10783976 DOI: 10.1055/a-2145-7139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Recently, clot-fibrinolysis waveform analysis (CFWA), which is a coagulation and fibrinolysis global assay based on assessing the activated partial thromboplastin time with tissue-type plasminogen activator, was developed. This study aimed to investigate the characteristics of CFWA using plasma samples from patients in the critical care unit. MATERIALS AND METHODS The fibrinolysis times using CFWA were measured in 298 plasma samples. These samples were divided into three groups based on the reference interval (RI) of fibrinolysis time using CFWA: shortened group, less than RI; within group, within RI; prolonged group, more than RI. The coagulation and fibrinolysis markers, including D-dimer, plasmin-α2 plasmin inhibitor complex (PIC), fibrin monomer complex (FMC), plasmin-α2 plasmin inhibitor (α2-PI), plasminogen (Plg), and fibrinogen (Fbg) were analyzed and compared among the three groups. RESULTS The FMC level decreased in the order of shortened, within, and prolonged groups, and the decrease was statistically significant among all three group pairs. The opposite tendency was observed for Fbg and fibrinolysis-related markers of α2-PI and Plg, and significant differences were recognized in all pair comparisons except for between within and prolonged groups in Plg. The mean values of the fibrinolysis markers D-dimer and PIC in all three groups were higher than the cut-off values, and the PIC value differed significantly between the within and prolonged groups. CONCLUSION The fibrinolysis reaction was detected in all three groups, but the status differed. CFWA has the potential to reflect the fibrinolysis status in one global assay.
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Affiliation(s)
- Takumi Tsuchida
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Mineji Hayakawa
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Osamu Kumano
- Sysmex Corporation, Kobe, Japan
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Takamatsu, Japan
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Dragoș D, Manea MM, Dobri AM, Stoican IC, Enache II, Ghenu MI, Tuta S. Risk factors for the outcome after thrombolysis in acute ischemic stroke - the prominent role of kidney dysfunction: A retrospective cohort observational study. Medicine (Baltimore) 2023; 102:e35688. [PMID: 37904370 PMCID: PMC10615531 DOI: 10.1097/md.0000000000035688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 09/27/2023] [Indexed: 11/01/2023] Open
Abstract
A complex interplay of factors reflecting the general biological, cardiovascular, neurological, renal, and metabolic status of patients influences the outcome of thrombolysis in stroke patients. This is a retrospective cohort observational study aimed to determine the importance of kidney dysfunction among these factors. Data (demographic, lifestyle, physical examination, laboratory, imaging, including metabolic and cardiovascular risk factors and comorbidities, neurological scores, and outcomes) of all stroke patients who underwent thrombolysis have been registered since January 1, 2016, in an online database. A total of 296 patients registered until December 31, 2020, were included in the study. The National Institutes of Health Stroke Scale, modified Rankin scale, Barthel index, percentage of hemorrhagic transformation, and in hospital death were used to evaluate the neurological status and outcomes of the patients. Regression analysis, Mann-Whitney test, Fisher exact test, logistic regression, and multivariate analysis were used for statistical analysis. Kidney dysfunction, as reflected by the estimated glomerular filtration rate, was associated with in hospital death and all but one of the neurological scores. Other risk factors most frequently associated with neurological scores were age, international normalized ratio, and cognitive decline. Multivariate analysis revealed estimated glomerular filtration rate (as determined by chronic kidney disease-EPI equation) as a determinant for all but one of these scores, and as the most important determinant for most of them, except for those reflecting the pre-intervention neurological status of the patient. Kidney dysfunction seems to be the most important determinant of the outcome of thrombolysed stroke patients, a result obtained by no other study.
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Affiliation(s)
- Dorin Dragoș
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- 1st Internal Medicine Department, Emergency University Hospital, Bucharest, Romania
| | - Maria Mirabela Manea
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania
| | - Ana-Maria Dobri
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania
| | - Iulia-Cosmina Stoican
- Neurology Department, National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania
| | - Iulia-Ioana Enache
- Neurology Department, National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania
| | - Maria Iuliana Ghenu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- 1st Internal Medicine Department, Emergency University Hospital, Bucharest, Romania
| | - Sorin Tuta
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Neurology Department, National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania
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Abstract
Intravenous thrombolysis via tPA (tissue-type plasminogen activator) is the only approved pharmacological treatment for acute ischemic stroke, but its benefits are limited by hemorrhagic transformation. Emerging evidence reveals that tPA swiftly mobilizes immune cells which extravasate into the brain parenchyma via the cerebral vasculature, augmenting neurovascular inflammation, and tissue injury. In this review, we summarize the pronounced alterations of immune cells induced by tPA in patients with stroke and experimental stroke models. We argue that neuroinflammation, triggered by ischemia-induced cell death and exacerbated by tPA, compromises neurovascular integrity and the microcirculation, leading to hemorrhagic transformation. Finally, we discuss current and future approaches to attenuate thrombolysis-associated hemorrhagic transformation via uncoupling immune cells from the neurovascular unit.
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Affiliation(s)
- Qiang Liu
- Department of Neurology, Tianjin Medical University General Hospital, China (Q.L., F.-D.S.)
| | - Kaibin Shi
- Department of Neurology, National Clinical Research Center for Neurological Diseases of China, Beijing Tiantan Hospital, Capital Medical University (K.S., Y.W., F.-D.S.)
| | - Yongjun Wang
- Department of Neurology, National Clinical Research Center for Neurological Diseases of China, Beijing Tiantan Hospital, Capital Medical University (K.S., Y.W., F.-D.S.)
| | - Fu-Dong Shi
- Department of Neurology, Tianjin Medical University General Hospital, China (Q.L., F.-D.S.)
- Department of Neurology, National Clinical Research Center for Neurological Diseases of China, Beijing Tiantan Hospital, Capital Medical University (K.S., Y.W., F.-D.S.)
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Buus SMØ, Schmitz ML, Cordsen P, Paaske Johnsen S, Andersen G, Simonsen CZ. Socioeconomic Inequalities in Functional Outcome After Reperfusion-Treated Ischemic Stroke. Stroke 2023; 54:2040-2049. [PMID: 37377030 DOI: 10.1161/strokeaha.123.043547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND We aimed to investigate whether socioeconomic status (SES) was associated with functional outcome in patients with ischemic stroke treated with reperfusion therapy (intravenous thrombolysis and/or thrombectomy). METHODS This nationwide cohort study included reperfusion-treated patients with ischemic stroke ≥18 years registered in the Danish Stroke Registry between 2015 and 2018. Functional outcome was determined by the modified Rankin Scale score 90 days after stroke. SES was defined by educational attainment, family income, and employment status before stroke. SES data were available from Statistics Denmark and linked on the individual level with data from the Danish Stroke Registry. Uni- and multivariable ordinal logistic regression was performed for each socioeconomic parameter individually (education, income, and employment) to estimate the common odds ratios (cORs) for lower 90-day modified Rankin Scale scores. RESULTS A total of 5666 patients were included. Mean age was 68.7 years (95% CI, 68.3-69.0), and 38.4% were female. Low SES was associated with lower odds for achieving lower 90-day modified Rankin Scale score: Low versus high education, cOR, 0.69 (95% CI, 0.61-0.79), low versus high income, cOR, 0.59 (95% CI, 0.53-0.67), and unemployed versus employed, cOR, 0.70 (95% CI, 0.58-0.83). Inequalities were reduced after adjusting for age, sex, and immigrant status, except for unemployed versus employed patients, adjusted cOR, 0.66 (95% CI, 0.54-0.80). No statistically significant differences remained after adjusting for potentially mediating variables (eg, stroke severity, prestroke modified Rankin Scale, and smoking). CONCLUSIONS Socioeconomic inequalities were observed in functional outcome after reperfusion treated ischemic stroke. In particular, prestroke unemployment was negatively associated with good functional outcome. A more adverse prognostic profile among patients with low SES appeared to explain the majority of these inequalities.
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Affiliation(s)
- Sine Mette Øgendahl Buus
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark (S.M.Ø.B., M.L.S., G.A., C.Z.S.)
| | - Marie Louise Schmitz
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark (S.M.Ø.B., M.L.S., G.A., C.Z.S.)
| | - Pia Cordsen
- Danish Center for Health Services Research, Aalborg University, Gistrup, Denmark (P.C., S.P.J.)
| | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Aalborg University, Gistrup, Denmark (P.C., S.P.J.)
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark (S.M.Ø.B., M.L.S., G.A., C.Z.S.)
- Department of Clinical Medicine, Aarhus University, Denmark (G.A., C.Z.S.)
| | - Claus Ziegler Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark (S.M.Ø.B., M.L.S., G.A., C.Z.S.)
- Department of Clinical Medicine, Aarhus University, Denmark (G.A., C.Z.S.)
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Di Gioia S, Milillo L, Hossain MN, Carbone A, Petruzzi M, Conese M. Blood Clotting Dissolution in the Presence of a Magnetic Field and Preliminary Study with MG63 Osteoblast-like Cells-Further Developments for Guided Bone Regeneration? Bioengineering (Basel) 2023; 10:888. [PMID: 37627773 PMCID: PMC10451701 DOI: 10.3390/bioengineering10080888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND The influence of a magnetic field on the activation of bone cells and remodelling of alveolar bone is known to incite bone regeneration. Guided Bone Regeneration (GBR) aims to develop biomimetic scaffolds to allow for the functioning of the barrier and the precise succession of wound healing steps, including haemostasis. The effect of a magnetic field on blood clot dissolution has not been studied yet. METHODS We conducted a methodological study on the clot stability in the presence of a static magnetic field (SMF). Preformed whole blood (WB) clots were treated with either a broad proteolytic enzyme (trypsin) or a specific fibrinolytic agent, i.e., tissue-type plasminogen activator (t-PA). MG63 osteoblast-like cells were added to preformed WB clots to assess cell proliferation. RESULTS After having experienced a number of clotting and dissolution protocols, we obtained clot stability exerted by SMF when tissue factor (for clotting) and t-PA + plasminogen (for fibrinolysis) were used. WB clots allowed osteoblast-like cells to survive and proliferate, however no obvious effects of the magnetic field were noted. CONCLUSIONS Paramagnetic properties of erythrocytes may have influenced the reduction in clot dissolution. Future studies are warranted to fully exploit the combination of magnetic forces, WB clot and cells in GBR applied to orthodontics and prosthodontics.
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Affiliation(s)
- Sante Di Gioia
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy; (S.D.G.); (M.N.H.); (A.C.)
| | | | - Md Niamat Hossain
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy; (S.D.G.); (M.N.H.); (A.C.)
| | - Annalucia Carbone
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy; (S.D.G.); (M.N.H.); (A.C.)
| | - Massimo Petruzzi
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70126 Bari, Italy;
| | - Massimo Conese
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy; (S.D.G.); (M.N.H.); (A.C.)
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Gunner CB, Azmoon P, Mantuano E, Das L, Zampieri C, Pizzo SV, Gonias SL. An antibody that targets cell-surface glucose-regulated protein-78 inhibits expression of inflammatory cytokines and plasminogen activator inhibitors by macrophages. J Cell Biochem 2023; 124:743-752. [PMID: 36947703 DOI: 10.1002/jcb.30401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/02/2023] [Accepted: 03/12/2023] [Indexed: 03/24/2023]
Abstract
Glucose-regulated protein-78 (Grp78) is an endoplasmic reticulum chaperone, which is secreted by cells and associates with cell surfaces, where it functions as a receptor for activated α2 -macroglobulin (α2 M) and tissue-type plasminogen activator (tPA). In macrophages, α2 M and tPA also bind to the transmembrane receptor, LDL receptor-related protein-1 (LRP1), activating a cell-signaling receptor assembly that includes the NMDA receptor (NMDA-R) to suppress innate immunity. Herein, we demonstrate that an antibody targeting Grp78 (N88) inhibits NFκB activation and expression of proinflammatory cytokines in bone marrow-derived macrophages (BMDMs) treated with the toll-like receptor-4 (TLR4) ligand, lipopolysaccharide, or with agonists that activate TLR2, TLR7, or TLR9. Pharmacologic inhibition of the NMDA-R or deletion of the gene encoding LRP1 (Lrp1) in BMDMs neutralizes the activity of N88. The fibrinolysis protease inhibitor, plasminogen activator inhibitor-1 (PAI1), has been implicated in diverse diseases including metabolic syndrome, cardiovascular disease, and type 2 diabetes. Deletion of Lrp1 independently increased expression of PAI1 and PAI2 in BMDMs, as did treatment of wild-type BMDMs with TLR agonists. tPA, α2 M, and N88 inhibited expression of PAI1 and PAI2 in BMDMs treated with TLR-activating agents. Inhibiting Src family kinases blocked the ability of both N88 and tPA to function as anti-inflammatory agents, suggesting that the cell-signaling pathway activated by tPA and N88, downstream of LRP1 and the NMDA-R, may be equivalent. We conclude that targeting cell-surface Grp78 may be effective in suppressing innate immunity by a mechanism that requires LRP1 and the NMDA-R.
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Affiliation(s)
- Cory B Gunner
- Department of Pathology, University of San Diego California School of Medicine, La Jolla, California, USA
| | - Pardis Azmoon
- Department of Pathology, University of San Diego California School of Medicine, La Jolla, California, USA
| | - Elisabetta Mantuano
- Department of Pathology, University of San Diego California School of Medicine, La Jolla, California, USA
| | - Lipsa Das
- Department of Cellular and Molecular Medicine, University of Arizona Cancer Center, Tucson, Arizona, USA
| | - Carlotta Zampieri
- Department of Pathology, University of San Diego California School of Medicine, La Jolla, California, USA
| | - Salvatore V Pizzo
- Department of Pathology, Duke University Medical Center, Durham, North Carolina, USA
| | - Steven L Gonias
- Department of Pathology, University of San Diego California School of Medicine, La Jolla, California, USA
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10
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Xu Y, Chen D, Liu P, Hu Y, Peng S, Chen S, Li Y, Lin W, Jiang L, Yuan C, Huang M. A triple fusion tissue-type plasminogen activator (TriF-ΔtPA) enhanced thrombolysis in carotid embolism-induced stroke model. Int J Pharm 2023; 637:122878. [PMID: 36958614 DOI: 10.1016/j.ijpharm.2023.122878] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/06/2023] [Accepted: 03/18/2023] [Indexed: 03/25/2023]
Abstract
Recombinant tissue-type plasminogen activator (rtPA) is the first approved thrombolytic agent in acute ischemic stroke, but suffers from a short half-life and poor resistance to plasminogen activator inhibitor (PAI-1), limiting its clinical use. Thus, the development of novel thrombolytic agents with improved benefit/risk balance has always been of great significance. In this study, We identified a serine protease domain of tPA mutant (named ΔtPAA146V) capable of escaping the inhibition by endogenous PAI-1 with 66-fold increased resistance compared to the wild type. Based on this mutant, we generated a triple fusion ΔtPA (TriF-ΔtPA), including albumin and fibrin binding peptide(FBP). The fusion with albumin effectively prolonged the plasma half-life of ΔtPA in mice to 144 minutes, which is much longer than ΔtPA and did not affect its thrombolytic activity. Furthermore, FBP rendered fibrin specificity of the fusion protein, giving a KD of ∼25 ± 0.9 μM. In a novel murine carotid embolism-induced stroke (CES) model, i.v. administration of TriF-ΔtPA promoted vascular recanalization, reduced infarct volume, and mitigated neurobehavioral deficits more significantly compared to ΔtPA-HSA or Alteplase, showing little bleeding risk. Together, this long-acting PAI-1-resistant thrombolytic agent holds great potential for clinical applications.
