51
|
Shahlaie K, Keachie K, Hutchins IM, Rudisill N, Madden LK, Smith KA, Ko KA, Latchaw RE, Muizelaar JP. Risk factors for posttraumatic vasospasm. J Neurosurg 2011; 115:602-11. [PMID: 21663415 DOI: 10.3171/2011.5.jns101667] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECT Posttraumatic vasospasm (PTV) is an underrecognized cause of ischemic damage after severe traumatic brain injury (TBI) that independently predicts poor outcome. There are, however, no guidelines for PTV screening and management, partly due to limited understanding of its pathogenesis and risk factors. METHODS A database review of 46 consecutive cases of severe TBI in pediatric and adult patients was conducted to identify risk factors for the development of PTV. Univariate analysis was performed to identify potential risk factors for PTV, which were subsequently analyzed using a multivariate logistic regression model to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Fever on admission was an independent risk factor for development of PTV (OR 22.2, 95% CI 1.9-256.8), and patients with hypothermia on admission did not develop clinically significant vasospasm during their hospital stay. The presence of small parenchymal contusions was also an independent risk factor for PTV (OR 7.8, 95% CI 0.9-69.5), whereas the presence of subarachnoid hemorrhage or other patterns of intracranial injury were not. Other variables, such as age, sex, ethnicity, degree of TBI severity, or admission laboratory values, were not independent predictors for the development of clinically significant PTV. CONCLUSIONS Independent risk factors for PTV include parenchymal contusions and fever. These results suggest that diffuse mechanical injury and activation of inflammatory pathways may be underlying mechanisms for the development of PTV, and that a subset of patients with these risk factors may be an appropriate population for aggressive screening. Further studies are needed to determine if treatments targeting fever and inflammation may be effective in reducing the incidence of vasospasm following severe TBI.
Collapse
Affiliation(s)
- Kiarash Shahlaie
- Department of Neurological Surgery, University of California Davis School of Medicine, Sacramento, California 95817, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
52
|
Targeted temperature management in critical care: a report and recommendations from five professional societies. Crit Care Med 2011; 39:1113-25. [PMID: 21187745 DOI: 10.1097/ccm.0b013e318206bab2] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Representatives of five international critical care societies convened topic specialists and a nonexpert jury to review, assess, and report on studies of targeted temperature management and to provide clinical recommendations. DATA SOURCES Questions were allocated to experts who reviewed their areas, made formal presentations, and responded to questions. Jurors also performed independent searches. Sources used for consensus derived exclusively from peer-reviewed reports of human and animal studies. STUDY SELECTION Question-specific studies were selected from literature searches; jurors independently determined the relevance of each study included in the synthesis. CONCLUSIONS AND RECOMMENDATIONS 1) The jury opines that the term "targeted temperature management" replace "therapeutic hypothermia." 2) The jury opines that descriptors (e.g., "mild") be replaced with explicit targeted temperature management profiles. 3) The jury opines that each report of a targeted temperature management trial enumerate the physiologic effects anticipated by the investigators and actually observed and/or measured in subjects in each arm of the trial as a strategy for increasing knowledge of the dose/duration/response characteristics of temperature management. This enumeration should be kept separate from the body of the report, be organized by body systems, and be made without assertions about the impact of any specific effect on the clinical outcome. 4) The jury STRONGLY RECOMMENDS targeted temperature management to a target of 32°C-34°C as the preferred treatment (vs. unstructured temperature management) of out-of-hospital adult cardiac arrest victims with a first registered electrocardiography rhythm of ventricular fibrillation or pulseless ventricular tachycardia and still unconscious after restoration of spontaneous circulation (strong recommendation, moderate quality of evidence). 5) The jury WEAKLY RECOMMENDS the use of targeted temperature management to 33°C-35.5°C (vs. less structured management) in the treatment of term newborns who sustained asphyxia and exhibit acidosis and/or encephalopathy (weak recommendation, moderate quality of evidence).
