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Laghi F, Shaikh H, Caccani N. Basing intubation of acutely hypoxemic patients on physiologic principles. Ann Intensive Care 2024; 14:86. [PMID: 38864960 PMCID: PMC11169311 DOI: 10.1186/s13613-024-01327-w] [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: 10/26/2023] [Accepted: 05/31/2024] [Indexed: 06/13/2024] Open
Abstract
The decision to intubate a patient with acute hypoxemic respiratory failure who is not in apparent respiratory distress is one of the most difficult clinical decisions faced by intensivists. A conservative approach exposes patients to the dangers of hypoxemia, while a liberal approach exposes them to the dangers of inserting an endotracheal tube and invasive mechanical ventilation. To assist intensivists in this decision, investigators have used various thresholds of peripheral or arterial oxygen saturation, partial pressure of oxygen, partial pressure of oxygen-to-fraction of inspired oxygen ratio, and arterial oxygen content. In this review we will discuss how each of these oxygenation indices provides inaccurate information about the volume of oxygen transported in the arterial blood (convective oxygen delivery) or the pressure gradient driving oxygen from the capillaries to the cells (diffusive oxygen delivery). The decision to intubate hypoxemic patients is further complicated by our nescience of the critical point below which global and cerebral oxygen supply become delivery-dependent in the individual patient. Accordingly, intubation requires a nuanced understanding of oxygenation indexes. In this review, we will also discuss our approach to intubation based on clinical observations and physiologic principles. Specifically, we consider intubation when hypoxemic patients, who are neither in apparent respiratory distress nor in shock, become cognitively impaired suggesting emergent cerebral hypoxia. When deciding to intubate, we also consider additional factors including estimates of cardiac function, peripheral perfusion, arterial oxygen content and its determinants. It is not possible, however, to pick an oxygenation breakpoint below which the benefits of mechanical ventilation decidedly outweigh its hazards. It is futile to imagine that decision making about instituting mechanical ventilation in an individual patient can be condensed into an algorithm with absolute numbers at each nodal point. In sum, an algorithm cannot replace the presence of a physician well skilled in the art of clinical evaluation who has a deep understanding of pathophysiologic principles.
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Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital (111N) and Loyola University of Chicago Stritch School of Medicine, 60141, Hines, IL, USA.
| | - Hameeda Shaikh
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital (111N) and Loyola University of Chicago Stritch School of Medicine, 60141, Hines, IL, USA
| | - Nicola Caccani
- Department of Physiology and Pharmacology, Center for Molecular Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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2
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Steinberg A. Emergent Management of Hypoxic-Ischemic Brain Injury. Continuum (Minneap Minn) 2024; 30:588-610. [PMID: 38830064 DOI: 10.1212/con.0000000000001426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article outlines interventions used to improve outcomes for patients with hypoxic-ischemic brain injury after cardiac arrest. LATEST DEVELOPMENTS Emergent management of patients after cardiac arrest requires prevention and treatment of primary and secondary brain injury. Primary brain injury is minimized by excellent initial resuscitative efforts. Secondary brain injury prevention requires the detection and correction of many pathophysiologic processes that may develop in the hours to days after the initial arrest. Key physiologic parameters important to secondary brain injury prevention include optimization of mean arterial pressure, cerebral perfusion, oxygenation and ventilation, intracranial pressure, temperature, and cortical hyperexcitability. This article outlines recent data regarding the treatment and prevention of secondary brain injury. Different patients likely benefit from different treatment strategies, so an individualized approach to treatment and prevention of secondary brain injury is advisable. Clinicians must use multimodal sources of data to prognosticate outcomes after cardiac arrest while recognizing that all prognostic tools have shortcomings. ESSENTIAL POINTS Neurologists should be involved in the postarrest care of patients with hypoxic-ischemic brain injury to improve their outcomes. Postarrest care requires nuanced and patient-centered approaches to the prevention and treatment of primary and secondary brain injury and neuroprognostication.
