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Luzzi S, Bektaşoğlu PK, Doğruel Y, Güngor A. Beyond nimodipine: advanced neuroprotection strategies for aneurysmal subarachnoid hemorrhage vasospasm and delayed cerebral ischemia. Neurosurg Rev 2024; 47:305. [PMID: 38967704 PMCID: PMC11226492 DOI: 10.1007/s10143-024-02543-5] [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: 12/11/2023] [Revised: 05/15/2024] [Accepted: 06/24/2024] [Indexed: 07/06/2024]
Abstract
The clinical management of aneurysmal subarachnoid hemorrhage (SAH)-associated vasospasm remains a challenge in neurosurgical practice, with its prevention and treatment having a major impact on neurological outcome. While considered a mainstay, nimodipine is burdened by some non-negligible limitations that make it still a suboptimal candidate of pharmacotherapy for SAH. This narrative review aims to provide an update on the pharmacodynamics, pharmacokinetics, overall evidence, and strength of recommendation of nimodipine alternative drugs for aneurysmal SAH-associated vasospasm and delayed cerebral ischemia. A PRISMA literature search was performed in the PubMed/Medline, Web of Science, ClinicalTrials.gov, and PubChem databases using a combination of the MeSH terms "medical therapy," "management," "cerebral vasospasm," "subarachnoid hemorrhage," and "delayed cerebral ischemia." Collected articles were reviewed for typology and relevance prior to final inclusion. A total of 346 articles were initially collected. The identification, screening, eligibility, and inclusion process resulted in the selection of 59 studies. Nicardipine and cilostazol, which have longer half-lives than nimodipine, had robust evidence of efficacy and safety. Eicosapentaenoic acid, dapsone and clazosentan showed a good balance between effectiveness and favorable pharmacokinetics. Combinations between different drug classes have been studied to a very limited extent. Nicardipine, cilostazol, Rho-kinase inhibitors, and clazosentan proved their better pharmacokinetic profiles compared with nimodipine without prejudice with effective and safe neuroprotective role. However, the number of trials conducted is significantly lower than for nimodipine. Aneurysmal SAH-associated vasospasm remains an area of ongoing preclinical and clinical research where the search for new drugs or associations is critical.
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Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Pınar Kuru Bektaşoğlu
- Department of Neurosurgery, University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, İstanbul, Türkiye
| | - Yücel Doğruel
- Department of Neurosurgery, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Türkiye
| | - Abuzer Güngor
- Faculty of Medicine, Department of Neurosurgery, Istinye University, İstanbul, Türkiye
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2
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Inflammatory Response and Immune Regulation in Brain-Heart Interaction after Stroke. Cardiovasc Ther 2022; 2022:2406122. [PMID: 36474712 PMCID: PMC9683992 DOI: 10.1155/2022/2406122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022] Open
Abstract
Cerebrocardiac syndrome (CCS) is one of the secondary myocardial injuries after stroke. Cerebrocardiac syndrome may result in a poor prognosis with high mortality. Understanding the mechanism of the brain-heart interaction may be crucial for clinical treatment of pathological changes in CCS. Accumulating evidence suggests that the inflammatory response is involved in the brain-heart interaction after stroke. Systemic inflammatory response syndrome (SIRS) evoked by stroke may injure myocardial cells directly, in which the interplay between inflammatory response, oxidative stress, cardiac sympathetic/parasympathetic dysfunction, and splenic immunoregulation may be also the key pathophysiology factor. This review article summarizes the current understanding of inflammatory response and immune regulation in brain-heart interaction after stroke.
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3
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Fung C, Z'Graggen WJ, Jakob SM, Gralla J, Haenggi M, Rothen HU, Mordasini P, Lensch M, Söll N, Terpolilli N, Feiler S, Oertel MF, Raabe A, Plesnila N, Takala J, Beck J. Inhaled Nitric Oxide Treatment for Aneurysmal SAH Patients With Delayed Cerebral Ischemia. Front Neurol 2022; 13:817072. [PMID: 35250821 PMCID: PMC8894247 DOI: 10.3389/fneur.2022.817072] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/24/2022] [Indexed: 11/22/2022] Open
Abstract
Background We demonstrated experimentally that inhaled nitric oxide (iNO) dilates hypoperfused arterioles, increases tissue perfusion, and improves neurological outcome following subarachnoid hemorrhage (SAH) in mice. We performed a prospective pilot study to evaluate iNO in patients with delayed cerebral ischemia after SAH. Methods SAH patients with delayed cerebral ischemia and hypoperfusion despite conservative treatment were included. iNO was administered at a maximum dose of 40 ppm. The response to iNO was considered positive if: cerebral artery diameter increased by 10% in digital subtraction angiography (DSA), or tissue oxygen partial pressure (PtiO2) increased by > 5 mmHg, or transcranial doppler (TCD) values decreased more than 30 cm/sec, or mean transit time (MTT) decreased below 6.5 secs in CT perfusion (CTP). Patient outcome was assessed at 6 months with the modified Rankin Scale (mRS). Results Seven patients were enrolled between February 2013 and September 2016. Median duration of iNO administration was 23 h. The primary endpoint was reached in all patients (five out of 17 DSA examinations, 19 out of 29 PtiO2 time points, nine out of 26 TCD examinations, three out of five CTP examinations). No adverse events necessitating the cessation of iNO were observed. At 6 months, three patients presented with a mRS score of 0, one patient each with an mRS score of 2 and 3, and two patients had died. Conclusion Administration of iNO in SAH patients is safe. These results call for a larger prospective evaluation.