Collapse
|
53
|
Takeuchi S, Nawashiro H, Otani N. Hypothermia in patients with brain injury: the way forward? Lancet Neurol 2011; 10:404; author reply 406-7. [PMID: 21511191 DOI: 10.1016/s1474-4422(11)70083-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
54
|
Oda Y, Gao G, Wei EP, Povlishock JT. Combinational therapy using hypothermia and the immunophilin ligand FK506 to target altered pial arteriolar reactivity, axonal damage, and blood-brain barrier dysfunction after traumatic brain injury in rat. J Cereb Blood Flow Metab 2011; 31:1143-54. [PMID: 21157473 PMCID: PMC3070975 DOI: 10.1038/jcbfm.2010.208] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This study evaluated the utility of combinational therapy, coupling delayed posttraumatic hypothermia with delayed FK506 administration, on altered cerebral vascular reactivity, axonal injury, and blood-brain barrier (BBB) disruption seen following traumatic brain injury (TBI). Animals were injured, subjected to various combinations of hypothermic/FK506 intervention, and equipped with cranial windows to assess pial vascular reactivity to acetylcholine. Animals were then processed with antibodies to the amyloid precursor protein and immunoglobulin G to assess axonal injury and BBB disruption, respectively. Animals were assigned to five groups: (1) sham injury plus delayed FK506, (2) TBI, (3) TBI plus delayed hypothermia, (4) TBI plus delayed FK506, and (5) TBI plus delayed hypothermia with FK506. Sham injury plus FK506 had no impact on vascular reactivity, axonal injury, or BBB disruption. Traumatic brain injury induced dramatic axonal injury and altered pial vascular reactivity, while triggering local BBB disruption. Delayed hypothermia or FK506 after TBI provided limited protection. However, TBI with combinational therapy achieved significantly enhanced vascular and axonal protection, with no BBB protection. This study shows the benefits of combinational therapy, using posttraumatic hypothermia with FK506 to attenuate important features of TBI. This suggests that hypothermia not only protects but also extends the therapeutic window for improved FK506 efficacy.
Collapse
Affiliation(s)
- Yasutaka Oda
- Department of Anatomy and Neurobiology, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298, USA
| | | | | | | |
Collapse
|
55
|
Wei G, Lu XCM, Shear DA, Yang X, Tortella FC. Neuroprotection of Selective Brain Cooling After Penetrating Ballistic-like Brain Injury in Rats. Ther Hypothermia Temp Manag 2011; 1:33-42. [DOI: 10.1089/ther.2010.0007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Guo Wei
- Department of Applied Neurobiology, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Xi-Chun M. Lu
- Department of Applied Neurobiology, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Deborah A. Shear
- Department of Applied Neurobiology, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Xiaofang Yang
- Department of Applied Neurobiology, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Frank C. Tortella
- Department of Applied Neurobiology, Walter Reed Army Institute of Research, Silver Spring, Maryland
| |
Collapse
|
56
|
A mouse model of ischemic spinal cord injury with delayed paralysis caused by aortic cross-clamping. Anesthesiology 2010; 113:880-91. [PMID: 20808212 DOI: 10.1097/aln.0b013e3181ec61ee] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Spinal cord ischemia and paralysis are devastating perioperative complications that can accompany open or endovascular repair surgery for aortic aneurysms. Here, we report on the development of a new mouse model of spinal cord ischemia with delayed paralysis induced by cross-clamping the descending aorta. METHODS Transient aortic occlusion was produced in mice by cross-clamping the descending aorta through a lateral thoracotomy. To establish an optimal surgical procedure with limited mortality, variable cross-clamp times and core temperatures were tested between experiments. RESULTS The onset of paresis or paralysis and postsurgical mortality varied as a function of cross-clamp time and core temperature that was maintained during the period of cross-clamp. Using optimal surgical parameters (7.5-min cross-clamp duration at 33°C core temperature), the onset of paralysis is delayed 24-36 h after reperfusion, and more than 95% of mice survive through 9 weeks after surgery. These mice are further stratified into two groups, 70% (n = 19/27) of mice developing severe hind limb paralysis and the remaining mice showing mild, though still permanent, behavioral deficits. CONCLUSION This new model should prove useful as a preclinical tool for screening neuroprotective therapeutics and for defining the basic biologic mechanisms that cause delayed paralysis and neurodegeneration after transient spinal cord ischemia.
