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Stroke
Pathophysiology, Diagnosis, and Management
SEVENTH EDITION
JAMES C. GROTTA, MD ENG H. LO, PhD

Director of Stroke Research and Mobile Stroke Unit Professor of Neurology and Radiology
Clinical Innovation and Research Institute Harvard Medical School
Memorial Hermann Hospital-Texas Medical Center Boston, Massachusetts
Houston, Texas Director, Neuroprotection Research Laboratories
Massachusetts General Hospital
Charlestown, Massachusetts
GREGORY W. ALBERS, MD
Professor
Department of Neurology and Neurological Sciences RALPH L. SACCO, MD
Stanford University Chairman, Department of Neurology
Stanford, California Olemberg Family Chair in Neurological Disorders
Miller Professor of Neurology, Public Health Sciences,
Human Genetics, and Neurosurgery
JOSEPH P. BRODERICK, MD University of Miami Miller School of Medicine
Professor Chief of Service, Neurology
Department of Neurology and Rehabilitation Medicine Jackson Health System
University of Cincinnati Gardner Neuroscience Institute Miami, Florida
Cincinnati, Ohio
LAWRENCE K.S. WONG, MD

ARTHUR L. DAY, MD Professor
Professor and Co-Chairman Department of Medicine and Therapeutics
Director of Cerebrovascular Surgery Chinese University of Hong Kong
Residency Program Director Shatin, Hong Kong, China
Department of Neurosurgery
University of Texas Medical School at Houston
Houston, Texas
SCOTT E. KASNER, MD
Professor, Department of Neurology
University of Pennsylvania
Director, Comprehensive Stroke Center
University of Pennsylvania Health System
Philadelphia, Pennsylvania
Elsevier
1600 John F. Kennedy Blvd.
Ste 1600
Philadelphia, PA 19103-2899
STROKE: PATHOPHYSIOLOGY, DIAGNOSIS, AND MANAGEMENT: ISBN: 978-0-323-69424-7

SEVENTH EDITION
Copyright © 2022 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
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Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. Because of rapid advances
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Last digit is the print number: 9 8 7 6 5 4 3 2 1

Video Contents
Video 30.1 Important concepts regarding Video 32.9 TTE of large posterior mitral annular
angioarchitecture, classification, and risk calcification (MAC) with central echo lucency,
factors for arteriovenous malformations. suggesting caseous MAC.
Video 30.2 Endovascular embolization of a frontal Video 33.1 Large atherosclerotic plaque in the mid-portion
arteriovenous malformation. of the aortic arch with large superimposed,
Video 30.3 Endovascular and surgical techniques in the mobile thrombus (also Fig. 33.6).
treatment of dural arteriovenous fistulae. Video 33.2 Mobile aortic plaque in the superior aspect of
Video 32.1 Mobile atheroma: An intraoperative video 3D the aortic arch, just proximal to the takeoff of
TEE image of a mobile atheroma in the aortic the innominate artery (also Fig. 33.10A and B).
arch, visualized during a transcatheter aortic Video 35.1 3D reconstruction of carotid angiography
valve replacement (TAVR), consistent with in a 40-year-old woman with right-sided
grade 5 atheromatous disease. numbness. Anterior, posterior, and left lateral
Video 32.2 (A) Positive bubble study: Markedly positive rotational video of the left internal carotid
bubble study consistent with a large atrial artery demonstrates a web.
level shunt. (B) Negative bubble study: Video 60.1 Knee-ankle-foot-orthosis: A knee-ankle-foot
Agitated saline contrast (“bubble”) study orthosis enabled this hemiplegic person with
showing no evidence of an interatrial sensorimotor loss to prevent the knee from
communication. snapping back in the mid- to late stance phase
Video 32.3 TEE bubble study with intrapulmonary of gait, prevent catching the forefoot when
shunt: A bubble study on TEE with delayed initiating swing, and improved control of the
passage of bubbles into the left atrium via the stability of foot placement during the stance
right upper pulmonary vein, suggesting an phase.
intrapulmonary shunt, such as a pulmonary Video 72.1 Minimally invasive endoscopic ICH
atriovenous malformation. evacuation. The procedure begins with a
Video 32.4 Takotsubo cardiomyopathy: TTE revealing 1.5-cm incision, a 1-cm craniectomy, and
akinesis of mid- and apical left ventricular stereotactic placement of a 19F (6.3-mm)
segments with hypercontractile basal sheath into the hematoma. The introducer
segments, consistent with a stress-mediated is then removed from the sheath, and the
cardiomyopathy (Takotsubo cardiomyopathy). endoscope is placed down the sheath with
an adjunctive aspiration device inserted
Video 32.5 Mobile atrial septum with positive bubble in the working channel of the endoscope.
study: Mobile atrial septum, consistent with
Continuous irrigation with lactated Ringers is
an atrial septal aneurysm. Agitated saline
used throughout the procedure.
contrast (“bubble”) study reveals passage
of bubbles into the left heart after the atrial Video 72.2 Minimally invasive endoport-mediated ICH
septum bulges into the left atrium, suggesting evacuation. The procedure begins with a
a transient increase in right atrial pressure. 4-cm incision, a 2.5-cm craniotomy, and
This finding is consistent with the presence of stereotactic placement of a 13.5-cm endoport
a patent foramen ovale (PFO). into the hematoma. The introducer is
then removed from the endoport, and the
Video 32.6 TTE of a large left atrial myxoma, filling the
endoport is fixed in place. A microscope or
entire left atrium and resulting in obstruction
an exoscope is then positioned to provide
to left ventricular filling.
visibility down the endoport and into the
Video 32.7 Papillary fibroelastoma: TEE of the aortic cavity.
valve revealing a linear echo density on the
Video 75.1 Surgical management of a cerebral cavernous
ventricular surface of the valve, consistent
malformation.
with a papillary fibroelastoma.
Video 32.8 2D (A) and 3D (B) images of a large burden of Video 77.1 Superficial temporal artery to middle cerebral
artery bypass.
clot in the left atrium and left atrial appendage
in a patient with a cardiomyopathy and atrial Video 78.1 Decompressive craniectomy in a patient with
flutter, presenting with a stroke. malignant middle cerebral artery infarction.
ix
Foreword to the Seventh Edition
This original editor continues to marvel at the advances in The growing participation in stroke management by
the field of stroke, justifying the seventh edition of this book. those in allied fields has done nothing to displace the role
Among other topics, the first edition had a mere 15 chap- of neurovascular clinicians, whose commitment includes
ters, and in 347 pages covered “Stroke Therapy.” The subjects studying how the brain works. Insights from modern basic
ranged from management of risk factors to rehabilitation. biology, increasingly sophisticated imaging, prospective
This edition has no less than 28 such chapters, clustered in clinically detailed databases, and even access to video Zoom
stand-alone sections for medical and interventional therapy. follow-ups are providing windows into what was formerly
The page length for all of subjects has steadily expanded by called semiology. Decades ago, the neurology literature was
editions: proof, if needed, of progress. Gone—and good rid- dotted with titles beginning with “The Neurology of…” by
dance!—are the days when those interested in stroke were which the author(s) implied how a clinical syndrome allowed
considered clinically irrelevant for lack of definitive therapies. insight into diagnosis or prognosis. Today, a surprising number
Instead, far from an arcane subspecialty, stroke prevention of outcomes for acute focal syndromes formerly considered
and management now has an impact on the clinical practice static, prevented from their full development, or deemed
of many medical and surgical fields whose training not long modified favorably by acute interventions, are yielding insights
ago scarcely touched on the subject. into the mysteries of functional reorganization. The increasing
Stroke clinicians now find their clinical judgment opportunities to understand this effect offers literature-
tested—sometimes to their vexation—by the application of oriented neurovascular clinicians the chance to be links in an
hyperacute management algorithms driven mainly by scor- unbroken chain of inquiry dating back to antiquity.
ing systems, meta-analyses, and outcomes from the wave of
clinical trials. Few can argue with the positive effect of rapid J.P. Mohr, MD
assessment and intervention, especially for acute ischemic Daniel Sciarra Professor of Neurology
strokes. Insights spanning genetics, basic biology, computer- Department of Neurology
driven population studies, web-based meta-analyses, and Director and Neurologist
increasingly common longitudinal outcome reports are wel- Doris and Stanley Tanenbaum Stroke Center
come signs of progress. Only novelists should designate their Columbia University Irving Medical Center
published work free from revision. The current contributors New York, New York
can expect further changes to justify an eighth edition in the
foreseeable future.
x
Preface
The seventh edition of the text has a number of important Other unsolved areas that receive substantial updating
changes. First, this edition has even more on-line features, include intracerebral hemorrhage by new author Dr. Anderson
making it easier to access its content in a digital-friendly for- and arteriovenous malformations by Drs. Samaniego, Roa,
mat. The eBook includes the entire book plus full reference Ortega-Gutierrez, and Derdeyn. In addition, the chapters
lists (as opposed to the Key References that appear in the chap- on the surgical management of different types of brain
ters) and a larger number of videos than the previous edition. hemorrhage have all been updated by new authors.
Access to the Expert Consult eBook version is included with The previous edition appeared just as the trials demonstrating
print purchase. This enhanced eBook experience allows you the benefit of endovascular thrombectomy were published, so
to search all of the text, figures, and references on a variety of the coverage of this revolution in treatment was incomplete.
devices. The content can also be downloaded to tablets and In this edition, Dr. Broderick’s section, Interventional Therapy,
smart phones for offline use. and in particular the chapter by Drs. Saver and Jahn on the
Another important change includes our new Surgical endovascular treatment of acute ischemic stroke, have been
Therapy section editor, Arthur Day, MD. Dr. Day is an substantially updated to include the results of all those pivotal
international authority on the surgical management of clinical trials, as well as the myriad studies that followed.
cerebral aneurysms, intracranial hemorrhage, and extracranial The final unresolved topic receiving increased coverage
vascular disease. He is the recipient of numerous neurosurgical in this edition is how best to deliver these effective new
leadership awards, and from first-hand experience I can attest treatments (e.g., stroke systems of care). We have added a new
to his passion for teaching and the wisdom that has grown chapter on this topic, written by Drs. Czap, Harmel, Audebert,
out of decades of skillfully managing the complexities of the and myself, that explores different models and approaches to
entire array of neurovascular surgical cases. Of particular value reorganizing our stroke centers, resources, and staffing. and
for his role as editor, Dr. Day has been an important leader In addition, first-time contributors to this title, Drs. Kircher
of the neurosurgical field as it has emerged from open to and Adeoye, have expanded the chapter on prehospital and
endovascular approaches and as it has partnered with vascular emergency care.
neurology in the conduct of clinical trials. As a result of his While I have focused my editorial spotlight on a few of the
intimate knowledge of the entire neurovascular landscape and major unresolved topics that are receiving substantial and well-
its leaders, you will see that the authors of almost all of the deserved increased attention, I want to emphasize that each and
chapters in the Surgical Therapy section have changed and the every chapter has been updated with new information. There
chapters have all been updated. I think that the readers will be is a new chapter on posterior reversible encephalopathy, which
impressed by the combined experience, fresh perspective, and replaces the old chapter on hypertensive encephalopathy with
new information in every chapter in the section. new authors (Drs. Balu and Fischer); the imaging chapters on
Other notable changes in this edition justified enlarging CT and MRI have been updated, with expanded discussion of
attention given to several underappreciated and yet unresolved the important role of imaging in patient selection for acute
problems in the field. In line with the increasing evidence of therapy; the chapters on cardiac disease, cryptogenic stroke,
vascular disease as the most important modifiable contributor and secondary prevention provide more information on
to dementia and much-needed attention to the biology atrial fibrillation detection, other possible causes of embolic-
underlying small vessel disease, a new chapter on this topic appearing stroke without known source, and their long
has been added to the Pathophysiology section, which has term management; the antiplatelet therapy chapter includes
been overseen by the senior editor, Dr. Lo. In addition, the updated data from recent trials of dual antiplatelet therapy;
chapters on the clinical aspects of vascular dementia and and the design of stroke clinical trials chapter has been
small vessel disease have been updated by new authors (Drs. rewritten by new authors (Drs. Perez, Elm, and Saver) and
Rundek, Seshadri, and Caunca) in the Epidemiology and Risk includes emerging novel approaches to figuring out if new
Factors section, and important new information is found in the treatments work.
chapters on genetics and CADASIL. Somewhat linked to this All in all, I hope that the exciting relevant new data that fill
topic and also reflecting a maturing interest in non-imaging the pages of our journals and make stroke such a dynamic and
stroke biomarkers in general is an entirely new chapter on interesting field are distilled into these pages in a readable and
“OMICs,” written by Drs. Jickling and Sharp. authoritative format that will help the reader understand their
Disparities in stroke incidence and outcomes has become patients and their underlying disease, which they see every
a hot topic, accentuated recently by the spotlight cast on this day, and also provide the foundation for new knowledge that
issue during the COVID-19 pandemic and the racial unrest in will be the substrate for the next edition.
the United States. The already outstanding chapter on stroke
disparities by Drs. Howard, Howard, and McCullough has James C. Grotta, MD
been updated, and this topic has also been woven through
other chapters where relevant.
xi
Contributors
Harold P. Adams Jr., MD Hugo J. Aparicio, MD, MPH Hakan Ay, MD

Professor Assistant Professor Associate Professor
Department of Neurology Department of Neurology Departments of Neurology and
Carver College of Medicine Boston University School of Medicine Radiology
University of Iowa Investigator, The Framingham Heart Massachusetts General Hospital
Iowa City, Iowa Study Harvard Medical School
Boston, Massachusetts Boston, Massachusetts
Opeolu Adeoye, MD
Takeda Pharmaceutical Company
Vice Chair, Research Ken Arai, PhD
Limited
Co-Director, UC Stroke Team Associate Professor
Cambridge, Massachusetts
Professor Neuroprotection Research Laboratory
Department of Emergency Medicine Departments of Radiology and Selva Baltan, MD, PhD
University of Cincinnati Neurology Professor and Vice Chair for Basic
Cincinnati, Ohio Massachusetts General Hospital Research
Harvard Medical School Anesthesiology and Peri-Operative
Gregory W. Albers, MD
Boston, Massachusetts Medicine
Professor
Oregon Health and Science University
Department of Neurology and Jaroslaw Aronowski, PhD, MD
School of Medicine
Neurological Sciences Professor and Vice Chair
Portland, Oregon
Stanford University Roy M. and Phyllis Gough Huffington
Stanford, California Chair in Neurology Ramani Balu, MD, PhD
McGovern Medical School Assistant Professor
Andrei V. Alexandrov, MD, RVT
University of Texas Health Science Division of Neurocritical Care
Semmes-Murphey Professor and Chairman
Center at Houston Department of Neurology
Department of Neurology
Houston, Texas University of Pennsylvania
The University of Tennessee Health
Science Center Kunakorn Atchaneeyasakul, MD
Memphis, Tennessee Clinical Instructor of Neurology Mandana Behbahani, MD
StrokeNet Fellow Resident
Sepideh Amin-Hanjani, MD
Department of Neurology Department of Neurosurgery
Professor and Program Director
University of Pittsburg School of University of Illinois at Chicago
Medicine Chicago, Illinois
Co-Director, Neurovascular Surgery
Pittsburg, Pennsylvania
University of Illinois at Chicago Oscar R. Benavente, MD
Stroke Vascular Fellow
Chicago, Illinois Professor
UCLA Health
Department of Medicine
Hongyu An, PhD Los Angeles, California
Director
Associate Professor
Heinrich Audebert, MD Stroke and Cerebrovascular Health
Department of Radiology
Senior Physician Research
Washington University School of
Assistant Director of the Department CBF Brain Research Center
Medicine
Department of Neurology Division of Neurology
St. Louis, Missouri
Center for Stroke Research University of British Columbia
Craig S. Anderson, MD, PhD Charité University Medicine Berlin Vancouver, British Columbia, Canada
Professor of Neurology Berlin, Germany
Eric M. Bershad, MD
The George Institute for Global Health
Roland N. Auer, MD, PhD Associate Professor
University of New South Wales
Professor and Neuropathologist Neurology, Neurosurgery, and Space
Sydney, Australia
Department of Pathology Medicine
Josef Anrather, VMD Royal University Hospital Baylor College of Medicine
Professor of Neuroscience Saskatoon, Saskatchewan, Canada Houston, Texas
Feil Family Brain and Mind Research
Issam A. Awad, MD Jimmy V. Berthaud, MD, MPH
Institute
The John Harper Seeley Professor of Assistant Professor
Weill Cornell Medicine
Surgery (Neurosurgery) Department of Neurology
New York, New York
Director, Neurovascular Surgery University of Michigan Medical School
Department of Neurosurgery Ann Arbor, Michigan
University of Chicago
Chicago, Illinois
xii
Contributors xiii
Spiros L. Blackburn, MD Louis R. Caplan, MD Greg Christorforids, MD

Associate Professor Professor Professor
Department of Neurosurgery Department of Neurology Department of Radiology
University of Texas Houston Health Harvard University University of Chicago
Science Center Beth Israel Deaconess Medical Center Chicago, Illinois
Houston, Texas Boston, Massachusetts
E. Sander Connolly, Jr., MD
Leo H. Bonati, MD Julián Carrión-Penagos, MD Bennett M. Stein Professor
Professor of Neurology Neurology Resident Chairman
Head Stroke Center Department of Neurology Department of Neurological Surgery
Department of Neurology University of Chicago Columbia University Medical Center
University Hospital Basel Chicago, Illinois New York, New York
Department of Clinical Research
Mar Castellanos, MD Steven C. Cramer, MD
University of Basel
Department of Neurology Professor
Basel, Switzerland
Complexo Hospitalario Universitario A Department of Neurology
Julian Bösel, MD Coruña David Geffen School of Medicine
Professor Biomedical Research Institute of A University of California, Los Angeles
Department of Neurology Coruña Los Angeles, California
Klinikum Kassel A Coruña, Spain
Brett L. Cucchiara, MD
Kassel, Germany
Michelle R. Caunca, PhD Professor
Marie Germaine Bousser, MD Medical Scientist Training Program Department of Neurology
Department of Neurology and CERVCO University of Miami Miller School of University of Pennsylvania
Reference Center for Rare Vascular Medicine Philadelphia, Pennsylvania
Diseases of the Eye and Brain Miami, Florida
Alexandra L. Czap, MD
Hôpital Lariboisiére
Hugues Chabriat, MD, PhD Neuro-oncologist
Assistance Publique Hôpital de Paris;
Department of Neurology and CERVCO Assistant Professor
Université of Paris
Reference Center for Rare Vascular Department of Neurology
Paris, France
Diseases of the Eye and Brain McGovern Medical School
Joseph P. Broderick, MD Hôpital Lariboisiére University of Texas Health Science
Professor Assistance Publique Hôpital de Paris Center at Houston
Department of Neurology and Ambroise Paré Houston, Texas
Rehabilitation Medicine INSERM U 1161
Mark J. Dannenbaum, MD
University of Cincinnati Gardner Genetics and Physiopathology of
Assistant Professor
Neuroscience Institute Cerebrovascular Diseases
Cincinnati, Ohio Université of Paris
University of Texas Houston Health
Service de Neurologie
Martin M. Brown, MA, MD Science Center
Hôpital Lariboisière
Emeritus Professor of Stroke Medicine Houston, Texas
Paris, France
UCL Queen Square Institute of
Patricia H. Davis, MD
Neurology Angel Chamorro, MD, PhD
Professor Emeritus
University College London Professor of Neurology
London, United Kingdom Department of Neurosciences
Carver College of Medicine
Hospital Clinic of Barcelona
Wendy Brown, MD University of Iowa
Barcelona, Spain
Stroke Director Iowa City, Iowa
Sutter Roseville Medical Center Jieli Chen, MD
Ted M. Dawson, MD, PhD
Roseville California Senior Scientist
Director, Institute for Cell Engineering
John C.M. Brust, MD Professor of Neurology
Henry Ford Hospital
Professor John Hopkins University School of
Detroit, Michigan
Department of Neurology Medicine
Columbia University College of Jun Chen, MD, PhD Baltimore, Maryland
Physicians and Surgeons Professor
Valina L. Dawson, PhD
New York, New York Department of Neurology
Director, Neuroregeneration and Stem
University of Pittsburgh
Cheryl Bushnell, MD, MHS Cell Programs
Pittsburgh, Pennsylvania
Department of Neurology Institute for Cell Engineering
Wake Forest School of Medicine Michael Chopp, PhD Professor of Neurology, Neuroscience,
Winston-Salem, North Carolina Senior Scientist and Physiology
Department of Neurology Johns Hopkins School of Medicine
Patrícia Canhão, MD, PhD
Henry Ford Hospital Baltimore, Maryland
Department of Neurosciences
Detroit, Michigan
(Neurology) Arthur L. Day, MD
Distinguished Professor
Hospital de Santa Maria-CHULN Professor and Co-Chairman
Department of Physics
Instituto de Medicina Molecular João Director of Cerebrovascular Surgery
Oakland University
Lobo Antunes Residency Program Director
Rochester, Michigan
Faculdade de Medicina Department of Neurosurgery
Universidade de Lisboa University of Texas Medical School at
Lisbon, Portugal Houston
Houston, Texas
xiv Contributors
T. Michael De Silva, PhD Bruce H. Dobkin, MD Myriam Fornage, PhD

