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Kirschen MP, Majmudar T, Diaz-Arrastia R, Berg R, Abella BS, Topjian A, Balu R. Deviations from PRx-derived optimal blood pressure are associated with mortality after cardiac arrest. Resuscitation 2022; 175:81-87. [PMID: 35276311 PMCID: PMC9135307 DOI: 10.1016/j.resuscitation.2022.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 01/18/2023]
Abstract
AIM Pressure reactivity index (PRx) provides a surrogate measurement of cerebrovascular autoregulation (CAR). We determined whether deviations from PRx-derived optimal mean arterial pressure (MAPopt) were associated with in-hospital mortality after adult cardiac arrest. METHODS Retrospective analysis of post-cardiac arrest patients who had continuously recorded intracranial pressure (ICP) and MAP. PRx was calculated as a moving, linear correlation between ICP and MAP. Impaired CAR was defined as PRx ≥ 0.3. MAPopt was calculated using a multi-window weighted algorithm. The burdens of MAP < 5 mmHg below MAPopt (MAPopt-5) and > 5 mmHg above MAPopt (MAPopt + 5) were calculated by integrating the area between MAP and MAPopt-5 or MAPopt + 5 curves, respectively. Univariate logistic regression tested the association between burden of MAP < MAPopt-5 and outcome. RESULTS Twenty-two patients were analyzed. Thirteen (59%) patients died before hospital discharge. Time (median [IQR]) between ROSC and monitoring initiation was 16 [14, 21] hours and duration of monitoring was 35 [22, 48] hours; neither differed between survivors and non-survivors. Median MAPopt was 89 [85, 97] mmHg and did not differ between survivors and non-survivors (89 [83, 94] vs. 91 [85, 105] mmHg, p = 0.64). Burden of MAP < MAPopt-5 was greater for non-survivors compared to survivors (OR 3.6 [95% CI 1.2-15.6]). Range of intact CAR (upper-lower limit) was narrower for non-survivors when compared to survivors (5 [0, 22] vs. 24 [7, 36] mmHg, p = 0.03). CONCLUSION A greater burden of MAP below PRx-derived MAPopt-5 was associated with mortality after cardiac arrest. Non-survivors had a narrower range of intact CAR than survivors.
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Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, United States.
| | | | | | - Robert Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, United States
| | - Benjamin S Abella
- Department of Emergency Medicine, University of Pennsylvania, United States; Center for Resuscitation Science, University of Pennsylvania, United States
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, United States
| | - Ramani Balu
- Department of Emergency Medicine, University of Pennsylvania, United States; Center for Resuscitation Science, University of Pennsylvania, United States
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152
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The Effect of Hyperoxemia on Neurological Outcomes of Adult Patients: A Systematic Review and Meta-Analysis. Neurocrit Care 2022; 36:1027-1043. [PMID: 35099713 PMCID: PMC9110471 DOI: 10.1007/s12028-021-01423-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/14/2021] [Indexed: 12/29/2022]
Abstract
Hyperoxemia commonly occurs in clinical practice and is often left untreated. Many studies have shown increased mortality in patients with hyperoxemia, but data on neurological outcome in these patients are conflicting, despite worsened neurological outcome found in preclinical studies. To investigate the association between hyperoxemia and neurological outcome in adult patients, we performed a systematic review and meta-analysis of observational studies. We searched MEDLINE, Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and ClinicalTrials.gov from inception to May 2020 for observational studies correlating arterial oxygen partial pressure (PaO2) with neurological status in adults hospitalized with acute conditions. Studies of chronic pulmonary disease or hyperbaric oxygenation were excluded. Relative risks (RRs) were pooled at the study level by using a random-effects model to compare the risk of poor neurological outcome in patients with hyperoxemia and patients without hyperoxemia. Sensitivity and subgroup analyses and assessments of publication bias and risk of bias were performed. Maximum and mean PaO2 in patients with favorable and unfavorable outcomes were compared using standardized mean difference (SMD). Of 6255 records screened, 32 studies were analyzed. Overall, hyperoxemia was significantly associated with an increased risk of poor neurological outcome (RR 1.13, 95% confidence interval [CI] 1.05-1.23, statistical heterogeneity I2 58.8%, 22 studies). The results were robust across sensitivity analyses. Patients with unfavorable outcome also showed a significantly higher maximum PaO2 (SMD 0.17, 95% CI 0.04-0.30, I2 78.4%, 15 studies) and mean PaO2 (SMD 0.25, 95% CI 0.04-0.45, I2 91.0%, 13 studies). These associations were pronounced in patients with subarachnoid hemorrhage (RR 1.34, 95% CI 1.14-1.56) and ischemic stroke (RR 1.41, 95% CI 1.14-1.74), but not in patients with cardiac arrest, traumatic brain injury, or following cardiopulmonary bypass. Hyperoxemia is associated with poor neurological outcome, especially in patients with subarachnoid hemorrhage and ischemic stroke. Although our study cannot establish causality, PaO2 should be monitored closely because hyperoxemia may be associated with worsened patient outcome and consequently affect the patient's quality of life.
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153
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Kim S, Park I, Lee JH, Kim S, Jang DH, Jo YH. Vagus Nerve Stimulation Improves Mitochondrial Dysfunction in Post–cardiac Arrest Syndrome in the Asphyxial Cardiac Arrest Model in Rats. Front Neurosci 2022; 16:762007. [PMID: 35692415 PMCID: PMC9178208 DOI: 10.3389/fnins.2022.762007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Cerebral mitochondrial dysfunction during post–cardiac arrest syndrome (PCAS) remains unclear, resulting in a lack of therapeutic options that protect against cerebral ischemia–reperfusion injury. We aimed to assess mitochondrial dysfunction in the hippocampus after cardiac arrest and whether vagus nerve stimulation (VNS) can improve mitochondrial dysfunction and neurological outcomes. In an asphyxial cardiac arrest model, male Sprague–Dawley rats were assigned to the vagus nerve isolation (CA) or VNS (CA + VNS) group. Cardiopulmonary resuscitation was performed 450 s after pulseless electrical activity. After the return of spontaneous circulation (ROSC), left cervical VNS was performed for 3 h in the CA + VNS group. Mitochondrial respiratory function was evaluated using high-resolution respirometry of the hippocampal tissue. The neurologic deficit score (NDS) and overall performance category (OPC) were assessed at 24, 48, and 72 h after resuscitation. The leak respiration and oxidative phosphorylation capacity of complex I (OXPHOS CI) at 6 h after ROSC were significantly higher in the CA + VNS group than in the CA group (p = 0.0308 and 0.0401, respectively). Compared with the trends of NDS and OPC in the CA group, the trends of those in the CA + VNS group were significantly different, thus suggesting a favorable neurological outcome in the CA + VNS group (p = 0.0087 and 0.0064 between times × groups interaction, respectively). VNS ameliorated mitochondrial dysfunction after ROSC and improved neurological outcomes in an asphyxial cardiac arrest rat model.
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Affiliation(s)
- Seonghye Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Inwon Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea
- *Correspondence: Jae Hyuk Lee,
| | - Serin Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Dong-Hyun Jang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea
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154
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Düring J, Annborn M, Dankiewicz J, Dupont A, Forsberg S, Friberg H, Kern KB, May TL, McPherson J, Patel N, Seder DB, Stammet P, Sunde K, Søreide E, Ullén S, Nielsen N. Influence of circulatory shock at hospital admission on outcome after out-of-hospital cardiac arrest. Sci Rep 2022; 12:8293. [PMID: 35585159 PMCID: PMC9117194 DOI: 10.1038/s41598-022-12310-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 05/09/2022] [Indexed: 01/27/2023] Open
Abstract
Hypotension after cardiac arrest could aggravate prolonged hypoxic ischemic encephalopathy. The association of circulatory shock at hospital admission with outcome after cardiac arrest has not been well studied. The objective of this study was to investigate the independent association of circulatory shock at hospital admission with neurologic outcome, and to evaluate whether cardiovascular comorbidities interact with circulatory shock. 4004 adult patients with out-of-hospital cardiac arrest enrolled in the International Cardiac Arrest Registry 2006-2017 were included in analysis. Circulatory shock was defined as a systolic blood pressure below 90 mmHg and/or medical or mechanical supportive measures to maintain adequate perfusion during hospital admission. Primary outcome was cerebral performance category (CPC) dichotomized as good, (CPC 1-2) versus poor (CPC 3-5) outcome at hospital discharge. 38% of included patients were in circulatory shock at hospital admission, 32% had good neurologic outcome at hospital discharge. The adjusted odds ratio for good neurologic outcome in patients without preexisting cardiovascular disease with circulatory shock at hospital admission was 0.60 [0.46-0.79]. No significant interaction was detected with preexisting comorbidities in the main analysis. We conclude that circulatory shock at hospital admission after out-of-hospital cardiac arrest is independently associated with poor neurologic outcome.
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Affiliation(s)
- Joachim Düring
- Department of Clinical Sciences, Anesthesia & Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden.
| | - Martin Annborn
- Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Allison Dupont
- Department of Cardiology, Northside Cardiovascular Institute, Atlanta, GA, USA
| | - Sune Forsberg
- Department of Intensive Care, Norrtälje Hospital, Karolinska Institute, Norrtälje, Sweden
- Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anesthesia & Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Karl B Kern
- Division of Cardiology Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Teresa L May
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | | | - Nainesh Patel
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
| | - David B Seder
- Division of Cardiology Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Pascal Stammet
- Department of Intensive Care Medicine, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
- Faculty of Science, Technology and Medicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Kjetil Sunde
- Department of Anesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eldar Søreide
- Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Susann Ullén
- Clinical Studies Sweden- Forum South, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
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155
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Song H, Oh SH, Woo HR. Brain Death and Its Prediction in Out-of-Hospital Cardiac Arrest Patients Treated with Targeted Temperature Management. Diagnostics (Basel) 2022; 12:diagnostics12051190. [PMID: 35626345 PMCID: PMC9140750 DOI: 10.3390/diagnostics12051190] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/04/2022] [Accepted: 05/06/2022] [Indexed: 02/01/2023] Open
Abstract
Evolution toward brain death (BD) in out-of-hospital cardiac arrest patients with targeted temperature management (TTM) provides opportunities for organ donation. However, knowledge regarding BD in these patients is limited. We retrospectively analyzed the TTM registry of one hospital where life-sustaining therapy was not withdrawn. In-hospital death patients were categorized into BD and non-BD groups. We explored the process of evolution toward BD and its predictors by comparing the serial measurements of clinical variables and the results of various prognostic tests between the two groups. Of the 121 patients who died before hospital discharge, 19 patients (15.7%) developed BD at a median of 6 (interquartile range, 5.0–7.0) days after cardiac arrest. Four patients with pupillary light reflexes at 48 h eventually developed BD. The area under the curves of the gray-to-white matter ratio (GWR) on early brain computed tomography images and the level of S100 calcium-binding protein B (S100B) at 72 h were 0.67 (95% CI, 0.55–0.77) and 0.70 (95% CI, 0.55–0.83), respectively. In conclusion, approximately one-sixth of all in-hospital deaths were diagnosed with BD at a median of 6 days after cardiac arrest. The use of GWR and serial S100B measurements may help to screen potential BD.
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Affiliation(s)
- Hwan Song
- Department of Emergency Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
- Correspondence: ; Tel.: +82-2-2258-1988; Fax: +82-2-2258-1997
| | - Hye Rim Woo
- Department of Emergency Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
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156
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Khan ZA, Sumsuzzman DM, Choi J, Kamenos G, Hong Y. Pre- and post-conditioning with poly I:C exerts neuroprotective effect against cerebral ischemia injury in animal models: A systematic review and meta-analysis. CNS Neurosci Ther 2022; 28:1168-1182. [PMID: 35510663 PMCID: PMC9253751 DOI: 10.1111/cns.13851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 02/08/2022] [Accepted: 04/07/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Toll-like receptor (TLR) agonist polyinosinic-polycytidylic acid (poly I:C) exerts neuroprotective effects against cerebral ischemia (CI), but concrete evidence supporting its exact mechanism of action is unclear. METHODS We evaluated the neuroprotective role of poly I:C by assessing CI indicators such as brain infarct volume (BIV), neurological deficit score (N.S.), and signaling pathway proteins. Moreover, we performed a narrative review to illustrate the mechanism of action of TLRs and their role in CI. Our search identified 164 articles and 10 met the inclusion criterion. RESULTS Poly I:C reduces BIV and N.S. (p = 0.00 and p = 0.03). Interestingly, both pre- and post-conditioning decrease BIV (preC p = 0.04 and postC p = 0.00) and N.S. (preC p = 0.03 and postC p = 0.00). Furthermore, poly I:C upregulates TLR3 [SMD = 0.64; CIs (0.56, 0.72); p = 0.00], downregulates nuclear factor-κB (NF-κB) [SMD = -1.78; CIs (-2.67, -0.88); p = 0.0)], and tumor necrosis factor alpha (TNF-α) [SMD = -16.83; CIs (-22.63, -11.02); p = 0.00]. CONCLUSION We showed that poly I:C is neuroprotective and acts via the TLR3/NF-κB/TNF-α pathway. Our review indicated that suppressing TLR 2/4 may illicit neuroprotection against CI. Further research on simultaneous activation of TLR3 with poly I:C and suppression of TLR 2/4 might open new vistas for the development of therapeutics against CI.
