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Lincoln JA, Hasan KM, Gabr RE, Wolinsky JS. Characterizing the time course of cerebrovascular reactivity in multiple sclerosis. J Neuroimaging 2022; 32:430-435. [PMID: 35165962 PMCID: PMC9090952 DOI: 10.1111/jon.12979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Changes in cerebral perfusion occur early in relapsing and progressive multiple sclerosis (MS) patients, though whether cerebral blood flow (CBF) can be altered by therapy is unknown. We sought to characterize the time course of change in CBF (cerebral vascular reactivity [CVR]), following intravenous (IV) acetazolamide (ACZ) in whole brain and within various gray and white matter brain regions in MS patients. METHODS We enrolled five relapsing MS patients on injectable therapies. Participants received a 1000 mg IV bolus of ACZ and CBF was measured using pseudocontinuous arterial spin labeling MRI. To quantify differences in time course between patients, we calculated the numerical integration of CVR over time using the trapezoidal rule to estimate area under the curve (AUC(CVR) ). RESULTS A change in whole brain CBF of 30%-65% was seen in all participants at 15 minutes after ACZ challenge. CBF increases >20% above baseline were sustained for 90 minutes within whole-brain, normal-appearing white matter and total T2-hyperintense lesioned tissue. AUC(CVR) values for both gray (cortical and deep gray matter) and white (normal-appearing and T2-lesioned) matter regions were similar between patients. CONCLUSION Our findings show a prolonged time course in vascular reactivity after ACZ stimulus in MS patients with a similar time course for both gray and white matter brain regions, including in previously injured tissue. Our preliminary results suggest that blood flow can be augmented in the established MS lesion suggesting that even previously injured tissue might be responsive to treatment.
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Affiliation(s)
- John A Lincoln
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA
| | - Khader M Hasan
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA
| | - Refaat E Gabr
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA
| | - Jerry S Wolinsky
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA
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Wood MD, Boyd JG, Wood N, Frank J, Girard TD, Ross-White A, Chopra A, Foster D, Griesdale DEG. The Use of Near-Infrared Spectroscopy and/or Transcranial Doppler as Non-Invasive Markers of Cerebral Perfusion in Adult Sepsis Patients With Delirium: A Systematic Review. J Intensive Care Med 2021; 37:408-422. [PMID: 33685273 PMCID: PMC8772019 DOI: 10.1177/0885066621997090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: Several studies have previously reported the presence of altered cerebral perfusion during sepsis. However, the role of non-invasive neuromonitoring, and the impact of altered cerebral perfusion, in sepsis patients with delirium remains unclear. Methods: We performed a systematic review of studies that used near-infrared spectroscopy (NIRS) and/or transcranial Doppler (TCD) to assess adults (≥18 years) with sepsis and delirium. From study inception to July 28, 2020, we searched the following databases: Ovid MedLine, Embase, Cochrane Library, and Web of Science. Results: Of 1546 articles identified, 10 met our inclusion criteria. Although NIRS-derived regional cerebral oxygenation was consistently lower, this difference was only statistically significant in one study. TCD-derived cerebral blood flow velocity was inconsistent across studies. Importantly, both impaired cerebral autoregulation during sepsis and increased cerebrovascular resistance were associated with delirium during sepsis. However, the heterogeneity in NIRS and TCD devices, duration of recording (from 10 seconds to 72 hours), and delirium assessment methods (e.g., electronic medical records, confusion assessment method for the intensive care unit), precluded meta-analysis. Conclusion: The available literature demonstrates that cerebral perfusion disturbances may be associated with delirium in sepsis. However, future investigations will require consistent definitions of delirium, delirium assessment training, harmonized NIRS and TCD assessments (e.g., consistent measurement site and length of recording), as well as the quantification of secondary and tertiary variables (i.e., Cox, Mxa, MAPOPT), in order to fully assess the relationship between cerebral perfusion and delirium in patients with sepsis.