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3
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Chalifoux N, Ko T, Slovis J, Spelde A, Kilbaugh T, Mavroudis CD. Cerebral Autoregulation: A Target for Improving Neurological Outcomes in Extracorporeal Life Support. Neurocrit Care 2024:10.1007/s12028-024-02002-5. [PMID: 38811513 DOI: 10.1007/s12028-024-02002-5] [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: 01/05/2024] [Accepted: 04/18/2024] [Indexed: 05/31/2024]
Abstract
Despite improvements in survival after illnesses requiring extracorporeal life support, cerebral injury continues to hinder successful outcomes. Cerebral autoregulation (CA) is an innate protective mechanism that maintains constant cerebral blood flow in the face of varying systemic blood pressure. However, it is impaired in certain disease states and, potentially, following initiation of extracorporeal circulatory support. In this review, we first discuss patient-related factors pertaining to venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and their potential role in CA impairment. Next, we examine factors intrinsic to ECMO that may affect CA, such as cannulation, changes in pulsatility, the inflammatory and adaptive immune response, intracranial hemorrhage, and ischemic stroke, in addition to ECMO management factors, such as oxygenation, ventilation, flow rates, and blood pressure management. We highlight potential mechanisms that lead to disruption of CA in both pediatric and adult populations, the challenges of measuring CA in these patients, and potential associations with neurological outcome. Altogether, we discuss individualized CA monitoring as a potential target for improving neurological outcomes in extracorporeal life support.
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Affiliation(s)
- Nolan Chalifoux
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Tiffany Ko
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Julia Slovis
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Audrey Spelde
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Todd Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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4
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Brassard P, Roy MA, Burma JS, Labrecque L, Smirl JD. Quantification of dynamic cerebral autoregulation: welcome to the jungle! Clin Auton Res 2023; 33:791-810. [PMID: 37758907 DOI: 10.1007/s10286-023-00986-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023]
Abstract
PURPOSE Patients with dysautonomia often experience symptoms such as dizziness, syncope, blurred vision and brain fog. Dynamic cerebral autoregulation, or the ability of the cerebrovasculature to react to transient changes in arterial blood pressure, could be associated with these symptoms. METHODS In this narrative review, we go beyond the classical view of cerebral autoregulation to discuss dynamic cerebral autoregulation, focusing on recent advances pitfalls and future directions. RESULTS Following some historical background, this narrative review provides a brief overview of the concept of cerebral autoregulation, with a focus on the quantification of dynamic cerebral autoregulation. We then discuss the main protocols and analytical approaches to assess dynamic cerebral autoregulation, including recent advances and important issues which need to be tackled. CONCLUSION The researcher or clinician new to this field needs an adequate comprehension of the toolbox they have to adequately assess, and interpret, the complex relationship between arterial blood pressure and cerebral blood flow in healthy individuals and clinical populations, including patients with autonomic disorders.
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Affiliation(s)
- Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada.
- Research center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada.
| | - Marc-Antoine Roy
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada
- Research center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Joel S Burma
- Cerebrovascular Concussion Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Lawrence Labrecque
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada
- Research center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Jonathan D Smirl
- Cerebrovascular Concussion Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
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5
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Bordoni L, Thoren AE, Gutiérrez‐Jiménez E, Åbjørsbråten KS, Bjørnstad DM, Tang W, Stern M, Østergaard L, Nagelhus EA, Frische S, Ottersen OP, Enger R. Deletion of aquaporin-4 improves capillary blood flow distribution in brain edema. Glia 2023; 71:2559-2572. [PMID: 37439315 PMCID: PMC10952478 DOI: 10.1002/glia.24439] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 07/14/2023]
Abstract
Brain edema is a feared complication to disorders and insults affecting the brain. It can be fatal if the increase in intracranial pressure is sufficiently large to cause brain herniation. Moreover, accruing evidence suggests that even slight elevations of intracranial pressure have adverse effects, for instance on brain perfusion. The water channel aquaporin-4 (AQP4), densely expressed in perivascular astrocytic endfeet, plays a key role in brain edema formation. Using two-photon microscopy, we have studied AQP4-mediated swelling of astrocytes affects capillary blood flow and intracranial pressure (ICP) in unanesthetized mice using a mild brain edema model. We found improved regulation of capillary blood flow in mice devoid of AQP4, independently of the severity of ICP increase. Furthermore, we found brisk AQP4-dependent astrocytic Ca2+ signals in perivascular endfeet during edema that may play a role in the perturbed capillary blood flow dynamics. The study suggests that astrocytic endfoot swelling and pathological signaling disrupts microvascular flow regulation during brain edema formation.
