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Schoknecht K, Maechler M, Wallach I, Dreier JP, Liotta A, Berndt N. Isoflurane lowers the cerebral metabolic rate of oxygen and prevents hypoxia during cortical spreading depolarization in vitro: An integrative experimental and modeling study. J Cereb Blood Flow Metab 2024; 44:1000-1012. [PMID: 38140913 PMCID: PMC11318408 DOI: 10.1177/0271678x231222306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 10/23/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023]
Abstract
Cortical spreading depolarization (SD) imposes a massive increase in energy demand and therefore evolves as a target for treatment following acute brain injuries. Anesthetics are empirically used to reduce energy metabolism in critical brain conditions, yet their effect on metabolism during SD remains largely unknown. We investigated oxidative metabolism during SD in brain slices from Wistar rats. Extracellular potassium ([K+]o), local field potential and partial tissue oxygen pressure (ptiO2) were measured simultaneously. The cerebral metabolic rate of oxygen (CMRO2) was calculated using a reaction-diffusion model. By that, we tested the effect of clinically relevant concentrations of isoflurane on CMRO2 during SD and modeled tissue oxygenation for different capillary pO2 values. During SD, CMRO2 increased 2.7-fold, resulting in transient hypoxia in the slice core. Isoflurane decreased CMRO2, reduced peak [K+]o, and prolonged [K+]o clearance, which indicates reduced synaptic transmission and sodium-potassium ATPase inhibition. Modeling tissue oxygenation during SD illustrates the need for increased capillary pO2 levels to prevent hypoxia. In the absence thereof, isoflurane could improve tissue oxygenation by lowering CMRO2. Therefore, isoflurane is a promising candidate for pre-clinical studies on neuronal survival in conditions involving SD.
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Affiliation(s)
- Karl Schoknecht
- Carl-Ludwig-Institute of Physiology, Medical Faculty, Leipzig University, Leipzig, Germany
| | - Mathilde Maechler
- Department of Anesthesiology and Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Neurophysiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Computer-Assisted Cardiovascular Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
| | - Iwona Wallach
- Institute of Computer-Assisted Cardiovascular Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jens P Dreier
- Centre for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Bernstein Centre for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Centre for Neurosciences Berlin, Berlin, Germany
| | - Agustin Liotta
- Department of Anesthesiology and Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Neurophysiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Computer-Assisted Cardiovascular Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Health at Charité – Universitätsmedizin Berlin, Berlin
- Neuroscience Research Center, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nikolaus Berndt
- Institute of Computer-Assisted Cardiovascular Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Department of Molecular Toxicology, Nuthetal, Germany
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2
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Lindquist BE. Spreading depolarizations pose critical energy challenges in acute brain injury. J Neurochem 2024; 168:868-887. [PMID: 37787065 PMCID: PMC10987398 DOI: 10.1111/jnc.15966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/08/2023] [Accepted: 09/10/2023] [Indexed: 10/04/2023]
Abstract
Spreading depolarization (SD) is an electrochemical wave of neuronal depolarization mediated by extracellular K+ and glutamate, interacting with voltage-gated and ligand-gated ion channels. SD is increasingly recognized as a major cause of injury progression in stroke and brain trauma, where the mechanisms of SD-induced neuronal injury are intimately linked to energetic status and metabolic impairment. Here, I review the established working model of SD initiation and propagation. Then, I summarize the historical and recent evidence for the metabolic impact of SD, transitioning from a descriptive to a mechanistic working model of metabolic signaling and its potential to promote neuronal survival and resilience. I quantify the energetic cost of restoring ionic gradients eroded during SD, and the extent to which ion pumping impacts high-energy phosphate pools and the energy charge of affected tissue. I link energy deficits to adaptive increases in the utilization of glucose and O2, and the resulting accumulation of lactic acid and CO2 downstream of catabolic metabolic activity. Finally, I discuss the neuromodulatory and vasoactive paracrine signaling mediated by adenosine and acidosis, highlighting these metabolites' potential to protect vulnerable tissue in the context of high-frequency SD clusters.
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Affiliation(s)
- Britta E Lindquist
- Department of Neurology, University of California, San Francisco, California, USA
- Gladstone Institute of Neurological Diseases, San Francisco, California, USA
- Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
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3
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Santos E, Lopez-Navarro JM, Suarez-Gutierrez MA, Holzwarth N, Albiña-Palmarola P, Kirchner T, Hernandez-Aguilera A, Fernandez-Amador JA, Vazifehdan F, Woitzik J, Maier-Hein L, Sanchez-Porras R. Depth-Specific Hypoxic Responses to Spreading Depolarizations in Gyrencephalic Swine Cortex Unveiled by Photoacoustic Imaging. Transl Stroke Res 2024:10.1007/s12975-024-01247-8. [PMID: 38622426 DOI: 10.1007/s12975-024-01247-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/17/2024]
Abstract
Spreading depolarizations (SDs) are a marker of brain injury and have a causative effect on ischemic lesion progression. The hemodynamic responses elicited by SDs are contingent upon the metabolic integrity of the affected tissue, with vasoconstrictive reactions leading to pronounced hypoxia often indicating poor outcomes. The stratification of hemodynamic responses within different cortical layers remains poorly characterized. This pilot study sought to elucidate the depth-specific hemodynamic changes in response to SDs within the gray matter of the gyrencephalic swine brain. Employing a potassium chloride-induced SD model, we utilized multispectral photoacoustic imaging (PAI) to estimate regional cerebral oxygen saturation (rcSO2%) changes consequent to potassium chloride-induced SDs. Regions of interest were demarcated at three cortical depths covering up to 4 mm. Electrocorticography (ECoG) strips were placed to validate the presence of SDs. Through PAI, we detected 12 distinct rcSO2% responses, which corresponded with SDs detected in ECoG. Notably, a higher frequency of hypoxic responses was observed in the deeper cortical layers compared to superficial layers, where hyperoxic and mixed responses predominated (p < 0.001). This data provides novel insights into the differential oxygenation patterns across cortical layers in response to SDs, underlining the complexity of cerebral hemodynamics post-injury.
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Affiliation(s)
- Edgar Santos
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl Von Ossietzky University of Oldenburg, Marienstraße 11, 26121, Oldenburg, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
- Spine Center Stuttgart, Paulinenhilfe, Diakonie-Klinikum Stuttgart, Stuttgart, Germany
| | - Juan M Lopez-Navarro
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl Von Ossietzky University of Oldenburg, Marienstraße 11, 26121, Oldenburg, Germany
| | - Marcos Alejandro Suarez-Gutierrez
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl Von Ossietzky University of Oldenburg, Marienstraße 11, 26121, Oldenburg, Germany
| | - Niklas Holzwarth
- Division of Intelligent Medical Systems, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Pablo Albiña-Palmarola
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
- Department of Anatomy, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Thomas Kirchner
- Institut Für Physik, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Germany
| | - Adrian Hernandez-Aguilera
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Farzam Vazifehdan
- Spine Center Stuttgart, Paulinenhilfe, Diakonie-Klinikum Stuttgart, Stuttgart, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl Von Ossietzky University of Oldenburg, Marienstraße 11, 26121, Oldenburg, Germany
| | - Lena Maier-Hein
- Division of Intelligent Medical Systems, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Renan Sanchez-Porras
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl Von Ossietzky University of Oldenburg, Marienstraße 11, 26121, Oldenburg, Germany.
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4
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Zhou Y, Li R, Wang K, Lin F, Chen Y, Yang J, Han H, Li T, Jia Y, Yuan K, Zhang H, Li R, Li Z, Zhao Y, Hao Q, Chen X, Zhao Y. A retrospective study on the relationship between serum electrolyte disorder and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2024; 33:107579. [PMID: 38325032 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107579] [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: 07/12/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 02/09/2024] Open
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI)-induced cerebral infarction is a major cause of adverse neurological outcomes following aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to investigate the relationship between postoperative serum electrolyte levels and DCI in patients with aSAH. MATERIALS AND METHODS We analyzed the data of patients with aSAH between 2015 and 2022. The patients were classified into two groups according to whether they experienced DCI. Electrolyte levels were categorized into three groups based on the normal ranges for electrolytes. Logistic regression models were used to study the relationship between electrolyte levels and DCI. Another logistic regression analysis was conducted to explore the relationship between the different severity levels of statistically significant indicators and DCI. A restrictive cubic spline model was adopted to assess the potential linear relationship between electrolytes and DCI. Subsequently, sensitivity analysis was performed to assess the impact of collinearity among ions. Finally, subgroup analysis was performed. RESULTS This study included 1,099 patients. Patients with hyperchloremia were more prone to DCI than those with normal chloride levels. Subsequently, excluding the population with hypochloremia, both mild and severe hyperchloremia were found to be associated with an increased risk of DCI compared with normal chloride levels. Within the framework of a restrictive cubic spline, our findings revealed an increased incidence of DCI (P for nonlinear = 0.735) as chloride levels increased. Sensitivity analysis revealed that patients with severe hyperchloremia were more susceptible to DCI. CONCLUSIONS This study found that patients with aSAH and postoperative hyperchloremia are more prone to developing DCI.
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Affiliation(s)
- Yunfan Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tu Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yitong Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yahui Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Stroke Center, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Stroke Center, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Stroke Center, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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5
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Zhang X, Zhang Y, Su Q, Liu Y, Li Z, Yong VW, Xue M. Ion Channel Dysregulation Following Intracerebral Hemorrhage. Neurosci Bull 2024; 40:401-414. [PMID: 37755675 PMCID: PMC10912428 DOI: 10.1007/s12264-023-01118-6] [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: 01/27/2023] [Accepted: 06/14/2023] [Indexed: 09/28/2023] Open
Abstract
Injury to the brain after intracerebral hemorrhage (ICH) results from numerous complex cellular mechanisms. At present, effective therapy for ICH is limited and a better understanding of the mechanisms of brain injury is necessary to improve prognosis. There is increasing evidence that ion channel dysregulation occurs at multiple stages in primary and secondary brain injury following ICH. Ion channels such as TWIK-related K+ channel 1, sulfonylurea 1 transient receptor potential melastatin 4 and glutamate-gated channels affect ion homeostasis in ICH. They in turn participate in the formation of brain edema, disruption of the blood-brain barrier, and the generation of neurotoxicity. In this review, we summarize the interaction between ions and ion channels, the effects of ion channel dysregulation, and we discuss some therapeutics based on ion-channel modulation following ICH.
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Affiliation(s)
- Xiangyu Zhang
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, 450000, China
| | - Yan Zhang
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, 450000, China
| | - Qiuyang Su
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, 450000, China
| | - Yang Liu
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, 450000, China
| | - Zhe Li
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, 450000, China
| | - V Wee Yong
- Hotchkiss Brain Institute and Department of Clinical Neurosciences, University of Calgary, Calgary, AB, T2N 1N4, Canada.
| | - Mengzhou Xue
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China.
- Academy of Medical Science, Zhengzhou University, Zhengzhou, 450000, China.
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6
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Kojder K, Jarosz K, Bosiacki M, Andrzejewska A, Zacha S, Solek-Pastuszka J, Jurczak A. Cerebrolysin in Patients with Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:6638. [PMID: 37892776 PMCID: PMC10607250 DOI: 10.3390/jcm12206638] [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: 08/30/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
Subarachnoid Hemorrhage (SAH) is one of the acute neurological conditions that is associated with high mortality and recovery failure rates. In recent years, due to the development of endovascular and classical techniques, the mortality rate after SAH has decreased. Currently, more research is focused on understanding the molecular mechanisms underlying SAH. Methods of treatment are investigated in order to obtain the best treatment result, not only survival. One of the drugs used in stroke, including SAH, is Cerebrolysin. It is a mixture of neuropeptides that has similar properties to neurotrophic factors. Its positive impact on strokes has been analyzed; however, there are no meta-analyses concerning only the subpopulation of patients diagnosed with SAH in the current literature. Therefore, we conducted a meta-analysis of available clinical trials to evaluate the effect of Cerebrolysin on the treatment outcome. The data suggest a positive effect of Cerebrolysin on the mortality of SAH patients. However, further randomized clinical trials with larger groups of patients are needed to draw final conclusions.
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Affiliation(s)
- Klaudyna Kojder
- Anesthesiology and Intensive Care Department, Pomeranian Medical University, 70-210 Szczecin, Poland;
| | - Konrad Jarosz
- Department of Specialist Nursing, Pomeranian Medical University, 70-210 Szczecin, Poland;
| | - Mateusz Bosiacki
- Department of Functional Diagnostics and Physical Medicine, Pomeranian Medical University, Zołnierska 54 Str., 71-210 Szczecin, Poland; (M.B.); (A.J.)
| | - Agata Andrzejewska
- Anesthesiology and Intensive Care Department, University Hospital 1, 72-252 Szczecin, Poland;
| | - Sławomir Zacha
- Department of Pediatric Orthopedics and Oncology of the Musculoskeletal System, Pomeranian Medical University, 70-210 Szczecin, Poland;
| | - Joanna Solek-Pastuszka
- Anesthesiology and Intensive Care Department, Pomeranian Medical University, 70-210 Szczecin, Poland;
| | - Anna Jurczak
- Department of Specialist Nursing, Pomeranian Medical University, 70-210 Szczecin, Poland;
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7
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Sanicola HW, Stewart CE, Luther P, Yabut K, Guthikonda B, Jordan JD, Alexander JS. Pathophysiology, Management, and Therapeutics in Subarachnoid Hemorrhage and Delayed Cerebral Ischemia: An Overview. PATHOPHYSIOLOGY 2023; 30:420-442. [PMID: 37755398 PMCID: PMC10536590 DOI: 10.3390/pathophysiology30030032] [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: 07/20/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
Subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke resulting from the rupture of an arterial vessel within the brain. Unlike other stroke types, SAH affects both young adults (mid-40s) and the geriatric population. Patients with SAH often experience significant neurological deficits, leading to a substantial societal burden in terms of lost potential years of life. This review provides a comprehensive overview of SAH, examining its development across different stages (early, intermediate, and late) and highlighting the pathophysiological and pathohistological processes specific to each phase. The clinical management of SAH is also explored, focusing on tailored treatments and interventions to address the unique pathological changes that occur during each stage. Additionally, the paper reviews current treatment modalities and pharmacological interventions based on the evolving guidelines provided by the American Heart Association (AHA). Recent advances in our understanding of SAH will facilitate clinicians' improved management of SAH to reduce the incidence of delayed cerebral ischemia in patients.
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Affiliation(s)
- Henry W. Sanicola
- Department of Neurology, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA;
| | - Caleb E. Stewart
- Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA;
| | - Patrick Luther
- School of Medicine, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA; (P.L.); (K.Y.)
| | - Kevin Yabut
- School of Medicine, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA; (P.L.); (K.Y.)