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Affiliation(s)
- Michael D Wood
- Department of Anesthesiology, Pharmacology and Therapeutics, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - J Gordon Boyd
- Department of Critical Care Medicine, 4257Queen's University, Kingston, Ontario, Canada
| | - Nicole Wood
- Department of Physics, 8430University of Waterloo, Waterloo, Ontario, Canada
| | - James Frank
- Department of Physics, 7497Brock University, St. Catharines, Ontario, Canada
| | - Timothy D Girard
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Akash Chopra
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Denise Foster
- Division of Critical Care Medicine, Department of Medicine, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald E G Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, 8166University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, Department of Medicine, 8166University of British Columbia, Vancouver, British Columbia, Canada.,Center for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
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Heming N, Mazeraud A, Azabou E, Moine P, Annane D. Vasopressor Therapy and the Brain: Dark Side of the Moon. Front Med (Lausanne) 2020; 6:317. [PMID: 31998736 PMCID: PMC6966606 DOI: 10.3389/fmed.2019.00317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/13/2019] [Indexed: 12/14/2022] Open
Abstract
Sepsis, a leading cause of morbidity and mortality, is caused by a deregulated host response to pathogens, and subsequent life-threatening organ dysfunctions. All major systems, including the cardiovascular, respiratory, renal, hepatic, hematological, and the neurological system may be affected by sepsis. Sepsis associated neurological dysfunction is triggered by multiple factors including neuro-inflammation, excitotoxicity, and ischemia. Ischemia results from reduced cerebral blood flow, caused by extreme variations of blood pressure, occlusion of cerebral vessels, or more subtle defects of the microcirculation. International guidelines comprehensively describe the initial hemodynamic management of sepsis, revolving around the normalization of systemic hemodynamics and of arterial lactate. By contrast, the management of sepsis patients suffering from brain dysfunction is poorly detailed, the only salient point being mentioned is that sedation and analgesia should be optimized. However, sepsis and the hemodynamic consequences thereof as well as vasopressors may have severe untoward neurological consequences. The current review describes the general neurological complications, as well as the consequences of vasopressor therapy on the brain and its circulation and addresses methods for cerebral monitoring during sepsis.
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Affiliation(s)
- Nicholas Heming
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France
| | - Aurélien Mazeraud
- Department of Neuro-Anesthesiology and Intensive Care Medicine, Sainte-Anne Teaching Hospital, Paris-Descartes University, Paris, France
| | - Eric Azabou
- U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France.,Department of Physiology, Assistance Publique-Hôpitaux de Paris, Raymond-Poincaré Hospital, Garches, France
| | - Pierre Moine
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France
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4
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What is a Clinician to Do? Crit Care Med 2019; 46:1205-1206. [PMID: 29912109 DOI: 10.1097/ccm.0000000000003174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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5
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Le Dorze M, Huché F, Coelembier C, Rabuel C, Payen D. Impact of fluid challenge increase in cardiac output on the relationship between systemic and cerebral hemodynamics in severe sepsis compared to brain injury and controls. Ann Intensive Care 2018; 8:74. [PMID: 29956057 PMCID: PMC6023801 DOI: 10.1186/s13613-018-0419-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 06/20/2018] [Indexed: 11/30/2022] Open
Abstract
Background Cognitive dysfunction and delirium after ICU are frequent and may partially result from brain ischemia episodes. We hypothesized that systemic inflammation (severe sepsis or septic shock) modifies the control of brain circulation and the relation between systemic and cerebral hemodynamic after a positive response to fluid challenge (FC). Methods Three groups of patients were studied if they increased stroke volume (SV) > 10% after 250 or 500 ml of crystalloids: control group: patients free of comorbidity anesthetized for orthopedic surgery; sepsis group: patients with severe sepsis or septic shock (classic definition); brain injury (BI) group: trauma brain jury or hemorrhagic stroke with no detectable systemic inflammation. The measurements before and after FC were mean arterial blood pressure (MAP) (radial catheter); SV and cardiac output (CO; transesophageal Doppler); bilateral middle cerebral artery (MCAv) velocity with peak systolic (PSV) and end diastolic (EDV) values (transcranial Doppler); end-tidal CO2. The role of MAP increase was investigated by an arbitrarily threshold increase of 5%, called responder in CO and MAP (RR). The remaining patients were call responders in CO and non-responders in MAP (RnR). Nonparametric tests were used for statistical analysis. Results Among the 86 screened patients, 66 have completed the protocol: 17 in control group; 38 in sepsis group; and 11 in BI group. All patients increased SV > 10% after FC. Only the sepsis group increased MAP [+ 12 (2–25%), p < 0.05] with a significant increase in PSV and EDV [(17 (3–30)% and 17 (12–42)%, respectively (p < 0.05)], which did not change in the two other groups. The septic RR or RnR had similar variations in MCAv after FC. The baseline MAP < or > baseline median MAP had similar MCAv. Conclusions After a FC-induced increase in SV, MCAv (PSV and EDV) increased only in septic group, mostly independently from MAP increase and from baseline MAP level. Cerebral perfusion becomes passively dependent on systemic blood flow, suggesting a modification of the control of cerebrovascular tone in sepsis-induced systemic inflammation. This information has been considered in the clinical management of septic patients. Electronic supplementary material The online version of this article (10.1186/s13613-018-0419-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthieu Le Dorze
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Florian Huché
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Clément Coelembier
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Christophe Rabuel
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Didier Payen
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France. .,UMR INSERM 1160, University Paris 7 Denis Diderot, Paris, France.
