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Abstract
Therapeutic hypothermia (TH) is a potent neuroprotective therapy in experimental cerebral ischemia, with multiple effects at several stages of the ischemic cascade. In animals, TH is so powerful that all preclinical stroke studies require strict temperature control. In humans, multiple clinical studies documented powerful protection with TH after accidental neonatal hypoxic-ischemic injury and global cerebral ischemia with return of spontaneous circulation after cardiac arrest. National and international guidelines recommend TH for selected survivors of global ischemia, with profound benefits seen. Recently, a study comparing target temperature 33-36°C failed to demonstrate significant effects in cardiac arrest patients. Additionally, clinical trials of TH for head trauma and stroke have so far failed to confirm benefit in humans despite a vast preclinical literature. Therefore, it is now critical to understand the fundamental explanation for the success of TH in some, but famously not all, clinical trials. TH in animals appears to work when used soon after ischemia onset; for a short duration; and at a deep target temperature.
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Abstract
Different mechanisms explain thermoregulatory dysfunction following ischemic stroke, hemorrhagic stroke, and traumatic brain injury. Temperature instability following brain injury likely involves hypothalamic injury, pathologic changes in cerebral blood flow, metabolic derangement, and a neurogenic inflammatory response. Although targeted temperature management (TTM) exerts pleiotropic effects, the heterogeneity of brain injury has hindered identification of patient subsets most likely to benefit from TTM. Early optimism about TTM's role in brain injury has been tempered by the failure of successive clinical trials to show improved patient outcomes. However, given the deleterious effects of fever, aggressive fever management is still warranted in the critically ill neurologic patient.
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Affiliation(s)
- Ram Gowda
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Matthew Jaffa
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Neeraj Badjatia
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States.
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Sandu RE, Dumbrava D, Surugiu R, Glavan DG, Gresita A, Petcu EB. Cellular and Molecular Mechanisms Underlying Non-Pharmaceutical Ischemic Stroke Therapy in Aged Subjects. Int J Mol Sci 2017; 19:ijms19010099. [PMID: 29286319 PMCID: PMC5796049 DOI: 10.3390/ijms19010099] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/22/2017] [Accepted: 12/24/2017] [Indexed: 12/12/2022] Open
Abstract
The incidence of ischemic stroke in humans increases exponentially above 70 years both in men and women. Comorbidities like diabetes, arterial hypertension or co-morbidity factors such as hypercholesterolemia, obesity and body fat distribution as well as fat-rich diet and physical inactivity are common in elderly persons and are associated with higher risk of stroke, increased mortality and disability. Obesity could represent a state of chronic inflammation that can be prevented to some extent by non-pharmaceutical interventions such as calorie restriction and hypothermia. Indeed, recent results suggest that H₂S-induced hypothermia in aged, overweight rats could have a higher probability of success in treating stroke as compared to other monotherapies, by reducing post-stroke brain inflammation. Likewise, it was recently reported that weight reduction prior to stroke, in aged, overweight rats induced by caloric restriction, led to an early re-gain of weight and a significant improvement in recovery of complex sensorimotor skills, cutaneous sensitivity, or spatial memory. CONCLUSION animal models of stroke done in young animals ignore age-associated comorbidities and may explain, at least in part, the unsuccessful bench-to-bedside translation of neuroprotective strategies for ischemic stroke in aged subjects.
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Affiliation(s)
- Raluca Elena Sandu
- Department of Functional Sciences, Center of Clinical and Experimental Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania.
| | - Danut Dumbrava
- Department of Functional Sciences, Center of Clinical and Experimental Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania.
| | - Roxana Surugiu
- Department of Functional Sciences, Center of Clinical and Experimental Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania.
| | - Daniela-Gabriela Glavan
- Department of Functional Sciences, Center of Clinical and Experimental Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania.
| | - Andrei Gresita
- Department of Functional Sciences, Center of Clinical and Experimental Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania.
| | - Eugen Bogdan Petcu
- Gold Coast Campus, School of Medicine, Griffith University, Southport 4222, Australia.
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Winkel P, Bath PM, Gluud C, Lindschou J, van der Worp HB, Macleod MR, Szabo I, Durand-Zaleski I, Schwab S. Statistical analysis plan for the EuroHYP-1 trial: European multicentre, randomised, phase III clinical trial of the therapeutic hypothermia plus best medical treatment versus best medical treatment alone for acute ischaemic stroke. Trials 2017; 18:573. [PMID: 29187242 PMCID: PMC5706304 DOI: 10.1186/s13063-017-2302-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 10/25/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Cooling may reduce infarct size and improve neurological outcomes in patients with ischaemic stroke. In phase II trials, cooling awake patients with ischaemic stroke has been shown to be feasible and safe, but the effects in functional outcomes has not yet been investigated in an adequately sized randomised clinical trial. METHODS/DESIGN The EuroHYP-1 trial is a multinational, randomised, superiority phase III clinical trial with masked outcome assessment testing the benefits and harms of therapeutic cooling in awake adult patients with acute ischaemic stroke. The outcomes dealt with here include the primary outcome the Rankin score (mRS) at day 91 +/-14 days after randomisation. The secondary and exploratory outcomes at day 91 +/-14 days unless otherwise stated encompassing: (1) death or dependency, defined as mRS score > 2; (2) death; (3) National Institutes of Health Stroke Score; (4) brain infarct size at 48 +/-24 hours; (5) EQ-5D-5 L score, and (6) WHODAS 2.0 score. Other outcomes are: the primary safety outcome serious adverse events; and the incremental cost-effectiveness, and cost utility ratios. The analysis sets include (1) the intention-to-treat population, and (2) the per protocol population. The sample size is estimated to 800 patients (5% type 1 and 20% type 2 errors). All analyses are adjusted for the protocol-specified stratification variables (nationality of centre), and the minimisation variables. In the analysis, we use ordinal regression (the primary outcome), logistic regression (binary outcomes), general linear model (continuous outcomes), and the Poisson or negative binomial model (rate outcomes). DISCUSSION Major adjustments compared with the original statistical analysis plan encompass: (1) adjustment of analyses by nationality; (2) power calculations for the secondary outcomes; (3) to address the multiplicity problem using of a fixed-sequence testing procedure starting with the primary outcome followed by the secondary outcomes ordered according to falling power; (4) assignment of worst possible score to patients who are not alive at the planned date of measurement of the continuous scores; (5) improved imputations; (6) outline of a supplementary exploratory analysis of the temperature measurements and time to death; and (7) substantial reduction of sample size. TRIAL REGISTRATION Clinicaltrials.gov, identifier: NCT01833312 . 4 April 2013.
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Affiliation(s)
- Per Winkel
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Blegdamsvej 9, Copenhagen, Denmark
| | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, NG5 1PB UK
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Blegdamsvej 9, Copenhagen, Denmark
| | - Jane Lindschou
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Blegdamsvej 9, Copenhagen, Denmark
| | - H. Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Malcolm R. Macleod
- Division of Clinical Neurosciences, University of Edinburgh, FU204, Chancellor’s Building, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, EH16 4SA UK
| | - Istvan Szabo
- European Stroke Research Network for Hypothermia, Square de Meeus 38/40, 1000 Brussels, Belgium
| | - Isabelle Durand-Zaleski
- ECEVE, UMR 1123, URCEcoIle de France Hôpital de l’Hotel Dieu, 1 Place du parvis de Notre Dame, F 75004 Paris, France
| | - Stefan Schwab
- Neurologische Klinik, Universitætsklinikum Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - for the EuroHYP-1 trial investigators
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Blegdamsvej 9, Copenhagen, Denmark
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, NG5 1PB UK
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Division of Clinical Neurosciences, University of Edinburgh, FU204, Chancellor’s Building, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, EH16 4SA UK
- European Stroke Research Network for Hypothermia, Square de Meeus 38/40, 1000 Brussels, Belgium
- ECEVE, UMR 1123, URCEcoIle de France Hôpital de l’Hotel Dieu, 1 Place du parvis de Notre Dame, F 75004 Paris, France
- Neurologische Klinik, Universitætsklinikum Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
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55
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Cobas MA, Vera-Arroyo A. Hypothermia: Update on Risks and Therapeutic and Prophylactic Applications. Adv Anesth 2017; 35:25-45. [PMID: 29103575 DOI: 10.1016/j.aan.2017.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Miguel A Cobas
- Department of Anesthesiology and Perioperative Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA.
| | - Arnaldo Vera-Arroyo
- Department of Anesthesiology and Perioperative Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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56
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Lillicrap T, Tahtalı M, Neely A, Wang X, Bivard A, Lueck C. A model based on the Pennes bioheat transfer equation is valid in normal brain tissue but not brain tissue suffering focal ischaemia. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2017; 40:841-850. [PMID: 29098600 DOI: 10.1007/s13246-017-0595-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 10/18/2017] [Indexed: 11/29/2022]
Abstract
Ischaemic stroke is a major public health issue in both developed and developing nations. Hypothermia is believed to be neuroprotective in cerebral ischaemia. Conversely, elevated brain temperature is associated with poor outcome after ischaemic stroke. Mechanisms of heat exchange in normally-perfused brain are relatively well understood, but these mechanisms have not been studied as extensively during focal cerebral ischaemia. A finite element model (FEM) of heat exchange during focal ischaemia in the human brain was developed, based on the Pennes bioheat equation. This model incorporated healthy (normally-perfused) brain tissue, tissue that was mildly hypoperfused but not at risk of cell death (referred to as oligaemia), tissue that was hypoperfused and at risk of death but not dead (referred to as penumbra) and tissue that had died as a result of ischaemia (referred to as infarct core). The results of simulations using this model were found to match previous in-vivo temperature data for normally-perfused brain. However, the results did not match what limited data are available for hypoperfused brain tissue, in particular the penumbra, which is the focus of acute neuroprotective treatments such as hypothermia. These results suggest that the assumptions of the Pennes bioheat equation, while valid in the brain under normal circumstances, are not valid during focal ischaemia. Further investigation into the heat exchange profiles that do occur during focal ischaemia may yield results for clinical trials of therapeutic hypothermia.
