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Thorén M, Escudero-Martínez I, Andersson T, Chen SY, Tsao N, Khurana D, Beretta S, Peeters A, Tsivgoulis G, Roffe C, Ahmed N. Reperfusion by endovascular thrombectomy and early cerebral edema in anterior circulation stroke: Results from the SITS-International Stroke Thrombectomy Registry. Int J Stroke 2023; 18:1193-1201. [PMID: 37226337 PMCID: PMC10676032 DOI: 10.1177/17474930231180451] [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: 02/22/2023] [Accepted: 05/08/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND A large infarct and expanding cerebral edema (CED) due to a middle cerebral artery occlusion confers a 70% mortality unless treated surgically. There is still conflicting evidence whether reperfusion is associated with a lower risk for CED in acute ischemic stroke. AIM To investigate the association of reperfusion with development of early CED after stroke thrombectomy. METHODS From the SITS-International Stroke Thrombectomy Registry, we selected patients with occlusion of the intracranial internal carotid or middle cerebral artery (M1 or M2). Successful reperfusion was defined as mTICI ⩾ 2b. Primary outcome was moderate or severe CED, defined as focal brain swelling ⩾1/3 of the hemisphere on imaging scans at 24 h. We used regression methods while adjusting for baseline variables. Effect modification by severe early neurological deficits, as indicators of large infarct at baseline and at 24 h, were explored. RESULTS In total, 4640 patients, median age 70 years and median National Institutes of Health Stroke Score (NIHSS) 16, were included. Of these, 86% had successful reperfusion. Moderate or severe CED was less frequent among patients who had reperfusion compared to patients without reperfusion: 12.5% versus 29.6%, p < 0.05, crude risk ratio (RR) 0.42 (95% confidence interval (CI): 0.37-0.49), and adjusted RR 0.50 (95% CI: 0.44-0.57). Analysis of effect modification indicated that severe neurological deficits weakened the association between reperfusion and lower risk of CED. The RR reduction was less favorable in patients with severe neurological deficits, defined as NIHSS score 15 or more at baseline and at 24 h, used as an indicator for larger infarction. CONCLUSION In patients with large artery anterior circulation occlusion stroke who underwent thrombectomy, successful reperfusion was associated with approximately 50% lower risk for early CED. Severe neurological deficit at baseline seems to be a predictor for moderate or severe CED also in patients with successful reperfusion by thrombectomy.
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Affiliation(s)
- Magnus Thorén
- Stroke Research Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Danderyd Hospital, Stockholm, Sweden
| | - Irene Escudero-Martínez
- Department of Neurology, Hospital Universitari i Politécnic La Fe, Valencia, Spain
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - Tomas Andersson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Nicole Tsao
- Global Medical Affairs, Biogen, Cambridge, MA, USA
| | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Simone Beretta
- Department of Neurology and Stroke Unit, San Gerardo Hospital, Monza, Italy
| | - Andre Peeters
- Department of Neurology and Stroke Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Niaz Ahmed
- Stroke Research Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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Han N, Ma L, Xie Y, Xu G, Jia Y, Zhang N, Wang H. Application of Sofia Plus catheter tip shaping in the treatment of acute middle cerebral artery occlusion: A case control study. Medicine (Baltimore) 2023; 102:e35864. [PMID: 37960793 PMCID: PMC10637553 DOI: 10.1097/md.0000000000035864] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/10/2023] [Indexed: 11/15/2023] Open
Abstract
To explore the safety and efficacy of Sofia Plus distal access catheter tip shaping for treatment of acute middle cerebral artery embolism. This single-center retrospective study involved patients eligible for acute embolic middle cerebral artery occlusion from January 2020 to October 2021. They were divided into a shaping and non-shaping group according to whether the Sofia Plus catheter tip was shaped intraoperatively. Baseline data, preoperative Alberta Stroke Program Early Computed Tomography (ASPECT) score, National Institutes of Health Stroke Scale (NIHSS) score, onset-to-admission time, admission-to-puncture time, Sofia Plus-clot time, puncture-to-reperfusion time, surgical approach, and use of a stent for rescue thrombectomy were compared between the 2 groups. Postoperative symptomatic intracerebral hemorrhage and the modified Rankin scale score at the 90-day follow-up were observed. In total, 54 patients were enrolled in this study (shaping group, 26 patients; non-shaping group, 28 patients). Their mean age was 64.8 ± 14.6 years, and the proportion of men was 68.5% (37/54). Successful recanalization was achieved in all patients. There were no differences in the baseline data (age, sex, history, pre-admission ASPECT score, or NIHSS score) between the shaping and non-shaping groups. Patients treated with a shaped Sofia Plus catheter had a shorter Sofia Plus-clot time [median (25th, 75th percentile: 4 (4, 7) vs 10.5 (5.25, 14) min, P = .006] and puncture-to-reperfusion time [16.5 (12, 30.5) vs 26 (16.25, 38.25) min, P = .036]. There were significant differences in the surgical approaches between the 2 groups. The rates of a favorable outcome (57.7% vs 64.3%, P = .62) and postoperative symptomatic intracerebral hemorrhage (7.7% vs 3.6%, P = .60) were not significantly different between the groups. Sofia Plus catheter tip shaping improved catheter trafficability and reduced the operative time. It was safe and effective for treatment of acute middle cerebral artery thrombotic occlusion.
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Affiliation(s)
- Ning Han
- Neurointerventional department, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Shijiazhuang, Hebei, China
| | - Liang Ma
- Neurointerventional department, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Shijiazhuang, Hebei, China
| | - Yanzhao Xie
- Neurointerventional department, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Shijiazhuang, Hebei, China
| | - Guodong Xu
- Neurointerventional department, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Shijiazhuang, Hebei, China
| | - Yangjuan Jia
- Department of Emergency Medicine, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Ning Zhang
- Department of Ultrasound, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Hebo Wang
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Shijiazhuang, Hebei, China
- Neurology Department, Hebei General Hospital, Shijiazhuang, Hebei, China
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3
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Housley SB, Turner RC, Bouslama M, Lim J, Raygor KP, Lai PMR, Monteiro A, Baig AA, Nyabuto E, Davies JM, Siddiqui AH, Snyder KV, Levy EI. Expansion and Subsequent Rupture of Carotid Pseudoaneurysm After Tandem Carotid and Middle Cerebral Artery Occlusion Treated With Mechanical Thrombectomy and Carotid Stenting. Oper Neurosurg (Hagerstown) 2023; 25:e206-e210. [PMID: 37387562 DOI: 10.1227/ons.0000000000000810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/03/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Extracranial carotid artery pseudoaneurysm is a rare entity with potential etiologies including infection, blunt trauma, postsurgical atherosclerotic disease, and invasive neoplasia. Although the natural history of carotid pseudoaneurysm is difficult to determine because of its rarity, complications such as stroke, rupture, and local mass effect may occur at staggering rates. CLINICAL PRESENTATION In this case, a middle-aged man presented with a tandem carotid, middle cerebral artery occlusion that was treated with a carotid stent and mechanical thrombectomy. He returned 3 weeks later with a ruptured carotid pseudoaneurysm that was then treated with a covered stent. He made a full recovery and was neurologically intact on follow-up. CONCLUSION This case illustrates a rare potential complication of carotid occlusion and stenting with possible catastrophic consequences. The goal of this report was to educate other clinicians in remaining vigilant in awareness of this complication and provide a framework for potential treatment if and when it occurs.
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Affiliation(s)
- Steven B Housley
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Ryan C Turner
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Mehdi Bouslama
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Kunal P Raygor
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Pui Man Rosalind Lai
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Elizabeth Nyabuto
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
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4
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Zhi L, Zhang F, Liu H, Jiang X, Zhang Y, Yang Q, Zhang X, Liu M, Zhang Z, Song J. CRS induces depression-like behavior after MCAO in rats possibly by activating p38 MAPK. Behav Brain Res 2023; 437:114104. [PMID: 36100011 DOI: 10.1016/j.bbr.2022.114104] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 07/14/2022] [Revised: 09/01/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022]
Abstract
Post-stroke depression (PSD) is a common neuropsychiatric complication of stroke, which seriously affects the quality of life and prognosis of patients. Nevertheless, the pathogenesis of PSD remains unclear. In our study, a PSD rat model was established by chronic restraint stress (CRS) combined with middle cerebral artery occlusion (MCAO). Depressive and anxiety-like behaviors were tested, as well as Neuronal loss and Apoptosis. The expression of synapse and p38 MAPK signaling pathway -relevant proteins was detected. Our data indicated that CRS combined with MCAO could induce depression-like and anxiety-like behaviors, which led to neuronal damage, apoptosis, and cellular loss in the left parietal cortex and left hippocampus. Furthermore, CRS combined with MCAO decreased synaptic plasticity in the parietal cortex and left hippocampus. We found that CRS combined with MCAO had activated the p38 MAPK signaling pathway, and decreased the expression of pathway-related proteins MKK6 and MKK3. These results suggested that CRS combined with MCAO could lead to depression-like behavior via neuronal damage, apoptosis and reduced synaptic plasticity, which might be related to the activation of the p38 MAPK pathway. Therefore, it provides novel ideas for the research on the intervention and prevention mechanisms of PSD.
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MESH Headings
- Animals
- Rats
- Depression/etiology
- Depression/metabolism
- Depression/psychology
- Disease Models, Animal
- Infarction, Middle Cerebral Artery/etiology
- Infarction, Middle Cerebral Artery/metabolism
- Infarction, Middle Cerebral Artery/pathology
- Infarction, Middle Cerebral Artery/psychology
- p38 Mitogen-Activated Protein Kinases/metabolism
- Quality of Life
- Rats, Sprague-Dawley
- Stroke/etiology
- Stroke/metabolism
- Stroke/psychology
- Arterial Occlusive Diseases/etiology
- Arterial Occlusive Diseases/metabolism
- Synapses/metabolism
- Signal Transduction
- Restraint, Physical/adverse effects
- Restraint, Physical/physiology
- Restraint, Physical/psychology
- Chronic Disease
- Stress, Psychological/etiology
- Stress, Psychological/metabolism
- Stress, Psychological/psychology
- Apoptosis
- Anxiety/etiology
- Anxiety/metabolism
- Anxiety/psychology
- Cerebral Cortex/metabolism
- Cerebral Cortex/pathology
- Hippocampus/metabolism
- Hippocampus/pathology
- Neurons/metabolism
- Neurons/pathology
- Mitogen-Activated Protein Kinase Kinases/metabolism
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Affiliation(s)
- Lingyun Zhi
- The Second Affiliated Hospital of Xinxiang Medical University (Henan Mental Hospital), China; The First Affiliated Hospital of Xinxiang Medical University, China; Henan Key Lab of Biological Psychiatry, Henan International Joint Laboratory of Psychiatry and Neuroscience, Xinxiang Medical University, China
| | - Fuping Zhang
- The Second Affiliated Hospital of Xinxiang Medical University (Henan Mental Hospital), China; Henan Key Lab of Biological Psychiatry, Henan International Joint Laboratory of Psychiatry and Neuroscience, Xinxiang Medical University, China
| | - Huanhuan Liu
- The Second Affiliated Hospital of Xinxiang Medical University (Henan Mental Hospital), China; Henan Key Lab of Biological Psychiatry, Henan International Joint Laboratory of Psychiatry and Neuroscience, Xinxiang Medical University, China
| | - Xinhui Jiang
- The Second Affiliated Hospital of Xinxiang Medical University (Henan Mental Hospital), China; Henan Key Lab of Biological Psychiatry, Henan International Joint Laboratory of Psychiatry and Neuroscience, Xinxiang Medical University, China
| | - Yunfei Zhang
- The First Affiliated Hospital of Xinxiang Medical University, China; Henan Key Lab of Biological Psychiatry, Henan International Joint Laboratory of Psychiatry and Neuroscience, Xinxiang Medical University, China
| | - Qianling Yang
- The Second Affiliated Hospital of Xinxiang Medical University (Henan Mental Hospital), China; Henan Key Lab of Biological Psychiatry, Henan International Joint Laboratory of Psychiatry and Neuroscience, Xinxiang Medical University, China
| | - Xinyue Zhang
- The Second Affiliated Hospital of Xinxiang Medical University (Henan Mental Hospital), China; Henan Key Lab of Biological Psychiatry, Henan International Joint Laboratory of Psychiatry and Neuroscience, Xinxiang Medical University, China
| | - Mengke Liu
- The First Affiliated Hospital of Xinxiang Medical University, China; Henan Key Lab of Biological Psychiatry, Henan International Joint Laboratory of Psychiatry and Neuroscience, Xinxiang Medical University, China
| | - Zhaohui Zhang
- The First Affiliated Hospital of Xinxiang Medical University, China.
| | - Jinggui Song
- The Second Affiliated Hospital of Xinxiang Medical University (Henan Mental Hospital), China; Henan Key Lab of Biological Psychiatry, Henan International Joint Laboratory of Psychiatry and Neuroscience, Xinxiang Medical University, China.
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5
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Srichawla BS, Fang T, Bose A, Kipkorir V, Ferris A. Successful Mechanical Thrombectomy of Bilateral Middle Cerebral Artery Occlusions Following Apixaban Discontinuation. J Investig Med High Impact Case Rep 2023; 11:23247096231206624. [PMID: 37843107 PMCID: PMC10580708 DOI: 10.1177/23247096231206624] [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: 06/05/2023] [Revised: 06/20/2023] [Accepted: 09/22/2023] [Indexed: 10/17/2023] Open
Abstract
Optimal anticoagulation management in patients with atrial fibrillation (AF) during acute ischemic stroke is complex and often poses a significant clinical challenge. An 82-year-old man with AF presented with left-sided hemiparesis and hypoesthesia due to occlusion of the right middle cerebral artery (MCA) after discontinuing apixaban for 5 days. Successful mechanical thrombectomy (MT) achieved thrombolysis in cerebral infarction (TICI) score of 2C. Anticoagulation was postponed due to a small risk of hemorrhagic conversion. However, the patient developed a rare bilateral M1 segment MCA occlusions on the fifth day with a National Institute of Health Stroke Scale (NIHSS) score of 23, leading to an emergent thrombectomy, resulting in TICI 3 and TICI 2C recanalization in left and right MCAs, respectively. The patient required admission to the intensive care unit and was eventually discharged to an inpatient rehabilitation facility with only residual left hemiparesis and moderate dysarthria. This case underscores the delicate balance between the risk of recurrent ischemic stroke and the potential for hemorrhagic conversion when treating anticoagulation in the acute setting. Close monitoring and an individualized approach are necessary for the treatment of patients with AF who have suffered an acute stroke, especially when anticoagulation must be stopped. We encourage future guidelines to incorporate both imaging and clinical data when determining the continuation of anticoagulation in patients with a recent ischemic stroke. This case also depicts the effectiveness of neuroendovascular interventions such as MT to effectively manage rare simultaneous large multi-vessel occlusions with good outcomes.