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Affiliation(s)
- Yanyan Xu
- College of Chemical Engineering, Fuzhou University, Fujian 350108, China
| | - Dan Chen
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Peiwen Liu
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Yinping Hu
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Shuangzhou Peng
- School of Pharmaceutical Sciences, Fujian Provincial Key Laboratory of Innovative Drug Target Research, Xiamen University, Xiamen, Fujian 361102, China
| | - Shanli Chen
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Yongkun Li
- Department of Neurology, Fujian Provincial Hospital, Shengli Clinical College of Fujian Medical University, No. 134 Dong Street, Fuzhou, Fujian 350001, P. R. China
| | - Wei Lin
- Fujian Institute of integrated traditional Chinese and Western Medicine, Fujian University of Traditional Chinese Medicine, Minhou District, Fuzhou, Fujian, 350122 P. R. China
| | - Longguang Jiang
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China
| | - Cai Yuan
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian, 350108, China; Fujian Key Laboratory of Marine Enzyme Engineering, Fuzhou University, Fuzhou, Fujian, 350108, China.
| | - Mingdong Huang
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, China.
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11
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Marulanda E, Bustillo A, Gutierrez CM, Rose DZ, Jameson A, Gardener H, Alkhachroum A, Zhou L, Ying H, Dong C, Foster D, Hanel R, Mehta B, Mokin M, Mueller-Kronast N, Landreth M, Sand C, Romano JG, Rundek T, Asdaghi N, Sacco RL. Nationally Certified Stroke Centers Outperform Self-Attested Stroke Centers in the Florida Stroke Registry. Stroke 2023; 54:840-847. [PMID: 36655557 DOI: 10.1161/strokeaha.122.038869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Florida Stroke Act, signed into law in 2004, set criteria for Comprehensive Stroke Centers (CSC). For a set time period, Florida hospitals were permitted to either receive national certification (NC) or could self-attest (SA) as fulfilling CSC criteria. The aim of this project was to evaluate the quality of ischemic stroke care in NC versus SA stroke centers in Florida, using well-known, guideline-driven ischemic stroke outcome metrics. METHODS A total of 37 CSCs (74% of Florida CSCs) in the Florida Stroke Registry from January 2013 through December 2018 were analyzed, including 19 SA CSCs and 18 NC (13 CSCs and 5 Thrombectomy-Capable Stroke Center). Hospital- and patient-level characteristics and stroke metrics were evaluated, adjusting for demographics, medical comorbidities, and stroke severity. RESULTS A total of 78 424 acute ischemic stroke cases, 36 089 from SA CSCs and 42 335 from NC CSC/Thrombectomy-Capable Stroke Centers were analyzed. NC centers had older patients (73 [61-83] versus 71 [60-81]; P<0.001) with more severe strokes (median National Institutes of Health Stroke Scale score of 5 versus 4; P<0.001). NC had higher intravenous tissue-type plasminogen activator utilization (15% versus 13%; P<0.001), endovascular treatment (10% versus 7%; P<0.001) and faster median door-to-computed tomography (23 minutes [11-73] versus 31 [12-78]; P<0.001), door-to-needle (37 minutes [26-50] versus 45 [34-58]; P<0.001) and door-to-puncture times (77 minutes [50-113] versus 93 [62-140]; P<0.001). In adjusted analysis, patients arriving to NC hospitals by 3 hours were more likely to get intravenous tissue-type plasminogen activator in the 3- to 4.5-hour window (adjusted odds ratio, 1.87 [95% CI, 1.30-2.68]; P=0.001) and more likely to be treated with intravenous tissue-type plasminogen activator within 45 minutes (adjusted odds ratio, 1.61 [95% CI, 1.04-2.50]; P=0.04) compared with SA CSCs. CONCLUSIONS Among Florida-Stroke Registry CSCs, acute ischemic stroke performance and treatment measures at NC centers are superior to SA CSCs. These findings have implications for stroke systems of care in Florida and support legislation updates requiring NC and removal of SA claims.
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Affiliation(s)
- Erika Marulanda
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Antonio Bustillo
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Carolina M Gutierrez
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - David Z Rose
- University of South Florida Morsani College of Medicine, Tampa (D.Z.R., A.J., M.M.)
| | - Angus Jameson
- University of South Florida Morsani College of Medicine, Tampa (D.Z.R., A.J., M.M.)
| | - Hannah Gardener
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Ayham Alkhachroum
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Lili Zhou
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Hao Ying
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Chuanhui Dong
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | | | - Ricardo Hanel
- Baptist Neurological Institute, Jacksonville, FL (R.H.)
| | - Brijesh Mehta
- Memorial Neuroscience Institute, Hollywood, FL (B.M.)
| | - Maxim Mokin
- University of South Florida Morsani College of Medicine, Tampa (D.Z.R., A.J., M.M.)
| | | | | | - Charles Sand
- St Joseph's Hospital Medical Center, Tampa, FL (C.S.)
| | - Jose G Romano
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Tatjana Rundek
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Negar Asdaghi
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
| | - Ralph L Sacco
- Department of Neurology, University of Miami, FL (E.M., A.B., C.M.G., H.G., A.A., L.Z., H.Y., C.D., J.G.R., T.R., N.A., R.L.S.)
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12
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Abstract
Recanalization therapy with endovascular procedures has led to significant advances in the treatment of acute ischemic stroke. Animal models have been the basis for enhancing the development of novel treatments and therapeutic modalities. However, previous translational failures led to an increasing consensus that large animals should be included to bridge the gap between rodent and human studies. In the era of large vessel recanalization, large animal ischemic stroke models should be optimized for preclinical and translational stroke studies. Here we highlight recent progress of reproducing ischemic and reperfusion mechanisms in large animal models of stroke through surgical and endovascular methods. The importance of optimizing large animal stroke modeling is suggested by evaluating new findings from clinical trials and preclinical experiments using large animals, such as adopting advanced imaging analysis and long-term functional evaluation. Furthermore, we also acknowledge the importance of adhering to the Stroke Treatment and Academic Roundtable recommendations and the "3 R" principles to improve the quality and validity of large animal experiments. Large animal models offer many translational benefits; however, more work is still needed to enhance studies using large animal model on acute ischemic stroke in the era of recanalization.
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Affiliation(s)
- Shen Li
- Department of Neurology and Psychiatry, Beijing Shijitan Hospital, Capital Medical University, China and Beijing Institute of Brain Disorders, Capital Medical University, China (S.L.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
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13
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Miwa K, Koga M, Jensen M, Inoue M, Yoshimura S, Fukuda-Doi M, Boutitie F, Ma H, Ringleb PA, Wu O, Schwamm LH, Warach S, Hacke W, Davis SM, Donnan GA, Gerloff C, Thomalla G, Toyoda K. Alteplase for Stroke With Unknown Onset Time in Chronic Kidney Disease: A Pooled Analysis of Individual Participant Data. Stroke 2022; 53:3295-3303. [PMID: 35997023 DOI: 10.1161/strokeaha.122.039086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although chronic kidney disease (CKD) is associated with worse stroke outcomes, data regarding the influence of CKD on intravenous thrombolysis outcomes are scarce. We sought to assess the efficacy and safety of intravenous thrombolysis for acute ischemic stroke with unknown onset time in patients with CKD. METHODS Patients with an acute stroke of unknown onset time from the EOS trials (Evaluation of Unknown Onset Stroke Thrombolysis) collaboration were evaluated using an individual patient-level database of randomized controlled trials comparing intravenous thrombolysis with placebo/standard treatment. CKD was defined as baseline estimated glomerular filtration rate of <60 ml/min/1.73m2 Mixed-effect logistic-regression analysis was performed to evaluate treatment effects. A favorable outcome was defined as a modified Rankin Scale score of 0 to 1 at 90 days. Safety outcomes were symptomatic intracranial hemorrhage at 22 to 36 hours and 90-day mortality. RESULTS Baseline data on renal function were available for 688 of 843 patients. Of these, CKD was present in 146 (21%), including 69 of 351 patients receiving alteplase and 77 of 337 patients receiving placebo/standard treatment. Overall, treatment with alteplase was associated with higher odds of favorable outcome, and CKD did not modify the treatment effect (Pinteraction=0.834). A favorable outcome was observed in 31 of 69 (46%) patients with CKD in the alteplase group and in 28 of 77 (36%) patients with CKD in the control group (adjusted odds ratio, 1.19 [95% CI, 0.55-2.58]). Among patients with CKD, symptomatic intracranial hemorrhage occurred in 2 patients (3%) in the alteplase group but in none of the controls (P=0.133). At 90 days, death was reported in 3 patients (4%) in the alteplase group compared with 2 patients (3%) in the controls (P=0.539). CONCLUSIONS The present analysis indicates that the benefit of alteplase does not differ between stroke patients with unknown onset time with and without CKD, although the statistical power was lacking to confirm the efficacy in subgroups. This study only applies to mild-to-moderate or predialysis CKD.
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Affiliation(s)
- Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. (K.M., M.K., M.I., S.Y., K.T.)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. (K.M., M.K., M.I., S.Y., K.T.)
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany (M.J., C.G., G.T.)
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. (K.M., M.K., M.I., S.Y., K.T.)
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. (K.M., M.K., M.I., S.Y., K.T.)
| | - Mayumi Fukuda-Doi
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan. (M.F.-D.)
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France (F.B.).,Université Lyon 1, Villeurbanne, France; Laboratoire de Biométrie et Biologie Evolutive, France (F.B.)
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia (H.M.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg, Germany (P.A.R., W.H.)
| | - Ona Wu
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA (O.W.)
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.)
| | - Steven Warach
- Dell Medical School, University of Texas at Austin (S.W.)
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Germany (P.A.R., W.H.)
| | - Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, VIC, Australia (S.M.D., G.A.D.)
| | - Geoffrey A Donnan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, VIC, Australia (S.M.D., G.A.D.)
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany (M.J., C.G., G.T.)
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany (M.J., C.G., G.T.)
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. (K.M., M.K., M.I., S.Y., K.T.)
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14
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Requiao LE, Oliveira RS, Reis LS, B Assis AP, G Moreno BN, Cordeiro LR, Solla DF. Short-Term Efficacy Outcomes of Tenecteplase versus Alteplase for Acute Ischemic Stroke: A Meta-Analysis of 5 Randomized Trials. Neurol India 2022; 70:1454-1459. [PMID: 36076643 DOI: 10.4103/0028-3886.355108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Tenecteplase (TNK) has been shown to be noninferior to Alteplase (ALT) for long term efficacy and safety outcomes. Whether this also applies to short term efficacy outcomes such as early clinical improvement and recanalization is unknown. To compare TNK and ALT regarding the short term efficacy outcomes: early neurological improvement and recanalization. The PRISMA was used to conduct a meta analysis, adapted to noninferiority analysis. The primary outcome was early (24-72 h) neurological improvement, defined as either NIHSS score 0 or reduction of at least 8 points compared to baseline. Recanalization was a secondary outcome. The noninferiority margin was set at 6.5%. Search strategy yielded 5 randomized clinical trials (1585 patients: 828 TNK, 757 ALT). Mean age was 70.8, 58.8% were men, mean baseline NIHSS was 7, and mean onset to treatment time was 148 min. Patients in intervention group received TNK at doses of 0.1 mg/kg (6.8%), 0.25 mg/kg (24.6%), and 0.4 mg/kg (68.6%), while all ALT patients received 0.9 mg/kg. In random effects meta analysis, TNK was noninferior to ALT for the primary outcome, early major neurological improvement (risk difference 8% in favor of TNK, 95% CI 1%-15%). Recanalization was also noninferior for the TNK compared to the ALT group (risk difference 9% in favor of TNK, 95% CI 6% to 23%). Fixed effects models yielded similarly noninferior results and signaled for a possible TNK superiority for both early neurological improvement and recanalization. TNK is noninferior to ALT at the short term efficacy outcomes: early neurological improvement and recanalization.
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Affiliation(s)
- Leticia E Requiao
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | | | - Lorena S Reis
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | - Ana P B Assis
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | | | - Luisa R Cordeiro
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | - Davi F Solla
- Division of Neurosurgery, University of São Paulo, São Paulo, São Paulo, Brazil
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15
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Roh DJ, Asonye IS, Carvalho Poyraz F, Magid-Bernstein J, Joiner EF, Avadhani R, Awad I, Hanley D, Ziai WC, Murthy SB. Intraventricular Hemorrhage Expansion in the CLEAR III Trial: A Post Hoc Exploratory Analysis. Stroke 2022; 53:1847-1853. [PMID: 35086362 PMCID: PMC9133068 DOI: 10.1161/strokeaha.121.037438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The objective of this study was to evaluate factors associated with intraventricular hemorrhage (IVH) expansion and its association with long-term outcomes. METHODS We performed a post hoc analysis of the international, multi-center CLEAR III trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) which enrolled IVH patients between September 1, 2009, and January 31, 2015. The exposure was IVH expansion, defined as >1 mL increase in volume between baseline and stability computed tomography scans, before treatment randomization. We assessed factors associated with IVH expansion and secondarily assessed the relationship of IVH expansion with clinical outcomes: composite of death or major disability (modified Rankin Scale score, >3), and mortality alone at 6 months. The relationship of IVH expansion on ventriculoperitoneal shunt placement was additionally explored. Multivariable logistic regression was used for all analyses. RESULTS Of 500 IVH patients analyzed, the mean age was 59 (±11) years old, 44% were female and 135 (27%) had IVH expansion. In multivariable regression models, factors associated with IVH expansion were baseline parenchymal intracerebral hemorrhage (ICH) volume (adjusted odds ratio [OR], 1.04 per 1 mL increase [95% CI, 1.01-1.08]), presence of parenchymal hematoma expansion: >33% (adjusted OR, 6.63 [95% CI, 3.92-11.24]), time to stability head CT (adjusted OR, 0.71 per 1 hour increase [95% CI, 0.54-0.94]), and thalamic hematoma location (adjusted OR, 1.68 [95% CI, 1.01-2.79]) while additionally adjusting for age, sex, and race. In secondary analyses, IVH expansion was associated with higher odds of poor 6-month outcomes (adjusted OR, 1.84 [95% CI, 1.12-3.02]) but not mortality (OR, 1.40 [95% CI, 0.78-2.50]) after adjusting for baseline ICH volume, thalamic ICH location, age, anticoagulant use, Glasgow Coma Scale score, any withdrawal of care order, and treatment randomization arm. However, there were no relationships of IVH expansion on subsequent ventriculoperitoneal shunt placement (adjusted OR, 1.02 [95% CI, 0.58-1.80]) after adjusting for similar covariates. CONCLUSIONS In a clinical trial cohort of patients with large IVH, acute hematoma characteristics, specifically larger parenchymal volume, hematoma expansion, and thalamic ICH location were associated with IVH expansion. Given that IVH expansion resulted in poor functional outcomes, exploration of treatment approaches to optimize hemostasis and prevent IVH expansion, particularly in patients with thalamic ICH, require further study. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT00784134.