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Affiliation(s)
| | - Murat Tahtalı
- School of Engineering and IT, UNSW Canberra, Canberra, Australia
| | - Andrew Neely
- School of Engineering and IT, UNSW Canberra, Canberra, Australia
| | - Xiaofei Wang
- National University of Singapore, Singapore, Singapore
| | - Andrew Bivard
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Christian Lueck
- Medical School, Australian National University, Canberra, Australia.,Neurology Department, The Canberra Hospital, Canberra, Australia
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57
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Rewell SSJ, Jeffreys AL, Sastra SA, Cox SF, Fernandez JA, Aleksoska E, van der Worp HB, Churilov L, Macleod MR, Howells DW. Hypothermia revisited: Impact of ischaemic duration and between experiment variability. J Cereb Blood Flow Metab 2017; 37:3380-3390. [PMID: 28084873 PMCID: PMC5624387 DOI: 10.1177/0271678x16688704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
To assess the true effect of novel therapies for ischaemic stroke, a positive control that can validate the experimental model and design is vital. Hypothermia may be a good candidate for such a positive control, given the convincing body of evidence from animal models of ischaemic stroke. Taking conditions under which substantial efficacy had been seen in a meta-analysis of hypothermia for focal ischaemia in animal models, we undertook three randomised and blinded studies examining the effect of hypothermia induced immediately following the onset of middle cerebral artery occlusion on infarct volume in rats (n = 15, 23, 264). Hypothermia to a depth of 33℃ and maintained for 130 min significantly reduced infarct volume compared to normothermia treatment (by 27-63%) and depended on ischaemic duration (F(3,244) = 21.242, p < 0.05). However, the protective effect varied across experiments with differences in both the size of the infarct observed in normothermic controls and the time to reach target temperature. Our results highlight the need for sample size and power calculations to take into account variations between individual experiments requiring induction of focal ischaemia.
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Affiliation(s)
- Sarah SJ Rewell
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Amy L Jeffreys
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Steven A Sastra
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Susan F Cox
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - John A Fernandez
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Elena Aleksoska
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonid Churilov
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Malcolm R Macleod
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK
| | - David W Howells
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania
- David W Howells, School of Medicine, Faculty of Health, University of Tasmania, Medical Science Precinct, 17 Liverpool Street, Hobart, Tasmania, Australia.
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58
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Challenges in the Anesthetic and Intensive Care Management of Acute Ischemic Stroke. J Neurosurg Anesthesiol 2017; 28:214-32. [PMID: 26368664 DOI: 10.1097/ana.0000000000000225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Acute ischemic stroke (AIS) is a devastating condition with high morbidity and mortality. In the past 2 decades, the treatment of AIS has been revolutionized by the introduction of several interventions supported by class I evidence-care on a stroke unit, intravenous tissue plasminogen activator within 4.5 hours of stroke onset, aspirin commenced within 48 hours of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. There is new class I evidence also demonstrating benefits of endovascular therapy on functional outcomes in those with anterior circulation stroke. In addition, the importance of the careful management of key systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose, has been appreciated. In line with this, the role of anesthesiologists and intensivists in managing AIS has increased. This review highlights the main challenges in the endovascular and intensive care management of AIS that, in part, result from the paucity of research focused on these areas. It also provides guidelines for the management of AIS based upon current evidence, and identifies areas for further research.
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Sadigh-Eteghad S, Majdi A, McCann SK, Mahmoudi J, Vafaee MS, Macleod MR. D-galactose-induced brain ageing model: A systematic review and meta-analysis on cognitive outcomes and oxidative stress indices. PLoS One 2017; 12:e0184122. [PMID: 28854284 PMCID: PMC5576729 DOI: 10.1371/journal.pone.0184122] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/18/2017] [Indexed: 12/16/2022] Open
Abstract
Animal models are commonly used in brain ageing research. Amongst these, models where rodents are exposed to d-galactose are held to recapitulate a number of features of ageing including neurobehavioral and neurochemical changes. However, results from animal studies are often inconsistent. To better understand the characteristics of the model and effects of d-galactose on neurobehavioral and neurochemical outcomes in rodents we performed a systematic review and meta-analysis. We applied random-effects meta-analysis to evaluate the effect of study features. Our results give an overview of the characteristics of the d-galactose rodent ageing model, including neurobehavioral and neurochemical outcomes. We found that few studies took measures to reduce risks of bias, and substantial heterogeneity in the reported effects of d-galactose in included studies. This highlights the need for improvements in the use of the d-galactose rodent ageing model if it is to provide useful in the development of drugs to treat human ageing.
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Affiliation(s)
- Saeed Sadigh-Eteghad
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Majdi
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
- * E-mail:
| | - Sarah K. McCann
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Javad Mahmoudi
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Manouchehr S. Vafaee
- Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Malcolm R. Macleod
- Department of Clinical Neurosciences, The University of Edinburgh, Edinburgh, United Kingdom
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60
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Kurisu K, Yenari MA. Therapeutic hypothermia for ischemic stroke; pathophysiology and future promise. Neuropharmacology 2017; 134:302-309. [PMID: 28830757 DOI: 10.1016/j.neuropharm.2017.08.025] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/12/2017] [Accepted: 08/17/2017] [Indexed: 01/08/2023]
Abstract
Therapeutic hypothermia, or cooling of the body or brain for the purposes of preserving organ viability, is one of the most robust neuroprotectants at both the preclinical and clinical levels. Although therapeutic hypothermia has been shown to improve outcome from related clinical conditions, the significance in ischemic stroke is still under investigation. Numerous pre-clinical studies of therapeutic hypothermia has suggested optimal cooling conditions, such as depth, duration, and temporal therapeutic window for effective neuroprotection. Several studies have also explored mechanisms underlying the mechanisms of neuroprotection by therapeutic hypothermia. As such, it appears that cooling affects multiple aspects of brain pathophysiology, and regulates almost every pathway involved in the evolution of ischemic stroke. This multifaceted mechanism is thought to contribute to its strong neuroprotective effect. In order to carry out this therapy in optimal clinical settings, methodological and pathophysiological understanding is crucial. However, more investigation is still needed to better understand the underlying mechanisms of this intervention, and to overcome clinical barriers which seem to preclude the routine use therapeutic hypothermia in stroke. This article is part of the Special Issue entitled 'Cerebral Ischemia'.
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Affiliation(s)
- Kota Kurisu
- Department of Neurology, University of California, San Francisco and Veterans Affairs Medical Center, San Francisco, CA 94121, USA
| | - Midori A Yenari
- Department of Neurology, University of California, San Francisco and Veterans Affairs Medical Center, San Francisco, CA 94121, USA.
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61
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Wowk S, Fagan KJ, Ma Y, Nichol H, Colbourne F. Examining potential side effects of therapeutic hypothermia in experimental intracerebral hemorrhage. J Cereb Blood Flow Metab 2017; 37:2975-2986. [PMID: 27899766 PMCID: PMC5536807 DOI: 10.1177/0271678x16681312] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 10/27/2016] [Accepted: 10/30/2016] [Indexed: 11/16/2022]
Abstract
Studies treating intracerebral hemorrhage (ICH) with therapeutic hypothermia (TH) have shown inconsistent benefits. We hypothesized that TH's anti-inflammatory effects may be responsible as inflammatory cells are essential for removing degrading erythrocytes. Here, we subjected rats to a collagenase-induced striatal ICH followed by whole-body TH (∼33℃ for 11-72 h) or normothermia. We used X-ray fluorescence imaging to spatially quantify total and peri-hematoma iron three days post-injury. At three and seven days, we measured non-heme iron levels. Finally, hematoma volume was quantified on one, three, and seven days. In the injured hemisphere, total iron levels were elevated ( p < 0.001) with iron increasing in the peri-hematoma region ( p = 0.007). Non-heme iron increased from three to seven days (p < 0.001). TH had no effect on any measure of iron ( p ≥ 0.479). At one and three days, TH did not affect hematoma volume ( p ≥ 0.264); however, at seven days there was a four-fold increase in hematoma volume in 40% of treated animals ( p = 0.032). Thus, even when TH does not interfere with initial increases in total and non-heme iron or its containment, TH can cause re-bleeding post-treatment. This serious complication could partly account for the intermittent protection previously observed. This also raises serious concerns for clinical usage of TH for ICH.
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Affiliation(s)
- Shannon Wowk
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Kelly J Fagan
- Department of Biology, MacEwan University, Edmonton, Canada
| | - Yonglie Ma
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
| | - Helen Nichol
- Department of Anatomy and Cell Biology, University of Saskatchewan, Saskatoon, Canada
| | - Frederick Colbourne
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
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Targeted temperature management in the ICU: Guidelines from a French expert panel. Anaesth Crit Care Pain Med 2017; 37:481-491. [PMID: 28688998 DOI: 10.1016/j.accpm.2017.06.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Over the recent period, the use of induced hypothermia has gained an increasing interest for critically ill patients, in particular in brain-injured patients. The term "targeted temperature management" (TTM) has now emerged as the most appropriate when referring to interventions used to reach and maintain a specific level temperature for each individual. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. This treatment is widely used in intensive care units, mostly as a primary neuroprotective method. Indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of TTM in adult and paediatric critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de réanimation de langue française [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie réanimation [SFAR]) with the participation of the French Emergency Medicine Association (Société française de médecine d'urgence [SFMU]), the French Group for Pediatric Intensive Care and Emergencies (Groupe francophone de réanimation et urgences pédiatriques [GFRUP]), the French National Association of Neuro-Anesthesiology and Critical Care (Association nationale de neuro-anesthésie réanimation française [ANARLF]), and the French Neurovascular Society (Société française neurovasculaire [SFNV]). Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations: cardiac arrest, traumatic brain injury, stroke, other brain injuries, and shock. This resulted in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were experts' opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations, which are exposed in the present article.