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Affiliation(s)
| | - Ton Fang
- University of Massachusetts Chan Medical School, Worcester, USA
| | - Abigail Bose
- University of Massachusetts Chan Medical School, Worcester, USA
| | | | - Annie Ferris
- University of Massachusetts Chan Medical School, Worcester, USA
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6
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Kutsuna A, Aoki J, Kodera H, Nishiyama Y, Nakane T, Kimura K. [Delayed white matter lesion after mechanical thrombectomy for middle cerebral artery occlusion with Libman-Sacks endocarditis]. Rinsho Shinkeigaku 2022; 62:716-721. [PMID: 36031377 DOI: 10.5692/clinicalneurol.cn-001749] [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: 06/15/2023]
Abstract
A 59-year-old woman presented with right hemiparesis and was transported from outside hospital. MRI revealed acute infarction and the left middle cerebral artery M2 occlusion. Intravenous infusion of recombinant tissue-type plasminogen activator, and mechanical thrombectomy (MT) were performed. The cause of cerebral infarction was diagnosed as Libman-Sacks endocarditis. She discharged without sequelae. After 10 months later, she presented with mild cognitive decline, and MRI showed new white matter lesion in left deep white matter. In magnetic resonance spectroscopy, the lesion showed an increased rate of choline/creatine, and a decreased rate of N-acetylaspartate/creatine, elevated lactate peak. When new higher brain dysfunction presented after recanalization by MT, it might be related to the delayed white matter lesion.
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Affiliation(s)
- Akihito Kutsuna
- Department of Neurology, Nippon Medical School Graduate School of Medicine
| | - Junya Aoki
- Department of Neurology, Nippon Medical School Graduate School of Medicine
| | - Hiroto Kodera
- Department of Neurology, Nippon Medical School Graduate School of Medicine
| | - Yasuhiro Nishiyama
- Department of Neurology, Nippon Medical School Graduate School of Medicine
| | - Toshinari Nakane
- Department of Neurology, Nippon Medical School Graduate School of Medicine
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School Graduate School of Medicine
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Abstract
We herein report an 84-year-old woman with right middle cerebral artery (MCA) stenosis who presented with persistent left hemichorea preceding cerebral infarction. She visited our hospital on day 9 after the hemichorea onset. Magnetic resonance imaging (MRI) showed no acute cerebral infarction. Magnetic resonance angiography revealed right MCA stenosis. Her hemichorea persisted for 19 days and subsequently disappeared. On day 21, she developed left hemiplegia. Repeat MRI revealed a cerebral infarction in the right putamen. MCA stenosis can present with persistent hemichorea, even in the absence of cerebral infarction. Persistent hemichorea with MCA stenosis may presage cerebral infarction.
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Affiliation(s)
- Yuki Ueta
- Department of Neurology, Tokyo Medical University Hachioji Medical Center, Japan
- Department of Neurology, Tokyo Medical University, Japan
| | - Haruhisa Kato
- Department of Neurology, Tokyo Medical University, Japan
| | - Makiko Naito
- Department of Neurology, Tokyo Medical University, Japan
| | - Takeshi Taguchi
- Department of Neurology, Tokyo Medical University Hachioji Medical Center, Japan
- Department of Neurology, Tokyo Medical University, Japan
| | - Hiroo Terashi
- Department of Neurology, Tokyo Medical University, Japan
| | - Hitoshi Aizawa
- Department of Neurology, Tokyo Medical University, Japan
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8
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Masaraddi SK, Desai RJ, Deshpande SH, Patel S. Bee sting leading to stroke: a case report and review of the literature. BMJ Case Rep 2021; 14:e240693. [PMID: 34782373 PMCID: PMC8593608 DOI: 10.1136/bcr-2020-240693] [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] [Accepted: 10/19/2021] [Indexed: 11/03/2022] Open
Abstract
In India, bee stings are very common, seen mainly in farmers and honey collectors. Usually, it presents with local reactions and anaphylaxis. It rarely requires urgent hospitalisation. Other major complications seen are acute renal failure, intravascular coagulation, rhabdomyolysis and acute pulmonary oedema. Stroke as a presentation is uncommon. We report a case of a 45-year-old man presenting with right-sided hemiplegia and aphasia due to multiple bee stings. Diffusion MRI showed left middle cerebral artery territory hyperacute infarct.
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Affiliation(s)
- Shivakumar K Masaraddi
- General Medicine, BVVS S Nijalingappa Medical College and HSK Hospital and Research Centre, Bagalkot, Karnataka, India
| | - Rohan J Desai
- General Medicine, BVVS S Nijalingappa Medical College and HSK Hospital and Research Centre, Bagalkot, Karnataka, India
| | | | - Sameet Patel
- General Surgery, BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
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9
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Abareshi A, Momenabadi S, Vafaei AA, Bandegi AR, Vakili A. Neuroprotective Effects of Chemerin on a Mouse Stroke Model: Behavioral and Molecular Dimensions. Neurochem Res 2021; 46:3301-3313. [PMID: 34431027 DOI: 10.1007/s11064-021-03432-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 04/28/2021] [Revised: 08/15/2021] [Accepted: 08/18/2021] [Indexed: 11/30/2022]
Abstract
The present study was conducted to investigate the effects of different doses of recombinant human Chemerin (rhChemerin) on brain damage, spatial memory, blood-brain barrier (BBB) disruption and cellular and molecular mechanisms in a mouse stroke model. The mouse stroke model was developed by blocking the middle cerebral artery for 1 h and performing reperfusion for 23 h. Immediately, one and three hours after the stroke, 200, 400 and 800 ng/mouse of intranasal rhChemerin was administered. Neuronal and BBB damage, spatial memory and neurological performance were examined 24 h after the stroke. Western blotting and immunofluorescence were utilized to determine the effects of rhChemerin on the expressions of nuclear factor kappa B (NF-κB), pro-inflammatory cytokines such as TNF-α and IL-1β, anti-inflammatory cytokines such as IL-10 and TGF-β and vascular endothelial growth factor (VEGF). Administering 400 and 800 ng/mouse of rhChemerin in the mice immediately and one hour after ischemia minimized the infarct size, BBB opening, spatial memory and neurological impairment (P < 0.001). Furthermore, 800 ng/mouse of rhChemerin significantly diminished terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL)-positive (apoptotic) cells, suppressed the expressions of NF-kB, TNF-α and IL-1β and upregulated IL-10 and VEGF in the cortex and hippocampus of the mice. The present findings showed that rhChemerin administered immediately and one hour after stroke alleviates neuronal and BBB injures and improves spatial memory. These effects of rhChemerin may be mediated by inhibiting inflammatory pathways and apoptotic machinery.
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Affiliation(s)
- Azam Abareshi
- Research Center and Department of Physiology, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran
- Department of Physiology, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Iran
| | - Shahein Momenabadi
- Research Center and Department of Physiology, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran
- Department of Physiology, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Iran
| | - Abbas Ali Vafaei
- Research Center and Department of Physiology, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran
- Department of Physiology, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Iran
| | - Ahmad Reza Bandegi
- Department of Biochemistry, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Iran
| | - Abedin Vakili
- Research Center and Department of Physiology, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran.
- Department of Physiology, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Iran.
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10
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Khanna O, Hafazalla K, Saiegh FA, Tahir R, Schunemann V, Theofanis TN, Mouchtouris N, Gooch MR, Tjoumakaris S, Rosenwasser RH, Jabbour PM. Simultaneous bilateral mechanical thrombectomy in a patient with COVID-19. Clin Neurol Neurosurg 2021; 206:106677. [PMID: 34020326 PMCID: PMC8117485 DOI: 10.1016/j.clineuro.2021.106677] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023]
Abstract
Owing to systemic inflammation and widespread vessel endotheliopathy, SARS-CoV-2 has been shown to confer an increased risk of cryptogenic stroke, particularly in patients without any traditional risk factors. In this report, we present a case of a 67-year-old female who presented with acute stroke from bilateral anterior circulation large vessel occlusions, and was incidentally found to be COVID-positive on routine hospital admission screening. The patient had a large area of penumbra bilaterally, and the decision was made to pursue bilateral simultaneous thrombectomy, with two endovascular neurosurgeons working on each side to achieve a faster time to recanalization. Our study highlights the utility and efficacy of simultaneous bilateral thrombectomy, and this treatment paradigm should be considered for use in patients who present with multifocal large vessel occlusions.
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Affiliation(s)
- Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Karim Hafazalla
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rizwan Tahir
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Victoria Schunemann
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Thana N Theofanis
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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11
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Mi Y, Jiao K, Xu JK, Wei K, Liu JY, Meng QQ, Guo TT, Zhang XN, Zhou D, Qing DG, Sun Y, Li N, Hou Y. Kellerin from Ferula sinkiangensis exerts neuroprotective effects after focal cerebral ischemia in rats by inhibiting microglia-mediated inflammatory responses. J Ethnopharmacol 2021; 269:113718. [PMID: 33352239 DOI: 10.1016/j.jep.2020.113718] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 06/12/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Ferula sinkiangensis K. M. Shen is a traditional Chinese medicine that has a variety of pharmacological properties relevant to neurological disorders and inflammations. Kellerin, a novel compound extracted from Ferula sinkiangensis, exerts a strong anti-neuroinflammatory effect by inhibiting microglial activation. Microglial activation plays a vital role in ischemia-induced brain injury. However, the potential therapeutic effect of kellerin on focal cerebral ischemia is still unknown. AIM OF THE STUDY To explore the effect of kellerin on cerebral ischemia and clarify its possible mechanisms, we applied the middle cerebral artery occlusion (MCAO) model and the LPS-activated microglia model in our study. MATERIALS AND METHODS Neurological outcome was examined according to a 4-tiered grading system. Brain infarct size was measured using TTC staining. Brain edema was calculated using the wet weight minus dry weight method. Neuron damage and microglial activation were observed by immunofluorescence in MCAO model in rats. In in vitro studies, microglial activation was examined by flow cytometry and the viability of neuronal cells cultured in microglia-conditioned medium was measured using MTT assay. The levels of pro-inflammatory cytokines were measured by qRT-PCR and ELISA. The proteins involved in NF-κB signaling pathway were determined by western blot. Intracellular ROS was examined using DCFH-DA method and NADPH oxidase activity was measured using the NBT assay. RESULTS We found that kellerin improved neurological outcome, reduced brain infarct size and decreased brain edema in MCAO model in rats. Under the pathologic conditions of focal cerebral ischemia, kellerin alleviated neuron damage and inhibited microglial activation. Moreover, in in vitro studies of LPS-stimulated BV2 cells kellerin protected neuronal cells from being damaged by inhibiting microglial activation. Kellerin also reduced the levels of pro-inflammatory cytokines, suppressed the NF-κB signaling pathway, and decreased ROS generation and NADPH oxidase activity. CONCLUSIONS Our discoveries reveal that the neuroprotective effects of kellerin may largely depend on its inhibitory effect on microglial activation. This suggests that kellerin could serve as a novel anti-inflammatory agent which may have therapeutic effects in ischemic stroke.
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Affiliation(s)
- Yan Mi
- College of Life and Health Sciences, Northeastern University, Shenyang, China; Key Laboratory of Data Analytics and Optimization for Smart Industry, Northeastern University, Ministry of Education, Shenyang, China
| | - Kun Jiao
- College of Life and Health Sciences, Northeastern University, Shenyang, China; Key Laboratory of Data Analytics and Optimization for Smart Industry, Northeastern University, Ministry of Education, Shenyang, China
| | - Ji-Kai Xu
- College of Life and Health Sciences, Northeastern University, Shenyang, China; Key Laboratory of Data Analytics and Optimization for Smart Industry, Northeastern University, Ministry of Education, Shenyang, China
| | - Kun Wei
- School of Chemical Science and Technology, Yunnan University, Kunming, China
| | - Jing-Yu Liu
- College of Life and Health Sciences, Northeastern University, Shenyang, China
| | - Qing-Qi Meng
- College of Life and Health Sciences, Northeastern University, Shenyang, China
| | - Ting-Ting Guo
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, Shenyang, China
| | - Xue-Ni Zhang
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, Shenyang, China
| | - Di Zhou
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, Shenyang, China
| | - De-Gang Qing
- XinJiang Institute of Chinese Materia Medica and Ethnodrug, Urumqi, China
| | - Yu Sun
- XinJiang Institute of Chinese Materia Medica and Ethnodrug, Urumqi, China
| | - Ning Li
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, Shenyang, China.
| | - Yue Hou
- College of Life and Health Sciences, Northeastern University, Shenyang, China; Key Laboratory of Data Analytics and Optimization for Smart Industry, Northeastern University, Ministry of Education, Shenyang, China.
