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Bagheri M, Habibzadeh S, Moeini M. Transient Changes in Cerebral Tissue Oxygen, Glucose, and Temperature by Microstrokes: A Computational Study. Microcirculation 2024; 31:e12872. [PMID: 38944839 DOI: 10.1111/micc.12872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 05/09/2024] [Accepted: 06/08/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE This study focuses on evaluating the disruptions in key physiological parameters during microstroke events to assess their severity. METHODS A mathematical model was developed to simulate the changes in cerebral tissue pO2, glucose concentration, and temperature due to blood flow interruptions. The model considers variations in baseline cerebral blood flow (CBF), capillary density, and blood oxygen/glucose levels, as well as ambient temperature changes. RESULTS Simulations indicate that complete blood flow obstruction still allows for limited glucose availability, supporting nonoxidative metabolism and potentially exacerbating lactate buildup and acidosis. Partial obstructions decrease tissue pO2, with minimal impact on glucose level, which can remain almost unchanged or even slightly increase. Reduced CBF, capillary density, or blood oxygen due to aging or disease enhances hypoxia risk at lower obstruction levels, with capillary density having a significant effect on stroke severity by influencing both pO2 and glucose levels. Conditions could lead to co-occurrence of hypoxia/hypoglycemia or hypoxia/hyperglycemia, each worsening outcomes. Temperature effects were minimal in deep brain regions but varied near the skull by 0.2-0.8°C depending on ambient temperature. CONCLUSIONS The model provides insights into the conditions driving severe stroke outcomes based on estimated levels of hypoxia, hypoglycemia, hyperglycemia, and temperature changes.
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Affiliation(s)
- Marzieh Bagheri
- Department of Chemical Engineering, Amirkabir University of Technology (Tehran Polytechnic), Tehran, Iran
| | - Sajjad Habibzadeh
- Department of Chemical Engineering, Amirkabir University of Technology (Tehran Polytechnic), Tehran, Iran
| | - Mohammad Moeini
- Department of Biomedical Engineering, Amirkabir University of Technology (Tehran Polytechnic), Tehran, Iran
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2
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Wu TW, Schmicker R, Wood TR, Mietzsch U, Comstock B, Heagerty PJ, Rao R, Gonzalez F, Juul S, Wu YW. Esophageal Versus Rectal Temperature Monitoring During Whole-Body Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy: Association with Short- and Long-Term Outcomes. J Pediatr 2024; 268:113933. [PMID: 38309524 PMCID: PMC11045319 DOI: 10.1016/j.jpeds.2024.113933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/13/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
OBJECTIVE To compare the short- and long-term outcomes of infants with hypoxic-ischemic encephalopathy (HIE) treated with whole-body therapeutic hypothermia (TH), monitored by esophageal vs rectal temperature. STUDY DESIGN We conducted a secondary analysis of the multicenter High-Dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) trial. All infants had moderate or severe HIE and were treated with whole-body TH. The primary outcome was death or neurodevelopmental impairment (NDI) at 22-36 months of age. Secondary outcomes included seizures, evidence of brain injury on magnetic resonance imaging, and complications of hypothermia. Logistic regression was used with adjustment for disease severity and site as clustering variable because cooling modality differed by site. RESULTS Of the 500 infants who underwent TH, 294 (59%) and 206 (41%) had esophageal and rectal temperature monitoring, respectively. There were no differences in death or NDI, seizures, or evidence of injury on magnetic resonance imaging between the 2 groups. Infants treated with TH and rectal temperature monitoring had lower odds of overcooling (OR 0.52, 95% CI 0.34-0.80) and lower odds of hypotension (OR 0.57, 95% CI 0.39-0.84) compared with those with esophageal temperature monitoring. CONCLUSIONS Although infants undergoing TH with esophageal monitoring were more likely to experience overcooling and hypotension, the rate of death or NDI was similar whether esophageal monitoring or rectal temperature monitoring was used. Further studies are needed to investigate whether esophageal temperature monitoring during TH is associated with an increased risk of overcooling and hypotension.
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Affiliation(s)
- Tai-Wei Wu
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Robert Schmicker
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Thomas R Wood
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Bryan Comstock
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Rakesh Rao
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Fernando Gonzalez
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Sandra Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, California
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3
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Arnautovic T, Sinha S, Laptook AR. Neonatal Hypoxic-Ischemic Encephalopathy and Hypothermia Treatment. Obstet Gynecol 2024; 143:67-81. [PMID: 37797337 PMCID: PMC10841232 DOI: 10.1097/aog.0000000000005392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/27/2023] [Indexed: 10/07/2023]
Abstract
Neonatal hypoxic-ischemic encephalopathy (HIE) is an important clinical entity because it is associated with death and long-term disability, including cognitive impairment, cerebral palsy, seizures, and neurosensory deficits. Over the past 40 years, there has been an intensive search to identify therapies to improve the prognosis of neonates with HIE. Hypothermia treatment represents the culmination of laboratory investigations including small and large animal studies, followed by pilot human studies, and, finally, randomized controlled trials to establish efficacy and safety. Clinical trials have demonstrated that hypothermia treatment reduces mortality and improves early childhood outcome among survivors. Hypoxic-ischemic encephalopathy is a multi-system disease process that requires intensive medical support for brain monitoring and monitoring of non-central nervous system organ dysfunction. Treatment must be conducted in a level III or IV neonatal intensive care unit with infrastructure for an integrated approach to care for critically ill neonates. Hypothermia treatment is the first and currently the only therapy to improve outcomes for neonates with HIE and indicates that HIE is modifiable. However, outcomes likely can be improved further. Hypothermia treatment has accelerated investigation of other therapies to combine with hypothermia. It has also stimulated a more intensive approach to brain monitoring, which allows earlier intervention for complications. Finally, HIE and hypothermia treatment negatively influences the psychological state of affected families, and there is growing recognition of the importance of trauma-informed principles to guide medical professionals.
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Affiliation(s)
- Tamara Arnautovic
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, and Warren Alpert Medical School of Brown University, Providence, Rhode Island
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4
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Walter AE, Bai X, Wilkes J, Neuberger T, Sebastianelli W, Slobounov SM. Selective head cooling in the acute phase of concussive injury: a neuroimaging study. Front Neurol 2023; 14:1272374. [PMID: 37965166 PMCID: PMC10641407 DOI: 10.3389/fneur.2023.1272374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction Neurovascular decoupling is a common consequence after brain injuries like sports-related concussion. Failure to appropriately match cerebral blood flow (CBF) with increases in metabolic demands of the brain can lead to alterations in neurological function and symptom presentation. Therapeutic hypothermia has been used in medicine for neuroprotection and has been shown to improve outcome. This study aimed to examine the real time effect of selective head cooling on healthy controls and concussed athletes via magnetic resonance spectroscopy (MRS) and arterial spin labeling (ASL) measures. Methods 24 participants (12 controls; 12 concussed) underwent study procedures including the Post-Concussion Symptom Severity (PCSS) Rating Form and an MRI cooling protocol (pre-cooling (T1 MPRAGE, ASL, single volume spectroscopy (SVS)); during cooling (ASL, SVS)). Results Results showed general decreases in brain temperature as a function of time for both groups. Repeated measures ANOVA showed a significant main effect of time (F = 7.94, p < 0.001) and group (F = 22.21, p < 0.001) on temperature, but no significant interaction of group and time (F = 1.36, p = 0.237). CBF assessed via ASL was non-significantly lower in concussed individuals at pre-cooling and generalized linear mixed model analyses demonstrated a significant main effect of time for the occipital left ROI (F = 11.29, p = 0.002) and occipital right ROI (F = 13.39, p = 0.001). There was no relationship between any MRI metric and PCSS symptom burden. Discussion These findings suggest the feasibility of MRS thermometry to monitor alterations of brain temperature in concussed athletes and that metabolic responses in response to cooling after concussion may differ from controls.
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Affiliation(s)
- Alexa E. Walter
- Department of Kinesiology, The Pennsylvania State University, University Park, PA, United States
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Xiaoxiao Bai
- Social, Life, and Engineering Science Imaging Center, The Pennsylvania State University, University Park, PA, United States
| | - James Wilkes
- Department of Kinesiology, The Pennsylvania State University, University Park, PA, United States
| | - Thomas Neuberger
- Department of Biomedical Engineering, and Social, Life, and Engineering Science Imaging Center, Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA, United States
| | - Wayne Sebastianelli
- Department of Athletic Medicine, The Pennsylvania State University, University Park, PA, United States
- Department of Orthopaedics, Penn State Health, State College, PA, United States
| | - Semyon M. Slobounov
- Department of Kinesiology, The Pennsylvania State University, University Park, PA, United States
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5
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Cannavò L, Perrone S, Gitto E. Brain-Oriented Strategies for Neuroprotection of Asphyxiated Newborns in the First Hours of Life. Pediatr Neurol 2023; 143:44-49. [PMID: 36996760 DOI: 10.1016/j.pediatrneurol.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 01/31/2023] [Accepted: 02/24/2023] [Indexed: 04/01/2023]
Abstract
Perinatal asphyxia represents the first cause of severe neurological disabilities and the second cause of neonatal death in term-born babies. Currently, no treatment can prevent immediate cell death from necrosis, but some therapeutic interventions, such as therapeutic hypothermia (TH), can reduce delayed cell death from apoptosis. TH significantly improves the combined outcome of mortality or major neurodevelopmental disability, but the number of patients to be treated is 7 to get 1 child with no adverse neurological outcome. The aim of this educational review is to analyze the other care strategies to be implemented to improve the neurological outcome of children with hypoxic ischemic encephalopathy (HIE). Hypocapnia, hypoglycemia, pain control, and functional brain monitoring are recognized as appropriate approaches to improve outcome in critically ill infants with HIE. Pharmacologic neuroprotective adjuncts are currently under investigation. New drugs such as allopurinol and melatonin seem to provide positive effects although more randomized controlled trials are required to establish the effective therapeutic scheme. In the meantime, sustaining the respiratory, metabolic, and cardiovascular system during TH can be a valuable aid in managing and treating the patient with HIE in an optimal way.
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Affiliation(s)
- Laura Cannavò
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Messina, Italy
| | - Serafina Perrone
- Neonatal Unit, University of Parma, Azienda Ospedaliero Universitaria di Parma, Parma, Italy.
| | - Eloisa Gitto
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Messina, Italy
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Watterberg KL, Carlo WA, Brion LP, Cotten CM, Higgins RD. Overview of the neonatal research network: History, contributions, challenges, and future. Semin Perinatol 2022; 46:151634. [PMID: 35786518 PMCID: PMC10996928 DOI: 10.1016/j.semperi.2022.151634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN) has been a leader in neonatal research since 1986. In this chapter we review its history and achievements in (1) continuing observation of populations, treatments, short and longer-term outcomes, and trends over time; (2) "negative studies" (trials with non-significant primary outcomes) and trials stopped for futility or adverse events, which have influenced practice and subsequent trial design; and, (3) landmark trials that have changed neonatal care. Its consistent framework has enabled the NRN to be a pioneer in conducting longer-term, school-age follow-up. Leveraging its established infrastructure, the NRN has also partnered with other NIH institutes, governmental agencies, and industry to more effectively advance neonatal care. As current examples of its evolution with changing times, the Network has instituted a process to open specific network trials to external institutions and is adding a parent and participant component to future endeavors.
