Remote Ischemic Conditioning May Improve Disability and Cognition After Acute Ischemic Stroke: A Pilot Randomized Clinical Trial

Abstract

Background and Aim: Remote ischemic conditioning is a procedure purported to reduce the ischemic injury of an organ. This study aimed to explore the efficiency and safety of remote ischemic conditioning in patients with acute ischemic stroke. We hypothesized that remote ischemic conditioning administered from the first day of hospital admission would improve the infarct volume and clinical outcome at 180 days.Material and Methods: We performed a unicentric double-blind randomized controlled trial. We included all patients consecutively admitted to an Emergency Neurology Department with acute ischemic stroke, ineligible for reperfusion treatment, up to 24 hours from onset. All subjects were assigned to receive secondary stroke prevention treatment along with remote ischemic conditioning on the non-paretic upper limb during the first 5 days of hospitalization, twice daily - a blood pressure cuff placed around the arm was inflated to 20 mmHg above the systolic blood pressure (up to 180 mmHg) in the experimental group and 30 mmHg in the sham group. The primary outcome was the difference in infarct volume (measured on brain CT scan) at 180 days compared to baseline, whereas the secondary outcomes included differences in clinical scores (NIHSS, mRS, IADL, ADL) and cognitive/mood changes (MoCA, PHQ-9) at 180 days compared to baseline.Results: We enrolled 40 patients; the mean age was 65 years and 60% were men. Subjects in the interventional group had slightly better recovery in terms of disability, as demonstrated by the differences in disability scores between admission and 6 months (e.g., the median difference score for Barthel was −10 in the sham group and −17.5 in the interventional group, for ADL −2 in the sham group and −2.5 in the interventional group), as well as cognitive performance (the median difference score for MoCA was −2 in the sham group and −3 in the interventional group), but none of these differences reached statistical significance. The severity of symptoms (median difference score for NIHSS = 5 for both groups) and depression rate (median difference score for PHQ-9 = 0 for both groups) were similar in the two groups. The median difference between baseline infarct volume and final infarct volume at 6 months was slightly larger in the sham group compared to the interventional group (p = 0.4), probably due to an initial larger infarct volume in the former.Conclusion: Our results suggest that remote ischemic conditioning might improve disability and cognition. The difference between baseline infarct volume and final infarct volume at 180 days was slightly larger in the sham group.

Cerebral protection by remote ischemic post-conditioning in patients with ischemic stroke: A systematic review and meta-analysis of randomized controlled trials

“…Poalelungi et al ( 33 ) noted in the study that the reason for the difference not being statistically significant could be that the intervention had already been administered to the patients at the time of the baseline measurement, when RIPostC had already had an effect on the patients' cerebral infarct volumes. Further, in that study the baseline measurement was performed after the intervention had began; and another reason could be that the sample size was not large enough ( n = 40).…”

“…A total of 12 eligible studies were included ( 22 – 33 ), all of which included patients with ischemic cerebrovascular disease. Eleven studies were analyzed quantitatively, and one study ( 33 ) was analyzed only qualitatively because the data could not be accurately extracted. A total of 713 patients were included, 353 in the trial group and 360 in the control group.…”

“…The cerebral infarct volume is measured in cm 3 by a professional technician in combination with magnetic resonance imaging (MRI) or computed tomography (CT) and manually outlined using software. The outcome indicators in the three studies were the differences in the final cerebral infarct volumes between the RIPostC group and control groups at 24h ( 32 ), 90 days ( 24 ), and 180 days ( 33 ), respectively, and the results are shown in Table 4 . The results of the study showed that the brain infarct volume in the RIPostC group was smaller than that in the control group after the intervention, but only the RIPostC group in Li et al study ( 24 ) showed a significant decrease in brain infarct volume among the three studies.…”

A review of remote ischemic conditioning as a potential strategy for neural repair poststroke

“…Poalelungi et al evaluated the effect of RIC applied in first 5 days after onset of patients, and results suggested that RIC partly improved disability and cognition without statistical difference. 91 Similarly, there are no significant improvements in infarct size or clinical outcome in patients who receive RIC for 4 days…”

“…The results of these studies emphasized the neuroprotection role of short‐term RIC at the beginning of stroke onset, but the effect of chronic RIC application on stroke patients remain unclear. Poalelungi et al evaluated the effect of RIC applied in first 5 days after onset of patients, and results suggested that RIC partly improved disability and cognition without statistical difference 91 . Similarly, there are no significant improvements in infarct size or clinical outcome in patients who receive RIC for 4 days after stroke 92 .…”