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Doron O, Patel AB, Hawryluk GWJ. Neurovascular Interventions for Neurotrauma: From Treatment of Injured Vessels to Treatment of the Injured Brain? Oper Neurosurg (Hagerstown) 2024; 26:247-255. [PMID: 37976141 DOI: 10.1227/ons.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/17/2023] [Indexed: 11/19/2023] Open
Abstract
Traumatic brain injury is often associated with a direct or secondary neurovascular pathology. In this review, we present recent advancements in endovascular neurosurgery that enable accurate and effective vessel reconstruction with emphasis on its role in early diagnosis, the expanding use of flow diversion in pseudoaneurysms, and traumatic arteriovenous fistulas. In addition, future directions in which catheter-based interventions could potentially affect traumatic brain injury are described: targeting blood brain barrier integrity using the advantages of intra-arterial drug delivery of blood brain barrier stabilizers to prevent secondary brain edema, exploring the impact of endovascular venous access as a means to modulate venous outflow in an attempt to reduce intracranial pressure and augment brain perfusion, applying selective intra-arterial hypothermia as a neuroprotection method mitigating some of the risks conferred by systemic cooling, trans-vessel wall delivery of regenerative therapy agents, and shifting attention using multimodal neuromonitoring to post-traumatic vasospasm to further characterize the role it plays in secondary brain injury. Thus, we believe that the potential of endovascular tools can be expanded because they enable access to the "highways" governing perfusion and flow and call for further research focused on exploring these routes because it may contribute to novel endovascular approaches currently used for treating injured vessels, harnessing them for treatment of the injured brain.
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Affiliation(s)
- Omer Doron
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston , Massachusetts , USA
- Department of Biomedical Engineering, The Aldar and Iby Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv , Israel
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Akron General Neuroscience Institute, Cleveland Clinic, Akron , Ohio , USA
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Chu KH, Olakorede I, Beqiri E, Czosnyka M, Smielewski P. Mathematical modelling of cerebral haemodynamics and their effects on ICP. BRAIN & SPINE 2024; 4:102772. [PMID: 38510619 PMCID: PMC10951776 DOI: 10.1016/j.bas.2024.102772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 01/17/2024] [Accepted: 02/18/2024] [Indexed: 03/22/2024]
Abstract
Introduction Electrical-equivalence mathematical models that integrate vascular and cerebrospinal fluid (CSF) compartments perform well in simulations of dynamic cerebrovascular variations and their transient effects on intracranial pressure (ICP). However, ICP changes due to sustained vascular diameter changes have not been comprehensively examined. We hypothesise that changes in cerebrovascular resistance (CVR) alter the resistance of the bulk flow of interstitial fluid (ISF). Research question We hypothesise that changes in CVR alter the resistance of the bulk flow of ISF, thus allowing simulations of ICP in response to sustained vascular diameter changes. Material and methods A lumped parameter model with vascular and CSF compartments was constructed and converted into an electrical analogue. The flow and pressure responses to transient hyperaemic response test (THRT) and CSF infusion test (IT) were observed. Arterial blood pressure (ABP) was manipulated to simulate ICP plateau waves. The experiments were repeated with a modified model that included the ISF compartment. Results Simulations of the THRT produced identical cerebral blood flow (CBF) responses. ICP generated by the new model reacted in a similar manner as the original model during ITs. Plateau pressure reached during ITs was however higher in the ISF model. Only the latter was successful in simulating the onset of ICP plateau waves in response to selective blood pressure manipulations. Discussion and conclusion Our simulations highlighted the importance of including the ISF compartment, which provides mechanism explaining sustained haemodynamic influences on ICP. Consideration of such interactions enables accurate simulations of the cerebrovascular effects on ICP.