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Affiliation(s)
- David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Ifeyinwa S. Asonye
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Fernanda Carvalho Poyraz
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jessica Magid-Bernstein
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY
| | - Evan F. Joiner
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, IL
| | - Daniel Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wendy C. Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY
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16
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Mun KT, Bonomo JB, Liebeskind DS, Saver JL. Fragility Index Meta-Analysis of Randomized Controlled Trials Shows Highly Robust Evidential Strength for Benefit of <3 Hour Intravenous Alteplase. Stroke 2022; 53:2069-2074. [PMID: 35543129 DOI: 10.1161/strokeaha.121.038153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cumulative fragility index (FI) analysis enables quantification of the evidential strength of intravenous alteplase's core indication-treatment of disabling acute ischemic stroke within 3 hours of onset. METHODS Meta-analyses were performed (study level) or identified (individual participant level) for freedom-from-disability (modified Rankin Scale [mRS] score 0-1, primary efficacy), functional independence (mRS score 0-2, secondary efficacy), and mortality outcomes. Individual trial and cumulative FI analyses were serially conducted after each successive randomized controlled trial (RCT). FI scores were classified as follows: not robust (FI 0-4), somewhat robust (FI 5-12), robust (FI 13-33), and highly robust (FI >33). RESULTS Nine randomized controlled trials were identified from 1995 to 2021 of within-3-hour intravenous alteplase for acute ischemic stroke. In study-level meta-analyses, alteplase increased freedom-from-disability outcome (mRS score 0-1), 31.0% versus 22.3%, relative risk, 1.39 (95% CI, 1.20-1.61); P<0.00001; increased functional independence (mRS score 0-2), 39.7% versus 31.2%, relative risk, 1.29 (95% CI, 1.14-1.45), P<0.000; and did not alter mortality, 24.1% versus 26.1%; P=0.23. Overall FIs for study-level meta-analyses were both highly robust at 42 and 40 for mRS score 0-1 and mRS score 0-2, respectively. Serial FI analyses showed robust evidential strength for intravenous alteplase superiority with publication of the 2 NINDS-tPA trials (National Institute of Neurological Disorders and Stroke-tissue-type plasminogen activator) in 1995, increased to highly robust in 2012, and remains highly robust in 2021. CONCLUSIONS Within-3-hour intravenous alteplase for acute ischemic stroke is one of the most robustly proven therapies in medicine. The initial concurrent trials 25 years ago showed robust evidence for benefit and, after additional studies, advanced to highly robust.
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Affiliation(s)
- Katherine T Mun
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles (K.T.M., D.S.L., J.L.S.)
| | - Jordan B Bonomo
- Departments of Emergency Medicine, Neurosurgery/Neurocritical Care, and Neurology, University of Cincinnati College of Medicine, University of Cincinnati, OH (J.B.B.)
| | - David S Liebeskind
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles (K.T.M., D.S.L., J.L.S.)
| | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles (K.T.M., D.S.L., J.L.S.)
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17
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Diaz A, Woo Y, Martin-Jimenez C, Merino P, Torre E, Yepes M. Tissue-type plasminogen activator induces TNF-α-mediated preconditioning of the blood-brain barrier. J Cereb Blood Flow Metab 2022; 42:667-682. [PMID: 34796748 PMCID: PMC9051146 DOI: 10.1177/0271678x211060395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ischemic tolerance is a phenomenon whereby transient exposure to a non-injurious preconditioning stimulus triggers resistance to a subsequent lethal ischemic insult. Despite the fact that not only neurons but also astrocytes and endothelial cells have a unique response to preconditioning stimuli, current research has been focused mostly on the effect of preconditioning on neuronal death. Thus, it is unclear if the blood-brain barrier (BBB) can be preconditioned independently of an effect on neuronal survival. The release of tissue-type plasminogen activator (tPA) from perivascular astrocytes in response to an ischemic insult increases the permeability of the BBB. In line with these observations, treatment with recombinant tPA increases the permeability of the BBB and genetic deficiency of tPA attenuates the development of post-ischemic edema. Here we show that tPA induces ischemic tolerance in the BBB independently of an effect on neuronal survival. We found that tPA renders the BBB resistant to an ischemic injury by inducing TNF-α-mediated astrocytic activation and increasing the abundance of aquaporin-4-immunoreactive astrocytic end-feet processes in the neurovascular unit. This is a new role for tPA, that does not require plasmin generation, and with potential therapeutic implications for patients with cerebrovascular disease.
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Affiliation(s)
- Ariel Diaz
- Division of Neuropharmacology and Neurologic Diseases, Yerkes National Primate Research Center, Atlanta, GA, USA
| | - Yena Woo
- Division of Neuropharmacology and Neurologic Diseases, Yerkes National Primate Research Center, Atlanta, GA, USA
| | - Cynthia Martin-Jimenez
- Division of Neuropharmacology and Neurologic Diseases, Yerkes National Primate Research Center, Atlanta, GA, USA
| | - Paola Merino
- Division of Neuropharmacology and Neurologic Diseases, Yerkes National Primate Research Center, Atlanta, GA, USA
| | - Enrique Torre
- Division of Neuropharmacology and Neurologic Diseases, Yerkes National Primate Research Center, Atlanta, GA, USA
| | - Manuel Yepes
- Division of Neuropharmacology and Neurologic Diseases, Yerkes National Primate Research Center, Atlanta, GA, USA.,Department of Neurology & Center for Neurodegenerative Disease, Emory University, Atlanta, GA, USA.,Department of Neurology, Veterans Affairs Medical Center, Atlanta, GA, USA
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18
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Zhou Y, Zhang L, Ospel J, Goyal M, McDonough R, Xing P, Li Z, Zhang X, Zhang Y, Zhang Y, Hong B, Xu Y, Huang Q, Li Q, Yu Y, Zuo Q, Ye X, Yang P, Liu J. Association of Intravenous Alteplase, Early Reperfusion, and Clinical Outcome in Patients With Large Vessel Occlusion Stroke: Post Hoc Analysis of the Randomized DIRECT-MT Trial. Stroke 2022; 53:1828-1836. [PMID: 35240861 DOI: 10.1161/strokeaha.121.037061] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The added value of intravenous alteplase in reperfusing ischemic brain tissue in patients undergoing endovascular treatment and directly presented to an endovascular treatment-capable hospital is uncertain. We conducted this post hoc analysis of a randomized trial (DIRECT-MT [Direct Intraarterial Thrombectomy in Order to Revascularize Acute Ischemic Stroke Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals: A Multicenter Randomized Clinical Trial]) to explore the association of intravenous alteplase, early (preendovascular treatment) reperfusion, and clinical outcome and to determine factors which may modify alteplase treatment effect on early reperfusion. METHODS In this post hoc analysis of the DIRECT-MT randomized trial comparing intravenous alteplase before endovascular treatment versus endovascular treatment only, 623 of 656 randomized patients, with adequate angiographic evaluation for early reperfusion assessment, were included. The association of intravenous alteplase and early reperfusion (defined as expanded Thrombolysis in Cerebral Infarction score ≥2a on angiogram) was assessed using unadjusted comparisons and multivariable logistic regression. RESULTS Among 623 patients included (317 received intravenous alteplase and 306 did not), early reperfusion occurred in 91 (15%) patients and was associated with better functional outcome (modified Rankin Scale score, 0-2 of 49/91 [54%] versus 178/531 [34%]; adjusted odds ratio, 1.92 [95% CI, 1.15-3.21]; P<0.001). Intravenous alteplase was independently associated with early reperfusion (59/317 [19%] versus 32/306 [10%]; adjusted odds ratio, 2.06 [95% CI, 1.27-3.33]; P=0.003), and the alteplase effect was modified by time from randomization to groin puncture (dichotomized by median, ≤33 minutes; adjusted odds ratio, 1.06 [95% CI, 0.53-2.10] versus >33 minutes; adjusted odds ratio, 4.07 [95% CI, 1.86-8.86]; Pinteraction=0.012). CONCLUSIONS For patients with large vessel occlusion directly presenting to an endovascular treatment-capable hospital, intravenous alteplase increases early reperfusion when endovascular treatment gets delayed more than approximately half an hour. Thus, intravenous alteplase should be considered if endovascular treatment delays are anticipated by the treating medical team. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03469206.
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Affiliation(s)
- Yu Zhou
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Johanna Ospel
- Department of Radiology, University Hospital Basel, Switzerland (J.O.)
| | - Mayank Goyal
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Canada (M.G., R.M.)
| | - Rosalie McDonough
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Canada (M.G., R.M.).,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Germany (R.M.)
| | - Pengfei Xing
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Zifu Li
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Xiaoxi Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Yongxin Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Bo Hong
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Yi Xu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Qinghai Huang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Qiang Li
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Ying Yu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Qiao Zuo
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Xiaofei Ye
- Health Statistics Department, Naval Medical University, Shanghai, China (X.Y.)
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
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Kim Y, Sharrief A, Kwak MJ, Khose S, Abdelkhaleq R, Salazar-Marioni S, Zhang GQ, Sheth SA. Underutilization of Endovascular Therapy in Black Patients With Ischemic Stroke: An Analysis of State and Nationwide Cohorts. Stroke 2022; 53:855-863. [PMID: 35067099 PMCID: PMC8979555 DOI: 10.1161/strokeaha.121.035714] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Endovascular therapy (EVT) is a very effective treatment but relies on specialized capabilities that are not available in every hospital where acute ischemic stroke is treated. Here, we assess whether access to and utilization of this therapy has extended uniformly across racial and ethnic groups. METHODS We conducted a retrospective, population-based study using the 2019 Texas Inpatient Public Use Data File. Acute ischemic stroke cases and EVT use were identified using the International Classification of Diseases, Tenth Revision (ICD-10) diagnosis and procedure codes. We examined EVT utilization by race/ethnicity and performed patient- and hospital-level analyses. To validate state-specific findings, we conducted patient-level analyses using the 2017 National Inpatient Sample for national estimates. To assess independent associations between race/ethnicity and EVT, multivariable modified Poisson regressions were fitted and adjusted relative risks were estimated accounting for patient risk factors and socioeconomic characteristics. RESULTS Among 40 814 acute ischemic stroke cases in Texas in 2019, 54% were White, 17% Black, and 21% Hispanic. Black patients had similar admissions to EVT-performing hospitals and greater admissions to comprehensive stroke centers (CSCs) compared with White patients (EVT 62% versus 62%, P=0.21; CSCs 45% versus 39%, P<0.001) but had lower EVT rates (4.1% versus 5.3%; adjusted relative risk, 0.76 [0.66-0.88]; P<0.001). There were no differences in EVT rates between Hispanic and White patients. Lower rates of EVT among Black patients were consistent in the subgroup of patients who arrived in early time windows and received intravenous recombinant tissue-type plasminogen activator (adjusted relative risk, 0.77 [0.61-0.98]; P=0.032) and the subgroup of those admitted to EVT-performing hospitals in both non-CSC (3.0% versus 5.5, P<0.001) and CSC hospitals (7.9% versus 10.4%, P<0.001) while there were no differences between Whites and Hispanic patients. Nationwide sample data confirmed this finding of lower utilization of EVT among Black patients (adjusted relative risk, 0.87 [0.77-0.98]; P=0.024). CONCLUSIONS We found no evidence of disparity in presentation to EVT-performing hospitals or CSCs; however, lower rates of EVT were observed in Black patients.
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Affiliation(s)
- Youngran Kim
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Anjail Sharrief
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Min Ji Kwak
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Swapnil Khose
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Rania Abdelkhaleq
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Sergio Salazar-Marioni
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Guo-Qiang Zhang
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Sunil A. Sheth
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
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20
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Tang MY, Gorin FA, Lein PJ. Review of evidence implicating the plasminogen activator system in blood-brain barrier dysfunction associated with Alzheimer's disease. Ageing Neurodegener Dis 2022; 2. [PMID: 35156107 PMCID: PMC8830591 DOI: 10.20517/and.2022.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Elucidating the pathogenic mechanisms of Alzheimer’s disease (AD) to identify therapeutic targets has been the focus of many decades of research. While deposition of extracellular amyloid-beta plaques and intraneuronal neurofibrillary tangles of hyperphosphorylated tau have historically been the two characteristic hallmarks of AD pathology, therapeutic strategies targeting these proteinopathies have not been successful in the clinics. Neuroinflammation has been gaining more attention as a therapeutic target because increasing evidence implicates neuroinflammation as a key factor in the early onset of AD disease progression. The peripheral immune response has emerged as an important contributor to the chronic neuroinflammation associated with AD pathophysiology. In this context, the plasminogen activator system (PAS), also referred to as the vasculature’s fibrinolytic system, is emerging as a potential factor in AD pathogenesis. Evolving evidence suggests that the PAS plays a role in linking chronic peripheral inflammatory conditions to neuroinflammation in the brain. While the PAS is better known for its peripheral functions, components of the PAS are expressed in the brain and have been demonstrated to alter neuroinflammation and blood-brain barrier (BBB) permeation. Here, we review plasmin-dependent and -independent mechanisms by which the PAS modulates the BBB in AD pathogenesis and discuss therapeutic implications of these observations.