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Affiliation(s)
- Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Werner J Z'Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hans-Ulrich Rothen
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Lensch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Terpolilli
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany
- Department of Neurosurgery, Munich University Hospital, Munich, Germany
| | - Sergej Feiler
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus F Oertel
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
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Zhang T, Zhang L, Nie K, Yang J, Lou H, Wang J, Huang S, Gu C, Yan M, Zhan R, Pan J. Admission Homocysteine as a Potential Predictor for Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Front Surg 2022; 8:813607. [PMID: 35211499 PMCID: PMC8861177 DOI: 10.3389/fsurg.2021.813607] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/30/2021] [Indexed: 11/20/2022] Open
Abstract
Background Delayed cerebral ischemia (DCI) is a primary cause of poor prognosis after aneurysmal subarachnoid hemorrhage (aSAH) and needs close medical attention in clinical practice. Homocysteine (Hcy) has been implicated in cerebrovascular diseases. This study aimed to investigate whether serum Hcy could help to predict the occurrence of DCI in aSAH patients, and compare its diagnostic value with traditional methods. Methods We enrolled 241 aSAH patients in this study. Serum Hcy levels were collected from each patient. The baseline information was reviewed and analyzed. The binary logistic regression was used to explore the relation of serum Hcy levels with occurrence of DCI, and diagnostic performance of serum Hcy for predicting DCI was evaluated using a receiver operating characteristic (ROC) curve. Results The admission serum Hcy levels were found significantly higher in aSAH patients with DCI than those without (P < 0.001). The serum Hcy levels were positively correlated with the World Federation of Neurosurgical Societies (WFNS) scores, modified Fisher scores as well as Hunt and Hess scores at admission. Multivariate analysis revealed that occurrence of DCI was associated with serum Hcy levels (Odds Ratio [OR] = 1.257; 95% Confidence Interval [CI], 1.133–1.396, P < 0.001), modified Fisher scores (OR = 1.871; 95%CI, 1.111–3.150, P = 0.018) and Hunt and Hess scores (OR = 2.581; 95%CI, 1.222–5.452, P = 0.013) after adjusting for the significant variables in univariate analysis. Meanwhile, serum Hcy levels achieved good performance for DCI prediction (area under the curve [AUC], 0.781; 95%CI, 0.723–0.831, P < 0.001). Conclusion Serum homocysteine might have the potential to be a useful and cost-effective biomarker for predicting the occurrence of DCI in aSAH patients.
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Affiliation(s)
- Tiesong Zhang
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Luyuan Zhang
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Kehui Nie
- Neusoft Medical System, Shanghai, China
| | - Jun Yang
- Neusoft Medical System, Shanghai, China
| | - Haiyan Lou
- Department of Radiology, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jincheng Wang
- Department of Radiology, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Sicong Huang
- Department of Hepatobiliary and Pancreatic Surgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Chenjie Gu
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Min Yan
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Renya Zhan
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jianwei Pan
- Department of Neurosurgery, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- *Correspondence: Jianwei Pan
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DCI after Aneurysmal Subarachnoid Hemorrhage Is Related to the Expression of MFG-E8. BIOMED RESEARCH INTERNATIONAL 2022; 2021:6568477. [PMID: 35005020 PMCID: PMC8741362 DOI: 10.1155/2021/6568477] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 12/05/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022]
Abstract
Objective To explore the predictive value of milk fat globule epidermal growth factor 8 (MFG-E8) in the occurrence of delayed cerebral ischemia (DCI) after an aneurysmal subarachnoid hemorrhage (aSAH). Methods We recruited 32 patients with aSAH as the case group and 24 patients with unruptured aneurysms as the control group. Serum MFG-E8 levels were measured by western blot and enzyme-linked immunosorbent assay. We analyzed the relationship between MFG-E8 levels and the risk of DCI. Results The levels of serum MFG-E8 in the case group (mean = 11160.9 pg/mL) were significantly higher than those in the control group (mean = 3081.0 pg/mL, p < 0.001). MFG-E8 levels highly correlated with the World Federation of Neurosurgical Societies (WFNS) and modified Fisher scores (r = -0.691 and - 0.767, respectively, p < 0.001). In addition, MFG-E8 levels in patients with DCI (5882.7 ± 3162.4 pg/mL) were notably higher than those in patients without DCI (15818.2 ± 3771.6 pg/mL, p < 0.001). A receiver operating characteristic curve showed that the occurrence of DCI could effectively be predicted by MFG-E8 (area under the curve = 0.976, 95%CI = 0.850-1.000). Kaplan-Meier survival analysis showed a remarkable decrease in the incidence of DCI in case group individuals with high levels of MFG-E8 (≥11160.9 pg/mL, p < 0.001). Conclusion MFG-E8 may be a useful predictive marker for DCI after an aSAH and could be a promising surrogate end point.