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63
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Muengtaweepongsa S, Srivilaithon W. Targeted temperature management in neurological intensive care unit. World J Methodol 2017; 7:55-67. [PMID: 28706860 PMCID: PMC5489424 DOI: 10.5662/wjm.v7.i2.55] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/12/2017] [Accepted: 05/18/2017] [Indexed: 02/06/2023] Open
Abstract
Targeted temperature management (TTM) shows the most promising neuroprotective therapy against hypoxic/ischemic encephalopathy (HIE). In addition, TTM is also useful for treatment of elevated intracranial pressure (ICP). HIE and elevated ICP are common catastrophic conditions in patients admitted in Neurologic intensive care unit (ICU). The most common cause of HIE is cardiac arrest. Randomized control trials demonstrate clinical benefits of TTM in patients with post-cardiac arrest. Although clinical benefit of ICP control by TTM in some specific critical condition, for an example in traumatic brain injury, is still controversial, efficacy of ICP control by TTM is confirmed by both in vivo and in vitro studies. Several methods of TTM have been reported in the literature. TTM can apply to various clinical conditions associated with hypoxic/ischemic brain injury and elevated ICP in Neurologic ICU.
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64
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Abstract
Over the recent period, the use of induced hypothermia has gained an increasing interest for critically ill patients, in particular in brain-injured patients. The term “targeted temperature management” (TTM) has now emerged as the most appropriate when referring to interventions used to reach and maintain a specific level temperature for each individual. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. This treatment is widely used in intensive care units, mostly as a primary neuroprotective method. Indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of TTM in adult and paediatric critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d’Anesthésie Réanimation [SFAR]) with the participation of the French Emergency Medicine Association (Société Française de Médecine d’Urgence [SFMU]), the French Group for Pediatric Intensive Care and Emergencies (Groupe Francophone de Réanimation et Urgences Pédiatriques [GFRUP]), the French National Association of Neuro-Anesthesiology and Critical Care (Association Nationale de Neuro-Anesthésie Réanimation Française [ANARLF]), and the French Neurovascular Society (Société Française Neurovasculaire [SFNV]). Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations: cardiac arrest, traumatic brain injury, stroke, other brain injuries, and shock. This resulted in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were experts’ opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations, which are exposed in the present article.
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Berge E, Salman RAS, van der Worp HB, Stapf C, Sandercock P, Sprigg N, Macleod MR, Kelly PJ, Nederkoorn PJ, Ford GA, Arnold M, Berge E, Diez-Tejedor E, Jatuzis D, Kelly PJ, Krieger DW, Nederkoorn PJ, Sandercock P, Stapf C, Weimar C, Ford GA, Salman RAS. Increasing value and reducing waste in stroke research. Lancet Neurol 2017; 16:399-408. [DOI: 10.1016/s1474-4422(17)30078-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/21/2022]
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66
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Babadjouni RM, Walcott BP, Liu Q, Tenser MS, Amar AP, Mack WJ. Neuroprotective delivery platforms as an adjunct to mechanical thrombectomy. Neurosurg Focus 2017; 42:E4. [PMID: 28366053 DOI: 10.3171/2017.1.focus16514] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Despite the success of numerous neuroprotective strategies in animal and preclinical stroke models, none have effectively translated to clinical medicine. A multitude of influences are likely responsible. Two such factors are inefficient recanalization strategies for large vessel occlusions and suboptimal delivery methods/platforms for neuroprotective agents. The recent endovascular stroke trials have established a new paradigm for large vessel stroke treatment. The associated advent of advanced mechanical revascularization devices and new stroke technologies help address each of these existing gaps. A strategy combining effective endovascular revascularization with administration of neuroprotective therapies is now practical and could have additive, if not synergistic, effects. This review outlines past and current neuroprotective strategies assessed in acute stroke trials. The discussion focuses on delivery platforms and their potential applicability to endovascular stoke treatment.
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Affiliation(s)
| | - Brian P Walcott
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Matthew S Tenser
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Arun P Amar
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - William J Mack
- Zilkha Neurogenetic Institute and.,Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Karsy M, Brock A, Guan J, Taussky P, Kalani MYS, Park MS. Neuroprotective strategies and the underlying molecular basis of cerebrovascular stroke. Neurosurg Focus 2017; 42:E3. [DOI: 10.3171/2017.1.focus16522] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Stroke is a leading cause of disability in the US. Although there has been significant progress in the area of medical and surgical thrombolytic technologies, neuroprotective agents to prevent secondary cerebral injury and to minimize disability remain limited. Only limited success has been reported in preclinical and clinical trials evaluating a variety of compounds. In this review, the authors discuss the most up-to-date information regarding the underlying molecular biology of stroke as well as strategies that aim to mitigate this complex signaling cascade. Results of historical research trials involving N-methyl-d-aspartate and α-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptor antagonists, clomethiazole, antioxidants, citicoline, nitric oxide, and immune regulators have laid the groundwork for current progress. In addition, more recent studies involving therapeutic hypothermia, magnesium, albumin, glyburide, uric acid, and a variety of other treatments have provided more options. The use of neuroprotective agents in combination or with existing thrombolytic treatments may be one of many exciting areas of further development. Although past trials of neuroprotective agents in ischemic stroke have been limited, significant insights into mechanisms of stroke, animal models, and trial design have incrementally improved approaches for future therapies.
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Abstract
OPINION STATEMENT In the past two decades, there has been much focus on the adverse effect of fever on neurologic outcome, the benefits of hypothermia on functional outcomes, and the interplay of associated complications. Despite decades of experience regarding randomized, safety and feasibility, case-controlled, retrospective studies, there has yet to be a large, randomized, multicenter, clinical trial with the appropriate power to address the potential benefits of targeted temperature modulation compared to hypothermia alone. What remains unanswered is the appropriate timing of initiation, duration, rewarming speed, and depth of targeted temperature management. We learn from the cardiac arrest literature that there is a neuroprotective value to hypothermia and, most recently, near normothermia (36 °C) as well. We have also established that increased depths of cooling are associated with increases in shivering, which warrant more aggressive pharmacologic management. Normothermia also has the advantage of allowing for more rapid clearance of sedating medications and less confounding of neuroprognostication. More difficult to quantify is the increased nursing and patient care complexity associated with moderate hypothermia compared to normothermia. It remains crucial, for those patients who are being considered for hypothermia/normothermia, to be cared for in an experienced ICU, driven under protocol, with aggressive shivering management and an expectation and acceptance of the complications associated with targeted temperature management. If targeted temperature management is not of consideration, then aggressive fever control should be undertaken pharmacologically and non-invasively, as they have been shown to be safe.
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Affiliation(s)
- Jonathan Marehbian
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, 15 York Street, Building LLCI, 10th Floor, Suite 1003, New Haven, CT, 06520, USA.
| | - David M Greer
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, LLCI 912, 15 York Street, New Haven, CT, 06520-8018, USA
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69
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Geurts M, Petersson J, Brizzi M, Olsson-Hau S, Luijckx GJ, Algra A, Dippel DW, Kappelle LJ, van der Worp HB. COOLIST (Cooling for Ischemic Stroke Trial). Stroke 2017; 48:219-221. [DOI: 10.1161/strokeaha.116.014757] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 10/01/2016] [Accepted: 10/10/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Animal studies suggest that cooling improves outcome after ischemic stroke. We assessed the feasibility and safety of surface cooling to different target temperatures in awake patients with acute ischemic stroke.
Methods—
A multicenter, randomized, open, phase II, clinical trial, comparing standard treatment with surface cooling to 34.0°C, 34.5°C, or 35.0°C in awake patients with acute ischemic stroke and an National Institutes of Health Stroke Scale score of ≥6, initiated within 4.5 hours after symptom onset and maintained for 24 hours. The primary outcome was feasibility, defined as the proportion of patients who had successfully completed the assigned treatment. Safety was a secondary outcome.
Results—
Inclusion was terminated after 22 patients because of slow recruitment. Five patients were randomized to 34.0°C, 6 to 34.5°C, 5 to 35.0°C (cooling was initiated in 4), and 6 to standard care. No (0%), 1 (17%), and 3 (75%) patients, respectively, completed the assigned treatment (
P
=0.03). No (0%), 2 (33%), and 4 (100%) patients reached the target temperature (
P
=0.01). Pneumonia occurred in 8 cooled patients but not in controls (absolute risk increase, 53%; 95% confidence interval, 28–79%;
P
=0.002).
Conclusions—
In awake patients with acute ischemic stroke, surface cooling is feasible to 35.0°C, but not to 34.5°C and 34.0°C. Cooling is associated with an increased risk of pneumonia.
Clinical Trial Registration—
URL:
http://www.trialregister.nl
. Unique identifier: NTR2616.