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA;
| | - J. Dedrick Jordan
- Department of Neurology, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA;
| | - J. Steven Alexander
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA 71103, USA
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8
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Chamanzar A, Elmer J, Shutter L, Hartings J, Grover P. Noninvasive and reliable automated detection of spreading depolarization in severe traumatic brain injury using scalp EEG. COMMUNICATIONS MEDICINE 2023; 3:113. [PMID: 37598253 PMCID: PMC10439895 DOI: 10.1038/s43856-023-00344-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 08/04/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND Spreading depolarizations (SDs) are a biomarker and a potentially treatable mechanism of worsening brain injury after traumatic brain injury (TBI). Noninvasive detection of SDs could transform critical care for brain injury patients but has remained elusive. Current methods to detect SDs are based on invasive intracranial recordings with limited spatial coverage. In this study, we establish the feasibility of automated SD detection through noninvasive scalp electroencephalography (EEG) for patients with severe TBI. METHODS Building on our recent WAVEFRONT algorithm, we designed an automated SD detection method. This algorithm, with learnable parameters and improved velocity estimation, extracts and tracks propagating power depressions using low-density EEG. The dataset for testing our algorithm contains 700 total SDs in 12 severe TBI patients who underwent decompressive hemicraniectomy (DHC), labeled using ground-truth intracranial EEG recordings. We utilize simultaneously recorded, continuous, low-density (19 electrodes) scalp EEG signals, to quantify the detection accuracy of WAVEFRONT in terms of true positive rate (TPR), false positive rate (FPR), as well as the accuracy of estimating SD frequency. RESULTS WAVEFRONT achieves the best average validation accuracy using Delta band EEG: 74% TPR with less than 1.5% FPR. Further, preliminary evidence suggests WAVEFRONT can estimate how frequently SDs may occur. CONCLUSIONS We establish the feasibility, and quantify the performance, of noninvasive SD detection after severe TBI using an automated algorithm. The algorithm, WAVEFRONT, can also potentially be used for diagnosis, monitoring, and tailoring treatments for worsening brain injury. Extension of these results to patients with intact skulls requires further study.
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Grants
- K23 NS097629 NINDS NIH HHS
- National Science Foundation (NSF)
- This work was supported, in part, by grants from the National Science Foundation (NSF), Chuck Noll Foundation for Brain Injury Research, the Office of the Assistant Secretary of Defense for Health Affairs through the Defense Medical Research and Development Program under Award No. W81XWH-16-2-0020, and the Center for Machine Learning and Health at CMU, under Pittsburgh Health Data Alliance. A Chamanzar was also supported by Neil and Jo Bushnell Fellowship in Engineering, Hsu Chang Memorial Fellowship, CMU Swartz Center for Entrepreneurship Innovation Commercialization Fellows program. Dr. Elmer’s research time was supported by the National Institutes of Health (NIH) through grant 5K23NS097629. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the Department of Defense.
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Affiliation(s)
- Alireza Chamanzar
- Electrical and Computer Engineering Department, Carnegie Mellon University, Pittsburgh, PA, USA.
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA, USA.
| | - Jonathan Elmer
- Departments of Emergency Medicine, Critical Care Medicine and Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jed Hartings
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Pulkit Grover
- Electrical and Computer Engineering Department, Carnegie Mellon University, Pittsburgh, PA, USA.
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA, USA.
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9
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Sanchez-Porras R, Ramírez-Cuapio FL, Hecht N, Seule M, Díaz-Peregrino R, Unterberg A, Woitzik J, Dreier JP, Sakowitz OW, Santos E. Cerebrovascular Pressure Reactivity According to Long-Pressure Reactivity Index During Spreading Depolarizations in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:135-144. [PMID: 36697998 PMCID: PMC10499750 DOI: 10.1007/s12028-022-01669-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/19/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Spreading depolarization (SD) has been linked to the impairment of neurovascular coupling. However, the association between SD occurrence and cerebrovascular pressure reactivity as a surrogate of cerebral autoregulation (CA) remains unclear. Therefore, we analyzed CA using the long-pressure reactivity index (L-PRx) during SDs in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS A retrospective study of patients with aSAH who were recruited at two centers, Heidelberg (HD) and Berlin (BE), was performed. Continuous monitoring of mean arterial pressure (MAP) and intracranial pressure (ICP) was recorded. ICP was measured using an intraparenchymal probe in HD patients and was measure in BE patients through external ventricular drainage. Electrocorticographic (ECoG) activity was continuously recorded between 3 and 13 days after hemorrhage. Autoregulation according to L-PRx was calculated as a moving linear Pearson's correlation of 20-min averages of MAP and ICP. For every identified SD, 60-min intervals of L-PRx were averaged, plotted, and analyzed depending on SD occurrence. Random L-PRx recording periods without SDs served as the control. RESULTS A total of 19 patients (HD n = 14, BE n = 5, mean age 50.4 years, 9 female patients) were monitored for a mean duration of 230.4 h (range 96-360, STD ± 69.6 h), during which ECoG recordings revealed a total number of 277 SDs. Of these, 184 represented a single SD, and 93 SDs presented in clusters. In HD patients, mean L-PRx values were 0.12 (95% confidence interval [CI] 0.11-0.13) during SDs and 0.07 (95% CI 0.06-0.08) during control periods (p < 0.001). Similarly, in BE patients, a higher L-PRx value of 0.11 (95% CI 0.11-0.12) was detected during SDs than that during control periods (0.08, 95% CI 0.07-0.09; p < 0.001). In a more detailed analysis, CA changes registered through an intraparenchymal probe (HD patients) revealed that clustered SD periods were characterized by signs of more severely impaired CA (L-PRx during SD in clusters: 0.23 [95% CI 0.20-0.25]; single SD: 0.09 [95% CI 0.08-0.10]; control periods: 0.07 [95% CI 0.06-0.08]; p < 0.001). This group also showed significant increases in ICP during SDs in clusters compared with single SD and control periods. CONCLUSIONS Neuromonitoring for simultaneous assessment of cerebrovascular pressure reactivity using 20-min averages of MAP and ICP measured by L-PRx during SD events is feasible. SD occurrence was associated with significant increases in L-PRx values indicative of CA disturbances. An impaired CA was found during SD in clusters when using an intraparenchymal probe. This preliminary study validates the use of cerebrovascular reactivity indices to evaluate CA disturbances during SDs. Our results warrant further investigation in larger prospective patient cohorts.
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Affiliation(s)
- Renan Sanchez-Porras
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Francisco L Ramírez-Cuapio
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
| | - Nils Hecht
- Department of Neurosurgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Seule
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Roberto Díaz-Peregrino
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Jens P Dreier
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Oliver W Sakowitz
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Edgar Santos
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany.
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
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10
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Li X, Zeng L, Lu X, Chen K, Yu M, Wang B, Zhao M. Early Brain Injury and Neuroprotective Treatment after Aneurysmal Subarachnoid Hemorrhage: A Literature Review. Brain Sci 2023; 13:1083. [PMID: 37509013 PMCID: PMC10376973 DOI: 10.3390/brainsci13071083] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Early brain injury (EBI) subsequent to subarachnoid hemorrhage (SAH) is strongly associated with delayed cerebral ischemia and poor patient prognosis. Based on investigations into the molecular mechanisms underlying EBI, neurovascular dysfunction resulting from SAH can be attributed to a range of pathological processes, such as microvascular alterations in brain tissue, ionic imbalances, blood-brain barrier disruption, immune-inflammatory responses, oxidative stress, and activation of cell death pathways. Research progress presents a variety of promising therapeutic approaches for the preservation of neurological function following SAH, including calcium channel antagonists, endothelin-1 receptor blockers, antiplatelet agents, anti-inflammatory agents, and anti-oxidative stress agents. EBI can be mitigated following SAH through neuroprotective measures. To enhance our comprehension of the relevant molecular pathways involved in brain injury, including brain ischemia-hypoxic injury, neuroimmune inflammation activation, and the activation of various cell-signaling pathways, following SAH, it is essential to investigate the evolution of these multifaceted pathophysiological processes. Facilitating neural repair following a brain injury is critical for improving patient survival rates and quality of life.
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Affiliation(s)
- Xiaopeng Li
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Lang Zeng
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xuanzhen Lu
- Department of Neurology, The Third Hospital of Wuhan, Wuhan 430073, China
| | - Kun Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Maling Yu
- Department of Neurology, The Third Hospital of Wuhan, Wuhan 430073, China
| | - Baofeng Wang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Min Zhao
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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11
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Zhou J, Yang F, Li H, Xu P, Wang Z, Shao F, Shao A, Zhang J. Regulatory T Cells Secrete IL10 to Suppress Neuroinflammation in Early Stage after Subarachnoid Hemorrhage. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1317. [PMID: 37512128 PMCID: PMC10383056 DOI: 10.3390/medicina59071317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/09/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023]
Abstract
Objective: Accumulating evidence supports neuroprotective effects of regulatory T cells (Tregs) in response to brain injury. However, the precise mechanisms underlying the beneficial effects of Tregs on suppressing neuroinflammation after subarachnoid hemorrhage (SAH) remain unclear. Methods: We performed flow cytometry to detect the infiltration of Tregs into the brain at different time points after SAH. Behavioral tests, including Adhesive and Rotarod, were performed to assess neurological deficits in mice after SAH. Bulk RNA sequencing was used to investigate the transcriptomic change of Tregs infiltrating into the brain after SAH. qPCR was performed to verify the variation of inflammatory cytokines expression in the brain after Tregs exogenous infusion. FoxP3-DTR mice and Il10 gene KO mice were used to explore the mechanism of Tregs inhibiting neuron apoptosis after infiltrating the brain following SAH onset. Results: Peripheral Tregs infiltrated into the brain one day after SAH and gradually accumulated in the hemorrhagic hemisphere. An exogenous infusion of Tregs significantly improved the neurological function of mice after SAH, while poor recovery of neurological function was observed in Tregs depletion mice. Transcriptome sequencing data suggested that the immunosuppressive function of brain-infiltrated Tregs was significantly upregulated. qPCR showed that the expression of pro-inflammatory cytokines decreased in the brain of SAH mice after exogenous Tregs infusion. Bioinformatic analysis revealed that IL-10 and other cytokines secreted by brain-infiltrated Tregs were upregulated after SAH. Moreover, exogenous infusion of Il10 gene KO Tregs did not totally improve neurological function in SAH mice. Conclusions: Tregs infiltrated into the brain in the early stage after SAH and exerted neuroprotective effect by secreting IL-10 to suppress neuroinflammation and reduce neuron apoptosis.
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Affiliation(s)
- Jingyi Zhou
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310006, China
| | - Fan Yang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310006, China
| | - Huaming Li
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310006, China
| | - Penglei Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310006, China
| | - Zefeng Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310006, China
| | - Fangjie Shao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310006, China
| | - Anwen Shao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310006, China
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310058, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310006, China
- Brain Research Institute, Zhejiang University, Hangzhou 310058, China
- Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou 310058, China
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12
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Wang HY, Liu X, Grover P, Chamanzar A. A Spatial-Temporal Graph Attention Network for Automated Detection and Width Estimation of Cortical Spreading Depression Using Scalp EEG. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38082965 DOI: 10.1109/embc40787.2023.10340281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
We present an end-to-end Spatial-Temporal Graph Attention Network (STGAT) for non-invasive detection and width estimation of Cortical Spreading Depressions (CSDs) on scalp electroencephalography (EEG). Our algorithm, that we refer to as CSD Spatial-temporal graph attention network or CSD-STGAT, is trained and tested on simulated CSDs with varying width and speed ranges. Using high-density EEG, CSD-STGAT achieves less than 10.96% normalized width estimation error for narrow CSDs, with an average normalized error of 6.35%±3.08% across all widths, enabling non-invasive and automated estimation of the width of CSDs for the first time. In addition, CSD-STGAT learns the temporal and spatial features of CSDs simultaneously, which improves the "spatio-temporal tracking accuracy" (i.e., the defined detection performance metric at each electrode) of the narrow CSDs by up to 14%, compared to the state-of-the-art CSD-SpArC algorithm, with only one-tenth of the network size. CSD-STGAT achieves the best spatio-temporal tracking accuracy of 86.27%±0.53% for wide CSDs using high-density EEG, which is comparable to the performance of CSD-SpArC with less than 0.38% performance reduction. We further stitch the detections across all electrodes and over time to evaluate the "temporal accuracy". Our algorithm achieves less than 0.7% false positive rate in the simulated dataset with inter-CSD intervals ranging from 5 to 60 minutes. The lightweight architecture of CSD-STGAT paves the way towards real-time detection and parameter estimation of these waves in the brain, with significant clinical impact.
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13
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Kentar M, Ramirez-Cuapio FL, Gutiérrez-Herrera MA, Sanchez-Porras R, Díaz-Peregrino R, Holzwarth N, Maier-Hein L, Woitzik J, Santos E. Mild hypothermia reduces spreading depolarizations and infarct size in a swine model. J Cereb Blood Flow Metab 2023; 43:999-1009. [PMID: 36722153 PMCID: PMC10196741 DOI: 10.1177/0271678x231154604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/06/2022] [Accepted: 12/15/2022] [Indexed: 02/02/2023]
Abstract
Spreading depolarizations (SDs) have been linked to infarct volume expansion following ischemic stroke. Therapeutic hypothermia provides a neuroprotective effect after ischemic stroke. This study aimed to evaluate the effect of hypothermia on the propagation of SDs and infarct volume in an ischemic swine model. Through left orbital exenteration, middle cerebral arteries were surgically occluded (MCAo) in 16 swine. Extensive craniotomy and durotomy were performed. Six hypothermic and five normothermic animals were included in the analysis. An intracranial temperature probe was placed right frontal subdural. One hour after ischemic onset, mild hypothermia was induced and eighteen hours of electrocorticographic (ECoG) and intrinsic optical signal (IOS) recordings were acquired. Postmortem, 4 mm-thick slices were stained with 2,3,5-triphenyltetrazolium chloride to estimate the infarct volume. Compared to normothermia (36.4 ± 0.4°C), hypothermia (32.3 ± 0.2°C) significantly reduced the frequency and expansion of SDs (ECoG: 3.5 ± 2.1, 73.2 ± 5.2% vs. 1.0 ± 0.7, 41.9 ± 21.8%; IOS 3.9 ± 0.4, 87.6 ± 12.0% vs. 1.4 ± 0.7, 67.7 ± 8.3%, respectively). Further, infarct volume among hypothermic animals (23.2 ± 1.8% vs. 32.4 ± 2.5%) was significantly reduced. Therapeutic hypothermia reduces infarct volume and the frequency and expansion of SDs following cerebral ischemia.
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Affiliation(s)
- Modar Kentar
- Department of Neurosurgery,
University of Heidelberg, Heidelberg, Germany
| | | | | | - Renan Sanchez-Porras
- Department of Neurosurgery,
Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg,
Oldenburg, Germany
| | | | - Niklas Holzwarth
- Division of Intelligent Medical
Systems, German Cancer Research Center, Heidelberg, Germany
| | - Lena Maier-Hein
- Division of Intelligent Medical
Systems, German Cancer Research Center, Heidelberg, Germany
| | - Johannes Woitzik
- Department of Neurosurgery,
Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg,
Oldenburg, Germany
| | - Edgar Santos
- Department of Neurosurgery,
University of Heidelberg, Heidelberg, Germany
- Department of Neurosurgery,
Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg,
Oldenburg, Germany
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14
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You F, Tang WJ, Zhang C, Ye MQ, Fang XG, Zhou YF. Whole-brain CT Perfusion at Admission and During Delayed Time-window Detects the Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage. Curr Med Sci 2023; 43:409-416. [PMID: 36864249 DOI: 10.1007/s11596-023-2703-z] [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: 04/22/2022] [Accepted: 10/23/2022] [Indexed: 03/04/2023]
Abstract
OBJECTIVE To evaluate the utility of computed tomography perfusion (CTP) both at admission and during delayed cerebral ischemia time-window (DCITW) in the detection of delayed cerebral ischemia (DCI) and the change in CTP parameters from admission to DCITW following aneurysmal subarachnoid hemorrhage. METHODS Eighty patients underwent CTP at admission and during DCITW. The mean and extreme values of all CTP parameters at admission and during DCITW were compared between the DCI group and non-DCI group, and comparisons were also made between admission and DCITW within each group. The qualitative color-coded perfusion maps were recorded. Finally, the relationship between CTP parameters and DCI was assessed by receiver operating characteristic (ROC) analyses. RESULTS With the exception of cerebral blood volume (P=0.295, admission; P=0.682, DCITW), there were significant differences in the mean quantitative CTP parameters between DCI and non-DCI patients both at admission and during DCITW. In the DCI group, the extreme parameters were significantly different between admission and DCITW. The DCI group also showed a deteriorative trend in the qualitative color-coded perfusion maps. For the detection of DCI, mean transit time to the center of the impulse response function (Tmax) at admission and mean time to start (TTS) during DCITW had the largest area under curve (AUC), 0.698 and 0.789, respectively. CONCLUSION Whole-brain CTP can predict the occurrence of DCI at admission and diagnose DCI during DCITW. The extreme quantitative parameters and qualitative color-coded perfusion maps can better reflect the perfusion changes of patients with DCI from admission to DCITW.