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Pang J, Wu Y, Peng J, Yang P, Chen L, Jiang Y. Association of Pericyte Loss With Microthrombosis After Subarachnoid Hemorrhage in ApoE-Deficient Mice. Front Neurol 2021; 12:726520. [PMID: 34566870 PMCID: PMC8460864 DOI: 10.3389/fneur.2021.726520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background: The occurrence of microthrombosis contributes to not only delayed cerebral ischemia (DCI), but also early brain injury (EBI) after SAH. However, the underlying mechanism is not completely investigated. In the current study, we explored the underlying mechanism of microthrombosis in EBI stage after SAH in ApoE-deficient mice. Methods: Experimental SAH was established by endovascular perforation in apolipoprotein E (ApoE)-deficient mice and wild type (WT) mice. Neurobehavioral, molecular biological and histopathological methods were used to assess the relationship between pericytes loss, neurobehavioral performance, and microthrombosis. Results: We found that the number of microthrombi was significantly increased and peaked 48 h after SAH in WT mice. The increased microthrombosis was related to the decreased effective microcirculation perfusion area and EBI severity. ApoE-deficient mice showed more extensive microthrombosis than that of WT mice 48 h after SAH, which was thereby associated with greater neurobehavioral deficits. Immunohistochemical staining showed that microthrombi were predominantly located in microvessels where pericytes coverage was absent. Mechanistically, ApoE deficiency caused more extensive CypA-NF-κB-MMP-9 pathway activation than that observed in WT mice, which thereby led to more degradation of N-cadherin, and subsequently more pericytes loss. Thereafter, the major adhesion molecule that promoting microthrombi formation in microvessels, P-selectin, was considerably increased in WT mice and increased to a greater extent in the ApoE-deficient mice. Conclusion: Taken together, these data suggest that pericytes loss is associated with EBI after SAH through promoting microthrombosis. Therapies that target ApoE to reduce microthrombosis may be a promising strategy for SAH treatment.
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Affiliation(s)
- Jinwei Pang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yue Wu
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jianhua Peng
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ping Yang
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ligang Chen
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Neurosurgery, Luzhou, China
| | - Yong Jiang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Neurosurgery, Luzhou, China.,Luzhou Key Laboratory of Neurological Diseases and Brain Function, Luzhou, China
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Wang J, Wang Y, Zuo Y, Duan J, Pan A, Li JM, Yan XX, Liu F. MFGE8 mitigates brain injury in a rat model of SAH by maintaining vascular endothelial integrity via TIGβ5/PI3K/CXCL12 signaling. Exp Brain Res 2021; 239:2193-2205. [PMID: 33991211 DOI: 10.1007/s00221-021-06111-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/08/2021] [Indexed: 12/25/2022]
Abstract
Leaked blood components, injured endothelial cells, local inflammatory response and vasospasm may converge to promote microthrombosis following subarachnoid hemorrhage (SAH). Previously, we showed that the milk fat globule-epidermal growth factor 8 (MFGE8) can mitigate SAH-induced microthrombosis. This present study was aimed to explore the molecular pathway participated in MFGE8-dependent protection on vascular endothelium. Immunofluorescence, immunoblot and behavioral tests were used to determine the molecular partner and signaling pathway mediating the effect of MFGE8 in vascular endothelium in rats with experimental SAH and controls, together with the applications of RNA silencing and pharmacological intervention methods. Relative to control, recombinant human MFGE8 (rhMFGE8) treatment increased 5-bromo-2'-deoxyuridine (BrdU) labeled new endothelial cells, reduced TUNUL-positive endothelial cells and elevated the expression of phosphatidylinositol 3-kinase (PI3K) and chemokine (C-X-C motif) ligand 12 (CXCL12), in the brains of SAH rats. These effects were reversed by MFGE8 RNA silencing, as well as following cilengitide and wortmannin intervention. These results suggest that MFGE8 promotes endothelial regeneration and mitigates endothelial DNA damage through the activation of the TIGβ5/PI3K/CXCL12 signaling pathway.
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Affiliation(s)
- Jikai Wang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Sun Yat-sen University, No. 52 Meihuadong Road, Zhuhai, 519000, Guangdong, China
| | - Yiping Wang
- Department of Neurosurgery, The Fifth Affiliated Hospital of Sun Yat-sen University, No. 52 Meihuadong Road, Zhuhai, 519000, Guangdong, China
| | - Yuchun Zuo
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Jiajia Duan
- Department of Anatomy and Neurobiology, Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Aihua Pan
- Department of Anatomy and Neurobiology, Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Jian-Ming Li
- Department of Anatomy, School of Basic Sciences, Changsha Medical University, Changsha, 410219, Hunan, China
| | - Xiao-Xin Yan
- Department of Anatomy and Neurobiology, Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Fei Liu
- Department of Neurosurgery, The Fifth Affiliated Hospital of Sun Yat-sen University, No. 52 Meihuadong Road, Zhuhai, 519000, Guangdong, China.
