The pathophysiological time window study of performing minimally invasive procedures for the intracerebral hematoma evacuation in rabbit

Cystatin C Attenuates Perihematomal Secondary Brain Injury by Inhibiting the Cathepsin B/NLRP3 Signaling Pathway in a Rat Model of Intracerebral Hemorrhage

Secondary brain injury (SBI) is a noticeable contributor to the high mortality and morbidity rates associated with intracerebral hemorrhage (ICH), and effective treatment options remain limited. Cystatin C (CysC) emerges as a novel candidate for SBI intervention. The therapeutic effects and underlying mechanisms of CysC in mitigating SBI following ICH were explored in the current research. An in vivo ICH rat model was established by injecting autologous blood into the right caudate nucleus. Western blotting (WB) was utilized to assess the levels of CysC, cathepsin B (CTSB), and the NLRP3 inflammasome. Subsequently, the ICH rat model was treated with exogenous CysC supplementation or CysC knockdown plasmids. Various parameters, including Evans blue (EB) extravasation, brain water content, and neurological function in rats, were examined. RT-qPCR and WB were employed to determine the expression levels of CTSB and the NLRP3 inflammasome. The co-expression of CTSB, CysC, and NLRP3 inflammasome with GFAP, NeuN, and Iba1 was assessed through double-labeled immunofluorescence. The interaction between CysC and CTSB was investigated using double-labeled immunofluorescence and co-immunoprecipitation. The findings revealed an elevation of CysC expression level, particularly at 24 h after ICH. Exogenous CysC supplementation alleviated severe brain edema, neurological deficit scores, and EB extravasation induced by ICH. Conversely, CysC knockdown produced opposite effects. The expression levels of CTSB and the NLRP3 inflammasome were significantly risen following ICH, and exogenous CysC supplement attenuated their expression levels. Double-labeled immunofluorescence illustrated that CysC, CTSB, and the NLRP3 inflammasome were predominantly expressed in microglial cells, and the interaction between CysC and CTSB was evidenced. CysC exhibited potential in ameliorating SBI following ICH via effectively suppressing the activation of the NLRP3 inflammasome mediated by CTSB specifically in microglial cells. These findings underscore the prospective therapeutic efficacy of CysC in the treatment of ICH-induced complications.

Association between the surgical approach and prognosis of spontaneous supratentorial deep intracerebral hemorrhage

The association between surgical approach and prognosis in patients with spontaneous supratentorial deep intracerebral hemorrhage is unclear. We aimed to explore the association between surgical approach and prognosis in these patients. A retrospective cohort of 311 patients from 3 centers who were treated with surgery 24 h after ictus was recruited. The surgical procedure involved removing the intracerebral hematoma using an aspirator through either the cortical approach or Sylvian fissure approach, assisted by an endoscope or microscope. The primary outcome was the one-year modified Rankin scale (mRS) score. The association between the surgical approach and the one-year mRS score was explored by using ordinal logistic regression and binary logistic regression. Baseline characteristics were balanced by propensity score matching and inverse propensity score weighting. In the adjusted analysis, compared with the cortex approach group, the Sylvian fissure approach group had better one-year mRS scores when analyzed as an ordinal variable (3.00 [2.00-4.00] vs. 4.00 [3.00-5.00]; adjusted odds ratio, 3.15; 95% CI, 1.78-5.58; p < 0.001) and a dichotomous variable (74.14% vs. 49.01%; adjusted odds ratio, 6.61; 95% CI, 2.75-15.88; p < 0.001). Surgical approach was not significantly associated with rebleeding (p = 0.88) or three-month mortality (p = 0.81). In univariate analysis after propensity score matching, there were significant differences in one-year mRS score between the two groups (p < 0.001), and there were no significant differences in rebleeding (Fisher's exact test, p > 0.999) or three-month mortality (Fisher's exact test, p > 0.999). Inverse probability weighted regression analysis showed better one-year mRS scores when analyzed as an ordinal variable (adjusted odds ratio, 3.03; 95% CI, 2.17-4.17; p < 0.001) and a dichotomous variable (adjusted odds ratio, 3.11; 95% CI, 2.16-4.77; p < 0.001) in the Sylvian fissure approach group; the surgical approach was not significantly associated with rebleeding (p = 0.50) or three-month mortality (p = 0.60). In the surgical treatment of patients with spontaneous supratentorial deep intracerebral hemorrhage, the Sylvian fissure approach may lead to a better functional outcome compared with the cortex approach. Future prospective studies are warranted to confirm this finding.

