Blood Pressure in Acute Ischemic Stroke

Michael McManus,David S Liebeskind 대한신경과학회 2016 Journal of Clinical Neurology Vol.12 No.2

Hypertension is present in up to 84% of patients presenting with acute stroke, and a smaller proportion of patients have blood pressures that are below typical values in the context of cerebral ischemia. Outcomes are generally worse in those who present with either low or severely elevated blood pressure. Several studies have provided valuable information about malignant trends in blood pressure during the transition from the acute to the subacute phase of stroke. It is not uncommon for practitioners in clinical practice to identify what appear to be pressure-dependent neurologic deficits. Despite physiologic and clinical data suggesting the importance of blood pressure modulation to support cerebral blood flow to ischemic tissue, randomized controlled trials have not yielded robust evidence for this in acute ischemic stroke. We highlight previous studies involving acute-stroke patients that have defined trends in blood pressure and that have evaluated the safety and efficacy of blood-pressure modulation in acute ischemic stroke. This overview reports the current status of this topic from the perspective of a stroke neurologist and provides a framework for future research.

Decision-Making Visual Aids for Late, Imaging-Guided Endovascular Thrombectomy for Acute Ischemic Stroke

Pouria Moshayedi,David S. Liebeskind,Ashutosh Jadhav,Reza Jahan,Maarten Lansberg,Latisha Sharma,Raul G. Nogueira,Jeffrey L. Saver 대한뇌졸중학회 2020 Journal of stroke Vol.22 No.3

Background and Purpose Speedy decision-making is important for optimal outcomes from endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Figural decision aids facilitate rapid review of treatment benefits and harms, but have not yet been developed for late-presenting patients selected for EVT based on multimodal computed tomography or magnetic resonance imaging. Methods For combined pooled study-level randomized trial (DAWN and DEFUSE 3) data, as well as each trial singly, 100 person-icon arrays (Kuiper-Marshall personographs) were generated showing beneficial and adverse effects of EVT for patients with AIS and large vessel occlusion using automated (algorithmic) and expert-guided joint outcome table specification. Results Among imaging-selected patients 6 to 24 hours from last known well, for the full 7-category modified Rankin Scale (mRS), EVT had number needed to treat to benefit 1.9 (interquartile range [IQR], 1.9 to 2.1) and number needed to harm 40.0 (IQR, 29.2 to 58.3). Visual displays of treatment effects among 100 patients showed that, with EVT: 52 patients have better disability outcome, including 32 more achieving functional independence (mRS 0 to 2); three patients have worse disability outcome, including one more experiencing severe disability or death (mRS 5 to 6), mediated by symptomatic intracranial hemorrhage and infarct in new territory. Similar features were present in person-icon figures based on a 6-level mRS (levels 5 and 6 combined) rather than 7-level mRS, and based on the DAWN trial alone and DEFUSE 3 trial alone. Conclusions Personograph visual decision aids are now available to rapidly educate patients, family, and healthcare providers regarding benefits and risks of EVT for late-presenting, imaging-selected AIS patients.

Stunned brain syndrome: serial diffusion perfusion MRI of delayed recovery following revascularisation for acute ischaemic stroke

Bang, O.Y.,Liebeskind, D.S.,Saver, J.L.,Kim, G.-M.,Chung, C.-S.,Lee, K.H.,Collaborators, UCLA-Samsung Stroke BMJ PUBLISHING GROUP 2011 Journal of neurology, neurosurgery and psychiatry Vol.82 No.1

Impact of Reperfusion after 3 Hours of Symptom Onset on Tissue Fate in Acute Cerebral Ischemia

Bang, Oh Young,Liebeskind, David S.,Buck, Brian H.,Yoon, Sa Rah,Alger, Jeffry R.,Ovbiagele, Bruce,Saver, Jeffrey L. Wiley (Blackwell Publishing) 2009 Journal of neuroimaging Vol.19 No.4