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Affiliation(s)
- Mei-Yun Tang
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, CA 95616, USA
| | - Fredric A Gorin
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, CA 95616, USA.,Department of Neurology, School of Medicine, University of California, Davis, CA 95616, USA
| | - Pamela J Lein
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, CA 95616, USA
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21
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Ikeme S, Kottenmeier E, Uzochukwu G, Brinjikji W. Evidence-Based Disparities in Stroke Care Metrics and Outcomes in the United States: A Systematic Review. Stroke 2022; 53:670-679. [PMID: 35105178 DOI: 10.1161/strokeaha.121.036263] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke disproportionately affects racial minorities, and the level to which stroke treatment practices differ across races is understudied. Here, we performed a systematic review of disparities in stroke treatment between racial minorities and White patients. A systematic literature search was performed on PubMed to identify studies published from January 1, 2010, to April 5, 2021 that investigated disparities in access to stroke treatment between racial minorities and White patients. A total of 30 studies were included in the systematic review. White patients were estimated to use emergency medical services at a greater rate (59.8%) than African American (55.6%), Asian (54.7%), and Hispanic patients (53.2%). A greater proportion of White patients (37.4%) were estimated to arrive within 3 hours from onset of stroke symptoms than African American (26.0%) and Hispanic (28.9%) patients. A greater proportion of White patients (2.8%) were estimated to receive tPA (tissue-type plasminogen activator) as compared with African American (2.3%), Hispanic (2.6%), and Asian (2.3%) patients. Rates of utilization of mechanical thrombectomy were also lower in minorities than in the White population. As shown in this review, racial disparities exist at key points along the continuum of stroke care from onset of stroke symptoms to treatment. Beyond patient level factors, these disparities may be attributed to other provider and system level factors within the health care ecosystem.
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Affiliation(s)
- Shelly Ikeme
- CERENOVUS, Johnson & Johnson, Irvine, CA (S.I., E.K.)
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22
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Gando S, Wada T. Pathomechanisms Underlying Hypoxemia in Two COVID-19-Associated Acute Respiratory Distress Syndrome Phenotypes: Insights From Thrombosis and Hemostasis. Shock 2022; 57:1-6. [PMID: 34172612 PMCID: PMC8662946 DOI: 10.1097/shk.0000000000001825] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/10/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The pathomechanisms of hypoxemia and treatment strategies for type H and type L acute respiratory distress syndrome (ARDS) in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced coronavirus disease 2019 (COVID-19) have not been elucidated. MAIN TEXT SARS-CoV-2 mainly targets the lungs and blood, leading to ARDS, and systemic thrombosis or bleeding. Angiotensin II-induced coagulopathy, SARS-CoV-2-induced hyperfibrin(ogen)olysis, and pulmonary and/or disseminated intravascular coagulation due to immunothrombosis contribute to COVID-19-associated coagulopathy. Type H ARDS is associated with hypoxemia due to diffuse alveolar damage-induced high right-to-left shunts. Immunothrombosis occurs at the site of infection due to innate immune inflammatory and coagulofibrinolytic responses to SARS-CoV-2, resulting in microvascular occlusion with hypoperfusion of the lungs. Lung immunothrombosis in type L ARDS results from neutrophil extracellular traps containing platelets and fibrin in the lung microvasculature, leading to hypoxemia due to impaired blood flow and a high ventilation/perfusion (VA/Q) ratio. COVID-19-associated ARDS is more vascular centric than the other types of ARDS. D-dimer levels have been monitored for the progression of microvascular thrombosis in COVID-19 patients. Early anticoagulation therapy in critical patients with high D-dimer levels may improve prognosis, including the prevention and/or alleviation of ARDS. CONCLUSIONS Right-to-left shunts and high VA/Q ratios caused by lung microvascular thrombosis contribute to hypoxemia in type H and L ARDS, respectively. D-dimer monitoring-based anticoagulation therapy may prevent the progression to and/or worsening of ARDS in COVID-19 patients.
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Affiliation(s)
- Satoshi Gando
- Acute and Critical Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
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23
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Hedou E, Douceau S, Chevilley A, Varangot A, Thiebaut AM, Triniac H, Bardou I, Ali C, Maillasson M, Crepaldi T, Comoglio P, Lemarchand E, Agin V, Roussel BD, Vivien D. Two-Chains Tissue Plasminogen Activator Unifies Met and NMDA Receptor Signalling to Control Neuronal Survival. Int J Mol Sci 2021; 22:ijms222413483. [PMID: 34948279 PMCID: PMC8707453 DOI: 10.3390/ijms222413483] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/16/2022] Open
Abstract
Tissue-type plasminogen activator (tPA) plays roles in the development and the plasticity of the nervous system. Here, we demonstrate in neurons, that by opposition to the single chain form (sc-tPA), the two-chains form of tPA (tc-tPA) activates the MET receptor, leading to the recruitment of N-Methyl-d-Aspartate receptors (NMDARs) and to the endocytosis and proteasome-dependent degradation of NMDARs containing the GluN2B subunit. Accordingly, tc-tPA down-regulated GluN2B-NMDAR-driven signalling, a process prevented by blockers of HGFR/MET and mimicked by its agonists, leading to a modulation of neuronal death. Thus, our present study unmasks a new mechanism of action of tPA, with its two-chains form mediating a crosstalk between MET and the GluN2B subunit of NMDARs to control neuronal survival.
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Affiliation(s)
- Elodie Hedou
- Normandie University, UNICAEN, INSERM U1237, Etablissement Français du Sang, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), 14000 Caen, France; (E.H.); (S.D.); (A.C.); (A.V.); (A.M.T.); (H.T.); (I.B.); (C.A.); (V.A.); (D.V.)
| | - Sara Douceau
- Normandie University, UNICAEN, INSERM U1237, Etablissement Français du Sang, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), 14000 Caen, France; (E.H.); (S.D.); (A.C.); (A.V.); (A.M.T.); (H.T.); (I.B.); (C.A.); (V.A.); (D.V.)
| | - Arnaud Chevilley
- Normandie University, UNICAEN, INSERM U1237, Etablissement Français du Sang, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), 14000 Caen, France; (E.H.); (S.D.); (A.C.); (A.V.); (A.M.T.); (H.T.); (I.B.); (C.A.); (V.A.); (D.V.)
| | - Alexandre Varangot
- Normandie University, UNICAEN, INSERM U1237, Etablissement Français du Sang, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), 14000 Caen, France; (E.H.); (S.D.); (A.C.); (A.V.); (A.M.T.); (H.T.); (I.B.); (C.A.); (V.A.); (D.V.)
| | - Audrey M. Thiebaut
- Normandie University, UNICAEN, INSERM U1237, Etablissement Français du Sang, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), 14000 Caen, France; (E.H.); (S.D.); (A.C.); (A.V.); (A.M.T.); (H.T.); (I.B.); (C.A.); (V.A.); (D.V.)
| | - Hortense Triniac
- Normandie University, UNICAEN, INSERM U1237, Etablissement Français du Sang, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), 14000 Caen, France; (E.H.); (S.D.); (A.C.); (A.V.); (A.M.T.); (H.T.); (I.B.); (C.A.); (V.A.); (D.V.)
| | - Isabelle Bardou
- Normandie University, UNICAEN, INSERM U1237, Etablissement Français du Sang, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), 14000 Caen, France; (E.H.); (S.D.); (A.C.); (A.V.); (A.M.T.); (H.T.); (I.B.); (C.A.); (V.A.); (D.V.)
| | - Carine Ali
- Normandie University, UNICAEN, INSERM U1237, Etablissement Français du Sang, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), 14000 Caen, France; (E.H.); (S.D.); (A.C.); (A.V.); (A.M.T.); (H.T.); (I.B.); (C.A.); (V.A.); (D.V.)
| | - Mike Maillasson
- University of Nantes, CHU Nantes, Inserm UMR1232, CNRS ERL6001, SFR Santé, FED 4203, Inserm UMS 016, CNRS UMS 3556, CRCINA, Impact Platform, 44200 Nantes, France;
| | - Tiziana Crepaldi
- Candiolo Cancer Institute IRCCS-FPO, Candiolo, 10060 Turin, Italy; (T.C.); (P.C.)
| | - Paolo Comoglio
- Candiolo Cancer Institute IRCCS-FPO, Candiolo, 10060 Turin, Italy; (T.C.); (P.C.)
| | - Eloïse Lemarchand
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Rd, Manchester M13 9PL, UK;
| | - Véronique Agin
- Normandie University, UNICAEN, INSERM U1237, Etablissement Français du Sang, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), 14000 Caen, France; (E.H.); (S.D.); (A.C.); (A.V.); (A.M.T.); (H.T.); (I.B.); (C.A.); (V.A.); (D.V.)
| | - Benoit D. Roussel
- Normandie University, UNICAEN, INSERM U1237, Etablissement Français du Sang, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), 14000 Caen, France; (E.H.); (S.D.); (A.C.); (A.V.); (A.M.T.); (H.T.); (I.B.); (C.A.); (V.A.); (D.V.)
- Correspondence: ; Tel.: +33-2-31470166; Fax: +33-2-31470222
| | - Denis Vivien
- Normandie University, UNICAEN, INSERM U1237, Etablissement Français du Sang, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), 14000 Caen, France; (E.H.); (S.D.); (A.C.); (A.V.); (A.M.T.); (H.T.); (I.B.); (C.A.); (V.A.); (D.V.)
- Department of Clinical Research, Caen-Normandie University Hospital, CHU, Avenue de la Côte de Nacre, 14000 Caen, France
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Xian Y, Xu H, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Hernandez AF, Peterson ED, Schwamm LH, Fonarow GC. Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention. Stroke 2021; 53:1328-1338. [PMID: 34802250 DOI: 10.1161/strokeaha.121.035853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. METHODS We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010-2013) and Target: Stroke Phase II (2014-2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. RESULTS Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60-98) preintervention, to 66 minutes (51-87) during Phase I, and 50 minutes (37-66) during Phase II (P<0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% (P<0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% (P<0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014-2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31-2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64-0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62-0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38-1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset. CONCLUSIONS A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.
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Affiliation(s)
- Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX. (Y.X.)
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (H.X., A.F.H.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (E.E.S.)
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
| | - Mathew J Reeves
- Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (H.X., A.F.H.)
| | - Eric D Peterson
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX. (E.D.P.)
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.)
| | - Gregg C Fonarow
- Division of Cardiology, University of California at Los Angeles (G.C.F.)
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25
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Muntendorf LK, Konnopka A, König HH, Boutitie F, Ebinger M, Endres M, Fiebach JB, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Gerloff C, Thomalla G. Cost-Effectiveness of Magnetic Resonance Imaging-Guided Thrombolysis for Patients With Stroke With Unknown Time of Onset. Value Health 2021; 24:1620-1627. [PMID: 34711362 DOI: 10.1016/j.jval.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 04/06/2021] [Accepted: 05/08/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Patients waking up with stroke symptoms are often excluded from intravenous thrombolysis with alteplase (IV-tpa). The WAKE-UP trial, a European multicenter randomized controlled trial, proved the clinical effectiveness of magnetic resonance imaging-guided IV-tpa for these patients. This analysis aimed to assess the cost-effectiveness of the intervention compared to placebo. METHODS A Markov model was designed to analyze the cost-effectiveness over a 25-year time horizon. The model consisted of an inpatient acute care phase and a rest-of-life phase. Health states were defined by the modified Rankin Scale (mRS). Initial transition probabilities to mRS scores were based on WAKE-UP data and health state utilities on literature search. Costs were based on data from the University Medical Center Hamburg-Eppendorf, literature, and expert opinion. Incremental costs and effects over the patients' lifetime were estimated. The analysis was conducted from a formal German healthcare perspective. Univariate and probabilistic sensitivity analyses were performed. RESULTS Treatment with IV-tpa resulted in cost savings of €51 009 and 1.30 incremental gains in quality-adjusted life-years at a 5% discount rate. Univariate sensitivity analysis revealed incremental cost-effectiveness ratio being sensitive to the relative risk of favorable outcome on mRS for placebo patients after stroke, the costs of long-term care for patients with mRS 4, and patient age at initial stroke event. In all cases, IV-tpa remained cost-effective. Probabilistic sensitivity analysis proved IV-tpa cost-effective in >95% of the simulations results. CONCLUSIONS Magnetic resonance imaging-guided IV-tpa compared to placebo is cost-effective in patients with ischemic stroke with unknown time of onset.
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Affiliation(s)
- Louisa-Kristin Muntendorf
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Alexander Konnopka
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France
| | - Martin Ebinger
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany; Zentrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Zentrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany; German Centre for Cardiovascular Research, Partner Site, Berlin, Germany; German Center for Neurodegenerative Diseases, Partner Site, Berlin, Germany
| | - Jochen B Fiebach
- Zentrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia; Department of Neurology, Austin Health, Heidelberg, Australia
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium; Division of Experimental Neurology, Department of Neurosciences, KU Leuven, University of Leuven, Leuven, Belgium; Laboratory of Neurobiology, VIB-KU Leuven Center for Brain and Disease Research, Leuven, Belgium
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, Scotland, UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Salvador Pedraza
- Department of Radiology, Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica de Girona, Girona, Italy
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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26
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Abstract
Tissue-type plasminogen activator (tPA) and urokinase-type plasminogen activator (uPA) are serine proteases and major activators of fibrinolysis in mammalian systems. Because fibrinolysis is an essential component of the response to tissue injury, diverse cells, including cells that participate in the response to injury, have evolved receptor systems to detect tPA and uPA and initiate appropriate cell-signaling responses. Formation of functional receptor systems for the plasminogen activators requires assembly of diverse plasma membrane proteins, including but not limited to: the urokinase receptor (uPAR); integrins; N-formyl peptide receptor-2 (FPR2), receptor tyrosine kinases (RTKs), the N-methyl-d-aspartate receptor (NMDA-R), and low-density lipoprotein receptor-related protein-1 (LRP1). The cell-signaling responses elicited by tPA and uPA impact diverse aspects of cell physiology. This review describes rapidly evolving knowledge regarding the structure and function of plasminogen activator receptor assemblies. How these receptor assemblies regulate innate immunity and inflammation is then considered.