PPARγ/RAD21 alleviates peripheral secondary brain injury in rat cerebral hemorrhage model through promoting M2 polarization of microglial cells

BACKGROUND

PPARγ has been reported to participate in intracerebral hemorrhage (ICH) progression, and recruit RAD21 through binding DNA. Our study aimed to explore the roles of PPARγ/RAD21 in ICH and their related mechanisms.

METHODS

ICH models in vitro and in vivo were established using thrombin and autologous blood injection, respectively. After that, rosiglitazone (RSG), GW9662, and RAD21 knockdown/overexpression plasmids were used to treat the ICH models. The cell apoptosis, the related inflammatory cytokines levels, and the neurological function of the rats were examined. Real-time quantitative PCR (RT-qPCR), western blot and immunofluorescence were employed to determine the expression of the M1/M2 polarization-related markers. Finally, the interaction of PPARγ and RAD21 in microglial cells was observed using double labeled immunofluorescence and co-immunoprecipitation.

RESULTS

After thrombin induction, the cell apoptosis, and TNF-α, IL-1β and IL-10 contents were all significantly increased (P < 0.05); whereas RSG and RAD21 overexpression evidently inhibited the apoptosis of thrombin-caused microglial cells, reduced TNF-α and IL-1β contents, further increased IL-10 content (P < 0.05). The combination of RAD21 and PPARγ was enhanced by RSG and RAD21 overexpression. In vivo experiments showed that RSG and RAD21 overexpression decreased neurological deficit score, brain water content and hematoma volume. Additionally, RSG and RAD21 overexpression up-regulated the expression of PPARγ, RAD21, Arg1, KLF4, and TGF-β, whereas down-regulated iNOS and CD32 expression. The actions of GW9662 and RAD21 knockdown were opposite to those of RSG and RAD21 overexpression.

CONCLUSION

PPARγ/RAD21 may alleviate ICH progression through promoting M2-type polarization of microglial cells and inhibiting inflammatory response.

Optimizing the Time Window of Minimally Invasive Stereotactic Surgery for Intracerebral Hemorrhage Evacuation Combined with Rosiglitazone Infusion Therapy in Rabbits

OBJECTIVE

This study aimed to explore the effects of minimally invasive surgery (MIS) in combination with rosiglitazone (RSG) on intracerebral hemorrhage (ICH) and determine the optimal time window.

METHODS

An ICH rabbit model was constructed using the injection of autologous arterial blood and then treated with RSG, MIS, and MIS combined with RSG at 6, 12, 18, and 24 hours. Thereafter, rabbits that underwent different treatments were used to measure the neurological deficit score, brain water content, and glutamate content. Expression of peroxisome proliferator-activated receptor γ (PPARγ) and CD36 in the different groups was detected using real-time quantitative polymerase chain reaction and Western blotting. In addition, oxidative stress-related and inflammation-related genes were examined.

RESULTS

Brain computed tomography indicated that an ICH rabbit model was successfully established. Compared to those in the control rabbits, the neurological deficit scores, brain water content, and glutamate content in the ICH rabbits were significantly increased at each time window (P < 0.05), while they were decreased at each time window after MIS combined with RSG treatment and declined to the lowest at 6 hours. Additionally, ICH significantly upregulated PPARγ and CD36 expression (P < 0.05). Moreover, superoxide dismutase content decreased after ICH, and nitric oxide synthase 2, tumor necrosis factor-alpha, interleukin-6, and interleukin-1 beta mRNA expression was upregulated, whereas MIS combined with RSG treatment reversed the levels caused by ICH.

CONCLUSIONS

Evacuation of MIS hematoma combined with RSG infusion at an early stage (6 hours) may attenuate secondary brain damage caused by ICH by regulating the PPARγ/CD36 pathway.