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12
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Jiang C, Li Y, Hao F, Yang J, Wang B, Fan Y. Y-configuration double-stent-retriever thrombectomy for refractory thrombus in middle cerebral artery bifurcation: A case report. Medicine (Baltimore) 2021; 100:e24993. [PMID: 33725971 PMCID: PMC7982166 DOI: 10.1097/md.0000000000024993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/11/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Stent retriever mechanical thrombectomy is a recommended treatment for acute ischemic stroke. However, refractory thrombus in artery bifurcation can reduce the rate of successful revascularization. PATIENT CONCERNS A 72-year-old male, owing to the acute onset of almost complete right-sided hemiplegia and global aphasia, received bridging therapy. National Institutes of Health Stroke Scale score was 16 at the time of admission. DIAGNOSES Cerebral digital subtraction angiography revealed occlusion of the M1 segment of the left MCA. INTERVENTIONS Thrombectomy with 3 passes of the Solitaire FR device (Medtronic, Minneapolis, MN) was unsuccessful. Two stent retrievers were inserted in parallel by one microcatheter access point to each M2 branch, and then both stents were gradually retrieved out of the catheter while continuous suction was maintained. OUTCOMES After thrombectomy, subsequent follow-up angiograms showed mTICI 3 reperfusion of MCA. The patient has mRS 2 at discharge and the 3-month mRS score after stroke is 1 score. LESSONS The presented Y-configuration double-stent-retriever thrombectomy technique constitutes a safe and effective rescue treatment method for refractory thrombus in MCA bifurcation.
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13
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Larpthaveesarp A, Pathipati P, Ostrin S, Rajah A, Ferriero D, Gonzalez FF. Enhanced Mesenchymal Stromal Cells or Erythropoietin Provide Long-Term Functional Benefit After Neonatal Stroke. Stroke 2021; 52:284-293. [PMID: 33349013 PMCID: PMC7770074 DOI: 10.1161/strokeaha.120.031191] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Perinatal stroke is a common cause of life-long neurobehavioral compromise. Mesenchymal stromal cells (MSCs) and EPO (erythropoietin) have each demonstrated short-term benefit with delayed administration after stroke, and combination therapy may provide the most benefit. The purpose of this study is to determine the long-term histological and functional efficacy of enhanced, intranasal stem cell therapy (MSC preexposed to EPO) compared with standard MSC or multidose systemic EPO. METHODS Transient middle cerebral artery occlusion or sham surgery was performed in postnatal day (P) 10 Sprague-Dawley rats, who were treated with single-dose intranasal MSC, MSC preexposed to EPO (MSC/EPO), multidose systemic EPO (EPO3; 1000 u/kg per dose×3 every 72 hours), or cell-conditioned media on P13 (day 3 [P13-P19] for EPO), or on P17 (day 7 [P17-P23] for EPO). At 2 months of age, animals underwent novel object recognition, cylinder rearing, and open field testing to assess recognition memory, sensorimotor function, and anxiety in adulthood. RESULTS MSC, MSC/EPO, and EPO3 improved brain volume when administered at 3 or 7 days after middle cerebral artery occlusion. MSC/EPO also enhanced long-term recognition memory with either day 3 or day 7 treatment, but EPO3 had the most long-term benefit, improving recognition memory and exploratory behavior and reducing anxiety. CONCLUSIONS These data suggest that single-dose MSC/EPO and multidose systemic EPO improve long-term neurobehavioral outcomes even when administration is delayed, although EPO was the most effective treatment overall. It is possible that EPO represents a final common pathway for improved long-term repair, although the specific mechanisms remain to be determined.
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Affiliation(s)
| | | | - Samuel Ostrin
- Department of Pediatrics, University of California, San Francisco
| | - Anthony Rajah
- Department of Pediatrics, University of California, San Francisco
| | - Donna Ferriero
- Department of Pediatrics, University of California, San Francisco
- Department of Neurology, University of California, San Francisco
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Abstract
RATIONALE Fungal endocarditis (FE) is a rare disease, in which antifungal treatment is necessary. When FE is complicated with prosthetic heart valve and/or atrial fibrillation, the coadministration of antifungal agents and warfarin is inevitable. We report a case of rheumatic heart disease with atrial fibrillation who developed FE following prosthetic heart valve replacement. The international normalized ratio (INR) increased significantly during the antifungal treatment with fluconazole. A discussion of the antifungal strategy in FE patients with prosthetic heart valves and/or atrial fibrillation and the interaction between antifungal agents and warfarin was performed. PATIENT CONCERNS A 54-year-old Chinese woman experienced intermittent fevers, aphemia, and weakness in her right extremities. Her temperature was 38.7°C, and there was atrial fibrillation with heart rate 110 times/min. Neurological examination revealed that she had drowsiness, Broca aphasia, right central facial paralysis, and hemiplegia (Medical Research Council scale, upper limb grade 0, lower limb grade II). DIAGNOSES Multiple infarction on magnetic resonance imaging and the occlusion of left middle cerebral artery suggested the occurrence of cerebral embolism. The presence of Candida parapsilosis in the results of 4 blood cultures and the existence of valve vegetation in the reexamination of echocardiogram supported the diagnosis of FE. INTERVENTIONS The patient was given antifungal therapy with fluconazol. The INR increased dramatically on the 9th day of antifungal treatment, and subcutaneous bruising occurred at the intravenous infusion site. The antagonist of vitamin K1 was used and warfarin was reduced to a smaller dosage. The antifungal agent was replaced with caspofungin. OUTCOMES Her speech improved significantly, and the muscle strength of her paralyzed side reached the Medical Research Council scale of grade IV. She continued to receive caspofungin for antifungal treatment with relatively stable INR and waited for heart valve surgery. LESSONS The choice of antifungal agents is often a big challenge for FE patients, especially when they need warfarin for anticoagulation. It is better to administer a low dose of warfarin while carefully monitoring the INR or choose the antifungal drugs with little or no effect on warfarin.
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Affiliation(s)
- Xiaoxia Zhu
- Department of Cardiology, The Second Affiliated Hospital of Anhui Medical University
| | - Shugang Cao
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
| | - Mingwu Xia
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
| | - Chandong Ding
- Department of Cardiology, The Second Affiliated Hospital of Anhui Medical University
| | - Rongfeng Wang
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
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15
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Lee S, Kim OJ, Lee KO, Jung H, Oh SH, Kim NK. Enhancing the Therapeutic Potential of CCL2-Overexpressing Mesenchymal Stem Cells in Acute Stroke. Int J Mol Sci 2020; 21:ijms21207795. [PMID: 33096826 PMCID: PMC7588958 DOI: 10.3390/ijms21207795] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [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: 09/14/2020] [Revised: 10/19/2020] [Accepted: 10/19/2020] [Indexed: 01/15/2023] Open
Abstract
Although intravenous administration of mesenchymal stem cells (MSCs) is effective for experimental stroke, low engraftment and the limited functional capacity of transplanted cells are critical hurdles for clinical applications. C-C motif chemokine ligand 2 (CCL2) is associated with neurological repair after stroke and delivery of various cells into the brain via CCL2/CCR2 (CCL2 receptor) interaction. In this study, after CCL2-overexpressing human umbilical cord-derived MSCs (hUC-MSCs) were intravenously transplanted with mannitol in rats with middle cerebral arterial occlusion, we compared the differences between four different treatment groups: mannitol + CCL2-overexpressing hUC-MSCs (CCL2-MSC), mannitol + naïve hUC-MSCs (M-MSC), mannitol only, and control. At four-weeks post-transplantation, the CCL2-MSC group showed significantly better functional recovery and smaller stroke volume relative to the other groups. Additionally, we observed upregulated levels of CCR2 in acute ischemic brain and the increase of migrated stem cells into these areas in the CCL2-MSC group relative to the M-MSC. Moreover, the CCL2-MSC group displayed increased angiogenesis and endogenous neurogenesis, decreased neuro-inflammation but with increased healing-process inflammatory cells relative to other groups. These findings indicated that CCL2-overexpressing hUC-MSCs showed better functional recovery relative to naïve hUC-MSCs according to the increased migration of these cells into brain areas of higher CCR2 expression, thereby promoting subsequent endogenous brain repair.
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Affiliation(s)
- Sanghun Lee
- Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam 13496, Korea; (S.L.); (K.O.L.); (H.J.); (S.-H.O.)
| | - Ok Joon Kim
- Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam 13496, Korea; (S.L.); (K.O.L.); (H.J.); (S.-H.O.)
- Correspondence: ; Tel.: +82-31-780-5481; Fax: +82-31-780-5269
| | - Kee Ook Lee
- Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam 13496, Korea; (S.L.); (K.O.L.); (H.J.); (S.-H.O.)
| | - Hyeju Jung
- Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam 13496, Korea; (S.L.); (K.O.L.); (H.J.); (S.-H.O.)
| | - Seung-Hun Oh
- Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam 13496, Korea; (S.L.); (K.O.L.); (H.J.); (S.-H.O.)
| | - Nam Keun Kim
- Institute for Clinical Research, CHA Bundang Medical Center, CHA University, Seongnam 13488, Korea;
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16
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Fara MG, Stein LK, Skliut M, Morgello S, Fifi JT, Dhamoon MS. Macrothrombosis and stroke in patients with mild Covid-19 infection. J Thromb Haemost 2020; 18:2031-2033. [PMID: 32464707 PMCID: PMC7283879 DOI: 10.1111/jth.14938] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [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: 05/20/2020] [Accepted: 05/23/2020] [Indexed: 12/01/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is a pandemic disease currently affecting millions of people worldwide. Its neurological implications are poorly understood, and further study is urgently required. A hypercoagulable state has been reported in patients with severe COVID-19, but nothing is known about coagulopathy in patients with milder disease. We describe cases of patients in New York City presenting with stroke secondary to large vessel thrombosis without occlusion, incidentally found to have COVID-19 with only mild respiratory symptoms. This is in contrast to the venous thrombosis and microangiopathy that has been reported in patients with severe COVID-19. Our cases suggest that even in the absence of severe disease, patients with COVID-19 may be at increased risk of thrombus formation leading to stroke, perhaps resulting from viral involvement of the endothelium. Further systematic study is needed because this may have implications for primary and secondary stroke prevention in patients with COVID-19.
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Affiliation(s)
- Michael G Fara
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maryna Skliut
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Susan Morgello
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Departments of Neuroscience and Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johanna T Fifi
- Departments of Neurology and Neurosurgery, Icahn School of Medicine, New York, NY, USA
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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17
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Genchi A, Schwarz G, Semerano A, Callea M, Sanvito F, Simionato F, Panni P, Scomazzoni F, Doglioni C, Comi G, Falini A, Ancona F, Filippi M, Roveri L, Bacigaluppi M. Large vessel occlusion stroke due to dislodged aortic valve calcification revealed by imaging and histopathology. J Neurol Sci 2020; 408:116573. [PMID: 31731112 DOI: 10.1016/j.jns.2019.116573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/03/2019] [Accepted: 11/06/2019] [Indexed: 11/15/2022]
Affiliation(s)
- A Genchi
- Neuroimmunology Unit, Institute of Experimental Neurology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Department of Neurology, Stroke Unit, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - G Schwarz
- Department of Neurology, Stroke Unit, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - A Semerano
- Neuroimmunology Unit, Institute of Experimental Neurology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Department of Neurology, Stroke Unit, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - M Callea
- Department of Pathology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - F Sanvito
- Department of Pathology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - F Simionato
- Department of Neuroradiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - P Panni
- Department of Neuroradiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - F Scomazzoni
- Department of Neuroradiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - C Doglioni
- Department of Pathology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - G Comi
- Department of Neurology, Stroke Unit, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - A Falini
- Department of Neuroradiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - F Ancona
- Department of Cardiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - M Filippi
- Department of Neurology, Stroke Unit, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - L Roveri
- Department of Neurology, Stroke Unit, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - M Bacigaluppi
- Neuroimmunology Unit, Institute of Experimental Neurology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Department of Neurology, Stroke Unit, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy.
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18
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Wu R, Luo S, Yang H, Hu X, Lin A, Pan G, Zhong X, Li Z. Transplantation of neural progenitor cells generated from human urine epithelial cell-derived induced pluripotent stem cells improves neurological functions in rats with stroke. Discov Med 2020; 29:53-64. [PMID: 32598863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
As a potentially unlimited autologous cell source, induced pluripotent stem cells (iPSCs) provide a needed option for the application of iPSC-derived neural progenitor cells (NPCs) for regenerative medicine for the treatment of stroke. To enable the application of iPSC technology, it is essential to develop a practical approach to generate iPSC cells under a non-viral, non-integration, feeder-free condition from the most optimal somatic cell type. In this study, we differentiated NPCs from a urine-derived iPSC line (UC-05) which was generated with optimized episomal vectors in a feeder-free culture system. UC-05 can be induced into NPCs efficiently in monolayer cultures using dual SMAD inhibitions, and have the ability to differentiate further into astrocytes and functional neurons in vitro. We then characterized UC-05-derived NPCs upon transplantation into the striatum of adult male rats subjected to transient middle cerebral artery occlusion (tMCAO) reperfusion. While NPCs were grafted into rats 7 days before the MCAO surgery, cells were found to migrate from the grafted side to the lesion side of the brain via corpus callosum 14 days after tMCAO. UC05-derived NPCs were grafted into the striatum 7 days after tMCAO, grafted cells can survive and differentiate into neurons and astrocytes 35 days after transplantation, and synaptic protein SYNAPSIN 1 could also be detected around the grafted human cells. tMCAO rats with NPC engraftment showed better behavior improvement in both postural reflex test and cylinder test compared to control rats engrafted with the cell medium only. Our data indicate that NPCs differentiated from urine-derived iPSCs could act similarly to endogenous neural progenitors in vitro and in vivo. Urine-derived iPSCs could be a potential candidate for cell transplantation therapy in stroke.