Lecturer in Physiology Professor Professor, Center for Human Genetics
Department of Physiology, Anatomy, Department of Neurology Laurence and Johanna Favrot
and Microbiology David Geffen School of Medicine Distinguished Professor in Cardiology
School of Life Sciences University of California, Los Angeles Brown Foundation Institute of
La Trobe University Los Angeles, California Molecular Medicine
Melbourne, Victoria, Australia McGovern Medical School
Imanuel Dzialowski, MD
University of Texas Health Science
Diana Aguiar de Sousa, MD, PhD Head of ELBLAND Center for
Center at Houston
Department of Neurosciences Neuro-Rehabilitation
Houston, Texas
(Neurology) Teaching Faculty
Hospital de Santa Maria-CHULN Technical University Dresden Karen L. Furie, MD, MPH
Instituto de Medicina Molecular João Dresden, Germany Neurologist-in-Chief
Lobo Antunes Rhode Island Hospital
Mitchell S.V. Elkind, MD
Faculdade de Medicina The Miriam Hospital and Bradley
Professor
Universidade de Lisboa Hospital
Lisbon, Portugal Samuel I. Kennison, MD, and Bertha
Columbia University College of
S. Kennison Professor of Clinical
Victor J. Del Brutto, MD Physicians and Surgeons
Neuroscience
Assistant Professor Professor
Chair of Neurology
Department of Neurology Department of Epidemiology
The Warren Alpert Medical School of
Stroke Division Columbia University Mailman School
Brown University
University of Miami Miller School of of Public Health
Providence, Rhode Island
Medicine New York, New York
Miami, Florida Lidia Garcia-Bonilla, PhD
Jordan Elm, PhD
Assistant Professor of Research in
Gregory J. del Zoppo, MD Associate Professor
Neuroscience
Professor Department of Public Health Sciences
Division of Hematology Medical University of South Carolina
Institute
Department of Neurology Charleston, South Carolina
Weill Cornell Medicine
University of Washington
Valery L. Feigin, MD, PhD New York, New York
Seattle, Washington
Professor of Epidemiology and
Steven L. Giannotta, MD
Colin P. Derdeyn, MD Neurology
Professor
Professor and Chair National Institute for Stroke and
Chair, Neurological Surgery
Radiology and Neurology Applied Neurosciences
Department of Neurology Faculty of Health and Environmental
Keck School of Medicine
Carver College of Medicine Studies
University of Southern California
University of Iowa Auckland University of Technology
Los Angeles, California
Iowa City, Iowa Auckland, New Zealand
Y. Pierre Gobin, MD
Marco R. Di Tullio, MD José Manuel Ferro, MD, PhD
Professor of Radiology in Neurology
Professor of Medicine Department of Neurosciences
and Neurosurgery
Division of Cardiology (Neurology)
Director, Interventional Neurology
Columbia University College of Hospital de Santa Maria-CHULN
Weill Cornell Medical Center
Physicians and Surgeons Principle Investigator
New York Presbyterian Hospital
Associate Director Instituto de Medicina Molecular João
New York, New York
Adult Cardiovascular Ultrasound Lobo Antunes
Laboratories Faculdade de Medicina Mark P. Goldberg, MD
Cardiologist Professor Professor of Neurology
Cardiology Division Universidade de Lisboa Associate Vice Chair of Institutional
Columbia University Irving Medical Lisbon, Portugal Advancement
Center University of Texas Southwestern
Thalia S. Field, MD
New York, New York Medical Center
Associate Professor
Dallas, Texas
Hans Christoph Diener, MD, PhD Department of Medicine
Professor of Neurology Emeritus University of British Columbia Larry B. Goldstein, MD
Medical Faculty of the University Vancouver, British Columbia, Canada Ruth L Works Professor and Chairman
Duisburg-Essen Department of Neurology
Marlene Fischer, MD, PhD
Institute for Medical Informatics, University of Kentucky
University Medical Center Hamburg-
Biometry and Epidemiology Co-Director, Kentucky Neuroscience
Eppendorf
Essen, Germany Institute
Center for Anesthesiology and Intensive
Lexington, Kentucky
Michael N. Diringer, MD Care Medicine
Professor Department of Intensive Care Medicine Nicole R. Gonzales, MD
Department of Neurology Hamburg, Germany Professor
Washington University School of Department of Neurology
Medicine McGovern Medical School
St. Louis, Missouri University of Texas Health Science
Center at Houston
Houston, Texas
Contributors xv
David M. Greer, MD Glen C. Jickling, MD Charles E. Kircher, MD

Richard B. Slifka Chief of Neurology Associate Professor Assistant Professor
Boston Medical Center Department of Medicine Department of Emergency Medicine
Professor and Chair Division of Neurology University of Cincinnati
Department of Neurology University of Alberta Neurointensivist
Boston University School of Medicine Edmonton, Alberta, Canada Gardner Neuroscience Institute
Boston, Massachusetts University of Cincinnati Medical Center
Anne Joutel, MD, PhD
Cincinnati, Ohio
James C. Grotta, MD INSERM U 1266
Director of Stroke Research and Mobile Pathogenesis of Small Vessel Diseases of Timo Krings, MD, PhD
Stroke Unit the Brain; The David Braley and Nancy
Clinical Innovation and Research Université of Paris Gordon Chair in Interventional
Institute Paris, France Neuroradiology
Memorial Hermann Hospital-Texas Chief, Diagnostic and Interventional
Scott E. Kasner, MD
Medical Center Neuroradiology
Professor
Houston, Texas Toronto Western Hospital and
University Health Network
Ruiming Guo University of Pennsylvania
Program Director, Interventional
Department of Neurology Director, Comprehensive Stroke Center
Neuroradiology
Pittsburgh Institute of Brain Disorders University of Pennsylvania Health
Toronto Western Hospital
and Recovery System
Professor
University of Pittsburgh Philadelphia, Pennsylvania
Departments of Radiology and Surgery
Mira Katan, MD, MS University of Toronto
Jose Gutierrez, MD, MPH Assistant Professor Toronto, Ontario, Canada
Assistant Professor of Neurology Department of Neurology
Rita V. Krishnamurthi, BSc, MApplSc,
Department of Neurology University Hospital of Zurich
PhD
Columbia University College of Zurich, Switzerland
Associate Professor
Physicians and Surgeons
Christopher P. Kellner, MD National Institute for Stroke and
New York, New York
Assistant Professor Applied Neurosciences
Peter Harmel, MD Department of Neurosurgery Faculty of Health and Environmental
Department of Neurology Icahn School of Medicine at Mount Studies
Charité University Medicine Berlin Sinai Auckland University of Technology
Berlin, Germany New York, New York Auckland, New Zealand
George Howard, DrPH Muhib Khan, MD Tobias Kurth, MD, ScD
Professor Clinical Assistant Professor Professor of Public Health and
Department of Biostatistics Department of Clinical Neuroscience Epidemiology
School of Public Health Michigan State University College of Institute of Public Health
University of Alabama at Birmingham Human Medicine Charité-Universitätsmedizin Berlin
Birmingham, Alabama Division Chief, Inpatient Neurology Berlin, Germany
Director, Comprehensive Stroke Center
Virginia J. Howard, PhD Maarten G. Lansberg, MD, PhD
Spectrum Health
Professor Professor
Grand Rapids, Michigan
Department of Epidemiology Neurology and Neurological Sciences
School of Public Health Chelsea S. Kidwell, MD Stanford University
University of Alabama at Birmingham Professor Stanford, California
Birmingham, Alabama Vice Chair of Research
Elad I. Levy, MD, MBA
Jee-Yeon Hwang, PhD Professor and L. Nelson Hopkins, MD,
University of Arizona College of
Assistant Professor Chairman
Medicine
Department of Pharmacology and Department of Neurological Surgery
Tuscon, Arizona
Neuroscience Jacobs School of Medicine and
Creighton University Helen Kim, MPH, PhD Biomedical Sciences
Omaha, Nebraska Professor University at Buffalo
Department of Anesthesia and Director, Interventional Stroke Services
Costantino Iadecola, MD
Perioperative Care Endovascular Neurosurgery Fellowship
Director and Chair
Director, Center for Cerebrovascular Kaleida Health
Research Buffalo, New York
Institute
University of California, San Francisco
Weill Cornell Medicine David S. Liebeskind, MD
San Francisco, California
New York, New York Professor of Neurology
Jong S. Kim, MD, PhD Director, Neurovascular Imaging
Reza Jahan, MD
Professor Research Core
Professor
Department of Neurology Director, Outpatient Stroke and
Division of Interventional
University of Ulsan Neurovascular Programs
Neuroradiology
Asan Medical Center Director, UCLA Cerebral Blood Flow
Department of Radiology
Seoul, South Korea Laboratory
David Geffen School of Medicine
Director, UCLA Vascular Neurology
University of California, Los Angeles
Residency Program
UCLA Department of Neurology
xvi Contributors
Sook-Lei Liew, PhD, OTR/L Jason M. Meckler, MD Maiken Nedergaard, MD, PhD
Assistant Professor Neurologist Professor and Director
Chan Division of Occupational Science Norton Neurology Services Center for Translational Neuromedicine
and Occupational Health Louisville, Kentucky University of Rochester Medical Center
Division of Biokinesiology and Physical Rochester, New York
James Frederick Meschia, MD
Therapy Professor and Director
Professor
Department of Neurology Center for Basic and Translational
Keck School of Medicine Neuroscience
Mayo Clinic
University of Southern California University of Copenhagen
Jacksonville, Florida
Los Angeles, California Copenhagen, Denmark
Steven R. Messé, MD
David J. Lin, MD Justin A. Neira, MD
Professor
Clinical Fellow Resident
Center for Neurotechnology and Department of Neurological Surgery
Perelman School of Medicine at the
Neurorecovery Columbia University Medical Center
University Hospital of Pennsylvania
Department of Neurology NY-Presbyterian Hospital
Massachusetts General Hospital New York, New York
Boston, Massachusetts J Mocco, MD
Sarah Newman, NP
Professor
Benjamin Lisle, PM, PhD Beth Israel Lahey Health
Department of Neurology Lahey Hospital and Medical Center
Icahn School of Medicine at Mount
University of Missouri Medical School Burlington, Massachusetts
Sinai
and Cox Health
New York, New York Patrick J. Nicholson, MB, BCh, BAO
Springfield, Missouri
Diagnostic and Interventional
Maxim Mokin, MD, PhD
Eng H. Lo, PhD Neuroradiologist
Associate Professor
Professor of Neurology and Radiology Toronto Western Hospital and
Harvard Medical School University Health Network
University of South Florida College of
Boston, Massachusetts University of Toronto
Medicine
Director, Neuroprotection Research Toronto, Ontario, Canada
Vascular Neurologist
Laboratories
Neurosciences Center Bo Norrving, MD, PhD
Tampa General Hospital Professor
Charlestown, Massachusetts
Tampa, Florida Department of Clinical Sciences
Patrick D. Lyden, MD Neurology Division
Michael A. Mooney, MD
Professor Lund University
Instructor
Department of Neurology Lund, Sweden
Cedars-Sinai Medical Center
Brigham and Women’s Hospital Martin O’Donnell, MB, PhD
Harvard Medical School Department of Medicine
Takakuni Maki, MD Boston, Massachusetts NUI Galway and Saolta University
Neuroprotection Research Laboratory Healthcare Group
Lewis B. Morgenstern, MD
Departments of Radiology and Galway, Ireland
Professor
Neurology
Department of Neurology Dimitry Ofengeim, PhD
Director, Stroke Program Department of Cell Biology
Harvard Medical School
University of Michigan Medical School Harvard Medical School
Boston, Massachusetts
Ann Arbor, Michigan Boston, Massachusetts
Kyoto University Graduate School of Michael A. Moskowitz, MD Jun Ogata, MD, PhD
Medicine Professor of Neurology Internal Medicine
Kyoto, Japan Harvard Medical School Hirakata General Hospital for
Senior Neuroscientist Developmental Disorders
Georgios A. Maragkos, MD
Departments of Radiology and Hirakata-shi, Osaka, Japan
Post-Doctoral Research Fellow
Neurology
Department of Neurosurgery Christopher S. Ogilvy, MD
Beth Israel Deaconess Medical Center Professor
Harvard Medical School Department of Neurosurgery
Boston, Massachusetts Michael T. Mullen, MD Harvard Medical School
Assistant Professor Director, Brain Aneurysm Institute
Miklos Marosfoi, MD
Department of Neurology Director, Endovascular and Operative
Assistant Professor of Radiology
Perelman School of Medicine at the Neurovascular Surgery
Tufts University School of Medicine
University Hospital of Pennsylvania Beth Israel Deaconess Medical Center
Beth Israel Lahey Health
Philadelphia, Pennsylvania Boston, Massachusetts
Lahey Hospital and Medical Center
Burlington, Massachusetts Steffen Nägel, MD Emanuele Orrù, MD
Departement of Neurology Assistant Professor of Radiology
Louise D. McCullough, MD, PhD
Martin-Luther-University Tufts University School of Medicine
Professor and Chair
Halle-Wittenberg Beth Israel Lahey Health
University Hospital Halle Lahey Hospital and Medical Center
McGovern Medical School
Halle, Germany Burlington, Massachusetts
University of Texas Health Science
Center at Houston
Houston, Texas
Contributors xvii
Santiago Ortega-Gutiérrez, MD Miguel A. Perez-Pinzon, PhD Christina P. Rossitto, BS

Associate Clinical Professor Professor and Vice-Chair for Basic Medical Student
Neurology, Neurosurgery, Radiology, Science of Neurology Icahn School of Medicine at Mount
and Anesthesia Peritz Scheinberg Endowed Professor in Sinai
Department of Neurology Neurology New York, New York
Carver College of Medicine Director, Peritz Scheinberg Cerebral
Tatjana Rundek, MD, PhD
University of Iowa Vascular Disease Research
Professor of Neurology
Iowa City, Iowa Laboratories
Matthew Maximillian Padrick, MD Evelyn F. McKnight Endowed Chair for
University of Miami Miller School of
Resident Physician Learning and Memory in Aging
Medicine
Department of Neurology Scientific Director, Evelyn F. McKnight
Miami, Florida
Cedars-Sinai Medical Center Brain Institute
Los Angeles, California John M. Picard, MD University of Miami Miller School of
Fellow Medicine
Kaushik Parsha, MD
Division of Neurocritical Care and Miami, Florida
Institute for Stroke and Cerebrovascular
Emergency Neurology
Diseases Jonathan J. Russin, MD
Yale New Haven Hospital
Department of Neurology Assistant Professor
New Haven, Connecticut
McGovern Medical School Director, Cerebrovascular Surgery
University of Texas Health Science Sean P. Polster, MD Department of Neurosurgery
Center at Houston Neurosurgery Resident Keck School of Medicine
Houston, Texas Department of Neurosurgery University of Southern California
University of Chicago Los Angeles, California
Mark Parsons
Chicago, Illinois
Professor of Medicine and Neurology Ralph L. Sacco, MD
Department of Neurology William J. Powers, MD Chairman, Department of Neurology
South Western Sydney Clinical School Professor of Neurology Olemberg Family Chair in Neurological
University of New South Wales Department of Neurology Disorders
Sydney, Australia University of North Carolina School of Miller Professor of Neurology, Public
Liverpool Hospital Medicine Health Sciences, Human Genetics,
Ingham Institute for Applied Medical Chapel Hill, North Carolina and Neurosurgery
Research University of Miami Miller School of
Volker Puetz, MD
Liverpool, Australia Medicine
Chief, Department of Neurology
Neil V. Patel, MD University Clinics Carl Gustav Carus
Jackson Memorial Hospital
Assistant Professor of Radiology Technische Universität Dresden
Miami, Florida
Tufts University School of Medicine Dresden, Germany
Beth Israel Lahey Health Apostolos Safouris, MD, PhD
Jukka Putaala, MD, PhD
Lahey Hospital and Medical Center Acute Stroke Unit
Associate Professor
Burlington, Massachusetts Metropolitan Hospital
Piraeus, Greece
Virendra I. Patel, MD, MPH Helsinki University Hospital and
Chief of Vascular Surgery University of Helsinki Edgar A. Samaniego, MD
Co-Director, Aortic Center Helsinki, Finland Associate Professor
Columbia University Irving Medical Neurology, Neurosurgery, and Radiology
Margarita Rabinovich, NP
Center Department of Neurology
New York, New York Carver College of Medicine
University of Iowa
Ludmila Pawlikowska, PhD Burlington, Massachusetts
Iowa City, Iowa
Associate Professor
Bruce R. Ransom, MD, PhD
Department of Anesthesia and Lauren H. Sansing, MD, MSTR
Professor and Chair
Perioperative Care Associate Professor
Department of Neuroscience
Center for Cerebrovascular Research Academic Chief
City University of Hong Kong
University of California, San Francisco Division of Stroke and Vascular
Hong Kong, China
San Francisco, California Neurology
Jorge A. Roa, MD Department of Neurology
Adriana Pérez, PhD
Post-doctoral Research Fellow Yale School of Medicine
Professor
Neurology and Neurosurgery New Haven, Connecticut
Department of Biostatistics and Data
University of Iowa Hospitals and Clinics
Science Nikunj Satani, MD, MPH
Iowa City, Iowa
The University of Texas Health Science Institute for Stroke and Cerebrovascular
Center at Houston Gary A. Rosenberg, MD Diseases
Austin, Texas Professor Department of Neurology
Department of Neurology McGovern Medical School
University of New Mexico Health University of Texas Health Science
Sciences Center Center at Houston
Director, Center for Memory and Aging Houston, Texas
University of New Mexico
Albuquerque, New Mexico
xviii Contributors
Ronald J. Sattenberg, MD Omar K. Siddiqi, MD Hiroo Takayama, MD, PhD

Radiologist Assistant Professor Director of Cardiovascular Institute
Louisville, Kentucky Section of Cardiovascular Medicine Co-Director, HCM Program, Division of
Department of Medicine Cardiac, Vascular & Thoracic Surgery
Jeffrey L. Saver, MD
Boston University School of Medicine Co-Director, Aortic Program
Boston, Massachusetts Co-Director, Marfan Clinic
David Geffen School of Medicine
Columbia University Irving Medical Center
Director, UCLA Stroke Center Aneesh B. Singhal, MD
New York, New York
University of California, Los Angeles Vice Chair of Neurology
Los Angeles, California Massachusetts General Hospital Joseph Tarsia, MD
Associate Professor of Neurology Neurologist
Sean I. Savitz, MD
Harvard Medical School Ochsner Health
Boston, Massachusetts New Orleans, Louisiana
Stroke Program Director
Institute for Stroke and Cerebrovascular Christopher G. Sobey, PhD Turgut Tatlisumak, MD, PhD
Diseases NHMRC Senior Research Fellow and Professor of Neurology and Stroke
Department of Neurology Professor in Physiology Medicine
McGovern Medical School Department of Physiology, Anatomy, Department of Clinical Neuroscience
University of Texas Health Science and Microbiology Institute of Neuroscience and
Center at Houston School of Life Sciences Physiology
Houston, Texas La Trobe University Sahlgrenska Academy at University of
Melbourne, Victoria, Australia Gothenburg
Christian Schmidt, MD
Chief Physician
Neurologist Clemens J. Sommer, MD
Department of Neurology Director, Institute of Neuropathology
Sahlgrenska University Hospital
Klinikum Kassel University Medical Center of the
Gothenburg, Sweden
Kassel, Germany Johannes Gutenberg-University Mainz
Department of Neurology Mainz, Germany Ajith J. Thomas, MD
Faculty of Human Medicine Assistant Professor
Robert F. Spetzler, MD
Georg August University Department of Neurosurgery
Emeritus President and Chief Executive
Göttingen, Germany Harvard Medical School
Officer
Co-Director
Sudha Seshadri, MD Emeritus Chair, Department of
Brain Aneurysm Institute
Director, Glenn Biggs Institute for Neurosurgery
Beth Israel Deaconess Medical Center
Alzheimer’s and Neurodegenerative Barrow Neurological Institute
Diseases Phoenix, Arizona
University of Texas Health Sciences Center John W. Thompson, PhD
Christopher J. Stapleton, MD
San Antonio, Texas Director of Basic Science Research
Instructor
Senior Investigator Department of Neurosurgery
Framingham Heart Study University of Miami Miller School of
Framingham, Massachusetts Medicine.
Adjunct Professor Miami, Florida
Department of Neurology Ben A. Strickland, MD
Georgios Tsivgoulis, MD, PhD, RVT
Boston University School of Medicine Department of Neurosurgery
Boston, Massachusetts Keck School of Medicine
Second Department of Neurology
University of Southern California
Vijay K. Sharma, MD National and Kapodistrian University of
Associate Professor Athens
Yong Loo Lin School of Medicine Hua Su, MD School of Medicine
National University of Singapore Professor Attikon University Hospital
Senior Consultant Department of Anesthesia and Athens, Greece
Department of Neurology Perioperative Care
Elizabeth Tournier-Lasserve, MD, PhD
National University Hospital Center for Cerebrovascular Research
Molecular Genetics Department and
Singapore University of California, San Francisco
CERVCO Reference Center for Rare
San Francisco, California
Frank R. Sharp, MD Vascular Diseases of the Eye and Brain
Professor José I. Suarez, MD Hopital Lariboisiére
Department of Neurology Director, Division of Neurosciences Assistance Publique Hôpital de Paris;
School of Medicine Critical Care Université of Paris
University of California, Davis Professor Paris, France
Sacramento, California Departments of Anesthesia and Critical
Gabriel Vidal, MD
Care Medicine, Neurology, and
Kevin N. Sheth, MD Neurologist
Neurosurgery
Professor of Neurology and System Stroke Medical Director
The Johns Hopkins University School of
Neurosurgery Ochsner Health
Medicine
Chief, Division of Neurocritical Care New Orleans, Louisiana
Baltimore, Maryland
and Emergency Neurology
Ajay K. Wakhloo, MD PhD FAHA
Associate Chair, Clinical Research
Professor of Radiology
Tufts University School of Medicine
Yale School of Medicine and Yale New
Haven Hospital
New Haven, Connecticut
Burlington, Massachusetts
Contributors xix
Babette B. Weksler, MD Shadi Yaghi, MD John H. Zhang, MD, PhD