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Affiliation(s)
- Steven L Gonias
- Department of Pathology, University of California, San Diego, California
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27
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Mahawish K, Gommans J, Kleinig T, Lallu B, Tyson A, Ranta A. Switching to Tenecteplase for Stroke Thrombolysis: Real-World Experience and Outcomes in a Regional Stroke Network. Stroke 2021; 52:e590-e593. [PMID: 34465202 DOI: 10.1161/strokeaha.121.035931] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose Due to practical advantages, increasing trial safety data, recent Australian Guideline endorsement and local population needs we switched to tenecteplase for stroke thrombolysis from alteplase. We describe our change process and real-world outcome data. Methods Mixed-methods including stakeholder engagement, preimplementation and postimplementation surveys, and assessment of patient treatment rates, metrics, and clinical outcomes preimplementation and postimplementation adjusting regression analyses for age, sex, National Institutes of Health Stroke Scale, premorbid modified Rankin Scale score, and thrombectomy using New Zealand National Stroke Registry data. Results Preswitch consultation involved stroke and emergency clinicians, pharmacists, national regulatory bodies, and hospital legal teams. All survey responders (90% response rate) supported the proposed change and remained satisfied 12 months postimplementation. Between January 2018 and February 2021, we treated 555 patients with alteplase and 283 with tenecteplase. Patients treated with tenecteplase had greater odds of a favorable modified Rankin Scale using both shift (adjusted odds ratio, 1.60 [95% CI, 1.15–2.22]) and dichotomous analyses (modified Rankin Scale score, 0–2; adjusted odds ratio, 2.17 [95% CI, 1.31–3.59]) and shorter median (interquartile range) door-to-needle time (median, 53 [38–73.5] versus 61 minutes [45–85], P=0.0002). Symptomatic intracranial hemorrhage rates (tenecteplase 1.8% versus 3.4%; adjusted odds ratio, 0.46 [95% CI, 0.13–1.64]), death by day 7 (tenecteplase 7.5% versus 11.8%; adjusted odds ratio, 0.46 [95% CI, 0.21–0.99]), and median (interquartile range) needle to groin time for the 42 transferred regional patients (tenecteplase 155 [113–248] versus 200 [158–266]; P=0.27) did not significantly differ. Conclusions Following stakeholder endorsement, a region-wide switch from alteplase to tenecteplase was successfully implemented. We found evidence of benefit and no evidence of harm.
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Affiliation(s)
| | | | | | | | | | - Annemarei Ranta
- Wellington Regional Hospital, NZ (A.T., A.R.).,University of Otago (A.R.)
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28
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Kappelhof M, Tolhuisen ML, Treurniet KM, Dutra BG, Alves H, Zhang G, Brown S, Muir KW, Dávalos A, Roos YBWEM, Saver JL, Demchuk AM, Jovin TG, Bracard S, Campbell BCV, van der Lugt A, Guillemin F, White P, Hill MD, Dippel DWJ, Mitchell PJ, Goyal M, Marquering HA, Majoie CBLM. Endovascular Treatment Effect Diminishes With Increasing Thrombus Perviousness: Pooled Data From 7 Trials on Acute Ischemic Stroke. Stroke 2021; 52:3633-3641. [PMID: 34281377 PMCID: PMC8547583 DOI: 10.1161/strokeaha.120.033124] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Thrombus perviousness estimates residual flow along a thrombus in acute ischemic stroke, based on radiological images, and may influence the benefit of endovascular treatment for acute ischemic stroke. We aimed to investigate potential endovascular treatment (EVT) effect modification by thrombus perviousness. Methods: We included 443 patients with thin-slice imaging available, out of 1766 patients from the pooled HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set of 7 randomized trials on EVT in the early window (most within 8 hours). Control arm patients (n=233) received intravenous alteplase if eligible (212/233; 91%). Intervention arm patients (n=210) received additional EVT (prior alteplase in 178/210; 85%). Perviousness was quantified by thrombus attenuation increase on admission computed tomography angiography compared with noncontrast computed tomography. Multivariable regression analyses were performed including multiplicative interaction terms between thrombus attenuation increase and treatment allocation. In case of significant interaction, subgroup analyses by treatment arm were performed. Our primary outcome was 90-day functional outcome (modified Rankin Scale score), resulting in an adjusted common odds ratio for a one-step shift towards improved outcome. Secondary outcomes were mortality, successful reperfusion (extended Thrombolysis in Cerebral Infarction score, 2B–3), and follow-up infarct volume (in mL). Results: Increased perviousness was associated with improved functional outcome. After adding a multiplicative term of thrombus attenuation increase and treatment allocation, model fit improved significantly (P=0.03), indicating interaction between perviousness and EVT benefit. Control arm patients showed significantly better outcomes with increased perviousness (adjusted common odds ratio, 1.2 [95% CI, 1.1–1.3]). In the EVT arm, no significant association was found (adjusted common odds ratio, 1.0 [95% CI, 0.9–1.1]), and perviousness was not significantly associated with successful reperfusion. Follow-up infarct volume (12% [95% CI, 7.0–17] per 5 Hounsfield units) and chance of mortality (adjusted odds ratio, 0.83 [95% CI, 0.70–0.97]) decreased with higher thrombus attenuation increase in the overall population, without significant treatment interaction. Conclusions: Our study suggests that the benefit of best medical care including alteplase, compared with additional EVT, increases in patients with more pervious thrombi.
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Affiliation(s)
- Manon Kappelhof
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.)
| | - Manon L Tolhuisen
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.L.T., B.G.D., H.A., H.A.M.)
| | - Kilian M Treurniet
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.)
| | - Bruna G Dutra
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.L.T., B.G.D., H.A., H.A.M.)
| | - Heitor Alves
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.L.T., B.G.D., H.A., H.A.M.)
| | - Guang Zhang
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.)
| | - Scott Brown
- Altair Biostatistics, St Louis Park, MN (S. Brown)
| | - Keith W Muir
- Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, United Kingdom (K.W.M.)
| | - Antoni Dávalos
- Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain (A.D.)
| | - Yvo B W E M Roos
- Neurology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (Y.B.W.E.M.R.)
| | - Jeffrey L Saver
- Neurology, Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (UCLA) (J.L.S.)
| | - Andrew M Demchuk
- Clinical Neurosciences, University of Calgary, Alberta, Canada. (A.M.D., M.D.H.)
| | - Tudor G Jovin
- Neurology, University of Pittsburgh Medical Center, PA (T.G.J.)
| | - Serge Bracard
- Diagnostic and Interventional Neuroradiology, University of Lorraine, University Hospital of Nancy, France. (S. Bracard)
| | - Bruce C V Campbell
- Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (B.C.V.C.)
| | - Aad van der Lugt
- Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands. (A.v.d.L.)
| | - Francis Guillemin
- Epidemiology, University of Lorraine, University Hospital of Nancy, France. (F.G.)
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Alberta, Canada. (A.M.D., M.D.H.)
| | | | - Peter J Mitchell
- Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (P.J.M.)
| | - Mayank Goyal
- Radiology, University of Calgary, Alberta, Canada.(M.G.)
| | - Henk A Marquering
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.L.T., B.G.D., H.A., H.A.M.)
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.)
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29
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Anand SK, Benjamin WJ, Adapa AR, Park JV, Wilkinson DA, Daou BJ, Burke JF, Pandey AS. Trends in acute ischemic stroke treatments and mortality in the United States from 2012 to 2018. Neurosurg Focus 2021; 51:E2. [PMID: 34198248 DOI: 10.3171/2021.4.focus21117] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The establishment of mechanical thrombectomy (MT) as a first-line treatment for select patients with acute ischemic stroke (AIS) and the expansion of stroke systems of care have been major advancements in the care of patients with AIS. In this study, the authors aimed to identify temporal trends in the usage of tissue-type plasminogen activator (tPA) and MT within the AIS population from 2012 to 2018, and the relationship to mortality. METHODS Using a nationwide private health insurance database, 117,834 patients who presented with a primary AIS between 2012 and 2018 in the United States were identified. The authors evaluated temporal trends in tPA and MT usage and clinical outcomes stratified by treatment and age using descriptive statistics. RESULTS Among patients presenting with AIS in this population, the mean age was 69.1 years (SD ± 12.3 years), and 51.7% were female. Between 2012 and 2018, the use of tPA and MT increased significantly (tPA, 6.3% to 11.8%, p < 0.0001; MT, 1.6% to 5.7%, p < 0.0001). Mortality at 90 days decreased significantly in the overall AIS population (8.7% to 6.7%, p < 0.0001). The largest reduction in 90-day mortality was seen in patients treated with MT (21.4% to 14.1%, p = 0.0414) versus tPA (11.8% to 7.0%, p < 0.0001) versus no treatment (8.3% to 6.3%, p < 0.0001). Age-standardized mortality at 90 days decreased significantly only in patients aged 71-80 years (11.4% to 7.8%, p < 0.0001) and > 81 years (17.8% to 11.6%, p < 0.0001). Mortality at 90 days stagnated in patients aged 18 to 50 years (3.0% to 2.2%, p = 0.4919), 51 to 60 years (3.8% to 3.9%, p = 0.7632), and 61 to 70 years (5.5% to 5.2%, p = 0.2448). CONCLUSIONS From 2012 to 2018, use of tPA and MT increased significantly, irrespective of age, while mortality decreased in the entire AIS population. The most dramatic decrease in mortality was seen in the MT-treated population. Age-standardized mortality improved only in patients older than 70 years, with no change in younger patients.
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Affiliation(s)
| | | | | | | | - D Andrew Wilkinson
- 1Department of Neurosurgery.,3Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania
| | | | - James F Burke
- 4Department of Neurology, University of Michigan, Ann Arbor, Michigan; and
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30
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Gauberti M, Martinez de Lizarrondo S, Vivien D. Thrombolytic strategies for ischemic stroke in the thrombectomy era. J Thromb Haemost 2021; 19:1618-1628. [PMID: 33834615 DOI: 10.1111/jth.15336] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 02/03/2023]
Abstract
Twenty-five years ago, intravenous thrombolysis has revolutionized the care of patients with acute ischemic stroke. Since 2015, randomized clinical trials have demonstrated that mechanical thrombectomy improves functional outcome in stroke patients over intravenous thrombolysis alone. More recently, three randomized clinical trials have suggested that mechanical thrombectomy alone is noninferior to a combined strategy with both intravenous thrombolysis and mechanical thrombectomy. In the present review, we will present the last clinical and preclinical studies on the use of thrombolysis in stroke patients in the modern thrombectomy era. At the cost of a potential increased risk of hemorrhagic transformation, thrombolysis may promote arterial recanalization before thrombectomy, improve the rate of successful recanalization after thrombectomy, and restore microcirculation patency downstream of the main thrombus. Besides, new thrombolytic strategies targeting tissue-type plasminogen activator resistant thrombi are being developed, which could strengthen the beneficial effects of thrombolysis without carrying additional pro-hemorrhagic effects. For instance, tenecteplase has shown improved rate of recanalization compared with tissue-type plasminogen activator (alteplase). Beyond fibrinolysis, DNA- and von Willebrand factor-targeted thrombolytic strategies have shown promising results in experimental models of ischemic stroke. New combined strategies, improved thrombolytics, and dedicated clinical trials in selected patients are eagerly awaited to further improve functional outcome in stroke.
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Affiliation(s)
- Maxime Gauberti
- Normandie Univ, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
- CHU Caen, Department of Neuroradiology, CHU de Caen Côte de Nacre, Caen, France
| | - Sara Martinez de Lizarrondo
- Normandie Univ, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
| | - Denis Vivien
- Normandie Univ, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
- CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, Caen, France
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31
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Evlakhov VI, Poiasov IZ. [Spontaneous fibrinolysis and possibilities of its acceleration in pulmonary embolism]. Angiol Sosud Khir 2021; 27:25-31. [PMID: 34166341 DOI: 10.33529/angio2021207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This review contains the data concerning the mechanisms of spontaneous fibrinolysis in pulmonary vessels and possibilities of its acceleration in pulmonary embolism. The spontaneous fibrinolysis system is known to be sequential and multifactorial, with the interaction of accelerators (t-PA and u-PA) and inhibitors (alpha-2-antiplasmin, PAI-1, TAFI). The fibrinolytic processes take place in case of prevailing reactions of accelerating factors over inhibiting ones. The endothelium of pulmonary vessels possesses pronounced antithrombogenic and profibrinolytic properties, therefore, the processes of fibrinolysis in the pulmonary vascular bed normally occur more intensively than in the vessels of the systemic circulation. The membrane proteins of the endothelium annexins A2 activate plasminogen, whereas thrombomodulin inhibits the activity of PAI-1. The main approaches to increase the fibrinolysis intensity in conditions of pulmonary embolism may be aimed at elevating the activity of fibrinolytic enzymes (enhancing the synthesis of annexins A2, the use of NMDA-receptor antagonists) and suppressing its inhibitors (the use of monoclonal antibodies to alpha-2-antiplasmin, as well as plasminogen activator inhibitor-1 (PAI-1) and thrombin-activatable fibrinolysis inhibitor (TAFI). Promising directions for future research can be the synthesis of a new generation of tissue-type plasminogen activators, and investigations of the possibility of clinical application of antithrombin and thrombomodulin, angiotensin converting enzyme inhibitors and cortisol antagonists. To meet these challenges, it is necessary to develop new models of venous thrombosis and acute pulmonary embolism in different animal species, with the assessment of the changes in the venous haemodynamics and pulmonary microcirculation on the background of administration of a new class of fibrinolytic agents.
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Affiliation(s)
- V I Evlakhov
- Laboratory of Physiology of Visceral Systems named after Academician K.M. Bykov, Institute of Experimental Medicine, Saint Petersburg, Russia
| | - I Z Poiasov
- Laboratory of Physiology of Visceral Systems named after Academician K.M. Bykov, Institute of Experimental Medicine, Saint Petersburg, Russia
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32
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Romano JG, Gardener H, Campo-Bustillo I, Khan Y, Tai S, Riley N, Smith EE, Sacco RL, Khatri P, Alger HM, Mac Grory B, Gulati D, Sangha NS, Craig JM, Olds KE, Benesch CG, Kelly AG, Brehaut SS, Kansara AC, Schwamm LH. Predictors of Outcomes in Patients With Mild Ischemic Stroke Symptoms: MaRISS. Stroke 2021; 52:1995-2004. [PMID: 33947209 DOI: 10.1161/strokeaha.120.032809] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Jose G Romano
- Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Hannah Gardener
- Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Iszet Campo-Bustillo
- Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Yosef Khan
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Sofie Tai
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Nikesha Riley
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Eric E Smith
- Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.)
| | - Ralph L Sacco
- Department of Neurology, University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (P.K.)
| | - Heather M Alger
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC (B.M.G.)
| | - Deepak Gulati
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus (D.G.)
| | | | | | - Karin E Olds
- Department of Neurology, St. Luke's Hospital, Kansas City, MO (K.E.O.)
| | - Curtis G Benesch
- Department of Neurology, University of Rochester Medical Center, NY (C.G.B., A.G.K.)
| | - Adam G Kelly
- Department of Neurology, University of Rochester Medical Center, NY (C.G.B., A.G.K.)
| | | | - Amit C Kansara
- Providence St. Vincent Medical Center, Portland, OR (A.C.K.)