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Duan HZ, Wu CW, Shen SL, Zhang JY, Li L. Neuroprotective Effects of Early Brain Injury after Subarachnoid Hemorrhage in Rats by Calcium Channel Mediating Hydrogen Sulfide. Cell Mol Neurobiol 2020; 41:1707-1714. [PMID: 32804313 DOI: 10.1007/s10571-020-00940-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 08/08/2020] [Indexed: 11/26/2022]
Abstract
The present study explored the modulating apoptosis effect of hydrogen sulfide (H2S) in subarachnoid hemorrhage (SAH) rats and its exact mechanism. A rat SAH model established by intravascular puncturing was used for the present study. After giving NaHS (donor of H2S), an L-type calcium channel opener (Bay K8644), or a calcium channel agonist (nifedipine), the neurological function of the rats, associated pathological changes, and expression of apoptosis-related proteins (Bcl-2, Bax, and caspase-3) and microtubule-associated protein (MAP-2) were examined. The concentration of H2S and expression of cystathionine beta synthase in the hippocampus changed upon early brain injury (EBI) after SAH. Compared with the SAH group, the neurological function of the rats and microstructure observed by electron microscopy were better in the SAH + NaHS group and SAH + Bay K8644 group. It was observed that apoptosis was more obvious in the SAH group than in the control group and was alleviated in the SAH + NaHS group. Furthermore, the alleviating effect of NaHS was partially weakened by nifedipine, indicating that the effect of anti-apoptosis in H2S might be correlated with the calcium channel. The expression of Bax and caspase-3 was elevated, while the expression of Bcl-2 decreased in the SAH group but improved in the SAH + NaHS and SAH + Bay K8644 group. Compared with the SAH + NaHS group, the expression of pro-apoptotic proteins was higher in the SAH + NaHS + nifedipine group. Therefore, upon EBI following SAH, the H2S system plays an important neurological protective effect by modulating the function of the L-type calcium channel and inhibiting apoptosis.
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Affiliation(s)
- Hong-Zhou Duan
- Department of Neurosurgery, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China.
| | - Chong-Wei Wu
- Department of Neurosurgery, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Sheng-Li Shen
- Department of Neurosurgery, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Jia-Yong Zhang
- Department of Neurosurgery, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Liang Li
- Department of Neurosurgery, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
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Oka F, Chung DY, Suzuki M, Ayata C. Delayed Cerebral Ischemia After Subarachnoid Hemorrhage: Experimental-Clinical Disconnect and the Unmet Need. Neurocrit Care 2020; 32:238-251. [PMID: 30671784 PMCID: PMC7387950 DOI: 10.1007/s12028-018-0650-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) is among the most dreaded complications following aneurysmal subarachnoid hemorrhage (SAH). Despite advances in neurocritical care, DCI remains a significant cause of morbidity and mortality, prolonged intensive care unit and hospital stay, and high healthcare costs. Large artery vasospasm has classically been thought to lead to DCI. However, recent failure of clinical trials targeting vasospasm to improve outcomes has underscored the disconnect between large artery vasospasm and DCI. Therefore, interest has shifted onto other potential mechanisms such as microvascular dysfunction and spreading depolarizations. Animal models can be instrumental in dissecting pathophysiology, but clinical relevance can be difficult to establish. METHODS Here, we performed a systematic review of the literature on animal models of SAH, focusing specifically on DCI and neurological deficits. RESULTS We find that dog, rabbit and rodent models do not consistently lead to DCI, although some degree of delayed vascular dysfunction is common. Primate models reliably recapitulate delayed neurological deficits and ischemic brain injury; however, ethical issues and cost limit their translational utility. CONCLUSIONS To facilitate translation, clinically relevant animal models that reproduce the pathophysiology and cardinal features of DCI after SAH are urgently needed.
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Affiliation(s)
- Fumiaki Oka
- Neurovascular Research Lab, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA.
- Department of Neurosurgery, Yamaguchi University School of Medicine, 1-1-1, Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan.