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Affiliation(s)
- Feng You
- Department of Radiology, the First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, China.,Department of Radiology, Affiliated Hangzhou First People's Hospital, Hangzhou, 310000, China
| | - Wen-Juan Tang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Chao Zhang
- Department of Radiology, the First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, China
| | - Ming-Quan Ye
- School of Medical Information, Wannan Medical College, Wuhu, 241001, China
| | - Xing-Gen Fang
- Department of Neurosurgery, the First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, China
| | - Yun-Feng Zhou
- Department of Radiology, the First Affiliated Hospital of Wannan Medical College, Wuhu, 241001, China.
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15
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Kang EJ, Prager O, Lublinsky S, Oliveira-Ferreira AI, Reiffurth C, Major S, Müller DN, Friedman A, Dreier JP. Stroke-prone salt-sensitive spontaneously hypertensive rats show higher susceptibility to spreading depolarization (SD) and altered hemodynamic responses to SD. J Cereb Blood Flow Metab 2023; 43:210-230. [PMID: 36329390 PMCID: PMC9903222 DOI: 10.1177/0271678x221135085] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spreading depolarization (SD) occurs in a plethora of clinical conditions including migraine aura, delayed ischemia after subarachnoid hemorrhage and malignant hemispheric stroke. It describes waves of near-breakdown of ion homeostasis, particularly Na+ homeostasis in brain gray matter. SD induces tone alterations in resistance vessels, causing either hyperperfusion in healthy tissue; or hypoperfusion (inverse hemodynamic response = spreading ischemia) in tissue at risk. Observations from mice with genetic dysfunction of the ATP1A2-encoded α2-isoform of Na+/K+-ATPase (α2NaKA) suggest a mechanistic link between (1) SD, (2) vascular dysfunction, and (3) salt-sensitive hypertension via α2NaKA. Thus, α2NaKA-dysfunctional mice are more susceptible to SD and show a shift toward more inverse hemodynamic responses. α2NaKA-dysfunctional patients suffer from familial hemiplegic migraine type 2, a Mendelian model disease of SD. α2NaKA-dysfunctional mice are also a genetic model of salt-sensitive hypertension. To determine whether SD thresholds and hemodynamic responses are also altered in other genetic models of salt-sensitive hypertension, we examined these variables in stroke-prone spontaneously hypertensive rats (SHRsp). Compared with Wistar Kyoto control rats, we found in SHRsp that electrical SD threshold was significantly reduced, propagation speed was increased, and inverse hemodynamic responses were prolonged. These results may have relevance to both migraine with aura and stroke.
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Affiliation(s)
- Eun-Jeung Kang
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ofer Prager
- Department of Physiology & Cell Biology, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Cognitive & Brain Sciences, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Svetlana Lublinsky
- Department of Cognitive & Brain Sciences, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ana I Oliveira-Ferreira
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Clemens Reiffurth
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Dominik N Müller
- Experimental and Clinical Research Center (ECRC), a Joint Cooperation between the Charité - Universitätsmedizin Berlin and Max-Delbrück-Center for Molecular Medicine, Berlin, Germany.,Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Alon Friedman
- Department of Physiology & Cell Biology, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Cognitive & Brain Sciences, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Medical Neuroscience and Brain Repair Center, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jens P Dreier
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.,Einstein Center for Neurosciences Berlin, Berlin, Germany
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16
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Meinert F, Lemâle CL, Major S, Helgers SOA, Dömer P, Mencke R, Bergold MN, Dreier JP, Hecht N, Woitzik J. Less-invasive subdural electrocorticography for investigation of spreading depolarizations in patients with subarachnoid hemorrhage. Front Neurol 2023; 13:1091987. [PMID: 36686541 PMCID: PMC9849676 DOI: 10.3389/fneur.2022.1091987] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/08/2022] [Indexed: 01/06/2023] Open
Abstract
Introduction Wyler-strip electrodes for subdural electrocorticography (ECoG) are the gold standard for continuous bed-side monitoring of pathological cortical network events, such as spreading depolarizations (SD) and electrographic seizures. Recently, SD associated parameters were shown to be (1) a marker of early brain damage after aneurysmal subarachnoid hemorrhage (aSAH), (2) the strongest real-time predictor of delayed cerebral ischemia currently known, and (3) the second strongest predictor of patient outcome at 7 months. The strongest predictor of patient outcome at 7 months was focal brain damage segmented on neuroimaging 2 weeks after the initial hemorrhage, whereas the initial focal brain damage was inferior to the SD variables as a predictor for patient outcome. However, the implantation of Wyler-strip electrodes typically requires either a craniotomy or an enlarged burr hole. Neuromonitoring via an enlarged burr hole has been performed in only about 10% of the total patients monitored. Methods In the present pilot study, we investigated the feasibility of ECoG monitoring via a less invasive burrhole approach using a Spencer-type electrode array, which was implanted subdurally rather than in the depth of the parenchyma. Seven aSAH patients requiring extraventricular drainage (EVD) were included. For electrode placement, the burr hole over which the EVD was simultaneously placed, was used in all cases. After electrode implantation, continuous, direct current (DC)/alternating current (AC)-ECoG monitoring was performed at bedside in our Neurointensive Care unit. ECoGs were analyzed following the recommendations of the Co-Operative Studies on Brain Injury Depolarizations (COSBID). Results Subdural Spencer-type electrode arrays permitted high-quality ECoG recording. During a cumulative monitoring period of 1,194.5 hours and a median monitoring period of 201.3 (interquartile range: 126.1-209.4) hours per patient, 84 SDs were identified. Numbers of SDs, isoelectric SDs and clustered SDs per recording day, and peak total SD-induced depression duration of a recording day were not significantly different from the previously reported results of the prospective, observational, multicenter, cohort, diagnostic phase III trial, DISCHARGE-1. No adverse events related to electrode implantation were noted. Discussion In conclusion, our findings support the safety and feasibility of less-invasive subdural electrode implantation for reliable SD-monitoring.
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Affiliation(s)
- Franziska Meinert
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Coline L. Lemâle
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Simeon O. A. Helgers
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Patrick Dömer
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Rik Mencke
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Martin N. Bergold
- Department of Anaesthesiology and Intensive Care Medicine, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Jens P. Dreier
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany,Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany,Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Nils Hecht
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany,Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,*Correspondence: Johannes Woitzik ✉
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17
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Kawakita F, Kanamaru H, Asada R, Suzuki Y, Nampei M, Nakajima H, Oinaka H, Suzuki H. Roles of glutamate in brain injuries after subarachnoid hemorrhage. Histol Histopathol 2022; 37:1041-1051. [PMID: 36065974 DOI: 10.14670/hh-18-509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a stroke type with a high rate of mortality and morbidity. Post-SAH brain injury as a determinant of poor outcome is classified into the following two types: early brain injury (EBI) and delayed cerebral ischemia (DCI). EBI consists of various acute brain pathophysiologies that occur within the first 72 hours of SAH in a clinical setting. The underlying mechanisms of DCI are considered to be cerebral vasospasm or microcirculatory disturbance, which develops mostly 4 to 14 days after clinical SAH. Glutamate is the principal neurotransmitter in the central nervous system, but excessive glutamate is known to induce neurotoxicity. Experimental and clinical studies have revealed that excessive glutamates are released after SAH. In addition, many studies have reported the relationships between excessive glutamate release or overactivation of glutamate receptors and excitotoxicity, cortical spreading depolarization, seizure, increased blood-brain barrier permeability, neuroinflammation, microthrombosis formation, microvasospasm, cerebral vasospasm, impairments of brain metabolic supply and demand, impaired neurovascular coupling, and so on, all of which potentially contribute to the development of EBI or DCI. As glutamates always exert their functions through one or more of 4 major receptors of glutamates, it would be valuable to know the mechanisms as to how glutamates cause these pathologies, and the possibility that a glutamate receptor antagonist may block the pathologies. To prevent the mechanistic steps leading to glutamate-mediated neurotoxicity may ameliorate SAH-induced brain injuries and improve the outcomes. This review addresses the current knowledge of glutamate-mediated neurotoxicity, focusing on EBI and DCI after SAH.
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Affiliation(s)
- Fumihiro Kawakita
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hideki Kanamaru
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Reona Asada
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yume Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Mai Nampei
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hideki Nakajima
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroki Oinaka
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan.
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18
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Alkhachroum A, Appavu B, Egawa S, Foreman B, Gaspard N, Gilmore EJ, Hirsch LJ, Kurtz P, Lambrecq V, Kromm J, Vespa P, Zafar SF, Rohaut B, Claassen J. Electroencephalogram in the intensive care unit: a focused look at acute brain injury. Intensive Care Med 2022; 48:1443-1462. [PMID: 35997792 PMCID: PMC10008537 DOI: 10.1007/s00134-022-06854-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/31/2022] [Indexed: 02/04/2023]
Abstract
Over the past decades, electroencephalography (EEG) has become a widely applied and highly sophisticated brain monitoring tool in a variety of intensive care unit (ICU) settings. The most common indication for EEG monitoring currently is the management of refractory status epilepticus. In addition, a number of studies have associated frequent seizures, including nonconvulsive status epilepticus (NCSE), with worsening secondary brain injury and with worse outcomes. With the widespread utilization of EEG (spot and continuous EEG), rhythmic and periodic patterns that do not fulfill strict seizure criteria have been identified, epidemiologically quantified, and linked to pathophysiological events across a wide spectrum of critical and acute illnesses, including acute brain injury. Increasingly, EEG is not just qualitatively described, but also quantitatively analyzed together with other modalities to generate innovative measurements with possible clinical relevance. In this review, we discuss the current knowledge and emerging applications of EEG in the ICU, including seizure detection, ischemia monitoring, detection of cortical spreading depolarizations, assessment of consciousness and prognostication. We also review some technical aspects and challenges of using EEG in the ICU including the logistics of setting up ICU EEG monitoring in resource-limited settings.
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Affiliation(s)
- Ayham Alkhachroum
- Department of Neurology, University of Miami, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Brian Appavu
- Department of Child Health and Neurology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Satoshi Egawa
- Neurointensive Care Unit, Department of Neurosurgery, and Stroke and Epilepsy Center, TMG Asaka Medical Center, Saitama, Japan
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Free University of Brussels, Brussels, Belgium
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Neurocritical Care and Emergency Neurology, Department of Neurology, Ale University School of Medicine, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Pedro Kurtz
- Department of Intensive Care Medicine, D'or Institute for Research and Education, Rio de Janeiro, Brazil
- Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Virginie Lambrecq
- Department of Clinical Neurophysiology and Epilepsy Unit, AP-HP, Pitié Salpêtrière Hospital, Reference Center for Rare Epilepsies, 75013, Paris, France
| | - Julie Kromm
- Departments of Critical Care Medicine and Clinical Neurosciences, Cumming School of Medicine, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, AB, Canada
| | - Paul Vespa
- Brain Injury Research Center, Department of Neurosurgery, University of California, Los Angeles, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Benjamin Rohaut
- Department of Neurology, Sorbonne Université, Pitié-Salpêtrière-AP-HP and Paris Brain Institute, ICM, Inserm, CNRS, Paris, France
| | - Jan Claassen
- Department of Neurology, Neurological Institute, Columbia University, New York Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
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19
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Masson A, Boulouis G, Janot K, Herbreteau D, Cottier JP, Bibi R, Cohen C, Obry S, Velut S, Amelot A, Ifergan H. Acute hydrocephalus and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2022; 164:2401-2408. [PMID: 35918615 DOI: 10.1007/s00701-022-05321-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 07/17/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Delayed cerebral infarction (DCIn) following aneurysmal subarachnoid hemorrhage (aSAH) is a major cause of morbi-mortality; yet, the causes for DCIn remain incompletely understood. OBJECTIVE We tested the hypothesis that acute hydrocephalus could be related to the occurrence of DCIn, independently of the occurrence and severity of vasospasm. METHODS Radiological and clinical data of patients treated at a single large volume academic center for aSAH between 2017 and 2019 were retrospectively analyzed. DCIn was defined as imaging stigma of cerebral infarction visible on 6-week imaging follow-up after aSAH. Hydrocephalus was defined on baseline imaging as a relative bicaudate index above 1. Cerebral vasospasm was defined by reduction of artery diameter in comparison with initial diameter. We used uni- and multivariable models to test the associations between these variables, hydrocephalus and DCIn. RESULTS Of 164 included patients, vasospasm occurred in 58 patients (35.4%), and DCIn in 47 (28.7%). Acute hydrocephalus was present in 85 patients (51.8%) on baseline CT. No relation was found between acute hydrocephalus and delayed cerebral infarction in our multivariate analysis (adjusted OR: 1.20 95% CI [0.43-3.37]; p = 0.732). Only vasospasm occurrence was independently associated with DCIn (adjusted OR: 10.97 95% CI [4.60-26.01]). CONCLUSION Our study did not show an association between acute hydrocephalus and DCIn after aSAH, after adjustment for the presence and severity of cerebral vasospasm.
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Affiliation(s)
- Axel Masson
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France.
| | - Grégoire Boulouis
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Kevin Janot
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Denis Herbreteau
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Jean-Phlippe Cottier
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Richard Bibi
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Clara Cohen
- Department of Diagnostic Neuroradiology, Orleans Hospital Center, Orleans, France
| | - Sandra Obry
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Stéphane Velut
- Department of Neurosurgery, Bretonneau Hospital, University of Tours, Tours, France
| | - Aymeric Amelot
- Department of Neurosurgery, Bretonneau Hospital, University of Tours, Tours, France
| | - Héloïse Ifergan
- Department of Diagnostic and Interventional Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France.