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Affiliation(s)
- Rui Wu
- Department of Rehabilitation Medicine, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510620, China
- Department of Neurology, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, China
- Guangdong Provincial Key Laboratory of Stem Cell and Regenerative Medicine, South China Institute for Stem Cell Biology and Regenerative Medicine, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, Guangdong 510535, China
| | - Shijian Luo
- Department of Neurology, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, China
| | - Huanchun Yang
- Department of Rehabilitation Medicine, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510620, China
| | - Xiquan Hu
- Department of Rehabilitation Medicine, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510620, China
| | - Aiping Lin
- Guangdong Provincial Key Laboratory of Stem Cell and Regenerative Medicine, South China Institute for Stem Cell Biology and Regenerative Medicine, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, Guangdong 510535, China
| | - Guangjin Pan
- Guangdong Provincial Key Laboratory of Stem Cell and Regenerative Medicine, South China Institute for Stem Cell Biology and Regenerative Medicine, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, Guangdong 510535, China
| | - Xiaofen Zhong
- Guangdong Provincial Key Laboratory of Stem Cell and Regenerative Medicine, South China Institute for Stem Cell Biology and Regenerative Medicine, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, Guangdong 510535, China
- Corresponding author
| | - Zhendong Li
- Department of Neurology, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, China
- Corresponding author
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19
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Jackson L, Li W, Abdul Y, Dong G, Baban B, Ergul A. Diabetic Stroke Promotes a Sexually Dimorphic Expansion of T Cells. Neuromolecular Med 2019; 21:445-453. [PMID: 31197651 PMCID: PMC6884673 DOI: 10.1007/s12017-019-08554-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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] [Received: 04/09/2019] [Accepted: 06/04/2019] [Indexed: 12/31/2022]
Abstract
We recently reported that diabetes negates the cerebrovascular protection typically seen in adult female rats resulting in cognitive impairment, which is worsened by increased parenchymal bleeding and edema after ischemic stroke. Although women experience more severe diabetes and suffer from a higher rate of diabetic complications, including stroke and cognitive impairment, underlying mechanisms contributing to sex differences are limited. Emerging evidence suggests interleukin (IL)-17 contributes to cerebrovascular pathologies: (1) high salt diet-mediated expansion of IL-17-producing T cells (Th17) in the gut microbiome promotes cerebrovascular dysfunction and cognitive impairment in male mice, (2) increased IL-17-producing γδTCR cells exacerbates stroke injury in male mice, and (3) IL-17 promotes rupture of cerebral aneurysms in female mice. Based on these premises, we investigated the potential involvement of IL-17-producing inflammatory cells in cerebrovascular dysfunction and post-stroke vascular injury in diabetes by measuring intestinal, circulating, or cerebral T cell profiles as well as in plasma IL-17 in both sexes. Cell suspensions prepared from naive or stroked (3 days after stroke) diabetic and control rats were analyzed by flow cytometry, and IL-17 levels were measured in plasma using ELISA. Diabetes deferentially promoted the expansion of cerebral Th17 cells in females. In response to stroke, diabetes had a sexually dimorphic effect on the expansion of numerous T cell profiles. These results suggest that a better understanding of the role of IL-17-producing cells in diabetes may identify potential avenues in which the molecular mechanisms contributing to these sex differences can be further elucidated.
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Affiliation(s)
- Ladonya Jackson
- Program in Clinical and Experimental Therapeutics, University of Georgia, Augusta, GA, USA
| | - Weiguo Li
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, 171 Ashley Ave. MSC 908, Charleston, SC, 29425, USA
- Ralph Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Yasir Abdul
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, 171 Ashley Ave. MSC 908, Charleston, SC, 29425, USA
- Ralph Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Guangkuo Dong
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Babak Baban
- Department of Oral Biology, Dental College of Georgia, Augusta University, Augusta, GA, USA
| | - Adviye Ergul
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, 171 Ashley Ave. MSC 908, Charleston, SC, 29425, USA.
- Ralph Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
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20
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Wu P, Yan XS, Zhou LL, Liu XL, Huo DS, Song W, Fang X, Wang H, Yang ZJ, Jia JX. Involvement of apoptosis in the protective effects of Dracocephalum moldavaica in cerebral ischemia reperfusion rat model. J Toxicol Environ Health A 2019; 82:1036-1044. [PMID: 31736438 DOI: 10.1080/15287394.2019.1684707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
An extract of Dracocephalum moldevica (DML) was found to exert protective effects on cerebral ischemia-reperfusion injury (CIRI); however, the mechanisms underlying the observed actions of this plant-derived mixture remain to be determined. Thus, the aim of this study was to examine the influence of DML on CIRI rat model induced by middle cerebral artery occlusion (MCAO). The following parameters were measured: (1) viable neurons in the infarcted area using Nissl staining; and (2) immunohistochemistry and Western blot were employed to determine protein expression levels of p53, bcl-2 associated X protein (bax) and B-cell lymphoma-2 (bcl-2), three biomarkers of apoptosis. MCAO significantly decreased the number of viable cortical pyramidal neurons in the infarcted area, while treatment with DML extract significantly elevated the number of viable neurons. MCAO was found to significantly elevate in gene expression levels of p53 and protein expression levels bax accompanied by diminished protein expression levels of bcl-2. Prior administration of DML extract produced marked reduction in gene expression levels of p53 and protein expression levels bax but increased in protein expression levels of bcl-2. Data suggested apoptosis was initiated in MCAO and that DML was effective in treating CIRI via an anti-apoptotic action as evidenced by inhibition of gene expression levels of p53 and protein expression levels of bax with concomitant elevation in protein expression levels of bcl-2. Our findings suggest that extract of DML may prove beneficial in treatment of cerebrovascular disorders.
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Affiliation(s)
- Peng Wu
- Department of Human Anatomy, Baotou Medical College, Inner Mongolia, China
| | - Xu-Sheng Yan
- Department of Human Anatomy, Baotou Medical College, Inner Mongolia, China
| | - Li-Li Zhou
- Department of Human Anatomy, Baotou Medical College, Inner Mongolia, China
| | - Xin-Lang Liu
- Department of Human Anatomy, Baotou Medical College, Inner Mongolia, China
| | - Dong-Sheng Huo
- Department of Human Anatomy, Baotou Medical College, Inner Mongolia, China
| | - Wei Song
- Department of Human Anatomy, Baotou Medical College, Inner Mongolia, China
| | - Xin Fang
- Department of Human Anatomy, Baotou Medical College, Inner Mongolia, China
| | - He Wang
- School of Health Sciences, University of Newcastle, Newcastle, Australia
| | - Zhan-Jun Yang
- Department of Human Anatomy, Baotou Medical College, Inner Mongolia, China
| | - Jian-Xin Jia
- Department of Human Anatomy, Baotou Medical College, Inner Mongolia, China
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21
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Pérez Fajardo G, García Castro E, Sánchez González A. Hyperdense middle cerebral artery sign: traumatic dissection of the internal carotid artery. Emergencias 2019; 31:363-364. [PMID: 31625313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Germán Pérez Fajardo
- Servicio de Urgencias, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, España
| | - Elvira García Castro
- Servicio de Urgencias, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, España
| | - Aurora Sánchez González
- Servicio de Urgencias, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, España
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22
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Vasquez CA, Moen SL, Juliano MJ, Jagadeesan BD, Pluhar GE, Chen CC, Grande AW. Development of a Novel Canine Model of Ischemic Stroke: Skull Base Approach with Transient Middle Cerebral Artery Occlusion. World Neurosurg 2019; 127:e251-e260. [PMID: 30898757 DOI: 10.1016/j.wneu.2019.03.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 01/27/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Although canine stroke models have several intrinsic advantages, establishing consistent and reproducible territorial stroke in these models has been challenging because of the abundance of collateral circulation. We have described a skull-base surgical approach that yields reproducible stroke volumes. METHODS Ten male beagles were studied. In all 10 dogs, a craniectomy was performed to expose the circle of Willis. Cerebral aneurysm clips were temporarily applied to the middle cerebral artery (MCA), anterior cerebral artery (ACA), posterior cerebral artery, and/or ophthalmic artery (OA) for 1 hour, followed by cauterization of the distal MCA pial collateral vessels. Indocyanine green angiography was performed to assess the local blood flow to the intended area of infarction. The dogs' neurologic examination was evaluated, and the stroke burden was quantified using magnetic resonance imaging. RESULTS High mortality was observed after 1-hour clip occlusion of the posterior cerebral artery, MCA, ACA, and OA (n = 4). Without coagulation of the MCA collateral vessels, 1-hour occlusion of the MCA and/or ACA and OA yielded inconsistent stroke volumes (n = 2). In contrast, after coagulation of the distal MCA pial collateral vessels, 1-hour occlusion of the MCA, ACA, and OA yielded consistent territorial stroke volumes (n = 4; average stroke volume, 9.13 ± 0.90 cm3; no surgical mortalities), with reproducible neurologic deficits. CONCLUSION Consistent stroke volumes can be achieved in male beagles using a skull base surgical approach with temporary occlusion of the MCA, ACA, and OA when combined with cauterization of the distal MCA pial collateral vessels.
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Affiliation(s)
- Ciro A Vasquez
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sean L Moen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mario J Juliano
- Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - G Elizabeth Pluhar
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew W Grande
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA; Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA; Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota, USA.
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23
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Nakayama T, Nagata E, Masuda H, Asahara T, Takizawa S. Regeneration-associated cell transplantation contributes to tissue recovery in mice with acute ischemic stroke. PLoS One 2019; 14:e0210198. [PMID: 30682162 PMCID: PMC6347160 DOI: 10.1371/journal.pone.0210198] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 12/18/2018] [Indexed: 01/05/2023] Open
Abstract
Various cell-based therapeutic strategies have been investigated for vascular and tissue regeneration after ischemic stroke. We have developed a novel cell population, called regeneration-associated cells (RACs), by quality- and quantity-controlled culture of unfractionated mononuclear cells. RACs were trans-arterially injected into 10-week-old syngeneic male mice at 1, 3, 5 or 7 days after permanent middle cerebral artery occlusion (MCAO) to determine the optimal timing for administration in terms of outcome at day 21. Next, we examined the effects of RACs injection at day 1 after MCAO on neurological deficits, infarct volume, and mediators of vascular regeneration and anti-inflammation at days 7 and 21. Infarct volume at day 21 was significantly reduced by transplantation of RACs at day 1 or 3. RACs injected at day 1 reduced the infarct volume at day 7 and 21. Angiogenesis and anti-inflammatory mediators, VEGF and IL-10, were increased at day 7, and VEGF was still upregulated at day 21. We also observed significantly enhanced ink perfusion in vivo, tube formation in vitro, and definitive endothelial progenitor cell colonies in colony assay. These results suggest that RAC transplantation in MCAO models promoted significant recovery of neural tissues through intensified anti-inflammatory and angiogenic effects.
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Affiliation(s)
- Taira Nakayama
- Department of Neurology, Tokai University School of Medicine, Isehara, Japan
| | - Eiichiro Nagata
- Department of Neurology, Tokai University School of Medicine, Isehara, Japan
| | - Haruchika Masuda
- Department of Physiology, Tokai University School of Medicine, Isehara, Japan
| | - Takayuki Asahara
- Department of Regenerative Medicine Science, Tokai University School of Medicine, Isehara, Japan
| | - Shunya Takizawa
- Department of Neurology, Tokai University School of Medicine, Isehara, Japan
- * E-mail:
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24
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Bayliss M, Trotman-Lucas M, Janus J, Kelly ME, Gibson CL. Pre-stroke surgery is not beneficial to normotensive rats undergoing sixty minutes of transient focal cerebral ischemia. PLoS One 2018; 13:e0209370. [PMID: 30592760 PMCID: PMC6310237 DOI: 10.1371/journal.pone.0209370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/04/2018] [Indexed: 11/18/2022] Open
Abstract
Experimental stroke in rodents, via middle cerebral artery occlusion (MCAO), can be associated with a negative impact on wellbeing and mortality. In hypertensive rodents, pre-stroke craniotomy increased survival and decreased body weight loss post-MCAO. Here we determined the effect, in normotensive Sprague-Dawley rats following 60 minutes MCAO, with or without pre-surgical craniotomy, on post-stroke outcomes in terms of weight loss, neurological deficit, lesion volume and functional outcomes. There was no effect of pre-stroke craniotomy on indicators of wellbeing including survival rate (P = 0.32), body weight loss (P = 0.42) and neurological deficit (P = 0.75). We also assessed common outcome measures following experimental stroke and found no effect of pre-stroke craniotomy on lesion volume as measured by T2-weighted MRI (P = 0.846), or functional performance up to 28 days post-MCAO (staircase test, P = 0.32; adhesive sticker test, P = 0.49; cylinder test, P = 0.38). Thus, pre-stroke craniotomy did not improve animal welfare in terms of body weight loss and neurological deficit. However, it is important, given that a number of drug delivery studies utilise the craniotomy procedure, to note that there was no effect on lesion volume or functional outcome following experimental stroke.
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MESH Headings
- Animals
- Blood Pressure
- Cerebrum/blood supply
- Cerebrum/diagnostic imaging
- Craniotomy
- Disease Models, Animal
- Humans
- Infarction, Middle Cerebral Artery/diagnostic imaging
- Infarction, Middle Cerebral Artery/etiology
- Infarction, Middle Cerebral Artery/mortality
- Infarction, Middle Cerebral Artery/prevention & control
- Ischemic Attack, Transient/diagnostic imaging
- Ischemic Attack, Transient/etiology
- Ischemic Attack, Transient/mortality
- Ischemic Attack, Transient/prevention & control
- Magnetic Resonance Imaging
- Male
- Rats
- Rats, Sprague-Dawley
- Survival Rate
- Treatment Outcome
- Weight Loss
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Affiliation(s)
- Michaela Bayliss
- Department of Neuroscience, Psychology & Behaviour, University of Leicester, Leicester, United Kingdom
| | - Melissa Trotman-Lucas
- Department of Neuroscience, Psychology & Behaviour, University of Leicester, Leicester, United Kingdom
| | - Justyna Janus
- Preclinical Imaging Facility, Core Biotechnology Services, University of Leicester, Leicester, United Kingdom
| | - Michael E. Kelly
- Preclinical Imaging Facility, Core Biotechnology Services, University of Leicester, Leicester, United Kingdom
| | - Claire L. Gibson
- Department of Neuroscience, Psychology & Behaviour, University of Leicester, Leicester, United Kingdom
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Li S, Zi W, Chen J, Zhang S, Bai Y, Guo Y, Shang X, Sun B, Liang M, Liu Y, Wan Y, Wang M, Zhao M, Liu R, Zhu W, Liu X, Xu G. Feasibility of Thrombectomy in Treating Acute Ischemic Stroke Because of Cervical Artery Dissection. Stroke 2018; 49:3075-3077. [PMID: 30571399 DOI: 10.1161/strokeaha.118.023186] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shun Li
- From the Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu, China (S.L., W. Zhu, X.L., G.X.)
| | - Wenjie Zi
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Jiangsu, China (W. Zi, M.W., M.Z., R.L., W. Zhu, X.L., G.X.)