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Affiliation(s)
- Ka Hing Chu
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Ihsane Olakorede
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
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Nassir A, Rosenthal G, Zadka Y, Houri S, Doron O, Barnea O. Estimating intracranial parameters using an inverse mathematical model with viscoelastic elements that closely predicts complex ICP morphologies. Comput Methods Biomech Biomed Engin 2024:1-13. [PMID: 38303646 DOI: 10.1080/10255842.2024.2308695] [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: 08/06/2023] [Accepted: 01/08/2024] [Indexed: 02/03/2024]
Abstract
The quantitative relationship between arterial blood pressure (ABP) and intracranial pressure (ICP) waveforms has not been adequately explained. We hypothesized that the ICP waveform results from interferences between propagating and reflected pressure waves occurring in the cranium following the initiating arterial waveform. To demonstrate cranial effects on interferences between waves and generation of an ICP waveform morphology, we modified our previously reported mathematical model to include viscoelastic elements that affect propagation velocity. Using patient data, we implemented an inverse model methodology to generate simulated ICP waveforms in response to given ABP waveforms. We used an open database of traumatic brain injury patients and studied 65 pairs of ICP and ABP waveforms from 13 patients (five pairs from each). Incorporating viscoelastic elements into the model resulted in model-generated ICP waveforms that very closely resembled the measured waveforms with a 16-fold increase in similarity index relative to the model with only pure elasticity elements. The mean similarity index for the pure elasticity model was 0.06 ± 0.12 SD, compared to 0.96 ± 0.28 SD for the model with viscoelastic components. The normalized root mean squared error (NRMSE) improved substantially for the model with viscoelastic elements compared to the model with pure elastic elements (NRMSE of 2.09% ± 0.62 vs. 15.2% ± 4.8, respectively). The ability of the model to generate complex ICP waveforms indicates that the model may indeed reflect intracranial dynamics. Our results suggest that the model may allow the estimation of intracranial biomechanical parameters with potential clinical significance. It represents a first step in the estimation of inaccessible intracranial parameters.
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Affiliation(s)
- Abed Nassir
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Guy Rosenthal
- Department of Neurosurgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Yuliya Zadka
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Saadit Houri
- Department of Neurosurgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Omer Doron
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ofer Barnea
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
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Qiu H, Zador Z, Lannon M, Farrokhyar F, Duda T, Sharma S. Identification of clinically relevant patient endotypes in traumatic brain injury using latent class analysis. Sci Rep 2024; 14:1294. [PMID: 38221527 PMCID: PMC10788338 DOI: 10.1038/s41598-024-51474-0] [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: 07/07/2023] [Accepted: 01/05/2024] [Indexed: 01/16/2024] Open
Abstract
Traumatic brain injury (TBI) is a complex condition where heterogeneity impedes the advancement of care. Understanding the diverse presentations of TBI is crucial for personalized medicine. Our study aimed to identify clinically relevant patient endotypes in TBI using latent class analysis based on comorbidity data. We used the Medical Information Mart for Intensive Care III database, which includes 2,629 adult TBI patients. We identified five stable endotypes characterized by specific comorbidity profiles: Heart Failure and Arrhythmia, Healthy, Renal Failure with Hypertension, Alcohol Abuse, and Hypertension. Each endotype had distinct clinical characteristics and outcomes: The Heart Failure and Arrhythmia endotype had lower survival rates than the Renal Failure with Hypertension despite featuring fewer comorbidities overall. Patients in the Hypertension endotype had higher rates of neurosurgical intervention but shorter stays in contrast to the Alcohol Abuse endotype which had lower rates of neurosurgical intervention but significantly longer hospital stays. Both endotypes had high overall survival rates comparable to the Healthy endotype. Logistic regression models showed that endotypes improved the predictability of survival compared to individual comorbidities alone. This study validates clinical endotypes as an approach to addressing heterogeneity in TBI and demonstrates the potential of this methodology in other complex conditions.