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20
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Andrew RD, Farkas E, Hartings JA, Brennan KC, Herreras O, Müller M, Kirov SA, Ayata C, Ollen-Bittle N, Reiffurth C, Revah O, Robertson RM, Dawson-Scully KD, Ullah G, Dreier JP. Questioning Glutamate Excitotoxicity in Acute Brain Damage: The Importance of Spreading Depolarization. Neurocrit Care 2022; 37:11-30. [PMID: 35194729 PMCID: PMC9259542 DOI: 10.1007/s12028-021-01429-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/20/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Within 2 min of severe ischemia, spreading depolarization (SD) propagates like a wave through compromised gray matter of the higher brain. More SDs arise over hours in adjacent tissue, expanding the neuronal damage. This period represents a therapeutic window to inhibit SD and so reduce impending tissue injury. Yet most neuroscientists assume that the course of early brain injury can be explained by glutamate excitotoxicity, the concept that immediate glutamate release promotes early and downstream brain injury. There are many problems with glutamate release being the unseen culprit, the most practical being that the concept has yielded zero therapeutics over the past 30 years. But the basic science is also flawed, arising from dubious foundational observations beginning in the 1950s METHODS: Literature pertaining to excitotoxicity and to SD over the past 60 years is critiqued. RESULTS Excitotoxicity theory centers on the immediate and excessive release of glutamate with resulting neuronal hyperexcitation. This instigates poststroke cascades with subsequent secondary neuronal injury. By contrast, SD theory argues that although SD evokes some brief glutamate release, acute neuronal damage and the subsequent cascade of injury to neurons are elicited by the metabolic stress of SD, not by excessive glutamate release. The challenge we present here is to find new clinical targets based on more informed basic science. This is motivated by the continuing failure by neuroscientists and by industry to develop drugs that can reduce brain injury following ischemic stroke, traumatic brain injury, or sudden cardiac arrest. One important step is to recognize that SD plays a central role in promoting early neuronal damage. We argue that uncovering the molecular biology of SD initiation and propagation is essential because ischemic neurons are usually not acutely injured unless SD propagates through them. The role of glutamate excitotoxicity theory and how it has shaped SD research is then addressed, followed by a critique of its fading relevance to the study of brain injury. CONCLUSIONS Spreading depolarizations better account for the acute neuronal injury arising from brain ischemia than does the early and excessive release of glutamate.
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Affiliation(s)
| | - Eszter Farkas
- Hungarian Centre of Excellence for Molecular Medicine-University of Szeged, Cerebral Blood Flow and Metabolism Research Group, Department of Cell Biology and Molecular Medicine, University of Szeged, Szeged, Hungary
| | | | | | | | | | | | - Cenk Ayata
- Harvard Medical School, Harvard University, Boston, MA USA
| | | | - Clemens Reiffurth
- Center for Stroke Research Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Omer Revah
- School of Medicine, Stanford University, Stanford, CA USA
| | | | | | | | - Jens P. Dreier
- Center for Stroke Research Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Corporate Member of Freie Universität Berlin, Berlin, Germany
- Department of Neurology, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Berlin Institute of Health, Berlin, Germany
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Berlin, Germany
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21
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Cortical Spreading Depolarizations and Clinically Measured Scalp EEG Activity After Aneurysmal Subarachnoid Hemorrhage and Traumatic Brain Injury. Neurocrit Care 2022; 37:49-59. [PMID: 34997536 PMCID: PMC9810077 DOI: 10.1007/s12028-021-01418-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/01/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Spreading depolarizations (SDs) are associated with worse outcome following subarachnoid hemorrhage (SAH) and traumatic brain injury (TBI), but gold standard detection requires electrocorticography with a subdural strip electrode. Electroencephalography (EEG) ictal-interictal continuum abnormalities are associated with poor outcomes after TBI and with both delayed cerebral ischemia (DCI) and poor outcomes after SAH. We examined rates of SD detection in patients with SAH and TBI with intraparenchymal and subdural strip electrodes and assessed which continuous EEG (cEEG) measures were associated with intracranially quantified SDs. METHODS In this single-center cohort, we included patients with SAH and TBI undergoing ≥ 24 h of interpretable intracranial monitoring via eight-contact intraparenchymal or six-contact subdural strip platinum electrodes or both. SDs were rated according to established consensus criteria and compared with cEEG findings rated according to the American Clinical Neurophysiology Society critical care EEG monitoring consensus criteria: lateralized rhythmic delta activity, generalized rhythmic delta activity, lateralized periodic discharges, generalized periodic discharges, any ictal-interictal continuum, or a composite scalp EEG tool for seizure risk estimation: the 2HELPS2B score. Among patients with SAH, cEEG was assessed for validated DCI biomarkers: new or worsening epileptiform abnormalities and new background deterioration. RESULTS Over 6 years, SDs were recorded in 5 (18%) of 28 patients recorded with intraparenchymal electrodes and 4 (40%) of 10 patients recorded with subdural strip electrodes. There was no significant association between occurrence of SDs and day 1 cEEG findings (American Clinical Neurophysiology Society main terms lateralized periodic discharges, generalized periodic discharges, lateralized rhythmic delta activity, or seizures, individually or in combination). After SAH, established cEEG DCI predictors were not associated with SDs. CONCLUSIONS Intraparenchymal recordings yielded low rates of SD, and documented SDs were not associated with ictal-interictal continuum abnormalities or other cEEG DCI predictors. Identifying scalp EEG correlates of SD may require training computational EEG analytics and use of gold standard subdural strip electrocorticography recordings.
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22
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Dreier JP, Winkler MKL, Major S, Horst V, Lublinsky S, Kola V, Lemale CL, Kang EJ, Maslarova A, Salur I, Lückl J, Platz J, Jorks D, Oliveira-Ferreira AI, Schoknecht K, Reiffurth C, Milakara D, Wiesenthal D, Hecht N, Dengler NF, Liotta A, Wolf S, Kowoll CM, Schulte AP, Santos E, Güresir E, Unterberg AW, Sarrafzadeh A, Sakowitz OW, Vatter H, Reiner M, Brinker G, Dohmen C, Shelef I, Bohner G, Scheel M, Vajkoczy P, Hartings JA, Friedman A, Martus P, Woitzik J. Spreading depolarizations in ischaemia after subarachnoid haemorrhage, a diagnostic phase III study. Brain 2022; 145:1264-1284. [PMID: 35411920 DOI: 10.1093/brain/awab457] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/18/2021] [Accepted: 11/21/2021] [Indexed: 02/06/2023] Open
Abstract
Focal brain damage after aneurysmal subarachnoid haemorrhage predominantly results from intracerebral haemorrhage, and early and delayed cerebral ischaemia. The prospective, observational, multicentre, cohort, diagnostic phase III trial, DISCHARGE-1, primarily investigated whether the peak total spreading depolarization-induced depression duration of a recording day during delayed neuromonitoring (delayed depression duration) indicates delayed ipsilateral infarction. Consecutive patients (n = 205) who required neurosurgery were enrolled in six university hospitals from September 2009 to April 2018. Subdural electrodes for electrocorticography were implanted. Participants were excluded on the basis of exclusion criteria, technical problems in data quality, missing neuroimages or patient withdrawal (n = 25). Evaluators were blinded to other measures. Longitudinal MRI, and CT studies if clinically indicated, revealed that 162/180 patients developed focal brain damage during the first 2 weeks. During 4.5 years of cumulative recording, 6777 spreading depolarizations occurred in 161/180 patients and 238 electrographic seizures in 14/180. Ten patients died early; 90/170 developed delayed infarction ipsilateral to the electrodes. Primary objective was to investigate whether a 60-min delayed depression duration cut-off in a 24-h window predicts delayed infarction with >0.60 sensitivity and >0.80 specificity, and to estimate a new cut-off. The 60-min cut-off was too short. Sensitivity was sufficient [= 0.76 (95% confidence interval: 0.65-0.84), P = 0.0014] but specificity was 0.59 (0.47-0.70), i.e. <0.80 (P < 0.0001). Nevertheless, the area under the receiver operating characteristic (AUROC) curve of delayed depression duration was 0.76 (0.69-0.83, P < 0.0001) for delayed infarction and 0.88 (0.81-0.94, P < 0.0001) for delayed ischaemia (reversible delayed neurological deficit or infarction). In secondary analysis, a new 180-min cut-off indicated delayed infarction with a targeted 0.62 sensitivity and 0.83 specificity. In awake patients, the AUROC curve of delayed depression duration was 0.84 (0.70-0.97, P = 0.001) and the prespecified 60-min cut-off showed 0.71 sensitivity and 0.82 specificity for reversible neurological deficits. In multivariate analysis, delayed depression duration (β = 0.474, P < 0.001), delayed median Glasgow Coma Score (β = -0.201, P = 0.005) and peak transcranial Doppler (β = 0.169, P = 0.016) explained 35% of variance in delayed infarction. Another key finding was that spreading depolarization-variables were included in every multiple regression model of early, delayed and total brain damage, patient outcome and death, strongly suggesting that they are an independent biomarker of progressive brain injury. While the 60-min cut-off of cumulative depression in a 24-h window indicated reversible delayed neurological deficit, only a 180-min cut-off indicated new infarction with >0.60 sensitivity and >0.80 specificity. Although spontaneous resolution of the neurological deficit is still possible, we recommend initiating rescue treatment at the 60-min rather than the 180-min cut-off if progression of injury to infarction is to be prevented.
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Affiliation(s)
- Jens P Dreier
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Centre for Computational Neuroscience Berlin, Berlin, Germany.,Einstein Centre for Neurosciences Berlin, Berlin, Germany
| | - Maren K L Winkler
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Robert Koch-Institute, Berlin, Germany
| | - Sebastian Major
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Viktor Horst
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Svetlana Lublinsky
- Department of Brain & Cognitive Sciences, Zlotowski Centre for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Centre, Beer-Sheva, Israel.,Department of Physiology & Cell Biology, Zlotowski Centre for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Centre, Beer-Sheva, Israel
| | - Vasilis Kola
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Eun-Jeung Kang
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anna Maslarova
- Department of Neurosurgery, University Hospital and Friedrich-Wilhelms-University Bonn, Bonn, Germany.,Department of Neurosurgery, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Irmak Salur
- Department of Neurosurgery, University Hospital and Friedrich-Wilhelms-University Bonn, Bonn, Germany.,Department of Neurosurgery, KRH Klinikum Nordstadt, Hannover, Germany
| | - Janos Lückl
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary.,Department of Neurology, University of Szeged, Szeged, Hungary
| | - Johannes Platz
- Department of Neurosurgery, Herz-Neuro-Zentrum Bodensee, Kreuzlingen, Switzerland
| | - Devi Jorks
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Centre for Computational Neuroscience Berlin, Berlin, Germany.,Clienia Schlössli AG, Privatklinik für Psychiatrie und Psychotherapie, Oetwil am See, Switzerland
| | - Ana I Oliveira-Ferreira
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Neuro-Electronics Research Flanders, Leuven, Belgium.,VIB-KU, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium.,Laboratory of Neural Circuits, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Karl Schoknecht
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Carl Ludwig Institute for Physiology, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Clemens Reiffurth
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Denny Milakara
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Research Campus STIMULATE, Otto-von-Guericke-University, Magdeburg, Germany
| | - Dirk Wiesenthal
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Univention GmbH, Bremen, Germany
| | - Nils Hecht
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Nora F Dengler
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Agustin Liotta
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Anaesthesiology and Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stefan Wolf
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christina M Kowoll
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - André P Schulte
- Department of Spinal Surgery, Krankenhaus der Augustinerinnen, Cologne, Germany
| | - Edgar Santos
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital and Friedrich-Wilhelms-University Bonn, Bonn, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Germany
| | - Asita Sarrafzadeh
- Division of Neurosurgery, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Medical Centre, Geneva, Switzerland
| | - Oliver W Sakowitz
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital and Friedrich-Wilhelms-University Bonn, Bonn, Germany
| | - Michael Reiner
- Medical Advisory Service of the Statutory Health Insurance of North Rhine, Germany
| | - Gerrit Brinker
- Department of Neurosurgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Christian Dohmen
- Department for Neurology and Neurological Intensive Care Medicine, LVR-Klinik Bonn, Bonn, Germany
| | - Ilan Shelef
- Department of Brain & Cognitive Sciences, Zlotowski Centre for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Centre, Beer-Sheva, Israel.,Department of Physiology & Cell Biology, Zlotowski Centre for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Centre, Beer-Sheva, Israel.,Institute of Radiology, Soroka University Medical Centre, Beer-Sheva, Israel
| | - Georg Bohner
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Peter Vajkoczy
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jed A Hartings
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alon Friedman
- Department of Brain & Cognitive Sciences, Zlotowski Centre for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Centre, Beer-Sheva, Israel.,Department of Physiology & Cell Biology, Zlotowski Centre for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Centre, Beer-Sheva, Israel.,Department of Medical Neuroscience and Brain Repair Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Johannes Woitzik
- Centre for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
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23
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Kramer A, Selbach M, Kerz T, Neulen A, Brockmann MA, Ringel F, Brockmann C. Continuous Intraarterial Nimodipine Infusion for the Treatment of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Retrospective, Single-Center Cohort Trial. Front Neurol 2022; 13:829938. [PMID: 35370871 PMCID: PMC8964957 DOI: 10.3389/fneur.2022.829938] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/04/2022] [Indexed: 11/14/2022] Open
Abstract
Background Delayed cerebral ischemia (DCI) occurs after aneurysmal subarachnoid hemorrhage (aSAH). Continuous intraarterial nimodipine infusion (CIAN) is a promising approach in patients with intracranial large vessel vasospasm (LVV). The objective of this retrospective single-center cohort study was to evaluate the outcome in aSAH-patients treated with CIAN. Methods CIAN was initiated and ended based on the clinical evaluation and transcranial Doppler (TCD), CT-angiography, CT-perfusion (PCT), and digital subtraction angiography (DSA). Nimodipine (0.5–2.0 mg/h) was administered continuously through microcatheters placed in the extracranial internal carotid and/or vertebral artery. Primary outcome measures were Glasgow Outcome Scale (GOS) at discharge and within 1 year after aSAH, and the occurrence of minor and major (<⅓ and >⅓ of LVV-affected territory) DCI-related infarctions in subsequent CT/MRI-scans. Secondary outcome measures were CIAN-associated complications. Results A total of 17 patients underwent CIAN. Median onset of CIAN was 9 (3–13) days after aSAH, median duration was 5 (1–13) days. A favorable outcome (GOS 4–5) was achieved in 9 patients (53%) at discharge and in 13 patients within 1 year (76%). One patient died of posthemorrhagic cerebral edema. Minor cerebral infarctions occurred in five and major infarctions in three patients. One patient developed cerebral edema possibly due to CIAN. Normalization of PCT-parameters within 2 days was observed in 9/17 patients. Six patients showed clinical response and thus did not require PCT imaging. Conclusion The favorable outcome in 76% of patients after 1 year is in line with previous studies. CIAN thus may be used to treat patients with severe therapy-refractory DCI.
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Affiliation(s)
- Andreas Kramer
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Moritz Selbach
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Thomas Kerz
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
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24
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Shah KA, White TG, Powell K, Woo HH, Narayan RK, Li C. Trigeminal Nerve Stimulation Improves Cerebral Macrocirculation and Microcirculation After Subarachnoid Hemorrhage: An Exploratory Study. Neurosurgery 2022; 90:485-494. [PMID: 35188109 PMCID: PMC9514749 DOI: 10.1227/neu.0000000000001854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 11/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) is the most consequential secondary insult after aneurysmal subarachnoid hemorrhage (SAH). It is a multifactorial process caused by a combination of large artery vasospasm and microcirculatory dysregulation. Despite numerous efforts, no effective therapeutic strategies are available to prevent DCI. The trigeminal nerve richly innervates cerebral blood vessels and releases a host of vasoactive agents upon stimulation. As such, electrical trigeminal nerve stimulation (TNS) has the capability of enhancing cerebral circulation. OBJECTIVE To determine whether TNS can restore impaired cerebral macrocirculation and microcirculation in an experimental rat model of SAH. METHODS The animals were randomly assigned to sham-operated, SAH-control, and SAH-TNS groups. SAH was induced by endovascular perforation on Day 0, followed by KCl-induced cortical spreading depolarization on day 1, and sample collection on day 2. TNS was delivered on day 1. Multiple end points were assessed including cerebral vasospasm, microvascular spasm, microthrombosis, calcitonin gene-related peptide and intercellular adhesion molecule-1 concentrations, degree of cerebral ischemia and apoptosis, and neurobehavioral outcomes. RESULTS SAH resulted in significant vasoconstriction in both major cerebral vessels and cortical pial arterioles. Compared with the SAH-control group, TNS increased lumen diameters of the internal carotid artery, middle cerebral artery, and anterior cerebral artery, and decreased pial arteriolar wall thickness. Additionally, TNS increased cerebrospinal fluid calcitonin gene-related peptide levels, and decreased cortical intercellular adhesion molecule-1 expression, parenchymal microthrombi formation, ischemia-induced hypoxic injury, cellular apoptosis, and neurobehavioral deficits. CONCLUSION Our results suggest that TNS can enhance cerebral circulation at multiple levels, lessen the impact of cerebral ischemia, and ameliorate the consequences of DCI after SAH.