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Affiliation(s)
- Zeeshan Ahmad Khan
- Department of Physical Therapy, College of Healthcare Medical Science & Engineering, Gimhae, Korea.,Biohealth Products Research Center (BPRC), Inje University, Gimhae, Korea.,Research Center for Aged-life Redesign (RCAR), Inje University, Gimhae, Korea
| | - Dewan Md Sumsuzzman
- Department of Physical Therapy, College of Healthcare Medical Science & Engineering, Gimhae, Korea.,Biohealth Products Research Center (BPRC), Inje University, Gimhae, Korea.,Research Center for Aged-life Redesign (RCAR), Inje University, Gimhae, Korea
| | - Jeonghyun Choi
- Department of Physical Therapy, College of Healthcare Medical Science & Engineering, Gimhae, Korea.,Biohealth Products Research Center (BPRC), Inje University, Gimhae, Korea.,Research Center for Aged-life Redesign (RCAR), Inje University, Gimhae, Korea
| | - George Kamenos
- Biohealth Products Research Center (BPRC), Inje University, Gimhae, Korea.,Research Center for Aged-life Redesign (RCAR), Inje University, Gimhae, Korea.,Department of Rehabilitation Science, Graduate School of Inje University, Gimhae, Korea
| | - Yonggeun Hong
- Department of Physical Therapy, College of Healthcare Medical Science & Engineering, Gimhae, Korea.,Biohealth Products Research Center (BPRC), Inje University, Gimhae, Korea.,Research Center for Aged-life Redesign (RCAR), Inje University, Gimhae, Korea.,Department of Rehabilitation Science, Graduate School of Inje University, Gimhae, Korea
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157
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Abstract
The efficacy of ultrasound (US) in real-time differential diagnosis and guiding further treatment decisions has been well demonstrated in prearrest conditions and during resuscitation. Evidence is limited regarding the application of US in postresuscitation care. Most of the patients following resuscitation remain comatose, and the requirement for transportation to other examination rooms increases their risk of injury. US can be performed at the bedside with high accessibility and timeliness without radiation. This narrative review provides an overview of current evidence regarding the application of US in identifying the cause of cardiac arrest (CA), hemodynamic monitoring, and prognostication in postresuscitation care. For identifying the cause of CA, cardiac US is mainly used to detect regional wall motion abnormality. However, postarrest myocardial dysfunction would confound the sonographic findings that a combination of electrocardiograms and biomarkers besides the cardiac US could improve the positive predictive value of coronary artery disease. For hemodynamic monitoring, left ventricular outlet tract velocity time integral has the best performance in predicting fluid responsiveness in conjunction with the passive leg raising test. The RUSH protocol assists in determining the subtypes of shock with high sensitivity and specificity in hypovolemic, cardiogenic, or obstructive shock. Evidence regarding the application of US for prognostication is still limited, and further evaluation should be needed.
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158
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Öcal Ö, Coşar A, Nazıroğlu M. Amantadine Attenuated Hypoxia-Induced Mitochondrial Oxidative Neurotoxicity, Apoptosis, and Inflammation via the Inhibition of TRPM2 and TRPV4 Channels. Mol Neurobiol 2022; 59:3703-3720. [DOI: 10.1007/s12035-022-02814-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
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159
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Khan ZA, Sumsuzzman DM, Choi J, Hong Y. Neurodegenerative effect of DAPK1 after cerebral hypoxia-ischemia is associated with its post-transcriptional and signal transduction regulations: A systematic review and meta-analysis. Ageing Res Rev 2022; 76:101593. [PMID: 35202858 DOI: 10.1016/j.arr.2022.101593] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 01/10/2022] [Accepted: 02/18/2022] [Indexed: 01/07/2023]
Abstract
Cerebral hypoxia-ischemia (CHI) causes brain aging, neurological disorders, cognitive decline, motor function impairment, and mortality. Inhibiting death-associated protein kinase 1 (DAPK1) has shown therapeutic potential against CHI, but several reports contradict its protective function, mechanism of activation, and signal transduction. Here, we systematically reviewed the role and the activation mechanism of DAPK1, and quantitatively assess the efficacy of DAPK1 inhibition (DI) methods in neuroprotection, following a CHI in animal models. Embase and PubMed were searched for relevant studies. Overall, 13 studies met the inclusion criteria, and the SYRCLE Risk of bias tool (RoB) tool was used to assess RoB. StataSE 16 was used for meta-analysis and network meta-analysis (NMA). Standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated to estimate the effect size. DI was associated with the reduction of brain infarct volume (BIV) [SMD = -1.70, 95% CI (-2.10, -1.30); p = 0.00], neurological score (N.S.), neuronal degeneration, with no change in the level of in cell death [SMD = -0.83, 95% CI (-2.00, 0.35); p = 0.17], indicating the protective role of DI against CHI. No differences were found in DAPK1 mRNA and protein levels [SMD = 0.50, 95% CI (-0.05, 1.04); p = 0.07] {single-study driven; upregulated after exclusion (p = 0.01, I2 = 36.43)}, whereas phospho-DAPK1 [SMD = -2.22, 95% CI (-3.69, -0.75); p = 0.00] was downregulated and phosphorylated myosin light chain [SMD = 3.37, 95% CI (2.51, 4.96); p = 0.00] was upregulated between CHI and sham groups. Furthermore, we performed NMA to understand the molecular level at which DI offers maximum protection against BIV. Post-transcriptional inhibition (PTI; SUCRA, 82.6%) and gene knockout showed best (KO; SUCRA, 81.3%), signal transduction inhibition (STI; SUCRA, 49.5%) offered 3rd best, while catalytic activity inhibition (CAI; SUCRA, 0.3%) exhibited the lowest reduction in BIV against CHI. The results demonstrate that DI has a neuroprotective effect against CHI and DAPK1 might be regulated at the post-transcriptional and post-translational levels after CHI. Inhibiting DAPK1 at the post-transcriptional level and blocking multiple signal transduction pathways of DAPK1 could lead to better functional recovery against CHI. AVAILABILITY OF DATA AND MATERIALS: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
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160
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Duan W, Sun Q, Wu X, Xia Z, Warner DS, Ulloa L, Yang W, Sheng H. Cervical Vagus Nerve Stimulation Improves Neurologic Outcome After Cardiac Arrest in Mice by Attenuating Oxidative Stress and Excessive Autophagy. Neuromodulation 2022; 25:414-423. [PMID: 35131154 DOI: 10.1016/j.neurom.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/11/2021] [Accepted: 12/15/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cerebral ischemia and reperfusion (I/R) induces oxidative stress and activates autophagy, leading to brain injury and neurologic deficits. Cervical vagus nerve stimulation (VNS) increases cerebral blood flow (CBF). In this study, we investigate the effect of VNS-induced CBF increase on neurologic outcomes after cardiac arrest (CA). MATERIALS AND METHODS A total of 40 male C57Bl/6 mice were subjected to ten minutes of asphyxia CA and randomized to vagus nerve isolation (VNI) or VNS treatment group. Eight mice received sham surgery and VNI. Immediately after resuscitation, 20 minutes of electrical stimulation (1 mA, 1 ms, and 10 Hz) was started in the VNS group. Electrocardiogram, blood pressure, and CBF were monitored. Neurologic and histologic outcomes were evaluated at 72 hours. Oxidative stress and autophagy were assessed at 3 hours and 24 hours after CA. RESULTS Baseline characteristics were not different among groups. VNS mice had better behavioral performance (ie, open field, rotarod, and neurologic score) and less neuronal death (p < 0.05, vs VNI) in the hippocampus. CBF was significantly increased in VNS-treated mice at 20 minutes after return of spontaneous circulation (ROSC) (p < 0.05). Furthermore, levels of 8-hydroxy-2'-deoxyguanosine in the blood and autophagy-related proteins (ie, LC-3Ⅱ/Ⅰ, Beclin-1, and p62) in the brain were significantly decreased in VNS mice. Aconitase activity was also reduced, and the p-mTOR/mTOR ratio was increased in VNS mice. CONCLUSIONS Oxidative stress induced by global brain I/R following CA/ROSC leads to early excessive autophagy and impaired autophagic flux. VNS promoted CBF recovery, ameliorating these changes. Neurologic and histologic outcomes were also improved.
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Affiliation(s)
- Weina Duan
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA; Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qian Sun
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaojing Wu
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhongyuan Xia
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - David S Warner
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Luis Ulloa
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Wei Yang
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Huaxin Sheng
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
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161
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Asymmetry Index Evaluation of Cerebral Volume and Cerebral Blood Flow in Neonatal Hypoxic–Ischemic Encephalopathy. Symmetry (Basel) 2022. [DOI: 10.3390/sym14030596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
The aim of the present study was to longitudinally evaluate the differences in cerebral volume and cerebral blood flow (CBF) on the right and left sides in rats with neonatal hypoxic–ischemic encephalopathy (HIE) using magnetic resonance imaging and the Rice–Vannucci model. Unilateral ligation of the left common carotid artery was performed on 8-day-old rats, followed by mild (1 h, n = 6) or severe (2 h, n = 7) hypoxic exposure. T2-weighted (T2W) and CBF images were obtained at 1 h and 1, 3, and 7 days following the HI insult. The cerebral volume (Vlesion and Vcontrol), CBF in both hemispheres (lesion and control sides), and asymmetry indices of the cerebral volume (AIvolume) and CBF (AICBF) were calculated for each group. Slight hyperintensities were noted in the lesion-side hemispheres on T2W images at 1 h and 1 day in both groups, as were pronounced hyperintensities at days 3 and 7 in the severe group. AIvolume was positive (Vlesion > Vcontrol) in the mild and severe groups until days 1 and 3, respectively, and changed to negative on days 3 and 7 in the mild and severe groups. These results suggest that the prolonged positive AIvolume prior to day 3 in the severe group was caused by long-term cell swelling following severe HI insult.
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162
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Das T, Kamle A, Kumar A, Chakravarty S. Hypoxia Induced Sex-Difference in Zebrafish Brain Proteome Profile Reveals the Crucial Role of H3K9me3 in Recovery From Acute Hypoxia. Front Genet 2022; 12:635904. [PMID: 35173759 PMCID: PMC8841817 DOI: 10.3389/fgene.2021.635904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
Understanding the molecular basis of sex differences in neural response to acute hypoxic insult has profound implications for the effective prevention and treatment of ischemic stroke. Global hypoxic-ischemic induced neural damage has been studied recently under well-controlled, non-invasive, reproducible conditions using a zebrafish model. Our earlier report on sex difference in global acute hypoxia-induced neural damage and recovery in zebrafish prompted us to conduct a comprehensive study on the mechanisms underlying the recovery. An omics approach for studying quantitative changes in brain proteome upon hypoxia insult following recovery was undertaken using iTRAQ-based LC-MS/MS approach. The results shed light on the altered expression of many regulatory proteins in the zebrafish brain upon acute hypoxia following recovery. The sex difference in differentially expressed proteins along with the proteins expressed in a uniform direction in both the sexes was studied. Core expression analysis by Ingenuity Pathway Analysis (IPA) showed a distinct sex difference in the disease function heatmap. Most of the upstream regulators obtained through IPA were validated at the transcriptional level. Translational upregulation of H3K9me3 in males led us to elucidate the mechanism of recovery by confirming transcriptional targets through ChIP-qPCR. The upregulation of H3K9me3 level in males at 4 h post-hypoxia appears to affect the early neurogenic markers nestin, klf4, and sox2, which might explain the late recovery in males, compared to females. Acute hypoxia-induced sex-specific comparison of brain proteome led us to reveal many differentially expressed proteins, which can be further studied for the development of novel targets for better therapeutic strategy.
