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Dhapola R, Medhi B, HariKrishnaReddy D. Insight into the pathophysiological advances and molecular mechanisms underlying cerebral stroke: current status. Mol Biol Rep 2024; 51:649. [PMID: 38733445 DOI: 10.1007/s11033-024-09597-0] [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: 01/30/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024]
Abstract
Molecular pathways involved in cerebral stroke are diverse. The major pathophysiological events that are observed in stroke comprises of excitotoxicity, oxidative stress, mitochondrial damage, endoplasmic reticulum stress, cellular acidosis, blood-brain barrier disruption, neuronal swelling and neuronal network mutilation. Various biomolecules are involved in these pathways and several major proteins are upregulated and/or suppressed following stroke. Different types of receptors, ion channels and transporters are activated. Fluctuations in levels of various ions and neurotransmitters have been observed. Cells involved in immune responses and various mediators involved in neuro-inflammation get upregulated progressing the pathogenesis of the disease. Despite of enormity of the problem, there is not a single therapy that can limit infarction and neurological disability due to stroke. This is because of poor understanding of the complex interplay between these pathophysiological processes. This review focuses upon the past to present research on pathophysiological events that are involved in stroke and various factors that are leading to neuronal death following cerebral stroke. This will pave a way to researchers for developing new potent therapeutics that can aid in the treatment of cerebral stroke.
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Affiliation(s)
- Rishika Dhapola
- Advanced Pharmacology and Neuroscience Laboratory, Department of Pharmacology, School of Health Sciences, Central University of Punjab, Ghudda, Bathinda, Punjab, 151401, India
| | - Bikash Medhi
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, Punjab, 160012, India
| | - Dibbanti HariKrishnaReddy
- Advanced Pharmacology and Neuroscience Laboratory, Department of Pharmacology, School of Health Sciences, Central University of Punjab, Ghudda, Bathinda, Punjab, 151401, India.
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2
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Wu Y, Liu X, Huang Y, Zhou T, Zhang F. An open relaxation-diffusion MRI dataset in neurosurgical studies. Sci Data 2024; 11:177. [PMID: 38326377 PMCID: PMC10850093 DOI: 10.1038/s41597-024-03013-9] [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: 10/04/2023] [Accepted: 01/25/2024] [Indexed: 02/09/2024] Open
Abstract
Diffusion MRI (dMRI) is a safe and noninvasive technique that provides insight into the microarchitecture of brain tissue. Relaxation-diffusion MRI (rdMRI) is an extension of traditional dMRI that captures diffusion imaging data at multiple TEs to detect tissue heterogeneity between relaxation and diffusivity. rdMRI has great potential in neurosurgical research including brain tumor grading and treatment response evaluation. However, the lack of available data has limited the exploration of rdMRI in clinical settings. To address this, we are sharing a high-quality rdMRI dataset from 18 neurosurgical patients with different types of lesions, as well as two healthy individuals as controls. The rdMRI data was acquired using 7 TEs, where at each TE multi-shell dMRI with high spatial and angular resolutions is obtained at each TE. Each rdMRI scan underwent thorough artifact and distortion corrections using a specially designed processing pipeline. The dataset's quality was assessed using standard practices, including quality control and assurance. This resource is a valuable addition to neurosurgical studies, and all data are openly accessible.
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Affiliation(s)
- Ye Wu
- School of Computer Science and Technology, Nanjing University of Science and Technology, Nanjing, China
| | - Xiaoming Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China.