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Affiliation(s)
- Kevin A. Shah
- Translational Brain Research Laboratory, The Feinstein Institutes for Medical Research, Manhasset, New York, USA;
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Timothy G. White
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Keren Powell
- Translational Brain Research Laboratory, The Feinstein Institutes for Medical Research, Manhasset, New York, USA;
| | - Henry H. Woo
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Raj K. Narayan
- Translational Brain Research Laboratory, The Feinstein Institutes for Medical Research, Manhasset, New York, USA;
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Chunyan Li
- Translational Brain Research Laboratory, The Feinstein Institutes for Medical Research, Manhasset, New York, USA;
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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25
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Neuroelectric Mechanisms of Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage. Int J Mol Sci 2022; 23:ijms23063102. [PMID: 35328523 PMCID: PMC8951073 DOI: 10.3390/ijms23063102] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/11/2022] [Accepted: 03/11/2022] [Indexed: 12/16/2022] Open
Abstract
Delayed cerebral ischemia (DCI) remains a challenging but very important condition, because DCI is preventable and treatable for improving functional outcomes after aneurysmal subarachnoid hemorrhage (SAH). The pathologies underlying DCI are multifactorial. Classical approaches to DCI focus exclusively on preventing and treating the reduction of blood flow supply. However, recently, glutamate-mediated neuroelectric disruptions, such as excitotoxicity, cortical spreading depolarization and seizures, and epileptiform discharges, have been reported to occur in high frequencies in association with DCI development after SAH. Each of the neuroelectric disruptions can trigger the other, which augments metabolic demand. If increased metabolic demand exceeds the impaired blood supply, the mismatch leads to relative ischemia, resulting in DCI. The neuroelectric disruption also induces inverted vasoconstrictive neurovascular coupling in compromised brain tissues after SAH, causing DCI. Although glutamates and the receptors may play central roles in the development of excitotoxicity, cortical spreading ischemia and epileptic activity-related events, more studies are needed to clarify the pathophysiology and to develop novel therapeutic strategies for preventing or treating neuroelectric disruption-related DCI after SAH. This article reviews the recent advancement in research on neuroelectric disruption after SAH.
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26
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Baang HY, Chen HY, Herman AL, Gilmore EJ, Hirsch LJ, Sheth KN, Petersen NH, Zafar SF, Rosenthal ES, Westover MB, Kim JA. The Utility of Quantitative EEG in Detecting Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. J Clin Neurophysiol 2022; 39:207-215. [PMID: 34510093 PMCID: PMC8901442 DOI: 10.1097/wnp.0000000000000754] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY In this review, we discuss the utility of quantitative EEG parameters for the detection of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage in the context of the complex pathophysiology of DCI and the limitations of current diagnostic methods. Because of the multifactorial pathophysiology of DCI, methodologies solely assessing blood vessel narrowing (vasospasm) are insufficient to detect all DCI. Quantitative EEG has facilitated the exploration of EEG as a diagnostic modality of DCI. Multiple quantitative EEG parameters such as alpha power, relative alpha variability, and alpha/delta ratio show reliable detection of DCI in multiple studies. Recent studies on epileptiform abnormalities suggest that their potential for the detection of DCI. Quantitative EEG is a promising, continuous, noninvasive, monitoring modality of DCI implementable in daily practice. Future work should validate these parameters in larger populations, facilitated by the development of automated detection algorithms and multimodal data integration.
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Affiliation(s)
| | - Hsin Yi Chen
- Dept of Neurology, Yale University, New Haven, CT USA 06520
| | | | | | | | - Kevin N Sheth
- Dept of Neurology, Yale University, New Haven, CT USA 06520
| | | | - Sahar F Zafar
- Dept of Neurology, Massachussetts General Hospital, Boston, MA USA 02114
| | - Eric S Rosenthal
- Dept of Neurology, Massachussetts General Hospital, Boston, MA USA 02114
| | - M Brandon Westover
- Dept of Neurology, Massachussetts General Hospital, Boston, MA USA 02114
| | - Jennifer A Kim
- Dept of Neurology, Yale University, New Haven, CT USA 06520
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27
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Lemale CL, Lückl J, Horst V, Reiffurth C, Major S, Hecht N, Woitzik J, Dreier JP. Migraine Aura, Transient Ischemic Attacks, Stroke, and Dying of the Brain Share the Same Key Pathophysiological Process in Neurons Driven by Gibbs–Donnan Forces, Namely Spreading Depolarization. Front Cell Neurosci 2022; 16:837650. [PMID: 35237133 PMCID: PMC8884062 DOI: 10.3389/fncel.2022.837650] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/19/2022] [Indexed: 12/15/2022] Open
Abstract
Neuronal cytotoxic edema is the morphological correlate of the near-complete neuronal battery breakdown called spreading depolarization, or conversely, spreading depolarization is the electrophysiological correlate of the initial, still reversible phase of neuronal cytotoxic edema. Cytotoxic edema and spreading depolarization are thus different modalities of the same process, which represents a metastable universal reference state in the gray matter of the brain close to Gibbs–Donnan equilibrium. Different but merging sections of the spreading-depolarization continuum from short duration waves to intermediate duration waves to terminal waves occur in a plethora of clinical conditions, including migraine aura, ischemic stroke, traumatic brain injury, aneurysmal subarachnoid hemorrhage (aSAH) and delayed cerebral ischemia (DCI), spontaneous intracerebral hemorrhage, subdural hematoma, development of brain death, and the dying process during cardio circulatory arrest. Thus, spreading depolarization represents a prime and simultaneously the most neglected pathophysiological process in acute neurology. Aristides Leão postulated as early as the 1940s that the pathophysiological process in neurons underlying migraine aura is of the same nature as the pathophysiological process in neurons that occurs in response to cerebral circulatory arrest, because he assumed that spreading depolarization occurs in both conditions. With this in mind, it is not surprising that patients with migraine with aura have about a twofold increased risk of stroke, as some spreading depolarizations leading to the patient percept of migraine aura could be caused by cerebral ischemia. However, it is in the nature of spreading depolarization that it can have different etiologies and not all spreading depolarizations arise because of ischemia. Spreading depolarization is observed as a negative direct current (DC) shift and associated with different changes in spontaneous brain activity in the alternating current (AC) band of the electrocorticogram. These are non-spreading depression and spreading activity depression and epileptiform activity. The same spreading depolarization wave may be associated with different activity changes in adjacent brain regions. Here, we review the basal mechanism underlying spreading depolarization and the associated activity changes. Using original recordings in animals and patients, we illustrate that the associated changes in spontaneous activity are by no means trivial, but pose unsolved mechanistic puzzles and require proper scientific analysis.
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Affiliation(s)
- Coline L. Lemale
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Janos Lückl
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Viktor Horst
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Clemens Reiffurth
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Jens P. Dreier
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Berlin, Germany
- *Correspondence: Jens P. Dreier,
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28
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Berhouma M, Eker OF, Dailler F, Rheims S, Balanca B. Cortical Spreading Depolarizations in Aneurysmal Subarachnoid Hemorrhage: An Overview of Current Knowledge and Future Perspectives. Adv Tech Stand Neurosurg 2022; 45:229-244. [PMID: 35976452 DOI: 10.1007/978-3-030-99166-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Despite significant advances in the management of aneurysmal subarachnoid hemorrhage (SAH), morbidity and mortality remain devastating particularly for high-grade SAH. Poor functional outcome usually results from delayed cerebral ischemia (DCI). The pathogenesis of DCI during aneurysmal SAH has historically been attributed to cerebral vasospasm, but spreading depolarizations (SDs) are now considered to play a central role in DCI. During SAH, SDs may produce an inverse hemodynamic response leading to spreading ischemia. Several animal models have contributed to a better understanding of the pathogenesis of SDs during aneurysmal SAH and provided new therapeutic approaches including N-methyl-D-aspartate receptor antagonists and phosphodiesterase inhibitors. Herein we review the current knowledge in the field of SDs' pathogenesis and we detail the key experimental and clinical studies that have opened interesting new therapeutic approaches to prevent DCI in aneurysmal SAH.
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Affiliation(s)
- Moncef Berhouma
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon (Lyon University Hospital), Lyon, France.
- Creatis Lab, CNRS UMR 5220, INSERM U1206, Lyon 1 University, INSA Lyon, Lyon, France.
| | - Omer Faruk Eker
- Creatis Lab, CNRS UMR 5220, INSERM U1206, Lyon 1 University, INSA Lyon, Lyon, France
- Department of Interventional Neuroradiology, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon (Lyon University Hospital), Lyon, France
| | - Frederic Dailler
- Department of Neuro-Anesthesia and Neuro-Critical Care, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon (Lyon University Hospital), Lyon, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon (Lyon University Hospital), Lyon, France
- Lyon's Neurosciences Research Center, INSERM U1028/CNRS, UMR 5292, University of Lyon, Lyon, France
| | - Baptiste Balanca
- Department of Neuro-Anesthesia and Neuro-Critical Care, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon (Lyon University Hospital), Lyon, France
- Lyon's Neurosciences Research Center, INSERM U1028/CNRS, UMR 5292, University of Lyon, Lyon, France
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29
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Andrew RD, Hartings JA, Ayata C, Brennan KC, Dawson-Scully KD, Farkas E, Herreras O, Kirov SA, Müller M, Ollen-Bittle N, Reiffurth C, Revah O, Robertson RM, Shuttleworth CW, Ullah G, Dreier JP. The Critical Role of Spreading Depolarizations in Early Brain Injury: Consensus and Contention. Neurocrit Care 2022; 37:83-101. [PMID: 35257321 PMCID: PMC9259543 DOI: 10.1007/s12028-021-01431-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 12/29/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND When a patient arrives in the emergency department following a stroke, a traumatic brain injury, or sudden cardiac arrest, there is no therapeutic drug available to help protect their jeopardized neurons. One crucial reason is that we have not identified the molecular mechanisms leading to electrical failure, neuronal swelling, and blood vessel constriction in newly injured gray matter. All three result from a process termed spreading depolarization (SD). Because we only partially understand SD, we lack molecular targets and biomarkers to help neurons survive after losing their blood flow and then undergoing recurrent SD. METHODS In this review, we introduce SD as a single or recurring event, generated in gray matter following lost blood flow, which compromises the Na+/K+ pump. Electrical recovery from each SD event requires so much energy that neurons often die over minutes and hours following initial injury, independent of extracellular glutamate. RESULTS We discuss how SD has been investigated with various pitfalls in numerous experimental preparations, how overtaxing the Na+/K+ ATPase elicits SD. Elevated K+ or glutamate are unlikely natural activators of SD. We then turn to the properties of SD itself, focusing on its initiation and propagation as well as on computer modeling. CONCLUSIONS Finally, we summarize points of consensus and contention among the authors as well as where SD research may be heading. In an accompanying review, we critique the role of the glutamate excitotoxicity theory, how it has shaped SD research, and its questionable importance to the study of early brain injury as compared with SD theory.
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Affiliation(s)
- R. David Andrew
- grid.410356.50000 0004 1936 8331Queen’s University, Kingston, ON Canada
| | - Jed A. Hartings
- grid.24827.3b0000 0001 2179 9593University of Cincinnati, Cincinnati, OH USA
| | - Cenk Ayata
- grid.38142.3c000000041936754XHarvard Medical School, Harvard University, Boston, MA USA
| | - K. C. Brennan
- grid.223827.e0000 0001 2193 0096The University of Utah, Salt Lake City, UT USA
| | | | - Eszter Farkas
- grid.9008.10000 0001 1016 96251HCEMM-USZ Cerebral Blood Flow and Metabolism Research Group, and the Department of Cell Biology and Molecular Medicine, Faculty of Science and Informatics & Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Oscar Herreras
- grid.419043.b0000 0001 2177 5516Instituto de Neurobiologia Ramon Y Cajal (Consejo Superior de Investigaciones Científicas), Madrid, Spain
| | - Sergei. A. Kirov
- grid.410427.40000 0001 2284 9329Medical College of Georgia, Augusta, GA USA
| | - Michael Müller
- grid.411984.10000 0001 0482 5331University of Göttingen, University Medical Center Göttingen, Göttingen, Germany
| | - Nikita Ollen-Bittle
- grid.39381.300000 0004 1936 8884University of Western Ontario, London, ON Canada
| | - Clemens Reiffurth
- grid.7468.d0000 0001 2248 7639Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; and the Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health., Berlin, Germany
| | - Omer Revah
- grid.168010.e0000000419368956School of Medicine, Stanford University, Stanford, CA USA
| | | | | | - Ghanim Ullah
- grid.170693.a0000 0001 2353 285XUniversity of South Florida, Tampa, FL USA
| | - Jens P. Dreier
- grid.7468.d0000 0001 2248 7639Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; and the Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health., Berlin, Germany
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30
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Oxygen-Induced and pH-Induced Direct Current Artifacts on Invasive Platinum/Iridium Electrodes for Electrocorticography. Neurocrit Care 2021; 35:146-159. [PMID: 34622418 PMCID: PMC8496677 DOI: 10.1007/s12028-021-01358-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 09/15/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Spreading depolarization (SD) and the initial, still reversible phase of neuronal cytotoxic edema in the cerebral gray matter are two modalities of the same process. SD may thus serve as a real-time mechanistic biomarker for impending parenchyma damage in patients during neurocritical care. Using subdural platinum/iridium (Pt/Ir) electrodes, SD is observed as a large negative direct current (DC) shift. Besides SD, there are other causes of DC shifts that are not to be confused with SD. Here, we systematically analyzed DC artifacts in ventilated patients by observing changes in the fraction of inspired oxygen. For the same change in blood oxygenation, we found that negative and positive DC shifts can simultaneously occur at adjacent Pt/Ir electrodes. METHODS Nurses and intensivists typically increase blood oxygenation by increasing the fraction of inspired oxygen at the ventilator before performing manipulations on the patient. We retrospectively identified 20 such episodes in six patients via tissue partial pressure of oxygen (ptiO2) measurements with an intracortical O2 sensor and analyzed the associated DC shifts. In vitro, we compared Pt/Ir with silver/silver chloride (Ag/AgCl) to assess DC responses to changes in pO2, pH, or 5-min square voltage pulses and investigated the effect of electrode polarization on pO2-induced DC artifacts. RESULTS Hyperoxygenation episodes started from a ptiO2 of 37 (30-40) mmHg (median and interquartile range) reaching 71 (50-97) mmHg. During a total of 20 episodes on each of six subdural Pt/Ir electrodes in six patients, we observed 95 predominantly negative responses in six patients, 25 predominantly positive responses in four patients, and no brain activity changes. Adjacent electrodes could show positive and negative responses simultaneously. In vitro, Pt/Ir in contrast with Ag/AgCl responded to changes in either pO2 or pH with large DC shifts. In response to square voltage pulses, Pt/Ir falsely showed smaller DC shifts than Ag/AgCl, with the worst performance under anoxia. In response to pO2 increase, Pt/Ir showed DC positivity when positively polarized and DC negativity when negatively polarized. CONCLUSIONS The magnitude of pO2-induced subdural DC shifts by approximately 6 mV was similar to that of SDs, but they did not show a sequential onset at adjacent recording sites, could be either predominantly negative or positive in contrast with the always negative DC shifts of SD, and were not accompanied by brain activity depression. Opposing polarities of pO2-induced DC artifacts may result from differences in baseline electrode polarization or subdural ptiO2 inhomogeneities relative to subdermal ptiO2 at the quasi-reference.
