Remote ischemic conditioning approach for the treatment of ischemic stroke

Stroke is the leading cause of disability and death in North America.There has been growing interest in identifying neuroprotective strategies to reduce ischemic burden in patients with acute ischemic stroke.However,despite extensive clinical trials,no neuroprotective agent has been found for prevention of ischemic damage.Remote ischemic preconditioning(RIC)is a promising non-invasive strategy that has been proven to provide renal and cardioprotection and has recently found to have a potential broad application in the treatment of neurovascular disease,which has bee linked to its possible effects on the release and activation of endogenous neuroprotective substances against the ischemia/reperfusion injuries in experimental studies.This endogenous neuroprotection might vaccinate neural tissues against effects of acute IR following primary infarction insult.Regardless of the method of RIC administration,through manual or automated blood pressure cuff,RIC procedure is inexpensive and easy to use.Based on the experimental and clinical data,application of RIC avoids possible adverse effects and interactions associated with chemical pharmacological agents.In previous clinical studies RIC was safe and associated with only minor transient adverse effects in few cases,including petechia and minor limb pain,which were mostly resolved shortly after completing the treatment.

Carotid artery endarterectomy in patients with symptomatic non-stenotic carotid artery disease

Object We sought to determine the safety and efficacy in secondary stroke prevention of carotid endarterectomy(CEA)in patients with symptomatic non-stenotic carotid artery disease(SyNC).Methods This was a single-centre retrospective case series.All patients who underwent CEA for unilateral anterior circulation cerebrovascular events with ipsilateral<50%carotid stenosis from 2002 to 2020 were included.Imaging hallmarks including the degree of luminal stenosis and the presence of various vulnerable plaque characteristics(eg,intraplaque haemorrhage(IPH)on MR angiography,ulceration or low-density plaque on CT angiography)were assessed.The presence of vulnerable plaque characteristics was compared between arteries ipsilateral to the ischaemic event and contralateral arteries.The prevalence of perioperative/intraoperative complications,as well as recurrent ischaemic events at follow-up was determined.Results Thirty-two patients were included in the analysis,of which 25.0%were female.Carotid arteries ipsilateral to an ischaemic event had a significantly higher prevalence of IPH when compared with contralateral arteries(80.0%vs 0.0%;p<0.001).There were no intraoperative complications.One patient(3.1%)developed symptoms of transient ipsilateral ischaemia 1 day following CEA which resolved without treatment.In a median follow-up of 18.0 months(IQR 5.0-36.0),only one patient(3.1%)experienced a transient neurologic deficit with complete resolution(annualised rate of recurrent stroke after CEA of 1.5%for a total follow-up of 788 patient-months following CEA).All other patients(31/32,96.9%)were free of recurrent ischaemic events.Conclusion CEA appears to be safe and well-tolerated in patients with SyNC.Additional studies with larger cohorts and longer follow-up intervals are needed in order to determine the role of CEA in this patient population.

Mechanisms of fibrinolysis resistance and potential targets for thrombolysis in acute ischaemic stroke: lessons from retrieved stroke emboli

There has been growing interest and insight into the histological composition of retrieved stroke emboli.One of the main focuses of the stroke clot analysis literature has been the implications of clot composition on mechanical thrombectomy procedures.However,the holy grail of clot analysis may not be in the field of clot-device interaction,but rather,in understanding mechanisms of fibrinolysis resistance.The mechanisms underlying the low response to fibrinolytic therapy,even with the newer,more powerful agents,remain poorly understood.While factors such as embolus size,location and collateral status influence alteplase delivery and recanalisation rates;compositional analyses focused on histological and ultrastructural characteristics offer unique insights into mechanisms of alteplase resistance.In this review,we strive to provide comprehensive review of current knowledge on clot composition and ultrastructural analyses that help explain resistance to fibrinolysis.

Endarterectomy for symptomatic non-stenotic carotids: a systematic review and descriptive analysis

Objective To systematically analyse prior reports of carotid endarterectomy(CEA)performed in cases of≤50%carotid stenosis in order to understand patient tolerance and potential benefit.Methods A systematic review and descriptive analysis was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.An English-language search was performed of online databases using librarian-selected search terms.Abstracts were reviewed for relevance which included mention of carotid endarterectomy and stenosis.Prospective or retrospective observational cohort studies that reported series of patients who underwent endarterectomy for minimal(≤50%)luminal stenosis with reported outcomes were included.Results Six studies(which included our institutional series)with a total of 143 patients met the inclusion criteria.The weighted mean age at the time of CEA was 72.3 years;113(79.0%)were male.55.8%of patients with available data had recurrent ipsilateral ischaemic events despite medical therapy.Two patients out of 129 with available perioperative data(1.6%)had perioperative MRI findings of acute ischaemic stroke,both within the hemisphere contralateral to the side of CEA.Of the 138 patients with available follow-up(mean,36 months),none had recurrent ipsilateral ischaemic events.Conclusions Endarterectomy for symptomatic carotid disease causing≤50%stenosis may be a potentially beneficial strategy to prevent stroke recurrence.Studies with robust methodology are needed to draw more definitive conclusions in terms of the safety and efficacy of endarterectomy for minimal stenosis with vulnerable features relative to intensive medical therapy.