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Affiliation(s)
- Marjolein Geurts
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.G., L.J.K., H.B.v.d.W.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, The Netherlands; Department of Neurology, Skåne University Hospital, Malmö, Sweden (J.P., M.B., S.O.-H.); Department of Neurology, University Medical Center Groningen, The Netherlands (G.-J.L.); and Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands (D.W.J.D.)
| | - Jesper Petersson
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.G., L.J.K., H.B.v.d.W.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, The Netherlands; Department of Neurology, Skåne University Hospital, Malmö, Sweden (J.P., M.B., S.O.-H.); Department of Neurology, University Medical Center Groningen, The Netherlands (G.-J.L.); and Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands (D.W.J.D.)
| | - Marco Brizzi
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.G., L.J.K., H.B.v.d.W.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, The Netherlands; Department of Neurology, Skåne University Hospital, Malmö, Sweden (J.P., M.B., S.O.-H.); Department of Neurology, University Medical Center Groningen, The Netherlands (G.-J.L.); and Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands (D.W.J.D.)
| | - Stefan Olsson-Hau
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.G., L.J.K., H.B.v.d.W.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, The Netherlands; Department of Neurology, Skåne University Hospital, Malmö, Sweden (J.P., M.B., S.O.-H.); Department of Neurology, University Medical Center Groningen, The Netherlands (G.-J.L.); and Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands (D.W.J.D.)
| | - Gert-Jan Luijckx
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.G., L.J.K., H.B.v.d.W.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, The Netherlands; Department of Neurology, Skåne University Hospital, Malmö, Sweden (J.P., M.B., S.O.-H.); Department of Neurology, University Medical Center Groningen, The Netherlands (G.-J.L.); and Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands (D.W.J.D.)
| | - Ale Algra
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.G., L.J.K., H.B.v.d.W.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, The Netherlands; Department of Neurology, Skåne University Hospital, Malmö, Sweden (J.P., M.B., S.O.-H.); Department of Neurology, University Medical Center Groningen, The Netherlands (G.-J.L.); and Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands (D.W.J.D.)
| | - Diederik W.J. Dippel
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.G., L.J.K., H.B.v.d.W.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, The Netherlands; Department of Neurology, Skåne University Hospital, Malmö, Sweden (J.P., M.B., S.O.-H.); Department of Neurology, University Medical Center Groningen, The Netherlands (G.-J.L.); and Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands (D.W.J.D.)
| | - L. Jaap Kappelle
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.G., L.J.K., H.B.v.d.W.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, The Netherlands; Department of Neurology, Skåne University Hospital, Malmö, Sweden (J.P., M.B., S.O.-H.); Department of Neurology, University Medical Center Groningen, The Netherlands (G.-J.L.); and Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands (D.W.J.D.)
| | - H. Bart van der Worp
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.G., L.J.K., H.B.v.d.W.) and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, The Netherlands; Department of Neurology, Skåne University Hospital, Malmö, Sweden (J.P., M.B., S.O.-H.); Department of Neurology, University Medical Center Groningen, The Netherlands (G.-J.L.); and Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands (D.W.J.D.)
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70
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Lee JH, Zhang J, Yu SP. Neuroprotective mechanisms and translational potential of therapeutic hypothermia in the treatment of ischemic stroke. Neural Regen Res 2017; 12:341-350. [PMID: 28469636 PMCID: PMC5399699 DOI: 10.4103/1673-5374.202915] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Stroke is a leading cause of disability and death, yet effective treatments for acute stroke has been very limited. Thus far, tissue plasminogen activator has been the only FDA-approved drug for thrombolytic treatment of ischemic stroke patients, yet its application is only applicable to less than 4–5% of stroke patients due to the narrow therapeutic window (< 4.5 hours after the onset of stroke) and the high risk of hemorrhagic transformation. Emerging evidence from basic and clinical studies has shown that therapeutic hypothermia, also known as targeted temperature management, can be a promising therapy for patients with different types of stroke. Moreover, the success in animal models using pharmacologically induced hypothermia (PIH) has gained increasing momentum for clinical translation of hypothermic therapy. This review provides an updated overview of the mechanisms and protective effects of therapeutic hypothermia, as well as the recent development and findings behind PIH treatment. It is expected that a safe and effective hypothermic therapy has a high translational potential for clinical treatment of patients with stroke and other CNS injuries.
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Affiliation(s)
- Jin Hwan Lee
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA; Veteran's Affair Medical Center, Center for Visual and Neurocognitive Rehabilitation, Atlanta, GA, USA
| | - James Zhang
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA; Veteran's Affair Medical Center, Center for Visual and Neurocognitive Rehabilitation, Atlanta, GA, USA
| | - Shan Ping Yu
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA; Veteran's Affair Medical Center, Center for Visual and Neurocognitive Rehabilitation, Atlanta, GA, USA
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71
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Geurts M, Scheijmans FEV, van Seeters T, Biessels GJ, Kappelle LJ, Velthuis BK, van der Worp HB. Temporal profile of body temperature in acute ischemic stroke: relation to infarct size and outcome. BMC Neurol 2016; 16:233. [PMID: 27871258 PMCID: PMC5117518 DOI: 10.1186/s12883-016-0760-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 11/13/2016] [Indexed: 11/29/2022] Open
Abstract
Background High body temperatures after ischemic stroke have been associated with larger infarct size, but the temporal profile of this relation is unknown. We assess the relation between temporal profile of body temperature and infarct size and functional outcome in patients with acute ischemic stroke. Methods In 419 patients with acute ischemic stroke we assessed the relation between body temperature on admission and during the first 3 days with both infarct size and functional outcome. Infarct size was measured in milliliters on CT or MRI after 3 days. Poor functional outcome was defined as a modified Rankin Scale score ≥3 at 3 months. Results Body temperature on admission was not associated with infarct size or poor outcome in adjusted analyses. By contrast, each additional 1.0 °C in body temperature on day 1 was associated with 0.31 ml larger infarct size (95% confidence interval (CI) 0.04–0.59), on day 2 with 1.13 ml larger infarct size(95% CI, 0.83–1.43), and on day 3 with 0.80 ml larger infarct size (95% CI, 0.48–1.12), in adjusted linear regression analyses. Higher peak body temperatures on days two and three were also associated with poor outcome (adjusted relative risks per additional 1.0 °C in body temperature, 1.52 (95% CI, 1.17–1.99) and 1.47 (95% CI, 1.22–1.77), respectively). Conclusions Higher peak body temperatures during the first days after ischemic stroke, rather than on admission, are associated with larger infarct size and poor functional outcome. This suggests that prevention of high temperatures may improve outcome if continued for at least 3 days.
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Affiliation(s)
- Marjolein Geurts
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Féline E V Scheijmans
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tom van Seeters
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Geert J Biessels
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
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72
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McCann SK, Cramond F, Macleod MR, Sena ES. Systematic Review and Meta-Analysis of the Efficacy of Interleukin-1 Receptor Antagonist in Animal Models of Stroke: an Update. Transl Stroke Res 2016; 7:395-406. [PMID: 27526101 PMCID: PMC5014900 DOI: 10.1007/s12975-016-0489-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 07/25/2016] [Accepted: 07/28/2016] [Indexed: 02/04/2023]
Abstract
Interleukin-1 receptor antagonist (IL-1 RA) is an anti-inflammatory protein used clinically to treat rheumatoid arthritis and is considered a promising candidate therapy for stroke. Here, we sought to update the existing systematic review and meta-analysis of IL-1 RA in models of ischaemic stroke, published in 2009, to assess efficacy, the range of circumstances in which efficacy has been tested and whether the data appear to be confounded due to reported study quality and publication bias. We included 25 sources of data, 11 of which were additional to the original review. Overall, IL-1 RA reduced infarct volume by 36.2 % (95 % confidence interval 31.6-40.7, n = 76 comparisons from 1283 animals). Assessments for publication bias suggest 30 theoretically missing studies which reduce efficacy to 21.9 % (17.3-26.4). Efficacy was higher where IL-1 RA was administered directly into the ventricles rather than peripherally, and studies not reporting allocation concealment during the induction of ischaemia reported larger treatment effects. The preclinical data supporting IL-1 RA as a candidate therapy for ischaemic stroke have improved. The reporting of measures to reduce the risk of bias has improved substantially in this update, and studies now include the use of animals with relevant co-morbidities.
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Affiliation(s)
- Sarah K McCann
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Fala Cramond
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Malcolm R Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Emily S Sena
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
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73
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Gervois P, Wolfs E, Ratajczak J, Dillen Y, Vangansewinkel T, Hilkens P, Bronckaers A, Lambrichts I, Struys T. Stem Cell-Based Therapies for Ischemic Stroke: Preclinical Results and the Potential of Imaging-Assisted Evaluation of Donor Cell Fate and Mechanisms of Brain Regeneration. Med Res Rev 2016; 36:1080-1126. [DOI: 10.1002/med.21400] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/27/2016] [Accepted: 06/17/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Pascal Gervois
- Morphology Research Group, Biomedical Research Institute, Hasselt University; Campus Diepenbeek; Bioville Diepenbeek Belgium
| | - Esther Wolfs
- Morphology Research Group, Biomedical Research Institute, Hasselt University; Campus Diepenbeek; Bioville Diepenbeek Belgium
| | - Jessica Ratajczak
- Morphology Research Group, Biomedical Research Institute, Hasselt University; Campus Diepenbeek; Bioville Diepenbeek Belgium
| | - Yörg Dillen
- Morphology Research Group, Biomedical Research Institute, Hasselt University; Campus Diepenbeek; Bioville Diepenbeek Belgium
| | - Tim Vangansewinkel
- Morphology Research Group, Biomedical Research Institute, Hasselt University; Campus Diepenbeek; Bioville Diepenbeek Belgium
| | - Petra Hilkens
- Morphology Research Group, Biomedical Research Institute, Hasselt University; Campus Diepenbeek; Bioville Diepenbeek Belgium
| | - Annelies Bronckaers
- Morphology Research Group, Biomedical Research Institute, Hasselt University; Campus Diepenbeek; Bioville Diepenbeek Belgium
| | - Ivo Lambrichts
- Morphology Research Group, Biomedical Research Institute, Hasselt University; Campus Diepenbeek; Bioville Diepenbeek Belgium
| | - Tom Struys
- Morphology Research Group, Biomedical Research Institute, Hasselt University; Campus Diepenbeek; Bioville Diepenbeek Belgium
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74
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Dumitrascu OM, Lamb J, Lyden PD. Still cooling after all these years: Meta-analysis of pre-clinical trials of therapeutic hypothermia for acute ischemic stroke. J Cereb Blood Flow Metab 2016; 36:1157-64. [PMID: 27089911 PMCID: PMC4929706 DOI: 10.1177/0271678x16645112] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 03/24/2016] [Indexed: 11/17/2022]
Abstract
Therapeutic hypothermia is the most potent neuroprotectant for experimental cerebral ischemia, illustrated in a 2007 meta-analysis published in this journal. To address recent therapeutic nihilism, we systematically reviewed recent experimental literature. Quality scoring showed considerable improvement in study design. Using several outcome measures in a variety of models and species, therapeutic hypothermia was protective compared with normothermia, with powerful and statistically significant normalized treatment effect sizes, in 60 papers comprising 216 comparisons. In the past 5 years, preclinical studies of ischemic stroke re-emphasize that therapeutic hypothermia is potently effective, justifying further development in larger human clinical trials.