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31
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Schenck H, Netti E, Teernstra O, De Ridder I, Dings J, Niemelä M, Temel Y, Hoogland G, Haeren R. The Role of the Glycocalyx in the Pathophysiology of Subarachnoid Hemorrhage-Induced Delayed Cerebral Ischemia. Front Cell Dev Biol 2021; 9:731641. [PMID: 34540844 PMCID: PMC8446455 DOI: 10.3389/fcell.2021.731641] [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: 06/27/2021] [Accepted: 08/06/2021] [Indexed: 12/02/2022] Open
Abstract
The glycocalyx is an important constituent of blood vessels located between the bloodstream and the endothelium. It plays a pivotal role in intercellular interactions in neuroinflammation, reduction of vascular oxidative stress, and provides a barrier regulating vascular permeability. In the brain, the glycocalyx is closely related to functions of the blood-brain barrier and neurovascular unit, both responsible for adequate neurovascular responses to potential threats to cerebral homeostasis. An aneurysmal subarachnoid hemorrhage (aSAH) occurs following rupture of an intracranial aneurysm and leads to immediate brain damage (early brain injury). In some cases, this can result in secondary brain damage, also known as delayed cerebral ischemia (DCI). DCI is a life-threatening condition that affects up to 30% of all aSAH patients. As such, it is associated with substantial societal and healthcare-related costs. Causes of DCI are multifactorial and thought to involve neuroinflammation, oxidative stress, neuroinflammation, thrombosis, and neurovascular uncoupling. To date, prediction of DCI is limited, and preventive and effective treatment strategies of DCI are scarce. There is increasing evidence that the glycocalyx is disrupted following an aSAH, and that glycocalyx disruption could precipitate or aggravate DCI. This review explores the potential role of the glycocalyx in the pathophysiological mechanisms contributing to DCI following aSAH. Understanding the role of the glycocalyx in DCI could advance the development of improved methods to predict DCI or identify patients at risk for DCI. This knowledge may also alter the methods and timing of preventive and treatment strategies of DCI. To this end, we review the potential and limitations of methods currently used to evaluate the glycocalyx, and strategies to restore or prevent glycocalyx shedding.
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Affiliation(s)
- Hanna Schenck
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Eliisa Netti
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Onno Teernstra
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Inger De Ridder
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Jim Dings
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Govert Hoogland
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Roel Haeren
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands.,Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
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32
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Dodd WS, Laurent D, Dumont AS, Hasan DM, Jabbour PM, Starke RM, Hosaka K, Polifka AJ, Hoh BL, Chalouhi N. Pathophysiology of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage: A Review. J Am Heart Assoc 2021; 10:e021845. [PMID: 34325514 PMCID: PMC8475656 DOI: 10.1161/jaha.121.021845] [Citation(s) in RCA: 103] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/09/2021] [Indexed: 01/23/2023]
Abstract
Delayed cerebral ischemia is a major predictor of poor outcomes in patients who suffer subarachnoid hemorrhage. Treatment options are limited and often ineffective despite many years of investigation and clinical trials. Modern advances in basic science have produced a much more complex, multifactorial framework in which delayed cerebral ischemia is better understood and novel treatments can be developed. Leveraging this knowledge to improve outcomes, however, depends on a holistic understanding of the disease process. We conducted a review of the literature to analyze the current state of investigation into delayed cerebral ischemia with emphasis on the major themes that have emerged over the past decades. Specifically, we discuss microcirculatory dysfunction, glymphatic impairment, inflammation, and neuroelectric disruption as pathological factors in addition to the canonical focus on cerebral vasospasm. This review intends to give clinicians and researchers a summary of the foundations of delayed cerebral ischemia pathophysiology while also underscoring the interactions and interdependencies between pathological factors. Through this overview, we also highlight the advances in translational studies and potential future therapeutic opportunities.
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Affiliation(s)
- William S. Dodd
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Dimitri Laurent
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Aaron S. Dumont
- Department of Neurological SurgerySchool of MedicineTulane UniversityNew OrleansLA
| | - David M. Hasan
- Department of NeurosurgeryCarver College of MedicineUniversity of IowaIowa CityIA
| | - Pascal M. Jabbour
- Department of Neurological SurgerySidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPA
| | - Robert M. Starke
- Department of Neurological SurgeryMiller School of MedicineUniversity of MiamiFL
| | - Koji Hosaka
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Adam J. Polifka
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Brian L. Hoh
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Nohra Chalouhi
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
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Rinaldi C, Donato L, Alibrandi S, Scimone C, D’Angelo R, Sidoti A. Oxidative Stress and the Neurovascular Unit. Life (Basel) 2021; 11:767. [PMID: 34440511 PMCID: PMC8398978 DOI: 10.3390/life11080767] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 12/15/2022] Open
Abstract
The neurovascular unit (NVU) is a relatively recent concept that clearly describes the relationship between brain cells and their blood vessels. The components of the NVU, comprising different types of cells, are so interrelated and associated with each other that they are considered as a single functioning unit. For this reason, even slight disturbances in the NVU could severely affect brain homeostasis and health. In this review, we aim to describe the current state of knowledge concerning the role of oxidative stress on the neurovascular unit and the role of a single cell type in the NVU crosstalk.
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Affiliation(s)
- Carmela Rinaldi
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (C.R.); (L.D.); (S.A.); (R.D.); (A.S.)
| | - Luigi Donato
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (C.R.); (L.D.); (S.A.); (R.D.); (A.S.)
- Department of Biomolecular Strategies, Genetics and Avant-Garde Therapies, Istituto Euro-Mediterraneo di Scienza e Tecnologia (I.E.ME.S.T.), Via Michele Miraglia, 90139 Palermo, Italy
| | - Simona Alibrandi
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (C.R.); (L.D.); (S.A.); (R.D.); (A.S.)
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno d’Alcontres 31, 98166 Messina, Italy
| | - Concetta Scimone
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (C.R.); (L.D.); (S.A.); (R.D.); (A.S.)
- Department of Biomolecular Strategies, Genetics and Avant-Garde Therapies, Istituto Euro-Mediterraneo di Scienza e Tecnologia (I.E.ME.S.T.), Via Michele Miraglia, 90139 Palermo, Italy
| | - Rosalia D’Angelo
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (C.R.); (L.D.); (S.A.); (R.D.); (A.S.)
| | - Antonina Sidoti
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Via Consolare Valeria 1, 98125 Messina, Italy; (C.R.); (L.D.); (S.A.); (R.D.); (A.S.)
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34
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Lenz IJ, Plesnila N, Terpolilli NA. Role of endothelial nitric oxide synthase for early brain injury after subarachnoid hemorrhage in mice. J Cereb Blood Flow Metab 2021; 41:1669-1681. [PMID: 33256507 PMCID: PMC8221759 DOI: 10.1177/0271678x20973787] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The first few hours and days after subarachnoid hemorrhage (SAH) are characterized by cerebral ischemia, spasms of pial arterioles, and a significant reduction of cerebral microperfusion, however, the mechanisms of this early microcirculatory dysfunction are still unknown. Endothelial nitric oxide production is reduced after SAH and exogenous application of NO reduces post-hemorrhagic microvasospasm. Therefore, we hypothesize that the endothelial NO-synthase (eNOS) may be involved in the formation of microvasospasms, microcirculatory dysfunction, and unfavorable outcome after SAH. SAH was induced in male eNOS deficient (eNOS-/-) mice by endovascular MCA perforation. Three hours later, the cerebral microcirculation was visualized using in vivo 2-photon-microscopy. eNOS-/- mice had more severe SAHs, more severe ischemia, three time more rebleedings, and a massively increased mortality (50 vs. 0%) as compared to wild type (WT) littermate controls. Three hours after SAH eNOS-/- mice had fewer perfused microvessels and 40% more microvasospasms than WT mice. The current study indicates that a proper function of eNOS plays a key role for a favorable outcome after SAH and helps to explain why patients suffering from hypertension or other conditions associated with impaired eNOS function, have a higher risk of unfavorable outcome after SAH.
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Affiliation(s)
- Irina J Lenz
- Institute for Stroke- and Dementia Research (ISD), Munich University Hospital and Ludwig-Maximilians University, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Nikolaus Plesnila
- Institute for Stroke- and Dementia Research (ISD), Munich University Hospital and Ludwig-Maximilians University, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Nicole A Terpolilli
- Institute for Stroke- and Dementia Research (ISD), Munich University Hospital and Ludwig-Maximilians University, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.,Department of Neurosurgery, Munich University Hospital, Munich, Germany
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35
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Tso MK, Turgeon P, Bosche B, Lee CK, Nie T, D'Abbondanza J, Ai J, Marsden PA, Macdonald RL. Gene expression profiling of brain endothelial cells after experimental subarachnoid haemorrhage. Sci Rep 2021; 11:7818. [PMID: 33837224 PMCID: PMC8035152 DOI: 10.1038/s41598-021-87301-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 02/09/2021] [Indexed: 12/12/2022] Open
Abstract
Subarachnoid haemorrhage (SAH) is a type of hemorrhagic stroke that is associated with high morbidity and mortality. New effective treatments are needed to improve outcomes. The pathophysiology of SAH is complex and includes early brain injury and delayed cerebral ischemia, both of which are characterized by blood–brain barrier (BBB) impairment. We isolated brain endothelial cells (BECs) from mice subjected to SAH by injection of blood into the prechiasmatic cistern. We used gene expression profiling to identify 707 unique genes (2.8% of transcripts, 403 upregulated, 304 downregulated, 24,865 interrogated probe sets) that were significantly differentially expressed in mouse BECs after SAH. The pathway involving prostaglandin synthesis and regulation was significantly upregulated after SAH, including increased expression of the Ptgs2 gene and its corresponding COX-2 protein. Celecoxib, a selective COX-2 inhibitor, limited upregulation of Ptgs2 in BECs. In this study, we have defined the gene expression profiling of BECs after experimental SAH and provide further insight into BBB pathophysiology, which may be relevant to other neurological diseases such as traumatic brain injury, brain tumours, ischaemic stroke, multiple sclerosis, and neurodegenerative disorders.
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Affiliation(s)
- Michael K Tso
- Division of Neurosurgery, University of Calgary, Calgary, AB, Canada.,Division of Neurosurgery, St. Michael's Hospital, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Department of Neurological Surgery, UCSF Fresno Campus, Fresno, USA
| | - Paul Turgeon
- Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - Bert Bosche
- Division of Neurosurgery, St. Michael's Hospital, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Department of Neurocritical Care, Neurological and Neurosurgical First Stage Rehabilitation and Weaning, MediClin Clinic Reichshof, Reichshof-Eckenhagen, Germany.,Institute of Neurophysiology, University of Cologne, Cologne, Germany.,Department of Neurology, University of Duisburg-Essen, Essen, Germany.,Department of Neurological Surgery, UCSF Fresno Campus, Fresno, USA
| | - Charles K Lee
- Division of Neurosurgery, St. Michael's Hospital, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Department of Neurological Surgery, UCSF Fresno Campus, Fresno, USA
| | - Tian Nie
- Division of Neurosurgery, St. Michael's Hospital, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Department of Neurological Surgery, UCSF Fresno Campus, Fresno, USA
| | - Josephine D'Abbondanza
- Division of Neurosurgery, St. Michael's Hospital, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Department of Neurological Surgery, UCSF Fresno Campus, Fresno, USA
| | - Jinglu Ai
- Division of Neurosurgery, St. Michael's Hospital, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Department of Neurological Surgery, UCSF Fresno Campus, Fresno, USA
| | - Philip A Marsden
- Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. .,Department of Neurological Surgery, UCSF Fresno Campus, Fresno, USA.
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36
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Rass V, Helbok R. How to diagnose delayed cerebral ischaemia and symptomatic vasospasm and prevent cerebral infarction in patients with subarachnoid haemorrhage. Curr Opin Crit Care 2021; 27:103-114. [PMID: 33405414 DOI: 10.1097/mcc.0000000000000798] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Delayed cerebral ischaemia (DCI) complicates the clinical course of patients with subarachnoid haemorrhage (SAH) in 20--30% and substantially worsens outcome. In this review, we describe a multimodal diagnostic approach based on underlying mechanisms of DCI and provide treatment options with a special focus on the most recently published literature. RECENT FINDINGS Symptomatic vasospasm refers to clinical deterioration in the presence of vasospasm whereas DCI constitutes multiple causes. Pathophysiologic mechanisms underlying DCI range beyond large vessel vasospasm from neuroinflammation, to microthromboembolism, impaired cerebral autoregulation, cortical spreading depolarizations and many others. The current definition of DCI can be challenged by these mechanisms. We propose a pragmatic approach using a combination of clinical examination, cerebral ultrasonography, neuroimaging modalities and multimodal neuromonitoring to trigger therapeutic interventions in the presence of DCI. In addition to prophylactic nimodipine and management principles to improve oxygen delivery and decrease the brain metabolic demand, other specific interventions include permissive hypertension, intra-arterial application of calcium channel blockers and in selected patients angioplasty. SUMMARY The complex pathophysiology underlying DCI urges for a multimodal diagnostic approach triggering targeted interventions. Novel treatment concepts still have to be proven in large trials.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse, Innsbruck, Austria
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37
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Petzold GC, Dreier JP. Spreading depolarization evoked by endothelin-1 is inhibited by octanol but not by carbenoxolone. BRAIN HEMORRHAGES 2021. [DOI: 10.1016/j.hest.2020.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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38
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Spencer P, Jiang Y, Liu N, Han J, Li Y, Vodovoz S, Dumont AS, Wang X. Update: Microdialysis for Monitoring Cerebral Metabolic Dysfunction after Subarachnoid Hemorrhage. J Clin Med 2020; 10:jcm10010100. [PMID: 33396652 PMCID: PMC7794715 DOI: 10.3390/jcm10010100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/25/2020] [Accepted: 12/25/2020] [Indexed: 01/07/2023] Open
Abstract
Cerebral metabolic dysfunction has been shown to extensively mediate the pathophysiology of brain injury after subarachnoid hemorrhage (SAH). The characterization of the alterations of metabolites in the brain can help elucidate pathophysiological changes occurring throughout SAH and the relationship between secondary brain injury and cerebral energy dysfunction after SAH. Cerebral microdialysis (CMD) is a tool that can measure concentrations of multiple bioenergetics metabolites in brain interstitial fluid. This review aims to provide an update on the implication of CMD on the measurement of metabolic dysfunction in the brain after SAH. A literature review was conducted through a general PubMed search with the terms “Subarachnoid Hemorrhage AND Microdialysis” as well as a more targeted search using MeSh with the search terms “Subarachnoid hemorrhage AND Microdialysis AND Metabolism.” Both experimental and clinical papers were reviewed. CMD is a suitable tool that has been used for monitoring cerebral metabolic changes in various types of brain injury. Clinically, CMD data have shown the dramatic changes in cerebral metabolism after SAH, including glucose depletion, enhanced glycolysis, and suppressed oxidative phosphorylation. Experimental studies using CMD have demonstrated a similar pattern of cerebral metabolic dysfunction after SAH. The combination of CMD and other monitoring tools has also shown value in further dissecting and distinguishing alterations in different metabolic pathways after brain injury. Despite the lack of a standard procedure as well as the presence of limitations regarding CMD application and data interpretation for both clinical and experimental studies, emerging investigations have suggested that CMD is an effective way to monitor the changes of cerebral metabolic dysfunction after SAH in real-time, and alternatively, the combination of CMD and other monitoring tools might be able to further understand the relationship between cerebral metabolic dysfunction and brain injury after SAH, determine the severity of brain injury and predict the pathological progression and outcomes after SAH. More translational preclinical investigations and clinical validation may help to optimize CMD as a powerful tool in critical care and personalized medicine for patients with SAH.