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Affiliation(s)
- Kristi L Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
| | - Waldemar A Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luc P Brion
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Raleigh, NC, USA
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Dhillon SK, Gunn ER, Lear BA, King VJ, Lear CA, Wassink G, Davidson JO, Bennet L, Gunn AJ. Cerebral Oxygenation and Metabolism After Hypoxia-Ischemia. Front Pediatr 2022; 10:925951. [PMID: 35903161 PMCID: PMC9314655 DOI: 10.3389/fped.2022.925951] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Perinatal hypoxia-ischemia (HI) is still a significant contributor to mortality and adverse neurodevelopmental outcomes in term and preterm infants. HI brain injury evolves over hours to days, and involves complex interactions between the endogenous protective and pathological processes. Understanding the timing of evolution of injury is vital to guide treatment. Post-HI recovery is associated with a typical neurophysiological profile, with stereotypic changes in cerebral perfusion and oxygenation. After the initial recovery, there is a delayed, prolonged reduction in cerebral perfusion related to metabolic suppression, followed by secondary deterioration with hyperperfusion and increased cerebral oxygenation, associated with altered neurovascular coupling and impaired cerebral autoregulation. These changes in cerebral perfusion are associated with the stages of evolution of injury and injury severity. Further, iatrogenic factors can also affect cerebral oxygenation during the early period of deranged metabolism, and improving clinical management may improve neuroprotection. We will review recent evidence that changes in cerebral oxygenation and metabolism after HI may be useful biomarkers of prognosis.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Alistair J. Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
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Pan S, Wu A, Weiner M, M Grinspan Z. Development and Evaluation of Computable Phenotypes in Pediatric Epilepsy:3 Cases. J Child Neurol 2021; 36:990-997. [PMID: 34315300 DOI: 10.1177/08830738211019578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Computable phenotypes allow identification of well-defined patient cohorts from electronic health record data. Little is known about the accuracy of diagnostic codes for important clinical concepts in pediatric epilepsy, such as (1) risk factors like neonatal hypoxic-ischemic encephalopathy; (2) clinical concepts like treatment resistance; (3) and syndromes like juvenile myoclonic epilepsy. We developed and evaluated the performance of computable phenotypes for these examples using electronic health record data at one center. METHODS We identified gold standard cohorts for neonatal hypoxic-ischemic encephalopathy, pediatric treatment-resistant epilepsy, and juvenile myoclonic epilepsy via existing registries and review of clinical notes. From the electronic health record, we extracted diagnostic and procedure codes for all children with a diagnosis of epilepsy and seizures. We used these codes to develop computable phenotypes and evaluated by sensitivity, positive predictive value, and the F-measure. RESULTS For neonatal hypoxic-ischemic encephalopathy, the best-performing computable phenotype (HIE ICD-9/10 and [brain magnetic resonance imaging (MRI) or electroencephalography (EEG) within 120 days of life] and absence of commonly miscoded conditions) had high sensitivity (95.7%, 95% confidence interval [CI] 85-99), positive predictive value (100%, 95% CI 95-100), and F measure (0.98). For treatment-resistant epilepsy, the best-performing computable phenotype (3 or more antiseizure medicines in the last 2 years or treatment-resistant ICD-10) had a sensitivity of 86.9% (95% CI 79-93), positive predictive value of 69.6% (95% CI 60-79), and F-measure of 0.77. For juvenile myoclonic epilepsy, the best performing computable phenotype (JME ICD-10) had poor sensitivity (52%, 95% CI 43-60) but high positive predictive value (90.4%, 95% CI 81-96); the F measure was 0.66. CONCLUSION The variable accuracy of our computable phenotypes (hypoxic-ischemic encephalopathy high, treatment resistance medium, and juvenile myoclonic epilepsy low) demonstrates the heterogeneity of success using administrative data to identify cohorts important for pediatric epilepsy research.
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Affiliation(s)
- Sabrina Pan
- Department of Population Health Sciences, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY, USA
| | - Alan Wu
- Department of Population Health Sciences, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY, USA
| | - Mark Weiner
- Department of Population Health Sciences, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY, USA
| | - Zachary M Grinspan
- Department of Population Health Sciences, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY, USA
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9
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Cai H, Bian X, Chen L, Zhang N, Li L, Tang W, Liu X, Li Z. Selective intra-arterial brain cooling induces cerebral protection against ischemia/reperfusion injury through SENP1-Sirt3 signaling. Free Radic Biol Med 2021; 171:272-283. [PMID: 34019931 DOI: 10.1016/j.freeradbiomed.2021.05.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/23/2021] [Accepted: 05/14/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although it is well known that selective intra-arterial cooling (SI-AC) elicits cerebral protection against ischemia/reperfusion (I/R) injury, the underlying mechanism remains unclear. This study aimed to determine whether SI-AC can protect against cerebral I/R injury by inhibiting oxidative stress and mitochondrial dysfunction through regulation of Sirt3 deSUMOylation via SENP1. METHODS All mice were subjected to 2 h of cerebral ischemia followed by 24 h of reperfusion. SI-AC treatment was performed by infusion with cold saline (10 °C, 20 mL/kg) for 15 min through a microcatheter placed in the internal carotid artery immediately before reperfusion. The infarct volume, survival rate, neurological deficit scores, behavioral parameters, histopathology findings, and apoptosis were assessed. HT22 cells were subjected to 2 h of oxygen and sugar deprivation (OGD) and 22 h of reoxygenation. HA-SUMO1, Flag-Sirt3, a Sirt3 mutation plasmid (Flag-Sirt3 K288R), His-SENP1, and SENP1 small interfering RNA were transfected into HT22 cells 48 h before OGD. Apoptosis-related proteins were analyzed by western blotting. SUMOylation of Sirt3, acetylation of cyclooxygenase 1 (COX1), superoxide dismutase 2 (SOD2), and isocitrate dehydrogenase 2 (IDH2), the activities of COX1, SOD2, and IDH2, oxidative stress, and mitochondrial dysfunction were evaluated. RESULTS Compared with the I/R group, SI-AC decreased cerebral infarct volume and neurological deficit scores and increased motor coordination, exploratory behavior, and memory. Hematoxylin and eosin and Nissl staining showed that SI-CA decreased karyopyknosis, nuclear fragmentation, and nucleolysis, increased neuron density, and decreased the cell apoptosis rate. In addition, Sirt3 was revealed as a target protein of SUMO1. SI-AC attenuated cerebral I/R injury through Sirt3 deSUMOylation via SENP1. CONCLUSIONS SENP1-mediated deSUMOylation of Sirt3 plays an essential role in SI-AC-induced cerebral protection against I/R injury. Our findings provide a promising therapeutic approach for treatment of acute cerebral I/R injury.
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Affiliation(s)
- Heng Cai
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, 110004, China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang, 110004, China; Key Laboratory of Neuro-oncology in Liaoning Province, Shenyang, 110004, China
| | - Xiyun Bian
- Central Laboratory, Development of Preterm Infants, The Fifth Central Hospital of Tianjin, Tianjin, 300450, China; Tianjin Key Laboratory of Epigenetics for Organ Development of Preterm Infants, The Fifth Central Hospital of Tianjin, Tianjin 300450, China
| | - Liangyu Chen
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, 110004, China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang, 110004, China; Key Laboratory of Neuro-oncology in Liaoning Province, Shenyang, 110004, China
| | - Nan Zhang
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, 110004, China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang, 110004, China; Key Laboratory of Neuro-oncology in Liaoning Province, Shenyang, 110004, China
| | - Lili Li
- Central Laboratory, Development of Preterm Infants, The Fifth Central Hospital of Tianjin, Tianjin, 300450, China; Tianjin Key Laboratory of Epigenetics for Organ Development of Preterm Infants, The Fifth Central Hospital of Tianjin, Tianjin 300450, China
| | - Wei Tang
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, 110004, China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang, 110004, China; Key Laboratory of Neuro-oncology in Liaoning Province, Shenyang, 110004, China
| | - Xiaozhi Liu
- Central Laboratory, Development of Preterm Infants, The Fifth Central Hospital of Tianjin, Tianjin, 300450, China; Tianjin Key Laboratory of Epigenetics for Organ Development of Preterm Infants, The Fifth Central Hospital of Tianjin, Tianjin 300450, China
| | - Zhiqing Li
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, 110004, China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang, 110004, China; Key Laboratory of Neuro-oncology in Liaoning Province, Shenyang, 110004, China.
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10
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Masè M, Micarelli A, Falla M, Regli IB, Strapazzon G. Insight into the use of tympanic temperature during target temperature management in emergency and critical care: a scoping review. J Intensive Care 2021; 9:43. [PMID: 34118993 PMCID: PMC8199814 DOI: 10.1186/s40560-021-00558-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/30/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Target temperature management (TTM) is suggested to reduce brain damage in the presence of global or local ischemia. Prompt TTM application may help to improve outcomes, but it is often hindered by technical problems, mainly related to the portability of cooling devices and temperature monitoring systems. Tympanic temperature (TTy) measurement may represent a practical, non-invasive approach for core temperature monitoring in emergency settings, but its accuracy under different TTM protocols is poorly characterized. The present scoping review aimed to collect the available evidence about TTy monitoring in TTM to describe the technique diffusion in various TTM contexts and its accuracy in comparison with other body sites under different cooling protocols and clinical conditions. METHODS The scoping review was conducted following the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews (PRISMA-ScR). PubMed, Scopus, and Web of Science electronic databases were systematically searched to identify studies conducted in the last 20 years, where TTy was measured in TTM context with specific focus on pre-hospital or in-hospital emergency settings. RESULTS The systematic search identified 35 studies, 12 performing TTy measurements during TTM in healthy subjects, 17 in patients with acute cardiovascular events, and 6 in patients with acute neurological diseases. The studies showed that TTy was able to track temperature changes induced by either local or whole-body cooling approaches in both pre-hospital and in-hospital settings. Direct comparisons to other core temperature measurements from other body sites were available in 22 studies, which showed a faster and larger change of TTy upon TTM compared to other core temperature measurements. Direct brain temperature measurements were available only in 3 studies and showed a good correlation between TTy and brain temperature, although TTy displayed a tendency to overestimate cooling effects compared to brain temperature. CONCLUSIONS TTy was capable to track temperature changes under a variety of TTM protocols and clinical conditions in both pre-hospital and in-hospital settings. Due to the heterogeneity and paucity of comparative temperature data, future studies are needed to fully elucidate the advantages of TTy in emergency settings and its capability to track brain temperature.
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Affiliation(s)
- Michela Masè
- Institute of Mountain Emergency Medicine, Eurac Research, Drususallee/Viale Druso 1, I-39100, Bolzano, Italy.,IRCS-HTA, Bruno Kessler Foundation, Trento, Italy
| | - Alessandro Micarelli
- Institute of Mountain Emergency Medicine, Eurac Research, Drususallee/Viale Druso 1, I-39100, Bolzano, Italy.,ITER Center for Balance and Rehabilitation Research (ICBRR), Rome, Italy
| | - Marika Falla
- Institute of Mountain Emergency Medicine, Eurac Research, Drususallee/Viale Druso 1, I-39100, Bolzano, Italy.,Centre for Mind/Brain Sciences, CIMeC, University of Trento, Rovereto, Italy
| | - Ivo B Regli
- Institute of Mountain Emergency Medicine, Eurac Research, Drususallee/Viale Druso 1, I-39100, Bolzano, Italy.,Department of Anesthesia and Intensive Care, "F. Tappeiner" Hospital, Merano, Italy
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Drususallee/Viale Druso 1, I-39100, Bolzano, Italy.
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11
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Goenka A, Yozawitz E, Gomes WA, Nafday SM. Selective Head versus Whole Body Cooling Treatment of Hypoxic-Ischemic Encephalopathy: Comparison of Electroencephalogram and Magnetic Resonance Imaging Findings. Am J Perinatol 2020; 37:1264-1270. [PMID: 31344712 DOI: 10.1055/s-0039-1693466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study aimed to compare the utility of electroencephalogram (EEG) and brain magnetic resonance imaging (MRI) to detect brain dysfunction and injury across a cohort of newborn infants treated with selective head cooling (SHC) or whole body cooling (WBC). STUDY DESIGN Therapeutic hypothermia (TH) is a standard neuroprotection tool for hypoxic-ischemic encephalopathy (HIE) in neonates. Sixty-six newborns, SHC (n = 22) and WBC (n = 44), were studied utilizing standardized scoring systems for interpretation of EEG and MRI based on the severity of the findings. RESULTS SHC- and WBC-treated groups did not differ significantly amongst most of the baseline parameters. EEGs obtained postcooling were abnormal in 58 of 61 (95%) infants. The severity of the EEG background changes (depressed and undifferentiated background) was more prevalent in the SHC (8/21 [38%]) than in the WBC group (5/40 [13%]). Brain MRIs showed HIE changes in 26 of 62 (42%) newborns treated with TH. MRI abnormalities of basal ganglia, thalamic, and parenchymal lesions were more common in the SHC (5/19) versus the WBC group (3/43); p = 0.04. CONCLUSION EEG abnormalities and MRI findings of HIE were more prevalent in the SHC than in the WBC group. WBC may offer better or at least similar neuroprotection to infants with HIE.