| | - Yunzhi Huang
- School of Artificial Intelligence, Nanjing University of Information Science and Technology, Nanjing, China
| | - Tao Zhou
- School of Computer Science and Technology, Nanjing University of Science and Technology, Nanjing, China
| | - Fan Zhang
- School of Information and Communication Engineering, University of Electronic Science and Technology of China, Chengdu, China
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Puthillathu N, Moffett JR, Korotcov A, Bosomtwi A, Vengilote R, Krishnan JKS, Johnson EA, Arun P, Namboodiri AM. Brief isoflurane administration as an adjunct treatment to control organophosphate-induced convulsions and neuropathology. Front Pharmacol 2023; 14:1293280. [PMID: 38230376 PMCID: PMC10790757 DOI: 10.3389/fphar.2023.1293280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/21/2023] [Indexed: 01/18/2024] Open
Abstract
Organophosphate-based chemical agents (OP), including nerve agents and certain pesticides such as paraoxon, are potent acetylcholinesterase inhibitors that cause severe convulsions and seizures, leading to permanent central nervous system (CNS) damage if not treated promptly. The current treatment regimen for OP poisoning is intramuscular injection of atropine sulfate with an oxime such as pralidoxime (2-PAM) to mitigate cholinergic over-activation of the somatic musculature and autonomic nervous system. This treatment does not provide protection against CNS cholinergic overactivation and therefore convulsions require additional medication. Benzodiazepines are the currently accepted treatment for OP-induced convulsions, but the convulsions become refractory to these GABAA agonists and repeated dosing has diminishing effectiveness. As such, adjunct anticonvulsant treatments are needed to provide improved protection against recurrent and prolonged convulsions and the associated excitotoxic CNS damage that results from them. Previously we have shown that brief, 4-min administration of 3%-5% isoflurane in 100% oxygen has profound anticonvulsant and CNS protective effects when administered 30 min after a lethal dose of paraoxon. In this report we provide an extended time course of the effectiveness of 5% isoflurane delivered for 5 min, ranging from 60 to 180 min after a lethal dose of paraoxon in rats. We observed substantial effectiveness in preventing neuronal loss as shown by Fluoro-Jade B staining when isoflurane was administered 1 h after paraoxon, with diminishing effectiveness at 90, 120 and 180 min. In vivo magnetic resonance imaging (MRI) derived T2 and mean diffusivity (MD) values showed that 5-min isoflurane administration at a concentration of 5% prevents brain edema and tissue damage when administered 1 h after a lethal dose of paraoxon. We also observed reduced astrogliosis as shown by GFAP immunohistochemistry. Studies with continuous EEG monitoring are ongoing to demonstrate effectiveness in animal models of soman poisoning.
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Affiliation(s)
- Narayanan Puthillathu
- Department of Anatomy, Physiology, and Genetics, Neuroscience Program and Molecular and Cell Biology Program, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - John R. Moffett
- Department of Anatomy, Physiology, and Genetics, Neuroscience Program and Molecular and Cell Biology Program, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Alexandru Korotcov
- Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- The Henry M. Jackson Foundation for the Advancement of Military Medicine (HJF), Bethesda, MD, United States
| | - Asamoah Bosomtwi
- The Henry M. Jackson Foundation for the Advancement of Military Medicine (HJF), Bethesda, MD, United States
| | - Ranjini Vengilote
- Department of Anatomy, Physiology, and Genetics, Neuroscience Program and Molecular and Cell Biology Program, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Jishnu K. S. Krishnan
- Department of Anatomy, Physiology, and Genetics, Neuroscience Program and Molecular and Cell Biology Program, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Erik A. Johnson
- Department of Neuroscience, United States Army Medical Research Institute of Chemical Defense, Gunpowder, MD, United States
| | - Peethambaran Arun
- Department of Anatomy, Physiology, and Genetics, Neuroscience Program and Molecular and Cell Biology Program, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Aryan M. Namboodiri