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Affiliation(s)
| | - Yinghua Jiang
- Correspondence: (Y.J.); (X.W.); Tel.: +504-988-9117 (Y.J.); +504-988-2646 (X.W.)
| | | | | | | | | | | | - Xiaoying Wang
- Correspondence: (Y.J.); (X.W.); Tel.: +504-988-9117 (Y.J.); +504-988-2646 (X.W.)
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39
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Jaquins-Gerstl A, Michael AC. Dexamethasone-Enhanced Microdialysis and Penetration Injury. Front Bioeng Biotechnol 2020; 8:602266. [PMID: 33364231 PMCID: PMC7752925 DOI: 10.3389/fbioe.2020.602266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/11/2020] [Indexed: 01/25/2023] Open
Abstract
Microdialysis probes, electrochemical microsensors, and neural prosthetics are often used for in vivo monitoring, but these are invasive devices that are implanted directly into brain tissue. Although the selectivity, sensitivity, and temporal resolution of these devices have been characterized in detail, less attention has been paid to the impact of the trauma they inflict on the tissue or the effect of any such trauma on the outcome of the measurements they are used to perform. Factors affecting brain tissue reaction to the implanted devices include: the mechanical trauma during insertion, the foreign body response, implantation method, and physical properties of the device (size, shape, and surface characteristics. Modulation of the immune response is an important step toward making these devices with reliable long-term performance. Local release of anti-inflammatory agents such as dexamethasone (DEX) are often used to mitigate the foreign body response. In this article microdialysis is used to locally deliver DEX to the surrounding brain tissue. This work discusses the immune response resulting from microdialysis probe implantation. We briefly review the principles of microdialysis and the applications of DEX with microdialysis in (i) neuronal devices, (ii) dopamine and fast scan cyclic voltammetry, (iii) the attenuation of microglial cells, (iv) macrophage polarization states, and (v) spreading depolarizations. The difficulties and complexities in these applications are herein discussed.
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40
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Balbi M, Vega MJ, Lourbopoulos A, Terpolilli NA, Plesnila N. Long-term impairment of neurovascular coupling following experimental subarachnoid hemorrhage. J Cereb Blood Flow Metab 2020; 40:1193-1202. [PMID: 31296132 PMCID: PMC7238370 DOI: 10.1177/0271678x19863021] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
CO2-reactivity and neurovascular coupling are sequentially lost within the first 24 h after subarachnoid hemorrhage (SAH). Whether and when these impairments recover is not known. Therefore, we investigated the reactivity of pial and intraparenchymal vessels by in vivo two-photon microscopy one month after experimental SAH. C57BL/6 mice were subjected to either sham surgery or SAH by filament perforation. One month later, cerebral blood flow following CO2-challenge and forepaw stimulation was assessed by laser Doppler fluxmetry. Diameters of pial and intraparenchymal arterioles were quantified by in vivo two-photon microscopy. One month after SAH, pial and parenchymal vessels dilated in response to CO2. Neurovascular coupling was almost completely absent after SAH: vessel diameter did not change upon forepaw stimulation compared to a 20% increase in sham-operated mice. The current results demonstrate that neurovascular function differentially recovers after SAH: while CO2-reactivity normalizes within one month after SAH, neurovascular coupling is still absent. These findings show an acute and persistent loss of neurovascular coupling after SAH that may serve as a link between early brain injury and delayed cerebral ischemia, two distinct pathophysiological phenomena after SAH that were so far believed not to be directly related.
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Affiliation(s)
- Matilde Balbi
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany.,Graduate School of Systemic Neurosciences (GSN), Munich University Hospital, Munich, Germany.,Munich Cluster of Systems Neurology (Synergy), Munich, Germany
| | - Max Jativa Vega
- Graduate School of Systemic Neurosciences (GSN), Munich University Hospital, Munich, Germany
| | - Athanasios Lourbopoulos
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany.,Munich Cluster of Systems Neurology (Synergy), Munich, Germany
| | - Nicole A Terpolilli
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany.,Munich Cluster of Systems Neurology (Synergy), Munich, Germany.,Department of Neurosurgery, Munich University Hospital, Munich, Germany
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany.,Graduate School of Systemic Neurosciences (GSN), Munich University Hospital, Munich, Germany.,Munich Cluster of Systems Neurology (Synergy), Munich, Germany
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41
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Ashayeri Ahmadabad R, Khaleghi Ghadiri M, Gorji A. The role of Toll-like receptor signaling pathways in cerebrovascular disorders: the impact of spreading depolarization. J Neuroinflammation 2020; 17:108. [PMID: 32264928 PMCID: PMC7140571 DOI: 10.1186/s12974-020-01785-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/24/2020] [Indexed: 02/08/2023] Open
Abstract
Cerebral vascular diseases (CVDs) are a group of disorders that affect the blood supply to the brain and lead to the reduction of oxygen and glucose supply to the neurons and the supporting cells. Spreading depolarization (SD), a propagating wave of neuroglial depolarization, occurs in different CVDs. A growing amount of evidence suggests that the inflammatory responses following hypoxic-ischemic insults and after SD plays a double-edged role in brain tissue injury and clinical outcome; a beneficial effect in the acute phase and a destructive role in the late phase. Toll-like receptors (TLRs) play a crucial role in the activation of inflammatory cascades and subsequent neuroprotective or harmful effects after CVDs and SD. Here, we review current data regarding the pathophysiological role of TLR signaling pathways in different CVDs and discuss the role of SD in the potentiation of the inflammatory cascade in CVDs through the modulation of TLRs.
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Affiliation(s)
- Rezan Ashayeri Ahmadabad
- Shefa Neuroscience Research Center, Khatam Alanbia Hospital, Tehran, Iran
- Department of Neurosurgery, Westfälische Wilhelms-Universität Münster, Münster, Germany
| | | | - Ali Gorji
- Shefa Neuroscience Research Center, Khatam Alanbia Hospital, Tehran, Iran.
- Department of Neurosurgery, Westfälische Wilhelms-Universität Münster, Münster, Germany.
- Epilepsy Research Center, Westfälische Wilhelms-Universität Münster, Münster, Germany.
- Department of Neurology, Westfälische Wilhelms-Universität Münster, Münster, Germany.
- Neuroscience research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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42
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Abstract
Cortical spreading depolarizations (SD) are strongly associated with worse tissue injury and clinical outcomes in the setting of aneurysmal subarachnoid hemorrhage (SAH). Animal studies have suggested a causal relationship, and new therapies to target SDs are starting to be tested in clinical studies. A recent set of single-center randomized trials assessed the effect of the phosphodiesterase inhibitor cilostazol in patients with SAH. Cilostazol led to improved functional outcomes and SD-related metrics in treated patients through a putative mechanism of improved cerebral blood flow. Another promising therapeutic approach includes attempts to block SDs with, for example, the NMDA receptor antagonist ketamine. SDs have emerged not only as a therapeutic target but also as a potentially useful biomarker for brain injury following SAH. Additional clinical and preclinical experimental work is greatly needed to assess the generalizability of existing therapeutic trials and to better delineate the relationship between SDs, SAH, and functional outcome.
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Affiliation(s)
- Kazutaka Sugimoto
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, 6403, Charlestown, MA, 02129, USA
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan
| | - David Y Chung
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, 6403, Charlestown, MA, 02129, USA.
- Division of Neurocritical Care, Department of Neurology, Boston Medical Center, Boston, MA, USA.
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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43
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van der Kleij LA, De Vis JB, Restivo MC, Turtzo LC, Hendrikse J, Latour LL. Subarachnoid Hemorrhage and Cerebral Perfusion Are Associated with Brain Volume Decrease in a Cohort of Predominantly Mild Traumatic Brain Injury Patients. J Neurotrauma 2020; 37:600-607. [PMID: 31642407 PMCID: PMC7045349 DOI: 10.1089/neu.2019.6514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Biomarkers are needed to identify traumatic brain injury (TBI) patients at risk for accelerated brain volume loss and its associated functional impairment. Subarachnoid hemorrhage (SAH) has been shown to affect cerebral volume and perfusion, possibly by induction of inflammation and vasospasm. The purpose of this study was to assess the impact of SAH due to trauma on cerebral perfusion and brain volume. For this, magnetic resonance imaging (MRI) was performed <48 h and at 90 days after TBI. The <48-h scan was used to assess SAH presence and perfusion. Brain volume changes were assessed quantitatively over time. Differences in brain volume change and perfusion were compared between SAH and non-SAH patients. A linear regression analysis with clinical and imaging variables was used to identify predictors of brain volume change. All patients had a relatively good status on admission, and 83% presented with the maximum Glasgow Coma Scale (GCS) score. Brain volume decrease was greater in the 11 SAH patients (-3.2%, interquartile range [IQR] -4.8 to -1.3%) compared with the 46 non-SAH patients (-0.4%, IQR -1.8 to 0.9%; p < 0.001). Brain perfusion was not affected by SAH, but it was correlated with brain volume change (ρ = 0.39; p < 0.01). Forty-three percent of brain volume change was explained by SAH (β -0.40, p = 0.001), loss of consciousness (β -0.24, p = 0.035), and peak perfusion curve signal intensity height (0.27, p = 0.012). SAH and lower perfusion in the acute phase may identity TBI patients at increased risk for accelerated brain volume loss, in addition to loss of consciousness occurrence. Future studies should determine whether the findings apply to TBI patients with worse clinical status on admission. SAH predicts brain volume decrease independent of brain perfusion. This indicates the adverse effects of SAH extend beyond vasoconstriction, and that hypoperfusion also occurs separately from SAH.
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Affiliation(s)
- Lisa A. van der Kleij
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Jill B. De Vis
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Matthew C. Restivo
- Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - L. Christine Turtzo
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
- Acute Studies Core, Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lawrence L. Latour
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
- Acute Studies Core, Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland
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44
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Capo-Rangel G, Gerardo-Giorda L, Somersalo E, Calvetti D. Metabolism plays a central role in the cortical spreading depression: Evidence from a mathematical model. J Theor Biol 2020; 486:110093. [PMID: 31778711 DOI: 10.1016/j.jtbi.2019.110093] [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: 08/01/2019] [Revised: 10/28/2019] [Accepted: 11/23/2019] [Indexed: 11/24/2022]
Abstract
The slow propagating waves of strong depolarization of neural cells characterizing cortical spreading depression, or depolarization, (SD) are known to break cerebral homeostasis and induce significant hemodynamic and electro-metabolic alterations. Mathematical models of cortical spreading depression found in the literature tend to focus on the changes occurring at the electrophysiological level rather than on the ensuing metabolic changes. In this paper, we propose a novel mathematical model which is able to simulate the coupled electrophysiology and metabolism dynamics of SD events, including the swelling of neurons and astrocytes and the concomitant shrinkage of extracellular space. The simulations show that the metabolic coupling leads to spontaneous repetitions of the SD events, which the electrophysiological model alone is not capable to produce. The model predictions, which corroborate experimental findings from the literature, show a strong disruption in metabolism accompanying each wave of spreading depression in the form of a sharp decrease of glucose and oxygen concentrations, with a simultaneous increase in lactate concentration which, in turn, delays the clearing of excess potassium in extracellular space. Our model suggests that the depletion of glucose and oxygen concentration is more pronounced in astrocyte than neuron, in line with the partitioning of the energetic cost of potassium clearing. The model suggests that the repeated SD events are electro-metabolic oscillations that cannot be explained by the electrophysiology alone. The model highlights the crucial role of astrocytes in cleaning the excess potassium flooding extracellular space during a spreading depression event: further, if the ratio of glial/neuron density increases, the frequency of cortical SD events decreases, and the peak potassium concentration in extracellular space is lower than with equal volume fractions.
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Affiliation(s)
| | | | - E Somersalo
- Basque Center for Applied Mathematics, Spain
| | - D Calvetti
- Department of Mathematics, Applied Mathematics and Statistics, Case Western Reserve University, Ohio.
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45
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Major S, Huo S, Lemale CL, Siebert E, Milakara D, Woitzik J, Gertz K, Dreier JP. Direct electrophysiological evidence that spreading depolarization-induced spreading depression is the pathophysiological correlate of the migraine aura and a review of the spreading depolarization continuum of acute neuronal mass injury. GeroScience 2020; 42:57-80. [PMID: 31820363 PMCID: PMC7031471 DOI: 10.1007/s11357-019-00142-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/20/2019] [Indexed: 02/07/2023] Open
Abstract
Spreading depolarization is observed as a large negative shift of the direct current potential, swelling of neuronal somas, and dendritic beading in the brain's gray matter and represents a state of a potentially reversible mass injury. Its hallmark is the abrupt, massive ion translocation between intraneuronal and extracellular compartment that causes water uptake (= cytotoxic edema) and massive glutamate release. Dependent on the tissue's energy status, spreading depolarization can co-occur with different depression or silencing patterns of spontaneous activity. In adequately supplied tissue, spreading depolarization induces spreading depression of activity. In severely ischemic tissue, nonspreading depression of activity precedes spreading depolarization. The depression pattern determines the neurological deficit which is either spreading such as in migraine aura or migraine stroke or nonspreading such as in transient ischemic attack or typical stroke. Although a clinical distinction between spreading and nonspreading focal neurological deficits is useful because they are associated with different probabilities of permanent damage, it is important to note that spreading depolarization, the neuronal injury potential, occurs in all of these conditions. Here, we first review the scientific basis of the continuum of spreading depolarizations. Second, we highlight the transition zone of the continuum from reversibility to irreversibility using clinical cases of aneurysmal subarachnoid hemorrhage and cerebral amyloid angiopathy. These illustrate how modern neuroimaging and neuromonitoring technologies increasingly bridge the gap between basic sciences and clinic. For example, we provide direct electrophysiological evidence for the first time that spreading depolarization-induced spreading depression is the pathophysiological correlate of the migraine aura.
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Affiliation(s)
- Sebastian Major
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Shufan Huo
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Denny Milakara
- Solution Centre for Image Guided Local Therapies (STIMULATE), Otto-von-Guericke-University, Magdeburg, Germany
| | - Johannes Woitzik
- Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Karen Gertz
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jens P Dreier
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.
