Cu(I)-assisted click chemistry strategy for conjugation of non-protected cross-bridged macrocyclic chelators to tumour-targeting peptides.

Copper(I)-catalyzed azide-alkyne cycloaddition (CuAAC) click chemistry has inherent challenges for copper-labeled radiopharmaceuticals. An azide-modified phosphonate-based cross-bridged macrocyclic chelator was synthesized for click chemistry conjugation with azide-modified Y3-TATE (a somatostatin analogue) on resin, without the need for protecting the chelator. The (64)Cu-labeled bioconjugate shows favourable in vitro and in vivo behaviour.

Intra-arterial revascularisation therapy for acute ischaemic stroke: initial experience in a Hong Kong hospital.

OBJECTIVES: To assess the outcome of acute ischaemic stroke patients who received intra-arterial therapy in our unit. DESIGN: Case series. SETTING: A tertiary hospital in Hong Kong. PATIENTS: Patients with ischaemic stroke due to large artery occlusion treated within 6 hours from symptom onset between January 2007 and May 2011. INTERVENTION: Acute intra-arterial revascularisation therapy. MAIN OUTCOME MEASURES: Primary outcome was functional independence (modified Rankin Scale score of ≤ 2) at 3 months. Secondary outcome was rate of recanalisation. Safety outcomes were symptomatic intracranial haemorrhage and 3-month mortality. RESULTS: Twenty-one patients with a mean age of 67 years fulfilled the inclusion criteria. Their mean National Institutes of Health Stroke Scale score was 18. The mean onset-to-puncture time was 212 minutes. Nine received intra-arterial tissue plasminogen activator alone, 11 had an adjunctive mechanical thrombectomy, and one received balloon angioplasty without tissue plasminogen activator. At the end of the procedure, thrombolysis grade 2a or better was attained in 18 (86%) of the patients, and 8 (38%) achieved functional independence at 3 months. Rates of symptomatic intracranial haemorrhage and 3-month mortality were 10% and 24%, respectively. CONCLUSION: In this setting, intra-arterial revascularisation therapy appeared safe and efficacious for this selected group of ischaemic stroke patients with large artery occlusions. Experience gained from this pilot study may help improve clinical outcomes of such patients.

Angiographic features, collaterals, and infarct topography of symptomatic occlusive radiation vasculopathy: a case-referent study.

BACKGROUND AND PURPOSE: Occlusive radiation vasculopathy (ORV) predisposes head-and-neck cancer survivors to ischemic strokes. METHODS: We analyzed the digital subtraction angiography acquired in 96 patients who had first-ever transient ischemic attack or ischemic strokes attributed to ORV. Another age-matched 115 patients who had no radiotherapy but symptomatic high-grade (>70%) carotid stenoses were enrolled as referent subjects. Digital subtraction angiography was performed within 2 months from stroke onset and delineated carotid and vertebrobasilar circulations from aortic arch up to intracranial branches. Two reviewers blinded to group assignment recorded all vascular lesions, collateral status, and infarct pattern. RESULTS: ORV patients had less atherosclerotic risk factors at presentation. In referent patients, high-grade stenoses were mostly focal at the proximal internal carotid artery. In contrast, high-grade ORV lesions diffusely involved the common carotid artery and internal carotid artery and were more frequently bilateral (54% versus 22%), tandem (23% versus 10%), associated with complete occlusion in one or both carotid arteries (30% versus 9%), vertebral artery (VA) steno-occlusions (28% versus 16%), and external carotid artery stenosis (19% versus 5%) (all P<0.05). With comparable rates of vascular anomaly, ORV patients showed more established collateral circulations through leptomeningeal arteries, anterior communicating artery, posterior communicating artery, suboccipital/costocervical artery, and retrograde flow in ophthalmic artery. In terms of infarct topography, the frequencies of cortical or subcortical watershed infarcts were similar in both groups. CONCLUSIONS: ORV angiographic features and corresponding collaterals are distinct from atherosclerotic patterns at initial stroke presentation. Clinical decompensation, despite more extensive collateralization, may precipitate stroke in ORV.

Young ischaemic stroke in South Auckland: a hospital-based study.