Minimally Invasive Surgery for ICH Evacuation Combined With Deferoxamine Treatment Increased Perihematomal Claudin-5 and ZO-1 Expression Levels and Decreased BBB Permeability in Rabbits

Objective

To investigate the role of minimally invasive surgery (MIS) in intracerebral hemorrhage (ICH) evacuation combined with deferoxamine (DFX) treatment on perihematomal tight junction protein (claudin-5 and ZO-1) expression levels and blood-brain barrier (BBB) permeability in rabbits.

Methods

We randomly assigned 65 male rabbits (weight: 1.9–2.6 kg) to a normal control group (NC group, 13 rabbits), hemorrhage model group (HM group, 13), DFX treatment group (DFX group, 13 rabbits), MIS group (MIS group, 13 rabbits), or MIS combined with DFX treatment group (MIS + DFX group, 13 rabbits). ICH was established in all of the groups except the NC group. MIS was performed to evacuate the hematoma 6 h after the ICH model was created in the MIS and MIS + DFX groups. The DFX and MIS + DFX groups were treated with DFX (100 mg/kg, dissolved in 2 mL of 0.9% saline solution, administered intramuscularly) at 2 h, and then every 12 h for 7 d. The same dose of 0.9% saline solution was administered to the NC, HM, and MIS groups at the same time points. Sixty-five rabbits were divided into 5 groups, and 13 rabbits in each group. Neurological deficit (i.e., Purdy's score) was recorded in all rabbits before euthanasia (N total = 65). In each group, 2 rabbits were used for iron concentration measurement (N total = 10), 2 rabbits were used for brain water content measurement (N total = 10), 3 rabbits were used for BBB permeability measurement (N total = 15), 3 rabbits were used for claudin-5, ZO-1 expression detection by Western Blotting (N total = 15), and 3 rabbits were used for claudin-5, ZO-1 mRNA detection by real-time PCR (N total = 15). On day 7, the rabbits were sacrificed and the perihematomal brain tissue was harvested to test the iron concentration, brain water content (BWC), tight junction proteins (claudin-5 and ZO-1) expression, and BBB permeability.

Results

Purdy's score, iron concentration, and BWC were lower in the MIS and MIS + DFX groups compared to the HM and DFX groups. The MIS + DFX group showed a significant decrease in these indicators. The use of MIS to evacuate the hematoma led to increased expression levels of claudin-5 and ZO-1, as well as decreased BBB permeability. The MIS + DFX group exhibited a remarkable increase in claudin-5 and ZO-1 expression levels and a significant decrease in BBB permeability.

Conclusions

MIS combined with DFX treatment could increase the expression levels of perihematomal tight junction proteins (claudin-5 and ZO-1) expression, reduce BBB permeability, and improve the neurological function. MIS combined with DFX treatment may also prevent secondary brain damage following ICH.

Early Minimally Invasive Parafascicular Surgery for Evacuation of Spontaneous Intracerebral Hemorrhage in the Setting of Computed Tomography Angiography Spot Sign: A Case Series

BACKGROUND

Spontaneous intracerebral hemorrhage (sICH) is associated with high morbidity and mortality, and the role of surgery is uncertain. Spot sign on computed tomography angiography (CTA) has previously been seen as a contraindication for minimally invasive techniques.

OBJECTIVE

To demonstrate the use of minimally invasive parafascicular surgery (MIPS) for early evacuation of sICH in patients with spot sign on CTA.

METHODS

Retrospective review of patients presenting to a US tertiary academic medical center from 2018 to 2020 with sICH and CTA spot sign who were treated with MIPS within 6 h of arrival.

RESULTS

Seven patients (6 men and 1 woman, mean age 54.4 yr) were included in this study. There was a significant decrease between preoperative and postoperative intracerebral hemorrhage volumes (75.03 ± 39.00 cm3 vs 19.48 ± 17.81 cm3, P = .005) and intracerebral hemorrhage score (3.1 ± 0.9 vs 1.9 ± 0.9, P = .020). The mean time from arrival to surgery was 3.72 h (±1.22 h). The mean percentage of hematoma evacuation was 73.78% (±21.11%). The in-hospital mortality was 14.29%, and the mean modified Rankin score at discharge was 4.6 (±1.3). No complications related to the surgery were encountered in any of the cases, with no abnormal intraoperative bleeding and no pathology demonstrating occult vascular lesion.