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Affiliation(s)
- Tapatee Das
- Applied Biology, CSIR-Indian Institute of Chemical Technology (IICT), Hyderabad, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
| | - Avijeet Kamle
- CSIR-Centre for Cellular and Molecular Biology (CCMB), Hyderabad, India
| | - Arvind Kumar
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
- CSIR-Centre for Cellular and Molecular Biology (CCMB), Hyderabad, India
| | - Sumana Chakravarty
- Applied Biology, CSIR-Indian Institute of Chemical Technology (IICT), Hyderabad, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
- *Correspondence: Sumana Chakravarty,
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163
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Guo Y, Cho SM, Wei Z, Wang Q, Modi HR, Gharibani P, Lu H, Thakor NV, Geocadin RG. Early Thalamocortical Reperfusion Leads to Neurologic Recovery in a Rodent Cardiac Arrest Model. Neurocrit Care 2022; 37:60-72. [PMID: 35072925 DOI: 10.1007/s12028-021-01432-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cerebral blood flow (CBF) plays an important role in neurological recovery after cardiac arrest (CA) resuscitation. However, the variations of CBF recovery in distinct brain regions and its correlation with neurologic recovery after return of spontaneous circulation (ROSC) have not been characterized. This study aimed to investigate the characteristics of regional cerebral reperfusion following resuscitation in predicting neurological recovery. METHODS Twelve adult male Wistar rats were studied, ten resuscitated from 7-min asphyxial CA and two uninjured rats, which were designated as healthy controls (HCs). Dynamic changes in CBF in the cerebral cortex, hippocampus, thalamus, brainstem, and cerebellum were assessed by pseudocontinuous arterial spin labeling magnetic resonance imaging, starting at 60 min after ROSC to 156 min (or time to spontaneous arousal). Neurologic outcomes were evaluated by the neurologic deficit scale at 24 h post-ROSC in a blinded manner. Correlations between regional CBF (rCBF) and neurological recovery were undertaken. RESULTS All post-CA animals were found to be nonresponsive during the 60-156 min post ROSC, with reductions in rCBF by 24-42% compared with HC. Analyses of rCBF during the post-ROSC time window from 60 to 156 min showed the rCBF recovery of hippocampus and thalamus were positively associated with better neurological outcomes (rs = 0.82, p = 0.004 and rs = 0.73, p < 0.001, respectively). During 96 min before arousal, thalamic and cortical rCBF exhibited positive correlations with neurological recovery (rs = 0.80, p < 0.001 and rs = 0.65, p < 0.001, respectively); for predicting a favorable neurological outcome, the thalamic rCBF threshold was above 50.84 ml/100 g/min (34% of HC) (area under the curve of 0.96), whereas the cortical rCBF threshold was above 60.43 ml/100 g/min (38% of HC) (area under the curve of 0.88). CONCLUSIONS Early magnetic resonance imaging analyses showed early rCBF recovery in thalamus, hippocampus, and cortex post ROSC was positively correlated with neurological outcomes at 24 h. Our findings suggest new translational insights into the regional reperfusion and the time window that may be critical in neurological recovery and warrant further validation.
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Affiliation(s)
- Yu Guo
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sung-Min Cho
- Departments of Neurology, Anesthesiology, Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA
| | - Zhiliang Wei
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Qihong Wang
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hiren R Modi
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Payam Gharibani
- Departments of Neurology, Division of Neuroimmunology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hanzhang Lu
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nitish V Thakor
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Romergryko G Geocadin
- Departments of Neurology, Anesthesiology, Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
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164
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Kainz E, Fischer M. [Targeted temperature management after cardiac arrest : What is new?]. Anaesthesist 2022; 71:85-93. [PMID: 35050390 DOI: 10.1007/s00101-022-01091-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 12/15/2022]
Abstract
The current guidelines of the European Resuscitation Council recommend targeted temperature management to improve functional neurological outcome in comatose survivors after cardiac arrest. With the pathophysiological background of hypothermia-induced neuroprotection for prevention of hypoxic-ischemic encephalopathy, targeted temperature management is a key measure and represents a central aspect in postresuscitation care.In the 2021 guidelines the application of targeted temperature management in postresuscitation care has been recommended for all rhythms and irrespective of the location of cardiac arrest. Targeted temperature management is advocated for adult patients who remain unresponsive following return of spontaneous circulation (ROSC) after either out-of-hospital cardiac arrest or in-hospital cardiac arrest. The body temperature should be maintained at a constant value between 32 °C and 36 °C for at least 24 h. To avoid rebound hyperthermia, fever following targeted temperature management, defined as a temperature above 37.7 °C, should be prevented and treated for at least 72 h after ROSC in persistently comatose patients. The routine use of prehospital cooling by rapid infusion of large volumes of cold i.v. fluid immediately after ROSC is not recommended.Based on a systematic review of the current literature, this article summarizes the results of randomized trials and new findings on targeted temperature management in comatose adult patients after cardiac arrest. The review has a particular focus on the most recent evidence regarding the optimum range of target temperatures. Furthermore, recent data on preclinical management, different patient populations, the duration of targeted temperature management, cooling methods and rebound hyperthermia are discussed.The impact of targeted temperature management on neurological outcome after cardiac arrest has been a matter of controversy. Despite contradictory results and heterogeneity of study designs, the current evidence supports the relevance and the necessity of strict temperature control in postresuscitation care for neuroprotection and improvement in functional neurological outcomes.
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Affiliation(s)
- Elena Kainz
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Marlene Fischer
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland. .,Klinik für Intensivmedizin, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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165
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Metabolomic Analysis of Carbohydrate and Amino Acid Changes Induced by Hypoxia in Naked Mole-Rat Brain and Liver. Metabolites 2022; 12:metabo12010056. [PMID: 35050178 PMCID: PMC8779284 DOI: 10.3390/metabo12010056] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/20/2022] Open
Abstract
Hypoxia poses a major physiological challenge for mammals and has significant impacts on cellular and systemic metabolism. As with many other small rodents, naked mole-rats (NMRs; Heterocephalus glaber), who are among the most hypoxia-tolerant mammals, respond to hypoxia by supressing energy demand (i.e., through a reduction in metabolic rate mediated by a variety of cell- and tissue-level strategies), and altering metabolic fuel use to rely primarily on carbohydrates. However, little is known regarding specific metabolite changes that underlie these responses. We hypothesized that NMR tissues utilize multiple strategies in responding to acute hypoxia, including the modulation of signalling pathways to reduce anabolism and reprogram carbohydrate metabolism. To address this question, we evaluated changes of 64 metabolites in NMR brain and liver following in vivo hypoxia exposure (7% O2, 4 h). We also examined changes in matched tissues from similarly treated hypoxia-intolerant mice. We report that, following exposure to in vivo hypoxia: (1) phenylalanine, tyrosine and tryptophan anabolism are supressed both in NMR brain and liver; (2) carbohydrate metabolism is reprogramed in NMR brain and liver, but in a divergent manner; (3) redox state is significantly altered in NMR brain; and (4) the AMP/ATP ratio is elevated in liver. Overall, our results suggest that hypoxia induces significant metabolic remodelling in NMR brain and liver via alterations of multiple metabolic pathways.
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166
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Nishikimi M, Shoaib M, Choudhary RC, Aoki T, Miyara SJ, Yagi T, Hayashida K, Takegawa R, Yin T, Becker LB, Kim J. Preserving brain
LPC‐DHA
by plasma supplementation attenuates brain injury after cardiac arrest. Ann Neurol 2022; 91:389-403. [DOI: 10.1002/ana.26296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 12/20/2021] [Accepted: 12/31/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Mitsuaki Nishikimi
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research Manhasset NY USA
- Department of Emergency Medicine Northshore University Hospital Manhasset NY USA
| | - Muhammad Shoaib
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research Manhasset NY USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead NY USA
| | - Rishabh C. Choudhary
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research Manhasset NY USA
| | - Tomoaki Aoki
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research Manhasset NY USA
| | - Santiago J. Miyara
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research Manhasset NY USA
| | - Tsukasa Yagi
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research Manhasset NY USA
| | - Kei Hayashida
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research Manhasset NY USA
| | - Ryosuke Takegawa
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research Manhasset NY USA
| | - Tai Yin
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research Manhasset NY USA
| | - Lance B. Becker
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research Manhasset NY USA
- Department of Emergency Medicine Northshore University Hospital Manhasset NY USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead NY USA
| | - Junhwan Kim
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research Manhasset NY USA
- Department of Emergency Medicine Northshore University Hospital Manhasset NY USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead NY USA
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167
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Murasaka K, Yamashita A, Owada H, Wato Y, Inaba H. Association between the types of bystander cardiopulmonary resuscitation and the survival with good neurologic outcome of preschool pediatric out-of-hospital cardiac arrest cases in Japan: A propensity score matching analysis using an extended nationwide database. Front Pediatr 2022; 10:1075983. [PMID: 36819193 PMCID: PMC9929575 DOI: 10.3389/fped.2022.1075983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/30/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Pediatric out-of-hospital cardiac arrests (OHCAs) are frequently associated with a respiratory etiology. Despite the high proportion of preschool children with OHCAs, very few studies on this special population exist. This study characterizes the epidemiologic features of preschool pediatric OHCAs and analyzes the advantage of conventional (ventilations with chest compressions) bystander cardiopulmonary resuscitation (CPR) over compression-only bystander CPR (BCPR) on the one-month post-event neurological status of the patient. METHODS Japanese nationwide databases for all ambulance transport events and OHCAs occurring during a 4-year period between 2016 and 2019 were combined, totalling 3,608 patient events. Children ≤6-years-old were included; physician- and EMS-witnessed events, no prehospital resuscitation effort events, and neonatal patient events were excluded. Neurologically favorable 1-month survival rates were compared among groups using univariate and multivariate analyses before and after propensity score matching. RESULTS From the combined database, 2,882 pediatric OHCAs meeting selection criteria were categorized as no BCPR (984), compression-only BCPR (1,428), and conventional BCPR (470). The proportion of bystander-witnessed cases was low (22.3%). Most OHCA witnesses were family members (88.5%), and most OHCAs occurred at home (88.0%). The neurologically favorable 1-month survival rates were: no BCPR 2.4%, compression only, 3.2%, and conventional 6.6% (P < 0.01). Multivariate logistic regression analysis before and after matching showed that conventional BCPR was associated with higher neurologically favorable 1-month survival than compression-only BCPR. Subgroup analyses after matching demonstrated that conventional BCPR was associated with better outcomes in nonmedical (adjusted odds ratio; 95% confidence interval, 2.83; 1.09-7.32) and unwitnessed OHCA cases (3.42; 1.09-10.8). CONCLUSIONS Conventional CPR is rarely performed by bystanders in preschool pediatric OHCA. However, conventional BCPR results in neurologically favorable outcomes in nonmedical and unwitnessed cases.
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Affiliation(s)
- Kenshi Murasaka
- Department of Emergency Medicine, Kanazawa Medical University, Uchinada, Japan
| | - Akira Yamashita
- Department of Cardiology, Noto General Hospital, Nanao, Japan
| | - Hitoshi Owada
- Department of Emergency Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Yukihiro Wato
- Department of Emergency Medicine, Kanazawa Medical University, Uchinada, Japan
| | - Hideo Inaba
- Department of Emergency Medicine, Kanazawa Medical University, Uchinada, Japan.,Department of Emergency Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan.,Kanazawa University, Kanazawa, Japan
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168
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Niu X, Jiao Z, Wang Z, Jiang A, Zhang X, Zhang H, Xue F. MiR-17-5p protects neonatal mice from hypoxic-ischemic brain damage by targeting Casp2. Neurosci Lett 2022; 772:136475. [DOI: 10.1016/j.neulet.2022.136475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/03/2022] [Accepted: 01/20/2022] [Indexed: 01/01/2023]
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169
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Marino B, Bellomo R, Evans RG. Renal and Cerebral Hypoxia and Inflammation During Cardiopulmonary Bypass. Compr Physiol 2021; 12:2799-2834. [PMID: 34964119 DOI: 10.1002/cphy.c210019] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiac surgery-associated acute kidney injury and brain injury remain common despite ongoing efforts to improve both the equipment and procedures deployed during cardiopulmonary bypass (CPB). The pathophysiology of injury of the kidney and brain during CPB is not completely understood. Nevertheless, renal (particularly in the medulla) and cerebral hypoxia and inflammation likely play critical roles. Multiple practical factors, including depth and mode of anesthesia, hemodilution, pump flow, and arterial pressure can influence oxygenation of the brain and kidney during CPB. Critically, these factors may have differential effects on these two vital organs. Systemic inflammatory pathways are activated during CPB through activation of the complement system, coagulation pathways, leukocytes, and the release of inflammatory cytokines. Local inflammation in the brain and kidney may be aggravated by ischemia (and thus hypoxia) and reperfusion (and thus oxidative stress) and activation of resident and infiltrating inflammatory cells. Various strategies, including manipulating perfusion conditions and administration of pharmacotherapies, could potentially be deployed to avoid or attenuate hypoxia and inflammation during CPB. Regarding manipulating perfusion conditions, based on experimental and clinical data, increasing standard pump flow and arterial pressure during CPB appears to offer the best hope to avoid hypoxia and injury, at least in the kidney. Pharmacological approaches, including use of anti-inflammatory agents such as dexmedetomidine and erythropoietin, have shown promise in preclinical models but have not been adequately tested in human trials. However, evidence for beneficial effects of corticosteroids on renal and neurological outcomes is lacking. © 2021 American Physiological Society. Compr Physiol 11:1-36, 2021.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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170
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Huh H, Lee EH, Oh SS, Kim JH, Seo YB, Choo YJ, Park J, Chang MC. The blood-brain barrier disruption after syncope: a dynamic contrast-enhanced magnetic resonance imaging study: A case report. Medicine (Baltimore) 2021; 100:e28258. [PMID: 34918695 PMCID: PMC8677986 DOI: 10.1097/md.0000000000028258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/25/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), we demonstrated blood-brain barrier (BBB) disruption following syncope. PATIENT CONCERNS A 45-year-old man experienced syncope with a chief complaint of syncope (duration: 1 minutes), 1 day before visiting a university hospital for examination. He had no history of medical problems and was not taking any medications. This episode was the first in his lifetime. DIAGNOSES After syncope, the patient did not have any illnesses or symptoms, such as headache, cognitive deficits, or somnolence. INTERVENTIONS Cardiac evaluation did not reveal any abnormal findings. In addition, in conventional brain and chest computed tomography and brain MRI, no abnormal lesions were observed. OUTCOMES DCE-MRI of the patient showed bright blue colored lines within the sulci throughout the cerebral cortex. The regions of interest, including bright blue colored lines, had significantly higher Ktrans values (6.86 times higher) than those in healthy control participants. These findings are indicative of BBB disruption of the vessels in the sulci. LESSONS Using DCE-MRI, we demonstrated BBB disruption following syncope. DCE-MRI is a useful tool for the detection of BBB disruption following syncope.