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Affiliation(s)
- Ajay Goenka
- Department of Neurology and Epilepsy, Dayton Children's Hospital, Dayton, Ohio
| | - Elissa Yozawitz
- Saul Korey Department of Neurology, Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York
| | - William A Gomes
- Department of Neuroradiology, Radiology, Advanced Physician Services, Hawthorne, New York
| | - Suhas M Nafday
- Division of Neonatology, Department of Pediatrics, Children's Hospital at Montefiore (Jack D. Weiler Hospital of Einstein Division) and Albert Einstein College of Medicine, Bronx, New York
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12
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Wu TW, Wisnowski JL, Geisler RF, Reitman A, Ho E, Tamrazi B, Chapman R, Blüml S. An In Vivo Assessment of Regional Brain Temperature during Whole-Body Cooling for Neonatal Encephalopathy. J Pediatr 2020; 220:73-79.e3. [PMID: 32089332 PMCID: PMC7265905 DOI: 10.1016/j.jpeds.2020.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/05/2019] [Accepted: 01/10/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To assess differences in regional brain temperatures during whole-body hypothermia and test the hypothesis that brain temperature profile is nonhomogenous in infants with hypoxic-ischemic encephalopathy. STUDY DESIGN Infants with hypoxic-ischemic encephalopathy were enrolled prospectively in this observational study. Magnetic resonance (MR) spectra of basal ganglia, thalamus, cortical gray matter, and white matter (WM) were acquired during therapeutic hypothermia. Regional brain tissue temperatures were calculated from the chemical shift difference between water signal and metabolites in the MR spectra after performing calibration measurements. Overall difference in regional temperature was analyzed by mixed-effects model; temperature among different patterns and severity of injury on MR imaging also was analyzed. Correlation between temperature and depth of brain structure was analyzed using repeated-measures correlation. RESULTS In total, 53 infants were enrolled (31 girls, mean gestational age: 38.6 ± 2 weeks; mean birth weight: 3243 ± 613 g). MR spectroscopy was acquired at mean age of 2.2 ± 0.6 days. A total of 201 MR spectra were included in the analysis. The thalamus, the deepest structure (36.4 ± 2.3 mm from skull surface), was lowest in temperature (33.2 ± 0.8°C, compared with basal ganglia: 33.5 ± 0.9°C; gray matter: 33.6 ± 0.7°C; WM: 33.8 ± 0.9°C, all P < .001). Temperatures in more superficial gray matter and WM regions (depth: 21.9 ± 2.4 and 21.5 ± 2.2 mm) were greater than the rectal temperatures (33.4 ± 0.4°C, P < .03). There was a negative correlation between temperature and depth of brain structure (rrm = -0.36, P < .001). CONCLUSIONS Whole-body hypothermia was effective in cooling deep brain structures, whereas superficial structures were warmer, with temperatures significantly greater than rectal temperatures.
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Affiliation(s)
- Tai-Wei Wu
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Jessica L. Wisnowski
- Department of Radiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA;,Rudi Schulte Research Institute, Santa Barbara, CA
| | - Robert F. Geisler
- Division of Neonatology, Children’s Hospital, Fetal and Neonatal Institute, Los Angeles
| | - Aaron Reitman
- Division of Neonatology, Children’s Hospital, Fetal and Neonatal Institute, Los Angeles
| | - Eugenia Ho
- Division of Neurology, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Benita Tamrazi
- Department of Radiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Rachel Chapman
- Division of Neonatology, Children’s Hospital, Fetal and Neonatal Institute, Los Angeles;,Department of Pediatrics, Keck School of Medicine, University of Southern California
| | - Stefan Blüml
- Department of Radiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA;,Rudi Schulte Research Institute, Santa Barbara, CA
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13
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Koehn J, Wang R, de Rojas Leal C, Kallmünzer B, Winder K, Köhrmann M, Kollmar R, Schwab S, Hilz MJ. Neck cooling induces blood pressure increase and peripheral vasoconstriction in healthy persons. Neurol Sci 2020; 41:2521-2529. [PMID: 32219592 PMCID: PMC8197712 DOI: 10.1007/s10072-020-04349-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/16/2020] [Indexed: 12/18/2022]
Abstract
Introduction Noninvasive temperature modulation by localized neck cooling might be desirable in the prehospital phase of acute hypoxic brain injuries. While combined head and neck cooling induces significant discomfort, peripheral vasoconstriction, and blood pressure increase, localized neck cooling more selectively targets blood vessels that supply the brain, spares thermal receptors of the face and skull, and might therefore cause less discomfort cardiovascular side effects compared to head- and neck cooling. The purpose of this study is to assess the effects of noninvasive selective neck cooling on cardiovascular parameters and cerebral blood flow velocity (CBFV). Methods Eleven healthy persons (6 women, mean age 42 ± 11 years) underwent 90 min of localized dorsal and frontal neck cooling (EMCOOLS Brain.Pad™) without sedation. Before and after cooling onset, and after every 10 min of cooling, we determined rectal, tympanic, and neck skin temperatures. Before and after cooling onset, after 60- and 90-min cooling, we monitored RR intervals (RRI), systolic, diastolic blood pressures (BPsys, BPdia), laser Doppler skin blood flow (SBF) at the index finger pulp, and CBFV at the proximal middle cerebral artery (MCA). We compared values before and during cooling by analysis of variance for repeated measurements with post hoc analysis (significance: p < 0.05). Results Neck skin temperature dropped significantly by 9.2 ± 4.5 °C (minimum after 40 min), while tympanic temperature decreased by only 0.8 ± 0.4 °C (minimum after 50 min), and rectal temperature by only 0.2 ± 0.3 °C (minimum after 60 min of cooling). Index finger SBF decreased (by 83.4 ± 126.0 PU), BPsys and BPdia increased (by 11.2 ± 13.1 mmHg and 8.0 ± 10.1 mmHg), and heart rate slowed significantly while MCA-CBFV remained unchanged during cooling. Conclusions While localized neck cooling prominently lowered neck skin temperature, it had little effect on tympanic temperature but significantly increased BP which may have detrimental effects in patients with acute brain injuries.
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Affiliation(s)
- Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Carmen de Rojas Leal
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Klemens Winder
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Rainer Kollmar
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.,Department of Neurology, General Hospital Darmstadt, Grafenstr. 9, 64283, Darmstadt, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany. .,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Lempke LB, Fraser JJ, Erdman NK, Barone NA, Saliba S, Resch JE. The Effects of Cranial Cryotherapy on Hemodynamics and Cognition in Healthy Adults. TRANSLATIONAL JOURNAL OF THE AMERICAN COLLEGE OF SPORTS MEDICINE 2020. [DOI: 10.1249/tjx.0000000000000124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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15
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Ko TS, Mavroudis CD, Baker WB, Morano VC, Mensah-Brown K, Boorady TW, Schmidt AL, Lynch JM, Busch DR, Gentile J, Bratinov G, Lin Y, Jeong S, Melchior RW, Rosenthal TM, Shade BC, Schiavo KL, Xiao R, Gaynor JW, Yodh AG, Kilbaugh TJ, Licht DJ. Non-invasive optical neuromonitoring of the temperature-dependence of cerebral oxygen metabolism during deep hypothermic cardiopulmonary bypass in neonatal swine. J Cereb Blood Flow Metab 2020; 40:187-203. [PMID: 30375917 PMCID: PMC6928559 DOI: 10.1177/0271678x18809828] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Management of deep hypothermic (DH) cardiopulmonary bypass (CPB), a critical neuroprotective strategy, currently relies on non-invasive temperature to guide cerebral metabolic suppression during complex cardiac surgery in neonates. Considerable inter-subject variability in temperature response and residual metabolism may contribute to the persisting risk for postoperative neurological injury. To characterize and mitigate this variability, we assess the sufficiency of conventional nasopharyngeal temperature (NPT) guidance, and in the process, validate combined non-invasive frequency-domain diffuse optical spectroscopy (FD-DOS) and diffuse correlation spectroscopy (DCS) for direct measurement of cerebral metabolic rate of oxygen (CMRO2). During CPB, n = 8 neonatal swine underwent cooling from normothermia to 18℃, sustained DH perfusion for 40 min, and then rewarming to simulate cardiac surgery. Continuous non-invasive and invasive measurements of intracranial temperature (ICT) and CMRO2 were acquired. Significant hysteresis (p < 0.001) between cooling and rewarming periods in the NPT versus ICT and NPT versus CMRO2 relationships were found. Resolution of this hysteresis in the ICT versus CMRO2 relationship identified a crucial insufficiency of conventional NPT guidance. Non-invasive CMRO2 temperature coefficients with respect to NPT (Q10 = 2.0) and ICT (Q10 = 2.5) are consistent with previous reports and provide further validation of FD-DOS/DCS CMRO2 monitoring during DH CPB to optimize management.
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Affiliation(s)
- Tiffany S Ko
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA.,Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA.,Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Constantine D Mavroudis
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Wesley B Baker
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vincent C Morano
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - Kobina Mensah-Brown
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Timothy W Boorady
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Jennifer M Lynch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David R Busch
- Department of Anesthesiology & Pain Management, University of Texas Southwestern, Dallas, TX, USA.,Department of Neurology & Neurotherapeutics, University of Texas Southwestern, Dallas, TX, USA
| | - Javier Gentile
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - George Bratinov
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yuxi Lin
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sejin Jeong
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Richard W Melchior
- Department of Perfusion Services, Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tami M Rosenthal
- Department of Perfusion Services, Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brandon C Shade
- Department of Perfusion Services, Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kellie L Schiavo
- Department of Perfusion Services, Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rui Xiao
- Department of Pediatrics, Division of Biostatistics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Licht
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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16
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Nonato M, Gheler L, Balestrieri JV, Audi M, Prandini M. Selective head cooling and whole body cooling as neuroprotective agents in severe perinatal asphyxia. ACTA ACUST UNITED AC 2019; 65:1116-1121. [PMID: 31531612 DOI: 10.1590/1806-9282.65.8.1116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/09/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The possibility that hypothermia has a therapeutic role during or after resuscitation from severe perinatal asphyxia has been a longstanding focus of research. Studies designed around this fact have shown that moderate cerebral hypothermia, initiated as early as possible, has been associated with potent, long-lasting neuroprotection in perinatal patients. OBJECTIVES To review the benefits of hypothermia in improving cellular function, based on the cellular characteristics of hypoxic-ischemic cerebral injury and compare the results of two different methods of cooling the brain parenchyma. METHODS Medline, Lilacs, Scielo, and PubMed were searched for articles registered between 1990 and 2019 in Portuguese and English, focused on trials comparing the safety and effectiveness of total body cooling with selective head cooling with HIE. RESULTS We found that full-body cooling provides homogenous cooling to all brain structures, including the peripheral and central regions of the brain. Selective head cooling provides a more extensive cooling to the cortical region of the brain than to the central structures. CONCLUSIONS Both methods demonstrated to have neuroprotective properties, although full-body cooling provides a broader area of protection. Recently, head cooling combined with some body cooling has been applied, which is the most promising approach. The challenge for the future is to find ways of improving the effectiveness of the treatment.
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Affiliation(s)
- Mahara Nonato
- Estudante de Medicina, Faculdade de Medicina do ABC - FMABC, Santo André , SP , Brasil
| | - Larissa Gheler
- Estudante de Medicina, Unifai , Adamantina , SP , Brasil
| | - João Vitor Balestrieri
- Estudante de Medicina, Universidade dos Grandes Lagos -Unilago, São José do Rio Preto , SP , Brasil
| | - Marise Audi
- Neurocirurgia Pediátrica, Hospital Beneficência Portuguesa - São Paulo , SP , Brasil
| | - Mirto Prandini
- Médico - PhD - Professor Associado Livre Docente - Universidade Federal de São Paulo - Unifesp, São Paulo , SP , Brasil
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17
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Wassink G, Davidson JO, Dhillon SK, Zhou K, Bennet L, Thoresen M, Gunn AJ. Therapeutic Hypothermia in Neonatal Hypoxic-Ischemic Encephalopathy. Curr Neurol Neurosci Rep 2019; 19:2. [PMID: 30637551 DOI: 10.1007/s11910-019-0916-0] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Therapeutic hypothermia reduces death or disability in term and near-term infants with moderate-severe hypoxic-ischemic encephalopathy. Nevertheless, many infants still survive with disability, despite hypothermia, supporting further research in to ways to further improve neurologic outcomes. RECENT FINDINGS Recent clinical and experimental studies have refined our understanding of the key parameters for hypothermic neuroprotection, including timing of initiation, depth, and duration of hypothermia, and subsequent rewarming rate. However, important knowledge gaps remain. There is encouraging clinical evidence from a small phase II trial that combined treatment of hypothermia with recombinant erythropoietin further reduces risk of disability but definitive studies are still needed. In conclusion, recent studies suggest that current protocols for therapeutic hypothermia are near-optimal, and that the key to better neurodevelopmental outcomes is earlier diagnosis and initiation of hypothermia after birth. Further research is essential to find and evaluate ways to further improve outcomes after hypoxic-ischemic encephalopathy, including add-on therapies for therapeutic hypothermia and preventing pyrexia during labor and delivery.