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Molnár L, Németh N, Berhés M, Hajdú E, Papp L, Molnár Á, Szabó J, Deák Á, Fülesdi B. Assessment of cerebral circulation in a porcine model of intravenously given E. coli induced fulminant sepsis. BMC Anesthesiol 2017; 17:98. [PMID: 28738837 PMCID: PMC5525280 DOI: 10.1186/s12871-017-0389-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 07/12/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The aim of the present work was to assess cerebral hemodynamic changes in a porcine model of E.coli induced fulminant sepsis. METHODS Nineteen healthy female Hungahib pigs, 10-12 weeks old, randomly assigned into two groups: Control (n = 9) or Septic Group (n = 10). In the Sepsis group Escherichia coli culture suspended in physiological saline was intravenously administrated in a continuously increasing manner according to the following protocol: 2 ml of bacterial culture suspended in physiological saline was injected in the first 30 min, then 4 ml of bacterial culture was administered within 30 min, followed by infusion of 32 ml bacterial culture for 2 h. Control animals received identical amount of saline infusion. Systemic hemodynamic parameters were assessed by PiCCo monitoring, and cerebral hemodynamics by transcranial Doppler sonography (transorbital approach) in both groups. RESULTS In control animals, systemic hemodynamic variables and cerebral blood flow velocities and pulsatility indices were relatively stable during the entire procedure. In septic animals shock developed in 165 (IQR: 60-255) minutes after starting the injection of E.coli solution. Blood pressure values gradully decreased, whereas pulse rate increased. A decrease in cardiac index, an increased systemic vascular resistance, and an increased stroke volume variation were observed. Mean cerebral blood flow velocity in the middle cerebral artery did not change during the procedure, but pulsatility index significantly increased. CONCLUSIONS There is vasoconstriction at the level of the cerebral arterioles in the early phase of experimental sepsis that overwhelmes autoregulatory response. These results may serve as additional pathophysiological information on the cerebral hemodynamic changes occurring during the septic process and may contribute to a better understanding of the pathomechanism of septic encephalopathy.
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Affiliation(s)
- Levente Molnár
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H 4032, Hungary
| | - Norbert Németh
- Department of Operative Techniques and Surgical Research, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Mariann Berhés
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H 4032, Hungary
| | - Endre Hajdú
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H 4032, Hungary
| | - Lóránd Papp
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H 4032, Hungary
| | - Ábel Molnár
- Department of Operative Techniques and Surgical Research, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Judit Szabó
- Department of Medical Microbiology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Ádám Deák
- Department of Operative Techniques and Surgical Research, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Béla Fülesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H 4032, Hungary. .,Outcomes Research Consortium, Cleveland, USA.
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de Azevedo DS, Salinet ASM, de Lima Oliveira M, Teixeira MJ, Bor-Seng-Shu E, de Carvalho Nogueira R. Cerebral hemodynamics in sepsis assessed by transcranial Doppler: a systematic review and meta-analysis. J Clin Monit Comput 2016; 31:1123-1132. [PMID: 27757739 DOI: 10.1007/s10877-016-9945-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/11/2016] [Indexed: 12/14/2022]
Abstract
Cerebral microcirculation is gradually compromised during sepsis, with significant reductions in the function of capillaries and blood perfusion in small vessels. Transcranial Doppler ultrasound (TCD) has been used to assess cerebral circulation in a typical clinical setting. This study was to systematically review TCD studies, assess their methodological quality, and identify trends that can be associated with the temporal evolution of sepsis and its clinical outcome. A meta-analysis of systematic reviews was conducted according to the PRISMA statement. Articles were searched from 1982 until the conclusion of this review in December 2015. Twelve prospective and observational studies were selected. Evaluations of cerebral blood flow, cerebral autoregulation, and carbon dioxide (CO2) vasoreactivity were summarized. A temporal pattern of the evolution of the illness was found. In early sepsis, the median blood flow velocity (Vm) and pulsatility index (PI) increased, and the cerebral autoregulation (CA) remained unchanged. In contrast, Vm normalization, PI reduction and CA impairment were found in later sepsis (patients with severe sepsis or septic shock). Cerebral haemodynamic is impaired in sepsis. Modifications in cerebral blood flow may be consequence to the endothelial dysfunction of the microvasculature induced by the release of inflammatory mediators. A better understanding of cerebral hemodynamics may improve the clinical management of patients with sepsis and, consequently, improve clinical outcomes.