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Affiliation(s)
- Luca Bordoni
- GliaLab and Letten Centre, Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical SciencesUniversity of OsloOsloNorway
- Department of BiomedicineAarhus UniversityAarhusDenmark
| | - Anna E. Thoren
- GliaLab and Letten Centre, Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical SciencesUniversity of OsloOsloNorway
| | - Eugenio Gutiérrez‐Jiménez
- Center of Functionally Integrative Neuroscience (CFIN), Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Knut S. Åbjørsbråten
- GliaLab and Letten Centre, Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical SciencesUniversity of OsloOsloNorway
| | - Daniel M. Bjørnstad
- GliaLab and Letten Centre, Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical SciencesUniversity of OsloOsloNorway
| | - Wannan Tang
- GliaLab and Letten Centre, Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical SciencesUniversity of OsloOsloNorway
- Department of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
- Department of Neurology, NeuroclinicSt. Olavs HospitalTrondheimNorway
| | - Mette Stern
- Department of BiomedicineAarhus UniversityAarhusDenmark
| | - Leif Østergaard
- Center of Functionally Integrative Neuroscience (CFIN), Department of Clinical MedicineAarhus UniversityAarhusDenmark
- Department of NeuroradiologyAarhus University HospitalAarhusDenmark
| | - Erlend A. Nagelhus
- GliaLab and Letten Centre, Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical SciencesUniversity of OsloOsloNorway
| | | | - Ole P. Ottersen
- GliaLab and Letten Centre, Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical SciencesUniversity of OsloOsloNorway
| | - Rune Enger
- GliaLab and Letten Centre, Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical SciencesUniversity of OsloOsloNorway
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6
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Xu D, Zhou J, Mei H, Li H, Sun W, Xu H. Impediment of Cerebrospinal Fluid Drainage Through Glymphatic System in Glioma. Front Oncol 2022; 11:790821. [PMID: 35083148 PMCID: PMC8784869 DOI: 10.3389/fonc.2021.790821] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/15/2021] [Indexed: 11/29/2022] Open
Abstract
Background Cerebrospinal fluid (CSF) plays an important role in maintaining tissue homeostasis in the central nervous system. In 2012, the new CSF outflow pathway, “the glymphatic system,” was discovered. The glymphatic system mediates CSF and interstitial fluid exchange through the perivascular pathway, which eliminates harmful solutes in the brain parenchyma. In recent studies, the importance of the glymphatic system has been demonstrated in healthy and neurodegenerative disease brains. However, there is limited research on the function of the CSF in brain tumors. Intracranial hypertension caused by glioma can affect CSF drainage, which impacts the delivery of chemotherapy drugs via intrathecal injection. This study focused on changes in the glymphatic system and the role of aquaporin 4 (AQP4) in glymphatic transport in glioma. Methods In glioma-bearing rats, the effect of tracer infusion on the intracranial pressure (ICP) was evaluated using an ICP microsensor. In vivo magnetic resonance imaging and ex vivo bright field were used to monitor CSF tracer distribution after cisterna magna injection. AQP4 expression was quantitatively detected, and AQP4 in the astrocytes around the vessels was observed using immunofluorescence. Results The ICP of the tumor group was higher than that of the control group and the infusion rate of 2 µl/min did not affect ICP. In vivo and ex vivo imaging showed that the circulation of CSF tracers was significantly impaired in the tumor. High-power confocal microscopy revealed that, in the tumor, the surrounding of AQP4 by Evans Blue was decreased. In both tumor and contralateral areas, data indicated that the number of cluster designation 34 (CD34+) alpha-smooth muscle actin (α-SMA−) veins were more than that of CD34+α-SMA+ arteries. Moreover, in the tumor area, AQP4 in the astrocytes around the vessels was decreased. Conclusions These findings indicate that the para-arterial influx of subarachnoid CSF is limited in glioma, especially in those with reduced levels of the fundamental protein AQP4. Our results provide evidence toward a potential new treatment method for glioma in the future.
