DENEYSEL İSKEMİ REPERFÜZYON MODELİNDE GEÇ TROMBOLİTİK TEDAVİ ÖNCESİ MAGNEZYUM SÜLFATIN ETKİNLİĞİ

Öz

AMAÇ: İskemik inmenin primer tedavisi oklüde vasküler yapıların rekanalizasyonudur. Bunun için kullanılan medikal tedavi doku plazminojen aktivatörü (tPA)’dür. Endikasyon süresi intravenöz ilk 4,5 saat ile sınırlı olduğundan, hastaların büyük kısmı bu tedaviye ulaşamamaktadır. Bu yüzden geç trombolitik tedavi öncesi magnezyum sülfat (MgSO₄)’ın etkinliğinin değerlendirildiği deneysel bir çalışma planlanmıştır.

GEREÇ VE YÖNTEM: 52 sıçan rastgele altı gruba ayrıldı. 1. grup, kontrol grubuydu ve herhangi bir işlem yapılmadı. 2. grup, sham grubuydu ve paratrakeal kas diseksiyonu ile karotis artere ulaşıldı. 3. gruba, karotis klemp oklüzyou sonrası 345. dakikada tPA (10mg/kg) başlandı. 4. gruba, oklüzyon sonrası 345. dakikada tPA, 120. dakikada MgSO₄ (90 mg/kg) başlandı. 5. gruba, 300. dakikada MgSO₄, 345. dakikada tPA başlandı. 6. gruba, 120. ve 300. dakikalarda MgSO₄, 345. dakikada tPA başlandı. Tüm gruplarda 360. dakikada reperfüzyon sağlandı. 24 saat sonra tüm sıçanların nörolojik muayeneleri yapıldı. Kan ve beyin dokusu örnekleri alındı. Kandan nöron spesifik enolaz (NSE) ve iskemi modifiye albümin (IMA) çalışıldı. Beyin dokusu Hematoksilen Eozin ve krezil viyole ile boyandı. Dejenere piramidal nöronlar değerlendirildi.

BULGULAR: Grup 3’de mortalite oranı %40, grup 4’de %22,2, grup 5’de %30 ve grup 6’da %11,11 idi. Grup 4’te %17,8, grup 5’te %10 ve grup 6’da %28,9 oranında mortalitede azalma vardı. Grup 6’nın fonksiyonel dizabilitesi ve dejenere nöronal yüzdesi en azdı (p=0,04; p=0,005). NSE seviyesi düşüklüğü fonksiyonel iyilik durumu ve tedavi etkinliği ile ilişkiliydi (r=0,54; p=0,005). IMA seviyesi arttıkça fonksiyonel dizabilite artmaktaydı (p=0,003; r=0,47). Ancak MgSO₄ verilen gruplar arasında IMA seviyelerinde farklılık yoktu (p=0,06).

SONUÇ: Geç trombolitik tedavi öncesi, MgSO₄’ın erken başlanması ve doz tekrarı ile daha iyi fonksiyonel ve histopatolojik sonuçlar elde edilmektedir. NSE ise tedavi etkinliği ve özürlülük durumu ile ilişkili bir biyobelirteçtir.

Anahtar Kelimeler

• Reperfüzyon,geç trombolitik,magnezyum sülfat,biyobelirteç

THE EFFICACY OF MAGNESIUM SULFATE BEFORE DELAYED THROMBOLYTIC TREATMENT IN EXPERIMENTAL MODEL OF ISCHEMIA REPERFUSION

Öz

OBJECTIVE: The primary treatment of ischemic stroke is recanalization of occluded vascular structure. The treatment for that is tissue plasminogen activator (tPA). Since the indication period is limited to the first 4.5 hours, the majority of patients can not reach this intravenous treatment. Therefore an experimental study was planned to evaluate the efficacy of magnesium sulfate (MgSO4) before delayed thrombolytic therapy.

MATERIAL AND METHODS: 52 rats were randomly divided to six groups. Group 1 was the control group and no operation was performed. Group 2 was sham group and paratracheal muscles were dissected and carotid artery was reached. In group 3, carotid artery was occluded and tPA was started after 345 minutes. In group 4, tPA was started after 345 minutes and MgSO4 was started after 120 minutes. In group 5, MgSO4 was started after 300 minutes and tPA was started after 345 minutes. In group 6, MgSO4 was started after 120 and 300 minutes; After 345 minutes, tPA was started. All groups were reperfused after 360 minutes. After 24 hours, neurological examinations of all rats were performed. Blood and brain tissue specimens were taken. Neuron specific enolase (NSE) and ischemia modified albumin (IMA) were analyzed from blood. Brain tissue was stained with Hematoxylin Eosin and cresyl violet. Degenerated pyramidal neurons were evaluated.

RESULTS: The mortality rate was 40% in group 3, 22.2% in group 4, 30% in group 5 and 11.11% in group 6. Mortality reduction was detected 17.8% for group 4, 10% for group 5 and 28.9% for group 6. Functional disability and percentage of degenerated neurons was the least in group 6 (p=0.04). Decreased NSE level was associated with functional improvement and treatment efficacy (p=0.005; r=0.54). Functional disability correlated with increasing of IMA level (p=0.003; r=0.47). But there was no difference in IMA levels among MgSO4-treated groups (p=0.06).

CONCLUSIONS: Early onset and repetetive dose MgSO4 have the best functional and histopathologic results in delayed thrombolytic treatment. NSE is a biomarker that is associated with treatment efficacy and disability.