CONCLUSION

Early intervention with MIPS appears to be a safe and effective means of hematoma evacuation despite the presence of CTA spot sign, and this finding should not delay early intervention when indicated. Intraoperative hemostasis may be facilitated by the direct visualization provided by a tubular retractor system.

Recent Updates in Neurosurgical Interventions for Spontaneous Intracerebral Hemorrhage: Minimally Invasive Surgery to Improve Surgical Performance

The efficacy and safety of surgical treatment for intracerebral hemorrhage (ICH) have long been subjects of investigation and debate. The recent results of the minimally invasive surgery plus alteplase for intracerebral hemorrhage evacuation (MISTIE) III trial demonstrated the safety of the procedure and a reduction in mortality compared to medical treatment. Although no improvement in functional outcomes was shown, the trial elucidated that benefits of intervention depend on surgical performance: a greater ICH reduction, defined as ≤ 15 mL end of treatment ICH volume or ≥70% volume reduction, correlated with significant functional improvement. Recent meta-analyses suggested the benefits of neurosurgical hematoma evacuation, especially when performed earlier and done using minimally invasive procedures. In MISTIE III, to confirm hemostasis and reduce the risk of rebleeding, the mean time from onset to surgery and treatment completion took 47 and 123 h, respectively. Theoretically, the earlier the hematoma is removed, the better the outcome. Therefore, a higher rate of hematoma reduction within an earlier time course may be beneficial. Neuroendoscopic surgery enables less invasive removal of ICH under direct visualization. Minimally invasive procedures have continued to evolve with the support of advanced guidance systems and devices in favor of better surgical performance. Ongoing randomized controlled trials utilizing emerging minimally invasive techniques, such as the Early Minimally Invasive Removal of Intra Cerebral Hemorrhage (ENRICH) trial, Minimally Invasive Endoscopic Surgical Treatment with Apollo/Artemis in Patients with Brain Hemorrhage (INVEST) trial, and the Dutch Intracerebral Hemorrhage Surgery Trial (DIST), may provide significant information on the optimal treatment for ICH.

When the Blood Hits Your Brain: The Neurotoxicity of Extravasated Blood

Hemorrhage in the central nervous system (CNS), including intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), and aneurysmal subarachnoid hemorrhage (aSAH), remains highly morbid. Trials of medical management for these conditions over recent decades have been largely unsuccessful in improving outcome and reducing mortality. Beyond its role in creating mass effect, the presence of extravasated blood in patients with CNS hemorrhage is generally overlooked. Since trials of surgical intervention to remove CNS hemorrhage have been generally unsuccessful, the potent neurotoxicity of blood is generally viewed as a basic scientific curiosity rather than a clinically meaningful factor. In this review, we evaluate the direct role of blood as a neurotoxin and its subsequent clinical relevance. We first describe the molecular mechanisms of blood neurotoxicity. We then evaluate the clinical literature that directly relates to the evacuation of CNS hemorrhage. We posit that the efficacy of clot removal is a critical factor in outcome following surgical intervention. Future interventions for CNS hemorrhage should be guided by the principle that blood is exquisitely toxic to the brain.

Activating PPARγ Increases NQO1 and γ-GCS Expression via Nrf2 in Thrombin-activated Microglia

The present study aimed to explore the molecular mechanisms underlying the increase of nicotinamide adenine dinucleotide phosphate:quinine oxidoreductase 1 (NQO1) and γ-glutamylcysteine synthetase (γ-GCS) in brain tissues after intracerebral hemorrhage (ICH). The microglial cells obtained from newborn rats were cultured and then randomly divided into the normal control group (NC group), model control group (MC group), rosiglitazone (RSG) intervention group (RSG group), retinoic-acid intervention group (RSG+RA group), and sulforaphane group (RSG+SF group). The expression levels of NQO1, γ-GCS, and nuclear factor E2-related factor 2 (Nrf2) were measured by real-time polymerase chain reaction (RT-PCR) and Western blotting, respectively. The results showed that the levels of NQO1, γ-GCS and Nrf2 were significantly increased in the MC group and the RSG group as compared with those in the NC group (P<0.01). They were found to be markedly decreased in the RSG+RA group and increased in the RSG+SF group when compared with those in the MC group or the RSG group (P<0.01). The RSG+SF group displayed the highest levels of NQO1, γ-GCS, and Nrf2 among the five groups. In conclusion, a medium dose of RSG increased the anti-oxidative ability of thrombin-activated microglia by increasing the expression of NQO1 and γ-GCS. The molecular mechanisms underlying the increase of NQO1 and γ-GCS in thrombin-activated microglia may be associated with the activation of Nrf2.