- Department of Anatomy, Physiology, and Genetics, Neuroscience Program and Molecular and Cell Biology Program, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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Kung Y, Wu CH, Lin MT, Liao WH, Chen WS, Hsiao MY. Blood-cerebrospinal fluid barrier opening by modified single pulse transcranial focused shockwave. Drug Deliv 2023; 30:97-107. [PMID: 36533878 PMCID: PMC9769131 DOI: 10.1080/10717544.2022.2157068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Transcranial focused shockwave (FSW) is a novel noninvasive brain stimulation that can open blood-brain barriers (BBB) and blood-cerebrospinal fluid barriers (BCSFB) with a single low-energy (energy flux density 0.03 mJ/mm2) pulse and low-dose microbubbles (2 × 106/kg). Similar to focused ultrasound, FSW deliver highly precise stimulation of discrete brain regions with adjustable focal lengths that essentially covers the whole brain. By opening the BCSFB, it allows for rapid widespread drug delivery to the whole brain by cerebrospinal fluid (CSF) circulation. Although no definite adverse effect or permeant injury was noted in our previous study, microscopic hemorrhage was infrequently observed. Safety concerns remain the major obstacle to further application of FSW in brain. To enhance its applicability, a modified single pulse FSW technique was established that present 100% opening rate but much less risk of adverse effect than previous methods. By moving the targeting area 2.5 mm more superficially on the left lateral ventricle as compared with the previous methods, the microscopic hemorrhage rate was reduced to zero. We systemically examine the safety profiles of the modified FSW-BCSFB opening regarding abnormal behavior and brain injury or hemorrhage 72 hr after 0, 1, and 10 pulses of FSW-treatment. Animal behavior, physiological monitor, and brain MRI were examined and recorded. Brain section histology was examined for hemorrhage, apoptosis, inflammation, oxidative stress related immunohistochemistry and biomarkers. The single pulse FSW group demonstrated no mortality or gross/microscopic hemorrhage (N = 30), and no observable changes in all examined outcomes, while 10 pulses of FSW was found to be associated with microscopic and temporary RBC extravasation (N = 6/30), and abnormal immunohistochemistry biomarkers which showed a trend of recovery at 72 hrs. The results suggest that single pulse low-energy FSW-BCSFB opening is effective, safe and poses minimal risk of injury to brain tissue (Sprague Dawley, SD rats).
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Affiliation(s)
- Yi Kung
- Department of Biomechatronic Engineering, National Chiayi University, Chiayi City, Taiwan
| | - Chueh-Hung Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital & National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Meng-Ting Lin
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital & National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Wei-Hao Liao
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital & National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Wen-Shiang Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital & National Taiwan University College of Medicine, Taipei City, Taiwan,Institute of Biomedical Engineering and Nanomedicine, National Health Research Institutes, Miaoli, Taiwan
| | - Ming-Yen Hsiao
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital & National Taiwan University College of Medicine, Taipei City, Taiwan,CONTACT Ming-Yen Hsiao
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Seblani M, Decherchi P, Brezun JM. Edema after CNS Trauma: A Focus on Spinal Cord Injury. Int J Mol Sci 2023; 24:ijms24087159. [PMID: 37108324 PMCID: PMC10138956 DOI: 10.3390/ijms24087159] [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: 02/24/2023] [Revised: 04/09/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Edema after spinal cord injury (SCI) is one of the first observations after the primary injury and lasts for few days after trauma. It has serious consequences on the affected tissue and can aggravate the initial devastating condition. To date, the mechanisms of the water content increase after SCI are not fully understood. Edema formation results in a combination of interdependent factors related to mechanical damage after the initial trauma progressing, along with the subacute and acute phases of the secondary lesion. These factors include mechanical disruption and subsequent inflammatory permeabilization of the blood spinal cord barrier, increase in the capillary permeability, deregulation in the hydrostatic pressure, electrolyte-imbalanced membranes and water uptake in the cells. Previous research has attempted to characterize edema formation by focusing mainly on brain swelling. The purpose of this review is to summarize the current understanding of the differences in edema formation in the spinal cord and brain, and to highlight the importance of elucidating the specific mechanisms of edema formation after SCI. Additionally, it outlines findings on the spatiotemporal evolution of edema after spinal cord lesion and provides a general overview of prospective treatment strategies by focusing on insights to prevent edema formation after SCI.