- Department of Neurology, Xinqiao Hospital, Third Military Medical University, Chongqing, China (W. Zi)
| | - Jingjing Chen
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Jiangsu, China (J.C., S.Z., Y.B., Y.G., X.S., B.S., X.L., G.X.)
| | - Shuai Zhang
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Jiangsu, China (J.C., S.Z., Y.B., Y.G., X.S., B.S., X.L., G.X.)
- Department of Neurology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Jiangsu, China (S.Z.)
| | - Yongjie Bai
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Jiangsu, China (J.C., S.Z., Y.B., Y.G., X.S., B.S., X.L., G.X.)
- Department of Neurology, First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan, China (Y.B.)
| | - Yongtao Guo
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Jiangsu, China (J.C., S.Z., Y.B., Y.G., X.S., B.S., X.L., G.X.)
- Department of Neurology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Nanjing Medical University, Huaian, Jiangsu, China (Y.G., B.S., )
| | - Xianjin Shang
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Jiangsu, China (J.C., S.Z., Y.B., Y.G., X.S., B.S., X.L., G.X.)
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China (X.S.)
| | - Bo Sun
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Jiangsu, China (J.C., S.Z., Y.B., Y.G., X.S., B.S., X.L., G.X.)
- Department of Neurology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Nanjing Medical University, Huaian, Jiangsu, China (Y.G., B.S., )
| | - Meng Liang
- Department of Neurology, Jinling Hospital, Second Military Medical University, Nanjing, Jiangsu, China (M.L.)
| | - Yong Liu
- Department of Neurology, Lu'an Affiliated Hospital of Anhui Medical University, China (Y.L.)
| | - Yue Wan
- Department of Neurology, Hubei Zhongshan Hospital, Wuhan, China (Y.W.)
| | - Mengmeng Wang
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Jiangsu, China (W. Zi, M.W., M.Z., R.L., W. Zhu, X.L., G.X.)
| | - Min Zhao
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Jiangsu, China (W. Zi, M.W., M.Z., R.L., W. Zhu, X.L., G.X.)
| | - Rui Liu
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Jiangsu, China (W. Zi, M.W., M.Z., R.L., W. Zhu, X.L., G.X.)
| | - Wusheng Zhu
- From the Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu, China (S.L., W. Zhu, X.L., G.X.)
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Jiangsu, China (W. Zi, M.W., M.Z., R.L., W. Zhu, X.L., G.X.)
| | - Xinfeng Liu
- From the Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu, China (S.L., W. Zhu, X.L., G.X.)
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Jiangsu, China (W. Zi, M.W., M.Z., R.L., W. Zhu, X.L., G.X.)
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Jiangsu, China (J.C., S.Z., Y.B., Y.G., X.S., B.S., X.L., G.X.)
| | - Gelin Xu
- From the Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu, China (S.L., W. Zhu, X.L., G.X.)
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Jiangsu, China (W. Zi, M.W., M.Z., R.L., W. Zhu, X.L., G.X.)
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, Jiangsu, China (J.C., S.Z., Y.B., Y.G., X.S., B.S., X.L., G.X.)
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Suzuki E, Nishimura N, Yoshikawa T, Kunikiyo Y, Hasegawa K, Hasumi K. Efficacy of SMTP-7, a small-molecule anti-inflammatory thrombolytic, in embolic stroke in monkeys. Pharmacol Res Perspect 2018; 6:e00448. [PMID: 30546909 PMCID: PMC6282002 DOI: 10.1002/prp2.448] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 10/01/2018] [Revised: 11/05/2018] [Accepted: 11/05/2018] [Indexed: 01/06/2023] Open
Abstract
SMTP-7 (Stachybotrys microspora triprenyl phenol-7) is a small molecule that promotes thrombolysis and suppresses inflammation possibly through plasminogen modulation and soluble epoxide hydrolase (sEH) inhibition, respectively. Here, we demonstrate an efficacy of SMTP-7 in a severe embolic stroke model in monkeys. The middle cerebral artery was embolized by an autologous blood clot. Saline, SMTP-7, or tissue-type plasminogen activator (t-PA) (n = 5 in each group) was given after 3 hours, and neurologic deficit scoring and infarct characterization were performed after 24 hours. Hemorrhagic infarct-accompanied premature death was observed for two animals in t-PA group. SMTP-7 treatment significantly reduced the sizes of infarct by 65%, edema by 37%, and clot by 55% compared to saline treatment. Plasma levels of the products of plasminogen activation (plasmin-α2-antiplasmin complex) and sEH reaction (dihydroxyeicosatrienoic acid) in SMTP-7 group were 794% (P < 0.05) and 60% (P = 0.085) compared to saline group, respectively. No significant changes in the plasma levels of MMP-9, CRP, MCP-1, and S100B were found. There was an inverse correlation between plasmin-α2-antiplasmin complex level and infarct volume (r = 0.93, P < 0.05), suggesting a role of thrombolysis in the SMTP-7 action to limit infarct development. In conclusion, SMTP-7 is effective in treating severe embolic stroke in monkeys under conditions where t-PA treatment tends to cause hemorrhagic infarct-associated premature death.
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Affiliation(s)
- Eriko Suzuki
- Department of Applied Biological ScienceTokyo Noko University (Tokyo University of Agriculture and Technology)TokyoJapan
| | | | | | - Yudai Kunikiyo
- Department of Applied Biological ScienceTokyo Noko University (Tokyo University of Agriculture and Technology)TokyoJapan
| | - Keiko Hasegawa
- Division of Research and DevelopmentTMS Co., Ltd.TokyoJapan
| | - Keiji Hasumi
- Department of Applied Biological ScienceTokyo Noko University (Tokyo University of Agriculture and Technology)TokyoJapan
- Division of Research and DevelopmentTMS Co., Ltd.TokyoJapan
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Sakamoto Y, Okubo S, Sekine T, Nito C, Suda S, Matsumoto N, Nishiyama Y, Aoki J, Shimoyama T, Kanamaru T, Suzuki K, Mishina M, Kimura K. Prior Direct Oral Anticoagulant Therapy is Related to Small Infarct Volume and No Major Artery Occlusion in Patients With Stroke and Non-Valvular Atrial Fibrillation. J Am Heart Assoc 2018; 7:e009507. [PMID: 30371159 PMCID: PMC6201431 DOI: 10.1161/jaha.118.009507] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/09/2018] [Indexed: 11/16/2022]
Abstract
Background The aims of the present study were to investigate the relationships between prior direct oral anticoagulant ( DOAC ) therapy and infarct volume and the site of arterial occlusion in patients with acute ischemic stroke and non-valvular atrial fibrillation. Methods and Results From March 2011 through November 2016, consecutive patients with acute ischemic stroke in the middle cerebral artery territory and non-valvular atrial fibrillation were recruited. The infarct volume was assessed semi-automatically using initial diffusion-weighted imaging, and the arterial occlusion site was evaluated on magnetic resonance angiography. The effect of prior DOAC treatment on the site of arterial occlusion was assessed by multivariate ordinal logistic regression analysis. A total of 330 patients (149 women; median age 79 [quartiles 71-86] years; median National Institutes of Health Stroke Scale score 11 [4-21]) were enrolled. Of these, 239 were on no anticoagulant, 40 were undertreated with a vitamin K antagonist ( VKA ), 22 were sufficiently treated with VKA ( PT - INR ≥1.6), and 29 were on a DOAC before the acute ischemic stroke. The infarct volume on admission differed among the groups (median 14.5 [2.0-59.8] cm3 in patients with no anticoagulation, 24.8 [2.1-63.0] in undertreated VKA , 1.3 [0.3-13.5] in sufficient VKA , and 2.3 [0.5-21.0] in DOAC , P=0.001). Multivariate analysis showed that prior DOAC treatment was independently and negatively associated with more proximal artery occlusion (odds ratio [OR] 0.34, P=0.015), compared with no anticoagulant. Conclusions DOAC treatment before the event was associated with smaller infarct volume and decreased risk of greater proximal artery occlusion in acute ischemic stroke patients with non-valvular atrial fibrillation, compared with no anticoagulation.
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Affiliation(s)
- Yuki Sakamoto
- Department of Neurological ScienceGraduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Seiji Okubo
- Department of Neurological ScienceGraduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Tetsuro Sekine
- Department of RadiologyGraduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Chikako Nito
- Department of Neurological ScienceGraduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Satoshi Suda
- Department of Neurological ScienceGraduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Noriko Matsumoto
- Department of Neurological ScienceGraduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Yasuhiro Nishiyama
- Department of Neurological ScienceGraduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Junya Aoki
- Department of Neurological ScienceGraduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Takashi Shimoyama
- Department of Neurological ScienceGraduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Takuya Kanamaru
- Department of Neurological ScienceGraduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Kentaro Suzuki
- Department of Neurological ScienceGraduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Masahiro Mishina
- Department of Neuro‐Pathophysiological ImagingGraduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Kazumi Kimura
- Department of Neurological ScienceGraduate School of MedicineNippon Medical SchoolTokyoJapan
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28
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Gil F, Rato M, Parente J, Teixeira N, Dias M, Duarte M. Varicella zoster virus reactivation and the increased risk of cerebrovascular accidents: the unexpected role dermatologists can play. Dermatol Online J 2018; 24:13030/qt7tr8r093. [PMID: 30677857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 06/09/2023] Open
Abstract
Varicella zoster virus (VZV) primary infection usually causes varicella and its reactivation may lead to different clinical manifestations depending on the site of viral reactivation and its subsequent tissue spread. There is a growing recognition of the association between VZV reactivation and ensuing cerebrovascular accidents (CVA). The virus can spread to cerebral arteries, causing a wide clinical spectrum related to VZV vasculopathy. Herein we present an 80-year-old man with a previously undiagnosed immunosuppressive condition, admitted with disseminated herpes zoster, who subsequently developed an acute ischemic CVA and showed a substantial neurologic recovery under antiviral therapy.
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MESH Headings
- Aged, 80 and over
- Antiviral Agents/therapeutic use
- Dermatologists
- Herpes Zoster/complications
- Herpes Zoster/diagnosis
- Herpes Zoster/drug therapy
- Herpes Zoster/immunology
- Herpesvirus 3, Human
- Humans
- Immunocompromised Host/immunology
- Infarction, Middle Cerebral Artery/diagnostic imaging
- Infarction, Middle Cerebral Artery/etiology
- Infarction, Middle Cerebral Artery/physiopathology
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Male
- Physician's Role
- Stroke
- Tomography, X-Ray Computed
- Virus Activation
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Affiliation(s)
- Francisco Gil
- Dermatology Department, Hospital de Santarem EPE, Santarem.
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29
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Fernández G, Moraga A, Cuartero MI, García-Culebras A, Peña-Martínez C, Pradillo JM, Hernández-Jiménez M, Sacristán S, Ayuso MI, Gonzalo-Gobernado R, Fernández-López D, Martín ME, Moro MA, González VM, Lizasoain I. TLR4-Binding DNA Aptamers Show a Protective Effect against Acute Stroke in Animal Models. Mol Ther 2018; 26:2047-2059. [PMID: 29910175 PMCID: PMC6094477 DOI: 10.1016/j.ymthe.2018.05.019] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [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: 08/07/2016] [Revised: 05/18/2018] [Accepted: 05/21/2018] [Indexed: 02/08/2023] Open
Abstract
Since Toll-like receptor 4 (TLR4) mediates brain damage after stroke, development of TLR4 antagonists is a promising therapeutic strategy for this disease. Our aim was to generate TLR4-blocking DNA aptamers to be used for stroke treatment. From a random oligonucleotide pool, we identified two aptamers (ApTLR#1R, ApTLR#4F) with high affinity for human TLR4 by systematic evolution of ligands by exponential enrichment (SELEX). Optimized truncated forms (ApTLR#1RT, ApTLR#4FT) were obtained. Our data demonstrate specific binding of both aptamers to human TLR4 as well as a TLR4 antagonistic effect. ApTLR#4F and ApTLR#4FT showed a long-lasting protective effect against brain injury induced by middle cerebral artery occlusion (MCAO), an effect that was absent in TLR4-deficient mice. Similar effects were obtained in other MCAO models, including in rat. Additionally, efficacy of ApTLR#4FT in a model of brain ischemia-reperfusion in rat supports the use of this aptamer in patients undergoing artery recanalization induced by pharmacological or mechanical interventions. The absence of major toxicology aspects and the good safety profile of the aptamers further encourage their future clinical positioning for stroke therapy and possibly other diseases in which TLR4 plays a deleterious role.