Professor Emerita Associate Professor Professor of Neurosurgery,
Department of Medicine Department of Neurology Anesthesiology, Neurology, and
Weill Cornell Medicine NYU Grossman School of Medicine Physiology and Pharmacology
New York, New York Director, Vascular Neurology Director of Neuroscience Research
NYU Langone Hospital-Brooklyn Associate Chair and Physiology
Joshua Z. Willey, MD
Director, Clinical Vascular Neurology Graduate Program Coordinator
Associate Professor
Research Loma Linda University School of
NYU Langone Health Medicine
Columbia University Irving Medical
New York, New York Loma Linda, California
Center
New York, New York Takenori Yamaguchi, MD, PhD Zhitong Zheng, MD
President Emeritus Visiting Fellow
Max Wintermark, MD
National Cerebral and Cardiovascular Department of Neurology
Professor
Center Henry Ford Hospital
Department of Radiology/Neuroimaging
Suita, Osaka, Japan Detroit, Michigan
and Neurointervention
Stanford University Tuo Yang, MD R. Suzanne Zukin, PhD
Stanford, California Research Instructor Professor
Department of Neurology Department of Neuroscience
Lawrence K.S. Wong, MD
Pittsburgh Institute of Brain Disorders F.M. Kirby Chair in Neural Repair and
Professor
and Recovery Protection
Department of Medicine and
University of Pittsburgh Director, Neuropsychopharmacology
Therapeutics
Pittsburgh, Pennsylvania Center
Chinese University of Hong Kong
Albert Einstein College of Medicine
Shatin, Hong Kong, China Masahiro Yasaka, MD, PhD
Bronx, New York
Director, Cerebrovaascular Center
Guohua Xi, MD
National Hospital Organization Kyushu Richard M. Zweifler, MD
Professor of Neurosurgery
Medical Center Associate Medical Director
Associate Director, Crosby Neurosurgical
Fukuoka, Japan Medical Services
Laboratories
Co-Medical Director of Neurosciences
Richard C. Schneider Research Professor Darin B. Zahuranec, MD
System Chair of Neurology
University of Michigan Associate Professor
Ochsner Health
Ann Arbor, Michigan Department of Neurology
New Orleans, Louisiana
University of Michigan Medical School
Jinchong Xu, PhD
Ann Arbor, Michigan
Assistant Professor
Neuroregeneration and Stem Cell Feng Zhang, MD, PhD
Programs Assistant Professor
Institute for Cell Engineering Department of Neurology
Johns Hopkins University School of Pittsburgh Institute of Brain Disorders
Medicine and Recovery
Baltimore, Maryland University of Pittsburgh
AHA Evidence-Based Classifications
TABLE 1 Applying Classification of Recommendations and Level of Evidence
SIZE OF TREATMENT EFFECT

CLASS III No Benefit
CLASS I CLASS IIa CLASS IIb or CLASS III Harm
Benefit > > > Risk Benefit > > Risk Benefit ≥ Risk Procedure/ Treatment
Additional studies with Additional studies with Test
Procedure/
focused objectives broad objectives
Treatment COR Not No Proves
needed needed; additional
SHOULD be III: No Helpful Benefit
registry data would be
performed/ IT IS REASONABLE to benefit
helpful
administered perform procedure/
administer treatment Procedure/Treatment COR Excess Harmful to
MAY BE CONSIDERED III: Cost w/o Patients
Harm Benefit or
Harmful
LEVEL A • Recommendation • Recommendation in • Recommendation’s • Recommendation that procedure or
ESTIMATE OF CERTAINTY (PRECISION) OF TREATMENT EFFECT
Multiple that procedure or favor of treatment usefulness/efficacy treatment is not useful/effective

populations treatment is or procedure being less well established and may be harmful
evaluated* useful/effective useful/effective • Greater conflicting • Sufficient evidence from multiple
Data derived from • Sufficient • Some conflicting evidence from randomized trials or meta-analyses
multiple evidence from evidence from multiple randomized
randomized multiple multiple randomized trials or meta-
clinical trials or randomized trails trials or meta- analyses
meta-analyses or meta-analyses analyses
LEVEL B • Recommendation • Recommendation in • Recommendation’s • Recommendation that procedure or
Limited that procedure or favor of treatment usefulness/efficacy treatment is not useful/effective
evaluated* useful/effective useful/effective • Greater conflicting • Evidence from single randomized
Data derived from • Evidence from • Some conflicting evidence from single trial or nonrandomized studies
a single single evidence from randomized trial or
randomized trial randomized trial single randomized nonrandomized
or nonrandomized or nonrandomized trial or studies
studies studies nonrandomized
studies
LEVEL C • Recommendation • Recommendation in • Recommendation’s • Recommendation that procedure or
Very limited that procedure or favor of treatment usefulness/efficacy treatment is not useful/effective
evaluated* useful/effective useful/effective • Only diverging expert • Only expert opinion, case studies,
Only consensus • Only expert • Only diverging opinion, case or standard of care
opinion of experts, opinion, case expert opinion, case studies, or standard
case studies, or studies, or studies, or standard of care
standard of care standard of care of care
Suggested phrases should is reasonable may/might be considered COR III COR III
for writing is recommended can be useful/effective/ may/might be reasonable No Benefit Harm
recommendations† is indicated beneficial usefulness/effectiveness is
is not potentially
is useful/effective/ is probably unknown/unclear/
recommended harmful
beneficial recommended or uncertain or not well
is not indicated causes harm
indicated established
should not be associated with
Comparative treatment/strategy A treatment/strategy A is done excess morbidity/
effectiveness is recommended/ probably recommended/ is not useful/ mortality
phrases† indicated in indicated in preference beneficial/effective should not be done
preference to to treatment B
treatment B treatment it is reasonable to
A should be chosen choose treatment A over
over treatment B treatment B
Reprinted with permission Circulation. 2010;121:1544–1579 ©2010, American Heart Association, Inc.
xx
AHA Evidence-Based Classifications xxi
BOX 1 Evidence Classifications

1. Size of treatment effect 2. Certainty of treatment effect
• Class I: Benefit >>> Risk. Procedure/treatment SHOULD be • Level A: Data derived from multiple randomized clinical trials or
performed/administered. meta-analyses.
• Class IIa: Benefit >> Risk. IT IS REASONABLE to perform • Level B: Data derived from a single randomized trial or
procedure/administer treatment. nonrandomized studies.
• Class IIb: Benefit ≥ Risk. Procedure/treatment MAY BE • Level C: Only consensus opinion of experts, case studies, or
CONSIDERED. standard of care.
• Class III: No Benefit/Harm. Procedure/treatment is not useful/
effective and may be harmful.
Adapted from Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement
for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke. Stroke. 2006;37:577–617.
SECTION
I Pathophysiology
Eng H. Lo
The first section in this new edition of Stroke provides an immune cells. New sections describe emerging opportunities
updated and comprehensive survey of the molecular, cellular, in tolerance and preconditioning, as well as interactions
and pathophysiologic mechanisms that underlie the brain’s between the immune system and the microbiome. The
reaction to ischemia and hemorrhage. At the cellular level, chapter on stroke recovery reviews a complex spectrum of
stroke affects pathways of hemostasis and perturbs interac compensatory response in resident precursor and circulating
tions between circulating blood elements, the blood vessel progenitor cells. New insights have been added to explore
itself, and brain parenchyma. At the functional level, the regu the role of exosomes and micro-RNA that may transfer and
lation and dysregulation of hemodynamics and metabolism coordinate signals between all cell types in the remodeling
mediates an integrated neurologic response. At the organ level, neurovascular unit. The chapter on white matter has also
stroke induces histopathologic reactions in all neural, glial, been expanded, with added material that links exercise to
and vascular cells. Hence this section begins with three chap oligodendrocyte homeostasis and resilience. The chapter
ters that define basic principles of vascular biology, cerebral on cerebral hemorrhage surveys advances in molecular and
blood flow and metabolism, and brain tissue injury. Updates cellular phenomena with new ideas that may link ferroptosis
include new information on hemodynamic responses to to translational opportunities and clinical trials. The chapter
thrombectomy and reperfusion, as well as new sections that on vascular malformations has been updated to link signaling
discuss correlations between experimental animal models and cascades in advanced zebrafish and mouse models with genes
clinical pathology. that are implicated in clinical disease. Finally, this section ends
Building on these fundamental principles, the next few with the addition of a new chapter that defines novel pathways
chapters then explore the molecular mechanisms of cell death in the neurovascular unit that mediate vascular contributions
and survival. Genes and pathways underlying necrosis and to cognitive impairment and dementia.
programmed cell death are balanced against an expanding Optimal translation for cerebrovascular disease cannot
family of endogenous neuroprotection mediators. The neuro occur without a rigorous dissection of the molecular and
vascular unit chapter remains a centerpiece for the overall cellular fundamentals in neurovascular and gliovascular
concept of cell-cell signaling. However, beyond the brain biology. The basic principles established in this section should
itself, interactions with other organ systems are also discussed provide not only mechanistic foundations but also a rational
in terms of crosstalk with neuroinflammatory cascades and basis for pursuing therapeutics and diagnostics in stroke.
1
SECTION
I Pathophysiology
1 Cerebral Vascular Biology in Health and Disease

T. Michael De Silva, Christopher G. Sobey
KEY POINTS collateral flow is thought to be important when blood flow in

one region is compromised.2 The pial arterioles then dive into
• C erebral artery tone is substantially modulated under the brain to give rise to parenchymal arterioles. Parenchymal
physiologic conditions by endothelium-derived arterioles are long, relatively unbranched arterioles that per-
nitric oxide, by reactive oxygen species, and through fuse a distinct area of brain tissue.3 The capillary network arises
hyperpolarization mediated by several types of K+ from the parenchymal arterioles, which is where the majority
channels. of nutrient and gas exchange occurs. Although much less is
known about their function during health or disease, cerebral
• Cerebral vascular function is very sensitive to venules and veins are also important components of the cere-
endothelial dysfunction that occurs during chronic bral circulation. For example, major disruption to blood-brain
disease, resulting in impairment of vasodilator barrier function during acute hypertension occurs in the pial
mechanisms. venules.4
• Oxidative stress and inflammation occur in the
cerebral circulation in response to cardiovascular risk PHYSIOLOGIC REGULATION OF CEREBRAL
factors present during atherosclerosis and chronic
hypertension, such as elevated plasma levels of
VASCULAR TONE
cholesterol and angiotensin II, respectively. Numerous mechanisms regulate cerebral artery function. Most
of the recent experimental evidence regarding such mecha-
nisms has come from pharmacologic studies and the use of
genetically modified mice. Major mechanisms include the
release of nitric oxide (NO) from the endothelium to underly-
INTRODUCTION ing smooth muscle cells (discussed in the Nitric Oxide and
The brain has a limited supply of nutrients; thus normal brain Cyclic Guanosine Monophosphate section); potassium ion
function relies on adequate perfusion by the cerebral circula- (K+) channels (see K+ Channels), which includes a discussion
tion for the delivery of oxygen and nutrients, as well as the of the newly described two-pore domain (K2P) channels, Rho/
removal of waste products. It is for this reason that cerebral Rho-kinase activity (see RhoA/Rho-Kinase); reactive oxygen
vascular tone is tightly regulated, and why any alterations in species (ROS), which are discussed in the Reactive Oxygen
mechanisms that modulate cerebral vessel function can pre- Species section; and the recently described transient receptor
dispose to cerebrovascular disease and stroke. Atherosclerosis potential (TRP) channels (discussed in the Transient Receptor
is the underlying pathologic process for both coronary and Potential Channels section).
cerebral artery disease, which are the two most common forms
of cardiovascular disease.1
The purpose of this chapter is thus to provide insight into
Nitric Oxide and Cyclic Guanosine Monophosphate
major mechanisms that regulate cerebral artery function, A major mechanism for maintenance of vascular tone by
and alterations in these mechanisms in two major clinical the endothelium involves the production of endothelium-
conditions that have a significant negative impact on health derived NO. In endothelium, NO is synthesized from endo-
worldwide—hypertension and atherosclerosis. The scope thelial nitric oxide synthase (eNOS); it then diffuses to the
is mostly limited to discussion of cerebral blood vessels underlying smooth muscle, where it activates soluble gua-
and mechanisms that regulate their tone, either under nylate cyclase, which in turn leads to increased intracellu-
basal conditions or in response to physiologically relevant lar cyclic guanosine monophosphate levels and subsequent
agonists. relaxation of the smooth muscle.5 Experimental evidence
for modulation of cerebral vascular tone by endothelium-
derived NO has been obtained by applying inhibitors of
ORGANIZATION OF THE CEREBRAL CIRCULATION NOS to cerebral blood vessels from several different species,
The brain is predominantly perfused by three pairs of intracra- both in vivo and in vitro, and has involved such inhibitors
nial arteries: the anterior, middle, and posterior cerebral arter- causing vasoconstriction (reviewed extensively in Faraci and
ies (ACA, MCA, and PCA, respectively). These arise from the Heistad6).
circle of Willis, a ring of arteries formed by the anterior and pos- NO release from the endothelium can also be stimulated
terior communicating arteries that connect the terminal ends in response to receptor- (e.g., acetylcholine, bradykinin)
of the basilar and internal carotid arteries. The ACA, MCA, and or non-receptor-mediated agonists, or in response to shear
PCA travel along the pial surface of the brain, branching into stress. Endothelium-dependent, NO-mediated cerebral
smaller arterioles. Importantly, anastomoses exist between vascular relaxation in response to such agonists is often used
the smaller arterioles of these three major arterial trees, and to determine the functional integrity of the endothelium.
3
4 SECTION I Pathophysiology
Endothelial dysfunction, manifested as diminished NO Recent evidence of the importance of Ca2+ spark activity
bioavailability experimentally by impaired endothelium- and BKCa channels as mediators of vasodilators has emerged,
dependent vasodilation, or reduced vasoconstriction in as TEA and iberiotoxin inhibit vasodilator responses in
response to a NOS inhibitor, is a common feature of many response to vasodilators that activate adenylate cyclase and
cerebrovascular-related diseases (discussed in the Alterations guanylate cyclase.12 Acidosis markedly increased Ca2+ spark
in Cerebral Vascular Function During Hypertension and activity and caused dilatation of brain parenchymal arterioles.
Atherosclerosis section). Such exogenously applied agonists Dilatation was inhibited by inhibitors of ryanodine receptors
are often useful in this way experimentally, and they may (ryanodine) and BKCa channels (paxilline), as well as in mice
also be important endogenously. For example, neurovascular lacking the BKCa channel.13 Hydrogen sulfide (an important
coupling in some brain regions is mediated by neuronally signaling molecule in the regulation of vascular tone and
released acetylcholine acting on the endothelium to blood pressure) also increased Ca2+ spark and BKCa current
stimulate eNOS.7 frequency, as well as causing dilatation in cerebral arterioles—
the vasodilatation was inhibited by ryanodine and iberiotoxin,
suggesting Ca2+ spark activity is important in the response.14
K+ Channels Intermittent hypoxia increased myogenic tone through loss of
The activity of K+ channels is a major regulator of smooth hydrogen sulfide activation of KCa channels.15 Hypoxia had
muscle cell membrane potential and, as such, is an important no effect on Ca2+ spark frequency but reduced KCa channel
regulator of vascular tone. This is because vessel diameter is in activity.16 Protein expression of KCa2.2, 2.3, and 3.1,16 as well
large part dependent on cytosolic Ca2+ concentration, which as α- and β1-subunits of BKCa channels17 in cerebral arteries,
in turn is dependent on membrane potential. There are five have been reported.
major types of K+ channels known to be expressed in cerebral
blood vessels: calcium (Ca2+)-activated (KCa) K+ channels, ATP
sensitive K+ (KATP) channels, voltage-sensitive K+ (KV) chan-
KATP Channels
nels, inwardly rectifying K+ (KIR) channels, and tandem-pore KATP channels are defined by their sensitivity to intracellular
(TREK-1) channels, and all are regulators of vascular tone. ATP, with their activity being inhibited by intracellular ATP.18
This is supported by the wealth of information using both Generally, the intracellular concentration of ATP is normally
pharmacologic inhibitors and gene-targeted mice to study sufficient that these channels have a low open probability
the regulation of membrane potential and vascular function. in most vascular smooth muscle cells under normal condi-
Potassium channels are also important mediators of vasodi- tions,19 and this appears to also be the case in the cerebral
lator responses to several vasodilators that regulate vascular circulation, where glibenclamide, a selective inhibitor of KATP
tone, and this will be also be discussed. channels, has no effect on cerebral vascular tone.20 However,
KATP channels appear to be present and functional in cerebral
vessels based on direct evidence for their expression (discussed
KCa-Activated K+ Channels as follows) and a wealth of evidence reporting glibenclamide-
There are three subtypes of KCa channels present in the vascu- sensitive relaxation of cerebral arteries in response to KATP
lature: large-conductance KCa (BKCa) channels, intermediate- channel activators.18
conductance (IKCa) channels, and small-conductance (SKCa) Several more recent studies have investigated the expression
channels. Most research regarding the functional importance of KATP in cerebral vessels. KATP channels are thought to be a
of this channel, especially in cerebral arteries, has centered hetero-multimeric complex of two subunits: one is a pore-
around the BKCa channel. forming inward-rectifying K+ channel type 6 (i.e., 6.1 or 6.2),
As the name suggests, these channels are activated in and the other is a sulfonylurea receptor (SUR), either SUR1 and
response to increases in intracellular Ca2+. Membrane SUR2, with the SUR2 gene generating the two splice variants
depolarization, myogenic responses (i.e., pressure-induced SUR2A and SUR2B.21 Messenger RNA (mRNA) expression for
vasoconstriction, important in development and maintenance both the pore-forming subunits (KIR6.1 and 6.2) and SUR1,
of basal vascular tone), and elevations in arterial pressure are 2A, and 2B has been demonstrated in cerebral arteries,21,22
associated with elevations in intracellular Ca2+ concentration although another study investigating SUR expression found
in cells of the vasculature.8 Thus an important function of no expression of SUR1 and reported only SUR2B expression.23
these channels appears to be to act as a negative feedback Protein expression of KIR6.1 and 6.2, as well as SUR1 and 2B,
mechanism during increases in Ca2+ to limit vasoconstriction. was also reported.22 Cerebral arterioles were found to express
A major mechanism of elevations in intracellular Ca2+ appears KIR6.1 and SUR2B,24 with human cerebral arteries found to
to be via Ca2+ sparks, which are localized elevations in express SUR2B.23
cytosolic Ca2+, due to the opening of ryanodine-sensitive Ca2+ Acidosis and reductions in intracellular pO2 are known
release channels in the sarcoplasmic reticulum to KCa channels to produce cerebral vasodilatation. KATP channels have been
located on the plasma membrane. shown to be involved in cerebral vasodilatation in response
These channels are important in modulating the basal to acidosis,25,26 as well as in vasodilatation to NMDA, which
tone of cerebral arteries, as selective inhibition of BKCa may be important in the coupling of cerebral metabolism
channels with tetraethylammonium ion (TEA) produces and blood flow.27 More direct evidence for a role of KATP
vasoconstriction.8–10 In mice deficient in the β1 subunit of channels in mediating vasodilatation in response to oxygen/
BKCa channels, increased intracellular Ca2+ concentration glucose deprivation was reported in that vasodilatation was
in response to ryanodine (which at low concentrations impaired in SUR-deficient compared with wild-type mice.23
depletes Ca2+ stores from the sarcoplasmic reticulum so Myogenic tone, and vasodilatation in response to hypoxia, are
that intracellular Ca2+ concentration increases) and cerebral not dependent on SUR2 expression,23 although relaxation to
vascular constriction to iberiotoxin (selective inhibitor of BKCa hypoxia is inhibited by glibenclamide,18,28 suggesting a role
channels) was reduced, suggesting that Ca2+ spark activity for KATP channels in hypoxia-induced vasodilatation where the
modulates myogenic tone through BKCa channel activation.11 KATP subunit composition does not involve SUR2. Hydrogen
These channels may be more important in the modulation of sulfide also dilates cerebral arteries, an effect that is inhibited
basal tone in larger cerebral arteries.8 by glibenclamide and in SUR2-deficient mice.24
Cerebral Vascular Biology in Health and Disease 5
KV Channels RhoA/Rho-Kinase 1
KV channels are activated in response to increases in pressure Smooth muscle cell contractility is ultimately governed by the
in cerebral arteries and modulate cerebral vascular tone, in that phosphorylation state of myosin light chain (MLC), vascular
pharmacologic inhibition of KV channels with 4-aminopyri- smooth muscle tone occurring in association with increasing
dine causes cerebral artery depolarization and constriction.29,30 levels of MLC phosphorylation. MLC is phosphorylated by
KV channels are also known to mediate cerebral artery dila- MLC-kinase—a Ca2+-calmodulin-dependent enzyme—and is
tions, including in response to NO.29,31 KV channel subunits dephosphorylated by MLC phosphatase (MLCP). MLC phos-
are expressed in cerebral vessels (e.g., KV1.2 and 1.5,32–34 and phorylation and smooth muscle contractility are not always
KV2.1 and 2.235,36)—including in humans.37 KV2-mediated directly proportional to intracellular Ca2+ concentration.
current is proposed to underlie KV-dependent modulation of Other mechanisms can regulate smooth muscle contractility
cerebral artery tone in that inhibition of the KV2 channel with independent of changes in intracellular Ca2+ concentration, a
stromatoxin-caused cerebral artery constriction.36 phenomenon known as Ca2+-sensitization. Ca2+-sensitization
can occur through several pathways and ultimately results
in inhibition of MLCP. One such pathway is the RhoA/Rho-
KIR Channels kinase (ROCK) pathway. When ROCK is activated, it phos-
This channel is so named since it conducts K+ current more phorylates the myosin-binding (i.e., regulatory) subunit of
readily into than out of the cell over a wide range of mem- MLCP, and thus inhibits MLCP activity, which ultimately leads
brane potentials. However, at membrane potentials within to smooth muscle (and thus vascular) contractility.67,68
the physiologic range, these channels actually conduct a small In vascular muscle, RhoA can be activated by stretch.
outward current. Consequently, when this channel is inhibited This is important since myogenic tone is characterized by
with the pharmacologic blocker, barium ion (Ba2+), depolar- pressure-induced vasoconstriction, making it important for
ization and constriction of cerebral arteries are observed.38–44 the development of basal vascular tone. The contribution of
Furthermore, in mice lacking the KIR2.1 subunit—the subunit ROCK activity to the cerebral artery myogenic response has
thought to be important in mediating vascular KIR current— been studied through the use of Y-27632 and fasudil (HA-
cerebral artery KIR channel currents are absent.45 1077), pharmacologic inhibitors of Rho-kinase.69 For example,
In the cerebral circulation, K+ is released during neuronal Y-27632 relaxes cerebral artery segments following pressure-
activity and may be siphoned to cerebral vessels directly by induced constriction,70 and pressure-induced cerebral artery
astrocytes after neuronal activation.46 Basal concentration of K+ constriction is inhibited by Y-27632 and fasudil.71–73 In vivo,
in cerebrospinal fluid is ∼3 mM and may increase to between where myogenic tone is present, several studies have reported
4 and 7 mM during neuronal activity. In this concentration that Y-27632 and fasudil cause the dilatation of cerebral
range (i.e., from 3 to 10 mM), K+ causes dilatation of cerebral arteries74–78 and arterioles.79 Recent work has begun to define
arteries38,40–42,47,48 and arterioles.39,43,44,49–56 Moreover, the role of ROCK isoforms in the cerebral vasculature. The use
K+-induced hyperpolarization and vasodilatation in this of the selective ROCK2 inhibitor SLX-2119 (also known as
concentration range are inhibited by Ba2+,38–42,48,53–55,57–59 KD025) has revealed that myogenic tone in brain parenchymal
suggesting KIR-mediated K+-induced vasodilation may be an arterioles is ROCK2-dependent.80 In addition, SLX-2119 dilates
important mechanism in the coupling of cerebral metabolism pial arterioles in vivo.80
and blood flow (neurovascular coupling). Furthermore, cerebral ROCK is also important in the regulation of endothelial
vascular relaxation responses to K+ are absent in mice lacking cell function via effects on NO signaling. ROCK has been
the KIR2.1 subunit.45 There have been reports of KIR2.1 channel shown to reduce NO bioavailability, which occurs via
expression in cerebral arteries.38,58 Regarding the role for KIR2.1 reducing NO production via reducing phosphorylation of the
channels in neurovascular coupling, recent work identified stimulatory Ser,11, 77 direct phosphorylation of the inhibitory
KIR2.1 channel on capillaries as critical for sensing neuronal Thr495 residue on endothelial NOS, and/or reducing eNOS
activity (via K+ release) and initiating a retrograde signal to mRNA stability. These findings, in combination with the role
dilate upstream arterioles, thereby increasing local blood flow.60 of ROCK in vascular muscle, provide good evidence that the
RhoA/Rho-kinase pathway is a major mechanism contributing
to cerebral vascular tone.
K2P Channels
A new family of channels—two pore domain K+ (K2P) chan-
nels—have recently been characterized.61 These channels
Reactive Oxygen Species
require two protein subunits, each contributing two pore ROS are known to influence cerebral vascular tone, and this
domains, to form a functional channel. There are several is reviewed extensively elsewhere.81 These ROS include the
members of the K2P family expressed in the vasculature, with parent molecule superoxide (O2−), as well as hydroxyl radical
some reported to be functionally important in the cerebral (OH) and hydrogen peroxide (H2O2). The closely related reac-
vasculature. Expression of TREK-1, TREK-2, TASK-1, TWIK-2, tive nitrogen species (RNS)—peroxynitrite—is also commonly
TRAAK, and THIK-1 has been reported in cerebral arteries, involved in such effects.
with TREK-1 being the most abundant.62,63 Protein and mRNA Superoxide, a negatively charged anion, can elicit either
expression of TREK-1 in the basilar artery was associated with dilatation82–85 or constriction82,86 of cerebral arteries.
vasodilatation induced by polyunsaturated fatty acids (which Superoxide reacts extremely efficiently with NO. As has
are important, as they improve brain resistance against cere- been discussed, NO is a major regulator of cerebral vascular
bral ischemia), such as α-linolenic acid in wild-type mice; tone; thus reduced NO bioavailability following increased
vasodilatation in response to linolenic acid was absent in mice superoxide levels will likely result in vasoconstriction,
deficient in TREK-1.64 Nevertheless, another study reported with vasoconstriction being reported in response to higher
similar vasodilator responses of the basilar artery to α-linolenic concentrations of superoxide82,83 and vasorelaxation at low
acid in wild-type and TREK-1-deficient mice.65 Cerebral artery concentrations.82
expression of TRAAK was associated with an important role in H2O2 is a chemically more stable species than superoxide,
mediating endothelium-independent vasodilatation.66 and it diffuses much more readily across cell membranes, thus
potentially being important as a signaling molecule. Many stress110 and uridine triphosphate.111 TRPV1, TRPV5, and
studies have reported that H2O2 acts as a cerebral vasodilator, TRPV6 channels do not appear to be expressed in cerebral
both in vivo and in vitro,85,87–94 although vasoconstriction has arteries.112 The melastatin TRP channel 4 (TRPM 4) is
also been reported.95 activated by high levels of intracellular Ca2+ and is known
Peroxynitrite, formed from the rapid chemical reaction of to be expressed in cerebral arteries.113 Expression in smooth
superoxide with NO, can also affect cerebral vascular tone, muscle cells is consistent with a role in the myogenic response,
with both dilatation96,97 and constriction97–99 of cerebral in that myogenic vasoconstriction was attenuated in cerebral
arteries reported. Lower concentrations of peroxynitrite appear arteries administered TRPM4 antisense.114 Pharmacologic
to cause cerebral vasoconstriction, with higher concentrations inhibition of the TRPM4 channel with 9-phenanthrol was
typically causing vasodilatation.97,100 able to cause hyperpolarization and prevent the development
and maintenance of myogenic tone, further underlining
its importance in the maintenance of myogenic tone in the
Transient Receptor Potential Channels cerebral circulation.115 Another study also reported cerebral
TRP channels are a superfamily of cation channels compris- vascular expression of TRPM4 protein, which, once inactivated,
ing at least 28 members and are assigned to 6 subfamilies results in reduced myogenic vasoconstriction in response to a
based on their sequence homology.101 These are TRPC (clas- PKC activator.116 TRPA1 channels are known to be expressed
sical), TRPV (vanilloid), TRPM (melastatin), TRPA (ankyrin), in cerebral vessels, specifically in endothelium, and mediate
TRPP (polycystin), and TRPML (mucolipin).102 The structure, endothelium-dependent vasodilatation.117 Finally, TRPP2
expression profile, and function of TRP channels have been channels have been shown to contribute to myogenic tone
reviewed in detail.103 generation in cerebral arteries.118 The role, if any, of other TRP
Depending on the specific TRP channel in question, channels in the cerebral vasculature is presently unknown.
activation can result in constriction or dilation of cerebral
arteries. TRPC1 channels have been shown to mediate
constriction of cerebral arteries via facilitating receptor- ALTERATIONS IN CEREBRAL VASCULAR FUNCTION
operated calcium entry in response to endothelin-1.104 TRPC3 DURING HYPERTENSION AND ATHEROSCLEROSIS
channels also facilitates vasoconstriction to endothelin-1,105
but this does not occur via receptor-operated calcium entry.
Atherosclerosis
TRPC3 has also been shown to mediate constriction to the Atherosclerosis is the underlying pathologic process for both
nucleotide, uridine triphosphate.106 Myogenic tone in cerebral coronary and cerebral artery disease.1 However, atheroscle-
arteries isolated from hypertensive mice was inhibited by rotic lesions progress at a slower rate in intracranial arteries
treatment with SKF93635 (a specific inhibitor of TRPC6 compared with extracranial arteries in both animal models
channels at the concentration used in that study). SKF93635 and humans.119 Atherosclerosis is thought to be initiated by
was without effect in arteries from aged mice, suggesting trapping of lipids in the subendothelial layer, leading to the
TRP channel function is disrupted in cerebral arteries from generation of biologically active oxidized species (i.e., oxi-
aged mice.107 Some TRP channels, such as the vanilloid TRP dized low-density lipoprotein [LDL]), ultimately leading
channel (TRPV3), are chemosensitive. The TRPV3 channel to recruitment of leukocytes to the artery wall.120 Oxidative
is expressed in the endothelium of cerebral arteries, and the modification of LDL present in the intima by ROS may thus
dietary agonist carvacrol, which may be cardioprotective, be a key initiating step in atherosclerosis.121 Endothelial dys-
mediates endothelium-dependent cerebral vasodilatation function is an early step in the development of atherosclerosis,
that is inhibited by a pharmacologic inhibitor of TRPV1-4 and traditional cardiovascular risk factors (e.g., dyslipidemia,
channels.108 TRPV4 channels are expressed in endothelium hypertension) are associated with endothelial dysfunction.122
and vascular muscle cells and appear to mediate vasodilation. Furthermore, atherosclerosis is characterized by chronic
While activation of TRPV4 channels results in calcium entry inflammation of the vasculature; thus these three key pro-
in vascular muscle cells, the resulting calcium sparks activate cesses characteristic of atherosclerosis—oxidative stress, endo-
BK channels and thus hyperpolarization and dilation of the thelial dysfunction, and inflammation—will be discussed here
artery.109 Endothelial TRPV4 channels are activated (resulting (also summarized in Fig. 1.1), with much of the discussion
in calcium influx) and mediate dilation in response to shear referring to data from the apolipoprotein E-deficient (ApoE−/−)
Hypercholesterolemia Hypertension / ↑Ang II
Fig. 1.1. Schematic diagram summarizing cerebrovascular