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Affiliation(s)
- Hongbo Qiu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Zsolt Zador
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Melissa Lannon
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Health, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Taylor Duda
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
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Zadka Y, Rosenthal G, Doron O, Barnea O. Limitation of cerebral blood flow by increased venous outflow resistance in elevated ICP. J Appl Physiol (1985) 2024; 136:224-232. [PMID: 38059286 DOI: 10.1152/japplphysiol.00477.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/13/2023] [Accepted: 12/03/2023] [Indexed: 12/08/2023] Open
Abstract
Extensive investigation and modeling efforts have been dedicated to cerebral pressure autoregulation, which is primarily regulated by the ability of the cerebral arterioles to change their resistance and modulate cerebral blood flow (CBF). However, the mechanisms by which elevated intracranial pressure (ICP) leads to increased resistance to venous outflow have received less attention. We modified our previously described model of intracranial fluid interactions with a newly developed model of a partially collapsed blood vessel, which we termed the "flow control zone" (FCZ). We sought to determine the degree to which ICP elevation causing venous compression at the FCZ becomes the main parameter limiting CBF. The FCZ component was designed using nonlinear functions representing resistance as a function of cross-sectional area and the pressure-volume relations of the vessel wall. We used our previously described swine model of cerebral edema with graduated elevation of ICP to calculate venous outflow resistance and a newly defined parameter, the cerebral resistance index (CRI), which is the ratio between venous outflow resistance and cerebrovascular resistance. Model simulations of cerebral edema and increased ICP led to increased venous outflow resistance. There was a close similarity between model predictions of venous outflow resistance and experimental results in the swine model (cross-correlation coefficient of 0.97, a mean squared error of 0.087, and a mean absolute error of 0.15). CRI was strongly correlated to ICP in the swine model (r2 = 0.77, P = 0.00012, 95% confidence interval [0.15, 0.45]). A CRI value of 0.5 was associated with ICP values above clinically significant thresholds (24 mmHg) in the swine model and a diminished capacity of changes in arteriolar resistance to influence flow in the mathematical model. Our results demonstrate the importance of venous compression at the FCZ in determining CBF when ICP is elevated. The cerebral resistance index may provide an indication of when compression of venous outflow becomes the dominant factor in limiting CBF following brain injury.NEW & NOTEWORTHY The goal of this study was to investigate the effects of venous compression caused by elevated intracranial pressure (ICP) due to cerebral edema, validated through animal experiments. The flow control zone model highlights the impact of cerebral venous compression on cerebral blood flow (CBF) during elevated ICP. The cerebral venous outflow resistance-to-cerebrovascular resistance ratio may indicate when venous outflow compression becomes the dominant factor limiting CBF. CBF regulation descriptions should consider how arterial or venous factors may predominantly influence flow in different clinical scenarios.
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Affiliation(s)
- Yuliya Zadka
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Guy Rosenthal
- Department of Neurosurgery, Hadassah University Medical Center, Jerusalem, Israel
| | - Omer Doron
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Ofer Barnea
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
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Dietvorst S, Vervekken A, Depreitere B. Developing a porcine model of severe traumatic brain injury induced by high amplitude rotational acceleration. BRAIN & SPINE 2023; 4:102728. [PMID: 38510621 PMCID: PMC10951692 DOI: 10.1016/j.bas.2023.102728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 11/29/2023] [Accepted: 12/08/2023] [Indexed: 03/22/2024]
Abstract
Introduction It is unclear which pathophysiological processes initiate and drive dynamic cerebrovascular autoregulation (CA) impairment as seen in traumatic brain injury (TBI). This is not solely attributable to raised intracranial pressure (ICP), but also results from local tissue damage. Research question In order to investigate CA disturbing processes, a porcine model is needed that mimics severe TBI as seen in humans. This model requires high amplitude rotational acceleration. Material and methods A customized device was built to produce a rotational impulse with high amplitude and short pulse duration. Following preparatory tests on cadaver piglets, six piglets of six weeks old were sedated, ventilated and subjected to rotational impulses of different magnitudes. The impulse was immediately followed by installment of invasive monitoring of ICP, PbO₂, Laser Doppler Flowmetry and arterial blood pressure. TBI was further characterized by magnetic resonance brain imaging. Results The current setup enabled to reach sagittal head rotational maximal acceleration magnitudes up to 30 krad/s2. Half of the animals had an increase in ICP, measured shortly after the impulse. It has proved impossible so far to produce a sustained rise in ICP as seen in human severe TBI. MRI showed no anatomical abnormalities which would confirm severe TBI. Discussion and conclusion The challenge to build a porcine model in which severe TBI with ICP raise and MRI changes as seen in humans can be reliably reproduced is still ongoing. It might be that higher peak rotational accelerations are needed.