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
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Liu M, Zaman K, Fortenberry YM. Overview of the Therapeutic Potential of Aptamers Targeting Coagulation Factors. Int J Mol Sci 2021; 22:3897. [PMID: 33918821 DOI: 10.3390/ijms22083897] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 12/11/2022] Open
Abstract
Aptamers are single-stranded DNA or RNA sequences that bind target molecules with high specificity and affinity. Aptamers exhibit several notable advantages over protein-based therapeutics. Aptamers are non-immunogenic, easier to synthesize and modify, and can bind targets with greater affinity. Due to these benefits, aptamers are considered a promising therapeutic candidate to treat various conditions, including hematological disorders and cancer. An active area of research involves developing aptamers to target blood coagulation factors. These aptamers have the potential to treat cardiovascular diseases, blood disorders, and cancers. Although no aptamers targeting blood coagulation factors have been approved for clinical use, several aptamers have been evaluated in clinical trials and many more have demonstrated encouraging preclinical results. This review summarized our knowledge of the aptamers targeting proteins involved in coagulation, anticoagulation, fibrinolysis, their extensive applications as therapeutics and diagnostics tools, and the challenges they face for advancing to clinical use.
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Tong X, Wang Y, Fiehler J, Bauer CT, Jia B, Zhang X, Huo X, Luo G, Wang A, Pan Y, Ma N, Gao F, Mo D, Song L, Sun X, Liu L, Deng Y, Li X, Wang B, Ma G, Wang Y, Ren Z, Miao Z. Thrombectomy Versus Combined Thrombolysis and Thrombectomy in Patients With Acute Stroke: A Matched-Control Study. Stroke 2021; 52:1589-1600. [PMID: 33657849 DOI: 10.1161/strokeaha.120.031599] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Xu Tong
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Yilong Wang
- Department of Neurology (Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, China.,China National Clinical Research Center for Neurological Diseases (A.W., Y.P., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, China
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (J.F.)
| | - Clayton T Bauer
- Department of Neurosurgery, University of South Florida, Tampa (C.T.B., Z.R.)
| | - Baixue Jia
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Xuelei Zhang
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Gang Luo
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases (A.W., Y.P., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases (A.W., Y.P., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, China
| | - Ning Ma
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Feng Gao
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Ligang Song
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Xuan Sun
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Lian Liu
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Yiming Deng
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | | | | | | | | | - Zeguang Ren
- Department of Neurosurgery, University of South Florida, Tampa (C.T.B., Z.R.)
| | - Zhongrong Miao
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
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Yafasova A, Fosbøl EL, Johnsen SP, Kruuse C, Petersen JK, Alhakak A, Vinding NE, Torp-Pedersen C, Gislason GH, Køber L, Butt JH. Time to Thrombolysis and Long-Term Outcomes in Patients With Acute Ischemic Stroke: A Nationwide Study. Stroke 2021; 52:1724-1732. [PMID: 33657854 DOI: 10.1161/strokeaha.120.032837] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Adelina Yafasova
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Denmark (S.P.J.)
| | - Christina Kruuse
- Department of Neurology, Herlev and Gentofte University Hospital, Denmark (C.K.).,University of Copenhagen, Institute of Clinical Medicine, Denmark (C.K.)
| | - Jeppe Kofoed Petersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
| | - Amna Alhakak
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
| | - Naja Emborg Vinding
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjaellands Hospital, Hillerød, Denmark (C.T.-P.).,Department of Cardiology, Aalborg University Hospital, Denmark (C.T.-P.)
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark (G.H.G.).,The Danish Heart Foundation, Copenhagen, Denmark (G.H.G.).,The National Institute of Public Health, University of Southern Denmark, Odense, Denmark (G.H.G.)
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
| | - Jawad Haider Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
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Kement D, Reumann R, Schostak K, Voß H, Douceau S, Dottermusch M, Schweizer M, Schlüter H, Vivien D, Glatzel M, Galliciotti G. Neuroserpin Is Strongly Expressed in the Developing and Adult Mouse Neocortex but Its Absence Does Not Perturb Cortical Lamination and Synaptic Proteome. Front Neuroanat 2021; 15:627896. [PMID: 33708076 PMCID: PMC7940840 DOI: 10.3389/fnana.2021.627896] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/02/2021] [Indexed: 11/13/2022] Open
Abstract
Neuroserpin is a serine protease inhibitor that regulates the activity of tissue-type plasminogen activator (tPA) in the nervous system. Neuroserpin is strongly expressed during nervous system development as well as during adulthood, when it is predominantly found in regions eliciting synaptic plasticity. In the hippocampus, neuroserpin regulates developmental neurogenesis, synaptic maturation and in adult mice it modulates synaptic plasticity and controls cognitive and social behavior. High expression levels of neuroserpin in the neocortex starting from prenatal stage and persisting during adulthood suggest an important role for the serpin in the formation of this brain region and in the maintenance of cortical functions. In order to uncover neuroserpin function in the murine neocortex, in this work we performed a comprehensive investigation of its expression pattern during development and in the adulthood. Moreover, we assessed the role of neuroserpin in cortex formation by comparing cortical lamination and neuronal maturation between neuroserpin-deficient and control mice. Finally, we evaluated a possible regulatory role of neuroserpin at cortical synapses in neuroserpin-deficient mice. We observed that neuroserpin is expressed starting from the beginning of corticogenesis until adulthood throughout the neocortex in several classes of glutamatergic projection neurons and GABA-ergic interneurons. However, in the absence of neuroserpin we did not detect any alteration either in cortical layer formation, or in neuronal soma size and dendritic length. Furthermore, no significant quantitative changes were observed in the proteome of cortical synapses upon neuroserpin deficiency. We conclude that, although strongly expressed in the neocortex, absence of neuroserpin does not lead to gross developmental abnormalities, and does not perturb the composition of the cortical synaptic proteome.
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Affiliation(s)
- Dilara Kement
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rebecca Reumann
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katrin Schostak
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannah Voß
- Institute of Clinical Chemistry and Laboratory Medicine, Mass Spectrometric Proteomics Group, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sara Douceau
- Physiopathology and Imaging of Neurological Disorders, Université Caen Normandie, INSERM U1237, Normandie Université, Caen, France
| | - Matthias Dottermusch
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michaela Schweizer
- Department of Electron Microscopy, Center for Molecular Neurobiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hartmut Schlüter
- Institute of Clinical Chemistry and Laboratory Medicine, Mass Spectrometric Proteomics Group, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Denis Vivien
- Physiopathology and Imaging of Neurological Disorders, Université Caen Normandie, INSERM U1237, Normandie Université, Caen, France.,Department of Clinical Research, Caen-Normandie University Hospital, Centre Hospitalier Universitaire, Caen, France
| | - Markus Glatzel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Giovanna Galliciotti
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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37
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Affiliation(s)
- Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
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38
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Kaesmacher J, Meinel TR, Nannoni S, Olivé-Gadea M, Piechowiak EI, Maegerlein C, Goeldlin M, Pierot L, Seiffge DJ, Mendes Pereira V, Heldner MR, Grunder L, Costalat V, Arnold M, Dobrocky T, Gralla J, Mordasini P, Fischer U. Bridging May Increase the Risk of Symptomatic Intracranial Hemorrhage in Thrombectomy Patients With Low Alberta Stroke Program Early Computed Tomography Score. Stroke 2021; 52:1098-1104. [PMID: 33504188 DOI: 10.1161/strokeaha.120.030508] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Whether intravenous thrombolysis (IVT) increases the risk for symptomatic intracranial hemorrhage (sICH) in patients treated with mechanical thrombectomy (MT) is a matter of debate. Purpose of this study was to evaluate the extent of early ischemia as a possible factor influencing the risk for sICH after IVT+MT versus direct MT. METHODS An explorative analysis of the BEYOND-SWIFT (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy) multicenter cohort was performed. We hypothesized that the sICH risk between IVT+MT versus direct MT differs across the strata of Alberta Stroke Program Early CT Scores (ASPECTS). For this purpose, all patients with ICA, M1, and M2 vessel occlusions and available noncontrast computed tomography or diffusion-weighed imaging ASPECTS (n=2002) were analyzed. We used logistic regression analysis in subgroups, as well as interaction terms, to address the risk of sICH in IVT+MT versus direct MT patients across the ASPECTS strata. RESULTS In 2002 patients (median age, 73.7 years; 50.7% women; median National Institutes of Health Stroke Scale score, 16), the overall rate of sICH was 6.5% (95% CI, 5.5%-7.7%). Risk of sICH differed across ASPECTS groups (9-10: 6.3%; 6-8: 5.6% and ≤5 9.8%; P=0.042). With decreasing ASPECTS, the risks of sICH in the IVT+MT versus the direct MT group increased from adjusted odds ratio of 0.61 ([95% CI, 0.24-1.60] ASPECTS 9-10), to 1.72 ([95% CI, 0.69-4.24] ASPECTS 6-8) and 6.31 ([95% CI, 1.87-21.29] ASPECTS ≤5), yielding a positive interaction term (1.91 [95% CI, 1.01-3.63]). Sensitivity analyses regarding diffusion-weighed imaging versus noncontrast computed tomography ASPECTS did not alter the primary observations. CONCLUSIONS The extent of early ischemia may influence relative risks of sICH in IVT+MT versus direct MT patients, with an excess sICH risk in IVT+MT patients with low ASPECTS. If confirmed in post hoc analyses of randomized controlled trial data, IVT may be administered more carefully in patients with low ASPECTS eligible for and with direct access to MT.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.P., T.D., J.G., P.M.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,University Institute of Diagnostic and Interventional and Pediatric Radiology (J.K., L.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Stefania Nannoni
- Stroke Centre and Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland (S.N.)
| | - Marta Olivé-Gadea
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M.O.-G.)
| | - Eike I Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.P., T.D., J.G., P.M.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M.)
| | - Martina Goeldlin
- Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | | | - David J Seiffge
- Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Vitor Mendes Pereira
- Joint Department of Medical Imaging, Toronto Western Hospital, ON, Canada (V.M.P.)
| | - Mirjam R Heldner
- Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Lorenz Grunder
- University Institute of Diagnostic and Interventional and Pediatric Radiology (J.K., L.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | | | - Marcel Arnold
- Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.P., T.D., J.G., P.M.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.P., T.D., J.G., P.M.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.P., T.D., J.G., P.M.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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Nakano T, Takahashi T, Yamamoto C, Yoshida E, Kaji T, Fujiwara Y. Arsenite Inhibits Tissue-Type Plasminogen Activator Synthesis through NRF2 Activation in Cultured Human Vascular Endothelial EA.hy926 Cells. Int J Mol Sci 2021; 22:E739. [PMID: 33451022 DOI: 10.3390/ijms22020739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/05/2021] [Accepted: 01/09/2021] [Indexed: 11/18/2022] Open
Abstract
Chronic arsenic exposure is known to be related to the progression of atherosclerosis. However, the pathogenic mechanisms of arsenic-induced atherosclerosis have not been fully elucidated. Because disruption of the blood coagulation/fibrinolytic system is involved in the development of arteriosclerosis, we investigated the effect of arsenite on fibrinolytic activity in human vascular endothelial EA.hy926 cells in the present study. Fibrinolysis depends on the balance between tissue-type plasminogen activator (t-PA) and plasminogen activator inhibitor 1 (PAI-1) secreted from vascular endothelial cells. We found that arsenite reduced fibrinolytic t-PA activity by inhibiting its synthesis without affecting PAI-1 production. The inhibitory effect of arsenite on t-PA expression was partially recovered by the reactive oxygen species (ROS) scavenger Trolox. The nuclear factor erythroid 2 related factor 2 (NRF2) pathway is known to be activated by arsenite via ROS production. We confirmed that arsenite activated the NRF2 pathway, and arsenite-induced inhibition of fibrinolytic t-PA activity was abrogated in NRF2-knockdown EA.hy926 cells. These results suggest that arsenite inhibits the fibrinolytic activity of t-PA by selectively suppressing its synthesis via activation of the NRF2 pathway in vascular endothelial cells.
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Abstract
RATIONALE Hemorrhagic complications represent a major limitation of intravenous thrombolysis using tPA (tissue-type plasminogen activator) in patients with ischemic stroke. The expression of tPA receptors on immune cells raises the question of what effects tPA exerts on these cells and whether these effects contribute to thrombolysis-related hemorrhagic transformation. OBJECTIVE We aim to determine the impact of tPA on immune cells and investigate the association between observed immune alteration with hemorrhagic transformation in ischemic stroke patients and in a rat model of embolic stroke. METHODS AND RESULTS Paired blood samples were collected before and 1 hour after tPA infusion from 71 patients with ischemic stroke. Control blood samples were collected from 27 ischemic stroke patients without tPA treatment. A rat embolic middle cerebral artery occlusion model was adopted to investigate the underlying mechanisms of hemorrhagic transformation. We report that tPA induces a swift surge of circulating neutrophils and T cells with profoundly altered molecular features in ischemic stroke patients and a rat model of focal embolic stroke. tPA exacerbates endothelial injury, increases adhesion and migration of neutrophils and T cells, which are associated with brain hemorrhage in rats subjected to embolic stroke. Genetic ablation of annexin A2 in neutrophils and T cells diminishes the effect of tPA on these cells. Decoupling the interaction between mobilized neutrophils/T cells and the neurovascular unit, achieved via a S1PR (sphingosine-1-phosphate receptor) 1 modulator RP101075 and a CCL2 (C-C motif chemokine ligand 2) synthesis inhibitor bindarit, which block lymphocyte egress and myeloid cell recruitment, respectively, attenuates hemorrhagic transformation and improves neurological function after tPA thrombolysis. CONCLUSIONS Our findings suggest that immune invasion of the neurovascular unit represents a previously unrecognized mechanism underlying tPA-mediated brain hemorrhage, which can be overcome by precise immune modulation during thrombolytic therapy.
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Affiliation(s)
- Kaibin Shi
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, China (K.S., M.Z., D.-M.J., X.Y., Q.L., F.-D.S.)
