
==== Front
Int J Surg
Int J Surg
JS9
International Journal of Surgery (London, England)
1743-9191
1743-9159
Lippincott Williams & Wilkins Hagerstown, MD

38814325
IJS-D-24-01988
10.1097/JS9.0000000000001715
00105
3
Correspondence
Letter to the Editor for the article ‘Impact of immediate postrecanalization cooling on outcome in acute ischemic stroke patients with a large ischemic core: prospective cohort study’
Xu Qian MM 120825345@qq.com
a
Huang Shicai MM b*hsc910313@163.com

a Suzhou Wujiang District Hospital of Traditional Chinese Medicine (Suzhou Wujiang District Second People’s Hospital), Suzhou
b Kunshan Integrated TCM and Western Medicine Hospital, Kunshan, People’s Republic of China
* Corresponding author. Address: Kunshan Integrated TCM and Western Medicine Hospital, Kunshan 215300, People’s Republic of China. Tel.: +86 512 576 939 54. E-mail: hsc910313@163.com (S. Huang).
9 2024
29 5 2024
110 9 59535954
11 5 2024
19 5 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

OPEN-ACCESSTRUE
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pmc Dear Editor,

Xuesong Bai and colleagues conducted a prospective cohort study analyzing acute ischemic stroke patients who underwent endovascular treatment and successfully reperfused from January 2021 to July 2022. Patients were divided into a Targeted Temperature Management (TTM) group and a non-TTM group, with the TTM group undergoing systemic cooling treatment aimed at a core body temperature of 33°C, maintained for at least 48 h. Study results indicated that a higher proportion of patients in the TTM group achieved good functional recovery during the 90-day follow-up period, suggesting potential improvement in clinical outcomes for stroke patients with larger ischemic core areas1. However, upon reviewing the article, we identified some shortcomings that may affect the interpretation and generalizability of the findings.

We found no significant differences in secondary outcomes in the study report (all P values were greater than 0.05); however, the discussion section of the paper misleadingly suggests substantial differences between the TTM and non-TTM groups. Such expressions may lead to misunderstandings about the efficacy of TTM. The correct approach should be to clearly indicate that there are no statistically significant differences in the results and to discuss why this phenomenon occurs, whether due to insufficient sample size or other factors. Regarding the baseline characteristics of the study patients, the smoking rate in the TTM group was significantly higher than that in the non-TTM group (46.7% compared to 13.8%, P=0.043), which represents a clear baseline imbalance. Smoking is a known aggravating factor for stroke; it enhances inflammatory responses and promotes the activity of inflammatory cells and cytokines. Inflammation is a key driver of atherosclerosis and a significant factor in the progression of brain tissue damage after stroke, which may affect patient recovery. This imbalance could confound the treatment effects, diminishing the efficacy observed in the TTM group2. Ideally, the study should address this imbalance through stratification or covariate adjustment to ensure the reliability of the results.

Finally, the incidence of adverse events, such as pneumonia and deep vein thrombosis, was higher in the TTM group. Specifically, the incidence of pneumonia in the TTM group reached 66.7%, significantly higher than 58.6% in the non-TTM group, yet the potential impact and clinical significance of this significant difference were not adequately discussed. The smoking rate was significantly higher in the TTM group than in the non-TTM group. Smoking can increase blood viscosity and alter the morphology and function of red blood cells, making blood more prone to clotting. These changes increase the likelihood of thrombus formation, which may lead to vascular obstruction, thus increasing the incidence of adverse events in the TTM group3. A thorough discussion of adverse events would help provide a clearer understanding of the study results.

In conclusion, this article lays a foundation for future research and highlights the importance of exploring and validating new therapeutic approaches in the complex field of stroke treatment. It provides crucial clinical data and guidance for clinicians treating such stroke patients, but the issues it presents cannot be overlooked. We also look forward to more randomized controlled trials to verify the effectiveness of this treatment strategy. Through future clinical trials, we may witness a transformation and progress in the use of cooling treatment strategies in the management of acute ischemic stroke.

Ethical approval

Not applicable.

Consent

Not applicable.

Sources of funding

Not applicable.

Author contribution

X.Q. and H.S.: conceptualization, methodology, validation, formal analysis, investigation, resources, data curation, writing – original draft, writing – review and editing, supervision, and project administration.

Conflicts of interest disclosure

There are no conflicts of interest.

Guarantor

Qian Xu and Shicai Huang.

Research registration unique identifying number (UIN)

Not applicable.

Data availability statement

Data sharing is not applicable to this article.

Provenance and peer review

Not applicable.

Acknowledgements

Assistance with the study: none.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 29 May 2024
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References

1 Bai X Qu X Nogueira RG . Impact of immediate postrecanalization cooling on outcome in acute ischemic stroke patients with a large ischemic core: prospective cohort study. Int J Surg (London, England) 2024;110 :2065–2070.
2 Shah RS Cole JW . Smoking and stroke: the more you smoke the more you stroke. Expert Rev Cardiovasc Ther 2010;8 :917–932.20602553
3 Shimada S Hasegawa K Wada H . High blood viscosity is closely associated with cigarette smoking and markedly reduced by smoking cessation. Circ J 2011;75 :185–189.21071876