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Affiliation(s)
- Oana M Dumitrascu
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Jessica Lamb
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Patrick D Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, USA
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75
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Klahr AC, Nadeau CA, Colbourne F. Temperature Control in Rodent Neuroprotection Studies: Methods and Challenges. Ther Hypothermia Temp Manag 2016; 7:42-49. [PMID: 27327871 DOI: 10.1089/ther.2016.0018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Extensive animal research facilitated the clinical translation of therapeutic hypothermia for cardiac arrest in adults and hypoxic-ischemic injury in infants. Similarly, clinical interest in hypothermia for other brain injuries, such as stroke, has been greatly supported by positive findings in preclinical work. The reliability, validity, and utility of animal models, among many research practices (blinding, randomization, etc.), are key to successful clinical translation. Here, we review methods used to induce and maintain hypothermia in animal models. These include physical and pharmacological methods. We emphasize the advantages and limitations of each approach, and the importance of using clinically relevant cooling protocols and appropriate monitoring and reporting approaches. Moreover, we performed a literature survey of ischemic stroke studies published in 2015 to highlight the continuing risk of temperature confounds in neuroprotection studies. For example, many still do not accurately monitor and report temperature during surgery (23.5%), even though almost half of these studies (46.0%) use pharmaceutical agents that likely influence temperature. We hope this review stimulates awareness and discussion of the importance of temperature in neuroprotective studies.
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Affiliation(s)
- Ana C Klahr
- 1 Neuroscience and Mental Health Institute, University of Alberta , Edmonton, Canada
| | - Colby A Nadeau
- 2 Department of Psychology, University of Alberta , Edmonton, Canada
| | - Frederick Colbourne
- 1 Neuroscience and Mental Health Institute, University of Alberta , Edmonton, Canada .,2 Department of Psychology, University of Alberta , Edmonton, Canada
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76
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Wu Z, Zhu SZ, Hu YF, Gu Y, Wang SN, Lin ZZ, Xie ZS, Pan SY. Glibenclamide enhances the effects of delayed hypothermia after experimental stroke in rats. Brain Res 2016; 1643:113-22. [PMID: 27134036 DOI: 10.1016/j.brainres.2016.04.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 04/24/2016] [Accepted: 04/27/2016] [Indexed: 11/25/2022]
Abstract
In order to evaluate whether glibenclamide can extend the therapeutic window during which induced hypothermia can protect against stroke, we subjected adult male Sprague-Dawley rats to middle cerebral artery occlusion (MCAO). We first verified the protective effects of hypothermia induced at 0, 2, 4 or 6h after MCAO onset, and then we assessed the effects of the combination of glibenclamide and hypothermia at 6, 8 or 10h after MCAO onset. At 24h after MCAO, we assessed brain edema, infarct volume, modified neurological severity score, Evans Blue leakage and expression of Sulfonylurea receptor 1 (SUR1) protein and pro-inflammatory factors. No protective effects were observed when hypothermia was induced too long after MCAO. At 6h after MCAO onset, hypothermia alone failed to decrease cerebral edema and infarct volume, but the combination of glibenclamide and hypothermia decreased both. The combination also improved neurological outcome, ameliorated blood-brain barrier damage and decreased levels of COX-2, TNF-α and IL-1β. These results suggest that glibenclamide enhances and extends the therapeutic effects of delayed hypothermia against ischemia stroke, potentially by ameliorating blood-brain barrier damage and declining levels of pro-inflammatory factors.
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Affiliation(s)
- Zhou Wu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shu-Zhen Zhu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ya-Fang Hu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yong Gu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Sheng-Nan Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhen-Zhou Lin
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zuo-Shan Xie
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Su-Yue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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77
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Forreider B, Pozivilko D, Kawaji Q, Geng X, Ding Y. Hibernation-like neuroprotection in stroke by attenuating brain metabolic dysfunction. Prog Neurobiol 2016; 157:174-187. [PMID: 26965388 DOI: 10.1016/j.pneurobio.2016.03.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 03/02/2016] [Accepted: 03/03/2016] [Indexed: 11/24/2022]
Abstract
Many mammalian species naturally undergo hibernation, a process that is associated with drastic changes in metabolism and systemic physiology. Their ability to retain an undamaged central nervous system during severely reduced cerebral blood flow has been studied for possible therapeutic application in human ischemic stroke. By inducing a less extreme 'hibernation-like' state, it has been hypothesized that similar neuroprotective effects reduce ischemia-mediated tissue damage in stroke patients. This manuscript includes reviews and evaluations of: (1) true hibernation, (2) hibernation-like state and its neuroprotective characteristics, (3) the preclinical and clinical methods for induction of artificial hibernation (i.e., therapeutic hypothermia, phenothiazine drugs, and ethanol), and (4) the mechanisms by which cerebral ischemia leads to tissue damage and how the above-mentioned induction methods function to inhibit those processes.
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Affiliation(s)
- Brian Forreider
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - David Pozivilko
- Michigan State University College of Human Medicine, East Lansing, MI, USA
| | - Qingwen Kawaji
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xiaokun Geng
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA; China-America Institute of Neuroscience, Luhe Hospital, Capital Medical University, Beijing, China.
| | - Yuchuan Ding
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA; China-America Institute of Neuroscience, Luhe Hospital, Capital Medical University, Beijing, China.
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78
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Henninger N, Fisher M. Extending the Time Window for Endovascular and Pharmacological Reperfusion. Transl Stroke Res 2016; 7:284-93. [DOI: 10.1007/s12975-015-0444-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 12/13/2015] [Accepted: 12/14/2015] [Indexed: 01/07/2023]
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Klahr AC, Dietrich K, Dickson CT, Colbourne F. Prolonged Localized Mild Hypothermia Does Not Affect Seizure Activity After Intracerebral Hemorrhage in Rats. Ther Hypothermia Temp Manag 2015; 6:40-7. [PMID: 26717112 DOI: 10.1089/ther.2015.0028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a devastating stroke with high morbidity and mortality. Post-ICH seizures are a common complication, potentially increasing brain injury and the risk of delayed epilepsy. Mild therapeutic hypothermia (HYPO, ∼33°C) is neuroprotective against several brain insults, such as ischemia, while also mitigating seizure incidence and severity in some instances. Therefore, we tested whether brain-selective HYPO reduced electrographic seizure activity after a collagenase-induced striatal ICH in rats. Animals were injected unilaterally with 0.14 U of bacterial collagenase, implanted with a unilateral brain cooling device, and a probe to bilaterally record electroencephalographic (EEG) activity. Cooling began 6 hours after collagenase infusion and was maintained for 48 hours, followed by rewarming over 6 hours. Our protocol did not affect EEG activity in naïve rats, nor did it increase bleeding after ICH (∼50 μL). Epileptiform activity commonly occurred in untreated ICH rats (∼60% of animals), but HYPO did not affect the incidence, timing, total duration of seizures, or the peaks occurring during epileptiform activity. However, longer average duration was detected on the ipsilateral side to stroke in the HYPO group (p < 0.05). Cooling did not affect neurological deficits (e.g., circling), measured 7 and 14 days after ICH, or lesion volume (∼35 mm(3)). In addition, there was no relationship among endpoints (e.g., seizures and lesion size). In summary, HYPO failed to reduce seizure activity after ICH, which fits with our separate findings that cooling does not mitigate thrombin and iron-mediated secondary injury mechanisms thought to cause seizures after ICH. Additional research is needed to identify better HYPO protocols and the use of cotreatments to maximize the benefit of HYPO to ICH patients.
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Affiliation(s)
- Ana C Klahr
- 1 Neuroscience and Mental Health Institute, University of Alberta , Edmonton, Canada
| | - Kristen Dietrich
- 1 Neuroscience and Mental Health Institute, University of Alberta , Edmonton, Canada
| | - Clayton T Dickson
- 1 Neuroscience and Mental Health Institute, University of Alberta , Edmonton, Canada .,2 Department of Psychology, University of Alberta , Edmonton, Canada
| | - Frederick Colbourne
- 1 Neuroscience and Mental Health Institute, University of Alberta , Edmonton, Canada .,2 Department of Psychology, University of Alberta , Edmonton, Canada
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80
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Wagner MW, Stern SE, Oshmyansky A, Huisman TAGM, Poretti A. The Role of ADC-Based Thermometry in Measuring Brain Intraventricular Temperature in Children. J Neuroimaging 2015; 26:315-23. [PMID: 26707790 DOI: 10.1111/jon.12325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 11/25/2015] [Accepted: 11/26/2015] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE To determine the feasibility of apparent diffusion coefficient (ADC)-based thermometry to assess intraventricular temperature in children. METHODS ADC maps were generated from diffusion tensor imaging data, which were acquired with diffusion gradients along 20 noncollinear directions using a b-value of 1000 s/mm(2) . The intraventricular temperature was calculated based on intraventricular ADC values and the mode method as previously reported. The calculated intraventricular temperature was validated with an estimated brain temperature based on temporal artery temperature measurements. We included 120 children in this study (49 females, 71 males, mean age 6.63 years), 15 consecutive children for each of the following age groups: 0-1, 1-2, 2-4, 4-6, 6-8, 8-10, 10-14, and 14-18 years. Forty-three children had a normal brain MRI and 77 children had an abnormal brain scan. Polynomial fitting to the temperature distribution and subsequent calculation of mode values was performed. A correlation coefficient and a coefficient of determination were calculated between ADC calculated temperatures and estimated brain temperatures. Linear regression analysis was performed to investigate the two temperature measures. RESULTS ADC-based intraventricular temperatures ranged between 31.5 and 39.6 °C, although estimated brain temperatures ranged between 36.3 and 38.1 °C. The difference between the temperatures is larger for children with more than 8,000 voxels within the lateral ventricles compared to children with less than 8,000 voxels. The correlation coefficient between ADC-based temperatures and the estimated brain temperatures is .1, the respective R(2) is .01 indicating that 1% of the changes in estimated brain temperatures are attributable to corresponding changes in ADC-based temperature measurements (P = .275). CONCLUSIONS ADC-based thermometry has limited application in the pediatric population mainly due to a small ventricular size.