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Affiliation(s)
- Guido Wassink
- Department of Physiology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Joanne O Davidson
- Department of Physiology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Simerdeep K Dhillon
- Department of Physiology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Kelly Zhou
- Department of Physiology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Laura Bennet
- Department of Physiology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Marianne Thoresen
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Alistair J Gunn
- Department of Physiology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, 92019, New Zealand.
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18
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Ibrani D, Molacavage S. The Six-Hour Window: How the Community Hospital Nursery Can Optimize Outcomes of the Infant with Suspected Hypoxic-Ischemic Encephalopathy. Neonatal Netw 2018; 37:155-163. [PMID: 29789056 DOI: 10.1891/0730-0832.37.3.155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Perinatal hypoxia is a devastating event before, during, or immediately after birth that deprives an infant's vital organs of oxygen. This injury at birth often requires a complex resuscitation and increases the newborn's risk of hypoxic-ischemic encephalopathy (HIE). The resuscitation team in a community hospital nursery may have less experience with complex resuscitation and post-resuscitation care of this infant than a NICU. This article provides the neonatal nurse in a Level I or Level II nursery with information about resuscitation and post-resuscitation care of an infant at risk of HIE while awaiting transport to a NICU for therapeutic cooling. The article describes the infant at risk for HIE, discusses pathophysiology and treatment of HIE, and lists essential components of post-resuscitation care while awaiting transport to an NICU, the importance of communication with the receiving NICU, and strategies for supporting the family.
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19
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Zhu L. Hypothermia Used in Medical Applications for Brain and Spinal Cord Injury Patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1097:295-319. [PMID: 30315552 DOI: 10.1007/978-3-319-96445-4_16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite more than 80 years of animal experiments and clinical practice, efficacy of hypothermia in improving treatment outcomes in patients suffering from cell and tissue damage caused by ischemia is still ongoing. This review will first describe the history of utilizing cooling in medical treatment, followed by chemical and biochemical mechanisms of cooling that can lead to neuroprotection often observed in animal studies and some clinical studies. The next sections will be focused on current cooling approaches/devices, as well as cooling parameters recommended by researchers and clinicians. Animal and clinical studies of implementing hypothermia to spinal cord and brain tissue injury patients are presented next. This section will review the latest outcomes of hypothermia in treating patients suffering from traumatic brain injury (TBI), spinal cord injury (SCI), stroke, cardiopulmonary surgery, and cardiac arrest, followed by a summary of available evidence regarding both demonstrated neuroprotection and potential risks of hypothermia. Contributions from bioengineers to the field of hypothermia in medical treatment will be discussed in the last section of this review. Overall, an accumulating body of clinical evidence along with several decades of animal research and mathematical simulations has documented that the efficacy of hypothermia is dependent on achieving a reduced temperature in the target tissue before or soon after the injury-precipitating event. Mild hypothermia with temperature reduction of several degrees Celsius is as effective as modest or deep hypothermia in providing therapeutic benefit without introducing collateral/systemic complications. It is widely demonstrated that the rewarming rate must be controlled to be lower than 0.5 °C/h to avoid mismatch between local blood perfusion and metabolism. In the past several decades, many different cooling methods and devices have been designed, tested, and used in medical treatments with mixed results. Accurately designing treatment protocols to achieve specific cooling outcomes requires collaboration among engineers, researchers, and clinicians. Although this problem is quite challenging, it presents a major opportunity for bioengineers to create methods and devices that quickly and safely produce hypothermia in targeted tissue regions without interfering with routine medical treatment.
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Affiliation(s)
- Liang Zhu
- Department of Mechanical Engineering, University of Maryland Baltimore County, Baltimore, MD, USA.
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20
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Owji ZP, Gilbert G, Saint-Martin C, Wintermark P. Brain Temperature Is Increased During the First Days of Life in Asphyxiated Newborns: Developing Brain Injury Despite Hypothermia Treatment. AJNR Am J Neuroradiol 2017; 38:2180-2186. [PMID: 28860214 DOI: 10.3174/ajnr.a5350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/12/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND PURPOSE Therapeutic hypothermia is the current treatment for neonates with hypoxic-ischemic encephalopathy. It is believed to work by decreasing the brain temperature and reducing the baseline metabolism and energy demand of the brain. This study aimed to noninvasively assess brain temperature during the first month of life in neonates with hypoxic-ischemic encephalopathy treated with hypothermia. MATERIALS AND METHODS Neonates with hypoxic-ischemic encephalopathy treated with hypothermia and healthy neonates were enrolled prospectively. MR imaging was used to identify the presence and extent of brain injury. MR imaging multivoxel spectroscopy was used to derive brain temperatures in the basal ganglia and white matter at different time points during the first month of life. Brain temperature measurements were compared between neonates with hypoxic-ischemic encephalopathy and healthy neonates. RESULTS Forty-three term neonates with hypoxic-ischemic encephalopathy treated with hypothermia had a total of 74 spectroscopy scans, and 3 healthy term neonates had a total of 9 spectroscopy scans during the first month of life. Brain temperatures were lower in neonates with hypoxic-ischemic encephalopathy during hypothermia, compared with the healthy neonates (respectively, on day 1 of life: basal ganglia, 38.81°C ± 2.08°C, and white matter, 39.11°C ± 1.99°C; and on days 2-3 of life: basal ganglia, 38.25°C ± 0.91°C, and white matter, 38.54°C ± 2.79°C). However, neonates with hypoxic-ischemic encephalopathy who developed brain injury had higher brain temperatures during hypothermia (respectively, on day 1 of life: basal ganglia, 35.55°C ± 1.31°C, and white matter, 37.35°C ± 2.55°C; and on days 2-3 of life: basal ganglia, 35.20°C ± 1.15°C, and white matter, 35.44°C ± 1.90°C) compared with neonates who did not develop brain injury (respectively, on day 1 of life: basal ganglia, 34.46°C ± 1.09°C, and white matter, 33.97°C ± 1.42°C; and on days 2-3 of life: basal ganglia, 33.90°C ± 1.34°C, and white matter, 33.07°C ± 1.71°C). Also, brain temperatures tended to remain slightly higher in the neonates who developed brain injury around day 10 of life and around 1 month of age. CONCLUSIONS Therapeutic hypothermia using current guidelines decreased the brain temperature of neonates with hypoxic-ischemic encephalopathy during the first days of life but did not prevent an early increase of brain temperature in neonates with hypoxic-ischemic encephalopathy who developed brain injury despite this treatment.
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Affiliation(s)
- Z P Owji
- From the Department of Pediatrics, Division of Newborn Medicine, Research Institute of the McGill University Health Centre (Z.P.O., P.W.)
| | - G Gilbert
- MR Clinical Science (G.G.), Philips Healthcare, Montreal, Quebec, Canada
| | - C Saint-Martin
- Department of Pediatric Radiology (C.S.-M.), Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - P Wintermark
- From the Department of Pediatrics, Division of Newborn Medicine, Research Institute of the McGill University Health Centre (Z.P.O., P.W.)
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21
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Lilla N, Rinne C, Weiland J, Linsenmann T, Ernestus RI, Westermaier T. Early Transient Mild Hypothermia Attenuates Neurologic Deficits and Brain Damage After Experimental Subarachnoid Hemorrhage in Rats. World Neurosurg 2017; 109:e88-e98. [PMID: 28951276 DOI: 10.1016/j.wneu.2017.09.109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 09/15/2017] [Accepted: 09/16/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Metabolic exhaustion in ischemic tissue is the basis for a detrimental cascade of cell damage. In the acute stage of subarachnoid hemorrhage (SAH), a sequence of global and focal ischemia occurs, threatening brain tissue to undergo ischemic damage. This study was conducted to investigate whether early therapy with moderate hypothermia can offer neuroprotection after experimental SAH. METHODS Twenty male Sprague-Dawley rats were subjected to SAH and treated by active cooling (34°C) or served as controls by continuous maintenance of normothermia (37.0°C). Mean arterial blood pressure, intracranial pressure, and local cerebral blood flow over both hemispheres were continuously measured. Neurologic assessment was performed 24 hours later. Hippocampal damage was assessed by hematoxylin-eosin and caspase-3 staining. RESULTS By a slight increase of mean arterial blood pressure in the cooling phase and a significant reduction of intracranial pressure, hypothermia improved cerebral perfusion pressure in the first 60 minutes after SAH. Accordingly, a trend to increased cerebral blood flow was observed during this period. The rate of injured neurons was significantly reduced in hypothermia-treated animals compared with normothermic controls. CONCLUSIONS The results of this series cannot finally answer whether this form of treatment permanently attenuates or only delays ischemic damage. In the latter case, slowing down metabolic exhaustion by hypothermia may still be a valuable treatment during this state of ischemic brain damage and prolong the therapeutic window for possible causal treatments of the acute perfusion deficit. Therefore, it may be useful as a first-tier therapy in suspected SAH.
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Affiliation(s)
- Nadine Lilla
- Department of Neurosurgery, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Christoph Rinne
- Department of Neurosurgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Judith Weiland
- Department of Neurosurgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Thomas Linsenmann
- Department of Neurosurgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, University Hospital Wuerzburg, Wuerzburg, Germany
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22
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Metzler M, Govindan R, Al-Shargabi T, Vezina G, Andescavage N, Wang Y, du Plessis A, Massaro AN. Pattern of brain injury and depressed heart rate variability in newborns with hypoxic ischemic encephalopathy. Pediatr Res 2017; 82:438-443. [PMID: 28376079 PMCID: PMC5570625 DOI: 10.1038/pr.2017.94] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 03/17/2017] [Indexed: 12/27/2022]
Abstract
BackgroundDecreased heart rate variability (HRV) is a measure of autonomic dysfunction and brain injury in newborns with hypoxic ischemic encephalopathy (HIE). This study aimed to characterize the relationship between HRV and brain injury pattern using magnetic resonance imaging (MRI) in newborns with HIE undergoing therapeutic hypothermia.MethodsHRV metrics were quantified in the time domain (αS, αL, and root mean square at short (RMSS) and long (RMSL) timescales) and frequency domain (relative low-(LF) and high-frequency (HF) power) over 24-27 h of life. The brain injury pattern shown by MRI was classified as no injury, pure cortical/white matter injury, mixed watershed/mild basal ganglia injury, predominant basal ganglia or global injury, and death. HRV metrics were compared across brain injury pattern groups using a random-effects mixed model.ResultsData from 74 infants were analyzed. Brain injury pattern was significantly associated with the degree of HRV suppression. Specifically, negative associations were observed between the pattern of brain injury and RMSS (estimate -0.224, SE 0.082, P=0.006), RMSL (estimate -0.189, SE 0.082, P=0.021), and LF power (estimate -0.044, SE 0.016, P=0.006).ConclusionDegree of HRV depression is related to the pattern of brain injury. HRV monitoring may provide insights into the pattern of brain injury at the bedside.