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Affiliation(s)
| | - Ana Moraga
- Unidad de Investigación Neurovascular, Departamento de Farmacología y Toxicología, Facultad de Medicina, Instituto Universitario de Investigación en Neuroquímica, Universidad Complutense de Madrid, 28040 Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i+12), 28041 Madrid, Spain
| | - María I Cuartero
- Unidad de Investigación Neurovascular, Departamento de Farmacología y Toxicología, Facultad de Medicina, Instituto Universitario de Investigación en Neuroquímica, Universidad Complutense de Madrid, 28040 Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i+12), 28041 Madrid, Spain
| | - Alicia García-Culebras
- Unidad de Investigación Neurovascular, Departamento de Farmacología y Toxicología, Facultad de Medicina, Instituto Universitario de Investigación en Neuroquímica, Universidad Complutense de Madrid, 28040 Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i+12), 28041 Madrid, Spain
| | - Carolina Peña-Martínez
- Unidad de Investigación Neurovascular, Departamento de Farmacología y Toxicología, Facultad de Medicina, Instituto Universitario de Investigación en Neuroquímica, Universidad Complutense de Madrid, 28040 Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i+12), 28041 Madrid, Spain
| | - Jesús M Pradillo
- Unidad de Investigación Neurovascular, Departamento de Farmacología y Toxicología, Facultad de Medicina, Instituto Universitario de Investigación en Neuroquímica, Universidad Complutense de Madrid, 28040 Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i+12), 28041 Madrid, Spain
| | | | - Silvia Sacristán
- Laboratorio de Aptámeros, Departamento de Bioquímica-Investigación, IRYCIS-Hospital Ramón y Cajal, 28034 Madrid, Spain
| | - M Irene Ayuso
- Grupo de Investigación Neurovascular, Instituto de Biomedicina de Sevilla, IBiS/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013 Sevilla, Spain
| | - Rafael Gonzalo-Gobernado
- Grupo de Investigación Neurovascular, Instituto de Biomedicina de Sevilla, IBiS/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013 Sevilla, Spain
| | - David Fernández-López
- Unidad de Investigación Neurovascular, Departamento de Farmacología y Toxicología, Facultad de Medicina, Instituto Universitario de Investigación en Neuroquímica, Universidad Complutense de Madrid, 28040 Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i+12), 28041 Madrid, Spain
| | - M Elena Martín
- Laboratorio de Aptámeros, Departamento de Bioquímica-Investigación, IRYCIS-Hospital Ramón y Cajal, 28034 Madrid, Spain
| | - María A Moro
- Unidad de Investigación Neurovascular, Departamento de Farmacología y Toxicología, Facultad de Medicina, Instituto Universitario de Investigación en Neuroquímica, Universidad Complutense de Madrid, 28040 Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i+12), 28041 Madrid, Spain
| | - Victor M González
- Laboratorio de Aptámeros, Departamento de Bioquímica-Investigación, IRYCIS-Hospital Ramón y Cajal, 28034 Madrid, Spain.
| | - Ignacio Lizasoain
- Unidad de Investigación Neurovascular, Departamento de Farmacología y Toxicología, Facultad de Medicina, Instituto Universitario de Investigación en Neuroquímica, Universidad Complutense de Madrid, 28040 Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (i+12), 28041 Madrid, Spain.
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Daudfar S, Gorman C, Pham JT. Hemiplegic Syndrome After Chopstick Penetration Injury in the Lateral Soft Palate of a Young Child. J Osteopath Med 2018; 118:555-559. [PMID: 30073339 DOI: 10.7556/jaoa.2018.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Soft palate penetrating injuries have been reported among children, particularly in children falling with objects in their mouth. The authors present a case of a healthy 14-month-old child who fell onto a blunt-ended chopstick, the subsequent cerebrovascular accident, and the role of the osteopathic tenets thereafter. The child had an acute infarction to the region of his right middle cerebral artery secondary to right internal carotid artery occlusion. Physicians should consider the neurologic sequelae of lateral soft palate injuries and damage to the surrounding anatomical structures. A thorough, whole-patient approach to physical examination is critical.
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Abstract
INTRODUCTION Neurological complications of acute sinusitis are exceptional, but potentially serious. CASE REPORT The authors report the case of a 6-year-old diabetic girl who presented with middle cerebral artery ischemic stroke secondary to inflammatory arteritis of the left internal carotid artery in a context of bilateral acute maxillary sinusitis. MRI confirmed ischaemic stroke associated with carotid arteritis and complete obstruction of the maxillary sinuses. A favourable outcome was observed after endoscopic drainage of the sinuses associated with broad-spectrum antibiotic therapy. DISCUSSION This complication was probably due to spread of an infectious inflammatory reaction of the intrapetrosal carotid artery and its branches via the pterygoid venous plexus. To our knowledge, this is the first published case report of maxillary sinusitis complicated by stroke.
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Affiliation(s)
- C Fabre
- Service hospitalo-universitaire d'ORL et chirurgie cervico-faciale, CHU Michalon CS 10217, 38043, Grenoble cedex 9, France.
| | - I Atallah
- Service hospitalo-universitaire d'ORL et chirurgie cervico-faciale, CHU Michalon CS 10217, 38043, Grenoble cedex 9, France; Faculté de médecine, universités des Alpes, Grenoble, France; UGA/UMR/CNRS 5309/Inserm 1209, institut Albert-Bonniot, Grenoble, France
| | - I Wroblewski
- Faculté de médecine, universités des Alpes, Grenoble, France; UGA/UMR/CNRS 5309/Inserm 1209, institut Albert-Bonniot, Grenoble, France; Réanimation et surveillance continue pédiatrique, pôle Couple Enfant, CHU de Grenoble, Grenoble, France
| | - C A Righini
- Service hospitalo-universitaire d'ORL et chirurgie cervico-faciale, CHU Michalon CS 10217, 38043, Grenoble cedex 9, France; Faculté de médecine, universités des Alpes, Grenoble, France; UGA/UMR/CNRS 5309/Inserm 1209, institut Albert-Bonniot, Grenoble, France
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Zhao ZN, Li XL, Liu JZ, Jiang ZM, Wang AH. Features of branch occlusive disease-type intracranial atherosclerotic stroke in young patients. BMC Neurol 2018; 18:87. [PMID: 29925330 PMCID: PMC6009042 DOI: 10.1186/s12883-018-1089-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/13/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Young ischemic stroke patients are common while classification and analysis based upon imaging characteristics are rarely reported. We intend to compare the clinical and MRI characteristics of cerebral stroke induced by intracranial atherosclerosis between young patients with branch occlusive disease (BOD) and those with non-branch occlusive disease (non-BOD) or small artery disease (SAD). METHODS A total of 151 subjects with acute infarction within the middle cerebral artery (MCA) territory were included and patients with ipsilateral internal carotid artery stenosis or cardioembolism were excluded. Based on the distribution characteristics of infarction and the presence of ipsilateral MCA stenosis, the patients were divided into three groups: BOD-striatocapsular area infarction with ipsilateral MCA stenosis; non-BOD -infarction size exceeds the striatocapsular area and accompanied by ipsilateral MCA stenosis; SAD. The clinical and MCA stenosis characteristics of the three groups were compared. RESULTS The number of BOD patients with hypertension was significantly higher than that of SAD (92.9% vs 53.7%, p = 0.000) and non-BOD (92.9% vs 57.1%, p = 0.001); subjects with smoking history significantly exceeded that of SAD (50% vs 26.9%, p = 0.03) and subjects with family history of cardiovascular disease was significantly less than that of non-BOD (14.3% vs 41.1%). Baseline NIHSS scores and mRS scores at discharge in patients with BOD were significantly lower than those with non-BOD (p = 0.000, p = 0.001). Majority of patients in non-BOD group displayed severe MCA stenosis (39 cases, 69.6%) while that in BOD group displayed mild stenosis (26 cases, 92.9%), and the difference was statistically significant (p = 0.000). Compared with non-BOD group, the stenosis in BOD group located at a relatively distal end in the M1 segment of MCA (S/M1, 58% vs 40%, p = 0.000) and was more localized (stenosis level/ (SL/M1), 1.86 (1.35-2.6) vs 2.9 (2.0-5.0), p = 0.002). CONCLUSION BOD in young patients with ischemic stroke induced by intracranial atherosclerosis is not rare (33.3%) and its clinical manifestations and prognosis are similar to those of SAD. This may be related to the mild localized stenosis at the distal end in the M1 segment of MCA. Control of hypertension might play a positive role in secondary prevention.
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Affiliation(s)
- Zhang-Ning Zhao
- Department of Neurology, Affiliated Qianfoshan Hospital of Shandong University, 66 Jingshi Road, Jinan, 250014 Shandong province People’s Republic of China
| | - Xiao-Lin Li
- Department of Critical Care Medicine, Affiliated Qianfoshan Hospital of Shandong University, 66 Jingshi Road, Jinan, 250014 Shandong province People’s Republic of China
| | - Jin-Zhi Liu
- Department of Neurology, Affiliated Qianfoshan Hospital of Shandong University, 66 Jingshi Road, Jinan, 250014 Shandong province People’s Republic of China
| | - Zhi-Ming Jiang
- Department of Critical Care Medicine, Affiliated Qianfoshan Hospital of Shandong University, 66 Jingshi Road, Jinan, 250014 Shandong province People’s Republic of China
| | - Ai-Hua Wang
- Department of Neurology, Affiliated Qianfoshan Hospital of Shandong University, 66 Jingshi Road, Jinan, 250014 Shandong province People’s Republic of China
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Ning X, Ye X, Si Y, Yang Z, Zhao Y, Sun Q, Chen R, Tang M, Chen K, Zhang X, Zhang S. Prevalence and prognosis of ventricular tachycardia/ventricular fibrillation in patients with post-infarction left ventricular aneurysm: Analysis of 575 cases. J Electrocardiol 2018; 51:742-746. [PMID: 29803411 DOI: 10.1016/j.jelectrocard.2018.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 02/06/2018] [Revised: 03/12/2018] [Accepted: 03/21/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND We investigated the prevalence of ventricular tachycardia/ventricular fibrillation (VT/VF) in Post-infarction left ventricular aneurysm (PI-LVA) patients and analyze clinical outcomes in patients presenting with VT/VF. METHODS 575 PI-LVA patients were enrolled and investigated by logistic regression analysis. Patients with VT/VF were followed up, the composite primary endpoint was cardiac death and appropriate ICD/external shocks. RESULTS The incidence of sustained VT/VF was 11%. Logistical regression analysis showed male gender, enlarged LV end diastolic diameter (LVEDD) and higher NYHA class were correlated with VT/VF development. During follow up of 46 ± 15 months, 19 out of 62(31%) patients reached study end point. Multivariate Cox regression analysis revealed that enlarged LVEDD and moderate/severe mitral regurgitation (MR) were independently predictive of clinical outcome. CONCLUSIONS Male gender, enlarged LVEDD and higher NYHA class associated with risk of sustained VT/VF in PI-LVA patients. Among VT/VF positive patients, enlarged LVEDD and moderate/severe MR independently predicted poor clinical prognosis.
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Affiliation(s)
- Xiaohui Ning
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Xuerui Ye
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Yanhua Si
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Zihe Yang
- Department of Nuclear Medicine, Anzhen Hospital, China
| | - Yunzi Zhao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Qi Sun
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Ruohan Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Min Tang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Keping Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Xiaoli Zhang
- Department of Nuclear Medicine, Anzhen Hospital, China
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China.
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Kimura T, Ibayashi K, Kawai K. Intraoperative Resuturing of Occluded Superficial Temporal Artery-Middle Cerebral Artery Anastomoses: Single-Center Retrospective Study. World Neurosurg 2018; 113:e650-e653. [PMID: 29499427 DOI: 10.1016/j.wneu.2018.02.114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/09/2017] [Revised: 02/17/2018] [Accepted: 02/19/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND In superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis, there is a certain risk of intraoperative acute occlusion of the bypass that can cause operative complications. OBJECTIVE We sought to assess the efficacy of resuturing at the same site after intraoperative acute occlusion of the bypass. METHODS In total, 129 STA-MCA anastomosis operations were performed on 125 patients at our institution. The electronic medical records of each patient were reviewed to gather information regarding intraoperative occlusion events, and the operative videos and postoperative radiologic images were also reviewed. RESULTS Twelve intraoperative acute occlusions were identified. In each case, resuturing was performed after cutting all knots, flushing the thrombus, and trimming the edges of the STAs. In 11 cases, indocyanine green videoangiography and/or Doppler sonography revealed patency during the operation, which was confirmed by postoperative magnetic resonance angiography. None of the 12 cases exhibited high-signal intensities in the MCA area on diffusion-weighted images. CONCLUSION If intraoperative acute occlusion of STA-MCA anastomosis occurs, reanastomosis at the site should be the first option.
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Affiliation(s)
- Toshikazu Kimura
- Department of Neurosurgery, Japanese Red Cross Medical Centre, Shibuya-ku, Tokyo, Japan.
| | - Kenji Ibayashi
- Department of Neurosurgery, Japanese Red Cross Medical Centre, Shibuya-ku, Tokyo, Japan
| | - Kensuke Kawai
- Department of Neurosurgery, Japanese Red Cross Medical Centre, Shibuya-ku, Tokyo, Japan
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Lv X, Zhang Y, Jiang W. Systematic Review of Woven EndoBridge for Wide-Necked Bifurcation Aneurysms: Complications, Adequate Occlusion Rate, Morbidity, and Mortality. World Neurosurg 2018; 110:20-25. [PMID: 29107726 DOI: 10.1016/j.wneu.2017.10.113] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [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: 09/18/2017] [Revised: 10/17/2017] [Accepted: 10/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the Woven EndoBridge (WEB [Sequent Medical, Aliso Viejo, California, USA]) is a highly innovative technique for the endovascular treatment of wide-necked bifurcation aneurysms (WNBAs), there are no studies available comparing this technique with surgical results or other endovascular results of stent-assisted coiling or balloon-assisted coiling for WNBAs. The purpose of this study was to assess complications, complete occlusion rate, and morbidity and mortality of the WEB in WNBA treatment. METHODS Published literature citing embolization results for WNBAs using the WEB was reviewed. A systematic review was performed to evaluate the complications, complete occlusion rate, and morbidity and mortality. RESULTS We identified 19 studies, including 935 patients. The most frequent aneurysm locations were the bifurcation of the middle cerebral artery (MCA) (42.8%), the anterior communicating artery (23%), and the basilar bifurcation (20.8%). The technical success rate of the WEB was 97% (95% confidence interval [CI], 96%-98%). The thromboembolic complication rate was 8% (95% CI, 6%-11%). The thromboembolic complication rate was 10% (95% CI, 7%-13%) in cases before 2013, which was higher than in cases after 2013 (6%; 95% CI, 4%-9%; P = 0.045). MCA bifurcation aneurysm has a higher thromboembolic complication rate than posterior circulation aneurysm. The overall bleeding complication rate of the WEB was 2% (95% CI, 1%-3%). The adequate occlusion rate was 81% (95% CI, 76%-85%). Morbidity during follow-up was 3% (95% CI, 1%-4%) (I2 = 30.4%), and mortality was 2% (95% CI, 1%-3%). CONCLUSIONS Adequate aneurysm occlusion was found in 81% of WEB cases with low morbidity and mortality.