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Affiliation(s)
- Dan Xu
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Jie Zhou
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Hao Mei
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Huan Li
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Wenbo Sun
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Haibo Xu
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
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7
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Mori MA, Meyer E, da Silva FF, Milani H, Guimarães FS, Oliveira RMW. Differential contribution of CB1, CB2, 5-HT1A, and PPAR-γ receptors to cannabidiol effects on ischemia-induced emotional and cognitive impairments. Eur J Neurosci 2021; 53:1738-1751. [PMID: 33522084 DOI: 10.1111/ejn.15134] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/03/2020] [Accepted: 01/17/2021] [Indexed: 01/08/2023]
Abstract
An ever-increasing body of preclinical studies has shown the multifaceted neuroprotective profile of cannabidiol (CBD) against impairments caused by cerebral ischemia. In this study, we have explored the neuropharmacological mechanisms of CBD action and its impact on functional recovery using a model of transient global cerebral ischemia in mice. C57BL/6J mice were subjected to bilateral common carotid artery occlusion (BCCAO) for 20 min and received vehicle or CBD (10 mg/Kg) 0.5 hr before and 3, 24, and 48 hr after reperfusion. To investigate the neuropharmacological mechanisms of CBD, the animals were injected with CB1 (AM251, 1 mg/kg), CB2 (AM630, 1 mg/kg), 5-HT1A (WAY-100635, 10 mg/kg), or PPAR-γ (GW9662, 3 mg/kg) receptor antagonists 0.5 hr prior to each injection of CBD. The animals were evaluated using a multi-task testing battery that included the open field, elevated zero maze, Y-maze (YM), and forced swim test. CBD prevented anxiety-like behavior, memory impairments, and despair-like behaviors induced by BCCAO in mice. The anxiolytic-like effects of CBD in BCCAO mice were attenuated by CB1 , CB2 , 5-HT1A , and PPAR-γ receptor antagonists. In the YM, both CBD and the CB1 receptor antagonist AM251 increased the exploration of the novel arm in ischemic animals, indicating beneficial effects of these treatments in the spatial memory performance. Together, these findings indicate the involvement of CB1 , CB2 , 5-HT1A, and PPAR-γ receptors in the functional recovery induced by CBD in BCCAO mice.
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Affiliation(s)
- Marco Aurélio Mori
- Department of Pharmacology and Therapeutics, State University of Maringá, Maringá, Brazil
| | - Erika Meyer
- Department of Pharmacology and Therapeutics, State University of Maringá, Maringá, Brazil
| | - Francielly F da Silva
- Department of Pharmacology and Therapeutics, State University of Maringá, Maringá, Brazil
| | - Humberto Milani
- Department of Pharmacology and Therapeutics, State University of Maringá, Maringá, Brazil
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Bordoni L, Li B, Kura S, Boas DA, Sakadžić S, Østergaard L, Frische S, Gutiérrez-Jiménez E. Quantification of Capillary Perfusion in an Animal Model of Acute Intracranial Hypertension. J Neurotrauma 2020; 38:446-454. [PMID: 32998634 DOI: 10.1089/neu.2019.6901] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Intracranial hypertension (IH) is a common feature of many pathologies, including brain edema. In the brain, the extended network of capillaries ensures blood flow to meet local metabolic demands. Capillary circulation may be severely affected by IH, but no studies have quantified the effect of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) on capillary perfusion during the development of brain edema. We used optical coherence tomography angiography to quantify relative changes of fractional perfused volume (FPV) in cortical capillaries and simultaneously monitored ICP and blood pressure (BP) in anesthetized male C57Bl/6NTac mice during development of brain edema induced by water intoxication (WI) within 30 min. WI induced severe IH and brain herniation. ICP and CPP reached 90.2 mm Hg and 38.4 mm Hg, respectively. FPV was significantly affected already at normal ICP (ICP <15 mm Hg, slope ≈ -1.46, p < 0.001) and, at the onset of IH (ICP = 20-22 mm Hg), FPV was 17.9 ± 13.3% lower than baseline. A decreasing trend was observed until the ICP peak (Δ%FPV = -43.6 ± 19.2%). In the ICP range of 7-42 mm Hg, relative changes in FPV were significantly correlated with ICP, BP, and CPP (p < 0.001), with ICP and CPP being the best predictors. In conclusion, elevated ICP induces a gradual collapse of the cerebral microvasculature, which is initiated before the clinical threshold of IH. In summary, the estimate of capillary perfusion might be essential in patients with IH to assess the state of the brain microcirculation and to improve the availability of oxygen and nutrients to the brain.