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Affiliation(s)
- Sofie Dietvorst
- Department of Neurosurgery, University Hospitals, Leuven, Belgium
- Research Group Experimental Neurosurgery and Neuroanatomy, KULeuven, Belgium
| | - Aline Vervekken
- Research Group Experimental Neurosurgery and Neuroanatomy, KULeuven, Belgium
| | - Bart Depreitere
- Department of Neurosurgery, University Hospitals, Leuven, Belgium
- Research Group Experimental Neurosurgery and Neuroanatomy, KULeuven, Belgium
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Purvis EM, Fedorczak N, Prah A, Han D, O’Donnell JC. Porcine Astrocytes and Their Relevance for Translational Neurotrauma Research. Biomedicines 2023; 11:2388. [PMID: 37760829 PMCID: PMC10525191 DOI: 10.3390/biomedicines11092388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/17/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
Astrocytes are essential to virtually all brain processes, from ion homeostasis to neurovascular coupling to metabolism, and even play an active role in signaling and plasticity. Astrocytic dysfunction can be devastating to neighboring neurons made inherently vulnerable by their polarized, excitable membranes. Therefore, correcting astrocyte dysfunction is an attractive therapeutic target to enhance neuroprotection and recovery following acquired brain injury. However, the translation of such therapeutic strategies is hindered by a knowledge base dependent almost entirely on rodent data. To facilitate additional astrocytic research in the translatable pig model, we present a review of astrocyte findings from pig studies of health and disease. We hope that this review can serve as a road map for intrepid pig researchers interested in studying astrocyte biology.
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Affiliation(s)
- Erin M. Purvis
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA (D.H.)
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Neuroscience, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Natalia Fedorczak
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA (D.H.)
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Annette Prah
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA (D.H.)
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Daniel Han
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA (D.H.)
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - John C. O’Donnell
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA (D.H.)
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Feng L, Sharma A, Wang Z, Muresanu DF, Tian ZR, Lafuente JV, Buzoianu AD, Nozari A, Li C, Zhang Z, Lin C, Huang H, Manzhulo I, Wiklund L, Sharma HS. Nanowired delivery of dl-3-n-butylphthalide with antibodies to alpha synuclein potentiated neuroprotection in Parkinson's disease with emotional stress. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2023; 171:47-82. [PMID: 37783563 DOI: 10.1016/bs.irn.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Stress is one of the most serious consequences of life leading to several chronic diseases and neurodegeneration. Recent studies show that emotional stress and other kinds of anxiety and depression adversely affects Parkinson's disease symptoms. However, the details of how stress affects Parkinson's disease is still not well known. Traumatic brain injury, stroke, diabetes, post-traumatic stress disorders are well known to modify the disease precipitation, progression and persistence. However, show stress could influence Parkinson's disease is still not well known. The present investigation we examine the role of immobilization stress influencing Parkinson's disease brain pathology in model experiments. In ore previous report we found that mild traumatic brain injury exacerbate Parkinson's disease brain pathology and nanodelivery of dl-3-n-butylphthalide either alone or together with mesenchymal stem cells significantly attenuated Parkinson's disease brain pathology. In this chapter we discuss the role of stress in exacerbating Parkinson's disease pathology and nanowired delivery of dl-3-n-butylphthalide together with monoclonal antibodies to alpha synuclein (ASNC) is able to induce significant neuroprotection. The possible mechanisms of dl-3-n-butylphthalide and ASNC induced neuroprotection and suitable clinical therapeutic strategy is discussed.