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Affiliation(s)
- Hyungkyu Huh
- Medical Interdisciplinary Team, Medical Device Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu, Korea
| | - Eun-Hee Lee
- Medical Interdisciplinary Team, Medical Device Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu, Korea
| | - Sung Suk Oh
- Medical Interdisciplinary Team, Medical Device Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu, Korea
| | - Jong-Hoon Kim
- Department of Neurosurgery, College of Medicine, Yeungnam University, Namku, Daegu, Republic of Korea
| | - Young Beom Seo
- Department of Neurosurgery, College of Medicine, Yeungnam University, Namku, Daegu, Republic of Korea
| | - Yoo Jin Choo
- Medical Interdisciplinary Team, Medical Device Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu, Korea
| | - Juyoung Park
- Department of High-tech medical device, Gachon University, Seongnam, Republic of Korea
- SonoTx, Seongnam, Republic of Korea
| | - Min Cheol Chang
- Department of Physical Medicine & Rehabilitation, College of Medicine, Yeungnam University, Namku, Daegu, Republic of Korea
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171
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Lucchetti J, Fumagalli F, Olivari D, Affatato R, Fracasso C, De Giorgio D, Perego C, Motta F, Passoni A, Staszewsky L, Novelli D, Magliocca A, Garattini S, Latini R, Ristagno G, Gobbi M. Brain Kynurenine Pathway and Functional Outcome of Rats Resuscitated From Cardiac Arrest. J Am Heart Assoc 2021; 10:e021071. [PMID: 34816736 PMCID: PMC9075408 DOI: 10.1161/jaha.121.021071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 09/03/2021] [Accepted: 09/29/2021] [Indexed: 11/24/2022]
Abstract
Background Brain injury and neurological deficit are consequences of cardiac arrest (CA), leading to high morbidity and mortality. Peripheral activation of the kynurenine pathway (KP), the main catabolic route of tryptophan metabolized at first into kynurenine, predicts poor neurological outcome in patients resuscitated after out-of-hospital CA. Here, we investigated KP activation in hippocampus and plasma of rats resuscitated from CA, evaluating the effect of KP modulation in preventing CA-induced neurological deficit. Methods and Results Early KP activation was first demonstrated in 28 rats subjected to electrically induced CA followed by cardiopulmonary resuscitation. Hippocampal levels of the neuroactive metabolites kynurenine, 3-hydroxy-anthranilic acid, and kynurenic acid were higher 2 hours after CA, as in plasma. Further, 36 rats were randomized to receive the inhibitor of the first step of KP, 1-methyl-DL-tryptophan, or vehicle, before CA. No differences were observed in hemodynamics and myocardial function. The CA-induced KP activation, sustained up to 96 hours in hippocampus (and plasma) of vehicle-treated rats, was counteracted by the inhibitor as indicated by lower hippocampal (and plasmatic) kynurenine/tryptophan ratio and kynurenine levels. 1-Methyl-DL-tryptophan reduced the CA-induced neurological deficits, with a significant correlation between the neurological score and the individual kynurenine levels, as well as the kynurenine/tryptophan ratio, in plasma and hippocampus. Conclusions These data demonstrate the CA-induced lasting activation of the first step of the KP in hippocampus, showing that this activation was involved in the evolving neurological deficit. The degree of peripheral activation of KP may predict neurological function after CA.
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Affiliation(s)
- Jacopo Lucchetti
- Department of Biochemistry and Molecular PharmacologyIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Francesca Fumagalli
- Department of Cardiovascular MedicineIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Davide Olivari
- Department of Cardiovascular MedicineIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Roberta Affatato
- Department of Cardiovascular MedicineIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Claudia Fracasso
- Department of Biochemistry and Molecular PharmacologyIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Daria De Giorgio
- Department of Cardiovascular MedicineIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Carlo Perego
- Department of Cardiovascular MedicineIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Francesca Motta
- Department of Cardiovascular MedicineIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Alice Passoni
- Department of Environmental Health SciencesIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Lidia Staszewsky
- Department of Cardiovascular MedicineIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Deborah Novelli
- Department of Cardiovascular MedicineIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Aurora Magliocca
- Department of Cardiovascular MedicineIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | | | - Roberto Latini
- Department of Cardiovascular MedicineIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Giuseppe Ristagno
- Department of Anesthesiology, Intensive Care and EmergencyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
- Department of Pathophysiology and TransplantationUniversity of MilanItaly
| | - Marco Gobbi
- Department of Biochemistry and Molecular PharmacologyIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
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Enciso-Olivera CO, Ordóñez-Rubiano EG, Casanova-Libreros R, Rivera D, Zarate-Ardila CJ, Rudas J, Pulido C, Gómez F, Martínez D, Guerrero N, Hurtado MA, Aguilera-Bustos N, Hernández-Torres CP, Hernandez J, Marín-Muñoz JH. Structural and functional connectivity of the ascending arousal network for prediction of outcome in patients with acute disorders of consciousness. Sci Rep 2021; 11:22952. [PMID: 34824383 PMCID: PMC8617304 DOI: 10.1038/s41598-021-98506-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/20/2021] [Indexed: 11/24/2022] Open
Abstract
To determine the role of early acquisition of blood oxygen level-dependent (BOLD) signals and diffusion tensor imaging (DTI) for analysis of the connectivity of the ascending arousal network (AAN) in predicting neurological outcomes after acute traumatic brain injury (TBI), cardiopulmonary arrest (CPA), or stroke. A prospective analysis of 50 comatose patients was performed during their ICU stay. Image processing was conducted to assess structural and functional connectivity of the AAN. Outcomes were evaluated after 3 and 6 months. Nineteen patients (38%) had stroke, 18 (36%) CPA, and 13 (26%) TBI. Twenty-three patients were comatose (44%), 11 were in a minimally conscious state (20%), and 16 had unresponsive wakefulness syndrome (32%). Univariate analysis demonstrated that measurements of diffusivity, functional connectivity, and numbers of fibers in the gray matter, white matter, whole brain, midbrain reticular formation, and pontis oralis nucleus may serve as predictive biomarkers of outcome depending on the diagnosis. Multivariate analysis demonstrated a correlation of the predicted value and the real outcome for each separate diagnosis and for all the etiologies together. Findings suggest that the above imaging biomarkers may have a predictive role for the outcome of comatose patients after acute TBI, CPA, or stroke.
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Affiliation(s)
- Cesar O Enciso-Olivera
- Department of Critical Care and Intensive Care Unit, Fundación Universitaria de Ciencias de La Salud (FUCS), Hospital Infantil Universitario de San José, Bogotá, Colombia
| | - Edgar G Ordóñez-Rubiano
- Department of Neurological Surgery, Fundación Universitaria de Ciencias de La Salud (FUCS), Hospital de San José, Bogotá, Colombia
| | - Rosángela Casanova-Libreros
- Division of Clinical Research, Fundación Universitaria de Ciencias de La Salud (FUCS), Hospital de San José, Hospital Infantil Universitario de San José, Bogotá, Colombia
| | - Diana Rivera
- Division of Clinical Research, Fundación Universitaria de Ciencias de La Salud (FUCS), Hospital de San José, Hospital Infantil Universitario de San José, Bogotá, Colombia
| | - Carol J Zarate-Ardila
- Division of Clinical Research, Fundación Universitaria de Ciencias de La Salud (FUCS), Hospital de San José, Hospital Infantil Universitario de San José, Bogotá, Colombia
| | - Jorge Rudas
- Department of Biotechnology, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Cristian Pulido
- Department of Mathematics, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Francisco Gómez
- Department of Computer Science, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Darwin Martínez
- Department of Computer Science, Universidad Central, Bogotá, Colombia
| | - Natalia Guerrero
- Department of Radiology, Fundación Universitaria de Ciencias de La Salud (FUCS), Hospital Infantil Universitario de San José, Bogotá, Colombia
| | - Mayra A Hurtado
- Department of Critical Care and Intensive Care Unit, Fundación Universitaria de Ciencias de La Salud (FUCS), Hospital Infantil Universitario de San José, Bogotá, Colombia
| | - Natalia Aguilera-Bustos
- Division of Clinical Research, Fundación Universitaria de Ciencias de La Salud (FUCS), Hospital de San José, Hospital Infantil Universitario de San José, Bogotá, Colombia
| | - Clara P Hernández-Torres
- Department of Psychology, Fundación Universitaria de Ciencias de La Salud (FUCS), Hospital Infantil Universitario de San José, Bogotá, Colombia
| | - José Hernandez
- Department of Neurology, Fundación Universitaria de Ciencias de La Salud (FUCS), Hospital Infantil Universitario de San José, Bogotá, Colombia
| | - Jorge H Marín-Muñoz
- Department of Radiology, Fundación Universitaria de Ciencias de La Salud (FUCS), Hospital Infantil Universitario de San José, Bogotá, Colombia. .,Innovation and Research Division, Imaging Experts and Healthcare Services (ImexHS), Street 92 # 11-51, Of 202, Bogotá, Colombia.
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173
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Bankert MJ, Cole RC, Puente AN. Case study: A positive cognitive outcome following an out-of-hospital cardiac arrest. APPLIED NEUROPSYCHOLOGY-ADULT 2021:1-8. [PMID: 34797747 DOI: 10.1080/23279095.2021.2004145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Time is critical with any out of hospital cardiac arrest (OHCA). The possibility of brain cell death increases, and the likelihood of a "good" outcome decreases with time. The most prominent impairments involve memory and attentional difficulties. Limited research and few cases have shown positive cognitive results following an OHCA to the extent that this case study depicts. METHOD The current case study presents a right-handed male in his late 40s, with master's and law degrees, and a high-level functioning in the workplace who experienced an OHCA. He was treated for his OHCA and subsequently underwent neuropsychological testing less than 2 months following his hospital discharge. RESULTS Expected results suggest impairments in key cognitive areas; however, a neuropsychological exam less than 2-months post-incident, testing pre-morbid IQ, overall cognitive ability, processing speed, attention, executive functioning, language, visuospatial abilities, and memory; each showing normal or better results. Additionally, self and collateral report questionnaires examining cognitive and emotional functioning reported no difficulties and no major changes since his cardiac arrest. CONCLUSIONS We speculate that this patient's exceptional outcome might be due to his cognitive reserve, and the immediateness of his intervention (5-10 min of CPR and return-of-spontaneous-circulation from an AED shock) and use of a saline cooling procedure upon arrival to the hospital. Overall, we highlight a patient with a remarkable cognitive outcome, utilizing data from neuropsychological testing within 2-months post-incident, and propose protective factors in neuropsychological functioning following an OHCA.