- China National Clinical Research Center for Neurological Diseases, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, China (K.S., F.-D.S.)
| | - Ming Zou
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, China (K.S., M.Z., D.-M.J., X.Y., Q.L., F.-D.S.)
| | - Dong-Mei Jia
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, China (K.S., M.Z., D.-M.J., X.Y., Q.L., F.-D.S.)
| | - Samuel Shi
- Neuroscience Graduate Program, Arizona State University, Tempe (S.S.)
| | - Xiaoxia Yang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, China (K.S., M.Z., D.-M.J., X.Y., Q.L., F.-D.S.)
| | - Qiang Liu
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, China (K.S., M.Z., D.-M.J., X.Y., Q.L., F.-D.S.)
| | - Jing-Fei Dong
- Division of Hematology, Department of Medicine, BloodWorks Northwest Research Institute, School of Medicine, University of Washington, Seattle (J.-f.D.)
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT (K.N.S.)
| | - Xiaoying Wang
- Department of Neurosurgery, Clinical Neuroscience Research Center, Tulane University School of Medicine, New Orleans, LA (X.W.)
| | - Fu-Dong Shi
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, China (K.S., M.Z., D.-M.J., X.Y., Q.L., F.-D.S.)
- China National Clinical Research Center for Neurological Diseases, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, China (K.S., F.-D.S.)
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Abstract
Dementia is a clinical syndrome that affects approximately 47 million people worldwide and is characterized by progressive and irreversible decline of cognitive, behavioral and sesorimotor functions. Alzheimer's disease (AD) accounts for approximately 60-80% of all cases of dementia, and neuropathologically is characterized by extracellular deposits of insoluble amyloid-β (Aβ) and intracellular aggregates of hyperphosphorylated tau. Significantly, although for a long time it was believed that the extracellular accumulation of Aβ was the culprit of the symptoms observed in these patients, more recent studies have shown that cognitive decline in people suffering this disease is associated with soluble Aβ-induced synaptic dysfunction instead of the formation of insoluble Aβ-containing extracellular plaques. These observations are translationally relevant because soluble Aβ-induced synaptic dysfunction is an early event in AD that precedes neuronal death, and thus is amenable to therapeutic interventions to prevent cognitive decline before the progression to irreversible brain damage. The plasminogen activating (PA) system is an enzymatic cascade that triggers the degradation of fibrin by catalyzing the conversion of plasminogen into plasmin via two serine proteinases: tissue-type plasminogen activator (tPA) and urokinase-type plasminogen activator (uPA). Experimental evidence reported over the last three decades has shown that tPA and uPA play a role in the pathogenesis of AD. However, these studies have focused on the ability of these plasminogen activators to trigger plasmin-induced cleavage of insoluble Aβ-containing extracellular plaques. In contrast, recent evidence indicates that activity-dependent release of uPA from the presynaptic terminal of cerebral cortical neurons protects the synapse from the deleterious effects of soluble Aβ via a mechanism that does not require plasmin generation or the cleavage of Aβ fibrils. Below we discuss the role of the PA system in the pathogenesis of AD and the translational relevance of data published to this date.
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Affiliation(s)
- Manuel Yepes
- Department of Neurology, Emory University School of Medicine; Department of Neurology, Veterans Affairs Medical Center; Division of Neuropharmacology and Neurologic Diseases, Yerkes National Primate Research Center, Atlanta, GA, USA
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Keragala CB, Woodruff TM, Liu Z, Niego B, Ho H, McQuilten Z, Medcalf RL. Tissue-Type Plasminogen Activator and Tenecteplase-Mediated Increase in Blood Brain Barrier Permeability Involves Cell Intrinsic Complement. Front Neurol 2020; 11:577272. [PMID: 33363504 PMCID: PMC7753024 DOI: 10.3389/fneur.2020.577272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/09/2020] [Indexed: 11/26/2022] Open
Abstract
Background: Tissue-type plasminogen activator (t-PA) has been the mainstay of therapeutic thrombolysis for patients with acute ischaemic stroke (AIS). However, t-PA can cause devastating intracerebral hemorrhage. t-PA can also influence the CNS in part by modulation of BBB permeability. Complement activation also occurs after AIS and has also been reported to increase BBB permeability. The complement components, C3 and C5, can also be activated by t-PA via plasmin formation and cell intrinsic complement may be involved in this process. Tenecteplase (TNK-tPA) is a t-PA variant with a longer plasma half-life, yet the ability of TNK-tPA to modulate the BBB and complement is less clear. Aim: To evaluate the effect of C5 and C5a-receptor 1 (C5aR1) inhibitors on t-PA- and TNK-tPA-mediated opening of the BBB. Methods: We used an in vitro model of the BBB where human brain endothelial cells and human astrocytes were co-cultured on the opposite sides of a porous membrane assembled in transwell inserts. The luminal (endothelial) compartment was stimulated with t-PA or TNK-tPA together with plasminogen, in the presence of PMX205 (a non-competitive C5aR1 antagonist), Avacopan (a competitive C5aR1 antagonist) or Eculizumab (a humanized monoclonal inhibitor of human C5). BBB permeability was assessed 5 and 24 h later. Immunofluorescence was also used to detect changes in C5 and C5aR1 expression in endothelial cells and astrocytes. Results: PMX205, but not Avacopan or Eculizumab, blocked t-PA-mediated increase in BBB permeability at both the 5 and 24 h time points. PMX205 also blocked TNK-tPA-mediated increase in BBB permeability. Immunofluorescence analysis revealed intracellular staining of C5 in both cell types. C5aR1 expression was also detected on the cell surfaces and also located intracellularly in both cell types. Conclusion: t-PA and TNK-tPA-mediated increase in BBB permeability involves C5aR1 receptor activation from cell-derived C5a. Selective inhibitors of C5aR1 may have therapeutic potential in AIS.
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Affiliation(s)
- Charithani B Keragala
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Trent M Woodruff
- School of Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Zikou Liu
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Be'eri Niego
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Heidi Ho
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Zoe McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
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Ye Y, Zhu YT, Tong HX, Han JY. The Protective Role of Immunomodulators on Tissue-Type Plasminogen Activator-Induced Hemorrhagic Transformation in Experimental Stroke: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:615166. [PMID: 33424615 PMCID: PMC7793743 DOI: 10.3389/fphar.2020.615166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Recanalization with tissue plasminogen activator (tPA) is the only approved agent available for acute ischemic stroke. But delayed treatment of tPA may lead to lethal intracerebral hemorrhagic transformation (HT). Numerous studies have reported that immunomodulators have good efficacy on tPA-induced HT in ischemic stroke models. The benefits of immunomodulators on tPA-associated HT are not clearly defined. Here, we sought to conduct a systematic review and meta-analysis of preclinical studies to further evaluate the efficacy of immunomodulators. Methods: The PubMed, Web of Science, and Scopus electronic databases were searched for studies. Studies that reported the efficacy of immunomodulators on tPA-induced HT in animal models of stroke were included. Animals were divided into two groups: immunomodulators plus tPA (intervention group) or tPA alone (control group). The primary outcome was intracerebral hemorrhage, and the secondary outcomes included infarct volume and neurobehavioral score. Study quality was assessed by the checklist of CAMARADES. We used standardized mean difference (SMD) to assess the impact of interventions. Regression analysis and subgroup analysis were performed to identify potential sources of heterogeneity and evaluate the impact of the study characteristics. The evidence of publication bias was evaluated using trim and fill method and Egger’s test. Results: We identified 22 studies that met our inclusion criteria involving 516 animals and 42 different comparisons. The median quality checklist score was seven of a possible 10 (interquartile range, 6–8). Immunomodulators improved cerebral hemorrhage (1.31 SMD, 1.09–1.52); infarct volume (1.35 SMD, 0.95–1.76), and neurobehavioral outcome (0.9 SMD, 0.67–1.13) in experimental stroke. Regression analysis and subgroup analysis indicated that control of temperature and time of assessment were important factors that influencing the efficacy of immunomodulators. Conclusion: Our findings suggested that immunomodulators had a favorable effect on tPA-associated intracerebral hemorrhage, cerebral infarction, and neurobehavioral impairments in animal models of ischemic stroke.
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Affiliation(s)
- Yang Ye
- Department of Integration of Chinese and Western Medicine, School of Basic Medical Sciences, Peking University, Beijing, China.,Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China
| | - Yu-Tian Zhu
- Department of Traditional Chinese Medicine, Peking University Third Hospital, Beijing, China.,Department of Urology, Peking University Third Hospital, Beijing, China
| | - Hong-Xuan Tong
- Institute of Basic Theory for Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jing-Yan Han
- Department of Integration of Chinese and Western Medicine, School of Basic Medical Sciences, Peking University, Beijing, China.,Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China
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Toyoda K, Inoue M, Yoshimura S, Yamagami H, Sasaki M, Fukuda-Doi M, Kimura K, Asakura K, Miwa K, Kanzawa T, Ihara M, Kondo R, Shiozawa M, Ohtaki M, Kamiyama K, Itabashi R, Iwama T, Aoki J, Minematsu K, Yamamoto H, Koga M. Magnetic Resonance Imaging-Guided Thrombolysis (0.6 mg/kg) Was Beneficial for Unknown Onset Stroke Above a Certain Core Size: THAWS RCT Substudy. Stroke 2020; 52:12-19. [PMID: 33297866 DOI: 10.1161/strokeaha.120.030848] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We determined to identify patients with unknown onset stroke who could have favorable 90-day outcomes after low-dose thrombolysis from the THAWS (Thrombolysis for Acute Wake-Up and Unclear-Onset Strokes With Alteplase at 0.6 mg/kg) database. METHODS This was a subanalysis of an investigator-initiated, multicenter, randomized, open-label, blinded-end point trial. Patients with stroke with a time last-known-well >4.5 hours who showed a mismatch between diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery were randomly assigned (1:1) to receive alteplase at 0.6 mg/kg intravenously or standard medical treatment. The patients were dichotomized by ischemic core size or National Institutes of Health Stroke Scale score, and the effects of assigned treatments were compared in each group. The efficacy outcome was favorable outcome at 90 days, defined as a modified Rankin Scale score of 0 to 1. RESULTS The median DWI-Alberta Stroke Program Early CT Score (ASPECTS) was 9, and the median ischemic core volume was 2.5 mL. Both favorable outcome (47.1% versus 48.3%) and any intracranial hemorrhage (26% versus 14%) at 22 to 36 hours were comparable between the 68 thrombolyzed patients and the 58 control patients. There was a significant treatment-by-cohort interaction for favorable outcome between dichotomized patients by ASPECTS on DWI (P=0.026) and core volume (P=0.035). Favorable outcome was more common in the alteplase group than in the control group in patients with DWI-ASPECTS 5 to 8 (RR, 4.75 [95% CI, 1.33-30.2]), although not in patients with DWI-ASPECTS 9 to 10. Favorable outcome tended to be more common in the alteplase group than in the control group in patients with core volume >6.4 mL (RR, 6.15 [95% CI, 0.87-43.64]), although not in patients with volume ≤6.4 mL. The frequency of any intracranial hemorrhage did not differ significantly between the 2 treatment groups in any dichotomized patients. CONCLUSIONS Patients developing unknown onset stroke with DWI-ASPECTS 5 to 8 showed favorable outcomes more commonly after low-dose thrombolysis than after standard treatment. Registration: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT02002325. URL: https://www.umin.ac.jp/ctr; Unique Identifier: UMIN000011630.
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Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Japan (H. Yamagami)
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan (M. Sasaki, H. Yamamoto)
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan.,Center for Advancing Clinical and Translational Sciences (M.F.-D., K.A.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan (K. Kimura, J.A.)
| | - Koko Asakura
- Center for Advancing Clinical and Translational Sciences (M.F.-D., K.A.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Isesaki, Japan (T.K.)
| | - Masafumi Ihara
- Department of Neurology (M. Ihara), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Rei Kondo
- Department of Neurosurgery, Yamagata City Hospital Saiseikan, Japan (R.K.)
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ohtaki
- Department of Neurosurgery, Obihiro Kosei Hospital, Japan (M.O.)
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan (K. Kamiyama)
| | - Ryo Itabashi
- Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (R.I.)
| | - Toru Iwama
- Department of Neurosurgery, Gifu University School of Medicine, Japan (T.I.)
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan (K. Kimura, J.A.)
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Haruko Yamamoto
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan (M. Sasaki, H. Yamamoto)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine (K.T., M. Inoue, S.Y., M.F.-D., K. Miwa, M. Shiozawa, K. Minematsu, M.K.), National Cerebral and Cardiovascular Center, Suita, Japan
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Ospel JM, Singh N, Almekhlafi MA, Menon BK, Butt A, Poppe AY, Jadhav A, Silver FL, Shah R, Dowlatshahi D, O'Hare AM, Demchuk AM, Goyal M, Hill MD. Early Recanalization With Alteplase in Stroke Because of Large Vessel Occlusion in the ESCAPE Trial. Stroke 2020; 52:304-307. [PMID: 33213288 DOI: 10.1161/strokeaha.120.031591] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Quantitating the effect of intravenous alteplase on the technical outcome of early recanalization of large vessel occlusions aids understanding. We report the prevalence of early recanalization in patients with stroke because of large vessel occlusion treated with and without intravenous alteplase and endovascular thrombectomy, and its association with clinical outcome. METHODS Patients with acute ischemic stroke with large vessel occlusion from the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times Trial) were included in this post hoc analysis. Outcomes of interest were the prevalence of early recanalization (1) and good outcome (2), defined as modified Rankin Scale score of 0 to 2 at 90 days. RESULTS Among 147 patients who did not receive endovascular thrombectomy, early recanalization occurred in 4/30 (13.3%) patients without and 48/117 (41.0%) patients with intravenous alteplase (adjusted risk ratios, 3.2 [95% CI, 1.2-8.1]). Good outcome was achieved by 34/116 (29.3%) of patients who received intravenous alteplase versus 10/29 (34.5%) who did not receive alteplase (adjusted risk ratios, 1.0 [95% CI, 0.6-1.5) and by 20/52 (38.5%) patients with versus 24/93 (25.8%) without early recanalization (adjusted risk ratios, 1.9 [95% CI, 1.2-2.9]). CONCLUSIONS Early recanalization was confirmed as a strong predictor of good outcome in patients who did not undergo endovascular thrombectomy and was improved with intravenous alteplase, yet a majority of patients (59.0%) did not achieve early reperfusion. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01778335.
