Inflammatory response after neurosurgery

Surgical Management of Trauma-Related Intracranial Hemorrhage-a Review

PURPOSE OF REVIEW

The surgical management of trauma-related intracranial hemorrhage is characterized by marked heterogeneity. Large prospective randomized trials have generally been prohibited by the ubiquity of concordant pathology, diversity of trauma systems, and paucity of clinical equipoise among providers.

RECENT FINDINGS

To date, the results of retrospective studies and surgeon preference have driven the indications, modality, extent, and timing of surgical intervention in the global neurosurgical community. With advances in our understanding of the pathophysiology of hemorrhagic TBI and the advent of novel surgical techniques, a reevaluation of surgical indication, timing, and approach is warranted. In this way, we can work to optimize surgical outcomes, achieving maximal functional recovery while minimizing surgical morbidity.

Diagnosis, Background, and Treatment of Hypothalamic Damage in Craniopharyngioma

Craniopharyngiomas (CP) are rare brain tumors managed primarily with surgery and radiotherapy. There are 2 phenotypes of CP, i.e., one with a rather good outcome without hypothalamic damage and another with hypothalamic damage. With hypothalamic damage, progressive disease with recurrent operations and additional cranial radiotherapy often result in hypothalamic obesity, an affected psychosocial life, and cognitive dysfunction. The morbidity and mortality are increased for particularly cerebrovascular diseases. Preoperative hypothalamic involvement to predict hypothalamic damage is important for decision making for hypothalamus-sparing surgery. Also a postoperative hypothalamic damage evaluation with the use of hypothalamus volume measurement can predict hypothalamic obesity, which is important for early treatment options. The morbidity of CP includes cognitive dysfunction with attention deficits and impaired episodic memory and processing speed. Again patients with hypothalamic damage are more affected. Treatment options of hypothalamic obesity in the chronic phase are scarce and not convincingly successful. The most optimal situation is to try to hinder or stop the evolution of hypothalamic obesity. Prevention of hypothalamic damage is recommended, with special regard to hypothalamus-sparing therapeutic approaches that respect the integrity of essential nuclei located in both the medial and the posterior hypothalamic areas.

Effect of local anesthesia with lidocaine on perioperative proinflammatory cytokine levels in plasma and cerebrospinal fluid in cerebral aneurysm patients: Study protocol for a randomized clinical trial

BACKGROUND

Cerebral aneurysm surgery has significant mortality and morbidity rate. Inflammation plays a key role in the pathogenesis of intracranial aneurysms, their rupture, subarachnoid hemorrhage and neurologic complications. Proinflammatory cytokine level in blood and cerebrospinal fluid (CSF) is an indicator of inflammatory response. Cytokines contribute to secondary brain injury and can worsen the outcome of the treatment. Lidocaine is local anesthetic that can be applied in neurosurgery as regional anesthesia of the scalp and as topical anesthesia of the throat before direct laryngoscopy and endotracheal intubation. Besides analgesic, lidocaine has systemic anti-inflammatory and neuroprotective effect.Primary aim of this trial is to determine the influence of local anesthesia with lidocaine on the perioperative levels of pro-inflammatory cytokines interleukin-1β, interleukin-6, and tumor necrosis factor-α in plasma and CSF in cerebral aneurysm patients.

METHODS

We will conduct prospective randomized clinical trial among patients undergoing craniotomy and cerebral aneurysm clipping surgery in general anesthesia. Patients included in the trial will be randomly assigned to the lidocaine group (Group L) or to the control group (Group C). Patients in Group L, following general anesthesia induction, will receive topical anesthesia of the throat before endotracheal intubation and also regional anesthesia of the scalp before Mayfield frame placement, both done with lidocaine. Patients in Group C will have general anesthesia only without any lidocaine administration. The primary outcomes are concentrations of cytokines interleukin-1β, interleukin-6 and tumor necrosis factor-α in plasma and CSF, measured at specific timepoints perioperatively. Secondary outcome is incidence of major neurological and infectious complications, as well as treatment outcome in both groups.