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Affiliation(s)
- Marina Metzler
- Division of Fetal and Transitional Medicine, Children’s National Health System, Washington, DC
| | - Rathinaswamy Govindan
- Division of Fetal and Transitional Medicine, Children’s National Health System, Washington, DC,The George Washington University School of Medicine, Washington, DC
| | - Tareq Al-Shargabi
- Division of Fetal and Transitional Medicine, Children’s National Health System, Washington, DC
| | - Gilbert Vezina
- Division of Diagnostic Imaging and Radiology, Children’s National Health System, Washington, DC,The George Washington University School of Medicine, Washington, DC
| | - Nickie Andescavage
- Divsion of Neonatology, Children’s National Health System, Washington, DC,The George Washington University School of Medicine, Washington, DC
| | - Yunfei Wang
- Division of Biostatistics and Study Methodology, Children’s National Health System, Washington, DC,The George Washington University School of Medicine, Washington, DC
| | - Adre du Plessis
- Division of Fetal and Transitional Medicine, Children’s National Health System, Washington, DC,The George Washington University School of Medicine, Washington, DC
| | - An N Massaro
- Division of Fetal and Transitional Medicine, Children’s National Health System, Washington, DC,Divsion of Neonatology, Children’s National Health System, Washington, DC,The George Washington University School of Medicine, Washington, DC
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Ji LY, Li XL, Liu Y, Sun XW, Wang HF, Chen L, Gao L. Time-Dependent Effects of Acute Exercise on University Students' Cognitive Performance in Temperate and Cold Environments. Front Psychol 2017; 8:1192. [PMID: 28747896 PMCID: PMC5506219 DOI: 10.3389/fpsyg.2017.01192] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 06/29/2017] [Indexed: 01/05/2023] Open
Abstract
Background: Few studies have examined the acute exercise-induced changes in cognitive performance in different thermal environments and the time course effects. Objective: Investigate the time-dependent effects of acute exercise on university students’ processing speed, working memory and cognitive flexibility in temperate and cold environments. Method: Twenty male university students (age 23.5 ± 2.0 years) with moderate physical activity level participated in a repeated-measures within-subjects design. Processing speed, working memory and cognitive flexibility were assessed using CogState test battery at baseline (BASE), followed by a 45-min rest (REST), immediately after (EX) and 30 min after (POST-EX) 30-min moderate-intensity treadmill running in both temperate (TEMP; 25°C) and cold (COLD; 10°C) environments. Mean skin temperature (MST) and thermal sensation (TS) were also recorded. Two-way repeated measures ANOVA was performed to analyze each variable. Spearman’s rho was used to identify the correlations between MST, TS and cognitive performance. Results: Reaction time (RT) of processing speed and working memory decreased immediately after exercise in both conditions (processing speed: p = 0.003; working memory: p = 0.007). The facilitating effects on processing speed disappeared within 30 min after exercise in TEMP (p = 0.163) and COLD (p = 0.667), while improvements on working memory remained 30 min after exercise in TEMP (p = 0.047), but not in COLD (p = 0.663). Though RT of cognitive flexibility reduced in both conditions (p = 0.003), no significance was found between EX and REST (p = 0.135). Increased MST and TS were significantly associated with reductions in processing speed RT (MST: r = -0.341, p < 0.001; TS: r = -0.262, p = 0.001) and working memory RT (MST: r = -0.282, p < 0.001; TS: r = -0.2229, p = 0.005), and improvements in working memory accuracy (MST: r = 0.249, p = 0.002; TS: r = 0.255, p = 0.001). Conclusion: The results demonstrate different time-dependent effects of acute exercise on cognition in TEMP and COLD. Our study reveals facilitating effects of exercise on university students’ processing speed and working memory in both environments. However, in contrast to TEMP, effects on working memory in COLD are transient.
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Affiliation(s)
- Ling-Yu Ji
- School of Mechanical Engineering, Xi'an Jiaotong UniversityXi'an, China
| | - Xiao-Ling Li
- School of Mechanical Engineering, Xi'an Jiaotong UniversityXi'an, China
| | - Yang Liu
- School of Mechanical Engineering, Xi'an Jiaotong UniversityXi'an, China
| | - Xiu-Wen Sun
- School of Mechanical Engineering, Xi'an Jiaotong UniversityXi'an, China
| | - Hui-Fen Wang
- School of Mechanical Engineering, Xi'an Jiaotong UniversityXi'an, China
| | - Long Chen
- China Research and Development Academy of Machinery EquipmentBeijing, China
| | - Liang Gao
- China Research and Development Academy of Machinery EquipmentBeijing, China
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Maoulainine FMR, Elbaz M, Elfaiq S, Boufrioua G, Elalouani FZ, Barkane M, El Idrissi Slitine N. Therapeutic Hypothermia in Asphyxiated Neonates: Experience from Neonatal Intensive Care Unit of University Hospital of Marrakech. Int J Pediatr 2017; 2017:3674140. [PMID: 28567061 PMCID: PMC5439062 DOI: 10.1155/2017/3674140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/02/2017] [Accepted: 03/16/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Therapeutic hypothermia (TH) is now recommended for the treatment neonates with hypoxic-ischemic encephalopathy (HIE). This treatment protocol is applied in our department since June 2012. The aim of this study is to report the first experience with head cooling in asphyxiated neonates in Morocco. PATIENTS AND METHODS Prospective study of newborns admitted for HIE from July 18, 2012, to May 15, 2014, in Neonatal Intensive Care Unit (NICU) of Mohamed VI University Hospital. The results were studied by comparing a newborn group who received hypothermia to a control group. RESULTS Seventy-two cases of neonates with perinatal asphyxia were admitted in the unit. According to inclusion criteria thirty-eight cases were eligible for the study. Only 19 cases have received the hypothermia protocol for different reason; the arrival beyond six hours of life was the main cause accounting for 41%. Complications of asphyxia were comparable in both groups with greater pulmonary hypertension recorded in the control group. The long-term follow-up of protocol group was normal in almost half of cases. CONCLUSION Our first experience with the controlled TH supports its beneficial effect in newborns with HIE. This treatment must be available in all the centers involved in the neonatal care in Morocco.
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Affiliation(s)
- F. M. R. Maoulainine
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
- Research Unit of Childhood Health and Development, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
| | - M. Elbaz
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
| | - S. Elfaiq
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
| | - G. Boufrioua
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
| | - F. Z. Elalouani
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
| | - M. Barkane
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
| | - Nadia El Idrissi Slitine
- Neonatal Intensive Care Unit, Mohamed VI University Hospital, Marrakech, Morocco
- Research Unit of Childhood Health and Development, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
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Therapeutic hypothermia translates from ancient history in to practice. Pediatr Res 2017; 81:202-209. [PMID: 27673420 PMCID: PMC5233584 DOI: 10.1038/pr.2016.198] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/28/2016] [Indexed: 12/16/2022]
Abstract
Acute postasphyxial encephalopathy around the time of birth remains a major cause of death and disability. The possibility that hypothermia may be able to prevent or lessen asphyxial brain injury is a "dream revisited". In this review, a historical perspective is provided from the first reported use of therapeutic hypothermia for brain injuries in antiquity, to the present day. The first uncontrolled trials of cooling for resuscitation were reported more than 50 y ago. The seminal insight that led to the modern revival of studies of neuroprotection was that after profound asphyxia, many brain cells show initial recovery from the insult during a short "latent" phase, typically lasting ~6 h, only to die hours to days later during a "secondary" deterioration phase characterized by seizures, cytotoxic edema, and progressive failure of cerebral oxidative metabolism. Studies designed around this conceptual framework showed that mild hypothermia initiated as early as possible before the onset of secondary deterioration, and continued for a sufficient duration to allow the secondary deterioration to resolve, is associated with potent, long-lasting neuroprotection. There is now compelling evidence from randomized controlled trials that mild induced hypothermia significantly improves intact survival and neurodevelopmental outcomes to midchildhood.
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Chalak LF, Tian F, Tarumi T, Zhang R. Cerebral Hemodynamics in Asphyxiated Newborns Undergoing Hypothermia Therapy: Pilot Findings Using a Multiple-Time-Scale Analysis. Pediatr Neurol 2016; 55:30-6. [PMID: 26858217 PMCID: PMC4748172 DOI: 10.1016/j.pediatrneurol.2015.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/21/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Improved quantitative assessment of cerebral hemodynamics in newborns might enable us to optimize cerebral perfusion. Our objective was to develop an approach to assess cerebral hemodynamics across multiple time scales during the first 72 hours of life in newborns during hypothermia therapy. METHODS Spontaneous oscillations in mean arterial pressure and regional cerebral tissue oxygen saturation were analyzed using a moving window correlation method with time scales ranging from 0.15 to 8 hours in this pilot methodology study. Abnormal neurodevelopmental outcome was defined by Bayley III scores and/or cerebral palsy by age 24 months using receiver operating curve. RESULTS Multiple-time-scale correlations between the mean arterial pressure and regional cerebral tissue oxygen saturation oscillations were tested in 10 asphyxiated newborns undergoing hypothermia therapy. Large noninduced fluctuations in the blood pressure were observed during cooling in all five infants with abnormal outcomes. Notably, these infants had two distinct patterns of correlation: a positive in-phase correlation at the short time scales (15 minutes) and/or a negative antiphase correlations observed at long time scales (4 hours.). Both the in-phase (area under the curve 0.6, [95% confidence interval 0.2-0.95]) and antiphase correlations (area under the curve 0.75, [95% confidence interval 0.4-0.95]) appeared to be related to an abnormal outcome. CONCLUSIONS Our observations suggest that the time scale is an important factor that needs to be standardized in the assessment of neonatal cerebral hemodynamics.
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Affiliation(s)
- Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Fenghua Tian
- Department of Bioengineering, University of Texas at Arlington, Dallas, Texas
| | - Takashi Tarumi
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas, Dallas, Texas
| | - Rong Zhang
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas, Dallas, Texas
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Tian F, Tarumi T, Liu H, Zhang R, Chalak L. Wavelet coherence analysis of dynamic cerebral autoregulation in neonatal hypoxic-ischemic encephalopathy. NEUROIMAGE-CLINICAL 2016; 11:124-132. [PMID: 26937380 PMCID: PMC4753811 DOI: 10.1016/j.nicl.2016.01.020] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 01/16/2016] [Accepted: 01/23/2016] [Indexed: 12/02/2022]
Abstract
Cerebral autoregulation represents the physiological mechanisms that keep brain perfusion relatively constant in the face of changes in blood pressure and thus plays an essential role in normal brain function. This study assessed cerebral autoregulation in nine newborns with moderate-to-severe hypoxic–ischemic encephalopathy (HIE). These neonates received hypothermic therapy during the first 72 h of life while mean arterial pressure (MAP) and cerebral tissue oxygenation saturation (SctO2) were continuously recorded. Wavelet coherence analysis, which is a time-frequency domain approach, was used to characterize the dynamic relationship between spontaneous oscillations in MAP and SctO2. Wavelet-based metrics of phase, coherence and gain were derived for quantitative evaluation of cerebral autoregulation. We found cerebral autoregulation in neonates with HIE was time-scale-dependent in nature. Specifically, the spontaneous changes in MAP and SctO2 had in-phase coherence at time scales of less than 80 min (< 0.0002 Hz in frequency), whereas they showed anti-phase coherence at time scales of around 2.5 h (~ 0.0001 Hz in frequency). Both the in-phase and anti-phase coherence appeared to be related to worse clinical outcomes. These findings suggest the potential clinical use of wavelet coherence analysis to assess dynamic cerebral autoregulation in neonatal HIE during hypothermia. Cerebral hemodynamics in HIE neonates were continuously recorded in hypothermia. Wavelet coherence can be used to assess dynamic autoregulation in HIE neonates. Wavelet-derived metrics have about 88.9% accuracy in predicting clinical outcomes. Wavelet phase, coherence, and gain are validated against transfer function analysis. Cerebral autoregulation in HIE neonates is time-scale-dependent in a wide range.
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Affiliation(s)
- Fenghua Tian
- Department of Bioengineering, University of Texas at Arlington, United States
| | - Takashi Tarumi
- Department of Internal Medicine, University of Texas Southwestern Medical Center, United States; Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, United States; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas, United States
| | - Hanli Liu
- Department of Bioengineering, University of Texas at Arlington, United States
| | - Rong Zhang
- Department of Internal Medicine, University of Texas Southwestern Medical Center, United States; Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, United States; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas, United States
| | - Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, United States.
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Sex differences in behavioral outcomes following temperature modulation during induced neonatal hypoxic ischemic injury in rats. Brain Sci 2015; 5:220-40. [PMID: 26010486 PMCID: PMC4493466 DOI: 10.3390/brainsci5020220] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 04/24/2015] [Accepted: 05/12/2015] [Indexed: 12/30/2022] Open
Abstract
Neonatal hypoxia ischemia (HI; reduced oxygen and/or blood flow to the brain) can cause various degrees of tissue damage, as well as subsequent cognitive/behavioral deficits such as motor, learning/memory, and auditory impairments. These outcomes frequently result from cardiovascular and/or respiratory events observed in premature infants. Data suggests that there is a sex difference in HI outcome, with males being more adversely affected relative to comparably injured females. Brain/body temperature may play a role in modulating the severity of an HI insult, with hypothermia during an insult yielding more favorable anatomical and behavioral outcomes. The current study utilized a postnatal day (P) 7 rodent model of HI injury to assess the effect of temperature modulation during injury in each sex. We hypothesized that female P7 rats would benefit more from lowered body temperatures as compared to male P7 rats. We assessed all subjects on rota-rod, auditory discrimination, and spatial/non-spatial maze tasks. Our results revealed a significant benefit of temperature reduction in HI females as measured by most of the employed behavioral tasks. However, HI males benefitted from temperature reduction as measured on auditory and non-spatial tasks. Our data suggest that temperature reduction protects both sexes from the deleterious effects of HI injury, but task and sex specific patterns of relative efficacy are seen.