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Affiliation(s)
- Xianli Lv
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China; New Era Stroke Care and Research Institute, The PLA Rocket Force General Hospital, Beijing, China
| | - Yupeng Zhang
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weijian Jiang
- New Era Stroke Care and Research Institute, The PLA Rocket Force General Hospital, Beijing, China.
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Aldakkan A, Dunn M, Warsi NM, Mansouri A, Marotta TR. Vascular Eagle's Syndrome: Two Cases Illustrating Distinct Mechanisms of Cerebral Ischemia. J Radiol Case Rep 2018; 11:1-7. [PMID: 29299100 DOI: 10.3941/jrcr.v11i8.3040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 11/15/2022] Open
Abstract
We report two cases of Vascular Eagle's Syndrome, which demonstrate two distinct mechanisms of cerebral ischemia. In the first case, hemodynamic transient cerebral ischemia arose as a direct result of compression of the internal carotid artery (ICA). In the second, embolic large left middle cerebral artery (MCA) infarction as a result of a thrombus from a pseudoaneurysmal dilatation of the left ICA.
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Affiliation(s)
- Abdulrahman Aldakkan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Marshall Dunn
- Department of Radiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Nebras M Warsi
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas R Marotta
- Department of Diagnostic & Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, Ontario, Canada
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Walters GK. Cervicocranial artery dissection and scuba diving: Is there a link or is it serendipity? Undersea Hyperb Med 2018; 45:65-73. [PMID: 29571234] [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] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Numerous reports have documented cervicocranial artery dissection (CCAD) associated with scuba diving. The question remains as to whether there are risk factors unique to scuba diving related to the occurrence of CCAD. OBJECTIVES This article aims to perform an examination of the reported cases to demonstrate any commonality among the injured divers and association with known risk factors for CCAD. METHODS A PubMed search was performed utilizing the key words: carotid artery dissection, dissection, arterial dissection, cranial artery dissection, scuba, diving, scuba diving. Articles including reports, reviews, trials, case series, and letters were considered. Each report was critically dissected for information specific to the dive itself and the diver and analyzed for similarities and consistency with known risks. RESULTS Twelve (12) reports of CCAD associated with scuba diving were identified. Activities involved with scuba diving appear to be consistent with CCAD risk factors. It is unclear if hyperbaric stress and physiological changes during a dive present specific risk. Trauma - e.g., environmental protection and activities associated with diving - was identified as a common risk factor in all cases. Ten (10) cases involved arteries at anatomic sites commonly associated with dissections. Seven divers documented to have dive profiles suspicious of decompression sickness were identified. CONCLUSIONS There appears to be a correlation with minor traumas that occur with diving and CCAD. The inconsistency of the dive-related specific information reported makes it impossible for investigation of hyperbaric stress-related risk factors for CCAD to be analyzed.
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Affiliation(s)
- Gerald K Walters
- Senior Physician Assistant, Johns Hopkins Bayview Medical Center, Johns Hopkins School of Medicine, Baltimore, Maryland U.S
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Salam KA, Rafeeque M, Hashim H, Mampilly N, Noone ML. Histology of Thrombectomy Specimen Reveals Cardiac Tumor Embolus in Cryptogenic Young Stroke. J Stroke Cerebrovasc Dis 2017; 27:e70-e72. [PMID: 29246671 DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 09/28/2017] [Revised: 10/27/2017] [Accepted: 11/11/2017] [Indexed: 11/17/2022] Open
Abstract
A 25-year-old woman presented with acute onset of right hemiplegia and global aphasia with National Institutes of Health Stroke Scale score of 19. Computed tomography angiography demonstrated occlusion of the left proximal middle cerebral artery. She was thrombolysed with intravenous recombinant tissue plasminogen activator (0.6 mg/kg) within 3 hours of onset of symptoms and was taken up for mechanical thrombectomy. The retrieved specimen appeared pale white and soft; histopathologic examination revealed a papillary neoplasm composed of papillae with hyalinized cores lined by endothelium, consistent with papillary fibroelastoma of cardiac origin. Transesophageal echocardiography showed no abnormalities, which can be explained by complete embolization of the mass into the cerebral circulation. On follow-up after 5 months, the patient recovered with only minimal aphasia and no cardiac symptoms. Our experience with this case highlights the importance of histopathologic examination of the mechanical thrombectomy specimen, as it provided the only clue to the etiology of stroke.
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Affiliation(s)
| | - Mohammed Rafeeque
- Department of Interventional Radiology, Baby Memorial Hospital, Kozhikode, Kerala, India
| | - Hisham Hashim
- Department of Neurology, Baby Memorial Hospital, Kozhikode, Kerala, India
| | - Neena Mampilly
- Department of Pathology, Baby Memorial Hospital, Kozhikode, Kerala, India
| | - Mohan Leslie Noone
- Department of Neurology, Baby Memorial Hospital, Kozhikode, Kerala, India.
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Ludwig DR, Austin MJ, Wallace AN, Kamran M, Kansagra AP, Osbun JW, Cross DT, Moran CJ. Isolated Internal Carotid Artery Thrombus and Cerebral Infarction in a Patient with Necrotizing Pancreatitis: Case Report. J Stroke Cerebrovasc Dis 2017; 27:e1-e4. [PMID: 28893576 DOI: 10.1016/j.jstrokecerebrovasdis.2017.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 06/06/2017] [Accepted: 08/12/2017] [Indexed: 11/19/2022] Open
Abstract
Isolated internal carotid artery (ICA) thrombus in the absence of underlying atherosclerotic disease is a rare entity. We report a case of a patient presenting with right arm weakness, slurred speech, and altered mental status in the setting of acute on chronic pancreatitis. The patient was found to have scattered left cerebral hemisphere cortical infarctions, and catheter angiography confirmed the presence of intraluminal left ICA thrombus, with no evidence of atherosclerotic disease in the cervical or intracranial vasculature. Further workup also demonstrated the presence of anemia of chronic disease. The patient was initiated on anticoagulation, and follow-up imaging demonstrated a complete resolution of the left ICA thrombus. In the reported case, coagulopathy in the setting of acute on chronic pancreatitis was presumably the primary etiology. Anemia of chronic disease, related to a proinflammatory state, may also play a contributory role.
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Affiliation(s)
- Daniel R Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri.
| | - Matthew J Austin
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Adam N Wallace
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Mudassar Kamran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri; Department of Neurosurgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Joshua W Osbun
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri; Department of Neurosurgery, Washington University School of Medicine, Saint Louis, Missouri
| | - DeWitte T Cross
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri; Department of Neurosurgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri; Department of Neurosurgery, Washington University School of Medicine, Saint Louis, Missouri
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Nishino W, Tajima Y, Inoue T, Hayasaka M, Katsu B, Ebihara K, Kawauchi D, Kubota M, Suda S. Severe Vasospasm of the Middle Cerebral Artery after Mechanical Thrombectomy Due to Infective Endocarditis: An Autopsy Case. J Stroke Cerebrovasc Dis 2017; 26:e186-e188. [PMID: 28669652 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 04/27/2017] [Revised: 05/15/2017] [Accepted: 06/01/2017] [Indexed: 11/18/2022] Open
Abstract
Untreated infective endocarditis (IE) often produces infective emboli in major cerebral arteries. We describe a case of middle cerebral artery occlusion due to IE, which caused severe vasospasm and reocclusion after mechanical thrombectomy (MT). We present the pathologic findings of the occluded middle cerebral artery and investigate the precautions to be taken while performing MT due to IE. A 72-year-old man with atrial fibrillation treated with dabigatran presented with right hemiparesis and aphasia. A diffusion-weighted image showed a high-intensity area in the left temporoparietal junction, and magnetic resonance angiography revealed a left M2 occlusion. Because of an elevated activated partial thromboplastin time, the thrombolytic therapy was contraindicated; instead, MT was performed. Just after the withdrawal of a stent retriever, the left M2 segment showed severe vasospasm. The next day, the left M2 segment reoccluded. Transthoracic echocardiogram and blood culture findings revealed IE. On the ninth day, the patient died. According to the autopsy report, the cause of death was pulmonary embolism. Pathologic analysis of the occluded M2 segment revealed fibrin thrombi containing vast amounts of neutrophils and invasion of neutrophils into the internal elastic lamina. Severe vasospasm was thought to have occurred because the vascular injury caused by the stent retriever in the vessel had a marked inflammation background. Our findings suggest that devices that are less invasive to the vascular wall are required for performing MT due to IE. The Penumbra aspiration system is thought to be a suitable device.
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Affiliation(s)
- Wataru Nishino
- Department of Neurosurgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan
| | - Yosuke Tajima
- Department of Neurosurgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan.
| | - Toru Inoue
- Department of Pathology, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan
| | - Michihiro Hayasaka
- Department of Neurosurgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan
| | - Bi Katsu
- Department of Cardiology, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan
| | - Koichi Ebihara
- Department of Neurosurgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan
| | - Daisuke Kawauchi
- Department of Neurosurgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan
| | - Masaaki Kubota
- Department of Neurosurgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan
| | - Sumio Suda
- Department of Neurosurgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan
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41
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Zhang Y, Qiao L, Xu W, Wang X, Li H, Xu W, Chu K, Lin Y. Paeoniflorin Attenuates Cerebral Ischemia-Induced Injury by Regulating Ca 2+/CaMKII/CREB Signaling Pathway. Molecules 2017; 22:molecules22030359. [PMID: 28264448 PMCID: PMC6155252 DOI: 10.3390/molecules22030359] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [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: 02/05/2017] [Revised: 02/22/2017] [Accepted: 02/23/2017] [Indexed: 01/26/2023] Open
Abstract
Paeoniflorin (PF) is an active ingredient of Paeoniae Radix which possesses the neuroprotective effect. However, so far, the neuroprotective mechanism of PF has still not been fully uncovered. The Ca2+/Ca2+/calmodulin-dependent protein kinase II (CaMKII)/cAMP response element-binding (CREB) signaling pathway plays an important role in the intracellular signal transduction pathway involved in cell proliferation, cell survival, inflammation and metabolism. Herein, the neuroprotective roles of PF in the models of middle cerebral artery occlusion (MCAO) followed by reperfusion in rats and N-methyl-d-aspartic acid (NMDA)-induced excitotoxicity in primary hippocampal neurons were investigated. Moreover, we attempted to confirm the hypothesis that its protection effect is via the modulation of the Ca2+/CaMKI)/CREB signaling pathway. In this study, PF not only significantly decreased neurological deficit scores and infarct volume in vivo, but also improved neurons’ cell viability, and inhibited neurons’ apoptosis and intracellular Ca2+ concentration in vitro. Furthermore, PF significantly up-regulated p-CREB and p-CaMKII, and down-regulated calmodulin (CaM) in vivo and in vitro. The results indicate that the protective effect of PF on cerebral ischemia reperfusion injury is possible through regulating the Ca2+/CaMKII/CREB signaling pathway.
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Affiliation(s)
- Yuqin Zhang
- College of Pharmacy of Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian 350122, China.
| | - Lifei Qiao
- College of Pharmacy of Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian 350122, China.
| | - Wen Xu
- College of Pharmacy of Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian 350122, China.
| | - Xiaoying Wang
- College of Pharmacy of Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian 350122, China.
| | - Huang Li
- College of Pharmacy of Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian 350122, China.
| | - Wei Xu
- College of Pharmacy of Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian 350122, China.
| | - Kedan Chu
- College of Pharmacy of Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian 350122, China.
| | - Yu Lin
- College of Pharmacy of Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian 350122, China.
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42
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Kaesmacher J, Maegerlein C, Kaesmacher M, Zimmer C, Poppert H, Friedrich B, Boeckh-Behrens T, Kleine JF. Thrombus Migration in the Middle Cerebral Artery: Incidence, Imaging Signs, and Impact on Success of Endovascular Thrombectomy. J Am Heart Assoc 2017; 6:e005149. [PMID: 28202431 PMCID: PMC5523786 DOI: 10.1161/jaha.116.005149] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/20/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Thrombus migration (TM) in intracranial vessels during ischemic stroke has been reported in the form of case reports, but its incidence, impact on the technical success of subsequent endovascular thrombectomy and patients' outcome have never been studied systematically. METHODS AND RESULTS Retrospective analysis was done of 409 patients with isolated middle cerebral artery occlusions treated with endovascular thrombectomy. TM was observed (1) by analyzing discrepancies between computed tomographic angiography and digital subtraction angiography and (2) by comparing infarct pattern in the striatocapsular region with exact, angiographically assessed thrombus location within the M1-segment and the involvement of the middle cerebral artery perforators. Preinterventional infarction of discrepant regions (infarction in regions supplied by more proximal vessels than those occluded by the clot) was ensured by carefully reviewing available preinterventional multimodal imaging. Adequate imaging inclusion criteria were met by 325 patients. Ninety-seven patients showed signs of TM (26 with direct evidence, 71 with indirect evidence). There was no difference in the frequency of preinterventional intravenous recombinant tissue plasminogen activator administration between patients with TM and those without (63.9% vs 64.9%, P=0.899). TM was associated with lower rates of complete reperfusion (Thrombolysis in Cerebral Infarction score 3) (adjusted odds ratio 0.400, 95% CI 0.226-0.707). Subsequently, preinterventional TM was associated with lower rates of substantial neurologic improvement (adjusted odds ratio 0.541, 95% CI 0.309-0.946). CONCLUSIONS Preinterventional TM does not seem to be facilitated by intravenous recombinant tissue plasminogen activator and often occurs spontaneously. However, TM is associated with the risk of incomplete reperfusion in subsequent thrombectomy, suggesting increased clot fragility. Occurrence of TM may thereby have a substantial impact on the outcome of endovascularly treated stroke patients.