BACKGROUND AND PURPOSE: To analyse the risk factors, trends in incidence and aetiology of stroke in young adults in a hospital-based population in South Auckland, New Zealand. METHOD: A retrospective review of patients aged 15 years to 45 years with a discharge diagnosis of ischaemic stroke (ICD 10 Codes I63 - I65, G46, I672, I675-I679, I694- I694) from June 1 2004 to December 31, 2009. Vascular risk factors, demographic factors, stroke severity, stroke subtype, results of investigations and stroke outcome were determined from review of the hospital record (paper copy and electronic record). RESULTS: A total of 131 patients were identified, representing 4.6% of all stroke discharges. Over one-half of the patients were of "underdetermined cause" (Trial of Org 10172 in Acute Stroke Treatment [TOAST] criteria), (1) mainly due to incomplete investigation. Cardioembolism (16%) was the second most common cause of stroke, followed by small vessel disease and stroke of other determined aetiology (both 12.2%). Confirmed large vessel atherosclerosis (6.1%) was the least common cause of stroke in this study population. The most common risk factors were hyperlipidaemia (45.8%), hypertension (42.7%), current tobacco smoking (42.7%) and obesity (36.6%). The indigenous Maori and Pacific Island people had a higher rate of stroke, at least double of other ethnicities. The in-hospital fatality rate was 3.1%. All surviving patients were discharged home. Eighty-six percent of the survivors were independent. CONCLUSIONS: Our study demonstrates strokes of undetermined aetiology and cardioembolism were the most common cause of stroke in young people in South Auckland, and that Maori and Pacific Island people have a higher rate of stroke.

Intravenous alteplase for Chinese patients with stroke and borderline eligibility.

Lack of efficacy and safety data among Chinese patients with stroke have contributed to the slow development of stroke thrombolysis as standard-of-care for these patients. We examined a retrospective cohort of 57 patients who received intravenous alteplase for acute ischemic stroke to identify predictors of outcome, including age, stroke severity, onset-to-treatment time, and early ischemic changes on brain CT scan. Overall, the mean National Institute of Health Stroke Scale (NIHSS) score was 15.7 and the mean onset-to-treatment time was 142 minutes. Twenty-nine (51%) patients had a favorable outcome with modified Rankin Scale (mRS) score of ≤2 at three months. Ten (17.5%) patients were deceased at three months. Four (7%) patients developed symptomatic intracranial hemorrhage (sICH). For patients aged >80 years (n=18), five (28%) achieved favorable outcome, six (33%) were deceased at three months and three (17%) had sICH. Prognosis was worst for patients with NIHSS score >25 (n=5); one (20%) was dependent (mRS 4) and the other four (80%) were deceased. Multivariate analysis found that the Alberta Stroke Program Early CT Score (ASPECTS) was associated with favorable outcome (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1-3.0), and mortality (OR 0.5, 95% CI 0.3-0.9). Our findings showed advanced age and severe stroke were associated with less favorable outcome in Chinese patients receiving intravenous alteplase, ASPECTS can be used reliably to identify patients at risk of poor outcomes. Further studies are warranted.

Is stroke thrombolysis safe and efficacious in Hong Kong?

OBJECTIVE: To investigate the safety and efficacy of stroke thrombolysis in a local hospital. DESIGN: Historical cohort study. SETTING: A tertiary hospital in Hong Kong. PATIENTS: The outcome of acute ischaemic stroke patients treated with intravenous tissue plasminogen activator between October 2008 and May 2011 was compared to those admitted during the same period who were thrombolysis-eligible, but treated conservatively due to unavailability of the thrombolysis service after-hours. INTERVENTIONS: Intravenous tissue plasminogen activator. MAIN OUTCOME MEASURES: Primary outcome was functional independence (modified Rankin Scale score of 2 or below) at 3 months. Safety outcomes were symptomatic intracranial haemorrhage and 3-month mortality. Secondary outcomes were hospital length of stay, direct home discharge, and nursing home discharge. RESULTS: A total of 48 thrombolysis and 63 non-thrombolysis patients were identified. Fifty-two percent of the thrombolysis group achieved functional independence compared to 24% of non-thrombolysis group (P=0.003), without significant increase in mortality (15% vs 13%, P=0.51) or symptomatic intracranial haemorrhage (4% vs 2%, P=0.58). Twenty-nine percent of the thrombolysis group patients were discharged home directly, versus 6% of non-thrombolysis group (P<0.001). Mean length of stay was shorter for the thrombolysis group (25 vs 35 days; P=0.034). A similar percentage from each group was discharged to nursing homes. CONCLUSION: Implementation of the stroke thrombolysis service in Hong Kong appeared safe and efficacious. Patients who received thrombolysis had better outcomes compared to non-thrombolysis cohort. Further studies are needed to investigate the economics of stroke thrombolysis in Hong Kong, which may help to improve funding for provision of this service.