DISCUSSION

Results of the trial could provide insight into influence of lidocaine on local and systemic inflammatory response in cerebrovascular surgery, and might improve future anesthesia practice and treatment outcome. TRIAL IS REGISTERED AT CLINICALTRIALS.GOV:: NCT03823482.

Design, synthesis and biological evaluation of hybrid nitroxide-based non-steroidal anti-inflammatory drugs

Dual-acting hybrid anti-oxidant/anti-inflammatory agents were developed employing the principle of pharmacophore hybridization. Hybrid agents were synthesized by combining stable anti-oxidant nitroxides with conventional non-steroidal anti-inflammatory drugs (NSAIDs). Several of the hybrid nitroxide-NSAID conjugates displayed promising anti-oxidant and anti-inflammatory effects on two Non-Small Cell Lung Cancer (NSCLC) cells (A549 and NCI-H1299) and in ameliorating oxidative stress induced in 661 W retinal cells. One ester-linked nitroxide-aspirin analogue (27) delivered better anti-inflammatory effects (cyclooxygenase inhibition) than the parent compound (aspirin), and also showed similar reactive oxygen scavenging activity to the anti-oxidant, Tempol. In addition, a nitroxide linked to the anti-inflammatory drug indomethacin (39) significantly ameliorated the effects of oxidative stress on 661 W retinal neurons at efficacies greater or equal to the anti-oxidant Lutein. Other examples of the hybrid conjugates displayed promising anti-cancer activity, as demonstrated by their inhibitory effects on the proliferation of A549 NSCLC cells.

Activation of nuclear factor kappa B pathway and reduction of hypothalamic oxytocin following hypothalamic lesions

Background

Hypothalamic obesity (HO) occurs in patients with tumors and lesions in the medial hypothalamic region. In this study, a hyperphagic rat model of combined medial hypothalamic lesions (CMHL) was used to test which specific inflammatory molecules are involved.

Methods

In order to target specific homeostatic medial hypothalamic nuclei (arcuate, ventromedial, and dorsomedial nuclei), male Sprague-Dawley rats (age of 8 weeks, ~250 g body weight) received four electrolytic lesions or sham surgery. Post-surgery food intake and weight changes were tracked and hypothalamic gene expression for inflammatory molecules as well as anorexigenic peptide oxytocin 7 days and 7 months post-surgery were tested.

Results

Seven days post-surgery, average food intake increased by 23%, and body weight gain had increased by 68%. Toll-like 4 receptor/nuclear factor–κB (TLR4/NF–κB)—pathway was specifically activated in the mediobasal hypothalamus (MBH), resulting in 3-fold higher tumor necrosis factor (TNF)-α, 10-fold higher interleukin (IL) 1-β mRNA levels, and higher expression of suppression of cytokine signaling (SOCS) 3, while oxytocin mRNA levels were significantly reduced in CMHL rats versus sham surgery rats 7 days post-surgery. At 7 months, inflammation was less stimulated in MBH of CMHL rats compared to 7 days post-surgery and SOCS 3 as well as oxytocin mRNA levels were comparable between the two groups.

Conclusion

Medial hypothalamic lesions are associated with strong post-surgery hyperphagia and activation of TLR4/NF–κB—pathway as well as reduced expression of oxytocin in the hypothalamus.

Hypothalamic Obesity in Craniopharyngioma Patients: Disturbed Energy Homeostasis Related to Extent of Hypothalamic Damage and Its Implication for Obesity Intervention