| | - David Y Chung
- Neurovascular Research Lab, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
- Stroke Service and Neuroscience Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University School of Medicine, 1-1-1, Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Cenk Ayata
- Neurovascular Research Lab, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
- Stroke Service and Neuroscience Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
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10
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van Dijk BJ, Meijers JCM, Kloek AT, Knaup VL, Rinkel GJE, Morgan BP, van der Kamp MJ, Osuka K, Aronica E, Ruigrok YM, van de Beek D, Brouwer M, Pekna M, Hol EM, Vergouwen MDI. Complement C5 Contributes to Brain Injury After Subarachnoid Hemorrhage. Transl Stroke Res 2019; 11:678-688. [PMID: 31811640 PMCID: PMC7340633 DOI: 10.1007/s12975-019-00757-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 10/29/2019] [Accepted: 11/19/2019] [Indexed: 12/13/2022]
Abstract
Previous studies showed that complement activation is associated with poor functional outcome after aneurysmal subarachnoid hemorrhage (SAH). We investigated whether complement activation is underlying brain injury after aneurysmal SAH (n = 7) and if it is an appropriate treatment target. We investigated complement expression in brain tissue of aneurysmal SAH patients (n = 930) and studied the role of common genetic variants in C3 and C5 genes in outcome. We analyzed plasma levels (n = 229) to identify the functionality of a single nucleotide polymorphism (SNP) associated with outcome. The time course of C5a levels was measured in plasma (n = 31) and CSF (n = 10). In an SAH mouse model, we studied the extent of microglia activation and cell death in wild-type mice, mice lacking the C5a receptor, and in mice treated with C5-specific antibodies (n = 15 per group). Brain sections from aneurysmal SAH patients showed increased presence of complement components C1q and C3/C3b/iC3B compared to controls. The complement component 5 (C5) SNP correlated with C5a plasma levels and poor disease outcome. Serial measurements in CSF revealed that C5a was > 1400-fold increased 1 day after aneurysmal SAH and then gradually decreased. C5a in plasma was 2-fold increased at days 3–10 after aneurysmal SAH. In the SAH mouse model, we observed a ≈ 40% reduction in both microglia activation and cell death in mice lacking the C5a receptor, and in mice treated with C5-specific antibodies. These data show that C5 contributes to brain injury after experimental SAH, and support further study of C5-specific antibodies as novel treatment option to reduce brain injury and improve prognosis after aneurysmal SAH.
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Affiliation(s)
- Bart J van Dijk
- UMC Utrecht Brain Center, Department of Translational Neurosciences, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands.,UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands
| | - Joost C M Meijers
- Department of Experimental Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands.,Department of Plasma Proteins, Sanquin Research, Plesmanlaan 125, Amsterdam, The Netherlands
| | - Anne T Kloek
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Veronique L Knaup
- Department of Experimental Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Gabriel J E Rinkel
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands
| | - B Paul Morgan
- Systems Immunity Research Institute, Cardiff University, Heath Park, Cardiff, UK
| | - Marije J van der Kamp
- UMC Utrecht Brain Center, Department of Translational Neurosciences, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands
| | - Koji Osuka
- Department of Neurological Surgery, Aichi Medical University, 1-1 Karimatayazako, Aichi, Japan
| | - Eleonora Aronica
- Department of Neuropathology, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Ynte M Ruigrok
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Matthijs Brouwer
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marcela Pekna
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Medicinaregatan 9A, Gothenburg, Sweden
| | - Elly M Hol
- UMC Utrecht Brain Center, Department of Translational Neurosciences, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands.,Netherlands Institute for Neuroscience, Institute of the Royal Netherlands Academy of Arts and Sciences, Meibergdreef 47, Amsterdam, The Netherlands
| | - Mervyn D I Vergouwen
- UMC Utrecht Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, The Netherlands.
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11
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Geraghty JR, Davis JL, Testai FD. Neuroinflammation and Microvascular Dysfunction After Experimental Subarachnoid Hemorrhage: Emerging Components of Early Brain Injury Related to Outcome. Neurocrit Care 2019; 31:373-389. [PMID: 31012056 PMCID: PMC6759381 DOI: 10.1007/s12028-019-00710-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Aneurysmal subarachnoid hemorrhage has a high mortality rate and, for those who survive this devastating injury, can lead to lifelong impairment. Clinical trials have demonstrated that cerebral vasospasm of larger extraparenchymal vessels is not the sole contributor to neurological outcome. Recently, the focus of intense investigation has turned to mechanisms of early brain injury that may play a larger role in outcome, including neuroinflammation and microvascular dysfunction. Extravasated blood after aneurysm rupture results in a robust inflammatory response characterized by activation of microglia, upregulation of cellular adhesion molecules, recruitment of peripheral immune cells, as well as impaired neurovascular coupling, disruption of the blood-brain barrier, and imbalances in endogenous vasodilators and vasoconstrictors. Each of these phenomena is either directly or indirectly associated with neuronal death and brain injury. Here, we review recent studies investigating these various mechanisms in experimental models of subarachnoid hemorrhage with special emphasis on neuroinflammation and its effect on microvascular dysfunction. We discuss the various therapeutic targets that have risen from these mechanistic studies and suggest the utility of a multi-targeted approach to preventing delayed injury and improving outcome after subarachnoid hemorrhage.
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Affiliation(s)
- Joseph R Geraghty
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois at Chicago, 912 S. Wood St. Suite 174N, Chicago, IL, 60612, USA.