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Affiliation(s)
- Michael J Bankert
- Department of Psychiatry and Behavioral Sciences, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Richard C Cole
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Antonio N Puente
- Department of Psychiatry and Behavioral Sciences, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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174
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Kang C, Jeong W, Park JS, You Y, Min JH, Cho YC, Ahn HJ, In YN, Lee IH. Different Stratification of Physiological Factors Affecting Cerebral Perfusion Pressure in Hypoxic-Ischemic Brain Injury after Cardiac Arrest According to Visible or Non-Visible Primary Brain Injury: A Retrospective Observational Study. J Clin Med 2021; 10:jcm10225385. [PMID: 34830665 PMCID: PMC8625895 DOI: 10.3390/jcm10225385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/04/2021] [Accepted: 11/16/2021] [Indexed: 12/05/2022] Open
Abstract
We aimed to explore the stratification of physiological factors affecting cerebral perfusion pressure, including arterial oxygen tension, arterial carbon dioxide tension, mean arterial pressure, intracranial pressure (ICP), and blood-brain barrier (BBB) status, with respect to primary or secondary brain injury (PBI or SBI) after out-of-hospital cardiac arrest (OHCA). Among the retrospectively enrolled 97 comatose OHCA survivors undergoing post-cardiac arrest (PCA) care, 46 (47.4%) with already established PBI (high signal intensity (HSI) on diffusion-weighted imaging (DWI) had higher ICP (p = 0.02) and poorer BBB status (p < 0.01) than the non-HSI group. On subgroup analysis within the non-HSI group to exclude the confounding effect of already established PBI, 40 (78.4%) patients with good neurological outcomes had lower ICP at 24 h (11.0 vs. 16.0 mmHg, p < 0.01) and more stable BBB status (p = 0.17 in pairwise comparison) compared to those with poor neurological outcomes, despite the non-significant differences in other physiological factors. OHCA survivors with HSI on DWI showed significantly higher ICP and poorer BBB status at baseline before PCA care than those without HSI. Despite the negative DWI findings before PCA care, OHCA survivors have a cerebral penumbra at risk for potentially leading the poor neurological outcome from unsuppressed SBI, which may be associated with increased ICP and BBB permeability.
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Affiliation(s)
- Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea; (J.H.M.); (Y.N.I.)
- Correspondence: ; Tel.: +82-42-280-6001
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea; (J.H.M.); (Y.N.I.)
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20 Bodeum 7-ro, Sejong 30099, Korea
| | - Yong Chul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea; (J.H.M.); (Y.N.I.)
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea; (J.H.M.); (Y.N.I.)
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20 Bodeum 7-ro, Sejong 30099, Korea
| | - In Ho Lee
- Department of Radiology, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea;
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175
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Coppler PJ, Elmer J. Optimizing cerebral oxygen delivery after cardiac arrest: A role for neuromonitoring. Resuscitation 2021; 169:220-222. [PMID: 34748767 DOI: 10.1016/j.resuscitation.2021.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.
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176
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Hwang M, Barnewolt CE, Jüngert J, Prada F, Sridharan A, Didier RA. Contrast-enhanced ultrasound of the pediatric brain. Pediatr Radiol 2021; 51:2270-2283. [PMID: 33599780 PMCID: PMC11458139 DOI: 10.1007/s00247-021-04974-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/10/2020] [Accepted: 01/14/2021] [Indexed: 12/16/2022]
Abstract
Brain contrast-enhanced ultrasound (CEUS) is an emerging application that can complement gray-scale US and yield additional insights into cerebral flow dynamics. CEUS uses intravenous injection of ultrasound contrast agents (UCAs) to highlight tissue perfusion and thus more clearly delineate cerebral pathologies including stroke, hypoxic-ischemic injury and focal lesions such as tumors and vascular malformations. It can be applied not only in infants with open fontanelles but also in older children and adults via a transtemporal window or surgically created acoustic window. Advancements in CEUS technology and post-processing methods for quantitative analysis of UCA kinetics further elucidate cerebral microcirculation. In this review article we discuss the CEUS examination protocol for brain imaging in children, current clinical applications and future directions for research and clinical uses of brain CEUS.
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Affiliation(s)
- Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Carol E Barnewolt
- Department of Radiology, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Jörg Jüngert
- Department of Pediatrics, Friedrich-Alexander University Erlangen - Nürnberg, Erlangen, Germany
| | - Francesco Prada
- Acoustic Neuroimaging and Therapy Laboratory, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
- Focused Ultrasound Foundation, Charlottesville, VA, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Ryne A Didier
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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177
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Wang L, Chen Y, Wei L, He J. BMP-6 Attenuates Oxygen and Glucose Deprivation-Induced Apoptosis in Human Neural Stem Cells through Inhibiting p38 MAPK Signaling Pathway. Int J Stem Cells 2021; 15:144-154. [PMID: 34711703 PMCID: PMC9148838 DOI: 10.15283/ijsc21093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/24/2021] [Accepted: 09/24/2021] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives Neural stem cells (NSCs) remain in the mammalian brain throughout life and provide a novel therapeutic strategy for central nervous system (CNS) injury. Bone morphogenetic protein-6 (BMP-6) had shown a protective effect in different types of cells. However, the role of BMP-6 in NSCs is largely unclear. The present study was aimed to investigate whether BMP-6 could protect human NSCs (hNSCs) against the oxygen and glucose deprivation (OGD)-induced cell death. Methods and Results Upon challenge with OGD treatment, cell viability was significantly decreased in a time-dependent manner, as indicated by the CCK-8 assay. BMP-6 could attenuate the OGD-induced cell injury in a dose-dependent manner and decrease the number of TUNEL-positive cells. Moreover, BMP-6 markedly weakened the OGD-induced alterations in the expression of procaspase-8/9/3 and reversed the expression of cleaved-caspase-3. Interestingly, noggin protein (the BMP-6 inhibitor) attenuated the neuroprotective effect of BMP-6 in cultured hNSCs. Furthermore, the p38 MAPK signaling pathway was activated by OGD treatment and BMP-6 markedly inhibited the phosphorylation of p38 in a concentration-dependent manner. Pretreatment with noggin abolished the effect of BMP-6 on p38 activation. SB239063, a selective p38 inhibitor, exerted similar effects with BMP-6 in protecting hNSCs against the OGD-induced apoptosis. These results indicated that blocking the phosphorylation of p38 might contribute to the neuroprotective effect of BMP-6 against the OGD-induced injury in hNSCs. Conclusions These findings suggested that BMP-6 might be a therapeutic target in the OGD-induced cell death, which provides a novel therapeutic strategy for enhancing host and graft NSCs survival in hypoxic-ischemic brain injury.
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Affiliation(s)
- Li Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, China
| | - Yang Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, China
| | - Lin Wei
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, China
| | - Jing He
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, China
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178
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Sandroni C, Cronberg T, Sekhon M. Brain injury after cardiac arrest: pathophysiology, treatment, and prognosis. Intensive Care Med 2021; 47:1393-1414. [PMID: 34705079 PMCID: PMC8548866 DOI: 10.1007/s00134-021-06548-2] [Citation(s) in RCA: 172] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/28/2021] [Indexed: 01/03/2023]
Abstract
Post-cardiac arrest brain injury (PCABI) is caused by initial ischaemia and subsequent reperfusion of the brain following resuscitation. In those who are admitted to intensive care unit after cardiac arrest, PCABI manifests as coma, and is the main cause of mortality and long-term disability. This review describes the mechanisms of PCABI, its treatment options, its outcomes, and the suggested strategies for outcome prediction.
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Affiliation(s)
- Claudio Sandroni
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy. .,Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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179
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Crippa IA, Vincent JL, Zama Cavicchi F, Pozzebon S, Annoni F, Cotoia A, Njimi H, Gaspard N, Creteur J, Taccone FS. Cerebral autoregulation in anoxic brain injury patients treated with targeted temperature management. J Intensive Care 2021; 9:67. [PMID: 34702372 PMCID: PMC8547304 DOI: 10.1186/s40560-021-00579-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/12/2021] [Indexed: 01/02/2023] Open
Abstract
Background Little is known about the prevalence of altered CAR in anoxic brain injury and the association with patients’ outcome. We aimed at investigating CAR in cardiac arrest survivors treated by targeted temperature management and its association to outcome.
Methods Retrospective analysis of prospectively collected data. Inclusion criteria: adult cardiac arrest survivors treated by targeted temperature management (TTM). Exclusion criteria: trauma; sepsis, intoxication; acute intra-cranial disease; history of supra-aortic vascular disease; severe hemodynamic instability; cardiac output mechanical support; arterial carbon dioxide partial pressure (PaCO2) > 60 mmHg; arrhythmias; lack of acoustic window. Middle cerebral artery flow velocitiy (FV) was assessed by transcranial Doppler (TCD) once during hypothermia (HT) and once during normothermia (NT). FV and blood pressure (BP) were recorded simultaneously and Mxa calculated (MATLAB). Mxa is the Pearson correlation coefficient between FV and BP. Mxa > 0.3 defined altered CAR. Survival was assessed at hospital discharge. Cerebral Performance Category (CPC) 3–5 assessed 3 months after CA defined unfavorable neurological outcome (UO). Results We included 50 patients (Jan 2015–Dec 2018). All patients had out-of-hospital cardiac arrest, 24 (48%) had initial shockable rhythm. Time to return of spontaneous circulation was 20 [10–35] min. HT (core body temperature 33.7 [33.2–34] °C) lasted for 24 [23–28] h, followed by rewarming and NT (core body temperature: 36.9 [36.6–37.4] °C). Thirty-one (62%) patients did not survive at hospital discharge and 36 (72%) had UO. Mxa was lower during HT than during NT (0.33 [0.11–0.58] vs. 0.58 [0.30–0.83]; p = 0.03). During HT, Mxa did not differ between outcome groups. During NT, Mxa was higher in patients with UO than others (0.63 [0.43–0.83] vs. 0.31 [− 0.01–0.67]; p = 0.03). Mxa differed among CPC values at NT (p = 0.03). Specifically, CPC 2 group had lower Mxa than CPC 3 and 5 groups. At multivariate analysis, initial non-shockable rhythm, high Mxa during NT and highly malignant electroencephalography pattern (HMp) were associated with in-hospital mortality; high Mxa during NT and HMp were associated with UO. Conclusions CAR is frequently altered in cardiac arrest survivors treated by TTM. Altered CAR during normothermia was independently associated with poor outcome. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-021-00579-z.
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Affiliation(s)
- Ilaria Alice Crippa
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Bruxelles, Belgium.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Bruxelles, Belgium
| | - Federica Zama Cavicchi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Bruxelles, Belgium
| | - Selene Pozzebon
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Bruxelles, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Bruxelles, Belgium
| | - Antonella Cotoia
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Bruxelles, Belgium.,Department of Anesthesia and Intensive Care, University Hospital of Foggia, Viale Luigi Pinto 1, 71122, Foggia, Italy
| | - Hassane Njimi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Bruxelles, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Bruxelles, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Bruxelles, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Bruxelles, Belgium
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180
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Oh SK, Park HJ, Yu GG, Jeong SH, Lee SW, Kim H. Secondary hypoxic ischemia alters neurobehavioral outcomes, neuroinflammation, and oxidative stress in mice exposed to controlled cortical impact. Clin Exp Emerg Med 2021; 8:216-228. [PMID: 34649410 PMCID: PMC8517469 DOI: 10.15441/ceem.20.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 02/04/2021] [Indexed: 12/05/2022] Open
Abstract
Objective Hypoxic ischemia (HI) is a secondary insult that can cause fatal neurologic outcomes after traumatic brain injury (TBI), ranging from mild cognitive deficits to persistent vegetative states. We here aimed to unravel the underlying pathological mechanisms of HI injury in a TBI mouse model. Methods Neurobehavior, neuroinflammation, and oxidative stress were assessed in a mouse model of controlled cortical impact (CCI) injury followed by HI. Mice underwent CCI alone, CCI followed by HI, HI alone, or sham operation. HI was induced by one-vessel carotid ligation with 1 hour of 8% oxygen in nitrogen. Learning and memory were assessed using the novel object recognition test, contextual and cued fear conditioning, and Barnes maze test. Brain cytokine production and oxidative stress-related components were measured. Results Compared to TBI-only animals, TBI followed by HI mice exhibited significantly poorer survival and health scores, spatial learning and memory in the Barnes maze test, discrimination memory in the novel object recognition test, and fear memory following contextual and cued fear conditioning. Malondialdehyde levels were significantly lower, whereas glutathione peroxidase activity was significantly higher in TBI followed by HI mice compared to TBI-only and sham counterparts, respectively. Interleukin-6 levels were significantly higher in TBI followed by HI mice compared to both TBI-only and sham animals. Conclusion Post-traumatic HI aggravated deficits in spatial, fear, and discrimination memory in an experimental TBI mouse model. Our results suggest that increased neuroinflammation and oxidative stress contribute to HI-induced neurobehavioral impairments after TBI.