Hypothalamic obesity (HO) occurs in patients with tumors and lesions in the medial hypothalamic region. Hypothalamic dysfunction can lead to hyperinsulinemia and leptin resistance. This review is focused on HO caused by craniopharyngiomas (CP), which are the most common childhood brain tumors of nonglial origin. Despite excellent overall survival rates, CP patients have substantially reduced quality of life because of significant long-term sequelae, notably severe obesity in about 50% of patients, leading to a high rate of cardiovascular mortality. Recent studies reported that both hyperphagia and decreased energy expenditure can contribute to severe obesity in HO patients. Recognized risk factors for severe obesity include large hypothalamic tumors or lesions affecting several medial and posterior hypothalamic nuclei that impact satiety signaling pathways. Structural damage in these nuclei often lead to hyperphagia, rapid weight gain, central insulin and leptin resistance, decreased sympathetic activity, low energy expenditure, and increased energy storage in adipose tissue. To date, most efforts to treat HO have shown disappointing long-term success rates. However, treatments based on the distinct pathophysiology of disturbed energy homeostasis related to CP may offer options for successful interventions in the future.

Intrathecal delivery of IL-6 reactivates the intrinsic growth capacity of pyramidal cells in the sensorimotor cortex after spinal cord injury

We have previously demonstrated the growth-promoting effect of intrathecal delivery of recombinant rat IL-6 immediately after corticospinal tract (CST) injury. Our present study aims to further clarify whether intrathecal delivery of IL-6 after CST injury could reactivate the intrinsic growth capacity of pyramidal cells in the sensorimotor cortex which project long axons to the spinal cord. We examined, by ELISA, levels of cyclic adenosine monophosphate (cAMP), adenylyl cyclase (AC, which synthesizes cAMP), phosphodiesterases (PDE, which degrades cAMP), and, by RT-PCR, the expression of regeneration-associated genes in the rat sensorimotor cortex after intrathecal delivery of IL-6 for 7 days, started immediately after CST injury. Furthermore, we injected retrograde neuronal tracer Fluorogold (FG) to the spinal cord to label pyramidal cells in the sensorimotor cortex, layers V and VI, combined with βIII-tubulin immunostaining, then we analyzed by immunohistochemisty and western blot the expression of the co-receptor gp-130 of IL-6 family, and pSTAT3 and mTOR, downstream IL-6/JAK/STAT3 and PI3K/AKT/mTOR signaling pathways respectively. We showed that intrathecal delivery of IL-6 elevated cAMP level and upregulated the expression of regeneration-associated genes including GAP-43, SPRR1A, CAP-23 and JUN-B, and the expression of pSTAT3 and mTOR in pyramidal cells of the sensorimotor cortex. In contrast, AG490, an inhibitor of JAK, partially blocked these effects of IL-6. All these results indicate that intrathecal delivery of IL-6 immediately after spinal cord injury can reactivate the intrinsic growth capacity of pyramidal cells in the sensorimotor cortex and these effects of IL-6 were partially JAK/STAT3-dependent.

Interferência e características do edema periorbital no exame pupilar após craniotomia

Objetivo Avaliar a interferência e características do edema periorbital no exame pupilar, em pacientes submetidos a craniotomia por via anterior. Métodos Estudo de coorte prospectivo realizado em pacientes no pós-operatório na unidade de terapia intensiva e internação de neurocirurgia. A interferência e características do edema periorbital no exame pupilar foram avaliados da admissão do paciente até sétimo dia de pós-operatório. O exame pupilar foi realizado por enfermeiros. Resultados Foram avaliados 100 pacientes e a incidência de edema periorbital foi de 80%. O enfermeiro não realizou o exame pupilar em 24 (30%) pacientes. As características que influenciaram na realização do exame pupilar foram coloração arroxeada e intenso edema periorbital. Conclusão O edema periorbital estava presente na maioria dos pacientes no pós-operatório de craniotomia e o exame pupilar não foi realizado em 30% dos pacientes. A presença de intenso edema periorbital e de coloração arroxeada foram características que prejudicaram o exame pupilar.

Factors affecting ¹⁸F FDOPA standardized uptake value in patients with primary brain tumors after treatment

AIM

To investigate the factors affecting (18)F FDOPA uptake in patients with primary brain tumors (PBT) after treatment.

MATERIALS AND METHODS

97 patients with PBT (6 were grade I, 40 were grade II, 29 were grade III and 22 were grade IV) underwent (18)F FDOPA positron emission tomography/computed tomography (PET/CT) after treatment. Intervals from surgery, chemotherapy (CHT) and radiotherapy (RT) were 41.48 (±42.27), 16.04 (±29.08) and 28.62 (±34.49) months respectively.