Efficacy and safety of four interventions for spontaneous supratentorial intracerebral hemorrhage: a network meta-analysis

OBJECT

To investigate the efficacy and safety of four interventions of spontaneous intracerebral hemorrhage simultaneously.

METHODS

PubMed, EmBase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials (RCTs) investigating endoscopic surgery (ES), minimally invasive puncture surgery (MIPS), conventional craniotomy (CC), and/or conservative medical treatment (CMT). Good functional outcome, death, and hemorrhage recurrence rates were evaluated by a network meta-analysis.

RESULTS

20 RCTs with 3603 patients were included. Compared with CMT, a higher rate of good functional outcome was found after ES (RR=2.21, 95% CI 1.37 to 3.55) and MIPS (RR=1.47, 95% CI 1.24 to 1.73). Both ES (RR=0.62, 95% CI 0.44 to 0.86) and MIPS (RR=0.72, 95% CI 0.58 to 0.90) markedly reduced the rate of death. However, there was no significant difference in efficacy and safety between ES and MIPS. The top ranked P score for the efficacy outcome was for ES (P score=0.9810). ES (P-score=0.0709) ranked lowest for the primary safety outcome. There was a higher risk of hemorrhage recurrence after CC (RR=3.80, 95% CI 1.90 to 7.63) and MIPS (RR=2.86, 95% CI 1.70 to 4.82) compared with CMT whereas no significant difference was found for ES (RR=1.46, 95% CI 0.53 to 4.02).

CONCLUSIONS

The results suggest that both ES and MIPS significantly improve neurological function and reduce the risk of death compared with CMT, and there is no significant difference between ES and MIPS. Ranking of P scores revealed that ES may be the most optimal intervention to improve functional outcome and prevent death. This needs to be evaluated further.

Rosiglitazone pretreatment influences thrombin-induced anti-oxidative action via activating NQO1and γ-GCS in rat microglial cells

Objective To explore the molecular mechanism involved in rosiglitazone against secondary brain damage caused by cerebral hemorrhage, we pretreated thrombin-induced microglial cells by rosiglitazone and then investigated its effect on antioxidant-related genes NQO1and γ-GCS expression change. Methods Primary microglial cells were obtained from the brain tissue of newborn Sprague-Dawley (SD) rats and were randomly divided into three groups: the normal (control), thrombin stimulation (TH), thrombin-treated plus rosiglitazone (TH+RGZ). The expression of NQO1and γ-GCS was measured by immunocytochemistry, real-time PCR, and western blot analysis. Results The immunocytochemistry showed that the number of NQO1and γ-GCS stained cells in TH and TH+RGZ group increased compared to the control group. In addition, the expression of NQO1 and γ-GCS in TH+RGZ group remarkably increased in mRNA and protein level compared to TH only group (p < 0.01). Conclusion Rosiglitazone can increase thrombin-induced microglia anti-oxidative ability by increasing NQO1and γ-GCS expression, which can effectively reduce secondary injury after cerebral hemorrhage.

Optimal Surgical Timing of Aspiration for Spontaneous Supratentorial Intracerebral Hemorrhage

OBJECTIVE

Minimally invasive techniques such as stereotactic aspiration have been regarded as promising alternative methods to replace craniotomy in the treatment of intracerebral hemorrhage (ICH). The aim of this study was to identify the optimal timing of stereotactic aspiration and analyze the factors affecting the clinical outcome.

MATERIALS AND METHODS

This retrospective study included 81 patients who underwent stereotactic aspiration for spontaneous supratentorial ICH at single institution. Volume of hematoma was calculated based on computed tomography scan at admission, just before aspiration, immediately after aspiration, and after continuous drainage. The neurologic outcome was compared with Glasgow outcome scale (GOS) score.