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Affiliation(s)
- Se-Kwang Oh
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hyun-Jeong Park
- Department of Emergency Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Gyeong-Gyu Yu
- Department of Emergency Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seong-Hae Jeong
- Department of Neurology, Chungnam National University College of Medicine, Daejeon, Korea
| | - Suk-Woo Lee
- Department of Emergency Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hoon Kim
- Department of Emergency Medicine, Chungbuk National University College of Medicine, Cheongju, Korea.,Department of Emergency Medicine, Chungbuk National University Hospital, Cheongju, Korea
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181
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Mueller M, Beitzke D, Scherz T, Loewe C, Mangold A, Marculescu R, Poppe M, Sterz F, Herkner H, Lang I, Testori C, Weiser C. Copeptin Levels Are Independent from Mild Therapeutic Hypothermia but Do Not Predict Infarct Size in Patients Presenting with ST-Segment Elevation Myocardial Infarction. J Cardiovasc Dev Dis 2021; 8:jcdd8100131. [PMID: 34677200 PMCID: PMC8539262 DOI: 10.3390/jcdd8100131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Mild therapeutic hypothermia (MTH) is a treatment adjunct in ST-segment elevation myocardial infarction (STEMI) that deserves investigation. Copeptin―a surrogate marker for vasopressin―is an early biomarker in STEMI. Data from cardiac arrest patients suggest a reduction of copeptin levels through MTH; however, copeptin levels have not been investigated in MTH during STEMI. Methods: We analyzed patients treated with MTH during STEMI in a sub-study of the STATIM trial (Testori, Heart 2019). Patients were randomized to normothermia or MTH with out-of-hospital initiation. Seven copeptin samples were collected from each patient. Primary endpoint was the difference in copeptin levels between the groups. As secondary endpoints, we defined differences in the kinetics between the sampling timepoints and the correlation between copeptin and the infarct size in relation to left ventricular myocardium. Results: We included 99 patients (MTH n = 47, control n = 52) in our intention to treat analysis. No differences in copeptin values at first medical contact between the MTH and normothermia groups were found. MTH showed no effect on copeptin levels, neither during cooling phase nor through the course. Copeptin peaked at first medical contact and hospital admission in both groups. No differences in kinetics between the timepoints were found. Copeptin showed no correlation with infarct size, neither at first medical contact nor hospital admission. Conclusions: Copeptin levels were not influenced by MTH in STEMI, suggesting the use of this biomarker also during temperature management. Furthermore, copeptin levels were not usable as a surrogate marker for infarct size at any timepoint.
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Affiliation(s)
- Matthias Mueller
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (M.M.); (M.P.); (F.S.); (H.H.); (C.W.)
| | - Dietrich Beitzke
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (D.B.); (C.L.)
| | - Thomas Scherz
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (T.S.); (A.M.); (I.L.)
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (D.B.); (C.L.)
| | - Andreas Mangold
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (T.S.); (A.M.); (I.L.)
| | - Rodrig Marculescu
- Department of Laboratory Medicine, Medical University of Vienna, 1090 Vienna, Austria;
| | - Michael Poppe
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (M.M.); (M.P.); (F.S.); (H.H.); (C.W.)
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (M.M.); (M.P.); (F.S.); (H.H.); (C.W.)
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (M.M.); (M.P.); (F.S.); (H.H.); (C.W.)
| | - Irene Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (T.S.); (A.M.); (I.L.)
| | - Christoph Testori
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (M.M.); (M.P.); (F.S.); (H.H.); (C.W.)
- Correspondence: ; Tel.: +43-40-400-19640; Fax: +43-40-400-19650
| | - Christoph Weiser
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (M.M.); (M.P.); (F.S.); (H.H.); (C.W.)
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182
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Deviations from NIRS-derived optimal blood pressure are associated with worse outcomes after pediatric cardiac arrest. Resuscitation 2021; 168:110-118. [PMID: 34600027 DOI: 10.1016/j.resuscitation.2021.09.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 12/20/2022]
Abstract
AIM Evaluate cerebrovascular autoregulation (CAR) using near-infrared spectroscopy (NIRS) after pediatric cardiac arrest and determine if deviations from CAR-derived optimal mean arterial pressure (MAPopt) are associated with outcomes. METHODS CAR was quantified by a moving, linear correlation between time-synchronized mean arterial pressure (MAP) and regional cerebral oxygenation, called cerebral oximetry index (COx). MAPopt was calculated using a multi-window weighted algorithm. We calculated burden (magnitude and duration) of MAP less than 5 mmHg below MAPopt (MAPopt - 5), as the area between MAP and MAPopt - 5 curves using numerical integration and normalized as percentage of monitoring duration. Unfavorable outcome was defined as death or pediatric cerebral performance category (PCPC) at hospital discharge ≥3 with ≥1 change from baseline. Univariate logistic regression tested association between burden of MAP less than MAPopt - 5 and outcome. RESULTS Thirty-four children (median age 2.9 [IQR 1.5,13.4] years) were evaluated. Median COx in the first 24 h post-cardiac arrest was 0.06 [0,0.20]; patients spent 27% [19,43] of monitored time with COx ≥ 0.3. Patients with an unfavorable outcome (n = 24) had a greater difference between MAP and MAPopt - 5 (13 [11,19] vs. 9 [8,10] mmHg, p = 0.01) and spent more time with MAP below MAPopt - 5 (38% [26,61] vs. 24% [14,28], p = 0.03). Patients with unfavorable outcome had a higher burden of MAP less than MAPopt - 5 than patients with favorable outcome in the first 24 h post-arrest (187 [107,316] vs. 62 [43,102] mmHg × Min/Hr; OR 4.93 [95% CI 1.16-51.78]). CONCLUSIONS Greater burden of MAP below NIRS-derived MAPopt - 5 during the first 24 h after cardiac arrest was associated with unfavorable outcomes.
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183
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Perkins GD, Callaway CW, Haywood K, Neumar RW, Lilja G, Rowland MJ, Sawyer KN, Skrifvars MB, Nolan JP. Brain injury after cardiac arrest. Lancet 2021; 398:1269-1278. [PMID: 34454687 DOI: 10.1016/s0140-6736(21)00953-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 12/16/2022]
Abstract
As more people are surviving cardiac arrest, focus needs to shift towards improving neurological outcomes and quality of life in survivors. Brain injury after resuscitation, a common sequela following cardiac arrest, ranges in severity from mild impairment to devastating brain injury and brainstem death. Effective strategies to minimise brain injury after resuscitation include early intervention with cardiopulmonary resuscitation and defibrillation, restoration of normal physiology, and targeted temperature management. It is important to identify people who might have a poor outcome, to enable informed choices about continuation or withdrawal of life-sustaining treatments. Multimodal prediction guidelines seek to avoid premature withdrawal in those who might survive with a good neurological outcome, or prolonging treatment that might result in survival with severe disability. Approximately one in three admitted to intensive care will survive, many of whom will need intensive, tailored rehabilitation after discharge to have the best outcomes.
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Affiliation(s)
- Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, University Hospitals Birmingham, Birmingham, UK.
| | - Clifton W Callaway
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Robert W Neumar
- Department of Emergency Medicine, Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Gisela Lilja
- Neurology, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Matthew J Rowland
- Kadoorie Centre for Critical Care Research, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kelly N Sawyer
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
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184
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Medico-legal considerations in the context of neonatal encephalopathy and therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101266. [PMID: 34301500 DOI: 10.1016/j.siny.2021.101266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Neonatal encephalopathy (NE) is a significant complication of the peripartum period. It can lead to lifelong neurologic disabilities, including cerebral palsy, cognitive impairments, developmental delays, and epilepsy. Induced hypothermia is the first therapy, which has shown promise in improving the outcomes for neonates with moderate to severe NE following a presumed intrapartum insult. NE is also a frequent source of medical malpractice litigation. In this paper, we will review salient features of the American Tort System as it pertains to medical malpractice. We will discuss the obstetric medico-legal implications of therapeutic hypothermia and suggest a five-step approach to analyzing neonatal cases for causation, etiology, timing of occurrence, responsibility, and liability. We will close with three illustrative clinical cases.
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185
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Sekhon MS, Hoiland RL, Griesdale DE. The importance of the oxygen cascade after cardiac arrest. Resuscitation 2021; 168:231-233. [PMID: 34592401 DOI: 10.1016/j.resuscitation.2021.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 09/15/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Centre for Heart, Lung, & Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Donald E Griesdale
- Centre for Heart, Lung, & Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
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Cardiac Oxidative Stress and the Therapeutic Approaches to the Intake of Antioxidant Supplements and Physical Activity. Nutrients 2021; 13:nu13103483. [PMID: 34684484 PMCID: PMC8540093 DOI: 10.3390/nu13103483] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/22/2021] [Accepted: 09/25/2021] [Indexed: 01/01/2023] Open
Abstract
Reactive oxygen species (ROS) are strongly reactive chemical entities that include oxygen regulated by enzymatic and non-enzymatic antioxidant defense mechanisms. ROS contribute significantly to cell homeostasis in the heart by regulating cell proliferation, differentiation, and excitation-contraction coupling. When ROS generation surpasses the ability of the antioxidant defense mechanisms to buffer them, oxidative stress develops, resulting in cellular and molecular disorders and eventually in heart failure. Oxidative stress is a critical factor in developing hypoxia- and ischemia-reperfusion-related cardiovascular disorders. This article aimed to discuss the role of oxidative stress in the pathophysiology of cardiac diseases such as hypertension and endothelial dysfunction. This review focuses on the various clinical events and oxidative stress associated with cardiovascular pathophysiology, highlighting the benefits of new experimental treatments such as creatine supplementation, omega-3 fatty acids, microRNAs, and antioxidant supplements in addition to physical exercise
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187
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Kim JG, Shin H, Cho JH, Choi HY, Kim W, Kim J, Moon S, Ahn C, Lee J, Cho Y, Shin DG, Lee Y. Prognostic value of changes in the cardiac arrest rhythms from the prehospital stage to the emergency department in out-of-hospital cardiac arrest patients without prehospital returns of spontaneous circulation: A nationwide observational study. PLoS One 2021; 16:e0257883. [PMID: 34582471 PMCID: PMC8478240 DOI: 10.1371/journal.pone.0257883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 09/14/2021] [Indexed: 11/18/2022] Open
Abstract
Background This study aimed to assess the prognostic value of the changes in cardiac arrest rhythms from the prehospital stage to the ED (emergency department) in out-of-hospital cardiac arrest (OHCA) patients without prehospital returns of spontaneous circulation (ROSC). Methods This retrospective analysis was performed using nationwide population-based OHCA data from South Korea between 2012 and 2016. Patients with OHCA with medical causes and without prehospital ROSC were included and divided into four groups according to the nature of their cardiac arrest rhythms (shockable or non-shockable) in the prehospital stage and in the ED: (1) the shockable and shockable (Shock-Shock) group, (2) the shockable and non-shockable (Shock-NShock) group, (3) the non-shockable and shockable (NShock-Shock) group, and (4) the non-shockable and non-shockable (NShock-NShock) group. The presence of a shockable rhythm was confirmed based on the delivery of an electrical shock. Propensity score matching and multivariate logistic regression analyses were used to assess the effect of changes in the cardiac rhythms on patient outcomes. The primary outcome was sustained ROSC in the ED; the secondary outcomes were survival to hospital discharge and good neurological outcomes at hospital discharge. Results After applying the exclusion criteria, 51,060 eligible patients were included in the study (Shock-Shock, 4223; Shock-NShock, 3060; NShock-Shock, 11,509; NShock-NShock, 32,268). The propensity score-matched data were extracted from the six comparative subgroups. For sustained ROSC in the ED, Shock-Shock showed a higher likelihood than Shock-NShock (P <0.01) and NShock-NShock (P <0.01), Shock-NShock showed a lower likelihood than NShock-Shock (P <0.01) and NShock-NShock (P <0.01), NShock-Shock showed a higher likelihood NShock-NShock (P <0.01). For survival to hospital discharge, Shock-Shock showed a higher likelihood than Shock-NShock (P <0.01), NShock-Shock (P <0.01), and NShock-NShock (P <0.01), Shock-NShock showed a higher likelihood than NShock-Shock (P <0.01) and NShock-NShock (P <0.01), of sustained ROSC in the ED. For good neurological outcomes, Shock-Shock showed higher likelihood than Shock-NShock (P <0.01), NShock-Shock (P <0.01), and NShock-NShock (P <0.01), Shock-NShock showed better likelihood than NShock-NShock (P <0.01), NShock-Shock showed a better likelihood than NShock-NShock (P <0.01). Conclusion Sustained ROSC in the ED may be expected for patients with shockable rhythms in the ED compared with those with non-shockable rhythms in the ED. For the clinical outcomes, survival to hospital discharge and neurological outcomes, patients with Shock-Shock showed the best outcome, whereas patients with NShock-NShock showed the poorest outcome and Shock-NShock showed a higher likelihood of achieving survival to hospital discharge with no significant differences in the neurological outcomes compared with NShock-Shock.