RESULTS

(18)F FDOPA uptake in the site of recurrence was not related to the interval from surgery and CHT while a significant relationship has been found with the interval from RT and tumor grade.

CONCLUSIONS

The results of our study show that the interval from RT and the grade of PBT should be considered carefully when evaluating brain PET/CT scans since these factors could directly affect (18)F FDOPA uptake.

IL-6 promotes regeneration and functional recovery after cortical spinal tract injury by reactivating intrinsic growth program of neurons and enhancing synapse formation

Most neurons in adult mammalian central nervous system (CNS) fail to regenerate their axons after injury. Peripherally conditioned primary sensory neurons have an increased capacity to regenerate their central processes. Recent studies demonstrate that a conditioning lesion increased intrinsic growth capability is associated with the up-regulation of a group of growth-associated genes, one of the most established is interleukin-6 (IL-6). However, the cellular and molecular mechanisms by which IL-6 exerts its beneficial effect on axonal regeneration and functional recovery remain to be elucidated. The purpose of this study is to further investigate the molecular mechanisms of IL-6 in promoting regeneration and functional recovery after spinal cord injury (SCI). Here, we demonstrate that in vitro administration of IL-6 enhances neurite outgrowth of neurons on an inhibitory substrate myelin proteins, accompanied by increased expression of growth-associated genes GAP-43, SPRR1A and Arginase I. In vivo, intrathecal delivery of IL-6 for 7 days after cortical spinal tract injury induces synaptic rearrangements of sprouting axons and increases the expression of mTOR in neurons surrounding the lesion site, accompanied by improved functional recovery. In conclusion, our results show that IL-6 increases the expression of growth-associated genes and induces the expression of mTOR in lesion adjacent neurons, resulting in reactivating the intrinsic growth program of neurons to promote axonal regrowth and functional recovery after SCI.

Glutamine concentration and immune response of spinal cord-injured rats

BACKGROUND/OBJECTIVES

Glutamine plays a key role in immune response. Spinal cord injury (SCI) leads to severe loss of muscle mass and to a high incidence of infections. This study investigated the acute effect of SCI (2 and 5 days) on the plasma glutamine and skeletal muscle concentrations and immune responses in rats.

METHODS

A total of 29 adult male Wistar rats were divided as follows: control (C; n = 5), sham-operated (S2; n = 5) and spinal cord-transected (T2; n = 7). They were killed on day 2 after surgery/transection (acute phase). Another set was sham-operated (S5; n = 5), spinal cord-transected (T5; n = 7), and killed at day 5 after surgery/transection (secondary phase). Blood was collected; the white portion of the epitrochlearis and gastrocnemius muscles and the red portion of soleus muscles were dissected to measure the glutamine concentration. Gut-associated lymphocytes and peritoneal macrophages were obtained for immune parameters measurements.

RESULTS

Glutamine concentration in the plasma, gastrocnemius, and soleus muscles in rats with SCI were significantly reduced but not in the epitrochlearis muscle in the acute (2 days) and secondary (5 days) phases. Phagocytic response was reduced in the acute phase but increased in the secondary phase in rats with SCI. Superoxide production, on the other hand, was significantly increased at days 2 and 5 after SCI, and CD8+ lymphocytes subset decreased significantly on days 2 and 5.

CONCLUSIONS

Our results showed reduction in plasma glutamine and skeletal muscle concentrations after spinal cord transection. They also suggest that SCI and glutamine reduction contribute to an alteration in immune competence.