Significance of good collateral compensation in symptomatic intracranial atherosclerosis.

BACKGROUND: Collateral circulation stabilizes cerebral blood flow in patients with acute occlusion, but its prognostic role is less studied in intracranial atherosclerosis and appears different in moderate to severe stenosis. We aimed to study the associations between antegrade flow across stenosis, collateral flow via leptomeningeal anastomosis, and the neurological outcome and recurrence risk in patients with symptomatic intracranial stenosis. METHODS: We examined a cohort of consecutive patients admitted for stroke or transient ischemic attack (TIA) with symptomatic intracranial stenosis confirmed by digital subtraction angiography in a single-center retrospective study. Angiograms were graded systematically in a blinded fashion for antegrade and collateral flow, using Thrombolysis in Cerebral Infarction (TICI) and American Society of Intervention and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) grading, respectively, and integrated to a simple composite circulation score. Demographic and clinical variables, modified Rankin Scale (mRS) scores at 3 months, recurrent stroke or TIA in 12 months were collected. Uni- and multivariate analyses were performed to identify independent predictors of good outcome (mRS 0-2) and recurrence in a logistic regression model. RESULTS: Among 69 patients with pure intracranial atherosclerosis ≥ 50%, compromised antegrade flow (TICI 0-2a) was observed in 26 (36%) patients and was associated with more severe arterial stenosis (mean 86 vs. 74%, p = 0.001). Poor collateral compensation resulting in a poor composite circulation score was observed in 8 (12%) patients. Patients with a good circulation score (n = 61, 88%) had preserved flow, which was associated with more favorable outcome (OR 7.50, 95% CI 1.11-50.7, p = 0.04) and less recurrent TIA or stroke (OR 0.18, 95% CI 0.04-0.96, p = 0.04). Prognosis was not significantly associated with antegrade or collateral grade per se. CONCLUSION: Good collateral compensations are more important in patients with symptomatic intracranial stenosis and compromised antegrade flow, and are associated with favorable outcome and less recurrence risk. The feasibility of composite flow assessment should be explored in future studies to identify high-risk intracranial stenosis with compromised hemodynamics.

Synthesis, Cu(II) complexation, 64Cu-labeling and biological evaluation of cross-bridged cyclam chelators with phosphonate pendant arms.

A new class of cross-bridged cyclam-based macrocycles featuring phosphonate pendant groups has been developed. 1,4,8,11-tetraazacyclotetradecane-1,8-di(methanephosphonic acid) (CB-TE2P, 1) and 1,4,8,11-tetraazacyclotetradecane-1-(methanephosphonic acid)-8-(methanecarboxylic acid) (CB-TE1A1P, 2) have been synthesized and have been shown to readily form neutral copper(II) complexes at room temperature as the corresponding dianions. Both complexes showed high kinetic inertness to demetallation and crystal structures confirmed complete encapsulation of copper(II) ion within each macrocycle's cleft-like structure. Unprecedented for cross-bridged cyclam derivatives, both CB-TE2P (1) and CB-TE1A1P (2) can be radiolabeled with (64)Cu at room temperature in less than 1 h with specific activities >1 mCi µg(-1). The in vivo behavior of both (64)Cu-CB-TE2P and (64)Cu-CB-TE1A1P were investigated through biodistribution studies using healthy male Lewis rats. Both new compounds showed rapid clearance with similar or lower accumulation in non-target organs/tissues when compared to other copper chelators including CB-TE2A, NOTA and Diamsar.