effects of hypercholesterolemia, and elevated Ang II and ↑ NOX2 oxidase ↑ AT1R
hypertension. Hypercholesterolemia induces oxidative
stress, and ultimately inflammation—comprising leukocyte ↑ NADPH oxidases
and platelet adhesion, and endothelial dysfunction. These ↑ ROS
effects are all attenuated in NOX2 oxidase-deficient mice.
↑ O2–, ONOO –
Ang II increases leukocyte and platelet adhesion, infiltration
of inflammatory/immune cells, and causes endothelial
dysfunction due to reduced nitric oxide (NO) bioavailability. ↑ Leukocyte ↓ NO Inflammation
and
These effects are largely inhibited by AT1 receptor (AT1R) ↑ Leukocyte ↓ NO Infiltration of
platelet
inhibitors and in AT1R-deficient mice; reactive oxygen and inflammatory,
adhesion
species (ROS) scavengers and NOX2 oxidase-deficiency, as platelet immune cells
well as in lymphocyte-deficiency (RAG−/−) mice, implicating Endothelial adhesion
AT1R; and nicotinamide adenine dinucleotide phosphate dysfunction
Endothelial
(NADPH) oxidase-derived ROS and the adaptive immune dysfunction ↑ Pro-inflammatory
system in the detrimental effects of chronic hypertension in cytokines and
the cerebral circulation. chemokines
mouse. The ApoE−/− mouse, characterized by high levels of in cerebral vessels of hypercholesterolemic mice—leukocyte
plasma cholesterol due to deletion of the APOE gene (impor- and platelet adhesion was prevented by immunoneutraliza- 1
tant in cholesterol metabolism), provides a very useful experi- tion of P-selectin and in NOX2-deficient mice, suggesting that
mental model for understanding the mechanisms of disease P-selectin and NOX2-dependent oxidative stress are important
initiation.1 mechanisms in hypercholesterolemia-induced inflammation
in the brain.123 Arginase type 1 expression was also increased
Cerebral Vascular Oxidative Stress in Models of in cerebral vessels from ApoE−/− mice,134 which is relevant
since oxidized LDL increases arginase activity and decreases
Atherosclerosis endothelial NO levels, ultimately leading to impaired NO
Some evidence suggests the prevalence of oxidative stress in function in the vascular endothelium.135 Vascular cell adhe-
cerebral vessels during hypercholesterolemia or atherosclero- sion molecule-1 (VCAM-1) expression was not altered in brain
sis. For example, in wild-type mice placed on a high choles- microvessels of ApoE−/− mice.136
terol diet for 2 weeks,123 and ApoE−/− mice on high-fat diet for
7 weeks,124 oxidative stress was found to be present in cerebral
arteries. The study by Miller et al.124 went on to suggest that
Hypertension
NOX2 oxidase was the source of the oxidative stress, as the oxi- Hypertension profoundly and negatively impacts the cere-
dative stress present in ApoE−/− was abolished in mice deficient bral circulation and brain, and is a major risk factor for stroke
in both ApoE and NOX2 (i.e., ApoE−/−/NOX2−/y; Fig. 1.2). and a leading cause of cognitive decline and dementia.137
Hypertension may promote the formation of atherosclerotic
Cerebral Vascular Endothelial Dysfunction in Models of plaques in cerebral arteries and arterioles,137 and there is a wealth
of experimental evidence demonstrating detrimental functional
Atherosclerosis consequences of hypertension on the cerebral circulation. Many
Several lines of evidence suggest that atherosclerosis is asso- initial studies focused on the spontaneously hypertensive rat
ciated with reduced NO bioavailability and endothelial dys- (SHR), where augmented NADPH oxidase-derived superoxide
function. In earlier reports, relaxation responses of the basilar production91 and impaired endothelium-dependent responses
artery to acetylcholine were impaired in hypercholesterolemic have been reported.58,75,138–141 What follows is a discussion of
versus normal rabbits,125 although cerebral vascular responses more recent data regarding the influence of hypertension on
to acetylcholine were reportedly preserved126,127 or even aug- the cerebral circulation—specifically, hypertension in response
mented128 during atherosclerosis. In atherosclerotic mon- to elevated angiotensin II (Ang II) levels (also summarized in
keys, contraction of basilar arteries in response to inhibition Fig. 1.1). Ang II is of major importance because it is involved in
of soluble guanylate cyclase was reduced compared with that many of the functional and structural changes occurring in the
in normal monkeys, suggesting the basal influence of soluble cerebral circulation during chronic hypertension.5,119,137
guanylate cyclase on basal tone of cerebral arteries is dimin-
ished during atherosclerosis, perhaps reflecting a reduced pro- Oxidative Stress in Hypertension Involving
duction/activity of NO during atherosclerosis.129 Similarly,
cerebral artery contractions in response to the application
Elevated Ang II
of l-NAME (a NOS inhibitor) were reduced in vessels from Ang II increases ROS production in the cerebral circulation.
ApoE−/− compared to normal mice,124 suggesting reduced NO Work from Iadecola’s group has found that acute intravenous
bioavailability was present during atherosclerosis. Reduced infusion of mice with Ang II increases both blood pressure
cerebral vascular relaxation to acetylcholine in ApoE−/ versus and ROS production by cerebral blood vessels.142–146 Increased
normal mice further suggests that reduced NO bioavailability ROS levels were prevented by treatment with the ROS scavenger
is associated with endothelial dysfunction in the cerebral cir- MnTBAP.146 This treatment also reportedly increases 3-nitro-
culation during atherosclerosis.130,131 Interestingly, magnetic tyrosine immunoreactivity (indicative of nitrosative stress) in
resonance imaging of cerebral arteries in rabbits fed a diet mouse cerebral vascular endothelial cells, an effect that was
high in cholesterol were narrower compared with their control prevented by a peroxynitrite scavenger and a NOS inhibitor,
counterparts,132 which may suggest increased vascular tone or and was also absent in NOX2 oxidase-deficient mice.143 Thus
potentially structural alterations. these findings suggest that Ang II increases peroxynitrite forma-
Further experiments were conducted to provide a link tion in the cerebral vasculature largely via the reaction of NOX2
between oxidative stress and vascular dysfunction. Impaired oxidase-derived superoxide with NO (see Fig. 1.2).
NO-dependent responses of cerebral vessels from ApoE−/−
mice were reversed in vessels from ApoE−/− mice treated Endothelial Dysfunction in Hypertension Involving
with a scavenger of ROS (tempol),124,130 the nicotinamide
adenine dinucleotide phosphate (NADPH) oxidase inhibitor
Elevated Ang II
apocynin,130 or in ApoE−/−/NOX2−/y mice,124 strongly suggesting Acute intravenous administration of Ang II has been reported
that NOX2 oxidase-derived superoxide is a major mediator of to impair NO-dependent increases in cerebral blood
cerebral vascular dysfunction during atherosclerosis (see Fig. 1.2). flow(CBF),145,146 an effect that was reversed by MnTBAP and
Oxidative stress and endothelial dysfunction is present despite the angiotensin type 1 (AT1) receptor antagonist losartan.146
the apparent absence of lesions in cerebral blood vessels.124,130 Topical application of Ang II to cerebral arterioles in vivo
causes impaired NO-dependent responses that can be pre-
Cerebral Vascular Inflammation in Models of vented by the superoxide scavenger tiron.147 Similarly, Ang
II-induced endothelial dysfunction in cerebral arterioles of
Atherosclerosis ECSOD-deficient mice in vivo was reversed by tempol.148 In a
Atherosclerosis is characterized by chronic inflammation of more chronic model of Ang II-dependent hypertension, Ang II
the vasculature. Platelet endothelial cell adhesion molecule-1 increased blood pressure and caused endothelial dysfunction
(PECAM-1) is involved in the inflammatory process and of the basilar artery. This effect of Ang II was absent in NOX2
in leukocyte-endothelial interactions, and its expression is oxidase-deficient mice, and partially attenuated in NOX1
increased in cerebral arterioles of ApoE−/− mice.133 Leukocyte oxidase-deficient mice, suggesting Ang II-induced endothelial
and platelet adhesion, as well as oxidative stress, were elevated dysfunction is dependent on NOX2 oxidase and, perhaps to
some, extent NOX1 oxidase.149 In spite of these findings, Ang dysfunction in Ang II hypertension via a mechanism involving
II increases blood pressure in both NOX2 and NOX1 oxidase TRPV4.153 Thus there is potential cross-talk between AT1R and
deficient mice, suggesting that the cerebral vascular and pressor MR. In a genetic model of hypertension (mice overexpressing
actions of Ang II are independent of one another.149 To further human renin and angiotensinogen), endothelial dysfunction of
confirm this point, previous studies have reported that systemic the basilar artery was completely reversed by the administration
administration of a nonpressor dose of Ang II caused endo- of polyethylene glycol superoxide dismutase (PEG-SOD).154
thelial dysfunction in the cerebral circulation.150 In addition, Taken together, these data suggest that Ang II causes endothe-
endothelial dysfunction precedes the development of hyperten- lial dysfunction in the cerebral circulation by activating AT1R
sion in response to a slow-pressor dose of Ang II.151 Endothelial expressed in the vessel wall, leading to an increase in superox-
dysfunction in response to Ang II was reversed by ROS scav- ide production, and subsequent oxidative inactivation of NO
engers.150,152 It has recently been reported that inhibition of (see Fig. 1.2). Recent evidence suggests that MR may also be
the mineralocorticoid receptor (MR) improves endothelial involved in the dysfunction caused by Ang II.
Hypercholesterolemia/ Hypertension
atherosclerosis
Ang II
Rho kinase AT1
NOX2
eNOS
oxidase Endothelial cell
O2– NO O2–
ONOO–
BKCa KIR KV KATP

K+ K+ K+ K+ Rho kinase P
MLC
sGC
Impaired membrane
hyperpolarization MLCP
Hyperpolarization
MLC
Vasodilation Vasoconstriction
Smooth muscle cell
NOX2
oxidase AT1
Ang II Perivascular macrophage