RESULTS

The mean volume ratio of residual hematoma was 59.5% and 17.6% immediately after aspiration and after continuous drainage for an average of 2.3 days, respectively. Delayed aspiration group showed significantly lower residual volume ratio immediately after aspiration. However, there was no significant difference in the residual volume ratio after continuous drainage. The favorable outcome of 1-month GOS 4 or 5 was significantly better in the group with delayed aspiration after more than 7 days (p = 0.029), despite no significant difference in postoperative 6-months GOS score. A factor which has significant correlation with postoperative 6-months favorable outcome was the final hematoma volume ratio after drainage (p = 0.028).

CONCLUSION

There is no difference in final residual volume of hematoma or 6-months neurologic outcome according to the surgical timing of hematoma aspiration. The only factor affecting the postoperative 6-months neurologic outcome is the final volume of remaining hematoma after drainage.

Rosiglitazone Infusion Therapy Following Minimally Invasive Surgery for Intracranial Hemorrhage Evacuation Decreased Perihematomal Glutamate Content and Blood-Brain Barrier Permeability in Rabbits

OBJECTIVE

To observe effects of rosiglitazone (RSG) infusion therapy on perihematomal peroxisome-proliferator-activated receptor gamma (PPARγ), glutamate, blood-brain barrier (BBB) permeability, and brain edema.

METHODS

Fifty male rabbits (2.8-3.4 kg) were randomly assigned to a normal control (NC) group, model control (MC) group, RSG group, minimally invasive surgery (MIS) group, or MIS and RSG (MIS+RSG) group. Intracranial hemorrhage was induced in all rabbits except for the NC group. MIS procedures were performed to evacuate the intracranial hemorrhage 6 hours after the intracranial hemorrhage model was prepared successfully. The animals were sacrificed on day 7, and the perihematomal brain tissue was obtained to determine PPARγ, glutamate, and BBB permeability.

RESULTS

Compared with the MC group, the MIS group displayed a remarkable decrease in PPARγ, glutamate, and BBB permeability. The RSG group showed similar results in glutamate level and BBB permeability but a significant increase in PPARγ. The MIS+RSG group displayed an increase in PPARγ and a more significant decrease in glutamate, BBB permeability, and neurologicl deficit scores compared with the other groups.

CONCLUSIONS

Performing MIS followed by RSG infusion therapy might increase PPARγ expression and might be more efficacious for reducing glutamate level and BBB permeability and improving neurologic function than MIS or RSG therapy used alone.

Minimally Invasive Surgery for Evacuating the Intracerebral Hematoma in Early Stages Decreased Secondary Damages to the Internal Capsule in Dog Model of ICH Observed by Diffusion Tensor Imaging

BACKGROUND

Diffusion tensor imaging was used to observe the effects of performing early minimally invasive surgery (MIS) on internal capsule in dog model of intracerebral hemorrhage (ICH).

METHODS

Twenty-five male dogs were selected to prepare an ICH model, and then they were randomly distributed into a model control (MC) group (5 dogs) or an MIS group (20 dogs). In the MIS group, the intracerebral hematoma was evacuated by stereotactic minimally invasive procedures over 6 hours (5 dogs), 12 hours (5 dogs), 18 hours (5 dogs), or 24 hours (5 dogs) after successful induction of ICH. The same procedure was performed in the MC group but without evacuating the hematoma. All the animals were sacrificed within 2 weeks after the hematoma was surgically evacuated. The neurologic deficit score and diffusion tensor imaging (DTI) were observed before and after the MIS. The perihematomal blood-brain barrier (BBB) permeability and the brain water content (BWC) were measured 2 weeks after the hematoma was surgically evacuated.

RESULTS

The DTI demonstrated that integrity of the internal capsule restored largely after surgery and the fractional anisotropy (FA) values of the internal capsule on the hematoma side increased significantly as compared with those in the MC group or those before surgery in the same group. The postoperative ratios of FA values of each MIS subgroup increased compared with the MC group and those before surgery in the same subgroup before operation. The neurologic deficit score, the perihematomal BBB permeability, and the BWC of each MIS subgroup decreased significantly compared with those of the MC group. The 6-12-hour group displayed a more favorable result.