<P>BACKGROUND: Reperfusion of penumbral tissue is a promising strategy for treatment of acute cerebral ischemia more than 3 hours from symptom onset. However, there has been only sparse direct evidence that reperfusion after 3 hours prevents infarct growth. METHODS: We analyzed clinical and serial magnetic resonance imaging (MRI) data on patients who received endovascular recanalization therapy 3-12 hours after last known well time. Multimodal MRIs were acquired pretreatment, early (1-20 hours), and late (2-7 days) after treatment. Degree of recanalization was assessed on end of procedure catheter angiogram, degree of reperfusion on early posttreatment perfusion MRI, and infarct growth by analysis of diffusion lesion volumes on pretreatment and late MRIs. RESULTS: Twenty-seven (12 men, 15 women) underwent endovascular recanalization procedures at 6.0 +/- 2.1 hours (range, 3.0-11.5 hours) after last known well time. Immediate posttreatment perfusion lesion (Tmax > or =4 seconds) volume correlated strongly with infarct growth (r= .951, P < .001), exceeding the correlations of vessel recanalization score (r=-.198, P= .446) and pretreatment diffusion-perfusion mismatch volume (r= .518, P= .033). Without reperfusion, enlargement of DWI lesion volume was observed in all patients, and extent of enlargement depended on volume of immediate posttreatment perfusion defects. CONCLUSION: Our data indicate that posttreatment reperfusion is the major determinant of threatened tissue outcome, and suggest reperfusion even after 3 hours of symptom onset can alter tissue fate over a wide range of mismatch volumes.</P>

Analgesic effects of electrical brain stimulation and stress

J.TIMOTHY CANNON,JOHN C. LIEBESKIND 경희대학교 동서의학연구소 1989 INTERNATIONAL SYMPOSIUM ON EAST-WEST MEDICINE Vol.1989 No.3

It has been 20 years since Melzack and Wall [1965]published their Gate Control Theory of pain. Included in this seminal work was a proposal that the brain could modulate the processing of nociceptive information at the spinal level. At that time, very little was known about the specifics of such a descending system. Particularly during the past decade, however, there has been rapid expansion of information concerning endogenous pain-inhibitory mechanisms. Models of the neural circuitry underlying pain intricate [Basbaum and Fields,1978, 1984]. Similarly, there is growing appreciation that responses to noxious sitmalation rely upon complex interactions between environement and organism. This review will focus on the analgesic effects of electrical brain stmulation (stimulation-produced analgesia) and some forms of stress (stress-induced analgesia). Research in these areas has provided some of the first glimpses of the nearal and biochemical bases of endogenous pain modulation. Additionally, it has contributed to our understanding of variables that define when these systems are called into play. Researchers in this field hope that such insights will contribute to more effective management of clinical pain states. With this goal in mind it is gratifying that there has already been a rapid transition from basic animal research [Mayer et al., 1971, Reynolds, 1969]to successful clinical trials in which electrical brain stmulation effectively attenuates some chronic pain states in man [Adams, 1976 ; Hosobuchi et al., 1977 : Richardson and Akil, 1977a, b].

Impact of Baseline Tissue Status (Diffusion-Weighted Imaging Lesion) Versus Perfusion Status (Severity of Hypoperfusion) on Hemorrhagic Transformation

Kim, Jong Hun,Bang, Oh Young,Liebeskind, David S.,Ovbiagele, Bruce,Kim, Gyeong-Moon,Chung, Chin Sang,Lee, Kwang Ho,Saver, Jeffrey L. Ovid Technologies Wolters Kluwer -American Heart A 2010 Stroke Vol.41 No.3

Clinical determinants of infarct pattern subtypes in large vessel atherosclerotic stroke

Bang, Oh Young,Ovbiagele, Bruce,Liebeskind, David S.,Restrepo, Lucas,Yoon, Sa Rah,Saver, Jeffrey L. Springer-Verlag 2009 Journal of neurology: Zeitschrift für Neurolo Vol.256 No.4

Cortical Thinning in High-Grade Asymptomatic Carotid Stenosis

Randolph S. Marshall,David S. Liebeskind,John Huston III,Lloyd J. Edwards,George Howard,James F. Meschia,Thomas G. Brott,Brajesh K. Lal,Donald Heck,Giuseppe Lanzino,Navdeep Sangha,Vikram S. Kashyap,Cl 대한뇌졸중학회 2023 Journal of stroke Vol.25 No.1