Collapse
|
57
|
Batchelor PE, Kerr NF, Gatt AM, Aleksoska E, Cox SF, Ghasem-Zadeh A, Wills TE, Howells DW. Hypothermia Prior to Decompression: Buying Time for Treatment of Acute Spinal Cord Injury. J Neurotrauma 2010; 27:1357-68. [DOI: 10.1089/neu.2010.1360] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Peter E. Batchelor
- National Stroke Research Institute and University of Melbourne, Department of Medicine, Heidelberg, Victoria, Australia
| | - Nicole F. Kerr
- National Stroke Research Institute and University of Melbourne, Department of Medicine, Heidelberg, Victoria, Australia
| | - Amy M. Gatt
- National Stroke Research Institute and University of Melbourne, Department of Medicine, Heidelberg, Victoria, Australia
| | - Elena Aleksoska
- National Stroke Research Institute and University of Melbourne, Department of Medicine, Heidelberg, Victoria, Australia
| | - Susan F. Cox
- National Stroke Research Institute and University of Melbourne, Department of Medicine, Heidelberg, Victoria, Australia
| | - Ali Ghasem-Zadeh
- Endocrinology Centre of Excellence, Austin Health, Heidelberg, Victoria, Australia
| | - Taryn E. Wills
- National Stroke Research Institute and University of Melbourne, Department of Medicine, Heidelberg, Victoria, Australia
| | - David W. Howells
- National Stroke Research Institute and University of Melbourne, Department of Medicine, Heidelberg, Victoria, Australia
| |
Collapse
|
58
|
Abstract
PURPOSE OF REVIEW Therapeutic hypothermia after traumatic brain injury (TBI)? For the last 10 years, no topic has been more popular and more controversial among neurointensivists. This article reviews the most current findings (experimental, clinical, adult and pediatric TBI), as well as the clinical management of therapeutic hypothermia. RECENT FINDINGS Despite ample experimental evidence, the clinical utility of therapeutic hypothermia has still to be conclusively demonstrated in terms of reduced mortality or improved functional recovery after TBI (even in pediatric TBI). Current findings support that hypothermia should be initiated as soon as possible, for at least 48 h duration, and that outcome is worse when barbiturates are part of ICU management. Currently, available cooling techniques, including prehospital cooling protocols, expand and improve clinical management of therapeutic hypothermia. SUMMARY Taking into consideration all results from clinical hypothermia TBI studies discussion has to be focused around the possibility that a better outcome could be achieved if protocols for therapeutic hypothermia are reviewed. It is possible that the negative effects of the cooling and the rewarming procedure currently overshadow the neuroprotective effects.
Collapse
|
59
|
Covaciu L, Allers M, Lunderquist A, Rubertsson S. Intranasal cooling with or without intravenous cold fluids during and after cardiac arrest in pigs. Acta Anaesthesiol Scand 2010; 54:494-501. [PMID: 19912127 DOI: 10.1111/j.1399-6576.2009.02157.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intranasal balloon catheters circulated with cold saline have previously been used for the induction and maintenance of selective brain cooling in pigs with normal circulation. In the present study, we investigated the feasibility of therapeutic hypothermia initiation, maintenance and rewarming using such intranasal balloon catheters with or without addition of intravenous ice-cold fluids during and after cardiac arrest treatment in pigs. MATERIAL AND METHODS Cardiac arrest was induced in 20 anaesthetised pigs. Following 8 min of cardiac arrest and 1 min of cardiopulmonary resuscitation (CPR), cooling was initiated after randomisation with either intranasal cooling (N) or combined with intravenous ice-cold fluids (N+S). Hypothermia was maintained for 180 min, followed by 180 min of rewarming. Brain and oesophageal temperatures, haemodynamic variables and intracranial pressure (ICP) were recorded. RESULTS Brain temperatures reductions after cooling did not differ (3.8 +/- 0.7 degrees C in the N group and 4.3 +/- 1.5 degrees C in the N+S group; P=0.47). The corresponding body temperature reductions were 3.6 +/- 1.2 degrees C and 4.6 +/- 1.5 degrees C (P=0.1). The resuscitation outcome was similar in both groups. Mixed venous oxygen saturation was lower in the N group after cooling and rewarming (P=0.024 and 0.002, respectively) as compared with the N+S group. ICP was higher after rewarming in the N group (25.2 +/- 2.9 mmHg; P=0.01) than in the N+S group (15.7 +/- 3.3 mmHg). CONCLUSIONS Intranasal balloon catheters can be used for therapeutic hypothermia initiation, maintenance and rewarming during CPR and after successful resuscitation in pigs.