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Affiliation(s)
- Lianyuan Feng
- Department of Neurology, Bethune International Peace Hospital, Zhongshan Road (West), Shijiazhuang, Hebei Province, P.R. China
| | - Aruna Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Dept. of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
| | - Zhenguo Wang
- Shijiazhuang Pharma Group NBP Pharmaceutical Co. Ltd., Economic and Technological Development Zone, Shijiazhuang City, Hebei Province, P.R. China
| | - Dafin F Muresanu
- Dept. Clinical Neurosciences, University of Medicine & Pharmacy, Cluj-Napoca, Romania; "RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Z Ryan Tian
- Dept. Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - José Vicente Lafuente
- LaNCE, Dept. Neuroscience, University of the Basque Country (UPV/EHU), Leioa, Bizkaia, Spain
| | - Anca D Buzoianu
- Department of Clinical Pharmacology and Toxicology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ala Nozari
- Department of Anesthesiology, Boston University, Albany str, Boston, MA, United States
| | - Cong Li
- Department of Neurosurgery, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Province Hospital of Chinese Medical, Guangzhou, Guangdong, P.R. China
| | - Ziquiang Zhang
- Department of Neurosurgery, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Province Hospital of Chinese Medical, Guangzhou, Guangdong, P.R. China
| | - Chen Lin
- Department of Neurosurgery, Dongzhimen Hospital, Beijing University of Traditional Chinese Medicine, Beijing, P.R. China
| | - Hongyun Huang
- Beijing Hongtianji Neuroscience Academy, Beijing, P.R. China
| | - Igor Manzhulo
- Laboratory of Pharmacology, National Scientific Center of Marine Biology, Far East Branch of the Russian Academy of Sciences, Vladivostok, Russia
| | - Lars Wiklund
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Dept. of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - Hari Shanker Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Dept. of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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Doron O, Zadka Y, Rosenthal G, Barnea O. Intracranial Pulsating Balloon-Based Cardiac-Gated ICP Modulation Impact on Brain Oxygenation: A Proof-of-Concept Study in a Swine Model. Neurocrit Care 2022; 37:689-696. [PMID: 35854081 DOI: 10.1007/s12028-022-01541-z] [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: 03/18/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Brain oxygenation improvement is a sought-after goal in neurocritical care patients. Previously, we have shown that cerebral blood flow improvement by cardiac-gated intracranial pressure (ICP) modulation using an intracranial pulsating balloon is feasible in a swine model. We sought to explore specific ICP modulation protocols to assess the feasibility of influencing brain oxygenation. METHODS A previously presented electrocardiogram (ECG)-gated intracranial balloon pump in which volume, timing, and duty cycle of balloon inflation could be altered was used. Different protocols were tested in a swine model of normal and elevated ICP attained by intracranial fluid infusion with continuous monitoring of physiological parameters, and brain tissue oxygen tension (PbtO2) was measured at baseline and after device activation. RESULTS We studied five swine, subjected to two main protocols differing in their phase relative to the cardiac cycle. In reduced brain perfusion status (ICP > 20 mm Hg, PbtO2 < 15 mm Hg), the late-diastolic-early-systolic (Inflation/deflation) protocol showed consistent elevation in PbtO2 (+ 9%, p < 0.01), coupled with ICP reduction (- 12%, p < 0.01), whereas the early-systolic-late-diastolic (inflation/deflation) protocol resulted in PbtO2 reduction (- 4%, p < 0.01), coupled with ICP increase (+ 5% above baseline, p < 0.01). No significant changes in brain oxygenation or ICP were observed at normal perfusion status (ICP < 20 mm Hg, PbtO2 > 15 mm Hg). CONCLUSIONS Intracranial cardiac-gated balloon pump activation can influence cerebral oxygenation and raise PbtO2 above threshold values. This study supports the concept of late-diastolic pressure rise, coupled with early-systolic pressure drop, as a potential effector of flow augmentation leading to improve brain tissue oxygenation. Further studies are warranted to assess the translational potential of using an intracranial cardiac-gated balloon pump device to improve brain tissue oxygenation.