Hypertension
Fig. 1.2. Atherosclerosis/hypercholesterolemia and hypertension profoundly alter key mechanisms that modulate cerebral artery tone.
Atherosclerosis/hypercholesterolemia and hypertension increase oxidative stress via activation of NOX2 oxidase. The increased superoxide (O2−)
levels scavenges endothelial nitric oxide synthase (eNOS)-derived nitric oxide (NO), resulting in reduced NO bioavailability and hence reduced
NO-mediated vasodilation and peroxynitrite formation (ONOO−). ONOO− can directly influence cerebrovascular tone (see text). K+ channel activity
modulates vascular tone. Most studies have investigated the effect of hypertension on BKCa channel function, with the outcome (i.e., increased
or decreased channel function) depending on the model of hypertension studied (see text). Baseline KV channel function is impaired, as is
KATP-mediated vasodilatation compared with normotensive conditions. Baseline KIR channel function is augmented, whereas KIR-mediated K+-
induced vasodilatation is impaired. In endothelial cells, Rho kinase can reduce eNOS activity (see text for details). In vascular muscle, Rho kinase
phosphorylates (and inactivates) myosin light chain phosphatase (MLCP), leading to enhanced phosphorylation of myosin light chain (MLC) and
increased contractility. During hypertension, Rho kinase activity is increased, impairing normal cerebrovascular regulation.
Cerebrovascular Inflammation in Hypertension Involving pharmacologic inhibition of these channels (with TEA and
iberiotoxin) elicits greater contraction of cerebral arteries from 1
Elevated Ang II hypertensive vs normotensive rats.10 Consistent with this, ibe-
Hypertension induces inflammation in the cerebral circula- riotoxin elicited enhanced contraction of cerebral arterioles
tion. This includes models that involve Ang II. Ang II results from hypertensive versus normotensive rats, an effect associ-
in elevated leukocyte and platelet adhesion in cerebral ves- ated with enhanced cerebral vascular expression of the KCa
sels, an effect prevented by the AT1 receptor antagonists can- channel α subunit.163 Inhibition of BKCa channels with TEA
desartan and losartan, as well as diphenyleneiodonium, an and charybdotoxin cause cerebral vascular contraction in hy-
inhibitor of flavoproteins such as NADPH oxidase.155 In stud- pertensive but not normotensive rats.164
ies performed to extend these findings, Ang II-induced hyper- By contrast, in a model of Ang II-dependent hypertension,
tension was associated with a marked increase in leukocyte contraction of cerebral arteries in response to iberiotoxin was
and platelet adhesion in cerebral vessels, which was attenu- reduced in hypertensive vs normotensive rats, and this was
ated in RAG−/− mice (i.e., deficient in T and B lymphocytes), associated with reduced coupling efficiency between Ca2+ sparks
AT1R−/− mice, and by treatment with losartan,156 suggesting and BKCa channels, as well as reduced β1 subunit expression,
the involvement of immune cells and AT1 receptors in this although α subunit expression was unaltered during chronic
effect. Leukocyte adhesion in response to Ang II in pial vessels hypertension.165 The mechanism may involve calcineurin/
in vivo was also prevented by tempol,157 further confirming NFATc3 signaling, as Ang II-induced reduction in β1 subunit
that cerebrovascular inflammation involves ROS production expression was absent in calcineurin/NFATc3-deficient mice.
and oxidative stress. Interestingly, although leukocyte and Calcineurin/NFATc3 is also important in the development
platelet adhesion in cerebral vessels was enhanced in models of Ang II-dependent hypertension.166 Furthermore, although
of Ang II and deoxycorticosterone acetate (DOCA)-salt hyper- iberiotoxin caused myogenic constriction in normal mice, in
tension, these effects were prevented in the presence of mild a model of Ang II-dependent hypertension, it had no effect
hypercholesterolemia, possibly due to the involvement of on myogenic constriction in cerebral arteries.107 In a model
high-density lipoprotein (HDL), suggesting that mild eleva- of diet-induced obesity where blood pressure was elevated,
tions in certain types of cholesterol may be beneficial in the cerebral vascular BKCaβ1 subunit expression was increased,
setting of hypertension.158 although myogenic tone was not altered.17 Thus functional
Other models of hypertension have also implicated a role alterations in KCa channels appear to be dependent on the
for Ang II in cerebrovascular inflammation. For example, model of experimental hypertension studied.
in a DOCA-salt model of hypertension, leukocyte and KATP Channels. To our knowledge, there is little information
platelet adhesion was prevented by losartan and in AT1R−/− regarding KATP channel function in hypertension. Vasodilator
mice.159 Furthermore, not only were these effects inhibited responses to the KATP channel activator aprikalim were signifi-
by tempol; they were also inhibited by mito-tempol,159 cantly impaired in cerebral arteries from hypertensive versus
implicating mitochondria-derived ROS in the cerebrovascular normotensive rats, suggesting impaired KATP channel function
inflammatory response. These anti-inflammatory effects during hypertension.138 Although SUR2B expression appears
occurred in the absence of any depressor action, suggesting to be increased in small cerebral arteries from hypertensive
that blood pressure is not necessarily a key mediator of rats compared with their normotensive controls,167 the func-
cerebrovascular inflammation where Ang II is involved. In the tional significance of this finding is unknown.
SHR, increased expression of intracellular adhesion molecule-1
(ICAM-1), as well as an increased number of infiltrating and KV Channels. Experimental hypertension may be associated
adherent macrophages in brain microvessels, were inhibited with cerebral artery depolarization and increased myogenic re-
by candesartan.160 Widespread inflammation in many brain sponse, perhaps indicating impaired KV channel function. Phar-
regions of the SHR was also inhibited by candesartan,161 macologic inhibition of KV channels with correolide and psora-4
further implicating a role for activation of AT1R by Ang II constricted cerebral arteries from normotensive rats, but was
and demonstrating a beneficial use for AT1R inhibitors in without effect in cerebral arteries from two models of hyperten-
preventing inflammation associated with cerebrovascular sion, suggesting a reduced contribution of KV channels to the
disease. modulation of basal tone. This was associated with reduced ex-
Perivascular macrophages appear to play a central pression of the pore-forming α1.2 and α1.5 subunits that compose
role in cerebrovascular dysfunction in response to Ang KV channels in hypertensive versus normotensive rats.168 This is
II.162 Faraco et al. showed that Ang II acts on AT1R on in agreeance with the impaired KV2 channel function of cerebral
perivascular macrophages, resulting in NOX2 oxidase- arteries reported in a model of Ang II-dependent hypertension,
dependent ROS production and endothelial dysfunction.162 in that stromatoxin-induced contraction of cerebral arteries was
Thus inflammation appears to be a key mechanism, decreased in arteries from hypertensive vs normotensive rats.36
leading to both oxidative stress and subsequent endothelial In Dahl salt-sensitive rats, KV channel current density was de-
dysfunction. creased in cerebral artery myocytes from hypertensive vs normo-
tensive rats.169 Lower KV current density was reported in cerebral
vascular smooth muscle cells from SHR compared with WKY.170
K+ Channel Function in Chronic Hypertension
Expression of K+ channels in the cerebral vasculature and the KIR Channels. The first evidence for impaired KIR channel
importance of their role in modulating arterial tone, includ- function during chronic hypertension was the finding that
ing mediation of vasodilator responses, has been described. Ba2+-sensitive cerebral vascular relaxant responses to K+ in hy-
The deleterious actions of chronic hypertension in the cere- pertensive rats were impaired when compared with normo-
bral vasculature are also well known;137 it is thus unsurprising tensive controls.171 A subsequent study reported altered KIR
that K+ channel function is altered in association with chronic channel function during chronic hypertension, whereby KIR
hypertension (see Fig. 1.2). channels were not the predominant mediator of cerebral vaso-
dilator responses to K+, unlike in normal animals. This was
BKCa Channels. Basal activity of BKCa channels may be great- despite responses to K+ being preserved (or even enhanced),
er in cerebral arteries during chronic hypertension, in that KIR2.1 expression being preserved, and an enhanced role for
KIR channels in modulating arterial tone during chronic hy- 59. Marrelli SP, Johnson TD, Khorovets A, Childres WF, Bryan Jr RM.
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2 Mechanisms of Thrombosis and Thrombolysis
Gregory J. del Zoppo
KEY POINTS Notably, all substances that promote plasmin formation have
the potential to increase the risk of hemorrhage.
• T he fundamental processes involved in thrombus The acute use of PAs has been associated with detectable
formation, thrombus dissolution, and thrombus clinical improvement in selected patients with symptoms
stability and their relevance to the central nervous of focal cerebral ischemia.1-9 Acute thrombolysis has thus
system (CNS) are described. attained pride of place in the treatment of ischemic stroke
so far. Currently, recombinant tissue plasminogen activator
• The role(s) of endogenous plasminogen activators (rt-PA) is licensed in the United States, Japan, Europe, and
(PAs, including tissue-type plasminogen activator, many other countries for the treatment of ischemic stroke
urokinase-type plasminogen activator) in within 3 hours of symptom onset, and up to 4.5 hours in
thrombus dissolution are presented, together with some jurisdictions.6,9 Early studies, a phase III prospective
considerations of their regulation in vivo. Their trial, and more recent experience suggest that extension of the
relevance to derived therapeutics is emphasized. treatment window is possible with strict limitations to patient
• Fibrinolytic agents tested or used as pharmaceuticals selection.3-5,9 Early on, few studies of acute rt-PA delivery
including recombinant and purified endogenous correlated improvement in patient outcome with imaging
PAs and exogenous PAs (including streptokinase, evidence of recanalization of an occluded brain-supplying
staphylokinase, PAs derived from Desmodus species, artery, however.4
and novel plasminogen activators) are presented. The development of agents that promote fibrin degradation
• The molecular basis for PA inhibition and modulation in the clinical setting stems from observations in the 19th
of vascular fibrinolysis is made. century of the spontaneous liquefaction of clotted blood and
the dissolution of fibrin thrombi. A growing understanding of
• These considerations form a basis for exploration of plasma proteolytic digestion of fibrin paralleled enquiry into
current information about the impact of PAs and of the mechanisms of streptococcal fibrinolysis. Streptokinase
plasmin generation on CNS vessel and microvessel (SK) was the first PA employed to dissolve closed space
integrity. (intrapleural) fibrin clots, but purified preparations were
• Exploration of the role(s) of endogenous PAs in required for lysis of intravascular thrombi. The development
CNS development, CNS integrity, and on neuronal of PAs for therapeutic lysis of vascular thrombi has progressed
function in the CNS is presented, and the potential along with insights into the mechanisms of thrombus
effects of therapeutic PAs on the CNS. formation and degradation. It should be remembered that
• The pioneering use of therapeutic plasminogen the concentrations of PAs used to degrade fibrin thrombi
activation in the acute setting in ischemic/thrombotic clinically far exceed those required to perform the same task
stroke, acute cerebral arterial recanalization, and its endogenously.
consequences are described.
• The use of PAs in experimental cerebral ischemia, THROMBUS FORMATION
recanalization and tissue injury reduction, and their
The relative platelet-fibrin composition of a specific thrombus
limitations and relevance to the clinical setting are
depends on the vascular bed, the local development of fibrin,
discussed.
platelet activation, and regional blood flow or shear stress.
• The risks of PAs in the acute intervention in ischemic Even in the same arterial territory there may be considerable
stroke and the quantitative effects on intracerebral variability and local heterogeneity in thrombus composition
hemorrhage are presented. Limitations to the clinical use as evidenced by thrombi removed in situ.10-13 Pharmacologic
of fibrinolytic agents in ischemic stroke are considered. inhibition of the platelet activation/aggregation and coagula-
tion processes can also alter thrombus composition and vol-
ume. At arterial flow rates thrombi are predominantly platelet
rich, whereas at lower shear rates characteristic of venous flow,
Thrombosis, and thrombus growth, dissolution, and migra- activation of coagulation seems to predominate. It has been
tion are inextricably connected. Thrombus formation involves suggested that the efficacy of pharmacologic thrombus lysis
activation of platelets, activation of the coagulation system, depends on (i) the relative fibrin content and (ii) the extent of
and the processes of fibrin dissolution. The central feature of fibrin cross-linking of the thrombus that may reflect thrombus
each of these processes is the generation of thrombin from age and thrombus remodeling. The latter may vary with loca-
prothrombin. Thrombin, in turn, generates the thrombus tion within a vascular bed (e.g., arterial, capillary, or venular).
fibrin network by the cleavage of circulating fibrinogen with Thrombin (factor IIa) is the central player in clot formation
formation of the fibrin network. Excess local vascular fibrin (Fig. 2.1). Thrombin, a serine protease, cleaves fibrinogen to
deposition can contribute to thrombus growth, while vascular generate fibrin, which forms the scaffolding for the growing
injury and excess degradation of fibrin in “hemostatic plugs” thrombus. Inter-fibrin strand cross-linking requires active
at sites of vascular injury can lead to hemorrhage. Plasmin can factor XIII, a transglutaminase bound to fibrinogen that
degrade fibrin and fibrinogen. Plasminogen activators (PAs), is itself activated by thrombin. Factor XIIIa stabilizes the
which convert plasminogen to plasmin, have been exploited fibrin network (Fig. 2.2).14,15 Thrombin-mediated fibrin
to dissolve clinically significant vascular thrombi acutely. polymerization leads to the generation of fibrin I and fibrin
11
EXTRINSIC PATHWAY INTRINSIC PATHWAY
HMWK
TF
VII TF: VIIa XI XII Pre-kallikrein
Ca2
X IX
Kallikrein
Ca2 XIIa
Fibrin
Fibrinogen
XIa
IIa
IXa VIII
Va Xa VIIIa
II
PF 1.2
Ca2 Ca 2
HMWK
TF
VII TF: VIIa XI XII Pre-kallikrein
Ca2
X IX
Kallikrein
Ca2 XIIa
Fibrin Fibrinogen
XIa
IIa
Xa IXa VIIIa VIII

Va
II
PF 1.2
Ca2 Ca 2
HMWK
TF
XI XII Pre-kallikrein
VII TF: VIIa
Ca2
X IX
Kallikrein
Ca2 XIIa Protein C

Fibrin Fibrinogen Thrombomodulin
XIa
IIa
AT APC
HC-III IXa VIII Protein S
Va Xa VIIIa
II
PF 1.2
Ca2 Ca 2
C
Fig. 2.1. Intrinsic and extrinsic coagulation pathways (see text). Phospholipid-containing membranes (e.g., platelets) provide the scaffold for
accelerating coagulation pathway activation. Both intrinsic and extrinsic pathways lead to prothrombin (factor II) activation, with fibrin generation
from circulating fibrinogen. The extrinsic pathway initiates coagulation through the interaction of factor VII with tissue factor (TF) in the vascular
adventitia, brain perivascular parenchyma, and activated monocytes. The TF:VIIa complex catalyzes activation of factor X and acceleration
of thrombin generation. The intrinsic system involves activation of components within the vascular lumen. Initiation of coagulation through
this pathway involves pre-kallikrein, kallikrein, high-molecular-weight kininogen (HMWK), and factors XI and XII. (A) Thrombin generation. The
intrinsic system activates factor X through the “tenase” complex (factors VIIIa and IXa, and Ca2+ on phospholipid). Both intrinsic and extrinsic
pathways activate prothrombin through the common “prothrombinase” complex (factors Xa and Va, and Ca2+). The platelet surface has
receptors for factors Va and VIIIa. Cleavage of prothrombin generates the prothrombin fragment 1.2 (PF 1.2) and thrombin (factor IIa). (B)
Thrombin has multiple stimulatory positive feedback effects. It catalyzes activation of factors XI and VIII as well as the activities of the tenase
and prothrombinase complexes. Thrombin also stimulates activation of platelets and granule secretion via specific thrombin receptors on their
surface. (C) Coagulation activation is regulated by interleaving inhibitor pathways. The effects of factors Va, Xa, and VIIIa are modulated by the
protein C pathway. Activated protein C (APC), generated by the action of the endothelial cell receptor thrombomodulin on protein C, with its
cofactor protein S, inhibits the action of factor V. AT, Antithrombin; HC-III, heparin cofactor-III.
Mechanisms of Thrombosis and Thrombolysis 13
II monomers and to the release of fibrinopeptide A (FPA) and active components of coagulation. Other vascular and cellular
fibrinopeptide B (FPB). stimuli also augment PA release, thereby pushing the hemostatic 2
Platelet activation is required for thrombus formation balance toward thrombolysis (see below).
under arterial flow conditions and accompanies thrombin- The development of arterial or venous thrombi requires loss
mediated fibrin formation. Platelet membrane receptors of the constitutive antithrombotic characteristics of endothelial
and phospholipids form a workbench for the generation of cells. In addition to both the antithrombotic properties of
thrombin through both the intrinsic and extrinsic coagulation endothelial cells and the circulating anticoagulants and
pathways.16 Platelets promote activation of the early stages their cofactors (i.e., activated protein C [APC], protein S),
of intrinsic coagulation by a process that involves the factor thrombus growth is limited by the endogenous thrombolytic
XI receptor and high-molecular-weight kininogen (HMWK) system. Thrombus dissolution or remodeling results from the
(see Fig. 2.1).17 Also, factors V and VIII interact with specific preferential conversion of plasminogen to plasmin on the
platelet membrane phospholipids (receptors) to facilitate the thrombus surface. There, fibrin binds t-PA in proximity to its
activation of factor X to Xa (the “tenase complex”) and the substrate (fibrin-bound) plasminogen, thereby accelerating
conversion of prothrombin to thrombin (the “prothrombinase local plasmin formation, in concert with local shear stress.21
complex”) on the platelet surface.18 Platelet-bound thrombin- The parallel role of scu-PA is discussed below.
modified factor V (factor Va) serves as a high-affinity platelet These processes may also promote embolization into the
receptor for factor Xa.19 These mechanisms accelerate the rate downstream cerebral vasculature. However, little is known
of thrombin generation, further catalyzing fibrin formation about the endogenous generation and secretion of PAs within
and the fibrin network. cerebral vessels.22 Exogenous application of pharmacologic
This process also leads to the conversion of plasminogen doses of PAs can accelerate conversion of plasminogen
to plasmin and to the activation of endogenous fibrinolysis. to plasmin and thereby prevent thrombus formation and
Thrombin provides one direct connection between thrombus promote thrombus dissolution, as discussed later.
formation and plasmin generation, through the localized
release of tissue plasminogen activator (t-PA) and single chain
urokinase (scu-PA) from endothelial cells. Thrombin has been
FIBRINOLYSIS
shown in vitro and in vivo to markedly stimulate t-PA release Plasmin formation is central to the lysis of vascular thrombi.
from endothelial stores.19,20 In one experiment, infusion of The endogenous fibrinolytic system comprises plasmino-
factor Xa and phospholipid into non-human primates resulted gen, scu-PA, urokinase (u-PA), and t-PA, and their inhibi-
in a pronounced increase in circulating t-PA activity, suggesting tors. Hence, plasmin degrades fibrin (and fibrinogen).
that significant vascular stores of this PA can be released by Plasminogen, its activators, and their inhibitors contribute
to the balance between vascular thrombosis and hemorrhage
(Fig. 2.3; Tables 2.1 and 2.2).
Plasmin formation occurs (i) in the plasma, where it can
Fibrinogen
cleave circulating fibrinogen and fibrin into soluble products,23
XIII IIa FPA
Ca2+ IIa
Fibrin I Plasminogen
XIIIa IIa FPB PAI PA
Fibrin II Plasmin
Cross-linked Fibrin(ogen) FDP
fibrin
Fig. 2.3. Plasminogen activation and fibrin(ogen)olysis. Degradation
Fig. 2.2. Generation of cross-linked fibrin. Fibrinogen is cleaved of fibrinogen and fibrin is catalyzed by plasmin. Plasminogen
successively to form fibrin I and fibrin II by thrombin (factor IIa) with activators (PAs), including tissue PA, urokinase PA, and novel
the release of fibrinopeptides A and B (FPA and FPB). Thrombin constructs, cleave plasminogen to the active plasmin. Characteristic
activates factor XIII to the active transglutaminase, which promotes products of fibrin and fibrinogen degradation (FDP) are generated
cross-linking of fibrin and stabilization of the growing thrombus. (see text). PAI, Plasminogen activator inhibitor.
TABLE 2.1 Plasminogen Activators.

Plasma Plasma
Molecular Concentration Concentration
Plasminogen Activators Weight (kDa) Chains (mg/dL) Half-Life (t1/2) Substrates
Endogenous
Plasminogen 92 2 20 2.2 days (Fibrin)
Tissue PA (t-PA) 68 (59) 1→2 5 × 10−4 5–8 min Fibrin/plasminogen
Single-chain urokinase PA 54 (46) 1→2 2–20 × 10−4 8 min Fibrin/plasmin(ogen)
(scu-PA)
Urokinase PA (u-PA) 54 (46) 2 8 × 10−4 9–12 min Plasminogen
Exogenous
Streptokinase 47 1 0 41 and 30 min Plasminogen,
fibrin(ogen)
Anisoylated plasminogen- 131 Complex 0 70–90 min Fibrin(ogen)
streptokinase activator
complex (APSAC)
Staphylokinase 16.5 0 Plasminogen
Desmoteplase 52 1 0 138 min Plasminogen
TABLE 2.2 Plasminogen Activator Inhibitors.