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Affiliation(s)
- Matthias W Wagner
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Steven E Stern
- School of Mathematical Sciences, Faculty of Science and Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Alexander Oshmyansky
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD.,School of Mathematical Sciences, Faculty of Science and Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Thierry A G M Huisman
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrea Poretti
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
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81
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Li X, Ji Z, Gu Y, Hu Y, Huang K, Pan S. Mild hypothermia decreases the total clearance of glibenclamide after low dose administration in rats. Neurosci Lett 2015; 614:55-9. [PMID: 26724224 DOI: 10.1016/j.neulet.2015.12.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 11/02/2015] [Accepted: 12/17/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Low dose glibenclamide exhibits pleiotropic protective effects in different central nervous system diseases. Previously, we have shown that mild hypothermia enhanced the efficacy of glibenclamide in the cultured cortical neuronal cells. This study aims to evaluate the impact of mild hypothermia on the pharmacokinetics of low dose glibenclamide in rats via its cytochrome P450 2C9 (CYP2C9) metabolic pathway. METHODS Male Sprague-Dawley rats were maintained at 37°C (normothermic group) or cooled to 33°C (hypothermic group). Glibenclamide (33μg/kg) or diclofenac (10mg/kg, a probe drug for assessing the activity of CYP2C9 which involves in glibenclamide and diclofenac metabolism in liver) were intravenously administered at 10min after stabilization of temperature. Plasma samples were collected at 9 different time points. Glibenclamide and diclofenac in sera were separated by liquid chromatography and quantified with tandem mass spectrometry. RESULTS Compared with normothermia, mild hypothermia significantly decreased the total clearance of glibenclamide (16.00±4.1-6.72±2.1mL/min/kg; p<0.01), and there was a non-significant trend in a slightly higher half-life, (1.64±0.34-2.71±1.7h, p=0.157). Area under the plasma concentration versus time curve (AUClast) in the hypothermic group was increased (33.2±11-77.8±18hng/mL, p<0.01). Moreover, mild hypothermia reduced the total clearance of diclofenac (10.33±1.53-7.20±1.66mL/min/kg, p<0.01), indicating that the CYP2C9 activity was compromised in reduced temperature. CONCLUSION Mild hypothermia reduced the total clearance of glibenclamide, probably via mediating the activity of CYP2C9. The impact of hypothermia in clinical application of glibenclamide should be considered.
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Affiliation(s)
- Xing Li
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhong Ji
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yong Gu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yafang Hu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Kaibin Huang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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82
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John RF, Colbourne F. Delayed localized hypothermia reduces intracranial pressure following collagenase-induced intracerebral hemorrhage in rat. Brain Res 2015; 1633:27-36. [PMID: 26723566 DOI: 10.1016/j.brainres.2015.12.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/15/2015] [Accepted: 12/16/2015] [Indexed: 01/30/2023]
Abstract
Brain injury, such as from intracerebral hemorrhage (ICH), causes edema and raises intracranial pressure (ICP)--a potentially life-threatening complication. Clinical studies suggest that therapeutic hypothermia (TH) reduces edema and ICP after ICH. Similarly, animal studies show that TH can sometimes reduce edema, but whether ICP would be attenuated is not known. Here we tested whether 24-h delayed TH reduces edema and ICP in rats with severe striatal ICH (collagenase model). First, we showed that ICH increased epidural ICP (mean of 18 vs. 6.5mm Hg in controls), measured via telemetry. Second, we confirmed that delayed TH did not affect hematoma size at 7d ay (~65 vs. ~61 µL in controls). A cranial cooling device lowered striatal temperature to ~33 °C from 24 to 72 h after ICH. Third, we compared normothermic rats to those with TH that were rewarmed immediately or over 6h. Both TH protocols significantly reduced average and peak ICP by the second treatment day, and benefits persisted after rewarming. However, TH with slow rewarming failed to mitigate edema at 96 h (83.2% vs. 83.6% in controls) whereas rapid rewarming worsened edema (85.7%). Finally, we compared normothermic and TH rats without rewarming and found no impact on edema at 72 h (~81%). In summary, it appears that 24-h delayed local TH lowers ICP by a mechanism other than edema. Rapid rewarming worsens edema after local cooling, but this did not markedly impact ICP. Thus, TH should reduce ICP in patients with severe ICH, but not necessarily through mitigating edema.
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Affiliation(s)
- Roseleen F John
- Neuroscience and Mental Health Institute University of Alberta, Edmonton, Alberta, Canada
| | - Frederick Colbourne
- Neuroscience and Mental Health Institute University of Alberta, Edmonton, Alberta, Canada; Department of Psychology, University of Alberta, Edmonton, Alberta, Canada.
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83
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Mundt HM, Yard BA, Krämer BK, Benck U, Schnülle P. Optimized donor management and organ preservation before kidney transplantation. Transpl Int 2015; 29:974-84. [DOI: 10.1111/tri.12712] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 07/02/2015] [Accepted: 10/30/2015] [Indexed: 12/30/2022]
Affiliation(s)
- Heiko M. Mundt
- 5th Department of Medicine (Nephrology/Endocrinology/Rheumatology); Medical Faculty Mannheim of the University of Heidelberg; University Hospital Mannheim; Mannheim Germany
| | - Benito A. Yard
- 5th Department of Medicine (Nephrology/Endocrinology/Rheumatology); Medical Faculty Mannheim of the University of Heidelberg; University Hospital Mannheim; Mannheim Germany
| | - Bernhard K. Krämer
- 5th Department of Medicine (Nephrology/Endocrinology/Rheumatology); Medical Faculty Mannheim of the University of Heidelberg; University Hospital Mannheim; Mannheim Germany
| | - Urs Benck
- 5th Department of Medicine (Nephrology/Endocrinology/Rheumatology); Medical Faculty Mannheim of the University of Heidelberg; University Hospital Mannheim; Mannheim Germany
| | - Peter Schnülle
- 5th Department of Medicine (Nephrology/Endocrinology/Rheumatology); Medical Faculty Mannheim of the University of Heidelberg; University Hospital Mannheim; Mannheim Germany
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84
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Twenty-four hours hypothermia has temporary efficacy in reducing brain infarction and inflammation in aged rats. Neurobiol Aging 2015; 38:127-140. [PMID: 26827651 DOI: 10.1016/j.neurobiolaging.2015.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/19/2015] [Accepted: 11/11/2015] [Indexed: 11/23/2022]
Abstract
Stroke is a major cause of disability for which no neuroprotective measures are available. Age is the principal nonmodifiable risk factor for this disease. Previously, we reported that exposure to hydrogen sulfide for 48 hours after stroke lowers whole body temperature and confers neuroprotection in aged animals. Because the duration of hypothermia in most clinical trials is between 24 and 48 hours, we questioned whether 24 hours exposure to gaseous hypothermia confers the same neuroprotective efficacy as 48 hours exposure. We found that a shorter exposure to hypothermia transiently reduced both inflammation and infarct size. However, after 1 week, the infarct size became even larger than in controls and after 2 weeks there was no beneficial effect on regenerative processes such as neurogenesis. Behaviorally, hypothermia also had a limited beneficial effect. Finally, after hydrogen sulfide-induced hypothermia, the poststroke aged rats experienced a persistent sleep impairment during their active nocturnal period. Our data suggest that cellular events that are delayed by hypothermia in aged rats may, in the long term, rebound, and diminish the beneficial effects.
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85
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Feketa VV, Marrelli SP. Systemic Administration of the TRPV3 Ion Channel Agonist Carvacrol Induces Hypothermia in Conscious Rodents. PLoS One 2015; 10:e0141994. [PMID: 26528923 PMCID: PMC4631363 DOI: 10.1371/journal.pone.0141994] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 10/15/2015] [Indexed: 11/19/2022] Open
Abstract
Therapeutic hypothermia is a promising new strategy for neuroprotection. However, the methods for safe and effective hypothermia induction in conscious patients are lacking. The current study explored the Transient Receptor Potential Vanilloid 3 (TRPV3) channel activation by the agonist carvacrol as a potential hypothermic strategy. It was found that carvacrol lowers core temperature after intraperitoneal and intravenous administration in mice and rats. However, the hypothermic effect at safe doses was modest, while higher intravenous doses of carvacrol induced a pronounced drop in blood pressure and substantial toxicity. Experiments on the mechanism of the hypothermic effect in mice revealed that it was associated with a decrease in whole-body heat generation, but not with a change in cold-seeking behaviors. In addition, the hypothermic effect was lost at cold ambient temperature. Our findings suggest that although TRPV3 agonism induces hypothermia in rodents, it may have a limited potential as a novel pharmacological method for induction of hypothermia in conscious patients due to suboptimal effectiveness and high toxicity.