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Affiliation(s)
- Omer Doron
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel. .,Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, 130 77th street, New York, NY, USA.
| | - Yuliya Zadka
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Guy Rosenthal
- Department of Neurosurgery, Hadassah University Medical Center, Jerusalem, Israel
| | - Ofer Barnea
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
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Ciarrocchi NM, Pose F, Saez P, Garcia MDC, Padilla F, Pedro Plou, Hem S, Karippacheril JG, Gutiérrez AF, Redelico FO. Reversible focal intracranial hypertension swine model with continuous multimodal neuromonitoring. J Neurosci Methods 2022; 373:109561. [PMID: 35301006 DOI: 10.1016/j.jneumeth.2022.109561] [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: 08/10/2021] [Revised: 11/24/2021] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Intracranial hypertension (HI) is associated with worse neurological outcomes and higher mortality. Although there are several experimental models of HI, in this article we present a reproducible, reversible, and reliable model of intracranial hypertension, with continuous multimodal monitoring. NEW METHOD A reversible intracranial hypertension model in swine with multimodal monitoring including intracranial pressure, arterial blood pressure, heart rate variation, brain tissue oxygenation, and electroencephalogram is developed to understand the relationship of ICP and EEG. By inflating and deflating a balloon, located 20 mm anterior to the coronal suture and a 15 mm sagittal suture, we generate intracranial hypertension events and simultaneously measure intracranial pressure and oxygenation in the contralateral hemisphere and the EEG, simulating the usual configuration in humans. RESULTS We completed 5 experiments and in all of them, we were able to complete at least 6 events of intracranial hypertension in a stable and safe way. For events of 20-40 mmHg of ICP we need an median (IQR) of 4.2 (3.64) ml of saline solution into the Foley balloon, a median (IQR) infusion time of 226 (185) second in each event and for events of 40-50 mmHg of ICP we need a median (IQR) of 5.1 (4.66) ml of saline solution, a median (IQR) infusion time of 280 (48) seconds and a median (IQR). The median (IQR) maintenance time was 352 (77) seconds and 392 (166) seconds for 20-40 mmHg and 40-50 mmHg of ICP, respectively. COMPARISON WITH EXISTING METHOD(S) Existing methods do not include EEG measures and do not present the reversibility of intracranial hypertension. CONCLUSIONS Our model is fully reproducible, it is capable of generating reversible focal intracranial hypertension through strict control of the injected volume, it is possible to generate different infusion rates of the volume in the balloon, in order to generate different scenarios, the data obtained are sufficient to determine the brain complacency in real time. and useful for understanding the pathophysiology of ICP and the relationship between ICP (CPP) and EEG.
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Affiliation(s)
| | - Fernando Pose
- Instituto de Medicina Traslacional e Ingeniería Biomédica, Hospital Italiano de Buenos Aires, Instituto Universitario del Hospital Italiano de Buenos Aires, CONICET, Perón 4190 - (C1199ABB) Ciudad Autónoma de Buenos Aires, Argentina
| | - Pablo Saez
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Argentina
| | | | - Fernando Padilla
- Servicio de Neurocirugía, Hopsital Italiano de Buenos Aires, Argentina
| | - Pedro Plou
- Servicio de Neurocirugía, Hopsital Italiano de Buenos Aires, Argentina
| | - Santiago Hem
- Servicio de Neurocirugía, Hopsital Italiano de Buenos Aires, Argentina
| | | | | | - Francisco O Redelico
- Instituto de Medicina Traslacional e Ingeniería Biomédica, Hospital Italiano de Buenos Aires, Instituto Universitario del Hospital Italiano de Buenos Aires, CONICET, Perón 4190 - (C1199ABB) Ciudad Autónoma de Buenos Aires, Argentina; Universidad Nacional de Quilmes, Departamento de Ciencia y Tecnología, Roque Sáenz Peña 352 - (B1876BXD) Bernal, Buenos Aires, Argentina.