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Affiliation(s)
- Jae Guk Kim
- Department of Emergency Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
- Department of Emergency Medicine, Graduate School of Medicine, Kangwon National University, Chuncheon, Republic of Korea
| | - Hyungoo Shin
- Department of Emergency Medicine, Hanyang University College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Jun Hwi Cho
- Department of Emergency Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
- * E-mail:
| | - Hyun Young Choi
- Department of Emergency Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Wonhee Kim
- Department of Emergency Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Jihoon Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Shinje Moon
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Chiwon Ahn
- Department of Emergency Medicine, Chung-Ang University, College of Medicine, Seoul, Republic of Korea
| | - Juncheol Lee
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Youngsuk Cho
- Department of Emergency Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Dong Geum Shin
- Department of Cardiology, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Seoul, Republic of Korea
| | - Yoonje Lee
- Department of Emergency Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
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Yuan A, Nixon RA. Neurofilament Proteins as Biomarkers to Monitor Neurological Diseases and the Efficacy of Therapies. Front Neurosci 2021; 15:689938. [PMID: 34646114 PMCID: PMC8503617 DOI: 10.3389/fnins.2021.689938] [Citation(s) in RCA: 119] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 09/02/2021] [Indexed: 01/01/2023] Open
Abstract
Biomarkers of neurodegeneration and neuronal injury have the potential to improve diagnostic accuracy, disease monitoring, prognosis, and measure treatment efficacy. Neurofilament proteins (NfPs) are well suited as biomarkers in these contexts because they are major neuron-specific components that maintain structural integrity and are sensitive to neurodegeneration and neuronal injury across a wide range of neurologic diseases. Low levels of NfPs are constantly released from neurons into the extracellular space and ultimately reach the cerebrospinal fluid (CSF) and blood under physiological conditions throughout normal brain development, maturation, and aging. NfP levels in CSF and blood rise above normal in response to neuronal injury and neurodegeneration independently of cause. NfPs in CSF measured by lumbar puncture are about 40-fold more concentrated than in blood in healthy individuals. New ultra-sensitive methods now allow minimally invasive measurement of these low levels of NfPs in serum or plasma to track disease onset and progression in neurological disorders or nervous system injury and assess responses to therapeutic interventions. Any of the five Nf subunits - neurofilament light chain (NfL), neurofilament medium chain (NfM), neurofilament heavy chain (NfH), alpha-internexin (INA) and peripherin (PRPH) may be altered in a given neuropathological condition. In familial and sporadic Alzheimer's disease (AD), plasma NfL levels may rise as early as 22 years before clinical onset in familial AD and 10 years before sporadic AD. The major determinants of elevated levels of NfPs and degradation fragments in CSF and blood are the magnitude of damaged or degenerating axons of fiber tracks, the affected axon caliber sizes and the rate of release of NfP and fragments at different stages of a given neurological disease or condition directly or indirectly affecting central nervous system (CNS) and/or peripheral nervous system (PNS). NfPs are rapidly emerging as transformative blood biomarkers in neurology providing novel insights into a wide range of neurological diseases and advancing clinical trials. Here we summarize the current understanding of intracellular NfP physiology, pathophysiology and extracellular kinetics of NfPs in biofluids and review the value and limitations of NfPs and degradation fragments as biomarkers of neurodegeneration and neuronal injury.
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Affiliation(s)
- Aidong Yuan
- Center for Dementia Research, Nathan Kline Institute, Orangeburg, NY, United States
- Department of Psychiatry, NYU Neuroscience Institute, New York, NY, United States
| | - Ralph A. Nixon
- Center for Dementia Research, Nathan Kline Institute, Orangeburg, NY, United States
- Department of Psychiatry, NYU Neuroscience Institute, New York, NY, United States
- Department of Cell Biology, New York University Grossman School of Medicine, (NYU), Neuroscience Institute, New York, NY, United States
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Tindale A, Valli H, Butt H, Beattie CJ, Adasuriya G, Warraich M, Ahmad M, Banerjee A, Providencia R, Haldar S. Different methods of providing automatic external defibrillators to out-of-hospital cardiac arrests to prevent sudden cardiac death. Hippokratia 2021. [DOI: 10.1002/14651858.cd014766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Alexander Tindale
- Royal Brompton and Harefield NHS Foundation Trust; London UK
- Imperial College London; London UK
| | - Haseeb Valli
- Department of Cardiology; Homerton University Hospital; London UK
| | - Haroun Butt
- Royal Brompton and Harefield NHS Foundation Trust; London UK
| | | | | | - Mazhar Warraich
- Department of Internal Medicine; The Royal Wolverhampton Hospitals NHS Trust; Wolverhampton UK
| | - Mahmood Ahmad
- Department of Cardiology; Royal Free Hospital, Royal Free London NHS Foundation Trust; London UK
| | - Amitava Banerjee
- Institute of Health Informatics Research; University College London; London UK
| | - Rui Providencia
- Barts Heart Centre; St Bartholomew's Hospital, Barts Health NHS Trust; London UK
| | - Shouvik Haldar
- Royal Brompton and Harefield NHS Foundation Trust; London UK
- Imperial College London; London UK
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190
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Wilcox C, Choi CW, Cho SM. Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research. JOURNAL OF NEUROCRITICAL CARE 2021. [DOI: 10.18700/jnc.210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The addition of extracorporeal membrane oxygenation (ECMO) to conventional cardiopulmonary resuscitation (CPR), termed extracorporeal cardiopulmonary resuscitation (ECPR), has significantly improved survival in selected patient populations. Despite this advancement, significant neurological impairment persists in approximately half of survivors. ECPR represents a potential advancement for patients who experience refractory cardiac arrest (CA) due to a reversible etiology and do not regain spontaneous circulation. Important risk factors for acute brain injury (ABI) in ECPR include lack of perfusion, reperfusion, and altered cerebral autoregulation. The initial hypoxic-ischemic injury caused by no-flow and low-flow states after CA and during CPR is compounded by reperfusion, hyperoxia during ECMO support, and nonpulsatile blood flow. Additionally, ECPR patients are at risk for Harlequin syndrome with peripheral cannulation, which can lead to preferential perfusion of cerebral vessels with deoxygenated blood. Lastly, the oxygenator membrane is prothrombotic and requires systemic anticoagulation. The two competing phenomena result in thrombus formation, hemolysis, and thrombocytopenia, increasing the risk of ischemic and hemorrhagic ABI. In addition to clinical studies, we assessed available ECPR animal models to identify the mechanisms underlying ABI at the cellular level. Standardized multimodal neurological monitoring may facilitate early detection of and intervention for ABI. With the increasing use of ECPR, it is critical to understand the pathophysiology of ABI, its prevention, and the management strategies for improving the outcomes of ECPR. Translational and clinical research focusing on acute ABI immediately after ECMO cannulation and its short- and long-term neurological outcomes are warranted.
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191
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Young PJ, Frei D. Oxygen therapy for critically Ill and post-operative patients. J Anesth 2021; 35:928-938. [PMID: 34490494 PMCID: PMC8420843 DOI: 10.1007/s00540-021-02996-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/28/2021] [Indexed: 11/02/2022]
Abstract
Nearly all patients receiving treatment in a peri-operative or intensive care setting receive supplemental oxygen therapy. It is biologically plausible that the dose of oxygen used might affect important patient outcomes. Most peri-operative research has focussed on oxygen regimens that target higher than normal blood oxygen levels. Whereas, intensive care research has mostly focussed on conservative oxygen regimens which assiduously avoid exposure to higher than normal blood oxygen levels. While such conservative oxygen therapy is preferred for spontaneously breathing patients with chronic obstructive pulmonary disease, the optimal oxygen regimen in other patient groups is not clear. Some data suggest that conservative oxygen therapy might be preferred for patients with hypoxic ischaemic encephalopathy. However, unless oxygen supplies are constrained, routinely aggressively down-titrating oxygen in either the peri-operative or intensive care setting is not necessary based on available data. Targeting higher than normal levels of oxygen might reduce surgical site infections in the perioperative setting and/or improve outcomes for intensive care patients with sepsis but further research is required and available data are not sufficiently strong to warrant routine implementation of such oxygen strategies.
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Affiliation(s)
- Paul J Young
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand. .,Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand. .,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia. .,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia.
| | - Daniel Frei
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand.,Department of Anaesthesia, Wellington Regional Hospital, Wellington, New Zealand
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Abstract
The susceptibility of the brain to ischaemic injury dramatically limits its viability following interruptions in blood flow. However, data from studies of dissociated cells, tissue specimens, isolated organs and whole bodies have brought into question the temporal limits within which the brain is capable of tolerating prolonged circulatory arrest. This Review assesses cell type-specific mechanisms of global cerebral ischaemia, and examines the circumstances in which the brain exhibits heightened resilience to injury. We suggest strategies for expanding such discoveries to fuel translational research into novel cytoprotective therapies, and describe emerging technologies and experimental concepts. By doing so, we propose a new multimodal framework to investigate brain resuscitation following extended periods of circulatory arrest.
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193
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Liu W, Ye Q, Xi W, Li Y, Zhou X, Wang Y, Ye Z, Hai K. The ERK/CREB/PTN/syndecan-3 pathway involves in heparin-mediated neuro-protection and neuro-regeneration against cerebral ischemia-reperfusion injury following cardiac arrest. Int Immunopharmacol 2021; 98:107689. [PMID: 34153666 DOI: 10.1016/j.intimp.2021.107689] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/23/2021] [Accepted: 04/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Heparin, a commonly used anticoagulant, has been found to improve cerebral ischemia-reperfusion injury (CIR-CA) following cardiopulmonary resuscitation (CPR). Here, we aimed to explore the role of pleiotrophin (PTN)/syndecan-3 pathway in heparin therapy for CIR-CA. MATERIALS AND METHODS The CA-CPR model was constructed in Sprague-Dawley (SD) rats, which were treated with low molecular weight heparin, and the neurological changes and brain histopathological changes were evaluated. For in-vitro experiments, the ischemic injury model of primary neurons was established by oxygen and glucose deprivation (OGD), and the neuron regeneration was detected via the Cell counting Kit-8 (CCK8) method, flow cytometry and microscopy. CREB antagonist (KG-501), ERK antagonist (PD98059) and si-PTN were used respectively to inhibit the expression of CREB, ERK and PTN in cells, so as to explore the role of heparin in regulating neuronal regeneration. RESULTS Compared with the sham rats, the neurological deficits and cerebral edema of CA-CPR rats were significantly improved after heparin treatment. Heparin also attenuated OGD-mediated neuronal apoptosis and promoted neurite outgrowth in vitro. Moreover, heparin attenuated CA-CPR-mediated neuronal apoptosis and microglial neuroinflammation. In terms of the mechanism, heparin upregulated the expression of ERK, CREB, NF200, BDNF, NGF, PTN and syndecan-3 in the rat brains. Inhibition of ERK, CREB and interference with PTN expression notably weakened the heparin-mediated neuroprotective effects and restrained the expression of ERK/CREB and PTN/syndecan-3 pathway. CONCLUSION Heparin attenuates the secondary brain injury induced by CA-CPR through regulating the ERK/CREB-mediated PTN/syndecan-3 pathway.
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Affiliation(s)
- Wenxun Liu
- Ningxia Medical University, Yinchuan 750004, Ningxia, China; Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, Ningxia, China; Ningxia Anesthesia Clinincal Medical Research Center, Yinchuan 750002, Ningxia, China
| | - Qingshan Ye
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, Ningxia, China; Ningxia Anesthesia Clinincal Medical Research Center, Yinchuan 750002, Ningxia, China
| | - Wenhua Xi
- Ningxia Medical University, Yinchuan 750004, Ningxia, China
| | - Yan Li
- Ningxia Medical University, Yinchuan 750004, Ningxia, China
| | - Xiaohong Zhou
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, Ningxia, China
| | - Yun Wang
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, Ningxia, China; Ningxia Anesthesia Clinincal Medical Research Center, Yinchuan 750002, Ningxia, China
| | - Zhenhai Ye
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, Ningxia, China
| | - Kerong Hai
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, Ningxia, China; Ningxia Anesthesia Clinincal Medical Research Center, Yinchuan 750002, Ningxia, China.