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Hoque N, Liu X, Chakkarapani E, Thoresen M. Minimal systemic hypothermia combined with selective head cooling evaluated in a pig model of hypoxia-ischemia. Pediatr Res 2015; 77:674-80. [PMID: 25665052 DOI: 10.1038/pr.2015.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 11/03/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Selective head cooling (SHC) with moderate hypothermia (HT) and whole-body cooling are beneficial following perinatal asphyxia. SHC with systemic normothermia (NT) or minimal HT is under-investigated, could obviate systemic complications of moderate HT, and be applicable to preterm infants. We hypothesized that minimal systemic HT with SHC following hypoxia-ischemia (HI) would be neuroprotective compared with systemic NT. METHODS Newborn pigs underwent global HI causing permanent brain injury before being randomized to NT (rectal temperature (Trectal) 38.5 °C) or minimal HT (Trectal 37.0 °C) with SHC (cooling cap and body wrap) for 48 h followed by 24-h NT with 72-h survival. RESULTS SHC did not reduce global or regional neuropathology score when correcting for insult severity or compared with a NT group matched for HI severity but increased mortality by 26%. During 48 h, the SHC mean ± SD Trectal was 37.0 ± 0.2 °C, and Tdeep brain and Tsuperficial brain were 35.0 ± 1.1 °C and 31.5 ± 1.6 °C, respectively, with stable Tbrain achieved ≥ 3 h after starting cooling. CONCLUSION This is the first study in newborn pigs of minimal systemic HT with SHC for 48 h and a further 24 h of NT following HI. Mortality was increased in the cooled group with no neuroprotection in survivors.
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Affiliation(s)
- Nicholas Hoque
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, Bristol, Avon, UK
| | - Xun Liu
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, Bristol, Avon, UK
| | - Ela Chakkarapani
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, Bristol, Avon, UK
| | - Marianne Thoresen
- 1] Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, Bristol, Avon, UK [2] Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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La Fontaine MD, McDaniel LS, Kubicek LN, Chappell RJ, Forrest LJ, Jeraj R. Patient characteristics influencing the variability of distributed parameter-based models in DCE-CT kinetic analysis. Vet Comp Oncol 2015; 15:105-117. [PMID: 25702795 DOI: 10.1111/vco.12143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 01/07/2015] [Accepted: 01/13/2015] [Indexed: 12/17/2022]
Abstract
Kinetic parameter variability may be sensitive to kinetic model choice, kinetic model implementation or patient-specific effects. The purpose of this study was to assess their impact on the variability of dynamic contrast-enhanced computed tomography (DCE-CT) kinetic parameters. A total of 11 canine patients with sinonasal tumours received high signal-to-noise ratio, test-double retest DCE-CT scans. The variability for three distributed parameter (DP)-based models was assessed by analysis of variance. Mixed-effects modelling evaluated patient-specific effects. Inter-model variability (CVinter ) was comparable to or lower than intra-model variability (CVintra ) for blood flow (CVinter :[4-28%], CVintra :[28-31%]), fractional vascular volume (CVinter :[3-17%], CVintra :[16-19%]) and permeability-surface area product (CVinter :[5-12%], CVintra :[14-15%]). The kinetic models were significantly (P<0.05) impacted by patient characteristics for patient size, area underneath the curve of the artery and of the tumour. In conclusion, DP-based models demonstrated good agreement with similar differences between models and scans. However, high variability in the kinetic parameters and their sensitivity to patient size may limit certain quantitative applications.
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Affiliation(s)
- M D La Fontaine
- Department of Medical Physics, University of Wisconsin, Madison, WI, USA
| | - L S McDaniel
- Department of Statistics, University of Wisconsin, Madison, WI, USA
| | - L N Kubicek
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, WI, USA
| | - R J Chappell
- Department of Statistics, University of Wisconsin, Madison, WI, USA
| | - L J Forrest
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, WI, USA
| | - R Jeraj
- Department of Medical Physics, University of Wisconsin, Madison, WI, USA
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Tusor N, Edwards AD. Birth asphyxia: 100 years of progress. J Pediatr 2014; 165:1081-3. [PMID: 25282068 DOI: 10.1016/j.jpeds.2014.08.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 08/26/2014] [Indexed: 01/07/2023]
Affiliation(s)
- Nora Tusor
- Center for the Developing Brain, Department of Perinatal Imaging and Health, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom
| | - A David Edwards
- Center for the Developing Brain, Department of Perinatal Imaging and Health, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom.
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Wang H, Wang B, Normoyle KP, Jackson K, Spitler K, Sharrock MF, Miller CM, Best C, Llano D, Du R. Brain temperature and its fundamental properties: a review for clinical neuroscientists. Front Neurosci 2014; 8:307. [PMID: 25339859 PMCID: PMC4189373 DOI: 10.3389/fnins.2014.00307] [Citation(s) in RCA: 190] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 09/12/2014] [Indexed: 01/13/2023] Open
Abstract
Brain temperature, as an independent therapeutic target variable, has received increasingly intense clinical attention. To date, brain hypothermia represents the most potent neuroprotectant in laboratory studies. Although the impact of brain temperature is prevalent in a number of common human diseases including: head trauma, stroke, multiple sclerosis, epilepsy, mood disorders, headaches, and neurodegenerative disorders, it is evident and well recognized that the therapeutic application of induced hypothermia is limited to a few highly selected clinical conditions such as cardiac arrest and hypoxic ischemic neonatal encephalopathy. Efforts to understand the fundamental aspects of brain temperature regulation are therefore critical for the development of safe, effective, and pragmatic clinical treatments for patients with brain injuries. Although centrally-mediated mechanisms to maintain a stable body temperature are relatively well established, very little is clinically known about brain temperature's spatial and temporal distribution, its physiological and pathological fluctuations, and the mechanism underlying brain thermal homeostasis. The human brain, a metabolically "expensive" organ with intense heat production, is sensitive to fluctuations in temperature with regards to its functional activity and energy efficiency. In this review, we discuss several critical aspects concerning the fundamental properties of brain temperature from a clinical perspective.
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Affiliation(s)
- Huan Wang
- Department of Neurosurgery, Carle Foundation Hospital, University of Illinois College of Medicine at Urbana-ChampaignUrbana, IL, USA
- Thermal Neuroscience Laboratory, Beckman Institute, University of Illinois at Urbana-ChampaignUrbana, IL, USA
| | - Bonnie Wang
- Department of Internal Medicine, Carle Foundation Hospital, University of Illinois College of Medicine at Urbana-ChampaignUrbana, IL, USA
| | - Kieran P. Normoyle
- Department of Internal Medicine, College of Medicine at Urbana-Champaign, University of IllinoisChampaign, Urbana, IL, USA
- Department of Molecular and Integrative Physiology, University of Illinois College of Medicine at Urbana-ChampaignUrbana, IL, USA
| | - Kevin Jackson
- Thermal Neuroscience Laboratory, Beckman Institute, University of Illinois at Urbana-ChampaignUrbana, IL, USA
| | - Kevin Spitler
- Department of Internal Medicine, Carle Foundation Hospital, University of Illinois College of Medicine at Urbana-ChampaignUrbana, IL, USA
| | - Matthew F. Sharrock
- Department of Internal Medicine, College of Medicine at Urbana-Champaign, University of IllinoisChampaign, Urbana, IL, USA
| | - Claire M. Miller
- Department of Internal Medicine, College of Medicine at Urbana-Champaign, University of IllinoisChampaign, Urbana, IL, USA
- Neuroscience Program, University of Illinois at Urbana-ChampaignUrbana, IL, USA
| | - Catherine Best
- Molecular and Cellular Biology, University of Illinois at Urbana-ChampaignUrbana, IL, USA
| | - Daniel Llano
- Thermal Neuroscience Laboratory, Beckman Institute, University of Illinois at Urbana-ChampaignUrbana, IL, USA
- Department of Molecular and Integrative Physiology, University of Illinois College of Medicine at Urbana-ChampaignUrbana, IL, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical SchoolBoston, MA, USA
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Chalak LF, Tarumi T, Zhang R. The "neurovascular unit approach" to evaluate mechanisms of dysfunctional autoregulation in asphyxiated newborns in the era of hypothermia therapy. Early Hum Dev 2014; 90:687-94. [PMID: 25062804 PMCID: PMC4170014 DOI: 10.1016/j.earlhumdev.2014.06.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 06/27/2014] [Indexed: 10/25/2022]
Abstract
Despite improvements in obstetrical and neonatal care, and introduction of hypothermia as a neuroprotective therapy, perinatal brain injury remains a frequent cause of cerebral palsy, mental retardation and epilepsy. The recognition of dysfunction of cerebral autoregulation is essential for a real time measure of efficacy to identify those who are at highest risk for brain injury. This article will focus on the "neurovascular unit" approach to the care of asphyxiated neonates and will address 1) potential mechanisms of dysfunctional cerebral blood flow (CBF) regulation, 2) optimal monitoring methodology such as NIRS (near infrared spectroscopy), and TCD (transcutaneous Doppler), and 3) clinical implications of monitoring in the neonatal intensive care setting in asphyxiated newborns undergoing hypothermia and rewarming. Critical knowledge of the functional regulation of the neurovascular unit may lead to improved ability to predict outcomes in real time during hypothermia, as well as differentiate non-responders who might benefit from additional therapies.
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Affiliation(s)
- Lina F. Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX,Correspondence: Lina F. Chalak, MD, MSCS, Associate professor at the University of Texas Southwestern Medical Center at Dallas, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, 5323 Harry Hines Boulevard, Dallas, Texas 75390-9063, Phone: (214) 648-3903, Fax: (214) 648-2481,
| | - Takashi Tarumi
- Department of internal medicine at University of Texas Southwestern Medical Center, Dallas, TX
| | - Rong Zhang
- Department of internal medicine at University of Texas Southwestern Medical Center, Dallas, TX
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Arango JI, Allred K, Adelson PD, Soni P, Stradleigh R, Wahnoun R, Carballo C. Hypothermia in hypoxic ischemic encephalopathy: a 5-year experience at Phoenix Children's Hospital Neuro NICU. Adv Pediatr 2014; 61:215-23. [PMID: 25037129 DOI: 10.1016/j.yapd.2014.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We found TH to be safe and effective in improving survival and neurodevelopmental outcomes following HIE in term children. Additionally, the use of a multidisciplinary team involved with these complex patients and the use of advanced monitoring techniques will likely assist in identifying second insults (ie, seizures), leading to more rapidly instituted treatments. Our study, however, had the limitation of including only retrospective data from patients in whom TH was provided. This makes it difficult to identify the specific sources for the improved outcomes and/or the presence of complications.
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Affiliation(s)
- Jorge I Arango
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA
| | - Kimberlee Allred
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA
| | - P David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA
| | - Parita Soni
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA
| | - Ryan Stradleigh
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA
| | - Remy Wahnoun
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA
| | - Cristina Carballo
- Barrow Neurological Institute at Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, USA.