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Doron O, Barnea O, Stocchetti N, Or T, Nossek E, Rosenthal G. Cardiac-gated intracranial elastance in a swine model of raised intracranial pressure: a novel method to assess intracranial pressure-volume dynamics. J Neurosurg 2021; 134:1650-1657. [PMID: 32503002 DOI: 10.3171/2020.3.jns193262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Previous studies have demonstrated the importance of intracranial elastance; however, methodological difficulties have limited widespread clinical use. Measuring elastance may offer potential benefit in helping to identify patients at risk for untoward intracranial pressure (ICP) elevation from small rises in intracranial volume. The authors sought to develop an easily used method that accounts for the changing ICP that occurs over a cardiac cycle and to assess this method in a large-animal model over a broad range of ICPs. METHODS The authors used their previously described cardiac-gated intracranial balloon pump and swine model of cerebral edema. In the present experiment they measured elastance at 4 points along the cardiac cycle-early systole, peak systole, mid-diastole, and end diastole-by using rapid balloon inflation to 1 ml over an ICP range of 10-30 mm Hg. RESULTS The authors studied 7 swine with increasing cerebral edema. Intracranial elastance rose progressively with increasing ICP. Peak-systolic and end-diastolic elastance demonstrated the most consistent rise in elastance as ICP increased. Cardiac-gated elastance measurements had markedly lower variance within swine compared with non-cardiac-gated measures. The slope of the ICP-elastance curve differed between swine. At ICP between 20 and 25 mm Hg, elastance varied between 8.7 and 15.8 mm Hg/ml, indicating that ICP alone cannot accurately predict intracranial elastance. CONCLUSIONS Measuring intracranial elastance in a cardiac-gated manner is feasible and may offer an improved precision of measure. The authors' preliminary data suggest that because elastance values may vary at similar ICP levels, ICP alone may not necessarily best reflect the state of intracranial volume reserve capacity. Paired ICP-elastance measurements may offer benefit as an adjunct "early warning monitor" alerting to the risk of untoward ICP elevation in brain-injured patients that is induced by small increases in intracranial volume.
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Affiliation(s)
- Omer Doron
- 1Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Barnea
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Nino Stocchetti
- 3Department of Physiopathology and Transplantation, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; and
| | - Tal Or
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Erez Nossek
- 4Department of Neurosurgery, New York University Medical Center, New York, New York
| | - Guy Rosenthal
- 1Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem
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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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Doron O, Or T, Battino L, Rosenthal G, Barnea O. Cerebral blood flow augmentation using a cardiac-gated intracranial pulsating balloon pump in a swine model of elevated ICP. J Neurosurg 2020; 132:1606-1615. [PMID: 30978692 DOI: 10.3171/2019.1.jns182864] [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: 10/20/2018] [Accepted: 01/03/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Augmenting brain perfusion or reducing intracranial pressure (ICP) dose is the end target of many therapies in the neuro-critical care unit. Many present therapies rely on aggressive systemic interventions that may lead to untoward effects. Previous studies have used a cardiac-gated intracranial balloon pump (ICBP) to model hydrocephalus or to flatten the ICP waveform. The authors sought to sought to optimize ICBP activation parameters to improve cerebral physiological parameters in a swine model of raised ICP. METHODS The authors developed a cardiac-gated ICBP in which the volume, timing, and duty cycle (time relative to a single cardiac cycle) of balloon inflation could be altered. They studied the ICBP in a swine model of elevated ICP attained by continuous intracranial fluid infusion with continuous monitoring of systemic and cerebral physiological parameters, and defined two specific protocols of ICBP activation. RESULTS Eleven swine were studied, 3 of which were studied to define the optimal timing, volume, and duty cycle of balloon inflation. Eight swine were studied with two defined protocols at baseline and with ICP gradually raised to a mean of 30.5 mm Hg. ICBP activation caused a consistent modification of the ICP waveform. Two ICBP activation protocols were used. Balloon activation protocol A led to a consistent elevation in cerebral blood flow (8%-25% above baseline, p < 0.00001). Protocol B resulted in a modest reduction of ICP over time (8%-11%, p < 0.0001) at all ICP levels. Neither protocol significantly affected systemic physiological parameters. CONCLUSIONS The preliminary results indicate that optimized protocols of ICBP activation may have beneficial effects on cerebral physiological parameters, with minimal effect on systemic parameters. Further studies are warranted to explore whether ICBP protocols may be of clinical benefit in patients with brain injuries with increased ICP.