CONCLUSIONS

Performing the MIS in the early stage (6-12 hours) after ICH could decrease the secondary damages to the internal capsule so as to promote the recovery of motor function. The optimal time window for MIS should be within 6-12 hours after onset of ICH.

Minimally invasive surgery for ICH evacuation followed by rosiglitazone infusion therapy increased perihematomal PPARγ expression and improved neurological outcomes in rabbits

OBJECTIVES

To observe the effects of minimally invasive surgery (MIS) for intracerebral hematoma (ICH) evacuation followed by rosiglitazone infusion therapy on peroxisome proliferator-activated receptor-gamma (PPARγ), blood-brain barrier (BBB) permeability, and neurological function.

METHODS

A total of 75 male rabbits (2.8-3.4 kg) were randomly assigned to a normal control group (NC group), a model control group (MC group), a rosiglitazone group (RSG group), a minimally invasive treatment group (MIS group) or a MIS combined with rosiglitazone group (MIS+RSG group). ICH was induced in all of the animals except for those in the NC group. The rosiglitazone was infused into the hematoma area in the RSG group and the MIS+RSG group. A MIS was performed to evacuate the ICH 6 h after the successful preparation of the ICH model in the MIS group and the MIS+RSG group. Each group included 15 rabbits and was divided equally into 3 subgroups (each subgroup included 5 rabbits that were killed on day 1, day 3, or day 7). Neurological deficit scores were determined, and the perihematomal brain tissue was removed to determine the PPARγ level and BBB permeability.

RESULTS

Neurological deficit scores, perihematomal PPARγ levels, and BBB permeability were all significantly increased in the MC group compared to the NC group. Performing the MIS alone to evacuate the ICH resulted in a marked decrease in these indices. The RSG used alone increased PPARγ levels and decreased BBB disruption. The MIS+RSG group displayed a marked increase in PPARγ levels and a more significant decrease in BBB permeability and neurological deficit scores.

CONCLUSIONS

Performing MIS followed by PPARγ agonist infusion therapy is more efficacious for reducing secondary damage to the brain and improving neurological function.

Rosiglitazone infusion therapy following minimally invasive surgery for intracerebral hemorrhage evacuation decreases matrix metalloproteinase-9 and blood-brain barrier disruption in rabbits

Background

The objective of this study was to investigate the effects of Rosiglitazone (RSG) infusion therapy following minimally invasive surgery (MIS) for intracerebral hemorrhage(ICH) evacuation on perihematomal secondary brain damage as assessed by MMP-9 levels, blood–brain barrier (BBB) permeability and neurological function.

Methods

A total of 40 male rabbits (2.8–3.4 kg) was randomly assigned to a normal control group (NC group; 10 rabbits), a model control group (MC group; 10 rabbits), a minimally invasive treatment group (MIS group; 10 rabbits) or a combined MIS and RSG group (MIS + RSG group; 10 rabbits). ICH was induced in all the animals, except for the NC group. MIS was performed to evacuate ICH 6 hours after the successful preparation of the ICH model in the MIS and MIS + RSG groups. The animals in the MC group underwent the same procedures for ICH evacuation but without hematoma aspiration, and the NC group was subjected to sham surgical procedures. The neurological deficit scores (Purdy score) and ICH volumes were determined on days 1, 3 and 7. All of the animals were sacrificed on day 7, and the perihematomal brain tissue was removed to determine the levels of PPARγ, MMP-9, BBB permeability and brain water content (BWC).

Results

The Purdy score, perihematomal PPARγ levels, BBB permeability, and BWC were all significantly increased in the MC group compared to the NC group. After performing the MIS for evacuating the ICH, the Purdy score and the ICH volume were decreased on days 1, 3 and 7 compared to the MC group. A remarkable decrease in perihematomal levels of PPARγ, MMP-9, BBB permeability and BWC were observed. The MIS + RSG group displayed a remarkable increase in PPARγ as well as significant decrease in MMP-9, BBB permeability and BWC compared with the MIS group.

Conclusions

RSG infusion therapy following MIS for ICH treatment might be more efficacious for reducing the levels of MMP-9 and secondary brain damage than MIS therapy alone.

Effects of minimally invasive procedures for evacuation of intracerebral hematoma in early stages on MMP-9 and BBB permeability in rabbits

BACKGROUND

The effects of performing a minimally invasive procedure at different stages after intracerebral hemorrhage on perihematomal MMP-9 expression and blood-brain barrier (BBB) permeability were evaluated.