- Medical Scientist Training Program, University of Illinois at Chicago, Chicago, IL, USA.
| | - Joseph L Davis
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois at Chicago, 912 S. Wood St. Suite 174N, Chicago, IL, 60612, USA
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois at Chicago, 912 S. Wood St. Suite 174N, Chicago, IL, 60612, USA
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12
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Vadokas G, Koehler S, Weiland J, Lilla N, Stetter C, Westermaier T. Early Antiinflammatory Therapy Attenuates Brain Damage After Sah in Rats. Transl Neurosci 2019; 10:104-111. [PMID: 31098320 PMCID: PMC6487785 DOI: 10.1515/tnsci-2019-0018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 03/18/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Early inflammatory processes may play an important role in the development of early brain injury (EBI) after subarachnoid hemorrhage (SAH). Experimental studies suggest that anti-inflammatory and membrane-stabilizing drugs might have beneficial effects, although the underlying mechanisms are not fully understood. The aim of this study was to investigate the effect of early treatment with methylprednisolone and minocycline on cerebral perfusion and EBI after experimental SAH. METHODS Male Sprague-Dawley rats were subjected to SAH using the endovascular filament model. 30 minutes after SAH, they were randomly assigned to receive an intravenous injection of methylprednisolone (16mg/kg body weight, n=10), minocycline (45mg/kg body weight, n=10) or saline (n=11). Mean arterial blood pressure (MABP), intracranial pressure (ICP) and local cerebral blood flow (LCBF) over both hemispheres were recorded continuously for three hours following SAH. Neurological assessment was performed after 24 hours. Hippocampal damage was analyzed by immunohistochemical staining (caspase 3). RESULTS Treatment with methylprednisolone or minocycline did not result in a significant improvement of MABP, ICP or LCBF. Animals of both treatment groups showed a non-significant trend to better neurological recovery compared to animals of the control group. Mortality was reduced and hippocampal damage significantly attenuated in both methylprednisolone and minocycline treated animals. CONCLUSION The results of this study suggest that inflammatory processes may play an important role in the pathophysiology of EBI after SAH. Early treatment with the anti-inflammatory drugs methylprednisolone or minocycline in the acute phase of SAH has the potential to reduce brain damage and exert a neuroprotective effect.
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Affiliation(s)
- Georg Vadokas
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
- Department of Urology, Canisius Wilhelmina Hospital Nijmegen, Weg door Jonkerbos 100, 6532 SZ Nijmegen, Netherlands
| | - Stefan Koehler
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
| | - Judith Weiland
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
| | - Nadine Lilla
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
| | - Christian Stetter
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
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13
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Khattar NK, James RF. Heparin: The Silver Bullet of Aneurysmal Subarachnoid Hemorrhage? Front Neurol 2018; 9:97. [PMID: 29636721 PMCID: PMC5880902 DOI: 10.3389/fneur.2018.00097] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 02/12/2018] [Indexed: 01/27/2023] Open
Abstract
Various neurological diseases have recently been associated with neuroinflammation and worsening outcomes. Subarachnoid hemorrhage has been shown to generate a potent neuroinflammatory response. Heparin is a potential effective anti-inflammatory agent to prevent initial injury as well as delayed neurological decline. Different mechanisms of action for heparin have been proposed including, but not limited to the binding and neutralization of oxyhemoglobin, decreased transcription and signal transduction of endothelin-1, inhibition of binding to vessel wall selectins and vascular leakage into the subarachnoid space as well as direct binding and neutralization of inflammatory molecules. With a reasonably safe side-effect profile, heparin has shown significant promise in small series in human studies of aneurysmal subarachnoid hemorrhage in decreasing both initial and delayed neurological injury. Further studies are needed to validate various neuroprotective features of heparin in subarachnoid hemorrhage as well as other disease states.
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Affiliation(s)
- Nicolas K Khattar
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, United States
| | - Robert F James
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, United States
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14
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Yang XM, Chen XH, Lu JF, Zhou CM, Han JY, Chen CH. In vivo observation of cerebral microcirculation after experimental subarachnoid hemorrhage in mice. Neural Regen Res 2018; 13:456-462. [PMID: 29623930 PMCID: PMC5900508 DOI: 10.4103/1673-5374.228728] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute brain injury caused by subarachnoid hemorrhage is the major cause of poor prognosis. The pathology of subarachnoid hemorrhage likely involves major morphological changes in the microcirculation. However, previous studies primarily used fixed tissue or delayed injury models. Therefore, in the present study, we used in vivo imaging to observe the dynamic changes in cerebral microcirculation after subarachnoid hemorrhage. Subarachnoid hemorrhage was induced by perforation of the bifurcation of the middle cerebral and anterior cerebral arteries in male C57/BL6 mice. The diameter of pial arterioles and venules was measured by in vivo fluorescence microscopy at different time points within 180 minutes after subarachnoid hemorrhage. Cerebral blood flow was examined and leukocyte adhesion/albumin extravasation was determined at different time points before and after subarachnoid hemorrhage. Cerebral pial microcirculation was abnormal and cerebral blood flow was reduced after subarachnoid hemorrhage. Acute vasoconstriction occurred predominantly in the arterioles instead of the venules. A progressive increase in the number of adherent leukocytes in venules and substantial albumin extravasation were observed between 10 and 180 minutes after subarachnoid hemorrhage. These results show that major changes in microcirculation occur in the early stage of subarachnoid hemorrhage. Our findings may promote the development of novel therapeutic strategies for the early treatment of subarachnoid hemorrhage.