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Affiliation(s)
- Omer Doron
- 1Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem; and
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Tal Or
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Limor Battino
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Guy Rosenthal
- 1Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem; and
| | - Ofer Barnea
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
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Eftekhari S, Westgate CSJ, Uldall MS, Jensen RH. Preclinical update on regulation of intracranial pressure in relation to idiopathic intracranial hypertension. Fluids Barriers CNS 2019; 16:35. [PMID: 31767019 PMCID: PMC6878629 DOI: 10.1186/s12987-019-0155-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/13/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Elevated intracranial pressure (ICP) is observed in association with a range of brain disorders. One of these challenging disorders is idiopathic intracranial hypertension (IIH), characterized by raised ICP of unknown cause with significant morbidity and limited therapeutic options. In this review, special focus is put on the preclinical research performed in order to understand the pathophysiology behind ICP regulation and IIH. This includes cerebrospinal fluid dynamics, molecular mechanisms underlying disturbances in brain fluids leading to elevated ICP, role of obesity in IIH, development of an IIH model and ICP measurements in rodents. The review also discusses existing and new drug targets for IIH that have been evaluated in vivo. CONCLUSIONS ICP monitoring in rodents is challenging and different methods have been applied. Some of these methods are invasive, depend on use of anesthesia and only allow short-term monitoring. Long-term ICP recordings are needed to study IIH but existing methods are hampered by several limitations. As obesity is one of the most common risk factors for IIH, a rodent obese model has been developed that mimics some key aspects of IIH. The most commonly used drugs for IIH have been evaluated in vivo for their efficacy at lowering ICP in the existing animal models. These studies suggest these drugs, including acetazolamide, might have limited or no reducing effect on ICP. Two drug targets that can impact ICP in healthy rodents are topiramate and a glucagon-like peptide-1 receptor (GLP-1R) agonist. However, it remains to evaluate their effect in an IIH model with more precise and valid ICP monitoring system. Therefore, continued evaluation in the preclinical research with refined tools is of great importance to further understand the pathophysiology behind disorders with raised ICP and to explore new drug targets.
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Affiliation(s)
- Sajedeh Eftekhari
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Rigshospitalet-Glostrup, University of Copenhagen, Nordstjernevej 42, 2600 Glostrup, Denmark
| | - Connar Stanley James Westgate
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Rigshospitalet-Glostrup, University of Copenhagen, Nordstjernevej 42, 2600 Glostrup, Denmark
| | - Maria Schmidt Uldall
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Rigshospitalet-Glostrup, University of Copenhagen, Nordstjernevej 42, 2600 Glostrup, Denmark
| | - Rigmor Hoejland Jensen
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Rigshospitalet-Glostrup, University of Copenhagen, Nordstjernevej 42, 2600 Glostrup, Denmark
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