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Affiliation(s)
- Johannes Kaesmacher
- Department of Neuroradiology, Klinikum rechts der Isar, TU München, Munich, Germany
| | - Christian Maegerlein
- Department of Neuroradiology, Klinikum rechts der Isar, TU München, Munich, Germany
| | - Mirjam Kaesmacher
- Department of Neuroradiology, Klinikum rechts der Isar, TU München, Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, TU München, Munich, Germany
| | - Holger Poppert
- Department of Neurology, Klinikum rechts der Isar, TU München, Munich, Germany
| | - Benjamin Friedrich
- Department of Neuroradiology, Klinikum rechts der Isar, TU München, Munich, Germany
| | | | - Justus F Kleine
- Department of Neuroradiology, Klinikum rechts der Isar, TU München, Munich, Germany
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43
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Cağavi F, Tekkök IH, Akpinar G. Malignant Cerebral Infarction Secondary to Internal Carotid Injury in Closed Head Trauma: Good Outcome with Aggressive Treatment. Angiology 2016; 56:107-14. [PMID: 15678265 DOI: 10.1177/000331970505600116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 25-year-old male patient in whom occlusion of the internal carotid artery developed secondary to a skull base fracture is presented. The diagnosis of internal carotid artery occlusion was reached 12 hours after the admission and 17 hours after the injury. The patient was initially treated for ischemic edema and when the patient showed signs of cerebral herniation, decompressive craniectomy was necessary. The outcome was good. The clinical and radiologic characteristics of internal carotid artery occlusion in closed head injury are highlighted and treatment options are reviewed in light of pertinent literature.
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MESH Headings
- Adult
- Brain Edema/diagnosis
- Brain Edema/etiology
- Brain Edema/surgery
- Brain Ischemia/diagnosis
- Brain Ischemia/etiology
- Brain Ischemia/surgery
- Carotid Artery Injuries/complications
- Carotid Artery Injuries/diagnosis
- Carotid Artery Injuries/surgery
- Carotid Artery, Internal/surgery
- Carotid Stenosis/diagnosis
- Carotid Stenosis/etiology
- Carotid Stenosis/surgery
- Cerebral Angiography
- Craniotomy
- Decompression, Surgical
- Diagnosis, Differential
- Encephalocele/diagnosis
- Encephalocele/etiology
- Encephalocele/surgery
- Head Injuries, Closed/complications
- Head Injuries, Closed/diagnosis
- Head Injuries, Closed/surgery
- Hemiplegia/diagnosis
- Hemiplegia/etiology
- Hemiplegia/surgery
- Humans
- Infarction, Middle Cerebral Artery/diagnosis
- Infarction, Middle Cerebral Artery/etiology
- Infarction, Middle Cerebral Artery/surgery
- Male
- Occipital Bone/injuries
- Skull Base/injuries
- Skull Fractures/complications
- Skull Fractures/diagnosis
- Skull Fractures/surgery
- Temporal Bone/injuries
- Tomography, X-Ray Computed
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44
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Kodankandath TV, Mishra S, Libman RB, Wright P. Recurrent Stroke due to Patent Foramen Ovale Closure Device Thrombus Eight Years after Implantation. J Stroke Cerebrovasc Dis 2016; 25:e161-2. [PMID: 27444520 DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 04/28/2016] [Accepted: 06/25/2016] [Indexed: 11/16/2022] Open
Abstract
Patent foramen ovale (PFO) is a common heart defect and is found in about 25% of the general population. Although randomized trials have failed to show the superiority of percutaneous closure of PFO over medical management, the number of patients with closure device placement has grown over the years. Delayed complications from PFO closure are rare. We present a case of cardioembolic stroke secondary to a mobile thrombus on a PFO closure device 8 years after implantation.
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Affiliation(s)
- Thomas V Kodankandath
- Department of Neurology, Hofstra Northwell School of Medicine, North Shore University Hospital, Manhasset, New York.
| | - Sanskriti Mishra
- Department of Neurology, Hofstra Northwell School of Medicine, North Shore University Hospital, Manhasset, New York
| | - Richard B Libman
- Department of Neurology, Hofstra Northwell School of Medicine, North Shore University Hospital, Manhasset, New York
| | - Paul Wright
- Department of Neurology, Hofstra Northwell School of Medicine, North Shore University Hospital, Manhasset, New York
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45
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Abstract
Objective: To compare the effect of two different extra-corporeal circuits on the counts of high-intensity transient signals (HITS) during pediatric cardiopulmonary bypass (CPB). Methods: Transcranial Doppler was used to detect HITS associated with extracorporeal sources during the period of aortic crossclamping in the middle cerebral artery of children undergoing CPB. Based on body size, children were assigned one of two extracorporeal circuits (A or B). Circuit A included a D-705 oxygenator and associated reservoir, and circuit B included a Lilliput oxygenator and reservoir. Patients were further classified into two groups according to the complexity of surgical repair: single simple lesions or multiple complex lesions. Results: We studied 109 pediatric patients. Surgery for multiple complex lesions was associated with longer periods of aortic crossclamping and CPB (p <0.0001). The median count of extra-corporeal HITS was 12 (25th, 75th percentiles: 3, 51). The type of extracorporeal circuit (p=0.012) and the complexity of surgical repair (p <0.0001) had an effect on the HITS counts. The use of circuit A was associated with higher HITS counts during surgery for multiple complex lesions compared to single simple lesions (p <0.0001). Conversely, no differences were found with the use of circuit B between these two surgical groups (p >0.25). During surgery for multiple complex lesions, patients treated with circuit A showed higher HITS counts than those with circuit B (p <0.01), but there were no circuit-related differences in HITS counts (p=0.30) during single simple lesions. Conclusion: Variations in the design characteristics of extracorporeal circuits can increase cerebral emboli during CPB in children. This may be related to the reduced ability of some circuits to remove emboli during long periods of CPB for complex congenital heart-surgery.
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MESH Headings
- Aorta
- Cardiopulmonary Bypass/instrumentation
- Cardiopulmonary Bypass/methods
- Child
- Child, Preschool
- Constriction
- Embolism, Air/diagnostic imaging
- Embolism, Air/etiology
- Embolism, Fat/diagnostic imaging
- Embolism, Fat/etiology
- Equipment Design
- Extracorporeal Circulation/instrumentation
- Extracorporeal Circulation/methods
- Head-Down Tilt
- Heart Defects, Congenital/surgery
- Humans
- Incidence
- Infarction, Middle Cerebral Artery/diagnostic imaging
- Infarction, Middle Cerebral Artery/epidemiology
- Infarction, Middle Cerebral Artery/etiology
- Nervous System Diseases/epidemiology
- Nervous System Diseases/etiology
- Postoperative Complications/etiology
- Postoperative Complications/mortality
- Randomized Controlled Trials as Topic/statistics & numerical data
- Retrospective Studies
- Ultrasonography, Doppler, Transcranial
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Affiliation(s)
- Rosendo A Rodriguez
- Department of Surgery, Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada.
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46
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Patiroglu T, Karakukcu M. Middle Cerebral Arterial Thrombosis in a Patient with Hypofibrinogenemia, 5 Days After rFVIIa and FFP Infusion. Clin Appl Thromb Hemost 2016; 12:111-3. [PMID: 16444445 DOI: 10.1177/107602960601200119] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A 13-year-old female patient is presented who had hypofibrinogenemia diagnosed as von Willebrand disease at 5 years of age at another hospital. She was admitted to the department of pediatric hematology with a severe headache, vomiting, and progressive right flaccid hemiplegia and lethargy. Contrast-enhanced computed tomography scan showed subdural hematoma in posterior parietal region of the brain and impending cerebellar herniation. She was given fresh-frozen plasma (FFP) and then activated factor VII (rFVIIa), 80 μg/kg was infused for replacement of von Willebrand factor. The subdural hematoma was emergently drained. The results of coagulation tests before infusion of FFP and rFVIIa revealed hypofibrinogenemia, and FFP was given every 48 hours. The patient recovered dramatically in a few days. Five days after rFVIIa infusion, a magnetic resonance angiography-proven right middle cerebral arterial thrombosis developed. It is an interesting point of discussion whether the middle cerebral arterial thrombosis was provoked as a consequence of rFVIIa and FFP infusion.
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Affiliation(s)
- Turkan Patiroglu
- Erciyes University Medical School, Department of Pediatric Hematology, Kayseri-Turkey.
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47
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Abstract
This study investigated whether inhibition of reduced nicotinamide adenine dinucleotide phosphate (NADPH) oxidase attenuates cerebral infarction after transient focal ischaemia in rats. Focal ischaemia (1.5 h) was produced in male Sprague-Dawley rats (250 − 280 g) by middle cerebral artery occlusion. Some rats also received treatment with 50 mg/kg apocynin, a NADPH oxidase inhibitor, by intraperitoneal injection 30 min prior to reperfusion. Two hours after reperfusion, brains were harvested to measure NADPH oxidase activity and superoxide levels. After 24 h, the remaining brains were harvested to investigate infarct size. NADPH oxidase activity and superoxide level were all augmented 2 h after reperfusion compared with controls. Apocynin treatment significantly reduced NADPH oxidase activity and superoxide levels. Cerebral infarct size was significantly smaller in the apocynin-treated group compared with those undergoing ischaemia/reperfusion alone. These results indicate that inhibition of NADPH oxidase attenuates cerebral infarction after transient focal ischaemia in rats, suggesting that inhibition of NADPH oxidase may provide a therapeutic strategy for ischaemic stroke.
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MESH Headings
- Acetophenones/therapeutic use
- Animals
- Brain Chemistry
- Disease Models, Animal
- Enzyme Inhibitors/therapeutic use
- Infarction, Middle Cerebral Artery/etiology
- Infarction, Middle Cerebral Artery/metabolism
- Infarction, Middle Cerebral Artery/pathology
- Infarction, Middle Cerebral Artery/prevention & control
- Injections, Intraperitoneal
- Ischemic Attack, Transient/complications
- Ischemic Attack, Transient/metabolism
- Ischemic Attack, Transient/pathology
- Male
- NADPH Oxidases/antagonists & inhibitors
- NADPH Oxidases/metabolism
- Rats
- Rats, Sprague-Dawley
- Reperfusion Injury/etiology
- Reperfusion Injury/metabolism
- Reperfusion Injury/pathology
- Reperfusion Injury/prevention & control
- Superoxides/metabolism
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Affiliation(s)
- L L Tang
- Department of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, The People's Republic of China
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48
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van Casteren D, Adriani KS. A 49-year-old woman presenting with aphasia. Neth J Med 2016; 74:221. [PMID: 27323679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- D van Casteren
- Department of Neurology, Tergooiziekenhuizen, Blaricum and Hilversum, the Netherlands
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49
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Altintas O, Kumas M, Altintas MO. Neuroprotective effect of ischemic preconditioning via modulating the expression of adropin and oxidative markers against transient cerebral ischemia in diabetic rats. Peptides 2016; 79:31-8. [PMID: 27020247 DOI: 10.1016/j.peptides.2016.03.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [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] [Received: 01/13/2016] [Revised: 03/18/2016] [Accepted: 03/23/2016] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Ischemic preconditioning (IPreC) can render the brain more tolerant to a subsequent potential lethal ischemic injury. Hyperglycemia has been shown to increase the size of ischemic stroke and worsen the clinical outcome following a stroke, thus exacerbating oxidative stress. Adropin has a significant association with cardiovascular disease, especially with diabetes. In this study, we aimed to evaluate the role of the IPreC due to modulating the expression of adropin and oxidative damage markers against stroke by induced transient middle cerebral artery occlusion (MCAo) in streptozotocin (STZ)-induced diabetic rats. MATERIAL-METHOD 72 male Spraque Dawley rats were allocated to 8 groups. In order to evaluate alterations of anti/oxidative status and adropin level, we induced transient MCAo seven days after STZ-induced diabetes. Also we performed IPreC 72h before transient MCAo to assess whether IPreC could have a neuroprotective effect against ischemia-reperfusion injury. RESULTS The general characteristics of STZ-treated rats (STZ) included reduced body weight and elevated blood glucose levels compared to non-diabetic ones. Ischemic preconditioning before cerebral ischemia significantly reduced infarction size compared with the other groups [IPreC+MCAo (27±11mm(3)) vs. MCAo (109±17mm(3)) p<0.001; STZ+IPreC+MCAo (38±10mm(3)) vs. STZ+MCAo (165±45mm(3)) p<0.001, respectively]. The mean total antioxidant status level in IPreC groups was higher than other groups (p≤0.05). Moreover, IPreC considerably decreased mean adropin levels compared with other groups (p≤0.05). CONCLUSION The study results supported the neuroprotective effects of ischemic preconditioning in MCA infarcts correlated with the level of oxidative damage markers and adropin.
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Affiliation(s)
- O Altintas
- Bor State Hospital, Neurology Clinic, Istasyon Street, 51700 Bor, Nigde, Turkey.
| | - M Kumas
- BezmiAlem Vakif University, Vocational School of Health Services, Medical Laboratory Techniques, Adnan Menderes Bulvarı, 34093 Fatih, Istanbul, Turkey
| | - M O Altintas
- Fatih University, Faculty of Engineering, Department of Genetics and Bioengineering, Buyukcekmece Campus, 34500 Buyukcekmece, Istanbul, Turkey
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50
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Schwamm LH, Jaff MR, Dyer KS, Gonzalez RG, Huck AE. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 13-2016. A 49-Year-Old Woman with Sudden Hemiplegia and Aphasia during a Transatlantic Flight. N Engl J Med 2016; 374:1671-80. [PMID: 27119240 DOI: 10.1056/nejmcpc1501151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Lee H Schwamm
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| | - Michael R Jaff
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| | - K Sophia Dyer
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| | - R Gilberto Gonzalez
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
| | - Amelia E Huck
- From the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Massachusetts General Hospital, the Departments of Neurology (L.H.S.), Medicine (M.R.J.), Radiology (R.G.G.), and Pathology (A.E.H.), Harvard Medical School, and the Department of Emergency Medicine, Boston Medical Center, and the Department of Emergency Medicine, Boston University School of Medicine (K.S.D.) - all in Boston
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