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Affiliation(s)
- Luca Bordoni
- Institute of Biomedicine, Aarhus University, Aarhus C, Denmark
| | - Baoqiang Li
- Brain Cognition and Brain Disease Institute, Chinese Academy of Sciences, Shenzhen, China.,Shenzhen-Hong Kong Institute of Brain Science, Shenzhen Fundamental Research Institutions, Shenzhen, China
| | - Sreekanth Kura
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, USA
| | - David A Boas
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Sava Sakadžić
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Leif Østergaard
- Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark.,Department of Neuroradiology, Aarhus University Hospital, Aarhus C, Denmark
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9
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Quispe Cornejo A, Fernandes Vilarinho CS, Crippa IA, Peluso L, Calabrò L, Vincent JL, Creteur J, Taccone FS. The use of automated pupillometry to assess cerebral autoregulation: a retrospective study. J Intensive Care 2020; 8:57. [PMID: 32765886 PMCID: PMC7395368 DOI: 10.1186/s40560-020-00474-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/22/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Critically ill patients are at high risk of developing neurological complications. Among all the potential aetiologies, brain hypoperfusion has been advocated as one of the potential mechanisms. Impairment of cerebral autoregulation (CAR) can result in brain hypoperfusion. However, assessment of CAR is difficult at bedside. We aimed to evaluate whether the automated pupillometer might be able to detect impaired CAR in critically ill patients. METHODS We included 92 patients in this retrospective observational study; 52 were septic. CAR was assessed using the Mxa index, which is the correlation index between continuous recording of cerebral blood flow velocities using the transcranial Doppler and invasive arterial blood pressure over 8 ± 2 min. Impaired CAR was defined as an Mxa > 0.3. Automated pupillometer (Neuroptics, Irvine, CA, USA) was used to assess the pupillary light reflex concomitantly to the CAR assessment. RESULTS The median Mxa was 0.33 in the whole cohort (0.33 in septic patients and 0.31 in the non-septic patients; p = 0.77). A total of 51 (55%) patients showed impaired CAR, 28 (54%) in the septic group and 23 (58%) in the non-septic group. We found a statistically significant although weak correlation between Mxa and the Neurologic Pupil Index (r 2 = 0.04; p = 0.048) in the whole cohort as in septic patients (r 2 = 0.11; p = 0.026); no correlation was observed in non-septic patients and for other pupillometry-derived variables. CONCLUSIONS Automated pupillometry cannot predict CAR indices such as Mxa in a heterogeneous population of critically ill patients.