Molecular Weight Plasma Concentration Plasma Concentration
Inhibitor (kDa) Chains (mg/dL−1) Half-Life (t1/2) Inhibitor Substrates
Plasmin Inhibitors
α2-antiplasmin 65 1 7 3.3 min Plasmin
α2-macroglobulin 740 4 250 Plasmin (excess)
Plasminogen Activator Inhibitors
PAI-1 48–52 1 5 × 10−2 7 min t-PA, u-PA
PAI-2 47, 70 1 <5 × 10−4 24 h t-PA, u-PA
PAI-3 50 u-PA, t-PA
PAI, Plasminogen activator inhibitor; t1/2, half-life; t-PA, tissue plasminogen activator; u-PA, urokinase plasminogen activator.
and (ii) on reactive surfaces (e.g., thrombi or cells). The fibrin vasculature. Thrombin, generated by either intrinsic or extrin-
network provides the scaffold for plasminogen activation, sic coagulation, stimulates secretion of t-PA from endothelial
whereas various cells, including polymorphonuclear (PMN) stores.19,37
leukocytes, platelets, and endothelial cells, express receptors Several serine proteases can convert plasminogen to
for plasminogen to bind to.23 Specific cellular receptors plasmin by cleaving the arg560-val561 bond.31 Serine proteases
concentrate plasminogen and specific activators (e.g., have common structural features, including an NH2-terminal
urokinase plasminogen activator [u-PA]) on the cell surface, “A” chain with substrate-binding affinity, a COOH-terminal
thereby enhancing local plasmin production. Similar receptors “B” chain with the active site, and intra-chain disulfide
on tumor cells (e.g., the urokinase plasminogen activator bridges. Plasminogen-cleaving serine proteases include the
receptor [u-PAR], which concentrates u-PA) also facilitate coagulation proteins factor IX, factor X, and prothrombin
dissolution of basement membranes and matrix, promoting (factor II), protein C, chymotrypsin and trypsin, various
metastases. u-PA and u-PAR are both expressed by microvessels leukocyte elastases, the plasminogen activators u-PA and t-PA,
and neurons in the ischemic bed.24,25 Plasmin can also cleave and plasmin itself.31
various extracellular matrix (ECM) glycoprotein components Activation of plasminogen by t-PA is accelerated by a
(e.g., laminins, collagen IV, perlecan) found in the basal ternary complex with fibrin. In the circulation, plasmin
lamina of microvessels of the central nervous system, and in binds rapidly to the inhibitor α2-antiplasmin and is thereby
other organs.26-28 inactivated. Activation of thrombus-bound plasminogen also
protects plasmin from the inhibitors α2-antiplasmin and
α2-macroglobulin.31 Here, the lysine-binding sites and the
Plasminogen catalytic site of plasmin are occupied by fibrin, thereby blocking
The naturally circulating PAs, single-chain t-PA and single-chain its interaction with α2-antiplasmin.31 Furthermore, fibrin and
u-PA (scu-PA or pro-UK), catalyze plasmin formation.29,30 fibrin-bound plasminogen render t-PA relatively inaccessible
Plasmin derives from the zymogen plasminogen, a glycosyl- to inhibition by other circulating plasma inhibitors.
ated single-chain 92-kDa serine protease.31,32 Structurally,
plasminogen contains five kringles and a protease domain,
two of which (K1 and K5) mediate the binding of plasmino-
Thrombus Dissolution
gen to fibrin through characteristic lysine-binding sites (Fig. Fibrinolysis occurs predominantly at the surface, and so may
2.4).31,33,34 Glu-plasminogen has an NH2-terminal glutamic be augmented by increased local blood flow, but also by flow
acid, and lys-plasminogen, which lacks an 8-kDa peptide, has within the thrombus.38,39 During thrombus consolidation, plas-
an NH2-terminal lysine. Plasmin cleavage of the NH2-terminal minogen bound to fibrin and to platelets allows local release of
fragment of glu-plasminogen generates lys-plasminogen. Glu- plasmin. In the circulation, plasmin cleaves the fibrinogen Aα
plasminogen has a plasma clearance half-life (t1/2) of ∼2.2 chain appendage, generating fragment X (DED), Aα fragments,
days, whereas the t1/2 of lys-plasminogen is 0.8 days. Both and Bβ. Further cleavage of fragment X leads to the generation
t-PA and u-PA catalyze the conversion of glu-plasminogen to of fragments DE, D, and E. By contrast, degradation of the fibrin
lys-plasmin through either of two intermediates, glu-plasmin network generates YY/DXD, YD/DY, and the unique DD/E (frag-
or lys-plasminogen.35 The lysine-binding sites of plasmino- ment X = DED and fragment Y = DE). Cross-linkage of DD with
gen mediate the binding of plasminogen to α2-antiplasmin, fragment E is vulnerable to further cleavage, producing D-dimer
thrombospondin, components of the vascular ECM, and fragments. The measurement of D-dimer levels can have clinical
histidine-rich glycoprotein (HRG).32 α2-Antiplasmin prevents utility, in that the absence of circulating D dimer correlates with
binding of plasminogen to fibrin by this mechanism.35 Partial the absence of massive thrombosis.40 Ordinarily, in the setting
degradation of the fibrin network enhances the binding of glu- of focal cerebral ischemia, the thrombus load is small and the
plasminogen to fibrin, promoting further local fibrinolysis. meaning of any D-dimer elevation is uncertain. The generation
of the degradation products has two consequences: (i) incor-
poration of some of these products into the forming thrombus
Plasminogen Activation destabilizes the fibrin network of the thrombus and (ii) reduced
Plasminogen activation is tied to activation of the coagulation circulating fibrinogen and the generation of breakdown prod-
system and can involve secretion of physiologic PAs (“extrinsic ucts of fibrin(ogen) limits the protection from hemorrhage by
activation”). It has been suggested that kallikrein, factor XIa, hemostatic thrombi.
and factor XIIa, in the presence of HMWK, can directly acti-
vate plasminogen.35,36 Several lines of evidence suggest that
scu-PA activates plasminogen under physiologic conditions.
PLASMINOGEN ACTIVATORS
Tissue-type PA, which is secreted from the endothelium and All fibrinolytic agents are obligate PAs (see Table 2.1).
other cellular sources, appears to be the primary PA in the Tissue PA, scu-PA, and u-PA are endogenous PAs involved in
H T C Q H K K C Q S W
S G W S T G S
S
P H
A H G Y I P S K
F
P V
T
V A
Q
T T
T
T S
M
T
2
Q N A H C P S F C P
S K T W T W
V T H S T H
D N P P
N N T T D R
W A G
L G S H G P H
A R L E R K
P R K R Q N R S Q
Q W D
P K
Y V K3 K
R Y V K4 D
K
C C N R C Y N G A
N R T S R
E F K2 E W
D
P Q W
D
P P
T
L T P
D I E G E N
G T W E L C P P S
G N E E
D P N K R P
T
Y R N D Y R N
S R P C
M T S G C F G C C Y
C T G K Y N Y
T K P H P
P N
K
L P I N C Y K L MT N
S T S E K K L A
I K G S C H M Y D L N G
G D Y N E C Q C C C C
E Q D S
D V G T
E S V E A S
E S L Y P V V
E V S A
C P T P
G L C K V S P T E V
E E E S T L E D P L L P
E K E V V P
S N I L K E
Q L P E
P T E R
Y D A P T A D
H G F
C C C G Y R G K R
T R N L M F G N G K A
Y T
A N G V
D T
P
P
K V A A C
D Y P Q V
S N R N D S P T
V V R K R P N
F D K Y R F V Y L T G
G G D C Y D
R P K1 E R M
G P
E V Q D T T
P P G R P P K G C Y P
Q
R G D T I
C
V
C
K K
N
Y C K5 C C
T R W
H P M I A K Q
W T N P P
P C Y S D G D V G G D
I H P A C L E
S K S P I P L W
T T V A
S K S H S G
SW K
K Q C T I G N K R L
S
D P A A
R S W R Q
N T V T N E
P P
E R Q I Y N P
W T E H
A F P T
V V F I S H R
M G V
L E K A
I M H F C A
C S P
V E G E T Q G
I E E Q K G H P S D W T F
S C C Q R G
S G A R S G
G A T A
H T A P L T
A A I G
M Y L T S K E
E G K C F L
Q I L S L
H L C F L
C R A S V Y L
K Q K
E T P E W K A C
E K F V
E V I E E
V F L
K D E E I D K A
V D P
T E L N L Q
L K K G
V P
S F Q TN V A G R G L
L L S A G H E Q H T
Y P
L V I S
V P V
L Y Q E L D
E I E V F L I
L D S R L Q G
E
F D G G Q
L K S L L N
E P
Signal G Q G V
W
G C C
S
K
T S A V
D N R Y E F L N
NH 2 Protease R
T
C
P G
G
N R
G
K A C L E T S Q V
P A G
G
V L H
R V Y
V
S
R
F
V
T
W
I
E G V M R N N COOH
Fig. 2.4. The secondary structure of plasminogen.
physiologic fibrinolysis. Recombinant t-PA, scu-PA, and u-PA, two kringle domains are homologous to the kringle regions
as well as SK, acylated plasminogen streptokinase activator of plasminogen.
complex (APSAC), staphylokinase (STK), PAs from Desmodus The single-chain form of t-PA is converted to the two-chain
species, and other newer novel agents in clinical use (e.g. form by plasmin cleavage of the arg275-isoleu276 bond. Both
reteplase [r-PA], and tenecteplase [TNK]), are termed exogenous single-chain and two-chain species are enzymatically active
PAs.38,39 t-PA, scu-PA, and a number of novel agents have rela- and have relatively fibrin-selective properties. Infusion studies
tive fibrin and thrombus specificity.40 in humans indicate that both single-chain and two-chain t-PA
have circulating plasma t1/2 values of 3–8 minutes, although
the biologic t1/2s are longer. Tissue PA is considered to be fibrin-
Endogenous Plasminogen Activators selective because of its favorable binding constant for fibrin-bound
plasminogen and its activation of plasminogen in association
Tissue Plasminogen Activator with fibrin. Significant inactivation of circulating factors V and
Tissue PA is a 70-kDa, single-chain glycosylated serine prote- VIII does not occur with infused rt-PA, and an anticoagulant state
ase that has four distinct domains—a finger (F-) domain, an is generally not produced. However, if sufficiently high rt-PA
epidermal growth factor (EGF) domain (residues 50–87), two dose-rates are employed, clinically measurable fibrinogenolysis
kringle regions (K1 and K2), and a serine protease domain and plasminogen consumption can be produced.
(Fig. 2.5).41 The COOH-terminal serine protease domain con- Physiologically, secretion of t-PA from cultured endothelial
tains the active site for plasminogen cleavage, and the finger cells is stimulated by thrombin,37,43 APC,44 histamine,37
and K2 domains are responsible for fibrin affinity.41,42 The phorbol myristate esterase, and other mediators.45 Physical
S C L
A E C T N W G A P W
G N S S N
S E S
S
Y C W
117 A T V H C
W
M
I
E L
V P L L P L
A A K
F K S I
N K
T K S Q H G
K R
S A A K
D T R
W P V
G G D
T R Y L Y
K S R G
G T T
Y D G A
R Y W D
S P R Q
Y P
A G S R A E N
F K S N N H
Y
G I E P S R P A S P
C F R G C C S I W
D
E
P C
G
Q
C
S
C
A N 184 D Y A
A
D Q
E Y G V N Q
C D T N I F A
I E F H A A
Q P
C D Y P H R Y K G L G L G
L
I
T A NG L S
V C C L G C C G F
R C R K
P F F A T S I A
N D S D T C
G L R Q F R K
E
G S E Y S QP Q 275 H
S G S
N R
C G F
S T Y P L C V T S R
C L A P GP
R P V K
Q A L D
R
R
E
L Q V
L
R
V Q L L
F RF P P H
W P P V C E H
S
S
N
V D S I GG Q L
S W L F
Q R H C T S I T
H V Q A T M R G C V
E Y R L D E H E A E S I
Q C G
V N C GK Q S A
Q W G L Y L L
Y C N S E G A C A
I I C L S S W I L S G
MQ I V P C R
T K R
E D R C T V S L F T
Q Y S Y
W P Y
S 1 G G E
S S
D E E
R
L R K Q V
R L G K E
G A E S F G V
A H E
P S Q E I H A R F R R G C C QG D K P
V S V L V
F G A R Q E
V Q D K
A L L Y
K H H L L I
G D L
Y
P T S Q L V
N
C V N
A Q
S S R C
R A 448 H
L MA D
M NH2 P PG
T I K
L L G R K G S
R T D V E
L V C C G G A C L M N D T N
V F
DY T D D D
Y
T
K
V T
N Y L DW I R D
N M R P COOH
Fig. 2.5. The secondary structure of tissue plasminogen activator (t-PA). Conversion of single-chain t-PA to two-chain t-PA by plasmin occurs at
the arg275-isoleu276 bond (arrow).
exercise and certain vasoactive substances produce measurable It has been postulated that t-PA is primarily involved in
increases in circulating t-PA levels, and 1-deamino(8-d- the maintenance of hemostasis through the dissolution of
arginine) vasopressin (DDAVP) may produce a 3-4-fold fibrin, whereas u-PA is involved in generating pericellular
increase in t-PA antigen levels within 60 minutes of parenteral proteolytic activity by cells expressing the u-PA receptor,
infusion in some patients. Both t-PA and u-PA have been which is needed for degradation of the ECM for migration.
reported to be secreted by endothelial cells, neurons, The roles of these two PAs in central nervous system cell
astrocytes, and microglia in vivo or in vitro.22,46-51 The reasons function are not fully understood. However, recent work has
for this broad cell expression are not known, however. provided further insight between the interactions of t-PA and
the u-PA precursor.
Urokinase-Type Plasminogen Activator
Single-chain u-PA is a 54-kDa glycoprotein synthesized by Recent Considerations of Endogenous
endothelial and renal cells as well as by certain malignant cells Thrombolysis That Suggest Approaches to
(Fig. 2.6).23 This single-chain proenzyme of u-PA is unusual
in that it has fibrin-selective plasmin-generating activity52 and
Thrombotic Stroke
also has been synthesized by recombinant techniques.53 The antithrombotic milieu of the endothelium is maintained
The relationship of scu-PA to u-PA is complex: cleavage or in part by secretion of t-PA and the single-chain urokinase PA
removal of lys158 from scu-PA by plasmin produces 54-kDa, (scu-PA, pro-UK) and two-chain u-PA (urokinase). As pointed
two-chain u-PA. This PA consists of an A-chain (157 residues) out above, t-PA binds to fibrin and fibrin-bound plasminogen
and a glycosylated B-chain (253 residues), which are linked within the thrombus in a ternary complex that efficiently ini-
by the disulfide bridge between cys148 and cys279. Further tiates fibrin degradation.56,57 Plasmin thus generated exposes
cleavages at lys135 and arg156 produce low-molecular-weight two new plasminogen binding sites,58,59 the first of which
(31-kDa) u-PA.41 Both high- and low-molecular-weight species causes a conformational change in the plasminogen that scu-
are enzymatically active. PA recognizes, which is then activated to plasmin.60 Plasmin
The 54-kDa urokinase (u-PA) activates plasminogen further activates scu-PA to two-chain u-PA, which in turn acti-
by first-order kinetics.38,53 The two forms of u-PA exhibit vates fibrin-bound plasminogen on the second binding site.61
measurable fibrinolytic and fibrinogenolytic activities in vitro Hence, t-PA activates one fibrin-bound plasminogen initially
and in vivo, and have plasma t1/2 values of 9–12 minutes.54,55 and u-PA activates plasminogen on newly exposed binding
When infused as a therapeutic agent, pharmacologic doses sites on degraded fibrin in the thrombus.62,63 This provides
of u-PA lead to plasminogen consumption and inactivation a further efficiency to endogenous thrombus lysis and is the
of factors II (prothrombin), V, and VIII. The latter changes basis for potential further refinement of pharmacologic vascu-
constitute the systemic lytic state. lar thrombolysis.64
M G R P C L
P W N S A T V
T
D
T
V
Q V Y CW
L 80
Q T
I E N Q P 2
P Q T W
S G Plasmin (PN) F
R T F
A L activation A
R Y 160 G E
K K 120 R G A
P H I
60 G N I I
R L A
R F K Y
D H P
V P R
Y Q L 180 R
N R
F E R
T Y T V S HR
NH S K V G G R
H C C D Q C
S A G Q I T G
N G M Y L T S G C F I D
C I R L
E G G N N 100 Q H Y P K K
F G
V H K G L G L Kidney Q C S I E
L Q 40 H F L 280 T D
H K E enzyme P S Y
H D K P P A
Q K C Y L Q I
P C S A C S
C E V
V PN C E
T
A
D G
140 E M E N C W V I 200
N I P Y K S R Y
P D K K P S S P T S N 220 L
S C K S
K N G 300 D G N L
D E R
NCD C W P F Y T S RG
L H PN L K Q
Q G S
N I Y G
20 V C F T P R E M
T GG N G I E I K F
S E K 260 E V
N S T S C Q
K Y F T H S M R L E
K R 400 L T G L L N
E I T Q L S C V K
E L A L
PN N W G 360 P K V V T M I 240 I
G P I L
L L G D L
V
A F S G I 320 H Y YG N H Fig. 2.6. The secondary structure of single-
L W S
H G S P S H K
COOH S R G
D H Q E H D
chain urokinase plasminogen activator (scu-
V G Q R
R E CQ V A Y PA; 54 kDa). Activation by plasmin takes place
T 380 C C L
T
Y V A T D A S
G P
K D K L
S D T K W Q P D A
A C L M K T at the 158–159 bond (arrow). The zigzag line
340 represents the glycosylation site.
Exogenous Plasminogen Activators complex that activates free plasminogen. The binding of STK
to plasmin has been worked out in detail.67,69,70 Recombinant
Streptokinase STK has been prepared from the known gene nucleotide
Streptokinase (SK) is a 47-kDa, single-chain polypeptide sequence and has been tested in the setting of acute myocar-
derived from group C β-hemolytic streptococci. The active dial infarction (MI), and has been tested preliminarily in focal
[SK-plasminogen] complex converts circulating plasminogen cerebral ischemia model studies.71,72
directly to plasmin and undergoes further activation to form the
[SK-plasmin] complex. The [SK-plasminogen], [SK-plasmin], Plasminogen Activators Derived From Desmodus
and plasmin species circulate together.65 The [SK-plasmin]
complex (not bound by the inhibitor α2-antiplasmin) and free
rotundus
circulating plasmin degrade both fibrinogen and fibrin and Recombinant PAs identical to those derived from the saliva
inactivate prothrombin, factor V, and factor VIII. of Desmodus species are fibrin-dependent. The α form of
The kinetics of SK elimination are complex. Desmodus salivary PA (DSPA-α; desmoteplase) and vampire
Antistreptococcal antibodies formed from antecedent bat salivary plasminogen activator (bat-PA) are more fibrin-
infections neutralize infused SK and arise maximally by 4–7 dependent than t-PA and may be superior to t-PA in terms
days after initiation of an SK infusion. Therefore, the doses of sustained recanalization without fibrinogenolysis.73,74
of SK required to achieve steady-state plasminogen activation The plasma t1/2 of DSPA-α is significantly longer than that of
must be individualized. Plasminogen depletion through rt-PA.73 A program of studies of desmoteplase as acute treat-
conversion to plasmin and by, as yet, poorly understood ment for ischemic stroke by several sponsors has so far failed
clearance mechanisms for the [SK-plasminogen] complex to demonstrate improved outcomes in patients.75 Recently,
can lead to hypoplasminogenemia. Generation of plasmin is treatment of ischemic stroke patients, appearing within 3–9
limited at both low and high SK infusion dose-rates because hours after symptom onset, with desmoteplase was not found
of inadequate plasminogen conversion and depletion of to have different outcome (mRS = 0–2) compared to those
plasminogen, respectively. treated with placebo, and no difference in the hemorrhagic
APSAC (e.g., Anistreplase) was an artificial activator risk or mortality was observed.76 No additional studies of this
construct consisting of plasminogen and SK bound non- compound have been reported.
covalently. Fibrin selectivity relies on the fibrin-attachment
properties of the plasminogen kringles. The activity of APSAC
depends on the deacylation rate of the acyl-plasminogen
Novel Plasminogen Activators
component. Hydrolytic activation of the acyl-protected Efforts to alter the stability and thrombus selectivity of endog-
active site of plasminogen allows plasmin formation by SK enous PAs have led to a growing list of possible pharmacologic
within the complex in the presence of fibrin. From those agents. Point and deletion mutations in t-PA and u-PA have
observations and on the basis of the terminal t1/2 of SK and provided molecules with unique specificities.77 For instance,
the t1/2 for APSAC deacylation, APSAC has a longer circulation t-PA sequences lacking the K1 and K2 domains possess fibrin
time than SK.66,67 However, despite these clinically favorable specificity, normal specific activity, but reduced inhibition by
characteristics APSAC has not found a place in the treatment PA inhibitor-1 (PAI-1).42 In theory, the increased fibrin selec-
of vascular thrombosis. tivity might provide greater thrombolytic effect; however, in
studies of the use of this agent in coronary artery thromboses,
significant advantages did not arise.
Staphylokinase For the clinical target of myocardial ischemia, several
Staphylokinase (STK) is a 16.5-kDa polypeptide derived from t-PA mutants with prolonged t1/2 and delayed clearance have
certain strains of Staphylococcus aureus.67-69 STK combines stoi- been devised that may have benefit when infused as a single
chiometrically (1:1) with plasminogen to form an irreversible bolus78,79:
In the circulation, α2-antiplasmin is the primary inhibitor

• Reteplase, a non-glycosylated PA consisting of the K2 and of fibrinolysis, inhibiting plasmin directly. Excess plasmin is
protease domains of t-PA, has a 4.5- to 12.3-fold longer t1/2 inactivated by α2-macroglobulin. The potential risk of vascular
owing in part to lower affinity for the hepatic cell t-PA recep- thrombosis then depends on the balance between plasminogen
tor.79,80 It also possesses lower fibrin selectivity. activation and plasmin activity and their respective inhibitors
• Tenecteplase (TNK-t-PA or TNK) differs from t-PA at three in the circulation.
mutation sites (T103N, N117Q, and KHRR[296–299]AAAA), Thrombospondin interferes with fibrin-associated
which alter two glycosylation sites and increase fibrin selec- plasminogen activation by t-PA. Inhibitors of the contact
tivity. The changes also result in decreased clearance and pro- activation system and complement (C1 inhibitor) have an
longed t1/2.81 Application of TNK to clinical ischemic stroke indirect effect on fibrinolysis. HRG is a competitive inhibitor of
has been formally tested in a small trial,82 based upon lim- plasminogen. Generally, though, these physiologic modulators
ited experimental studies. Recent report of a non-random- of plasmin activity are overwhelmed by pharmacologic
ized pilot study indicates the feasibility of intravenous TNK concentrations of PAs.
treatment within 3–6 hours of symptom onset.83 In addition For SK, APSAC, and STK, circulating neutralizing antibodies
to enhanced fibrin selectivity, TNK has relative resistance to appear, which directly inhibit their activation of plasminogen.
inhibition by PAI-1. A recent report has suggested that TNK
may be relatively useful as a preparation for endovascular re-
moval of thrombi in a symptomatic artery;84 however, further
α2-Antiplasmin and α2-Macroglobulin
controlled examination of this analysis is required. Circulating plasmin generated during fibrinolysis is bound by
• Lanoteplase (n-PA), another t-PA mutant with greater t1/2, α2-antiplasmin in the plasma. The two forms of α2-antiplasmin
derives from deletion of the fibronectin finger and EGF do- are (i) the native form, which binds plasminogen, and (ii) a
mains and mutation of asn117 to gln117.78 second form that cannot bind plasminogen.94 Ordinarily, α2-
• Monteplase (E6010) is a t-PA–like construct with moderate antiplasmin is found in either plasminogen-bound or free cir-
fibrin selectivity. This molecule differs from t-PA in the loca- culating forms. Fibrin-bound plasmin is protected because of
tion and organization of disulfide bridges and the complex- its interaction with fibrin and because α2-antiplasmin is already
ity of glycosylation. occupied. Excess free plasmin is bound by α2-macroglobulin.
• Pamiteplase (YM866) has fibrin selectivity and spe- α2-Macroglobulin is a relatively nonspecific inhibitor of fibri-
cific activity that are nearly identical to those of t-PA, but nolysis that inactivates plasmin, kallikrein, t-PA, and u-PA.
pamiteplase has a longer t1/2.85,86