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Affiliation(s)
- Mostafa Seblani
- Aix Marseille Univ, CNRS, ISM, UMR 7287, Institut des Sciences du Mouvement: Etienne-Jules MAREY, Equipe «Plasticité des Systèmes Nerveux et Musculaire» (PSNM), Parc Scientifique et Technologique de Luminy, CC910-163, Avenue de Luminy, F-13288 Marseille, CEDEX 09, France
| | - Patrick Decherchi
- Aix Marseille Univ, CNRS, ISM, UMR 7287, Institut des Sciences du Mouvement: Etienne-Jules MAREY, Equipe «Plasticité des Systèmes Nerveux et Musculaire» (PSNM), Parc Scientifique et Technologique de Luminy, CC910-163, Avenue de Luminy, F-13288 Marseille, CEDEX 09, France
| | - Jean-Michel Brezun
- Aix Marseille Univ, CNRS, ISM, UMR 7287, Institut des Sciences du Mouvement: Etienne-Jules MAREY, Equipe «Plasticité des Systèmes Nerveux et Musculaire» (PSNM), Parc Scientifique et Technologique de Luminy, CC910-163, Avenue de Luminy, F-13288 Marseille, CEDEX 09, France
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Han W, Song Y, Rocha M, Shi Y. Ischemic brain edema: Emerging cellular mechanisms and therapeutic approaches. Neurobiol Dis 2023; 178:106029. [PMID: 36736599 DOI: 10.1016/j.nbd.2023.106029] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/14/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Brain edema is one of the most devastating consequences of ischemic stroke. Malignant cerebral edema is the main reason accounting for the high mortality rate of large hemispheric strokes. Despite decades of tremendous efforts to elucidate mechanisms underlying the formation of ischemic brain edema and search for therapeutic targets, current treatments for ischemic brain edema remain largely symptom-relieving rather than aiming to stop the formation and progression of edema. Recent preclinical research reveals novel cellular mechanisms underlying edema formation after brain ischemia and reperfusion. Advancement in neuroimaging techniques also offers opportunities for early diagnosis and prediction of malignant brain edema in stroke patients to rapidly adopt life-saving surgical interventions. As reperfusion therapies become increasingly used in clinical practice, understanding how therapeutic reperfusion influences the formation of cerebral edema after ischemic stroke is critical for decision-making and post-reperfusion management. In this review, we summarize these research advances in the past decade on the cellular mechanisms, and evaluation, prediction, and intervention of ischemic brain edema in clinical settings, aiming to provide insight into future preclinical and clinical research on the diagnosis and treatment of brain edema after stroke.
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Affiliation(s)
- Wenxuan Han
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America
| | - Yang Song
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America
| | - Marcelo Rocha
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America
| | - Yejie Shi
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America.
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Molecular, Pathological, Clinical, and Therapeutic Aspects of Perihematomal Edema in Different Stages of Intracerebral Hemorrhage. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:3948921. [PMID: 36164392 PMCID: PMC9509250 DOI: 10.1155/2022/3948921] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/17/2022] [Accepted: 09/03/2022] [Indexed: 02/07/2023]
Abstract
Acute intracerebral hemorrhage (ICH) is a devastating type of stroke worldwide. Neuronal destruction involved in the brain damage process caused by ICH includes a primary injury formed by the mass effect of the hematoma and a secondary injury induced by the degradation products of a blood clot. Additionally, factors in the coagulation cascade and complement activation process also contribute to secondary brain injury by promoting the disruption of the blood-brain barrier and neuronal cell degeneration by enhancing the inflammatory response, oxidative stress, etc. Although treatment options for direct damage are limited, various strategies have been proposed to treat secondary injury post-ICH. Perihematomal edema (PHE) is a potential surrogate marker for secondary injury and may contribute to poor outcomes after ICH. Therefore, it is essential to investigate the underlying pathological mechanism, evolution, and potential therapeutic strategies to treat PHE. Here, we review the pathophysiology and imaging characteristics of PHE at different stages after acute ICH. As illustrated in preclinical and clinical studies, we discussed the merits and limitations of varying PHE quantification protocols, including absolute PHE volume, relative PHE volume, and extension distance calculated with images and other techniques. Importantly, this review summarizes the factors that affect PHE by focusing on traditional variables, the cerebral venous drainage system, and the brain lymphatic drainage system. Finally, to facilitate translational research, we analyze why the relationship between PHE and the functional outcome of ICH is currently controversial. We also emphasize promising therapeutic approaches that modulate multiple targets to alleviate PHE and promote neurologic recovery after acute ICH.