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Affiliation(s)
- Armin Quispe Cornejo
- Department of Intensive Care Medicine, Erasme University Hospital, Route de Lennik, 808, 1070 Brussels, Belgium
| | | | - Ilaria Alice Crippa
- Department of Intensive Care Medicine, Erasme University Hospital, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care Medicine, Erasme University Hospital, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Lorenzo Calabrò
- Department of Intensive Care Medicine, Erasme University Hospital, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care Medicine, Erasme University Hospital, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care Medicine, Erasme University Hospital, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Erasme University Hospital, Route de Lennik, 808, 1070 Brussels, Belgium
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10
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Giannasi S, Kani Y, Hsu F, Rossmeisl JH. Comparison of direct measurement of intracranial pressures and presumptive clinical and magnetic resonance imaging indicators of intracranial hypertension in dogs with brain tumors. J Vet Intern Med 2020; 34:1514-1523. [PMID: 32415794 PMCID: PMC7379039 DOI: 10.1111/jvim.15802] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 04/14/2020] [Accepted: 05/01/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Intracranial hypertension (ICH) is often presumptively diagnosed based on clinical or imaging findings. Clinical or imaging surrogates of ICH are not usually validated with reference standard direct intracranial pressure (dICP) recordings. HYPOTHESES Dogs with brain magnetic resonance imaging (MRI) or clinical features of presumed ICH would have higher dICP than dogs lacking those features. ANIMALS Twenty dogs with gliomas and 3 normal controls. METHODS Prospective, convenience study. Dogs were presumptively categorized with normal ICP or ICH from scores generated from described clinical and brain MRI indicators of ICH. dICP was recorded in anesthetized dogs using an intraparenchymal microsensor and compared between groups. RESULTS dICP was not different between control (10.4 ± 2.1 mm Hg) and dogs with glioma (15.6 ± 8.3 mm Hg), or between dogs in clinically predicted ICP groups. Compared with dogs with MRI-predicted normal ICP, MRI-predicted ICH dogs had higher dICP (10.3 ± 4.1 versus 19.2 ± 7.9 mm Hg, P = .004), larger tumors (1.45 ± 1.2 versus 5.71 ± 3.03 cm3 , P = .0004), larger optic nerve sheath diameters, and 14/14 (100%) displayed structural anatomical shifts on MRI. At a dICP threshold of 15 mm Hg, the sensitivity of MRI for predicting ICH was 90% and the specificity 69%. CONCLUSIONS AND CLINICAL RELEVANCE dICP measurements are feasible in dogs with brain tumors. MRI features including brain herniations, mass effect, and optic nerve size aid in the identification of dogs with ICH. Clinical estimation of ICP did not discriminate between dogs with and without ICH.
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Affiliation(s)
- Savannah Giannasi
- Veterinary and Comparative Neuro‐Oncology LaboratoryVirginia‐Maryland College of Veterinary Medicine, Virginia TechBlacksburgVirginiaUSA
| | - Yukitaka Kani
- Veterinary and Comparative Neuro‐Oncology LaboratoryVirginia‐Maryland College of Veterinary Medicine, Virginia TechBlacksburgVirginiaUSA
| | - Fang‐Chi Hsu
- Department of Biostatistics and Data Science, Comprehensive Cancer Center and Brain Tumor Center of ExcellenceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - John H. Rossmeisl
- Veterinary and Comparative Neuro‐Oncology LaboratoryVirginia‐Maryland College of Veterinary Medicine, Virginia TechBlacksburgVirginiaUSA
- Department of Cancer Biology, Comprehensive Cancer Center and Brain Tumor Center of ExcellenceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
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11
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Chavkin NW, Hirschi KK. Single Cell Analysis in Vascular Biology. Front Cardiovasc Med 2020; 7:42. [PMID: 32296715 PMCID: PMC7137757 DOI: 10.3389/fcvm.2020.00042] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/05/2020] [Indexed: 12/12/2022] Open
Abstract
The ability to quantify DNA, RNA, and protein variations at the single cell level has revolutionized our understanding of cellular heterogeneity within tissues. Via such analyses, individual cells within populations previously thought to be homogeneous can now be delineated into specific subpopulations expressing unique sets of genes, enabling specialized functions. In vascular biology, studies using single cell RNA sequencing have revealed extensive heterogeneity among endothelial and mural cells even within the same vessel, key intermediate cell types that arise during blood and lymphatic vessel development, and cell-type specific responses to disease. Thus, emerging new single cell analysis techniques are enabling vascular biologists to elucidate mechanisms of vascular development, homeostasis, and disease that were previously not possible. In this review, we will provide an overview of single cell analysis methods and highlight recent advances in vascular biology made possible through single cell RNA sequencing.