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Iwata S, Tachtsidis I, Takashima S, Matsuishi T, Robertson NJ, Iwata O. Dual role of cerebral blood flow in regional brain temperature control in the healthy newborn infant. Int J Dev Neurosci 2014; 37:1-7. [DOI: 10.1016/j.ijdevneu.2014.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 05/21/2014] [Accepted: 05/27/2014] [Indexed: 11/25/2022] Open
Affiliation(s)
- Sachiko Iwata
- Centre for Developmental and Cognitive NeuroscienceDepartment of Paediatrics and Child HealthKurume University School of MedicineKurumeFukuokaJapan
- Institute for Women's HealthUniversity College LondonLondonUK
| | - Ilias Tachtsidis
- Department of Medical Physics and BioengineeringUniversity College LondonLondonUK
| | - Sachio Takashima
- Yanagawa Institute for Developmental DisabilitiesInternational University of Health and WelfareFukuokaJapan
| | - Toyojiro Matsuishi
- Centre for Developmental and Cognitive NeuroscienceDepartment of Paediatrics and Child HealthKurume University School of MedicineKurumeFukuokaJapan
| | | | - Osuke Iwata
- Centre for Developmental and Cognitive NeuroscienceDepartment of Paediatrics and Child HealthKurume University School of MedicineKurumeFukuokaJapan
- Institute for Women's HealthUniversity College LondonLondonUK
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Hoque N, Sabir H, Maes E, Bishop S, Thoresen M. Validation of a neuropathology score using quantitative methods to evaluate brain injury in a pig model of hypoxia ischaemia. J Neurosci Methods 2014; 230:30-6. [PMID: 24747875 DOI: 10.1016/j.jneumeth.2014.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/30/2014] [Accepted: 04/05/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND Neuropathological examination is the classic outcome measure in experimental studies of newborn brain injury to evaluate novel therapies. We have used a graded neuropathology score in an established global model of perinatal hypoxic-ischaemic (HI) injury. We wished to validate the score using cell counting in our model. NEW METHOD 32 newborn pigs underwent a 45 min global HI insult then maintained at normothermia (NT, rectal temperature, Trectal 38.5 °C) for 72 h or mild total body hypothermia (HT, Trectal 37.0 °C) combined with selective head cooling for 48 h and subsequently maintained at NT for 24h before brain perfusion fixation. A perinatal pathologist scored haematoxylin and eosin stained 6 μm histological sections for injury in the hippocampus and basal ganglia on a 9-step scale (0.0=no injury, 4.0=>75% injury). We counted the number of healthy neurons in the hippocampus CA1 region and putamen using morphological criteria in eight random, non-overlapping fields from representative sections. RESULTS Healthy neuronal cell density correlated with neuropathology score in the hippocampus CA1 (r = -0.74) and in the putamen (r = -0.75) and both measures detected a difference between groups. The correlation coefficients were better for the NT compared to the HT group in both the hippocampus (r = -0.87 vs. -0.53) and putamen (r = -0.77 vs. -0.54). COMPARISON WITH EXISTING METHOD We have validated a histological neuropathological scoring system in our model of perinatal HI by showing correlation between neuronal cell count and estimated injury. CONCLUSIONS Our neuropathology score is a valid method to assess brain injury with good reproducibility and sensitivity.
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Affiliation(s)
- Nicholas Hoque
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, St Michael's Hospital, Southwell Street, Bristol, Avon BS2 8EG, United Kingdom
| | - Hemmen Sabir
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, St Michael's Hospital, Southwell Street, Bristol, Avon BS2 8EG, United Kingdom
| | - Elke Maes
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, St Michael's Hospital, Southwell Street, Bristol, Avon BS2 8EG, United Kingdom; Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Postboks 1103, Blindern, 0317 Oslo, Norway
| | - Sarah Bishop
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, St Michael's Hospital, Southwell Street, Bristol, Avon BS2 8EG, United Kingdom
| | - Marianne Thoresen
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, St Michael's Hospital, Southwell Street, Bristol, Avon BS2 8EG, United Kingdom; Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Postboks 1103, Blindern, 0317 Oslo, Norway.
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Cotten CM, Shankaran S. Hypothermia for hypoxic-ischemic encephalopathy. ACTA ACUST UNITED AC 2014; 5:227-239. [PMID: 20625441 DOI: 10.1586/eog.10.7] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Moderate to severe hypoxic-ischemic injury in newborn infants, manifested as encephalopathy immediately or within hours after birth, is associated with a high risk of either death or a lifetime with disability. In recent multicenter clinical trials, hypothermia initiated within the first 6 postnatal hours has emerged as a therapy that reduces the risk of death or impairment among infants with hypoxic-ischemic encephalopathy. Prior to hypothermia, no therapies directly targeting neonatal encephalopathy secondary to hypoxic-ischemic injury had convincing evidence of efficacy. Hypothermia therapy is now becoming increasingly available at tertiary centers. Despite the deserved enthusiasm for hypothermia, obstetric and neonatology caregivers, as well as society at large, must be reminded that in the clinical trials more than 40% of cooled infants died or survived with impairment. Although hypothermia is an evidence-based therapy, additional discoveries are needed to further improve outcome after HIE. In this article, we briefly present the epidemiology of neonatal encephalopathy due to hypoxic-ischemic injury, describe the rationale for the use of hypothermia therapy for hypoxic-ischemic encephalopathy, and present results of the clinical trials that have demonstrated the efficacy of hypothermia. We also present findings noted during and after these trials that will guide care and direct research for this devastating problem.
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Affiliation(s)
- C Michael Cotten
- Associate Professor of Pediatrics, Duke University Medical Center, Box 2739 DUMC, Durham, NC 27710, USA, Tel.: +1 919 681 4844, ,
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Gladen A, Iaizzo PA, Bischof JC, Erdman AG, Divani AA. A Head and Neck Support Device for Inducing Local Hypothermia. J Med Device 2013; 8:0110021-110029. [PMID: 26734117 DOI: 10.1115/1.4025448] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Revised: 09/12/2013] [Indexed: 01/01/2023] Open
Abstract
The present work describes the design of a device/system intended to induce local mild hypothermia by simultaneously cooling a patient's head and neck. The therapeutic goal is to lower the head and neck temperatures to 33-35 °C, while leaving the core body temperature unchanged. The device works by circulating a cold fluid around the exterior of the head and neck. The head surface area is separated into five different cooling zones. Each zone has a cooling coil and can be independently controlled. The cooling coils are tightly wrapped concentric circles of tubing. This design allows for a dense packing of tubes in a limited space, while preventing crimping of the tubing and minimizing the fluid pressure head loss. The design in the neck region also has multiple tubes wrapping around the circumference of the patient's neck in a helix. Preliminary testing indicates that this approach is capable of achieving the design goal of cooling the brain tissue (at a depth of 2.5 cm from the scalp) to 35 °C within 30- 40 min, without any pharmacologic or circulatory manipulation. In a comparison with examples of current technology, the device has shown the potential for improved cooling capability.
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Affiliation(s)
- Adam Gladen
- Department of Mechanical Engineering, University of Minnesota , Minneapolis, MN 55455
| | - Paul A Iaizzo
- Department of Surgery, University of Minnesota , Minneapolis, MN 55455
| | - John C Bischof
- Department of Mechanical Engineering, University of Minnesota , Minneapolis, MN 55455
| | - Arthur G Erdman
- Department of Mechanical Engineering, University of Minnesota , Minneapolis, MN 55455
| | - Afshin A Divani
- Department of Mechanical Engineering, University of Minnesota , Minneapolis, MN 55455
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Bainbridge A, Kendall GS, De Vita E, Hagmann C, Kapetanakis A, Cady EB, Robertson NJ. Regional neonatal brain absolute thermometry by 1H MRS. NMR IN BIOMEDICINE 2013; 26:416-423. [PMID: 23074155 DOI: 10.1002/nbm.2879] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 08/28/2012] [Accepted: 09/04/2012] [Indexed: 06/01/2023]
Abstract
Therapeutic hypothermia is standard care for infants with moderate to severe encephalopathy. (1) H MRS thermometry (MRSt) measures regional brain absolute temperature using the temperature-dependent water chemical shift. This study evaluates the clinical feasibility of MRSt in human neonates, and correlates white matter (WM) and thalamus (Thal) MRSt with conventional rectal temperature (Trectal ) measurement. Fifty-six infants born at term underwent perinatal MRSt for suspected hypoxic-ischaemic brain injury and 33 infants born preterm had MRSt at a term-equivalent age; 56 of the 89 had Trectal measured after MRSt of either a Thal or posterior WM voxel, or both. MRSt used point-resolved spectroscopy (no water suppression; TR = 1370 ms; TE = 288 ms; 1.5 × 1.5 × 1.5 cm(3) Thal and 1.1 × 1.3 × 1.4 cm(3) WM voxels). Time domain data were phase and frequency corrected before summation and motion-corrupted data were excluded from further analysis using simple criteria [preprocessing + quality assurance (QA)]. Two published water temperature-dependence calibrations [both using cerebral creatine (Cr), choline (Cho) and N-acetylaspartate (Naa) as independent reference peaks] were compared. The temperature measurements derived from Cr, Cho and Naa were combined to give a single amplitude-weighted combination temperature (TAWC ). WM and Thal TAWC correlated linearly with Trectal (Thal slope, 0.82 ± 0.04, R(2) = 0.85, p < 0.05; WM slope, 0.95 ± 0.04, R(2) = 0.78, p < 0.05). Preprocessing + QA improved the correlation between WM TAWC and Trectal (R(2) increased from 0.27 to 0.78, p < 0.001). Both calibration datasets showed specific inconsistencies between the temperatures calculated using Cr, Cho and Naa reference peaks when applied to this neonatal dataset. Neonatal MRSt is clinically feasible. Preprocessing + QA improved MRSt reliability in WM. The consideration of MRSt calibration internal biases is necessary before combining MRSt temperatures from multiple reference peaks to obtain TAWC.
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Affiliation(s)
- Alan Bainbridge
- Medical Physics and Bioengineering, University College London Hospitals NHS Foundation Trust, London, UK
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40
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Arunachalam S, Poon WB. Therapeutic Hypothermia for Hypoxic Ischaemic Encephalopathy in Singapore General Hospital: Two Patient Case Series and Review of Literature. PROCEEDINGS OF SINGAPORE HEALTHCARE 2012. [DOI: 10.1177/201010581202100411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Neonatal encephalopathy affects 2–5/1000 live births and hypoxic ischaemic encephalopathy (HIE) is the major cause1. Therapeutic hypothermia reduces brain injury and improves the neurodevelopmental outcome.We are sharing our local experience in therapeutic hypothermia in the form of a case series of two patients. Our incidence of moderate to severe HIE is 0.6/1000 live births. Both patients were cooled for 72 hours.The challenges faced were mainly in the time taken for achieving the target temperature and the time needed for re-warming, which varied from one to six hours and 4–24 hours, respectively. Complications like hyponatremia, hypokalemia, sinus bradycardia and thrombocytopenia were noted. Amplitude integrated electroencephalogram (aEEG) remained abnormal post cooling for both babies. Clinical markers, aEEG and MRI head findings combine to prognosticate well for the neurodevelopmental outcomes.We need to be familiar with the protocol for timely implementation of cooling, whichever the cooling method. Concentrating these high-risk cases in selected tertiary centres capable of instituting cooling as well as long-term follow-up will ensure better outcomes.
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Affiliation(s)
| | - Woei Bing Poon
- Neonatal and Developmental Medicine, Singapore General Hospital
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41
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Liu Q, Cai Y, Lin W, Turner GH, An H. A magnetic resonance (MR) compatible selective brain temperature manipulation system for preclinical study. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2012; 5:13-22. [PMID: 23166453 PMCID: PMC3500969 DOI: 10.2147/mder.s26835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
There is overwhelming evidence that hypothermia can improve the outcome of an ischemic stroke. However, the most widely used systemic cooling method could lead to multiple side effects, while the incompatibility with magnetic resonance imaging of the present selective cooling methods highly limit their application in preclinical studies. In this study, we developed a magnetic resonance compatible selective brain temperature manipulation system for small animals, which can regulate brain temperature quickly and accurately for a desired period of time, while maintaining the normal body physiological conditions. This device was utilized to examine the relationship between T1 relaxation, cerebral blood flow, and temperature in brain tissue during magnetic resonance imaging of ischemic stroke. The results showed that this device can be an efficient brain temperature manipulation tool for preclinical studies needing local hypothermic or hyperthermic conditions.
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Affiliation(s)
- Qingwei Liu
- Biomedical Research Imaging Center, University of North Carolina at Chapel Hill, NC, USA
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42
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Merrill L. Therapeutic hypothermia to treat hypoxic ischemic encephalopathy in newborns: implications for nurses. Nurs Womens Health 2012; 16:126-134. [PMID: 22900770 DOI: 10.1111/j.1751-486x.2012.01718.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Hypoxic ischemic encephalopathy (HIE) in newborns is caused by an injury to the brain following a hypoxic or an ischemic event during the peripartum, intrapartum or postpartum period. HIE may result in death or cause serious impairment in survivors, and remains a significant cause of morbidity and mortality among neonates. Mild hypothermia as a treatment for HIE is commonly used to treat moderate to severe HIE, with promising results. Nurses play an integral role in identifying newborns at risk of developing HIE.