Collapse
Affiliation(s)
- L Covaciu
- Department of Surgical Sciences, Anaesthesiology & Intensive Care, Uppsala University, Uppsala, Sweden.
| | | | | | | |
Collapse
|
60
|
|
61
|
The adverse pial arteriolar and axonal consequences of traumatic brain injury complicated by hypoxia and their therapeutic modulation with hypothermia in rat. J Cereb Blood Flow Metab 2010; 30:628-37. [PMID: 19904286 PMCID: PMC2949135 DOI: 10.1038/jcbfm.2009.235] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study examined the effect of posttraumatic hypoxia on cerebral vascular responsivity and axonal damage, while also exploring hypothermia's potential to attenuate these responses. Rats were subjected to impact acceleration injury (IAI) and equipped with cranial windows to assess vascular reactivity to topical acetylcholine, with postmortem analyses using antibodies to amyloid precursor protein to assess axonal damage. Animals were subjected to hypoxia alone, IAI and hypoxia, IAI and hypoxia before induction of moderate hypothermia (33 degrees C), IAI and hypoxia induced during hypothermic intervention, and IAI and hypoxia initiated after hypothermia. Hypoxia alone had no impact on vascular reactivity or axonal damage. Acceleration injury and posttraumatic hypoxia resulted in dramatic axonal damage and altered vascular reactivity. When IAI and hypoxia were followed by hypothermic intervention, no axonal or vascular protection ensued. However, when IAI was followed by hypoxia induced during hypothermia, axonal and vascular protection followed. When this same hypoxic insult followed the use of hypothermia, no benefit ensued. These studies show that early hypoxia and delayed hypoxia exert damaging axonal and vascular consequences. Although this damage is attenuated by hypothermia, this follows only when hypoxia occurs during hypothermia, with no benefit found if the hypoxic insult proceeds or follows hypothermia.
Collapse
|
62
|
Grände PO, Reinstrup P, Romner B. Active cooling in traumatic brain-injured patients: a questionable therapy? Acta Anaesthesiol Scand 2009; 53:1233-8. [PMID: 19681780 DOI: 10.1111/j.1399-6576.2009.02074.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hypothermia is shown to be beneficial for the outcome after a transient global brain ischaemia through its neuroprotective effect. Whether this is also the case after focal ischaemia, such as following a severe traumatic brain injury (TBI), has been investigated in numerous studies, some of which have shown a tendency towards an improved outcome, whereas others have not been able to demonstrate any beneficial effect. A Cochrane report concluded that the majority of the trials that have already been published have been of low quality, with unclear allocation concealment. If only high-quality trials are considered, TBI patients treated with active cooling were more likely to die, a conclusion supported by a recent high-quality Canadian trial on children. Still, there is a belief that a modified protocol with a shorter time from the accident to the start of active cooling, longer cooling and rewarming time and better control of blood pressure and intracranial pressure would be beneficial for TBI patients. This belief has led to the instigation of new trials in adults and in children, including these types of protocol adjustments. The present review provides a short summary of our present knowledge of the use of active cooling in TBI patients, and presents some tentative explanations as to why active cooling has not been shown to be effective for outcome after TBI. We focus particularly on the compromised circulation of the penumbra zone, which may be further reduced by the stress caused by the difference in thermostat and body temperature and by the hypothermia-induced more frequent use of vasoconstrictors, and by the increased risk of contusional bleedings under hypothermia. We suggest that high fever should be reduced pharmacologically.
Collapse
Affiliation(s)
- P-O Grände
- Department of Anaesthesia and Intensive Care, Lund University Hospital, Lund, Sweden.
| | | | | |
Collapse
|