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Affiliation(s)
- Nicholas W Chavkin
- Department of Cell Biology, Developmental Genomics Center, School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Karen K Hirschi
- Department of Cell Biology, Developmental Genomics Center, School of Medicine, University of Virginia, Charlottesville, VA, United States.,Departments of Medicine and Genetics, Cardiovascular Research Center, School of Medicine, Yale University, New Haven, CT, United States
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Song X, Zhao X, Liebeskind DS, Xu W, Zhang J, Wei C, Xu Y, Wang L, Zheng Z, Wu J. Associations between systemic blood pressure parameters and intraplaque hemorrhage in symptomatic intracranial atherosclerosis: a high-resolution MRI-based study. Hypertens Res 2020; 43:688-695. [PMID: 32037397 DOI: 10.1038/s41440-020-0411-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/18/2019] [Accepted: 01/21/2020] [Indexed: 11/09/2022]
Abstract
The associations between blood pressure parameters and intracranial vulnerable plaques have not been fully elucidated. The purpose of this study was to investigate the associations between systemic blood pressure parameters, as well as their variability, and intraplaque hemorrhage (IPH) in stroke patients with intracranial atherosclerosis. We retrospectively analyzed the high-resolution MRI data set of intracranial atherosclerosis from a comprehensive stroke center. The atherosclerotic plaque burden and presence of IPH in each vessel were obtained from vessel wall imaging. Blood pressure parameters in the first week of admission were used. The systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and their variability (standard deviation [SD] and coefficient of variation [CV]) were compared between the IPH (+) and IPH (-) groups. Logistic regression analysis was used to demonstrate the correlations between different blood pressure parameters and IPH. The results indicated that SBP and PP were associated with multiple plaques and severe luminal stenosis after adjusting for confounders, with OR = 1.071, 95% CI: (1.044-1.098) and OR = 1.039, 95% CI: (1.019-1.060) for SBP and OR = 1.058, 95% CI: (1.027-1.089) and OR = 1.044, 95% CI: (1.019-1.070) for PP, respectively. SBP was associated with IPH after adjusting for cardiovascular risk factors, with OR = 1.021, 95% CI: (1.003-1.038), but not after correcting for plaque burden, with OR = 1.014, 95% CI: (0.996-1.032). No associations between blood pressure variability and atherosclerotic plaque burden or IPH were detected in this study. In conclusion, SBP is associated with IPH after adjusting for cardiovascular risk factors but not after further correction for atherosclerotic plaque burden. The association between blood pressure variability and intracranial atherosclerosis requires further study.
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Affiliation(s)
- Xiaowei Song
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xihai Zhao
- Department of Radiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.,Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
| | - David S Liebeskind
- Neurovascular Imaging Research Core and Stroke Center, Department of Neurology, University of California at Los Angeles, Los Angeles, CA, USA
| | - Wendeng Xu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jun Zhang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Chenming Wei
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yilan Xu
- Department of Radiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Lixue Wang
- Department of Radiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhuozhao Zheng
- Department of Radiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China. .,Tsinghua University Hospital, Beijing, China.
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Bulwa Z, Gomez CR, Morales-Vidal S, Biller J. Management of Blood Pressure After Acute Ischemic Stroke. Curr Neurol Neurosci Rep 2019; 19:29. [PMID: 31037389 DOI: 10.1007/s11910-019-0941-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW The present manuscript examines the significance of blood pressure elevation in patients with acute ischemic stroke, the physiologic principles worthy of consideration during its treatment, and the recent empirical evidence that should guide management protocols. It also provides a sound and practical approach to treatment along the time continuum, with particular relevance to reperfusion strategies. RECENT FINDINGS The existing evidence shows that both insufficient and excessive blood pressures are detrimental to the outcome of patients with acute ischemic stroke. This "U-shaped" relation, however, relates to measurements at the time of presentation, and clinical studies lack detail and specificity relative to differential measurements along the time continuum, particularly prior to and following reperfusion. Extrapolating from recent series, it is possible to construct treatment protocols balanced for effectiveness and safety. The management of blood pressure after acute ischemic stroke is an important, complex, and challenging aspect of care, requiring a thorough understanding of cerebrovascular physiology. Along the time continuum, the therapeutic priorities start with the preservation of penumbral tissue prior to reperfusion and then follow with the limitation of the damaging effects of excessive blood pressure readings after reperfusion, optimizing the chances of improved outcomes.
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Affiliation(s)
- Zachary Bulwa
- Department of Neurology, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri Columbia, Columbia, MO, USA.
| | - Sarkis Morales-Vidal
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - José Biller
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
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