INHIBITORS OF PLASMINOGEN ACTIVATORS AND
These mutants have been developed for bolus infusion
application in the setting of MI.
FIBRINOLYSIS
What advantage delayed clearance or prolonged t1/2 of a PAIs also reduce the activity of t-PA, scu-PA, and u-PA by direct
t-PA mutant may have in acute application in ischemic stroke binding (see Table 2.2).
is yet to be demonstrated.87 Dose-adjustment studies in PAI-1 specifically inhibits both plasma t-PA and u-PA. PAI-1
patients with stroke have not been reported. One unproven is derived from both endothelial cell and platelet sources.95
concern with long t1/2 molecules is that they may increase the Several lines of evidence indicate that the K2 domain of t-PA
intracerebral hemorrhage risk in the setting of ischemic stroke. is responsible for the interaction between t-PA and PAI-1 and
A similar situation exists for other novel PA constructs. that this interaction is altered by the presence of fibrin.96 PAI-1
These have included single-site mutants and variants of rt-PA is also an acute-phase reactant,97 and deep venous thrombosis,
and recombinant scu-PA, t-PA/scu-PA and t-PA/u-PA chimerae, septicemia, and type II diabetes mellitus, for instance, are
u-PA/antifibrin monoclonal antibodies, u-PA/antiplatelet associated with elevated plasma PAI-1 levels.
monoclonal antibodies, bifunctional antibody conjugates, PAI-2, which is found in a 70-kDa form and a 47-kDa low-
and scu-PA deletion mutants.88-90 molecular-weight form, has a lower Ki for u-PA and two-chain
Recently, interest in recombinant pro-UK (scu-PA) has t-PA. PAI-2 is derived from placental tissue, granulocytes,
reappeared, based upon a report of its potential utility in acute monocytes/macrophages, and histiocytes.98 This inhibitor
MI.91 M5, a single site mutation (K300H) of pro-UK, is more probably plays little role in the physiologic antagonism of t-PA,
stable in plasma than pro-UK and can remain in its pro-enzymatic and is most important in the utero-placental circulation.99 The
form at therapeutic doses.92,93 The mutation reduces the intrinsic kinetics of PA inhibition by PAI-2 differs from that for PAI-1.
activity of pro-UK five-fold and increases its reactivity to plasma PAI-3 is a serine protease inhibitor of u-PA, t-PA, and APC
C1 inhibitor, which forms a complex with the enzymatic form. found in plasma and urine.
Complex formation potentially reduces the risk of hemorrhage Thrombin-activable fibrinolysis inhibitor (TAFI) is an
without interfering with the thrombolytic effect. endogenous inhibitor of glu-plasminogen and therefore
fibrinolysis. TAFI is a precursor of plasma carboxypeptidase B
Sequential Combinations of Plasminogen Activators in and, when activated by thrombin in the plasma, produces an
antifibrinolytic effect.
Exogenous Thrombolysis
When given following a low dose rt-PA bolus infusion, pro-UK CLINICAL CONSEQUENCES OF THERAPEUTIC
produced acceptable arterial recanalization acutely in coronary
artery thrombosis patients compared historically to rt-PA alone.91
PLASMINOGEN ACTIVATION
This has been the basis for the development of a more stable pro- PAs given at pharmacologic doses significantly alter hemosta-
UK analogue with a longer circulation time than the wild-type sis and have been used as treatments of acute vascular throm-
molecule that will be tested acutely in ischemic stroke patients. bosis. u-PA, SK, and occasionally t-PA produce systemically
detectable fibrin(ogen) degradation, measured by a fall in
fibrinogen concentration, and a reduction in circulating plas-
REGULATION OF ENDOGENOUS FIBRINOLYSIS minogen and α2-antiplasmin (through binding of the plasmin
Endogenous fibrinolysis is modulated by several families of generated). Both u-PA and SK inactivate factors V and VIII,
inhibitors of plasmin and of the PAs. which contribute to the “systemic lytic state” or “anticoagulant
state.” Fragments of fibrin(ogen) interfere with fibrin multi- neurons and oligodendrocytes during process outgrowth in
merization and contribute to thrombus destabilization, the rodent brain.105 Although t-PA is expressed by neurons in 2
whereas the circulating fragments, hypofibrinogenemia, and many brain regions, extracellular proteolysis seems confined
factor depletion produce an anticoagulant state that limits to specific, discrete brain regions. Studies suggesting that
thrombus formation and extension. The clinical consequences t-PA can mediate neurodegeneration during excitotoxicity or
of u-PA or SK infusion include a progressive decrease or deple- following focal cerebral ischemia in the hippocampus have
tion of circulating plasminogen and fibrinogen, prolongation opened a discussion about whether PAs play roles in cellular
of the aPTT due to significant fibrinogen reduction, and inac- viability outside the fibrinolytic system in the circulation.106
tivation of factors V and VIII. With repletion of these elements Strickland and colleagues have summarized studies indicating
the anticoagulant state may be transient. the involvement of t-PA on CNS cellular function and
Platelet function can also be affected. Clinical studies experimental focal ischemia outcomes.107 Other more recent
of rt-PA have demonstrated prolongation of standardized summaries have highlighted specific aspects of this data.108,109
template bleeding times.100 In experimental systems, infusion Plasminogen generation is confined to discrete regions of the
of rt-PA produces greater hemorrhage.101 Furthermore, t-PA is CNS.105 Early during focal ischemia, activators of plasminogen
known to cause disaggregation of human platelets through are expressed by microvessels and adjacent neurons (e.g.,
selective proteolysis of interplatelet fibrin, which is inhibitable u-PA);25 however, there is little evidence yet that plasmin
by α2-antiplasmin.102 Lys-plasminogen and glu-plasminogen activity per se is generated in the ischemic territory. Although
can potentiate the platelet disaggregatory effect of rt-PA. It is the loss of basal lamina components are compatible with its
likely that the risk of intracerebral hemorrhage that attends PA action,28 other proteases are generated that can account for
infusion involves disruption of sustained platelet aggregation this. In addition, evidence of local plasminogen activation has
and lysis of fibrin formed at sites of vascular injury. been shown by in situ zymography.110 Proteolytic fragments of
matrix constituents (e.g., laminin) have been associated with
LIMITATIONS TO THE CLINICAL USE OF enhanced excitotoxicity in the CNS in experimental settings.111
The roles for t-PA, while not overtly upregulated in non-
FIBRINOLYTIC AGENTS FOR ISCHEMIC STROKE human primate ischemia,25 have been implicated in neuron
The clinical setting in which PAs are used is an important and survival and injury.112
relevant variable for both the efficacy and the reduction of
hemorrhagic risk. Intracerebral hemorrhage is a known risk
of the clinical use of PAs. The use of rt-PA in pharmacologic
Plasminogen Activators and Neuronal Functions
doses in the acute setting of ischemic stroke must conform to PAs participate in CNS development.105,113 It is not surpris-
the original report,6 as confirmed subsequently,103 and in the ing that as many cells harbor receptors for PAs, the PA system
package insert (see https://www.accessdata.fda.gov/drugsatfda could play distinct roles in CNS development and function.
_docs/label/2015/103172s5203lbl.pdf). u-PA has been shown to participate in (i) forebrain postna-
An abbreviated summary of the strict contraindications to tal development (along with u-PAR), (ii) neuron and axo-
the use of fibrinolytic agents includes (i) a history of previous nal growth in the CNS,113 and (iii) epileptogenesis (along
intracranial hemorrhage, (ii) septic embolism, (iii) malignant with u-PAR).114,115 In experimental systems under normoxia
hypertension or sustained diastolic or systolic blood pressure t-PA is synthesized by neurons and appears to participate in
in excess of 180/110, (iv) conditions consistent with ongoing (i) hippocampal neuron function and responses,116 (ii) epi-
parenchymal hemorrhage (e.g., gastrointestinal source), (v) leptogenesis,115,117 and (iii) excitotoxic injury of neurons.49
pregnancy or parturition, (vi) a history of recent trauma or Microglia appear to require t-PA for proper function in
surgery, and (vii) known acquired (e.g., from anticoagulant use) phagocytosis.118
or inherited hemorrhagic diatheses. These contraindications Tsirka et al. have demonstrated that deletion of t-PA
currently apply to the use of rt-PA in selected patients with prevents the excitotoxic generation of neuron injury (in the
ischemic stroke less than 3 hours after symptom onset as well hippocampus).49 In contrast, it had been suggested that rt-PA
as other approved clinical indications for the use of rt-PA, (alteplase) promotes neuron injury during ischemic stroke.
u-PA, or SK. Somewhat different selection criteria were used Wang et al. reported that injury volumes were significantly
for the 4.5 hour entry window in the subsequent randomized smaller in t-PA−/− mice (129/Sv and C57 Bl/6 backgrounds)
placebo-controlled study ECASS III.9 subject to transient ischemia, compared with wild-type
companions.119 In both strains infusion of human rt-PA at 0.9–
1.0 mg/kg increased infarction volumes.119 High t-PA doses (10
PLASMINOGEN ACTIVATORS IN CEREBRAL TISSUE mg/kg) increase MMP-9 levels in brain.120 The increase in injury
Although current clinical focus is on the use of PAs as thera- volume has been attributed directly to neuron injury by the
peutic agents for vascular reperfusion, cerebral tissue also gen- ability of rt-PA (alteplase) to potentiate N-methyl-d-aspartate
erates and uses PAs. PA activity has been associated with brain (NMDA) receptor signaling,121 evidence of direct proteolytic
tissue development, vascular remodeling, cell migration, neu- cleavage of the NR1 subunit of that receptor by rt-PA,121
ron viability, tumor development, and vascular invasion in the or t-PA expression in the hippocampus and amygdala.117
central nervous system. However, the pathways involved are Concerns have been raised that the proteolytic activity could be
still under study. associated with the serum in which cells were grown and/or the
In normal cerebral tissue, t-PA antigen is expressed by suprapharmacologic concentrations of human rt-PA used in the
microvessels similar in size to those of the vasa vasorum of mouse preparations (e.g., 10 mg/kg). Alternatively, murine cells
the aorta.21 Expression of PA activity has been reported in could be more sensitive to the human rt-PA, as species controls
non-ischemic tissues of mice, spontaneously hypertensive and have not been reported. The role(s) and the mechanisms of PA
Wistar-Kyoto rats, and primates.104 Sappino et al. described action in individual reports are often difficult to define, in part
the localization of t-PA and protease nexin (PN)-1 in the because the methodologies and the settings of experimental
adult mouse brain,105 while u-PA mRNA has been shown to testing have often not been fully described. In another setting,
be expressed in the adult brain.50 Tissue-type PA and u-PA modulation of the NR2B component of the NMDA receptor
are secreted by endothelial cells, neurons, astrocytes, and by rt-PA (alteplase, 100 μg/mL) increased ethanol-withdrawal
microglia in vivo or in vitro.46-51 u-PA mRNA is expressed in seizures in mice (C57 Bl/6 background).117
Further technical concerns have appeared. Yi et al. have thrombin,24,146 (iii) cathepsin-L,135 and (iv) heparanase.28,135
demonstrated that reduction in infarction volume in an middle Their individual involvement in brain injury is now
cerebral artery (MCA) occlusion model in the Sprague-Dawley certain.135,137,141,143,147-152 However, no study to date has
rat occurred when rt-PA (alteplase), the S478A mutant of shown a clear causal relationship; their involvement has been
t-PA, or denatured rt-PA were given by intracerebroventricular mostly circumstantial.
injection compared to control.122 It has also been noted that In the setting of experimental focal ischemia, it is not
low-molecular-weight contaminants (potentially L-arginine) known whether the proteases are released in active form
in commercial preparations of human rt-PA (alteplase) could and degrade microvessel ECM directly or are activated from
cause cell toxicity, and similarly contaminants in plasmin the inactive precursors released from cellular or matrix
preparations could stimulate neuron Ca+2 flux.123 Those sources. The inactive gelatinase pro-MMP-2 is released from
studies suggest that non-fibrinolytic off-target effects may vascular endothelium and pro-MMP-9 is released from PMN
be responsible for the increased injury observed with high leukocytes, monocytes, microglia, pericytes, and other cells
concentrations of human rt-PA in murine model systems. during inflammation. pro-MMP-2 is activated by membrane
How these observations relate to ischemic stroke is uncertain. bound MT1- and MT3-MMP, plasmin, and other proteases.
Many studies have not taken into account the importance Considerable experimental work employing focal ischemia
of species differences with regard to coagulation system models has focused on the active gelatinases.120,145,153 In the
activation. Korninger et al. have demonstrated that for primate MMP-2 antigen is found throughout the ischemic core
thrombus lysis, non-human systems require a 10-fold higher acutely,24 but only the inactive pro-MMP-2 form is observed by
concentration of human rt-PA than human-relevant thrombus high-sensitivity zymography.141 Less than 1% of total MMP-2
lysis systems ex vivo.124 This applies to vascular thrombosis. in ischemic basal ganglia appears to be active.141
Often, with non-thromboembolic models of MCA occlusion, It has been suggested that hemorrhage observed with rt-PA
the use of rt-PA has been associated with an increase in use in murine focal cerebral ischemia models is caused by
infarction volume. the generation of MMP-9 by rt-PA in the ischemic tissue.154
In the non-human primate no change in infarction volume Data to support this claim have been developed in murine
was observed at several doses of rt-PA (alteplase or duteplase) models;120,131,155-157 however, recently this notion has been
infused intravenously.125 Furthermore, Overgaard et al. had countered in another model system.157 This question remains
demonstrated significant reduction in infarction volume with unresolved and may depend upon technical issues.11
rt-PA at 10 mg/kg following ischemia in rat models of MCA Technical issues confound confirmation of matrix-cleaving
occlusion.126-128 Those observations suggest that in rat strains activity in tissue derived from ischemia models, including (i)
thrombus lysis is feasible resulting in reduction in infarction retention of plasma from unperfused brain samples, (ii) the
volume, while in mouse strains the rt-PA concentrations presence of hemorrhage, (iii) activation of samples during
achieved are toxic. protease extraction, (iv) inconsistencies in assigning molecular
In culture, injury to cells occurs consistently at masses to active forms, and (v) the absence of sufficient details
suprapharmacologic concentrations of rt-PA (del Zoppo GJ, in the preparation methods to be certain. Species differences
Gu Y-H, personal observation; and,129-131). Furthermore, there in protease expression during focal ischemia between primate
is no clear indication that rt-PA results in a worsening of the (pro-MMP-2) and mouse strains (pro-MMP-9) accentuate
injury territories in human stroke patients, independent of this problem.135,149 Gene deletion studies provide only an
hemorrhage, who are treated appropriately. indirect impression of the possible impact of specific matrix
Therefore, further investigation of the interactions of the proteases on evolving ischemic injury,120,149,150,153,158 and are
PA system and its substrates within the neurovascular unit is subject to significant limitations. These include compensatory
required to understand better the roles of this system. changes during development, several MMP-9−/− constructs
with different phenotypes, failure to identify other protease
Plasminogen Activators and Cerebral Microvessel families, unknown cell sources, and the appearance of similar
injury phenotypes with different gene constructs (e.g., within
Integrity the PA family, for instance).159 These concerns argue strongly
A clinically relevant notion proposed is that rt-PA can increase for identifying the exact enzyme pathways and their cell
cerebral vascular permeability and the risk of hemorrhage by sources in the CNS during injury.
increasing the vascular matrix degradation. Work has focused
on the matrix metalloproteinases (MMPs) and other proteases Plasminogen Activators in Experimental Cerebral
with matrix protein degrading activities.
Loss of the basal lamina matrix28,132-137 and rapid
Ischemia
reorganization of microvessel endothelial cell and Focal cerebral ischemia rapidly increases the endogenous
astrocyte matrix adhesion receptors occurs during focal expression of u-PA and PAI-1 within striatal tissue of the pri-
ischemia.28,135,138-140 Heo et al. first described the acute mate.25,141 Endogenous t-PA decreases transiently as it binds
appearance of pro-MMP-2 in ischemic tissue, and the PAI-1, but otherwise does not change. u-PA is an indirect activa-
association of pro-MMP-9 with hemorrhagic transformation tor of pro-MMP-2, which is also generated early following MCA
in the primate.141 Rosenberg et al. explored the role(s) that occlusion.24 It has been postulated that loss of basal lamina
gelatinases play in permeability barrier loss, neuron injury, and integrity contributes to hemorrhagic transformation of the
the evolution of infarction.142-145 Within the ECM, collagen evolving infarction.28,140 Whether exogenous PAs contribute to
IV, laminin, and fibronectin decrease significantly during focal the loss in microvessel integrity in this manner is under study.
ischemia.28,140 A limited number of experimental studies have tested the
A plausible explanation for the cerebral vascular ECM ability of PAs to increase arterial recanalization. Improved
changes seen following MCA occlusion is the acute appearance clinical (behavioral and/or neurologic) outcomes have been
of active matrix-cleaving proteases in the ischemic territory. reported in rodent models of focal cerebral ischemia treated
Four families of matrix-altering enzymes acutely increase with PAs (mostly rt-PA) very soon after thromboembolism.
following MCA occlusion in the non-human primate: (i) Early infusion of rt-PA in a rabbit multiple-thromboembolism
(pro-)MMP-2 and (pro-)MMP-9,141 and the activation system model demonstrated significant improvement in clinical
for pro-MMP-2,24 (ii) serine proteases, including u-PA and outcome in comparison with untreated controls.160 The use
of rt-PA with putative inhibitors of PMN leukocyte adhesion the co-administration of heparin,162 and was confirmed
supports this notion, although differences among rt-PA cohorts in a follow-on open phase III study.165 Many, but not all, 2
were observed in various experimental sets. In an rt-PA dose-rate subjects in those studies in whom early recanalization
study in a nonembolic non-human primate stroke model, no was documented experienced clinical improvement. Lack
significant difference in motor-weighted neurologic outcome of clinical improvement despite recanalization may be
was observed, compared with controls.125 However, another influenced by longer times to reperfusion, poor perfusion,
study demonstrated a significant reduction in infarction volume and/or poor collateralization although this issue is
after reperfusion of the MCA territory in one model.161 unproven.
Mechanical disruption with either catheter-type devices
PLASMINOGEN ACTIVATORS AND RECANALIZATION or ultrasonography has been employed to enhance
recanalization in limited clinical series. High ultrasound
IN ISCHEMIC STROKE frequencies have been shown to alter the properties of
Experimental and clinical studies indicate that timely resto- the fibrin network to increase transport of rt-PA into the
ration of blood flow to the ischemic cerebral parenchyma is structure, increase thrombus penetration,166 increase rt-PA
required for improved clinical outcome. The substrate and binding to fibrin,167 and to increase flow through fibrin gel
condition requirements of PAs have supported their poten- in in vitro systems. Fibrin disaggregation can also occur. It
tial use in cerebrovascular ischemia. Angiographic studies has been postulated that such high frequencies will also
have provided valuable information about the anatomy of the cause injury to the brain parenchyma and to the vessel wall
vasculature, the magnitude of thrombus burden, and the suc- structure.
cess of recanalization with PAs.3,162-164 u-PA and rt-PA appear
to contribute to arterial reperfusion as anticipated by their
known activities (Table 2.3).
Endovascular Interventions
Quite recently, interest has turned to the subpopulations
(∼25%) of stroke patients with proximal MCA, internal carotid
Intervention With Plasminogen Activators artery (ICA), or carotid “T” occlusions with a low likelihood of
The frequency of successful arterial recanalization appears to be acute recanalization by rt-PA.3 Direct intra-arterial thrombus
greater when the PA is administered by the intra-arterial route retrieval has been shown to effect recanalization and in some
within the brain-supplying arteries to the ischemic territory cases significant clinical improvement.168-174 Among these
than by intravenous delivery (see Table 2.3). That observation is studies, intravenous thrombolysis has been employed as the
consistent with the notion that enhanced efficacy may be due to trial comparator in many,168-175 and/or has been employed as
higher local concentrations of the PA at the thrombus surface. an adjunct to the endovascular procedure.168-175 While current
However, this has not been shown in the clinical setting. practice is evolving, the benefit of PAs as adjuncts to endovascu-
Only a handful of studies have prospectively compared lar treatment is not proven at this time.
recanalization rates in PA-treated patients with a matched
control group.4,162,165 In those studies, recanalization PLASMINOGEN ACTIVATORS AND CEREBRAL
was significantly greater in patients receiving the PA
for angiographically proven occlusion of the MCA. In
HEMORRHAGE IN ISCHEMIC STROKE
a phase II study of recombinant scu-PA (pro-UK), the Acute rt-PA administration in ischemic stroke can be com-
recanalization frequency was significantly improved by plicated by the development of symptomatic parenchymal
TABLE 2.3 Plasminogen Activators in Acute Ischemic Stroke: Carotid Territory.