Anahtar Kelimeler

• Reperfusion injury,Intravenous thrombolysis,Magnesium sulfate

Kaynakça

1. Furlan AJ, Eyding D, Albers GW, et al. Dose escalation of desmoteplase for acute ischemic stroke (DEDAS): evidence of safety and efficacy 3 to 9 hours after stroke onset. Stroke 2006;37:1227-31.
2. Hacke W, Kaste M, Fieschi C, et al. İntravenous trombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. JAMA 1995;274:1017-59.
3. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008;359:1317-29.
4. Gursoy-Ozdemir Y, Can A, Dalkara T. Reperfusion-induced oxidative/nitrative injury to neurovascular unit after focal cerebral ischemia. Stroke 2004;35:1449-53.
5. Yang Y, Li Q, Ahmad F, Shuaib A. Survival and histological evaluation of therapeutic window of post- ischemia treatment with magnesium sulfate in embolic stroke model of rat. Neurosci Lett 2000;285:119-22.
6. Muir KW, Lees KR. Dose optimization of intravenous magnesium sulphate after acute stroke. Stroke 1998;29:918-23.
7. Jauch EC, Lindsell C, Broderick J, Fagan SC, Tilley BC, Levine SR. Association of serial biochemical markers with acute ischemic stroke: the national institute of neurological disorders and stroke recombinant tissue plasminogen activator stroke study. Stroke 2006;37:2508-13.
8. Longa EZ, Weinstein PR, Carlson S, Cummins R. Reversible middle cerebral artery occlusion without craniectomy in rats. Stroke 1989;20:84-91.

9. Liu W, Hendren J, Qin XJ, Liu KJ. Normobaric hyperoxia reduces the neurovascular complications associated with delayed tissue plasminogen activator treatment in a rat model of focal cerebral ischemia. Stroke 2009;40:2526-31.
10. Campbell K, Meloni BP, Knuckey NW. Combined magnesium and mild hypothermia (35 degrees C) treatment reduces infarct volumes after permanent middle cerebral artery occlusion in the rat at 2 and 4, but not 6 h. Brain Res 2008;1230:258-64.
11. Bederson JB, Pitts LH, Tsuji M, Nishimura MC, Davis RL, Bartkowski H. Rat middle cerebral artery occlusion: evaluation of the model and development of a neurologic examination. Stroke 1986;17:472-76.
12. Chen J, Li Y, Wang L, et al. Therapeutic benefit of intravenous administration of bone marrow stromal cells after cerebral ischemia in rats. Stroke 2001;32:1005-11.
13. Garman RH. Histology of the central nervous system. Toxicol Pathol 2011;39:22-35.
14. Blair JL, Warner DS, Todd MM. Effects of elevated plasma magnesium versus calcium on cerebral ischemic injury in rats. Stroke 1989;20:507-12.
15. Okawa M. Effects of magnesium sulfate on brain damage by complete global brain ischemia. Jap J Anesthesiol 1992;41:341-55.
16. Mori K, Yamamoto T, Nakao Y, et al. Novel neuroprotective effect of cisternal and intracerebral magnesium sulfate solution infusion on delayed cerebral death in rat hippocampal neurons after transient global ischemia. Brain Res 2012;1480:72-80.
17. Lin JY, Chung SY, Lin MC, Cheng FC. Effects of magnesium sulphate on energy metabolites and glutamate in the cortex during focal cerebral ischemia and reperfusion in the gerbil monitored by a dual-probe microdialysis technique. Life Sci 2002;71:803-11.
18. Wang LC, Huang CY, Wang HK, Wu MH, Tsai KJ. Magnesium sulfate and nimesulide have synergistic effects on rescuing brain damage after transient focaliIschemia. J Neurotrauma 2012;29:1518-29.
19. Lampl Y, Gilad R, Geva D, Eshel Y, Sadeh M. Intravenous magnesium sulphate in acute stroke: A randomised double blind study. Clin Neuropharmacol 2001;24:11-15.
20. Intravenous Magnesium Efficacy in Stroke (IMAGES) Study Investigators. Magnesium for acute stroke (Intravenous magnesium efficacy in stroke trial): randomised controlled trial. Lancet 2004;363:439-45.
21. Afshari D, Moradian N, Rezaei M. Evaluation of the intravenous magnesium sulfate effect in clinical improvement of patients with acute ischemic stroke. Clin Neurol Neurosurg 2013;115:400-4.
22. Pfefferkorn T, Rosenberg GA. Closure of the blood-brain barrier by matrix metalloproteinase inhibition reduces rtPa-mediated mortality in cerebral ischemia with delayed reperfusion. Stroke 2003;34:2025-30.
23. Schatlo B, Benning EC, Pluta RM, et al. Nitrite does not provide additional protection to thrombolysis in a rat model of stroke with delayed reperfusion. J Cereb Blood Flow Metab 2008;28:482-9.
24. Tan Z, Lucke Wold BP, Logsdon AF, et al. Bryostatin extends tPA time window to 6 h following middle cerebral artery occlusion in aged female rats. Eur J Pharmacol 2015;764:404-12.
25. Lu K, Xu X, Cui S, Wang F, Zhang B, Zhao Y. Serum neuron specific enolase level as a predictor of prognosis in acute ischemic stroke patients after intravenous thrombolysis. J Neurol Sci 2015;359:202-6.
26. Abbound H, Labreuche J, Meseguer E, et al. Ischemia modified albumin in acute stroke. Cerebrovasc Dis 2007;23:216-20.