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Affiliation(s)
- Xiao-Mei Yang
- Department of Human Anatomy and Embryology, Peking University Health Science Center, Beijing, China
| | - Xu-Hao Chen
- School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Jian-Fei Lu
- Department of Human Anatomy and Embryology, Peking University Health Science Center, Beijing, China
| | - Chang-Man Zhou
- Department of Human Anatomy and Embryology, Peking University Health Science Center, Beijing, China
| | - Jing-Yan Han
- Tasly Microcirculation Research Center, Peking University Health Science Center, Beijing, China
| | - Chun-Hua Chen
- Department of Human Anatomy and Embryology, Peking University Health Science Center, Beijing, China
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15
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Delayed Cerebral Ischemia after Subarachnoid Hemorrhage: Beyond Vasospasm and Towards a Multifactorial Pathophysiology. Curr Atheroscler Rep 2017; 19:50. [PMID: 29063300 DOI: 10.1007/s11883-017-0690-x] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Delayed cerebral ischemia (DCI) is common after subarachnoid hemorrhage (SAH) and represents a significant cause of poor functional outcome. DCI was mainly thought to be caused by cerebral vasospasm; however, recent clinical trials have been unable to confirm this hypothesis. Studies in humans and animal models have since supported the notion of a multifactorial pathophysiology of DCI. This review summarizes some of the main mechanisms under investigation including cerebral vascular dysregulation, microthrombosis, cortical spreading depolarizations, and neuroinflammation. RECENT FINDINGS Recent guidelines have differentiated between DCI and angiographic vasospasm and have highlighted roles of the microvasculature, coagulation and fibrinolytic systems, cortical spreading depressions, and the contribution of the immune system to DCI. Many therapeutic interventions are underway in both preclinical and clinical studies to target these novel mechanisms as well as studies connecting these mechanisms to one another. Clinical trials to date have been largely unsuccessful at preventing or treating DCI after SAH. The only successful pharmacologic intervention is the calcium channel antagonist, nimodipine. Recent studies have provided evidence that cerebral vasospasm is not the sole contributor to DCI and that additional mechanisms may play equal if not more important roles.
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16
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van Lieshout JH, Dibué-Adjei M, Cornelius JF, Slotty PJ, Schneider T, Restin T, Boogaarts HD, Steiger HJ, Petridis AK, Kamp MA. An introduction to the pathophysiology of aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2017; 41:917-930. [PMID: 28215029 DOI: 10.1007/s10143-017-0827-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 02/06/2023]
Abstract
Pathophysiological processes following subarachnoid hemorrhage (SAH) present survivors of the initial bleeding with a high risk of morbidity and mortality during the course of the disease. As angiographic vasospasm is strongly associated with delayed cerebral ischemia (DCI) and clinical outcome, clinical trials in the last few decades focused on prevention of these angiographic spasms. Despite all efforts, no new pharmacological agents have shown to improve patient outcome. As such, it has become clear that our understanding of the pathophysiology of SAH is incomplete and we need to reevaluate our concepts on the complex pathophysiological process following SAH. Angiographic vasospasm is probably important. However, a unifying theory for the pathophysiological changes following SAH has yet not been described. Some of these changes may be causally connected or present themselves as an epiphenomenon of an associated process. A causal connection between DCI and early brain injury (EBI) would mean that future therapies should address EBI more specifically. If the mechanisms following SAH display no causal pathophysiological connection but are rather evoked by the subarachnoid blood and its degradation production, multiple treatment strategies addressing the different pathophysiological mechanisms are required. The discrepancy between experimental and clinical SAH could be one reason for unsuccessful translational results.