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Affiliation(s)
- Johanna M Ospel
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Neuroradiology, University Hospital Basel, Switzerland (J.M.O.)
| | - Nishita Singh
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Community Health Sciences (M.A.A., B.K.M., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Community Health Sciences (M.A.A., B.K.M., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Asif Butt
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada (A.B.)
| | - Alexandre Y Poppe
- Department of Clinical Neurosciences, Centre Hospitalier de l'Université de Montréal, Montréal, Canada (A.Y.P.)
| | - Ashutov Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.J.)
| | - Frank L Silver
- Department of Medicine (Neurology), Toronto Western Hospital, University Health Network, Canada (F.L.S.)
| | - Ruchir Shah
- Erlanger Medical Centre (Neurosciences), Chattanooga, TN (R.S.)
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa, Canada (D.D.)
| | - Alan M O'Hare
- Department of Radiology (Neuroradiology), Beaumont Hospital, Dublin, Ireland (A.M.O.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Community Health Sciences (M.A.A., B.K.M., M.D.H.), University of Calgary, Canada.,Department of Medicine (M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
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Abstract
Tenecteplase is a fibrinolytic drug with higher fibrin specificity and longer half-life than the standard stroke thrombolytic, alteplase, permitting the convenience of single bolus administration. Tenecteplase, at 0.5 mg/kg, has regulatory approval to treat ST-segment-elevation myocardial infarction, for which it has equivalent 30-day mortality and fewer systemic hemorrhages. Investigated as a thrombolytic for ischemic stroke over the past 15 years, tenecteplase is currently being studied in several phase 3 trials. Based on a systematic literature search, we provide a qualitative synthesis of published stroke clinical trials of tenecteplase that (1) performed randomized comparisons with alteplase, (2) compared different doses of tenecteplase, or (3) provided unique quantitative meta-analyses. Four phase 2 and one phase 3 study performed randomized comparisons with alteplase. These and other phase 2 studies compared different tenecteplase doses and effects on early outcomes of recanalization, reperfusion, and substantial neurological improvement, as well as symptomatic intracranial hemorrhage and 3-month disability on the modified Rankin Scale. Although no single trial prospectively demonstrated superiority or noninferiority of tenecteplase on clinical outcome, meta-analyses of these trials (1585 patients randomized) point to tenecteplase superiority in recanalization of large vessel occlusions and noninferiority in disability-free 3-month outcome, without increases in symptomatic intracranial hemorrhage or mortality. Doses of 0.25 and 0.4 mg/kg have been tested, but no advantage of the higher dose has been suggested by the results. Current clinical practice guidelines for stroke include intravenous tenecteplase at either dose as a second-tier option, with the 0.25 mg/kg dose recommended for large vessel occlusions, based on a phase 2 trial that demonstrated superior recanalization and improved 3-month outcome relative to alteplase. Ongoing randomized phase 3 trials may better define the comparative risks and benefits of tenecteplase and alteplase for stroke thrombolysis and answer questions of tenecteplase efficacy in the >4.5-hour time window, in wake-up stroke, and in combination with endovascular thrombectomy.
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Affiliation(s)
- Steven J Warach
- Department of Neurology, Dell Medical School, University of Texas at Austin
| | - Adrienne N Dula
- Department of Neurology, Dell Medical School, University of Texas at Austin
| | - Truman J Milling
- Department of Neurology, Dell Medical School, University of Texas at Austin
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Anfray A, Drieu A, Hingot V, Hommet Y, Yetim M, Rubio M, Deffieux T, Tanter M, Orset C, Vivien D. Circulating tPA contributes to neurovascular coupling by a mechanism involving the endothelial NMDA receptors. J Cereb Blood Flow Metab 2020; 40:2038-2054. [PMID: 31665952 PMCID: PMC7786842 DOI: 10.1177/0271678x19883599] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The increase of cerebral blood flow evoked by neuronal activity is essential to ensure enough energy supply to the brain. In the neurovascular unit, endothelial cells are ideally placed to regulate key neurovascular functions of the brain. Nevertheless, some outstanding questions remain about their exact role neurovascular coupling (NVC). Here, we postulated that the tissue-type plasminogen activator (tPA) present in the circulation might contribute to NVC by a mechanism dependent of its interaction with endothelial N-Methyl-D-Aspartate Receptor (NMDAR). To address this question, we used pharmacological and genetic approaches to interfere with vascular tPA-dependent NMDAR signaling, combined with laser speckle flowmetry, intravital microscopy and ultrafast functional ultrasound in vivo imaging. We found that the tPA present in the blood circulation is capable of potentiating the cerebral blood flow increase induced by the activation of the mouse somatosensorial cortex, and that this effect is mediated by a tPA-dependent activation of NMDAR expressed at the luminal part of endothelial cells of arteries. Although blood molecules, such as acetylcholine, bradykinin or ATP are known to regulate vascular tone and induce vessel dilation, our present data provide the first evidence that circulating tPA is capable of influencing neurovascular coupling (NVC).
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Affiliation(s)
- Antoine Anfray
- Normandie University, UNICAEN, INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Caen, France
| | - Antoine Drieu
- Normandie University, UNICAEN, INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Caen, France
| | - Vincent Hingot
- Institut Langevin, CNRS, INSERM, ESPCI Paris, PSL Research University, Paris, France
| | - Yannick Hommet
- Normandie University, UNICAEN, INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Caen, France
| | - Mervé Yetim
- Normandie University, UNICAEN, INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Caen, France
| | - Marina Rubio
- Normandie University, UNICAEN, INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Caen, France
| | - Thomas Deffieux
- Institut Langevin, CNRS, INSERM, ESPCI Paris, PSL Research University, Paris, France
| | - Mickael Tanter
- Institut Langevin, CNRS, INSERM, ESPCI Paris, PSL Research University, Paris, France
| | - Cyrille Orset
- Normandie University, UNICAEN, INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Caen, France
| | - Denis Vivien
- Normandie University, UNICAEN, INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Caen, France
- CHU Caen, Department of Clinical Research, Caen Normandie University Hospital, Avenue de la Côte de Nacre, Caen, France
- Denis Vivien, INSERM UMR-S U1237 “Physiopathology and Imaging of Neurological Disorders”, University Caen Normandie, GIP Cyceron, Bd Becquerel, BP5229, Caen 14074, France.
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48
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Pasquet N, Douceau S, Naveau M, Lesept F, Louessard M, Lebouvier L, Hommet Y, Vivien D, Bardou I. Tissue-Type Plasminogen Activator Controlled Corticogenesis Through a Mechanism Dependent of NMDA Receptors Expressed on Radial Glial Cells. Cereb Cortex 2020; 29:2482-2498. [PMID: 29878094 DOI: 10.1093/cercor/bhy119] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Indexed: 01/24/2023] Open
Abstract
Modifications of neuronal migration during development, including processes that control cortical lamination are associated with functional deficits at adult stage. Here, we report for the first time that the lack of the serine protease tissue-type Plasminogen Activator (tPA), previously characterized as a neuromodulator and a gliotransmitter, leads to an altered cortical lamination in adult. This results in a neuronal migration defect of tPA deficient neurons which are stopped in the intermediate zone at E16. This phenotype is rescued by re-expressing a wild-type tPA in cortical neurons at E14 but not by a tPA that cannot interact with NMDAR. We thus hypothetized that the tPA produced by cortical neuronal progenitors can control their own radial migration through a mechanism dependent of NMDAR expressed at the surface of radial glial cells (RGC). Accordingly, conditional deletion of tPA in neuronal progenitors at E14 or overexpression of a dominant-negative NMDAR that cannot bind tPA in RGC also delayed neuronal migration. Moreover, the lack of tPA lead to an impaired maturation and orientation of RGC. These data provide the first demonstration that the neuronal serine protease tPA is an actor of a proper corticogenesis by its ability to control NMDAR signaling in RGC.
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Affiliation(s)
- Nolwenn Pasquet
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U 1237, "Physiopathology and Imaging of Neurological Disorders", GIP Cyceron, Caen, France
| | - Sara Douceau
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U 1237, "Physiopathology and Imaging of Neurological Disorders", GIP Cyceron, Caen, France
| | - Mickael Naveau
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U 1237, "Physiopathology and Imaging of Neurological Disorders", GIP Cyceron, Caen, France
| | - Flavie Lesept
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U 1237, "Physiopathology and Imaging of Neurological Disorders", GIP Cyceron, Caen, France
| | - Morgane Louessard
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U 1237, "Physiopathology and Imaging of Neurological Disorders", GIP Cyceron, Caen, France
| | - Laurent Lebouvier
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U 1237, "Physiopathology and Imaging of Neurological Disorders", GIP Cyceron, Caen, France
| | - Yannick Hommet
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U 1237, "Physiopathology and Imaging of Neurological Disorders", GIP Cyceron, Caen, France
| | - Denis Vivien
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U 1237, "Physiopathology and Imaging of Neurological Disorders", GIP Cyceron, Caen, France.,CHU Caen, Clinical Research Department, Caen University Hospital, Caen, France
| | - Isabelle Bardou
- Normandie Université, UNICAEN, INSERM, INSERM UMR-S U 1237, "Physiopathology and Imaging of Neurological Disorders", GIP Cyceron, Caen, France
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Abstract
BACKGROUND AND PURPOSE We performed a systematic review and meta-analysis to assess the incidence and risk of seizures following acute stroke reperfusion therapy (intravenous thrombolysis [IVT] with r-tPA [recombinant tissue-type plasminogen activator], mechanical thrombectomy or both). METHODS We searched major databases (MEDLINE, SCOPUS, and Cochrane Library) for articles published between 1995 and October 28, 2019. The primary outcome was the overall and treatment specific pooled incidence of poststroke seizures (PSS) following acute reperfusion therapy. We also computed the pooled incidence of early poststroke seizures and late poststroke seizures separately for all studies. We derived the risk of PSS associated with IVT in the pooled cohort of patients who received only IVT. The small number of studies (<3) that reported on the risk of PSS associated with mechanical thrombectomy alone or in combination with IVT did not allow us to compute an estimate of the risk of seizures associated with this therapy. RESULTS We identified 13 753 patients with stroke, of which 592 had seizures. The pooled incidence of PSS was 5.9 % (95% CI, 4.2%-8.2%). PSS incidence rates among patients with stroke treated with IVT, mechanical thrombectomy, and both were respectively 6.1% (95% CI, 3.6%-10.2%), 5.9% (95% CI, 4.1%-8.4%), and 5.8 % (95% CI, 3.0%-10.9%). The incidence of late PSS was 6.7% (95% CI, 4.01%-11.02%) and that of early PSS was 3.14% (95% CI, 2.05%-4.76%). The pooled odds ratio for the association between IVT and PSS was 1.24 (95% CI, 0.75-2.05). CONCLUSIONS The findings of this meta-analysis suggest that about one in 15 ischemic stroke patients treated with IVT, mechanical thrombectomy, or both develop seizures independently of the specific reperfusion treatment that they received.
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Affiliation(s)
- Alain Lekoubou
- Department of Neurology (A.L.), Penn State University, Hershey, PA.,Division of Epidemiology, Department of Public Health Sciences (A.L., P.S.), Penn State University, Hershey, PA
| | - Jonah Fox
- Department of Neurology, Medical University of South Carolina, Charleston (J.F.)
| | - Paddy Ssentongo
- Division of Epidemiology, Department of Public Health Sciences (A.L., P.S.), Penn State University, Hershey, PA
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50
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Flint AC, Avins AL, Eaton A, Uong S, Cullen SP, Hsu DP, Edwards NJ, Reddy PA, Klingman JG, Rao VA, Chan SL, Hartman J, Zrelak PA, Nguyen-Huynh MN. Risk of Distal Embolization From tPA ( Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment. Stroke 2020; 51:2697-2704. [PMID: 32757749 DOI: 10.1161/strokeaha.120.029025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE In large artery occlusion stroke, both intravenous (IV) tPA (tissue-type plasminogen activator) and endovascular stroke treatment (EST) are standard-of-care. It is unknown how often tPA causes distal embolization, in which a procedurally accessible large artery occlusion is converted to a more distal and potentially inaccessible occlusion. METHODS We analyzed data from a decentralized stroke telemedicine program in an integrated healthcare delivery system covering 21 hospitals, with 2 high-volume EST centers. We captured all cases sent for EST and examined the relationship between IV tPA administration and the rate of distal embolization, the rate of target recanalization (modified Treatment in Cerebral Infarction scale 2b/3), clinical improvement before EST, and short-term and long-term clinical outcomes. RESULTS Distal embolization before EST was quite common (63/314 [20.1%]) and occurred more often after IV tPA before EST (57/229 [24.9%]) than among those not receiving IV tPA (6/85 [7.1%]; P<0.001). Distal embolization was associated with an inability to attempt EST: after distal embolization, 26/63 (41.3%) could not have attempted EST because of the new clot location, while in cases without distal embolization, only 8/249 (3.2%) were unable to have attempted EST (P<0.001). Among patients who received IV tPA, 13/242 (5.4%) had sufficient symptom improvement that a catheter angiogram was not performed; 6/342 (2.5%) had improvement to within 2 points of their baseline NIHSS. At catheter angiogram, 2/229 (0.9%) of patients who had received tPA had complete recanalization without distal embolization. Both IV tPA and EST recanalization were associated with improved long-term outcome. CONCLUSIONS IV tPA administration before EST for large artery occlusion is associated with distal embolization, which in turn may reduce the chance that EST can be attempted and recanalization achieved. At the same time, some IV tPA-treated patients show symptomatic improvement and complete recanalization. Because IV tPA is associated with both distal embolization and improved long-term clinical outcome, there is a need for prospective clinical trials testing the net benefit or harm of IV tPA before EST.
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Affiliation(s)
- Alexander C Flint
- Division of Research, Kaiser Permanente Northern California, Oakland (A.C.F., A.L.A, A.E., S.U., M.N.N.-H.).,Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland (A.C.F., A.L.A, A.E., S.U., M.N.N.-H.)
| | - Abigail Eaton
- Division of Research, Kaiser Permanente Northern California, Oakland (A.C.F., A.L.A, A.E., S.U., M.N.N.-H.)
| | - Stephen Uong
- Division of Research, Kaiser Permanente Northern California, Oakland (A.C.F., A.L.A, A.E., S.U., M.N.N.-H.)
| | - Sean P Cullen
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | - Daniel P Hsu
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | - Nancy J Edwards
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | - Prasad A Reddy
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | | | - Vivek A Rao
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | - Sheila L Chan
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | | | | | - Mai N Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland (A.C.F., A.L.A, A.E., S.U., M.N.N.-H.).,Kaiser Permanente, Sacramento, CA (J.G.K., M.N.N.-H.)
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