Isomeric trimethylene and ethylene pendant-armed cross-bridged tetraazamacrocycles and in vitro/in vivo comparisions of their copper(II) complexes.

Ethylene cross-bridged tetraamine macrocycles are useful chelators in coordination, catalytic, medicinal, and radiopharmaceutical chemistry. Springborg and co-workers developed trimethylene cross-bridged analogues, although their pendant-armed derivatives received little attention. We report here the synthesis of a bis-carboxymethyl pendant-armed cyclen with a trimethylene cross-bridge (C3B-DO2A) and its isomeric ethylene-cross-bridged homocyclen ligand (CB-TR2A) as well as their copper(II) complexes. The in vitro and in vivo properties of these complexes are compared with respect to their potential application as (64)Cu-radiopharmaceuticals in positron emission tomography (PET imaging). The inertness of Cu-C3B-DO2A to decomplexation is remarkable, exceeding that of Cu-CB-TE2A. Electrochemical reduction of Cu-CB-TR2A is quasi-reversible, whereas that of Cu-C3B-DO2A is irreversible. The reaction conditions for preparing (64)Cu-C3B-DO2A (microwaving at high temperature) are relatively harsh compared to (64)Cu-CB-TR2A (basic ethanol). The in vivo behavior of the (64)Cu complexes was evaluated in normal rats. Rapid and continual clearance of (64)Cu-CB-TR2A through the blood, liver, and kidneys suggests relatively good in vivo stability, albeit inferior to (64)Cu-CB-TE2A. Although (64)Cu-C3B-DO2A clears continually, the initial uptake is high and only about half is excreted within 22 h, suggesting poor stability and transchelation of (64)Cu to proteins in the blood and/or liver. These data suggest that in vitro inertness of a chelator complex may not always be a good indicator of in vivo stability.

A new phosphonate pendant-armed cross-bridged tetraamine chelator accelerates copper(ii) binding for radiopharmaceutical applications.

A phosphonate pendant-armed cross-bridged cyclam chelator has been synthesized, complexed to Cu(ii), radiolabeled with (64)Cu under mild conditions, and its biodistribution studied.

Acute encephalopathy associated with influenza A infection in adults.

We report acute encephalopathy associated with influenza A infection in 3 adults. We detected high cerebrospinal fluid (CSF) and plasma concentrations of CXCL8/IL-8 and CCL2/MCP-1 (CSF/plasma ratios > or =3), and interleukin-6, CXCL10/IP-10, but no evidence of viral neuroinvasion. Patients recovered without sequelae. Hyperactivated cytokine response may play a role in pathogenesis.

The long and short of it: the influence of N-carboxyethyl versusN-carboxymethyl pendant arms on in vitro and in vivo behavior of copper complexes of cross-bridged tetraamine macrocycles.

A cross-bridged cyclam ligand bearing two N-carboxymethyl pendant arms (1) has been found to form a copper(II) complex that exhibits significantly improved biological behavior in recent research towards (64)Cu-based radiopharmaceuticals. Both the kinetic inertness and resistance to reduction of Cu-1 are believed to be relevant to its enhanced performance. To explore the influence of pendant arm length on these properties, new cross-bridged cyclam and cyclen ligands with longer N-carboxyethyl pendant arms, 2 and 4, and their respective copper(II) complexes have been synthesized. Both mono- as well as di-O-protonated forms of Cu-2 have also been isolated and structurally characterized. The spectral and structural properties of Cu-2 and Cu-4, their kinetic inertness in 5 M HCl, and electrochemical behavior have been obtained and compared to those of their N-carboxymethyl-armed homologs, Cu-1 and Cu-3. Only the cyclam-based Cu-1 and Cu-2 showed unusually high kinetic inertness towards acid decomplexation. While both of these complexes also exhibited quasi-reversible Cu(II)/Cu(I) reductions, Cu-2 is easier to reduce by a substantial margin of +400 mV, bringing it within the realm of physiological reductants. Similarly, of the cyclen-based complexes, Cu-4 is also easier to reduce than Cu-3 though both reductions are irreversible. Biodistribution studies of (64)Cu-labeled 2 and 4 were performed in Sprague Dawley rats. Despite comparable acid inertness to their shorter-armed congeners, both longer-armed ligand complexes have poorer bio-clearance properties. This inferior in vivo behavior may be a consequence of their higher reduction potentials.