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Wu D, Xiong W, Jia X, Geocadin RG, Thakor NV. Short- and long-latency somatosensory neuronal responses reveal selective brain injury and effect of hypothermia in global hypoxic ischemia. J Neurophysiol 2011; 107:1164-71. [PMID: 22157111 DOI: 10.1152/jn.00681.2011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Evoked potentials recorded from the somatosensory cortex have been shown to be an electrophysiological marker of brain injury in global hypoxic ischemia (HI). The evoked responses in somatosensory neurons carry information pertaining to signal from the ascending pathway in both the subcortical and cortical areas. In this study, origins of the subcortical and cortical signals are explored by decomposing the evoked neuronal activities into short- and long-latency responses (SLR and LLR), respectively. We evaluated the effect of therapeutic hypothermia on SLR and LLR during early recovery from cardiac arrest (CA)-induced HI in a rodent model. Twelve rats were subjected to CA, after which half of them were treated with hypothermia (32-34°C) and the rest were kept at normal temperature (36-37°C). Evoked neuronal activities from the primary somatosensory cortex, including multiunit activity (MUA) and local field potential (LFP), were continuously recorded during injury and early recovery. Results showed that upon initiation of injury, LLR disappeared first, followed by the disappearance of SLR, and after a period of isoelectric silence SLR reappeared prior to LLR. This suggests that cortical activity, which primarily underlies the LLR, may be more vulnerable to ischemic injury than SLR, which relates to subcortical activity. Hypothermia potentiated the SLR but suppressed the LLR by delaying its recovery after CA (hypothermia: 38.83 ± 5.86 min, normothermia: 23.33 ± 1.15 min; P < 0.05) and attenuating its amplitude, suggesting that hypothermia may selectively downregulate cortical activity as an approach to preserve the cerebral cortex. In summary, our study reveals the vulnerability of the somatosensory neural structures to global HI and the differential effects of hypothermia on these structures.
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Affiliation(s)
- Dan Wu
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
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44
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LEY O, BAYAZITOGLU Y, LAPTOOK ABBOTR. BRAIN TEMPERATURE CALCULATIONS FOR SWINE USING EXPERIMENTAL MEASUREMENTS OF CEREBRAL BLOOD FLOW. J MECH MED BIOL 2011. [DOI: 10.1142/s0219519404000904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In this study, numerical simulations are performed to analyze the brain temperature reduction in swine during selective head cooling, whole body cooling or while the animals experience ischemia. Brain temperature is calculated using a time dependent thermal model that incorporates available experimental measurements of the rectal temperature, the cerebral blood flow and the cerebral metabolic rate of oxygen consumption.The calculated temperature distribution is validated against the in vivo temperature measurements recorded during the different experiments. These comparisons help to better understand the relations between brain temperature, blood flow and metabolic activity, which are essential to successfully apply hypothermia in the treatment of brain injury.The calculations presented here reproduce the temperature behavior observed in all the experiments considered. It is observed that the arterial temperature and the cerebral metabolic rate are important parameters that affect the deep tissue temperature. It is also concluded that the accurate knowledge of parameters such as the skin and bone thermal conductivity are necessary for effective modeling.
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Affiliation(s)
- O. LEY
- Department of Mechanical Engineering and Materials Science, Rice University, Houston, Texas 77005-1892, USA
| | - Y. BAYAZITOGLU
- Department of Mechanical Engineering and Materials Science, Rice University, Houston, Texas 77005-1892, USA
| | - ABBOT R. LAPTOOK
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9063, USA
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45
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Reynolds R, Talmage S. "Caution! Contents should be cold": developing a whole-body hypothermia program. Neonatal Netw 2011; 30:225-30. [PMID: 21729853 DOI: 10.1891/0730-0832.30.4.225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hypoxic-ischemic encephalopathy (HIE) is characterized as brain injury that results from lack of oxygen or blood flow to the brain in the perinatal period. Neonatal whole-body hypothermia and selective head cooling are becoming increasingly common care practices across the U.S. and Canada for infants with moderate-to-severe HIE because of the demonstrated ability of these approaches to reduce reperfusion injury to the brain. Health care professionals must develop a clinical care path for these fragile infants. For best results, induced hypothermia should be initiated within six hours of birth; therefore, care must be organized and provided without delay. This article provides bedside clinicians with care recommendations for infants being treated with these new interventions.
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Wachtel EV, Hendricks-Muñoz KD. Current management of the infant who presents with neonatal encephalopathy. Curr Probl Pediatr Adolesc Health Care 2011; 41:132-53. [PMID: 21458747 DOI: 10.1016/j.cppeds.2010.12.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Neonatal encephalopathy after perinatal hypoxic-ischemic insult is a major contributor to global child mortality and morbidity. Brain injury in term infants in response to hypoxic-ischemic insult is a complex process evolving over hours to days, which provides a unique window of opportunity for neuroprotective treatment interventions. Advances in neuroimaging, brain monitoring techniques, and tissue biomarkers have improved the ability to diagnose, monitor, and care for newborn infants with neonatal encephalopathy as well as predict their outcome. However, challenges remain in early identification of infants at risk for neonatal encephalopathy, determination of timing and extent of hypoxic-ischemic brain injury, as well as optimal management and treatment duration. Therapeutic hypothermia is the most promising neuroprotective intervention to date for infants with moderate to severe neonatal encephalopathy after perinatal asphyxia and has currently been incorporated in many neonatal intensive care units in developed countries. However, only 1 in 6 babies with encephalopathy will benefit from hypothermia therapy; many infants still develop significant adverse outcomes. To enhance the outcome, specific diagnostic predictors are needed to identify patients likely to benefit from hypothermia treatment. Studies are needed to determine the efficacy of combined therapeutic strategies with hypothermia therapy to achieve maximal neuroprotective effect. This review focuses on important concepts in the pathophysiology, diagnosis, and management of infants with neonatal encephalopathy due to perinatal asphyxia, including an overview of recently introduced novel therapies.
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Affiliation(s)
- Elena V Wachtel
- Department of Pediatrics, Division of Neonatology, New York University School of Medicine, New York, NY, USA
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47
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Russ M, Ott S, Bedarf JR, Haacke N, Keckel T, Unger JK. Prolonged hypoxemia and acidemia in anesthetized pigs: a model for research on extracorporeal organ support in an intensive care setting. Int J Artif Organs 2011; 33:544-52. [PMID: 20872349 DOI: 10.1177/039139881003300805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2010] [Indexed: 11/15/2022]
Abstract
PURPOSE Hypoxemia and acidemia (hypoxemia/acidemia) are serious complications in the critically ill and often occur in unstable patients exposed to extracorporeal organ support. Still, little is known about the biocompatibility interactions of hypoxemia/acidemia with extracorporeal circuits (ECC). Existing animal models often include the release of mediator cascades (sepsis-, lung injury models) or are based on small laboratory animals. We established a porcine model of hypoxemia/acidemia without an underlying disease and further challenged the situation with an extracorporeal circuit (ECC). METHODS Hypoxemia/acidemia were induced (3.5 h) and maintained (3 h) in anesthetized pigs (40 kg) by a stepwise reduction in oxygenation, infusion of 0.4 mol.l⁻¹ lactic and hydrochloric acid and by low tidal volume ventilation, targeting an PaO₂ < 70 mmHg, SvO₂ < 65%, pH ~ 7.2. Venovenous hemofiltration (CVVH) operated in recirculation mode without volume exchange was chosen to prove the suitability of the model for studies on ECCs under clinical conditions (ECC group, n=6). Another 6 animals underwent the same protocol except for the CVVH (reference group, n=6). RESULTS The median PaO₂ during hypoxemia/acidemia was 62 mmHg, the median SvO₂ was 38%, and the median pH was 7.22. Hypoxemia/acidemia was successfully induced and maintained for 6.5 h in all pigs. CVVH could be performed for 3 h with blood flow rates up to 300 ml.min⁻¹ and filtrate rates up to 60 ml.min⁻¹. CONCLUSIONS Our model provides hypoxemia/acidemia with blood gas values comparable to critically ill adult patients for several hours, during which it is possible to perform CVVH. Thus, it enables research on the biocompatibility reactions of extracorporeal circuits under intensive care conditions.
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Affiliation(s)
- Martin Russ
- Department of Experimental Medicine (FEM), Charité - Campus Virchow, Humboldt University, Berlin, Germany
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48
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Cheng G, Sun J, Wang L, Shao X, Zhou W. Effects of selective head cooling on cerebral blood flow and metabolism in newborn piglets after hypoxia-ischemia. Early Hum Dev 2011; 87:109-14. [PMID: 21144680 DOI: 10.1016/j.earlhumdev.2010.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 10/21/2010] [Accepted: 11/10/2010] [Indexed: 10/18/2022]
Abstract
AIM the effect of selective head cooling on cerebral blood flow (CBF) and cerebral metabolism rate (CMR) was investigated in newborn piglets. METHODS seven days old newborn piglets were randomly assigned to one of the following three groups: Selective head cooling in normal piglets (n=4), selective head cooling after HI (n=6) and normal temperature after HI (n=6). CBF was measured with color microspheres. Cerebral oxygenation metabolism rate (CMRO(2)), Cerebral glucose consumption (CMR(Glu)) and Cerebral lactate production (CMR(lac)) were calculated. RESULT in normal piglets, CBF, CMRO(2) and CMR(glu) were significantly decreased at both 35°C (P<0.05) and 32°C (P<0.01), while CMR(lac) did not change. Compared to baseline, CBF and CMRO(2) were significantly reduced (P<0.05), while CMR(glu) and CMR(lac) were significantly increased (P<0.01), AVDO(2) was decreased (P<0.05), while AVD(glu) and AVD(lac) were significantly increased (P<0.01 respectively) in HI piglets with normal temperature respectively. Compared to normal temperature after HI, selective head cooling after HI significantly reduced CMR(glu) and CMR(lac), and AVDO(2), AVD(glu), AVD(lac) were improved at 35°C. CONCLUSION selective head cooling not only reduced energy consumption, but also improve brain oxygen metabolism in newborn after HI.
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Affiliation(s)
- Guoqiang Cheng
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai 201102, China.
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49
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Cooper DJ. Induced hypothermia for neonatal hypoxic-ischemic encephalopathy: pathophysiology, current treatment, and nursing considerations. Neonatal Netw 2011; 30:29-35. [PMID: 21317095 DOI: 10.1891/0730-0832.30.1.29] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Hypoxic-ischemic encephalopathy (HIE) can lead to devastating neurodevelopmental consequences such as cerebral palsy, seizure disorders, and significant developmental delays. HIE in the newborn is often the result of a hypoxic event, such as uterine rupture, placental abruption, or cord prolapse. Biphasic brain injury occurs in HIE. The first phase involves activation of the sympathetic nervous system as a compensatory mechanism. The second phase, known as reperfusion brain injury, occurs hours later. Induced hypothermia, a neuroprotective strategy for treating HIE, targets the second phase to prevent reperfusion injury. NICU nurses are in a unique position to detect patient instability and to maintain the therapeutic interventions that contribute to the healing process. This article highlights the significant role nurses play in the management of infants diagnosed with HIE who are treated with induced hypothermia.
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Abstract
Neonatal encephalopathy affects 2 to 5 of every 1000 live births and represents a major cause of mortality and long-term morbidity in affected infants. Hypoxic ischemic encephalopathy (HIE) is the major cause of encephalopathy in the neonatal period. Until recently, management of a newborn with encephalopathy has consisted largely of supportive care to restore and maintain cerebral perfusion, provide adequate gas exchange and treat seizure activity. Recent randomized controlled trials have shown that mild therapeutic hypothermia (cooling) initiated within 6 h of birth reduces death and disability in these infants. Cooling can be accomplished through whole-body cooling or selective head cooling. Meta-analysis of these trials suggests that for every six or seven infants with moderate to severe HIE who are treated with mild hypothermia, there will be one fewer infant who dies or has significant neurodevelopmental disability. In response to this evidence, major policy makers and guideline developers have recommended that cooling therapy be offered to infants with moderate to severe HIE. The dissemination of this new therapy will require improved identification of infants with HIE and regional commitment to allow these infants to be cared for in a timely manner.
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