- Einstein Center for Neurosciences Berlin, Berlin, Germany.
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46
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Bosche B, Mergenthaler P, Doeppner TR, Hescheler J, Molcanyi M. Complex Clearance Mechanisms After Intraventricular Hemorrhage and rt-PA Treatment-a Review on Clinical Trials. Transl Stroke Res 2019; 11:337-344. [PMID: 31522408 DOI: 10.1007/s12975-019-00735-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/29/2019] [Accepted: 09/04/2019] [Indexed: 12/15/2022]
Abstract
Intracerebral hemorrhage in combination with intraventricular hemorrhage (IVH) is a severe type of stroke frequently leading to prolonged clinical care, continuous disability, shunt dependency, and high mortality. The molecular mechanisms induced by IVH are complex and not fully understood. Moreover, the treatment options for IVH are limited. Intraventricular recombinant tissue plasminogen activator (rt-PA) dissolves the blood clot in the ventricular system; however, whether the clinical outcome is thereby positively affected is still being debated. The mechanistic cascade induced by intraventricular rt-PA therapy may cure and harm in parallel. Despite the fact that intraventricular blood clots are thereby dissolved, blood derivatives enter the parenchyma and may still adversely affect functional structures of the brain: Smaller blood clots may obstruct the perivascular (Virchow-Robin) space and thereby the glymphatic system with detrimental consequences for cerebrospinal fluid (CSF)/interstitial fluid (ISF) flow. These clots, blood cells but also blood derivatives in the perivascular space, destabilize the blood-brain barrier from the brain parenchyma side, thereby also functionally weakening the neurovascular unit. This may lead to further accommodation of serum proteins in the ISF and particularly in the perivascular space further contributing to the adverse effects on the neuronal microenvironment. Finally, the arterial (Pacchionian) granulations have to cope with ISF containing this "blood, cell, and protein cocktail," resulting in obstruction and insufficient function of the arterial granulations, followed by a malresorptive hydrocephalus. Particularly in light of currently improved knowledge on the physiologic and pathophysiologic clearance of cerebrospinal fluid and interstitial fluid, a critical discussion and reevaluation of our current therapeutic strategies to treat intraventricular hemorrhages are needed to successfully treat patients suffering from this severe type of stroke. In this review, we therefore summarize and discuss recent clinical trials and future directions for the field of IVH with respect to the currently increased understanding of the glymphatic system and the neurovascular unit pathophysiology.
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Affiliation(s)
- Bert Bosche
- Department of Neurocritical Care, Neurological and Neurosurgical First Stage Rehabilitation and Weaning, MediClin Klinik Reichshof, Berglandstr.1, 51580, Reichshof-Eckenhagen, Germany. .,Faculty of Medicine, Department of Neurology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany. .,Institute of Neurophysiology, Medical Faculty, University of Cologne, Cologne, Germany. .,Department of Surgery, Division of Neurosurgery, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada.
| | - Philipp Mergenthaler
- Departments of Experimental Neurology and Neurology, Center for Stroke Research Berlin, NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Thorsten R Doeppner
- Department of Neurology, University of Göttingen Medical School, Göttingen, Germany.
| | - Jürgen Hescheler
- Institute of Neurophysiology, Medical Faculty, University of Cologne, Cologne, Germany
| | - Marek Molcanyi
- Institute of Neurophysiology, Medical Faculty, University of Cologne, Cologne, Germany.,Department of Neurosurgery, Research Unit for Experimental Neurotraumatology, Medical University Graz, Graz, Austria
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47
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Robbins EM, Jaquins-Gerstl A, Fine DF, Leong CL, Dixon CE, Wagner AK, Boutelle MG, Michael AC. Extended (10-Day) Real-Time Monitoring by Dexamethasone-Enhanced Microdialysis in the Injured Rat Cortex. ACS Chem Neurosci 2019; 10:3521-3531. [PMID: 31246409 DOI: 10.1021/acschemneuro.9b00145] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Intracerebral microdialysis has proven useful for chemical monitoring in patients following traumatic brain injury. Recent studies in animals, however, have documented that insertion of microdialysis probes into brain tissues initiates a foreign-body response. Within a few days after probe insertion, the foreign body response impedes the use of microdialysis to monitor the K+ and glucose transients associated with spreading depolarization, a potential mechanism for secondary brain injury. Herein, we show that perfusing microdialysis probes with dexamethasone, a potent anti-inflammatory glucocorticoid, suppresses the foreign body response and facilitates the monitoring of spontaneous spreading depolarizations for at least 10 days following controlled cortical injury in the rat. In addition to spreading depolarizations, results of this study suggest that a progressive, apparently permanent, decline in pericontusional interstitial glucose may be an additional sequela of brain injury. This study establishes extended dexamethasone-enhanced microdialysis in the injured rodent cortex as a new paradigm for investigating trauma-induced metabolic crisis.
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Affiliation(s)
- Elaine M. Robbins
- Department of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - Andrea Jaquins-Gerstl
- Department of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - David F. Fine
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, United States
| | - Chi Leng Leong
- Department of Bioengineering, Imperial College London, London SW7 2AZ, United Kingdom
| | - C. Edward Dixon
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, United States
| | - Amy K. Wagner
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, United States
| | - Martyn G. Boutelle
- Department of Bioengineering, Imperial College London, London SW7 2AZ, United Kingdom
| | - Adrian C. Michael
- Department of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
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48
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Hartings JA, York J, Carroll CP, Hinzman JM, Mahoney E, Krueger B, Winkler MKL, Major S, Horst V, Jahnke P, Woitzik J, Kola V, Du Y, Hagen M, Jiang J, Dreier JP. Subarachnoid blood acutely induces spreading depolarizations and early cortical infarction. Brain 2019; 140:2673-2690. [PMID: 28969382 DOI: 10.1093/brain/awx214] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 07/10/2017] [Indexed: 01/05/2023] Open
Abstract
See Ghoshal and Claassen (doi:10.1093/brain/awx226) for a scientific commentary on this article.
Early cortical infarcts are common in poor-grade patients after aneurysmal subarachnoid haemorrhage. There are no animal models of these lesions and mechanisms are unknown, although mass cortical spreading depolarizations are hypothesized as a requisite mechanism and clinical marker of infarct development. Here we studied acute sequelae of subarachnoid haemorrhage in the gyrencephalic brain of propofol-anaesthetized juvenile swine using subdural electrode strips (electrocorticography) and intraparenchymal neuromonitoring probes. Subarachnoid infusion of 1–2 ml of fresh blood at 200 µl/min over cortical sulci caused clusters of spreading depolarizations (count range: 12–34) in 7/17 animals in the ipsilateral but not contralateral hemisphere in 6 h of monitoring, without meaningful changes in other variables. Spreading depolarization clusters were associated with formation of sulcal clots (P < 0.01), a high likelihood of adjacent cortical infarcts (5/7 versus 2/10, P < 0.06), and upregulation of cyclooxygenase-2 in ipsilateral cortex remote from clots/infarcts. In a second cohort, infusion of 1 ml of clotted blood into a sulcus caused spreading depolarizations in 5/6 animals (count range: 4–20 in 6 h) and persistent thick clots with patchy or extensive infarction of circumscribed cortex in all animals. Infarcts were significantly larger after blood clot infusion compared to mass effect controls using fibrin clots of equal volume. Haematoxylin and eosin staining of infarcts showed well demarcated zones of oedema and hypoxic-ischaemic neuronal injury, consistent with acute infarction. The association of spreading depolarizations with early brain injury was then investigated in 23 patients [14 female; age (median, quartiles): 57 years (47, 63)] after repair of ruptured anterior communicating artery aneurysms by clip ligation (n = 14) or coiling (n = 9). Frontal electrocorticography [duration: 54 h (34, 66)] from subdural electrode strips was analysed over Days 0–3 after initial haemorrhage and magnetic resonance imaging studies were performed at ∼ 24–48 h after aneurysm treatment. Patients with frontal infarcts only and those with frontal infarcts and/or intracerebral haemorrhage were both significantly more likely to have spreading depolarizations (6/7 and 10/12, respectively) than those without frontal brain lesions (1/11, P’s < 0.05). These results suggest that subarachnoid clots in sulci/fissures are sufficient to induce spreading depolarizations and acute infarction in adjacent cortex. We hypothesize that the cellular toxicity and vasoconstrictive effects of depolarizations act in synergy with direct ischaemic effects of haemorrhage as mechanisms of infarct development. Results further validate spreading depolarizations as a clinical marker of early brain injury and establish a clinically relevant model to investigate causal pathologic sequences and potential therapeutic interventions.
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Affiliation(s)
- Jed A Hartings
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,UC Gardner Neuroscience Institute and Mayfield Clinic, Cincinnati, OH, USA
| | - Jonathan York
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Christopher P Carroll
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jason M Hinzman
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Eric Mahoney
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bryan Krueger
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Maren K L Winkler
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Germany.,Department of Neurology, Charité University Medicine Berlin, Germany.,Department of Experimental Neurology, Charité University Medicine Berlin, Germany
| | - Viktor Horst
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Germany
| | - Paul Jahnke
- Department of Radiology Charité University Medicine Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Charité University Medicine Berlin, Germany
| | - Vasilis Kola
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Germany
| | - Yifeng Du
- Division of Pharmaceutical Sciences, University of Cincinnati College of Pharmacy, Cincinnati, OH, USA
| | - Matthew Hagen
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jianxiong Jiang
- Division of Pharmaceutical Sciences, University of Cincinnati College of Pharmacy, Cincinnati, OH, USA
| | - Jens P Dreier
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Germany.,Department of Neurology, Charité University Medicine Berlin, Germany.,Department of Experimental Neurology, Charité University Medicine Berlin, Germany
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49
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Carlson AP, Abbas M, Alunday RL, Qeadan F, Shuttleworth CW. Spreading depolarization in acute brain injury inhibited by ketamine: a prospective, randomized, multiple crossover trial. J Neurosurg 2019; 130:1513-1519. [PMID: 29799344 PMCID: PMC6279620 DOI: 10.3171/2017.12.jns171665] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 12/14/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Retrospective clinical data and case studies support a therapeutic effect of ketamine in suppression of spreading depolarization (SD) following brain injury. Preclinical data strongly support efficacy in terms of frequency of SD as well as recovery from electrocorticography (ECoG) depression. The authors present the results of the first prospective controlled clinical trial testing the role of ketamine used for clinical sedation on occurrence of SD. METHODS Ten patients with severe traumatic brain injury (TBI) or aneurysmal subarachnoid hemorrhage (SAH) were recruited for this pilot trial. A standard ECoG strip was placed at the time of craniotomy, and the patients were then placed on an alternating every-6-hour schedule of ketamine or other sedation agent. The order of treatment was randomized. The ketamine dose was adjusted to clinical effect or maintained at a subanesthetic basal dose (0.1 mg/kg/hr) if no sedation was required. SD was scored using standard criteria, blinded to ketamine dosing. Occurrence of SD was compared with the hourly dose of ketamine to determine the effect of ketamine on SD occurrence. RESULTS Successful ECoG recordings were obtained in all 10 patients: 8 with SAH and 2 with TBI. There were a total of 1642 hours of observations with adequate ECoG: 833 hours off ketamine and 809 hours on ketamine. Analysis revealed a strong dose-dependent effect such that hours off ketamine or on doses of less than 1.15 mg/kg/hr were associated with an increased risk of SD compared with hours on doses of 1.15 mg/kg/hr or more (OR 13.838, 95% CI 1.99-1000). This odds ratio decreased with lower doses of 1.0 mg/kg/hr (OR 4.924, 95% CI 1.337-43.516), 0.85 mg/kg/hr (OR 3.323, 95% CI 1.139-16.074), and 0.70 mg/kg/hr (OR 2.725, 95% CI 1.068-9.898) to a threshold of no effect at 0.55 mg/kg/hr (OR 1.043, 95% CI 0.565-2.135). When all ketamine data were pooled (i.e., on ketamine at any dose vs off ketamine), a nonsignificant overall trend toward less SD during hours on ketamine (χ2 = 3.86, p = 0.42) was observed. CONCLUSIONS Ketamine effectively inhibits SD over a wide range of doses commonly used for sedation, even in nonintubated patients. These data also provide the first prospective evidence that the occurrence of SD can be influenced by clinical intervention and does not simply represent an unavoidable epiphenomenon after injury. These data provide the basis for future studies assessing clinical improvement with SD-directed therapy.Clinical trial registration no.: NCT02501941 (clinicaltrials.gov).
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Affiliation(s)
- Andrew P. Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Mohammad Abbas
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Robert L. Alunday
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Fares Qeadan
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - C. William Shuttleworth
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, New Mexico
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50
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Dreier JP, Major S, Lemale CL, Kola V, Reiffurth C, Schoknecht K, Hecht N, Hartings JA, Woitzik J. Correlates of Spreading Depolarization, Spreading Depression, and Negative Ultraslow Potential in Epidural Versus Subdural Electrocorticography. Front Neurosci 2019; 13:373. [PMID: 31068779 PMCID: PMC6491820 DOI: 10.3389/fnins.2019.00373] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 04/01/2019] [Indexed: 11/13/2022] Open
Abstract
Spreading depolarizations (SDs) are characterized by near-complete breakdown of the transmembrane ion gradients, neuronal oedema and activity loss (=depression). The SD extreme in ischemic tissue, termed ‘terminal SD,’ shows prolonged depolarization, in addition to a slow baseline variation called ‘negative ultraslow potential’ (NUP). The NUP is the largest bioelectrical signal ever recorded from the human brain and is thought to reflect the progressive recruitment of neurons into death in the wake of SD. However, it is unclear whether the NUP is a field potential or results from contaminating sensitivities of platinum electrodes. In contrast to Ag/AgCl-based electrodes in animals, platinum/iridium electrodes are the gold standard for intracranial direct current (DC) recordings in humans. Here, we investigated the full continuum including short-lasting SDs under normoxia, long-lasting SDs under systemic hypoxia, and terminal SD under severe global ischemia using platinum/iridium electrodes in rats to better understand their recording characteristics. Sensitivities for detecting SDs or NUPs were 100% for both electrode types. Nonetheless, the platinum/iridium-recorded NUP was 10 times smaller in rats than humans. The SD continuum was then further investigated by comparing subdural platinum/iridium and epidural titanium peg electrodes in patients. In seven patients with either aneurysmal subarachnoid hemorrhage or malignant hemispheric stroke, two epidural peg electrodes were placed 10 mm from a subdural strip. We found that 31/67 SDs (46%) on the subdural strip were also detected epidurally. SDs that had longer negative DC shifts and spread more widely across the subdural strip were more likely to be observed in epidural recordings. One patient displayed an SD-initiated NUP while undergoing brain death despite continued circulatory function. The NUP’s amplitude was -150 mV subdurally and -67 mV epidurally. This suggests that the human NUP is a bioelectrical field potential rather than an artifact of electrode sensitivity to other factors, since the dura separates the epidural from the subdural compartment and the epidural microenvironment was unlikely changed, given that ventilation, arterial pressure and peripheral oxygen saturation remained constant during the NUP. Our data provide further evidence for the clinical value of invasive electrocorticographic monitoring, highlighting important possibilities as well as limitations of less invasive recording techniques.
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Affiliation(s)
- Jens P Dreier
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.,Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Vasilis Kola
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Clemens Reiffurth
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Karl Schoknecht
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Nils Hecht
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jed A Hartings
- UC Gardner Neuroscience Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States.,Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Johannes Woitzik
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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