Synthesis, characterization and in vivo studies of Cu(II)-64-labeled cross-bridged tetraazamacrocycle-amide complexes as models of peptide conjugate imaging agents.

Copper-64, a positron emitter suitable for positron emission tomography (PET), demonstrates improved in vivo clearance when chelated by the cross-bridged tetraazamacrocycle CB-TE2A compared to TETA. Good in vivo clearance was also observed for 64Cu-CB-TE2A conjugated to a peptide, which converts one coordinating carboxylate pendant arm to an amide. To better understand the in vivo stability of peptide- conjugated CB-TE2A, cross-bridged monoamides were synthesized. Crystal structures of natCu(II)-CB-TEAMA and natCu(II)-CB-PhTEAMA revealed hexadentate, distorted octahedral coordination geometry. In vivo biodistribution showed clearance of all 64Cu-radiolabeled cross-bridged monoamides from liver and bone marrow such that uptake at 24 h was <10% of uptake at 30 min. In contrast, >60% of 30 min uptake from 64Cu-TETA was retained in these tissues at 24 h. Clearance of 64Cu-cross-bridged monoamides from nontarget organs suggests good in vivo stability, thus supporting the use of CB-TE2A as a bifunctional chelator without modifications to the macrocycle backbone.

Stroke caused by small vessel occlusion in a patient taking etoricoxib and thalidomide.

We report a 33-year-old man with seronegative arthritis who had an acute infarct at the left lentiform nucleus while taking etoricoxib and thalidomide regularly. Extensive investigations did not find any evidence of large artery atherosclerosis, vasculitis, cardioembolic source or anti-phospholipid antibodies. While it is possible that a short smoking history, hyperlipidemia, and the use of thalidomide could have contributed to the thrombosis of a small penetrator vessel, we postulated that the prolonged use of etoricoxib is another possible contributing factor.

Tracheobronchial injuries from blunt trauma.

Tracheobronchial injuries from trauma can be life threatening. We present a case report of a 23-year-old man who suffered a left main bronchus transection after a motorbike accident. The diagnostic and management issues surrounding tracheobronchial injuries are reviewed. Early diagnosis and treatment lead to the best outcome, with almost complete return of pulmonary function.

Investigation of copper-azamacrocyclic complexes by high-performance liquid chromatography.

The use of copper radioisotopes in imaging and therapy has prompted an increased interest in chelators which form stable copper complexes, such as Cu(II)-azamacrocyclic complexes. The effects of charge, stability and the size of the macrocyclic backbone of the Cu(II)-azamacrocyclic complexes on biological behavior have been evaluated. Here we report a reversed-phase high-performance liquid chromatography (HPLC) method to separate several Cu(II)-azamacrocyclic complexes, including Cu(II) complexes of 1,4,8,11-tetraazacyclotetradecane-1,4,8,11-tetraacetic acid (TETA), 4,11-bis(carboxymethyl)-1,4,8,11-tetraazabicyclo[6.6.2]hexadecane (CB-TE2A) and 4,10-bis(carboxymethyl)-1,4,7,10-tetraazabicyclo[5.5.2]tetradecane (CB-DO2A). Absorbance at 280 nm was used to monitor the complexes as they eluted from the reversed-phase column. The effects of the concentration of the buffer, the pH of the buffered mobile phase and the concentration of the organic modifier, methanol, on the separation were investigated. Separation of these copper complexes by ion-pair HPLC with the use of a mass spectrometry-compatible ion-pair reagent, triethylammonium acetate, in the mobile phase at pH 6.3 is also presented. The reversed-phase chromatographic conditions utilized also allow the pK(a)s of Cu-TETA and the log(k'w) values of Cu-CB-TE2A, Cu-TETA and Cu-CB-DO2A to be estimated.