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Gu Y, Zhou C, Piao Z, Yuan H, Jiang H, Wei H, Zhou Y, Nan G, Ji X. Cerebral edema after ischemic stroke: Pathophysiology and underlying mechanisms. Front Neurosci 2022; 16:988283. [PMID: 36061592 PMCID: PMC9434007 DOI: 10.3389/fnins.2022.988283] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/01/2022] [Indexed: 11/30/2022] Open
Abstract
Ischemic stroke is associated with increasing morbidity and has become the main cause of death and disability worldwide. Cerebral edema is a serious complication arising from ischemic stroke. It causes an increase in intracranial pressure, rapid deterioration of neurological symptoms, and formation of cerebral hernia, and is an important risk factor for adverse outcomes after stroke. To date, the detailed mechanism of cerebral edema after stroke remains unclear. This limits advances in prevention and treatment strategies as well as drug development. This review discusses the classification and pathological characteristics of cerebral edema, the possible relationship of the development of cerebral edema after ischemic stroke with aquaporin 4, the SUR1-TRPM4 channel, matrix metalloproteinase 9, microRNA, cerebral venous reflux, inflammatory reactions, and cerebral ischemia/reperfusion injury. It also summarizes research on new therapeutic drugs for post-stroke cerebral edema. Thus, this review provides a reference for further studies and for clinical treatment of cerebral edema after ischemic stroke.
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Affiliation(s)
- Yuhang Gu
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Chen Zhou
- Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
| | - Zhe Piao
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Honghua Yuan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Huimin Jiang
- Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
| | - Huimin Wei
- Advanced Innovation Center for Big Data-Based Precision Medicine, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yifan Zhou
- Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
| | - Guangxian Nan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
- *Correspondence: Guangxian Nan,
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Xunming Ji,
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Chanraud S, Badaut J. The noninvasive imaging techniques in understanding brain pathophysiology from preclinical to clinical studies. J Neurosci Res 2022; 100:1125-1127. [PMID: 35266187 DOI: 10.1002/jnr.25043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/22/2022] [Accepted: 03/02/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Sandra Chanraud
- CNRS UMR5287, INCIA, EPHE, University of Bordeaux, Bordeaux, France.,EPHE-PSL University, Paris, France
| | - Jérôme Badaut
- CNRS UMR5536, CRMSB, University of Bordeaux, Bordeaux, France.,Basic Sciences, Loma Linda University School of Medicine, Loma Linda, California, USA
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Zhang X, Huang P, Zhang R. Evaluation and Prediction of Post-stroke Cerebral Edema Based on Neuroimaging. Front Neurol 2022; 12:763018. [PMID: 35087464 PMCID: PMC8786707 DOI: 10.3389/fneur.2021.763018] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Cerebral edema is a common complication of acute ischemic stroke that leads to poorer functional outcomes and substantially increases the mortality rate. Given that its negative effects can be reduced by more intensive monitoring and evidence-based interventions, the early identification of patients with a high risk of severe edema is crucial. Neuroimaging is essential for the assessment and prediction of edema. Simple markers, such as midline shift and hypodensity volume on computed tomography, have been used to evaluate edema in clinical trials; however, advanced techniques can be applied to examine the underlying mechanisms. In this study, we aimed to review current imaging tools in the assessment and prediction of cerebral edema to provide guidance for using these methods in clinical practice.
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Affiliation(s)
- Xiaocheng Zhang
- Department of Radiology, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Peiyu Huang
- Department of Radiology, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Ruiting Zhang
- Department of Radiology, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
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