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Affiliation(s)
- Viktor V. Feketa
- Department of Molecular Physiology and Biophysics Graduate Program, Cardiovascular Sciences Track, Baylor College of Medicine, Houston, Texas, United States of America
| | - Sean P. Marrelli
- Department of Molecular Physiology and Biophysics Graduate Program, Cardiovascular Sciences Track, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas, United States of America
- * E-mail:
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86
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No Relation between Body Temperature and Arterial Recanalization at Three Days in Patients with Acute Ischaemic Stroke. PLoS One 2015; 10:e0140777. [PMID: 26473959 PMCID: PMC4608560 DOI: 10.1371/journal.pone.0140777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 09/30/2015] [Indexed: 11/29/2022] Open
Abstract
Background Recanalization of an occluded intracranial artery is influenced by temperature-dependent enzymes, including alteplase. We assessed the relation between body temperature on admission and recanalization. Methods We included 278 patients with acute ischaemic stroke within nine hours after symptom onset, who had an intracranial arterial occlusion on admission CT angiography, in 13 participating centres. We calculated the relation per every 0.1°Celsius increase in admission body temperature and recanalization at three days. Results Recanalization occurred in 80% of occluded arteries. There was no relation between body temperature and recanalization at three days after adjustments for age, NIHSS score on admission and treatment with alteplase (adjusted odds ratio per 0.1°Celsius, 0.99; 95% confidence interval, 0.94–1.05; p = 0.70). Results for patients treated or not treated with alteplase were essentially the same. Conclusions Our findings suggest that in patients with acute ischaemic stroke there is no relation between body temperature on admission and recanalization of an occluded intracranial artery three days later, irrespective of treatment with alteplase.
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Niemann CU, Feiner J, Swain S, Bunting S, Friedman M, Crutchfield M, Broglio K, Hirose R, Roberts JP, Malinoski D. Therapeutic Hypothermia in Deceased Organ Donors and Kidney-Graft Function. N Engl J Med 2015. [PMID: 26222557 DOI: 10.1056/nejmoa1501969] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delayed graft function, which is reported in up to 50% of kidney-transplant recipients, is associated with increased costs and diminished long-term graft function. The effect that targeted mild hypothermia in organ donors before organ recovery has on the rate of delayed graft function is unclear. METHODS We enrolled organ donors (after declaration of death according to neurologic criteria) from two large donation service areas and randomly assigned them to one of two targeted temperature ranges: 34 to 35°C (hypothermia) or 36.5 to 37.5°C (normothermia). Temperature protocols, which were initiated after authorization was obtained for the organ to be donated and for the donor's participation in the study, ended when organ donors left the intensive care unit for organ recovery in the operating room. The primary outcome was delayed graft function in the kidney recipients, which was defined as the requirement for dialysis during the first week after transplantation. Secondary outcomes were the rates of individual organs transplanted in each treatment group and the total number of organs transplanted from each donor. RESULTS The study was terminated early, on the recommendation of an independent data and safety monitoring board, after the interim analysis showed efficacy of hypothermia. At trial termination, 370 organ donors had been enrolled (180 in the hypothermia group and 190 in the normothermia group). A total of 572 patients received a kidney transplant (285 kidneys from donors in the hypothermia group and 287 kidneys from donors in the normothermia group). Delayed graft function developed in 79 recipients of kidneys from donors in the hypothermia group (28%) and in 112 recipients of kidneys from donors in the normothermia group (39%) (odds ratio, 0.62; 95% confidence interval, 0.43 to 0.92; P=0.02). CONCLUSIONS Mild hypothermia, as compared with normothermia, in organ donors after declaration of death according to neurologic criteria significantly reduced the rate of delayed graft function among recipients. (Funded by the Health Resources and Services Administration; ClinicalTrials.gov number, NCT01680744.).
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Affiliation(s)
- Claus U Niemann
- From the Department of Anesthesia and Perioperative Care (C.U.N., J.F.) and the Department of Surgery, Division of Transplant Surgery (C.U.N., R.H., J.P.R.), University of California, San Francisco, San Francisco, the California Transplant Donor Network, Oakland (S.S.), and OneLegacy, Los Angeles (S.B., M.F.) - all in California; the Section of Surgical Critical Care, Veterans Affairs Portland Health Care System (M.C., D.M.), and the Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health and Science University (D.M.) - both in Portland; and Berry Consultants, Austin, TX (K.B.)
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Ntaios G, Dziedzic T, Michel P, Papavasileiou V, Petersson J, Staykov D, Thomas B, Steiner T. European Stroke Organisation (ESO) Guidelines for the Management of Temperature in Patients with Acute Ischemic Stroke. Int J Stroke 2015; 10:941-9. [DOI: 10.1111/ijs.12579] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 06/01/2015] [Indexed: 10/23/2022]
Abstract
Background Hyperthermia is a frequent complication in patients with acute ischemic stroke. On the other hand, therapeutically induced hypothermia has shown promising potential in animal models of focal cerebral ischemia. This Guideline Document presents the European Stroke Organisation guidelines for the management of temperature in patients with acute ischemic stroke. Methods A multidisciplinary group identified related questions and developed its recommendations based on evidence from randomized controlled trials elaborating the Grading of Recommendations Assessment, Development, and Evaluation approach. This Guideline Document was reviewed within the European Stroke Organisation and externally and was approved by the European Stroke Organisation Guidelines Committee and the European Stroke Organisation Executive Committee. Results We found low-quality evidence, and therefore, we cannot make any recommendation for treating hyperthermia as a means to improve functional outcome and/or survival in patients with acute ischemic stroke and hyperthermia; moderate evidence to suggest against routine prevention of hyperthermia with antipyretics as a means to improve functional outcome and/or survival in patients with acute ischemic stroke and normothermia; very low-quality evidence to suggest against routine induction of hypothermia as a means to improve functional outcome and/or survival in patients with acute ischemic stroke. Conclusions The currently available data about the management of temperature in patients with acute ischemic stroke are limited, and the strengths of the recommendations are therefore weak. We call for new randomized controlled trials as well as recruitment of eligible patients to ongoing randomized controlled trials to allow for better-informed recommendations in the future.
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Affiliation(s)
- George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece
| | - Tomasz Dziedzic
- Department of Neurology, Jagiellonian University, Krakow, Poland
| | - Patrik Michel
- Stroke center, Neurology Service, CHUV, University of Lausanne, Lausanne, Switzerland
| | | | - Jesper Petersson
- Department of Neurology, Skåne University Hospital, Malmö, Sweden
| | - Dimitre Staykov
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria
| | - Brenda Thomas
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University, Heidelberg, Germany
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Kollmar R. Latest evidence for the use of targeted temperature management in neurology. BMC Emerg Med 2015. [PMCID: PMC4480838 DOI: 10.1186/1471-227x-15-s1-a16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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90
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Feketa VV, Marrelli SP. Induction of therapeutic hypothermia by pharmacological modulation of temperature-sensitive TRP channels: theoretical framework and practical considerations. Temperature (Austin) 2015; 2:244-57. [PMID: 27227027 PMCID: PMC4844121 DOI: 10.1080/23328940.2015.1024383] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/25/2015] [Accepted: 02/25/2015] [Indexed: 12/22/2022] Open
Abstract
Therapeutic hypothermia has emerged as a remarkably effective method of neuroprotection from ischemia and is being increasingly used in clinics. Accordingly, it is also a subject of considerable attention from a basic scientific research perspective. One of the fundamental problems, with which current studies are concerned, is the optimal method of inducing hypothermia. This review seeks to provide a broad theoretical framework for approaching this problem, and to discuss how a novel promising strategy of pharmacological modulation of the thermosensitive ion channels fits into this framework. Various physical, anatomical, physiological and molecular aspects of thermoregulation, which provide the foundation for this text, have been comprehensively reviewed and will not be discussed exhaustively here. Instead, the first part of the current review, which may be helpful for a broader readership outside of thermoregulation research, will build on this existing knowledge to outline possible opportunities and research directions aimed at controlling body temperature. The second part, aimed at a more specialist audience, will highlight the conceptual advantages and practical limitations of novel molecular agents targeting thermosensitive Transient Receptor Potential (TRP) channels in achieving this goal. Two particularly promising members of this channel family, namely TRP melastatin 8 (TRPM8) and TRP vanilloid 1 (TRPV1), will be discussed in greater detail.
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Key Words
- DMH, dorso-medial hypothalamus
- MPA, medial preoptic area of hypothalamus
- TRP, Transient Receptor Potential
- TRPA1, Transient Receptor Potential cation channel, subfamily A, member 1
- TRPM8, Transient Receptor Potential cation channel, subfamily M, member 8
- TRPV1, Transient Receptor Potential cation channel, subfamily V, member 1
- TRPV2, Transient Receptor Potential cation channel, subfamily V, member 2
- TRPV3, Transient Receptor Potential cation channel, subfamily V, member 3
- TRPV4, Transient Receptor Potential cation channel, subfamily V, member 4
- ThermoTRPs
- ThermoTRPs, Thermosensitive Transient Receptor Potential cation channels
- body temperature
- core temperature
- pharmacological hypothermia
- physical cooling
- rMR, rostral medullary raphe region
- therapeutic hypothermia
- thermopharmacology
- thermoregulation
- thermosensitive ion channels
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Affiliation(s)
- Viktor V Feketa
- Department of Molecular Physiology and Biophysics Graduate Program; Cardiovascular Sciences Track; Baylor College of Medicine , Houston, TX, USA
| | - Sean P Marrelli
- Department of Molecular Physiology and Biophysics Graduate Program; Cardiovascular Sciences Track; Baylor College of Medicine, Houston, TX, USA; Department of Anesthesiology; Baylor College of Medicine, Houston, TX, USA
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91
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Lyden PD, Rincon F, Staykov D, Lyden PD. Clinical Studies Targeting Stroke. Ther Hypothermia Temp Manag 2015; 5:4-8. [DOI: 10.1089/ther.2015.1501] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Patrick D. Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Fred Rincon
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Dimitre Staykov
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Patrick D. Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California
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92
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Neuroprotection for ischaemic stroke: Current status and challenges. Pharmacol Ther 2015; 146:23-34. [DOI: 10.1016/j.pharmthera.2014.09.003] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 09/02/2014] [Indexed: 12/31/2022]
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93
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Abstract
Ischaemic stroke is a devastating condition that is the leading cause of disability in the USA. Over the last 2 decades, the focus of management has shifted from secondary stroke prevention to acute treatment. Coordinated care starts in the field with the emergency medical service providers and continues in the ambulance and the emergency department through to the intensive care unit. After diagnosis and stabilization, a major goal is reperfusion therapy with intravenous fibrinolytics. Neuroimaging research is focused on improving patient selection, expanding treatment windows, and increasing the safety of therapeutic intervention. The role of adjunctive intra-arterial and mechanical thrombectomy remains undefined, and methods to improve reperfusion using sonolysis and new-generation fibrinolytics are currently investigational. Treatment in the intensive care unit targets prevention of secondary brain injury through optimization of blood pressure, cerebral perfusion, glucose, and temperature management, ventilation, and oxygenation. The most feared complications include malignant cerebral edema and symptomatic hemorrhagic transformation. Decompressive craniectomy is life saving, but questions regarding patient selection and timing remain. Hyperosmolar agents are currently used to mitigate cerebral edema, but newer agents to prevent the formation of cerebral edema at the molecular level are being studied. We outline a practical approach to current emergency and intensive care management based on consensus guidelines and the best available evidence.