Total Symptomatic
Recanalization Hemorrhage Hemorrhage
Study Year Agent Patients (n) Δ (T-0)a (hours) (%) (%) (%)
Intra-arterial Delivery
del Zoppo et a.l1 1988 SK/u-PA 20 <24 90.0 20.0 0.0
Mori et al.2 1988 u-PA 22 <7 45.5 18.2 9.1
Matsumoto et al.181 1991 u-PA 39 <24 59.0 33.3 —
PROACT162 1997 scu-PA/h 26 <6 57.7 42.3 15.4
C/h 14 <6 14.3 7.1 7.1
Gönner et al.182 1998 u-PA 33 <6 58.0 21.2 6.1
PROACT II165 1999 scu-PA/h 121 <6 65.7 35.2 10.2
-/h (IV) 59 <6 18.0 13.0 1.8
Intravenous Delivery
Yamaguchi183 1991 rt-PA 58 <6 43.1 20.7 —
del Zoppo et al.3 1992 rt-PA 93 (104)b <8 34.4 30.8 9.6
Mori et al.4 1992 rt-PA 19 <6 47.4 52.6 —
C 12 16.7 41.7 —
von Kummer and 1992 rt-PA 32 <6 53.1 37.5 9.4
Hacke184
Yamaguchi et al.5 1993 rt-PA 47 (51) <6 21.3 47.1 7.8
C 46 (47) 4.4 46.8 10.6
aTime from symptom onset to treatment.
bIntention to treat.
C, Control or placebo; h, heparin; IV, intravenous; rt-PA, recombinant tissue plasminogen activator; scu-PA, single-chain urokinase plasminogen
activator; SK, streptokinase; u-PA, urokinase-type plasminogen activator.
hemorrhage. A number of randomized studies have docu- The interactions between PAs and the evolving ischemic
mented the increased risk of symptomatic hemorrhagic trans- cerebral tissue are still incompletely understood. However,
formation associated with intravenous infusion of PAs.6-8 it is clear that (i) dissolution of vascular thrombi in the
Rates of symptomatic hemorrhage for hemispheric stroke in CNS can be achieved acutely with PAs, (ii) rt-PA delivered
the cerebral artery territory range from 3.3% to 9.6% in this acutely can cause significant clinical improvement, and (iii)
setting.3,7-9,162 In addition, the development of symptomatic increased intracerebral hemorrhagic risk accompanies PA
hemorrhage in rt-PA-treated patients contributed to mortality use in this setting. Vascular injury is a necessary component
in properly controlled trials, including the National Institute of hemorrhage both with ischemic stroke and the use of
of Neurological Disorders and Stroke (NINDS) study,6-8 and antithrombotic agents, including PAs. Current unknowns
ECASS-3.9 Overall, however, those well-designed trials have regarding the generation of intracerebral hemorrhage include
shown significant neurologic benefit from the use of systemic (i) whether the PA (e.g., rt-PA) can cause vascular matrix
rt-PA. dissolution, (ii) whether, where, and how rt-PA can stimulate
Clinical features that have been associated with higher matrix protease generation, (iii) the timing of these events
intracerebral hemorrhage risk in the setting of PA use in the clinical setting, and (iv) non-vascular contributors. A
include advancing age and signs of early infarction on initial growing understanding of non-vascular PA effects covers brain
cranial computed tomography. Early signs of infarction may development, individual cerebral cell activities, and neuron
reflect otherwise undetectable injury to the matrix of the injury, specifically. Also, work proceeds to understand non-
microvascular bed.6-8 Increased time to treatment, low body vascular roles of coagulation factors in the CNS.
mass (higher relative rt-PA dose), diastolic hypertension, older The outcomes of these studies require the high-quality
age, early signs of ischemia, and the use of rt-PA are associated application of the scientific method, as in the study of the
with the risk of intracerebral hemorrhage.3,176,177 From recent thrombus pathways.
perfusion-weighted imaging (PWI) and diffusion-weighted
imaging (DWI) studies subgroups of patients receiving rt-PA The complete reference list is available at
have been identified for whom the risk of hemorrhage is www.expertconsult.inkling.com.
increased.178,179 This accords with evidence that the depth
and duration of focal ischemia is a contributor to the ultimate
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113. Dent MA, Sumi Y, Morris RJ, et al. Urokinase-type plasmino- induces active proteases that degrade microvascular matrix.
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ing process outgrowth in developing rat brain. Eur J Neurosci. 136. Milner R, Hung S, Wang X, et al. Responses of endothelial cell
1993;5:633–647. and astrocyte matrix-integrin receptors to ischemia mimic those
114. Lahtinen L, Huusko N, Myohanen H, et al. Expression of uro- observed in the neurovascular unit. Stroke. 2008;39:191–197.
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anesthetized baboon reduces brain damage following middle
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Fig. 77
Fig. 78
Fig. 79
Timber Trucks.—Timber trucks (fig. 78) are used for carrying

timber balks, iron girders, &c. They are usually 3 or 4 feet in length,
with a width of about 24 inches and a height of 22 inches. They are
made sufficiently strong to carry 6,000 lbs.
Fig. 80
Sack Trucks.—Sack trucks (fig. 79) are constructed of hard wood,

with fittings of wrought and cast iron and steel axles. They vary in
length up to 4 feet 4 inches, and the foot iron projects from 6 to 9
inches.
Crates, as shown on fig. 80, are constructed of oak with iron

bindings. They will carry a weight of 1,500 lbs. and hold 350 bricks.
They can be filled in the builder’s yard and transferred direct to the
working platform without disturbing the material, which, for saving
time, is often of great advantage. The absence of sides facilitates
loading, but on the other hand, if any materials, say bricks, are put in
loosely, they may fall out during transference, causing danger to the
workmen.
When used to carry rubble work which cannot be stacked, it is
better that sides should be fitted.
When used to carry a roll of lead, a stay should be placed, as
shown by dotted line on figure. This will prevent the crate buckling at
the bottom.
These crates are sometimes fitted with wheels to run on rails.
Ashlar Shears.—The shears (figs. 81 and 82) are useful for lifting
dressed work, the points fitting into small holes which have been cut
out for their reception in the ends or sides of the stone. There is
danger in their use if the points drag upwards and outwards. To
prevent this as far as possible, the holes should be cut low, but not
below the centre of gravity of the stone, or else it would turn over
and perhaps fall.
Fig. 81
Fig. 82
Fig. 82 is a bad form of shears, as, owing to the sharp curve, the
points can only clutch near the top of the stone.
Fig. 83
Fig. 84
Fig. 85
Stone Clips and Slings.—The clips (fig. 83) are useful for lifting
stone slabs. The hook rings slide along the chain, and the clips are
therefore adjustable to any stone not exceeding in width half the total
length of the chain.
The chain slings have a ring at one end and a hook at the other,
and are useful for a similar purpose; but the manner of slinging
depends upon the thickness of the stone. For instance fig. 84, known
as jack slinging, answers well with a slab, say, of over 6 inches in
depth, but a thinner slab lifted in this way would be liable to break in
the middle. If, however, the chain were placed as fig. 85, and which
is known as figure-eight slinging, this risk would be removed.
Stone Lewises.—Lewises may be divided into two classes,

curved and straight-sided.
Fig. 86 shows the first, and fig. 87 the second class.
Fig. 86
Fig. 87
Fig. 88
Fig. 89
The first class is the inferior, as, when fitted into the stone, any jerk
of the supporting chain would act at the points a as a blow on the
stone, thus increasing any tendency to fracture.
The hole for the reception of the lewis is cut, so that a line down its
centre would run across the centre of gravity of the stone; and it is
made as deep as may be required by the weight and hardness of the
material.
The side or splayed pieces of the lewis shown on fig. 87 are fitted
first, and the centre piece last. A bolt through the top fixes their
position and also the ring by which it is to be lifted.
Care should be taken that the sides of the second class of lewis fit
accurately, for if they fit as fig. 88 they may flush the edge and break
out, or if they fit as fig. 89 the risk of fracture, as in the first class,
presents itself. In any case there is always a danger of mishaps
occurring, especially where the stone is not free from vents.
Their use with safety can only be left to the judgment of the
mason.
Stone Cramps.—The cramps tighten on the stone by means of a

screw thread, as shown on fig. 90.
Fig. 90
They are useful for lifting light finished work. Packing should be
placed at aa to prevent damage.
The ring by which it is slung is movable to preserve equilibrium.
Wire and Chain Scaffold Lashings.—Wire rope scaffold lashings

are now to be obtained for use in place of fibre cords. They are
made in lengths from 12 to 18 feet, and are fitted at one end with an
eyelet. In fixing, they commence with a clove hitch, the knot being
continued as with a fibre cord until near the end, when the lash is
taken through the eyelet (see fig. 91) and finished with jamming
turns.
Fig. 91
It is claimed that no wedges are required for tightening wire rope
lashings, as they do not shrink or swell; on the other hand, owing to
their small circumference, they cannot be pulled very tight by the
workmen, and it is questionable if they would bear being twisted
round the scaffolder’s hammer without injury.
Accidents also might happen if the poles shrank at all after being
fixed.
Tests have been made from which it has been estimated that each
lashing will carry a direct load of 6 tons.
A chain and bracket arrangement for tying ledgers to standards is
shown on fig. 92. It is easily and rapidly adjusted, and is tightened by
means of screw nuts at a and b.
Fig. 92
Permanent injury might, however, be done to the standards by the
cutting in of the brackets when screwed up, especially after regular
use. The possible loss of the parts and their weight and consequent
disadvantage in transport are against their general adoption.
Tightening Screws.—Tightening screws or coupling links (fig. 93)

are fixed in the length of chain that connects the guys of the Scotch
cranes to the base of the queen legs.
Fig. 93
Under the continuous vibration of the scaffold they run down and
release the chain considerably.
This can be prevented to some extent by inserting a piece of wood
as shown on fig. 93, and tying its other end to a rigid member of the
leg. In any case the chain requires frequent examination, and, if
necessary, retightening.
Rollers.—Rollers (fig. 94) are used for moving heavy material

along a smooth surface.
Fig. 94
Pegs should be fixed at their ends, as shown on fig. 94, to form a
handle by which they can be moved when under the material without
danger to the workman’s hands, or better still, they should always be
longer than the load is wide.
Levers.—Levers of ash, fitted with iron shoes, as fig. 95, are used
to prise heavy material off the ground, to facilitate removal on rollers
or otherwise. In this case the lever acts as one of the first order. By
connecting the weight to the rings a and b it can be used as a lever
of the second or the third order.
Fig. 95
Dog Irons.—Dog irons (fig. 96) are bars of flat or round wrought
iron, turned up at the ends, which are pointed. If both ends point in
the same plane they are termed ‘male,’ if otherwise ‘female.’ The
shank is about 12 inches long. Besides holding the timbers together,
they exert a certain power of compression upon the joint they
enclose. This is gained by hammering the inside of the spikes to a
splay, leaving the outside to form a right angle with the shank.
Fig. 96
Fig. 97
Fig. 98
Fig. 99
They may be described as inferior straps, and their holding power
is from 600 to 900 lbs. per inch in length of spikes, as deduced from
experiments by Captain Fraser, R.E. Dog irons have the advantage
that their use does not injure the timber to any extent, and so
depreciate its value. Dogs are fixed according to the joint to be
enclosed. If the joint is at right angles to the run of the timbers, they
are fixed as fig. 97.
If the timbers are at right angles they are fixed as fig. 98.
If both these joints occur the irons are placed as fig. 99.
They should be fixed on both sides of the timbers joined.
Bolts.—Bolts (fig. 100) are of wrought iron, and their different

parts should be in the following proportions:
Thickness of nut = 1 diameter of bolt
Thickness of head = 3⁄
4 diameter of bolt
Diameter of head or nut over sides = 13⁄4 diameter of bolt
Size of square washer for fir = 31⁄2 diameter of bolt
Size of square washer for oak = 21⁄2 diameter of bolt
Thickness of washer = 1⁄3 diameter of bolt
There are disadvantages to the use of bolts in scaffolding. For
instance, the beams are weakened by the cutting of the fibres; and, if
the timber shrinks, the bolts may become loose. On the other hand,
they can be easily tightened after the framing has settled into
position.
Fig. 100
Their strength depends upon the quality of the iron, but varies
between 20 and 25 tons of tensile strain per square inch of the
smallest sectional area (Anderson).
Washers are used to prevent the nut sinking into the wood when
tightened, and are equally necessary, but not always seen, under the
head. They should not be cut into the under side of timbers
subjected to a cross strain, as the cutting of any fibres is a source of
weakness. Bolts are used where dogs and spikes are of insufficient
length or holding power.
Straps.—Straps are wrought-iron bands of different designs, and
are used to form a connection between timbers. Branched straps
(fig. 101) are used to strengthen angle joints. They are usually fixed
in pairs, and being fastened on the surface of the timbers they have
an advantage over bolts in that they do not cut into the material. If
the timbers settle at all, the straps may become subject to cross
strains.
Fig. 101
Wire Ropes.—Wire ropes are now in general use for heavy

purposes.
They are stranded and laid similarly to fibre ropes. They should be
of mild plough steel wire. The number of wires in a strand varies
from 12 to 37, and the number of strands is usually 6.
The following table gives the breaking strains of the ropes
according to their circumference, and the least diameter of barrel
and sheaves around which they may be worked at slow speeds.
In the table (p. 110) the diameters of the pulleys, &c. may be
slightly reduced for the more flexible ropes, but better results can
always be gained by using pulleys and sheaves of larger diameters.
A few points on the working of these ropes may be useful.
To remove a kink throw a turn out; it cannot be taken out by strain.
The ropes should be ungalvanised, and kept greased with any oil
that does not contain acid or alkali.
A rope running in a V groove has a short life.
A rope that is allowed to ride, chafe on its own part or to overlap,
will be almost immediately crippled.
The sign of an overloaded rope is excessive stretching.
Extra Flexible Special Extra

Flexible Rope. Rope. Flexible Rope.
6 strands, each 12 wires 6 strands, each 6 strands, each
24 wires 37 wires
Diam. of barrel
or sheave round
Size Guaranteed Guaranteed Guaranteed
which it may be
Circum. Breaking Strain Breaking Strain Breaking Strain
worked at a
slow speed
Inches Inches Tons Tons Tons
11⁄2 9 4 71⁄2 8
13⁄4 101⁄2 51⁄2 93⁄4 11
2 12 7 13 141⁄2
21⁄4 131⁄2 9 161⁄4 171⁄2
21⁄2 15 12 201⁄2 22
23⁄4 161⁄2 15 24 261⁄2
3 18 18 281⁄2 321⁄4
31⁄4 191⁄2 22 34 371⁄2
31⁄2 21 26 39 43
33⁄4 221⁄2 29 451⁄2 50
4 24 33 511⁄2 561⁄2
41⁄4 251⁄2 36 59 65
41⁄2 27 39 65 701⁄2
43⁄4 74 79
5 88
821⁄2
(Bullivant & Co. Ltd.)
Chains.—The strength of a chain depends upon the diameter and

quality of the iron of which the links are formed, governed by good
workmanship. The safe load for working can be calculated
approximately by the following method:—
Square the number of eighths of an inch which are contained in
the diameter of the iron of which the link is made, and strike off the
last figure as a decimal.
For example, where the iron is of 1⁄2-inch diameter, square the
number of 1⁄8 in the diameter, i.e. 4 × 4 = 16 = 1·6 tons.
Generally before leaving the factory, chains are tested up to half
the weight they should break under, and which is about double the
load they are intended to carry in practice. This test cannot be relied
upon for the future working of the chain, as any stretching of a link,
which would ultimately result in fracture, would probably not be
apparent under it. The links should therefore be examined
periodically for any appearance of weakness or stretching.
A stretched link should at once be cut out, as it may break with
much less load than that which it was first tested to carry. A chain
during use also deteriorates in quality, and it is a good rule to have it
periodically annealed.
The links should then be re-tested up to double the weight they
are again required to carry.
A reliable chain is made of the treble best Staffordshire scrap iron.
Crane and pulley chains should be made with the shortest link
possible, according to the diameter of the iron used, as there is a
considerable leverage exerted on a long link when running round a
pulley, more especially where the diameter of the pulley is small.
A Slater’s Truss.—Slaters’ trusses (fig. 102) are used in pairs by

slaters and tilers when laying their material. Boards are laid across
the trusses and form an effective platform on which the workman can
kneel without damage to that part of the roof already covered. They
are slung from the ridge or other suitable fixture, and can be pulled
higher as the work proceeds. An old sack or similar material laid
under the truss will prevent any possible damage during the
progress of the work.
Fig. 102
Duck Runs.—Duck runs (fig. 103) are laid upon slate and tile
roofs to give footing to, and to prevent damage being done by, the
workmen.
They should be firmly fixed, either by slinging from the ridge or
butting against a solid resistance.
Fig. 103
Mortar Boards.—A mortar board is used as a bed on which

mortar can be mixed or deposited. It is roughly made of four or five
9-inch boards each 3 or 4 feet long, framed together on the under
side. Their use prevents the new mortar coming in contact with the
scaffold boards with an injurious effect.
Wedges.—A wedge is a movable, double-inclined plane, used for

separating bodies, and by this means, tightening any connections
between the bodies they tend to separate. For scaffolding purposes
they should be of oak, or other wood which gives considerable
resistance to pressure across the grain. For tightening cordage

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Stroke: Pathophysiology, Diagnosis,

And Management 7th Edition James

Stroke: Pathophysiology, Diagnosis, And Management 7e

Stroke Pathophysiology Diagnosis and Management 5th

Cambridge IGCSE and O Level History Workbook 2C - Depth

Anemia with Online Resource Pathophysiology Diagnosis

Brain Ischemic Stroke From Diagnosis to Treatment 1st

Transient ischemic attack and stroke diagnosis

Diagnosis and Management of Cholangiocarcinoma A

Primary Mathematics 3A Hoerst

JAMES C. GROTTA, MD ENG H. LO, PhD

LAWRENCE K.S. WONG, MD

STROKE: PATHOPHYSIOLOGY, DIAGNOSIS, AND MANAGEMENT:  ISBN: 978-0-323-69424-7

Library of Congress Control Number: 2020952390

Senior Acquisitions Editor: Melanie Tucker

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Harold P. Adams Jr., MD Hugo J. Aparicio, MD, MPH Hakan Ay, MD

Spiros L. Blackburn, MD Louis R. Caplan, MD Greg Christorforids, MD

T. Michael De Silva, PhD Bruce H. Dobkin, MD Myriam Fornage, PhD

David M. Greer, MD Glen C. Jickling, MD Charles E. Kircher, MD

Santiago Ortega-Gutiérrez, MD Miguel A. Perez-Pinzon, PhD Christina P. Rossitto, BS

Ronald J. Sattenberg, MD Omar K. Siddiqi, MD Hiroo Takayama, MD, PhD

Babette B. Weksler, MD Shadi Yaghi, MD John H. Zhang, MD, PhD

SIZE OF TREATMENT EFFECT

Multiple that procedure or favor of treatment usefulness/efﬁcacy treatment is not useful/effective

BOX 1 Evidence Classifications ﻿

1 Cerebral Vascular Biology in Health and Disease

KEY POINTS collateral flow is thought to be important when blood flow in

Hypercholesterolemia Hypertension / ↑Ang II

Fig. 1.1. Schematic diagram summarizing cerebrovascular

Rho kinase AT1

BKCa KIR KV KATP

Smooth muscle cell

Ang II Perivascular macrophage

EXTRINSIC PATHWAY INTRINSIC PATHWAY

Xa IXa  VIIIa VIII

EXTRINSIC PATHWAY INTRINSIC PATHWAY

Ca2 XIIa Protein C

TABLE 2.1 Plasminogen Activators.

TABLE 2.2 Plasminogen Activator Inhibitors.

In the circulation, α2-antiplasmin is the primary inhibitor

TABLE 2.3 Plasminogen Activators in Acute Ischemic Stroke: Carotid Territory.

Timber Trucks.—Timber trucks (fig. 78) are used for carrying

Sack Trucks.—Sack trucks (fig. 79) are constructed of hard wood,

Crates, as shown on fig. 80, are constructed of oak with iron

Stone Lewises.—Lewises may be divided into two classes,

Stone Cramps.—The cramps tighten on the stone by means of a

Wire and Chain Scaffold Lashings.—Wire rope scaffold lashings

Tightening Screws.—Tightening screws or coupling links (fig. 93)

Rollers.—Rollers (fig. 94) are used for moving heavy material

Bolts.—Bolts (fig. 100) are of wrought iron, and their different

Wire Ropes.—Wire ropes are now in general use for heavy

Extra Flexible Special Extra

Chains.—The strength of a chain depends upon the diameter and

A Slater’s Truss.—Slaters’ trusses (fig. 102) are used in pairs by

Mortar Boards.—A mortar board is used as a bed on which

Wedges.—A wedge is a movable, double-inclined plane, used for

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STROKE: PATHOPHYSIOLOGY, DIAGNOSIS, AND MANAGEMENT: ISBN: 978-0-323-69424-7

BOX 1 Evidence Classifications

Xa IXa VIIIa VIII

Ca2 XIIa Protein C