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Affiliation(s)
- Daniel Silva de Azevedo
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| | - Angela Salomao Macedo Salinet
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| | - Marcelo de Lima Oliveira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| | - Manoel Jacobsen Teixeira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| | - Edson Bor-Seng-Shu
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil.
| | - Ricardo de Carvalho Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
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Lu N, Di Y, Feng XY, Qiang JW, Zhang JW, Wang YG, Liu Y. CT perfusion with acetazolamide challenge in C6 gliomas and angiogenesis. PLoS One 2015; 10:e0121631. [PMID: 25781321 PMCID: PMC4363697 DOI: 10.1371/journal.pone.0121631] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 02/11/2015] [Indexed: 12/16/2022] Open
Abstract
Background This study was performed to investigate the correlation between CT perfusion with acetazolamide challenge and angiogenesis in C6 gliomas. Methods Thirty-two male Sprague-Dawley rats were evaluated. The rats were divided randomly to four groups: eight rats with orthotopically implanted C6 gliomas at 10-days old (Group A), eight rats with gliomas at 14-days old (Group B), eight rats with gliomas at 18-days old (Group C), eight rats with orthotopically injected normal saline served as controls. CT perfusion was performed before and after administration of acetazolamide. Changes in perfusion parameters due to acetazolamide administration were calculated and analyzed. Results Elevated carbon dioxide partial pressure and decreased pH were found in all 32 rats post acetazolamide challenge (P<0.01). Cerebral blood flowpre-challenge was increased in group C (95.0±2.5 ml/100g/min), as compared to group B (80.1±11.3 ml/100g/min) and group A (63.1±2.1 ml/100g/min). Cerebral blood flow percentage changes were detected with a reduction in group C (54.2±4.8%) as compared to controls (111.3±22.2%). Cerebral blood volume pre-challenge was increased in group C (50.8±1.7ml/100g), as compared to group B (45.7±1.9 ml/100g) and group A (38.2±0.8 ml/100g). Cerebral blood volume percentage changes were decreased in group C (23.5±4.6%) as compared to controls (113.5±30.4%). Angiogenesis ratio = [(CD105-MVD) / (FVIII-MVD)] ×100%. Positive correlations were observed between CD105-microvessel density, angiogenesis ratio, vascular endothelial growth factor, proliferation marker and cerebral blood flowpre-challenge, cerebral blood volume pre-challenge. Negative correlations were observed between CD105-microvessel density and cerebral blood flow percentage changes (P<0.01, correlation coefficient r=-0.788), cerebral blood volume percentage changes (P<0.01, r=-0.703). Negative correlations were observed between angiogenesis ratio, vascular endothelial growth factor, proliferation marker and cerebral blood flow percentage changes, cerebral blood volume percentage changes. Conclusion Our findings suggest that CT perfusion with challenge can provide new insight into non-invasive assessment of rat C6 glioma angiogenesis.
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Affiliation(s)
- Na Lu
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Yue Di
- Department of Ophthalmology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Xiao-Yuan Feng
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
- * E-mail: (XYF); (JWQ)
| | - Jin-Wei Qiang
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
- * E-mail: (XYF); (JWQ)
| | - Jia-wen Zhang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yong-gang Wang
- Department of Oncology, The Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Liu
- Department of Pathology, Shanghai Medical College, Fudan University, Shanghai, China
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Abstract
Sepsis associated encephalopathy (SAE) is a common but poorly understood neurological complication of sepsis. It is characterized by diffuse brain dysfunction secondary to infection elsewhere in the body without overt CNS infection. The pathophysiology of SAE is complex and multifactorial including a number of intertwined mechanisms such as vascular damage, endothelial activation, breakdown of the blood brain barrier, altered brain signaling, brain inflammation, and apoptosis. Clinical presentation of SAE may range from mild symptoms such as malaise and concentration deficits to deep coma. The evaluation of cognitive dysfunction is made difficult by the absence of any specific investigations or biomarkers and the common use of sedation in critically ill patients. SAE thus remains diagnosis of exclusion which can only be made after ruling out other causes of altered mentation in a febrile, critically ill patient by appropriate investigations. In spite of high mortality rate, management of SAE is limited to treatment of the underlying infection and symptomatic treatment for delirium and seizures. It is important to be aware of this condition because SAE may present in early stages of sepsis, even before the diagnostic criteria for sepsis can be met. This review discusses the diagnostic approach to patients with SAE along with its epidemiology, pathophysiology, clinical presentation, and differential diagnosis.