Background and Purpose High-grade carotid artery stenosis may alter hemodynamics in the ipsilateral hemisphere, but consequences of this effect are poorly understood. Cortical thinning is associated with cognitive impairment in dementia, head trauma, demyelination, and stroke. We hypothesized that hemodynamic impairment, as represented by a relative time-to-peak (TTP) delay on MRI in the hemisphere ipsilateral to the stenosis, would be associated with relative cortical thinning in that hemisphere. Methods We used baseline MRI data from the NINDS-funded Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis–Hemodynamics (CREST-H) study. Dynamic contrast susceptibility MR perfusion-weighted images were post-processed with quantitative perfusion maps using deconvolution of tissue and arterial signals. The protocol derived a hemispheric TTP delay, calculated by subtraction of voxel values in the hemisphere ipsilateral minus those contralateral to the stenosis. Results Among 110 consecutive patients enrolled in CREST-H to date, 45 (41%) had TTP delay of at least 0.5 seconds and 9 (8.3%) subjects had TTP delay of at least 2.0 seconds, the maximum delay measured. For every 0.25-second increase in TTP delay above 0.5 seconds, there was a 0.006-mm (6 micron) increase in cortical thickness asymmetry. Across the range of hemodynamic impairment, TTP delay independently predicted relative cortical thinning on the side of stenosis, adjusting for age, sex, hypertension, hemisphere, smoking history, low-density lipoprotein cholesterol, and preexisting infarction (P=0.032). Conclusions Our findings suggest that hemodynamic impairment from high-grade asymptomatic carotid stenosis may structurally alter the cortex supplied by the stenotic carotid artery.

Impact of Baseline Ischemia on Outcome in Older Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke

황양하,김용원,강동훈,김용선,David S. Liebeskind, 대한신경과학회 2017 Journal of Clinical Neurology Vol.13 No.2

Background and Purpose The outcome for older stroke patients who undergo endovascular revascularization remains unsatisfactory. We aimed to determine the effect of the extent of baseline ischemia on outcome according to age, testing the hypothesis that the restorative capacity for recovery is only marginal in older patients. Methods Two hundred and thirteen patients who underwent endovascular revascularization due to occlusion in the M1 segment of the middle cerebral artery (with or without internal carotid artery occlusions) were selected for analysis. Patients were categorized into three age groups: group A (<66 years), group B (66–75 years), and group C (>75 years). Using pretreatment diffusion-weighted imaging (DWI), the Alberta Stroke Program Early CT Score (ASPECTS) and lesion volume were independently measured and analyzed in relation to a favorable outcome. Results A favorable outcome was achieved in 111 of 213 patients overall: in 60 of the 94 (63.8%) patients in group A, in 36 of the 70 (51.4%) patients in group B, and in 15 of the 49 (30.6%) patients in group C (p=0.001). In older stroke patients (group C), a DWI ASPECTS ≥9 and lesion volume ≤5 mL were found to predict a favorable outcome, which was more restrictive than the cutoffs for their younger counterparts (groups A and B; DWI ASPECTS ≥8 and lesion volume ≤20 mL). Conclusions The age-adjusted pretreatment DWI lesion volume and ASPECTS may represent useful surrogate markers for functional outcome according to age. The use of more-restrictive inclusion criteria for older stroke patients could be warranted, although larger studies are necessary to confirm these findings.

Benign Oligemia Despite a Malignant MRI Profile in Acute Ischemic Stroke

방오영,이광호,김석재,David S. Liebeskind, 대한신경과학회 2010 Journal of Clinical Neurology Vol.6 No.1

Background It has recently been suggested that diffusion and perfusion MRI can identify subgroups likely to benefit or potentially be harmed by reperfusion therapies. Case Report We investigated serial MRI data of two patients with occlusion of the proximal middle cerebral artery (MCA). In both cases, acute multiple cortical infarcts evident on diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) showed extensive areas of severe perfusion delays, indicating a malignant MRI profile. However, despite the malignant MRI profiles in these cases, no new ischemic lesions or hemorrhage evolved even in the presence of persistent arterial occlusion, and the patients recovered without sequelae. Conclusions These two cases suggest that time-domain PWI findings should be interpreted with caution in certain scenarios of acute ischemic stroke.