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Affiliation(s)
- Jasper H van Lieshout
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Maxine Dibué-Adjei
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Toni Schneider
- Institute for Neurophysiology, Medical Faculty, University of Cologne, Robert-Koch-Str. 39, 50931, Köln, Germany
| | - Tanja Restin
- Zurich Centre for Integrative Human Physiology, Institute of Physiology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.,Institute of Anesthesiology, Medical Faculty, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Medical Faculty, Radboud University Nijmegen, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Athanasios K Petridis
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marcel A Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
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17
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Guvenc Tuna B, Lachkar N, de Vos J, Bakker EN, VanBavel E. Cerebral Artery Remodeling in Rodent Models of Subarachnoid Hemorrhage. J Vasc Res 2015; 52:103-15. [DOI: 10.1159/000431366] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 05/13/2015] [Indexed: 11/19/2022] Open
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18
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The role of microclot formation in an acute subarachnoid hemorrhage model in the rabbit. BIOMED RESEARCH INTERNATIONAL 2014; 2014:161702. [PMID: 25110658 PMCID: PMC4109416 DOI: 10.1155/2014/161702] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/02/2014] [Indexed: 12/21/2022]
Abstract
Background. Microvascular dysfunction and microthrombi formation are believed to contribute to development of early brain injury (EBI) after aneurysmal subarachnoid hemorrhage (SAH). Objective. This study aimed to determine (i) extent of microthrombus formation and neuronal apoptosis in the brain parenchyma using a blood shunt SAH model in rabbits; (ii) correlation of structural changes in microvessels with EBI characteristics. Methods. Acute SAH was induced using a rabbit shunt cisterna magna model. Extent of microthrombosis was detected 24 h post-SAH (n = 8) by fibrinogen immunostaining, compared to controls (n = 4). We assessed apoptosis by terminal deoxynucleotidyl transferase nick end labeling (TUNEL) in cortex and hippocampus. Results. Our results showed significantly more TUNEL-positive cells (SAH: 115 ± 13; controls: 58 ± 10; P = 0.016) and fibrinogen-positive microthromboemboli (SAH: 9 ± 2; controls: 2 ± 1; P = 0.03) in the hippocampus after aneurysmal SAH. Conclusions. We found clear evidence of early microclot formation in a rabbit model of acute SAH. The extent of microthrombosis did not correlate with early apoptosis or CPP depletion after SAH; however, the total number of TUNEL positive cells in the cortex and the hippocampus significantly correlated with mean CPP reduction during the phase of maximum depletion after SAH induction. Both microthrombosis and neuronal apoptosis may contribute to EBI and subsequent DCI.
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19
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Østergaard L, Aamand R, Karabegovic S, Tietze A, Blicher JU, Mikkelsen IK, Iversen NK, Secher N, Engedal TS, Anzabi M, Jimenez EG, Cai C, Koch KU, Naess-Schmidt ET, Obel A, Juul N, Rasmussen M, Sørensen JCH. The role of the microcirculation in delayed cerebral ischemia and chronic degenerative changes after subarachnoid hemorrhage. J Cereb Blood Flow Metab 2013; 33:1825-37. [PMID: 24064495 PMCID: PMC3851911 DOI: 10.1038/jcbfm.2013.173] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 08/31/2013] [Accepted: 09/08/2013] [Indexed: 02/07/2023]
Abstract
The mortality after aneurysmal subarachnoid hemorrhage (SAH) is 50%, and most survivors suffer severe functional and cognitive deficits. Half of SAH patients deteriorate 5 to 14 days after the initial bleeding, so-called delayed cerebral ischemia (DCI). Although often attributed to vasospasms, DCI may develop in the absence of angiographic vasospasms, and therapeutic reversal of angiographic vasospasms fails to improve patient outcome. The etiology of chronic neurodegenerative changes after SAH remains poorly understood. Brain oxygenation depends on both cerebral blood flow (CBF) and its microscopic distribution, the so-called capillary transit time heterogeneity (CTH). In theory, increased CTH can therefore lead to tissue hypoxia in the absence of severe CBF reductions, whereas reductions in CBF, paradoxically, improve brain oxygenation if CTH is critically elevated. We review potential sources of elevated CTH after SAH. Pericyte constrictions in relation to the initial ischemic episode and subsequent oxidative stress, nitric oxide depletion during the pericapillary clearance of oxyhemoglobin, vasogenic edema, leukocytosis, and astrocytic endfeet swelling are identified as potential sources of elevated CTH, and hence of metabolic derangement, after SAH. Irreversible changes in capillary morphology and function are predicted to contribute to long-term relative tissue hypoxia, inflammation, and neurodegeneration. We discuss diagnostic and therapeutic implications of these predictions.
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Affiliation(s)
- Leif Østergaard
- 1] Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark [2] Center of Functionally Integrative Neuroscience and MINDLab, Aarhus University, Aarhus, Denmark
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20
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Steelman SM, Hein TW, Gorman A, Bix GJ. Effects of histidine-rich glycoprotein on cerebral blood vessels. J Cereb Blood Flow Metab 2013; 33:1373-5. [PMID: 23801240 PMCID: PMC3764380 DOI: 10.1038/jcbfm.2013.106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 05/21/2013] [Accepted: 05/31/2013] [Indexed: 11/09/2022]
Abstract
Delayed cerebral vasospasm is thought to be caused by factors released from a subarachnoid blood clot. Because vasospasm occurs several days after hemorrhage, we hypothesized that clotted blood releases vasoactive factors as it ages. Targeted proteomics identified histidine-rich glycoprotein (HRG) as a potentially vasoactive factor released within the first 72 hours of clot formation. In vitro studies revealed that HRG caused moderate (~30%) dilation of cannulated cerebral arterioles and proliferation of cerebrovascular endothelial cells. We conclude that HRG released from clotted blood, while unlikely to contribute to cerebral vasospasm, might provide important vasodilatory or angiogenic stimuli after hemorrhagic stroke.
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Affiliation(s)
- Samantha M Steelman
- Department of Veterinary Integrative Biosciences, Texas A&M University, College Station, TX, USA
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