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Pierrakos C, Antoine A, Velissaris D, Michaux I, Bulpa P, Evrard P, Ossemann M, Dive A. Transcranial doppler assessment of cerebral perfusion in critically ill septic patients: a pilot study. Ann Intensive Care 2013; 3:28. [PMID: 23965228 PMCID: PMC3765692 DOI: 10.1186/2110-5820-3-28] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 08/08/2013] [Indexed: 01/02/2023] Open
Abstract
Background The aim of this study is to evaluate the feasibility and efficacy of Transcranial Doppler (TCD) in assessing cerebral perfusion changes in septic patients. Methods Using TCD, we measured the mean velocity in the middle cerebral artery (VmMCA, cm/sec) and calculated the pulsatility index (PI), resistance index (RI) and cerebral blood flow index (CBFi = 10*MAP/1.47PI) on the first day of patients’ admission or on the first day of sepsis development; measurements were repeated on the second day. Sepsis was defined according to standard criteria. Results Forty-one patients without any known neurologic deficit treated in our 24-bed Critical Care Unit were assessed (Sepsis Group = 20, Control Group = 21). Examination was feasible in 91% of septic and 85% of non-septic patients (p = 0.89). No difference was found between the two groups in mean age, mean arterial pressure (MAP) or APACHE II score. The pCO2 values were higher in septic patients (46 ± 12 vs. 39 ± 4 mmHg p < 0.01). No statistically significant higher values of VmMCA were found in septic patients (110 ± 34 cm/sec vs. 99 ± 28 cm/sec p = 0.17). Higher values of PI and RI were found in septic patients (1.15 ± 0.25 vs. 0.98 ± 0.16 p < 0.01, 0.64 ± 0.08 vs. 0.59 ± 0.06 p < 0.01, respectively). No statistically significant lower values of CBFi were found in septic patients (497 ± 116 vs. 548 ± 110 p = 0.06). Conclusions Our results suggest cerebral vasoconstriction in septic compared to non-septic patients. TCD is an efficient and feasible exam to evaluate changes in cerebral perfusion during sepsis.
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Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
| | - Aurélie Antoine
- Department of Intensive Care, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
| | - Dimitrios Velissaris
- Department of Internal Medicine, University Hospital of Patras, Patras Rio 26504, Greece
| | - Isabelle Michaux
- Department of Intensive Care, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
| | - Pierre Bulpa
- Department of Intensive Care, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
| | - Patrick Evrard
- Department of Intensive Care, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
| | - Michel Ossemann
- Department of Neurology, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
| | - Alain Dive
- Department of Intensive Care, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
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Abstract
Sepsis-associated encephalopathy (SAE) is a diffuse brain dysfunction that occurs secondary to infection in the body without overt CNS infection. SAE is frequently encountered in critically ill patients in intensive care units, and in up to 70% of patients with severe systemic infection. The severity of SAE can range from mild delirium to deep coma. Seizures and myoclonus are infrequent and cranial nerves are almost always spared, but most severe cases have an associated critical illness neuromyopathy. Development of SAE probably involves a number of mechanisms that are not mutually exclusive and vary from patient to patient. Substantial neurological and psychological morbidities often occur in survivors. Mortality is almost always due to multiorgan failure rather than neurological complications, and is almost 70% in patients with severe SAE. Further research into the pathophysiology, management and prevention of SAE is needed. This Review discusses the epidemiology and clinical presentation of SAE. Recent evidence for SAE pathophysiology is outlined and a diagnostic approach to patients with this syndrome is presented. Lastly, prognosis and management of SAE is discussed.
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Affiliation(s)
- Teneille E Gofton
- Department of Clinical Neurological Sciences, London Health Sciences Centre, University Hospital, University of Western Ontario, 339 Windermere Road, London, ON N6A 5A5, Canada
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