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Skrifvars MB, Sekhon M, Åneman EA. Monitoring and modifying brain oxygenation in patients at risk of hypoxic ischaemic brain injury after cardiac arrest. Crit Care 2021; 25:312. [PMID: 34461973 PMCID: PMC8406909 DOI: 10.1186/s13054-021-03678-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Markus Benedikt Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Erik Anders Åneman
- Southwestern Clinical School, University of New South Wales, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- College of Health and Medicine, Australian National University, Canberra, NSW, Australia
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Liverpool, NSW, Australia
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195
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Grand J, Kjaergaard J, Hassager C, Møller JE, Bro-Jeppesen J. Comparing Doppler Echocardiography and Thermodilution for Cardiac Output Measurements in a Contemporary Cohort of Comatose Cardiac Arrest Patients Undergoing Targeted Temperature Management. Ther Hypothermia Temp Manag 2021; 12:159-167. [PMID: 34415801 DOI: 10.1089/ther.2021.0008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Measuring cardiac output is used to guide treatment during postresuscitation care. The aim of this study was to compare Doppler echocardiography (Doppler-CO) with thermodilution using pulmonary artery catheters (PAC-CO) for cardiac output estimation in a large cohort of comatose out-of-hospital cardiac arrest (OHCA) patients undergoing targeted temperature management (TTM). Single-center substudy of 141 patients included in the TTM trial randomly assigned to 33 or 36°C for 24 hours after OHCA. Per protocol, PAC-CO and Doppler-CO were measured simultaneously shortly after admission and again at 24 and 48 hours. Linear correlation was assessed between methods and positive predictive value (PPV) and negative predictive value (NPV) of Doppler to estimate low cardiac output (<3.5 L/min) was calculated. A total of 301 paired cardiac output measurements were available. Average cardiac output was 5.28 ± 1.94 L/min measured by thermodilution and 4.06 ± 1.49 L/min measured by Doppler with a mean bias of 1.22 L/min (limits of agreements -1.92 to 4.36 L/min). Correlation between methods was moderate (R2 = 0.36). Using PAC-CO as the gold standard, PPV of a low cardiac output measurement (<3.5 L/min) by Doppler was 33%. However, the NPV was 92%. Hypothermia at 33°C did not negatively affect the correlations of CO methods. In the lowest quartile of Doppler, 13% had elevated lactate (>2 mmol/L). In the lowest quartile of thermodilution, 36% had elevated lactate (>2 mmol/L). In ventilated OHCA patients, the two methods for estimating cardiac output correlated moderately and there was a consistent underestimation of Doppler-CO. Absolute cardiac output values from Doppler-CO should be interpreted with caution. However, Doppler can be used to exclude low cardiac output with high accuracy. TTM at 33°C did not negatively affect the correlation or bias of cardiac output measurements. ClinicalTrials.gov ID: NCT01020916.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - John Bro-Jeppesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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196
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Wiklund L, Sharma A, Patnaik R, Muresanu DF, Sahib S, Tian ZR, Castellani RJ, Nozari A, Lafuente JV, Sharma HS. Upregulation of hemeoxygenase enzymes HO-1 and HO-2 following ischemia-reperfusion injury in connection with experimental cardiac arrest and cardiopulmonary resuscitation: Neuroprotective effects of methylene blue. PROGRESS IN BRAIN RESEARCH 2021; 265:317-375. [PMID: 34560924 DOI: 10.1016/bs.pbr.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Oxidative stress plays an important role in neuronal injuries after cardiac arrest. Increased production of carbon monoxide (CO) by the enzyme hemeoxygenase (HO) in the brain is induced by the oxidative stress. HO is present in the CNS in two isoforms, namely the inducible HO-1 and the constitutive HO-2. Elevated levels of serum HO-1 occurs in cardiac arrest patients and upregulation of HO-1 in cardiac arrest is seen in the neurons. However, the role of HO-2 in cardiac arrest is not well known. In this review involvement of HO-1 and HO-2 enzymes in the porcine brain following cardiac arrest and resuscitation is discussed based on our own observations. In addition, neuroprotective role of methylene blue- an antioxidant dye on alterations in HO under in cardiac arrest is also presented. The biochemical findings of HO-1 and HO-2 enzymes using ELISA were further confirmed by immunocytochemical approach to localize selective regional alterations in cardiac arrest. Our observations are the first to show that cardiac arrest followed by successful cardiopulmonary resuscitation results in significant alteration in cerebral concentrations of HO-1 and HO-2 levels indicating a prominent role of CO in brain pathology and methylene blue during CPR followed by induced hypothermia leading to superior neuroprotection after return of spontaneous circulation (ROSC), not reported earlier.
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Affiliation(s)
- Lars Wiklund
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - Aruna Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
| | - Ranjana Patnaik
- Department of Biomaterials, School of Biomedical Engineering, Indian Institute of Technology, Banaras Hindu University, Varanasi, India
| | - Dafin F Muresanu
- Department of Clinical Neurosciences, University of Medicine & Pharmacy, Cluj-Napoca, Romania; "RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Seaab Sahib
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Z Ryan Tian
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Rudy J Castellani
- Department of Pathology, University of Maryland, Baltimore, MD, United States
| | - Ala Nozari
- Anesthesiology & Intensive Care, Massachusetts General Hospital, Boston, MA, United States
| | - José Vicente Lafuente
- LaNCE, Department of Neuroscience, University of the Basque Country (UPV/EHU), Leioa, Bizkaia, Spain
| | - Hari Shanker Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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197
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Mölström S, Nielsen TH, Nordström CH, Forsse A, Möller S, Venö S, Mamaev D, Tencer T, Schmidt H, Toft P. Bedside microdialysis for detection of early brain injury after out-of-hospital cardiac arrest. Sci Rep 2021; 11:15871. [PMID: 34354178 PMCID: PMC8342553 DOI: 10.1038/s41598-021-95405-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022] Open
Abstract
Bedside detection and early treatment of lasting cerebral ischemia may improve outcome after out-of-hospital cardiac arrest (OHCA). This feasibility study explores the possibilities to use microdialysis (MD) for continuous monitoring of cerebral energy metabolism by analyzing the draining cerebral venous blood. Eighteen comatose patients were continuously monitored with jugular bulb and radial artery (reference) MD following resuscitation. Median time from cardiac arrest to MD was 300 min (IQR 230–390) with median monitoring time 60 h (IQR 40–81). The lactate/pyruvate ratio in cerebral venous blood was increased during the first 20 h after OHCA, and significant differences in time-averaged mean MD metabolites between jugular venous and artery measurements, were documented (p < 0.02). In patients with unfavorable outcome (72%), cerebral venous lactate and pyruvate levels remained elevated during the study period. In conclusion, the study indicates that jugular bulb microdialysis (JBM) is feasible and safe. Biochemical signs of lasting ischemia and mitochondrial dysfunction are frequent and associated with unfavorable outcome. The technique may be used in comatose OHCA patients to monitor biochemical variables reflecting ongoing brain damage and support individualized treatment early after resuscitation.
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Affiliation(s)
- Simon Mölström
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark.
| | | | - Carl H Nordström
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Axel Forsse
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Sören Möller
- OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sören Venö
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Dmitry Mamaev
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Tomas Tencer
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Palle Toft
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
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198
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Editorial on: "Complement Activation is associated with poor outcome after out-of-hospital Cardiac Arrest". Resuscitation 2021; 166:142-143. [PMID: 34363858 DOI: 10.1016/j.resuscitation.2021.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/23/2021] [Indexed: 11/22/2022]
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199
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Kwon WY, Jung YS, Suh GJ, Kim T, Kwak H, Kim T, Kim JY, Lee MS, Kim KS, Shin J, Lee HJ, You KM. Regional cerebral oxygen saturation in cardiac arrest survivors undergoing targeted temperature management 36℃ versus 33℃: A randomized clinical trial. Resuscitation 2021; 167:362-371. [PMID: 34331985 DOI: 10.1016/j.resuscitation.2021.07.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/16/2021] [Accepted: 07/21/2021] [Indexed: 11/18/2022]
Abstract
AIM of study To investigate whether regional cerebral oxygen saturation (rSO2) differs in out-of-hospital cardiac arrest (OHCA) survivors undergoing targeted temperature management (TTM) 36℃ versus 33℃. METHODS A randomized clinical trial was conducted at intensive care units in two referral hospitals. Fifty-seven comatose OHCA survivors were randomized into either a 36℃ or 33℃ group. Patients were cooled and maintained at an oesophageal temperature of either 36℃ or 33℃ for 24 hours, rewarmed at a rate of 0.25℃/hour, and maintained at < 37.5℃ until 72 hours. During 72 hours of TTM, rSO2 was continuously monitored on the left forehead using near-infrared spectroscopy (INVOSTM 5100C). The rSO2 level at 72 hours was compared between the two groups. Next, serial rSO2 levels for 72 hours were compared using mixed effects regression. The association between rSO2 levels and 6-month neurological outcomes was also evaluated. RESULTS There were no significant differences in the rSO2 level at 72 hours between the 36℃ and 33℃ groups (p = 0.372). Furthermore, serial rSO2 levels for 72 hours of TTM were not different between the two groups (p = 0.733). However, low rSO2 levels, particularly at 24 hours of TTM, were significantly associated with poor 6-month neurological outcomes (odds ratio = 0.899, 95% confidence interval: 0.831 - 0.974). The area under the receiver operating characteristic curve of the rSO2 level at 24 hours for poor neurological outcomes was 0.800. CONCLUSIONS Regardless of target temperatures, low rSO2 levels during TTM were significantly associated with poor 6-month neurological outcomes in OHCA survivors.
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Affiliation(s)
- Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Yoon Sun Jung
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea.
| | - Taekyun Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Hyeongkyu Kwak
- Department of Emergency Medicine, Uijeongbu Eulji University Hospital/Eulji University School of Medicine, Uijeongbu-si, Gyeonggi-do, Republic of Korea
| | - Taekwon Kim
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Jeong Yeon Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Min Sung Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Kyung Su Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Jonghwan Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Hui Jai Lee
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Kyung Min You
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
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200
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Meyer E, Bonato JM, Mori MA, Mattos BA, Guimarães FS, Milani H, de Campos AC, de Oliveira RMW. Cannabidiol Confers Neuroprotection in Rats in a Model of Transient Global Cerebral Ischemia: Impact of Hippocampal Synaptic Neuroplasticity. Mol Neurobiol 2021; 58:5338-5355. [PMID: 34302281 DOI: 10.1007/s12035-021-02479-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/28/2021] [Indexed: 02/01/2023]
Abstract
Evidence for the clinical use of neuroprotective drugs for the treatment of cerebral ischemia (CI) is still greatly limited. Spatial/temporal disorientation and cognitive dysfunction are among the most prominent long-term sequelae of CI. Cannabidiol (CBD) is a non-psychotomimetic constituent of Cannabis sativa that exerts neuroprotective effects against experimental CI. The present study investigated possible neuroprotective mechanisms of action of CBD on spatial memory impairments that are caused by transient global cerebral ischemia (TGCI) in rats. Hippocampal synaptic plasticity is a fundamental mechanism of learning and memory. Thus, we also evaluated the impact of CBD on neuroplastic changes in the hippocampus after TGCI. Wistar rats were trained to learn an eight-arm aversive radial maze (AvRM) task and underwent either sham or TGCI surgery. The animals received vehicle or 10 mg/kg CBD (i.p.) 30 min before surgery, 3 h after surgery, and then once daily for 14 days. On days 7 and 14, we performed a retention memory test. Another group of rats that received the same pharmacological treatment was tested in the object location test (OLT). Brains were removed and processed to assess neuronal degeneration, synaptic protein levels, and dendritic remodeling in the hippocampus. Cannabidiol treatment attenuated ischemia-induced memory deficits. In rats that were subjected to TGCI, CBD attenuated hippocampal CA1 neurodegeneration and increased brain-derived neurotrophic factor levels. Additionally, CBD protected neurons against the deleterious effects of TGCI on dendritic spine number and the length of dendritic arborization. These results suggest that the neuroprotective effects of CBD against TGCI-induced memory impairments involve changes in synaptic plasticity in the hippocampus.
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Affiliation(s)
- Erika Meyer
- Department of Pharmacology and Therapeutics, State University of Maringá, Av. Colombo, Maringá, Paraná, 5790, 87020-900, Brazil
| | - Jéssica Mendes Bonato
- Department of Pharmacology and Therapeutics, State University of Maringá, Av. Colombo, Maringá, Paraná, 5790, 87020-900, Brazil
| | - Marco Aurélio Mori
- Department of Pharmacology and Therapeutics, State University of Maringá, Av. Colombo, Maringá, Paraná, 5790, 87020-900, Brazil
| | - Bianca Andretto Mattos
- Department of Pharmacology and Therapeutics, State University of Maringá, Av. Colombo, Maringá, Paraná, 5790, 87020-900, Brazil
| | - Francisco Silveira Guimarães
- Department of Pharmacology, School of Medicine, USP, Av. Bandeirantes, Ribeirão Preto, São Paulo, 14015-000, Brazil
| | - Humberto Milani
- Department of Pharmacology and Therapeutics, State University of Maringá, Av. Colombo, Maringá, Paraná, 5790, 87020-900, Brazil
| | - Alline Cristina de Campos
- Department of Pharmacology, School of Medicine, USP, Av. Bandeirantes, Ribeirão Preto, São Paulo, 14015-000, Brazil
| | - Rúbia Maria Weffort de Oliveira
- Department of Pharmacology and Therapeutics, State University of Maringá, Av. Colombo, Maringá, Paraná, 5790, 87020-900, Brazil.
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