Interleukin-6 promotes sprouting and functional recovery in lesioned organotypic hippocampal slice cultures

Interleukin (IL)-6 is a pro-inflammatory cytokine now widely recognized to contribute to the molecular events that follow CNS injury. Little is known, however, about its action on axonal sprouting and regeneration in the brain. We addressed this issue using the model of transection of Schaffer collaterals in mice organotypic hippocampal slice cultures. Transection of slice cultures was associated with a marked release of IL-6 that could be neutralized by an IL-6 blocking antibody. We monitored functional recovery across the lesion by recording synaptic responses using a multi-electrode array. We found that application of IL-6 antibodies to the cultures after lesioning significantly reduced functional recovery across the lesion. Furthermore, the level of expression of the 43-kDa growth-associated protein (GAP-43) was lower in slices treated with the IL-6 neutralizing antibody than in those treated with a control IgG. Conversely, addition of exogenous IL-6 to the culture medium resulted in a dose-dependent enhancement of functional recovery across the lesion and a higher level of expression of GAP-43. Co-culture of CA3 hemi-slices from thy1-YFP mice with CA1 hemi-slices from wild-type animals confirmed that IL-6-treated co-cultures exhibited an increased number of growing fluorescent fibres across the lesion site. Taken together these data indicate that IL-6 plays an important role in CNS repair mechanisms by promoting regrowth and axon regeneration.

Tolerogenic effect of fiber tract injury: reduced EAE severity following entorhinal cortex lesion

Despite transient, myelin-directed adaptive immune responses in regions of fiber tract degeneration, none of the current models of fiber tract injuries evokes disseminated demyelination, implying effective mechanisms maintaining or re-establishing immune tolerance. In fact, we have recently detected CD95L upregulation accompanied by apoptosis of leukocytes in zones of axonal degeneration induced by entorhinal cortex lesion (ECL), a model of layer-specific axonal degeneration. Moreover, infiltrating monocytes readily transformed into ramified microglia exhibiting a phenotype of immature (CD86+/CD80-) antigen-presenting cells. We now report the appearance of the axonal antigen neurofilament-light along with increased T cell apoptosis and enhanced expression of the pro-apoptotic gene Bad in cervical lymph nodes after ECL. In order to test the functional significance of such local and systemic depletory/regulatory mechanisms on subsequent immunity to central nervous system antigens, experimental autoimmune encephalomyelitis was induced by proteolipid protein immunization 30 days after ECL. In three independent experiments, we found significantly diminished disease scores and infiltrates in lesioned compared to sham-operated SJL mice. This is consistent with a previous meta-statistical analysis (Goodin et al. in Neurology 52:1737-1745, 1999) rejecting the O-hypothesis that brain trauma causes or exacerbates multiple sclerosis. Conversely, brain injuries may involve long-term tolerogenic effects towards brain antigens.

[Intensive medicine criteria for operability]

BACKGROUND

Operability is mainly determined by the interaction between the magnitude of an operation and the patient's tolerance for the procedure. A further factor is the benefit gained by performing the procedure versus the sequelae caused by its omission.

RESULTS

Major operations within the first 3 days after trauma appear to have an increased risk, particularly if they are performed during impaired respiratory function (pO(2)/F(i)O(2) ratio <280 mmHg) or increased inflammatory status. Such interventions are recommended to be postponed until a later time. Surgical interventions after day 3 require an individual decision with respect to the timing of the operation. Criteria that are of value in this decision comprise a pO(2)/F(i)O(2) ratio above 280 mmHg, a stable circulation, a platelet count above 100.000 to 150.000/microl, normal global coagulation tests, only moderate systemic inflammation as indicated by C-reactive protein or interleukin-6 levels, a normal fluid balance and in case of traumatic brain injury there should be no signs of increased intracranial pressure. Whether liver function, level of PEEP, catecholamine therapy and other factors will influence operability remains to be elucidated.

CONCLUSION

The pathophysiological consequences of accidental trauma show a phasic course with respect to the immunomodulatory response. An operative trauma inflicted by a secondary surgical intervention contributes an additional burden. Depending on the inflammatory phase during which this secondary hit is inflicted there may be a disturbance of homoeostasis that may even lead to multiple organ failure. Whether this happens can depend on type and magnitude of the surgical intervention. Minor operations result in smaller systemic effects and will be less critical with respect to operability.