METHODS

Sixty rabbits were randomly distributed into a model control group (MC group, 30 rabbits) or a minimally invasive group (MI group, 30 rabbits). A model of intracerebral hemorrhage was established in the MC and MI group. In the MI group, the intracerebral hematoma was evacuated by stereotactic minimally invasive procedures over 6 hours (6 rabbits), 12 hours (6 rabbits), 18 hours (6 rabbits) 24 hours or 48 hours (6 rabbits) following successful induction of intracerebral hemorrhage. The same procedure was performed in the MC group at the same time point but without evacuating the hematoma. All the animals were sacrificed within two weeks after the hematoma was surgically evacuated. A neurological deficit score was determined, and the perihematomal MMP-9 level and the BBB permeability were measured.

RESULTS

The neurological deficit score, perihematomal MMP-9 level and BBB permeability of the MI group decreased significantly compared to the MC group. Performing the MI procedure 6-12 h after intracerebral hemorrhage showed the most favorable outcome.

CONCLUSIONS

Regarding the pathophysiological changes surrounding the hematoma, the optimal time window of performing MI procedures for the intracerebral hematoma evacuation might be within 6-12 h after hemorrhage.

Frameless stereotactic aspiration for spontaneous intracerebral hemorrhage and subsequent fibrinolysis using urokinase

Objectives

The optimal management of patients with spontaneous intracerebral hemorrhage (ICH) remains controversial. The aim of this study was to evaluate technical results and clinical outcomes of frameless stereotactic aspiration and fibrinolysis using urokinase performed in a single center.

Materials and Methods

The subjects of this study were 62 consecutive patients with spontaneous ICH who were treated with frameless stereotactic aspiration and subsequent fibrinolysis using urokinase between February 2009 and June 2010 in our hospital. The surgical results, procedure-related complications, and clinical outcomes were evaluated.

Results

A total of 62 patients were enrolled in the study. The median age was 54 years (range, 32-86). The mean initial Glasgow coma scale score was 7.7 (range 5-11). The mean initial hemorrhage volume was 43 cm³ (range 30-70). Seven patients (11.2%) died of respiratory failure (four patients), postoperative edema (two patients), and heart disease (one patient). There were seven cases of procedure-related complications (11.2%), including malpositioning of catheters (two patients), pneumocephalus (one patient), and rebleeding (four patients, 6.4%). At the three-month follow-up, a good outcome (three-month Glasgow outcome scale > 3) was noted in 32 patients (51.6%).

Conclusions

Frameless stereotactic aspiration and subsequent fibrinolytic thearpy using urokinase for spontaneous ICH is a simple and safe procedure with low mortality and rebleeding rate.

Early stage minimally invasive procedures reduce perihematomal MMP-9 and blood-brain barrier disruption in a rabbit model of intracerebral hemorrhage

INTRODUCTION

The effects of performing a minimally invasive procedure at different stages after intracerebral hemorrhage (ICH) on perifocal MMP-9 expression and blood-brain barrier (BBB) permeability were evaluated.

METHODS

Thirty-six rabbits were randomly distributed into a normal control group (NC group, six rabbits), a model control group (MC group, six rabbits), and a minimally invasive group (MI group, 24 rabbits). A model of ICH was established in the MC and MI groups. In the MI group, the intracerebral hematoma was evacuated by stereotactic minimally invasive procedures over 6 hours (six rabbits), 12 hours (six rabbits), 18 hours (six rabbits), and 24 hours (six rabbits), following successful induction of ICH. All animals were sacrificed within 48 hours after the hematoma was surgically evacuated. A neurological deficit score was determined, and the perihematomal MMP-9 level and the BBB permeability were measured.

RESULTS

The neurological deficit score, the perihematomal MMP-9 level, and the BBB permeability of the MI group were decreased significantly compared with the MC group. Performing the MI procedure 6-12 hours after ICH showed the most significant decrease in MMP-9, BBB permeability, and neurological deficit score.

CONCLUSION

The optimal time window of performing MI procedures for the intracerebral hematoma evacuation might be within 6-12 hours after hemorrhage.