The effect of repeated remote ischemic postconditioning after an ischemic stroke (REPOST): A randomized controlled trial

Abstract

Background and aims: A potential strategy to treat ischemic stroke may be the application of repeated remote ischemic postconditioning (rIPostC). This consists of several cycles of brief periods of limb ischemia followed by reperfusion, which can be applied by inflating a simple blood pressure cuff and subsequently could result in neuroprotection after stroke.

Methods: Adult patients admitted with an ischemic stroke in the past 24 h were randomized 1:1 to repeated rIPostC or sham-conditioning. Repeated rIPostC was performed by inflating a blood pressure cuff around the upper arm (4 × 5 min at 200 mm Hg), which was repeated twice daily during hospitalization with a maximum of 4 days. Primary outcome was infarct size after 4 days or at discharge. Secondary outcomes included the modified Rankin Scale (mRS)-score after 12 weeks and the National Institutes of Health Stroke Scale (NIHSS) at discharge.

Results: The trial was preliminarily stopped after we included 88 of the scheduled 180 patients (average age: 70 years, 68% male) into rIPostC (n = 40) and sham-conditioning (n = 48). Median infarct volume was 2.19 mL in rIPostC group and 5.90 mL in sham-conditioning, which was not significantly different between the two groups (median difference: 3.71; 95% CI: -0.56 to 6.09; p = 0.31). We found no significant shift in the mRS score distribution between groups. The adjusted common odds ratio was 2.09 (95% CI: 0.88-5.00). We found no significant difference in the NIHSS score between groups (median difference: 1.00; 95% CI: -0.99 to 1.40; p = 0.51).

Conclusion: This study found no significant improvement in infarct size or clinical outcome in patients with an acute ischemic stroke who were treated with repeated remote ischemic postconditioning. However, due to a lower-than-expected inclusion rate, no definitive conclusions about the effectiveness of rIPostC can be drawn.

Keywords: Acute stroke therapy; MRI; ischemic stroke; neuroprotection; therapy; treatment.

Figure 1.

Flowchart REPOST trial.

Figure 2.

The effect of rIPostC on infarct volume. rIPostC: remote ischemic postconditioning; mL: milliliters. A boxplot that represents the infarct volume (in milliliters) for the sham-conditioning and rIPostC group at discharge. There were four patients with an infarct volume > 100 mL that are not visible in this graph but were used to determine the other characteristics in the boxplot.

Figure 3.

The effect of rIPostC on the mRS score. The distribution of the mRS scores for the rIPostC and sham-conditioning group after 12 weeks. There were no patients with an mRS score of 5.