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94
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Abstract
Brain injuries caused by stroke are common and costly in human and resource terms. The result of stroke is a cascade of molecular and physiological derangement, cell death, damage and inflammation in the brain. This, together with infection, if present, commonly results in patients having an increased temperature, which is associated with worse outcome. The usual clinical goal in stroke is therefore to reduce temperature to normal, or below normal (hypothermia) to reduce swelling if brain pressure is increased. However, research evidence does not yet conclusively show whether or not cooling patients after stroke improves their longer-term outcome (reduces death and disability). It is possible that complications of cooling outweigh the benefits. Cooling therapy may reduce damage and potentially improve outcome, and head cooling targets the site of injury and may have fewer side effects than systemic cooling, but the evidence base is unclear.
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Affiliation(s)
- Bridget A Harris
- />NHS Lothian and University of Edinburgh, Critical Care Unit, Western General Hospital, Edinburgh, EH4 2XU UK
| | - Peter JD Andrews
- />Department of Anaesthesia and Critical Care, University of Edinburgh and NHS Lothian, Western General Hospital, Edinburgh, EH4 2XU UK
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95
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Blacker DJ, Hankey GJ. Pre-hospital stroke management: an Australian perspective. Intern Med J 2014; 44:1151-3. [PMID: 25442754 DOI: 10.1111/imj.12615] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 10/12/2014] [Indexed: 01/01/2023]
Affiliation(s)
- D J Blacker
- Department of Neurology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia, Australia; West Australian Neurosciences Research Institute, Perth, Western Australia, Australia
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96
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Wowk S, Ma Y, Colbourne F. Mild Therapeutic Hypothermia Does Not Reduce Thrombin-Induced Brain Injury. Ther Hypothermia Temp Manag 2014; 4:180-7. [DOI: 10.1089/ther.2014.0014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Shannon Wowk
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Yonglie Ma
- Department of Psychology, University of Alberta, Edmonton, Canada
| | - Frederick Colbourne
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
- Department of Psychology, University of Alberta, Edmonton, Canada
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97
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Anastasian Z. Anaesthetic management of the patient with acute ischaemic stroke. Br J Anaesth 2014; 113:ii9-ii16. [DOI: 10.1093/bja/aeu372] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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98
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Poli S, Purrucker J, Priglinger M, Ebner M, Sykora M, Diedler J, Bulut C, Popp E, Rupp A, Hametner C. Rapid Induction of COOLing in Stroke Patients (iCOOL1): a randomised pilot study comparing cold infusions with nasopharyngeal cooling. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:582. [PMID: 25346332 PMCID: PMC4234831 DOI: 10.1186/s13054-014-0582-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 10/08/2014] [Indexed: 01/01/2023]
Abstract
Introduction Induction methods for therapeutic cooling are under investigated. We compared the effectiveness and safety of cold infusions (CI) and nasopharyngeal cooling (NPC) for cooling induction in stroke patients. Methods A prospective, open-label, randomised (1:1), single-centre pilot trial with partially blinded safety endpoint assessment was conducted at the neurointensive care unit of Heidelberg University. Intubated stroke patients with an indication for therapeutic cooling and an intracranial pressure (ICP)/temperature brain probe were randomly assigned to CI (4°C, 2L at 4L/h) or NPC (60L/min for 1 h). Previous data suggested a maximum decrease of tympanic temperature for CI (2.1L within 35 min) after 52 min. Therefore the study period was 1 hour (15 min subperiods I-IV). The brain temperature course was the primary endpoint. Secondary measures included continuous monitoring of neurovital parameters and extracerebral temperatures. Statistical analysis based on repeated-measures analysis of variance. Results Of 221 patients screened, 20 were randomized within 5 months. Infusion time of 2L CI was 33 ± 4 min in 10 patients and 10 patients received NPC for 60 min. During active treatment (first 30 min), brain temperature decreased faster with CI than during NPC (I: −0.31 ± 0.2 versus −0.12 ± 0.1°C, P = 0.008; II: −1.0 ± 0.3 versus −0.49 ± 0.3°C, P = 0.001). In the CI-group, after the infusion was finished, the intervention no longer decreased brain temperature, which increased after 3.5 ± 3.3 min. Oesophageal temperature correlated best with brain temperature during CI and NPC. Tympanic temperature reacted similarly to relative changes of brain temperature during CI, but absolute values slightly differed. CI provoked three severe adverse events during subperiods II-IV (two systolic arterial pressure (SAP), one shivering) compared with four in the NPC-group, all during subperiod I (three SAP, one ICP). Classified as possibly intervention-related, two cases of ventilator failure occurred during NPC. Conclusions In intubated stroke patients, brain cooling is faster during CI than during NPC. Importantly, contrary to previous expectations, brain cooling stopped soon after CI cessation. Oesophageal but neither bladder nor rectal temperature is suited as surrogate for brain temperature during CI and NPC. Several severe adverse events in CI and in NPC demand further studying of safety. Trial registration ClinicalTrials.gov NCT01573117. Registered 31 March 2012 Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0582-1) contains supplementary material, which is available to authorized users.
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McCann SK, Irvine C, Mead GE, Sena ES, Currie GL, Egan KE, Macleod MR, Howells DW. Efficacy of antidepressants in animal models of ischemic stroke: a systematic review and meta-analysis. Stroke 2014; 45:3055-63. [PMID: 25184357 DOI: 10.1161/strokeaha.114.006304] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE Poststroke depression is a prevalent complication of stroke with unclear pathogenesis. The benefits of antidepressants in this context and their effects on stroke recovery other than effects on mood are not clearly defined, with some studies suggesting efficacy in improving functional outcome in both depressed and nondepressed stroke patients. We have analyzed the preclinical animal data on antidepressant treatment in focal cerebral ischemia, modeled±depression, to help inform clinical trial design. METHODS We performed a systematic review and meta-analysis of data from experiments testing the efficacy of antidepressants versus no treatment to reduce infarct volume or improve neurobehavioral or neurogenesis outcomes in animal models of stroke. We used random-effects metaregression to test the impact of study quality and design characteristics and used trim and fill to assess publication bias. RESULTS We identified 44 publications describing the effects of 22 antidepressant drugs. The median quality checklist score was 5 of a possible 10 (interquartile range, 4-7). Overall, antidepressants reduced infarct volume by 27.3% (95% confidence interval, 20.7%-33.8%) and improved neurobehavioral outcomes by 53.7% (46.4%-61.1%). There was little evidence for an effect of selective serotonin reuptake inhibitors on infarct volume. For neurobehavioral outcomes there was evidence of publication bias. Selective serotonin reuptake inhibitors were the most frequently studied antidepressant subtype and improved neurobehavioral outcome by 51.8% (38.6%-64.9%) and increased neurogenesis by 2.2 SD (1.3-3.0). CONCLUSIONS In line with current clinical data and despite some limitations, antidepressant treatments seem to improve infarct volume and neurobehavioral outcome in animal models of ischemic stroke.
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Affiliation(s)
- Sarah K McCann
- From The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (S.K.M., E.S.S., D.W.H.); and Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom (C.I., G.E.M., E.S.S., G.L.C., K.E.E., M.R.M)
| | - Cadi Irvine
- From The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (S.K.M., E.S.S., D.W.H.); and Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom (C.I., G.E.M., E.S.S., G.L.C., K.E.E., M.R.M)
| | - Gillian E Mead
- From The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (S.K.M., E.S.S., D.W.H.); and Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom (C.I., G.E.M., E.S.S., G.L.C., K.E.E., M.R.M)
| | - Emily S Sena
- From The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (S.K.M., E.S.S., D.W.H.); and Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom (C.I., G.E.M., E.S.S., G.L.C., K.E.E., M.R.M)
| | - Gillian L Currie
- From The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (S.K.M., E.S.S., D.W.H.); and Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom (C.I., G.E.M., E.S.S., G.L.C., K.E.E., M.R.M)
| | - Kieren E Egan
- From The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (S.K.M., E.S.S., D.W.H.); and Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom (C.I., G.E.M., E.S.S., G.L.C., K.E.E., M.R.M)
| | - Malcolm R Macleod
- From The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (S.K.M., E.S.S., D.W.H.); and Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom (C.I., G.E.M., E.S.S., G.L.C., K.E.E., M.R.M).
| | - David W Howells
- From The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia (S.K.M., E.S.S., D.W.H.); and Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom (C.I., G.E.M., E.S.S., G.L.C., K.E.E., M.R.M)
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