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Bindal P, Kumar V, Kapil L, Singh C, Singh A. Therapeutic management of ischemic stroke. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:2651-2679. [PMID: 37966570 DOI: 10.1007/s00210-023-02804-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/19/2023] [Indexed: 11/16/2023]
Abstract
Stroke is the third leading cause of years lost due to disability and the second-largest cause of mortality worldwide. Most occurrences of stroke are brought on by the sudden occlusion of an artery (ischemic stroke), but sometimes they are brought on by bleeding into brain tissue after a blood vessel has ruptured (hemorrhagic stroke). Alteplase is the only therapy the American Food and Drug Administration has approved for ischemic stroke under the thrombolysis category. Current views as well as relevant clinical research on the diagnosis, assessment, and management of stroke are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for the available therapeutic regimes in the past, present, and future. With the advent of endovascular therapy in 2015 and intravenous thrombolysis in 1995, the therapeutic options for ischemic stroke have expanded significantly. A novel approach such as vagus nerve stimulation could be life-changing for many stroke patients. Therapeutic hypothermia, the process of cooling the body or brain to preserve organ integrity, is one of the most potent neuroprotectants in both clinical and preclinical contexts. The rapid intervention has been linked to more favorable clinical results. This study focuses on the pathogenesis of stroke, as well as its recent advancements, future prospects, and potential therapeutic targets in stroke therapy.
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Affiliation(s)
- Priya Bindal
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Vishal Kumar
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Lakshay Kapil
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Charan Singh
- Department of Pharmaceutical Sciences, HNB Garhwal University (A Central University), Chauras Campus, Distt. Tehri Garhwal, Uttarakhand, 246174, India
| | - Arti Singh
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India.
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Binda DD, Baker MB, Varghese S, Wang J, Badenes R, Bilotta F, Nozari A. Targeted Temperature Management for Patients with Acute Ischemic Stroke: A Literature Review. J Clin Med 2024; 13:586. [PMID: 38276093 PMCID: PMC10816923 DOI: 10.3390/jcm13020586] [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: 12/16/2023] [Revised: 01/03/2024] [Accepted: 01/11/2024] [Indexed: 01/27/2024] Open
Abstract
Despite significant advances in medical imaging, thrombolytic therapy, and mechanical thrombectomy, acute ischemic strokes (AIS) remain a major cause of mortality and morbidity globally. Targeted temperature management (TTM) has emerged as a potential therapeutic intervention, aiming to mitigate neuronal damage and improve outcomes. This literature review examines the efficacy and challenges of TTM in the context of an AIS. A comprehensive literature search was conducted using databases such as PubMed, Cochrane, Web of Science, and Google Scholar. Studies were selected based on relevance and quality. We identified key factors influencing the effectiveness of TTM such as its timing, depth and duration, and method of application. The review also highlighted challenges associated with TTM, including increased pneumonia rates. The target temperature range was typically between 32 and 36 °C, with the duration of cooling from 24 to 72 h. Early initiation of TTM was associated with better outcomes, with optimal results observed when TTM was started within the first 6 h post-stroke. Emerging evidence indicates that TTM shows considerable potential as an adjunctive treatment for AIS when implemented promptly and with precision, thereby potentially mitigating neuronal damage and enhancing overall patient outcomes. However, its application is complex and requires the careful consideration of various factors.
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Affiliation(s)
- Dhanesh D. Binda
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Maxwell B. Baker
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Shama Varghese
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Jennifer Wang
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Rafael Badenes
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Federico Bilotta
- Department of Anaesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I Teaching Hospital, Sapienza University of Rome, 00185 Rome, Italy;
| | - Ala Nozari
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
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Xu R, Nair SK, Kilgore CB, Xie ME, Jackson CM, Hui F, Gailloud P, McDougall CG, Gonzalez LF, Huang J, Tamargo RJ, Caplan J. Hypothermia is Associated with Improved Neurological Outcomes After Mechanical Thrombectomy. World Neurosurg 2024; 181:e126-e132. [PMID: 37690581 PMCID: PMC11060169 DOI: 10.1016/j.wneu.2023.09.010] [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: 04/12/2023] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Acute ischemic stroke (AIS) is the second leading cause of death globally. Mechanical thrombectomy (MT) has improved patient prognosis but expedient treatment is still necessary to minimize anoxic injury. Lower intraoperative body temperature decreases cerebral oxygen demand, but the role of hypothermia in treatment of AIS with MT is unclear. METHODS We retrospectively reviewed patients undergoing MT for AIS from 2014 to 2020 at our institution. Patient demographics, comorbidities, intraoperative parameters, and outcomes were collected. Maximum body temperature was extracted from minute-by-minute anesthesia readings, and patients with maximal temperature below 36°C were considered hypothermic. Risk factors were assessed by χ2 and multivariate ordinal regression. RESULTS Of 68 patients, 27 (40%) were hypothermic. There was no significant association of hypothermia with patient age, comorbidities, time since last known well, number of passes intraoperatively, favorable revascularization, tissue plasminogen activator use, and immediate postoperative complications. Hypothermic patients exhibited better neurologic outcome at 3-month follow-up (P = 0.02). On multivariate ordinal regression, lower maximum intraoperative body temperature was associated with improved 3-month outcomes (P < 0.001), when adjusting for other factors influencing neurological outcomes. Other significant protective factors included younger age (P = 0.03), better revascularization (P = 0.03), and conscious sedation (P = 0.02). CONCLUSIONS Lower intraoperative body temperature during MT was independently associated with improved neurological outcome in this single center retrospective series. These results may help guide clinicians in employing therapeutic hypothermia during MT to improve long-term neurologic outcomes from AIS, although larger studies are needed.
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Affiliation(s)
- Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Collin B Kilgore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael E Xie
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ferdinand Hui
- Division of Neurointerventional Surgery, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Phillipe Gailloud
- Department of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Belur AD, Sedhai YR, Truesdell AG, Khanna AK, Mishkin JD, Belford PM, Zhao DX, Vallabhajosyula S. Targeted Temperature Management in Cardiac Arrest: An Updated Narrative Review. Cardiol Ther 2023; 12:65-84. [PMID: 36527676 PMCID: PMC9986171 DOI: 10.1007/s40119-022-00292-4] [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: 09/19/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
The established benefits of cooling along with development of sophisticated methods to safely and precisely induce, maintain, monitor, and reverse hypothermia have led to the development of targeted temperature management (TTM). Early trials in human subjects showed that hypothermia conferred better neurological outcomes when compared to normothermia among survivors of cardiac arrest, leading to guidelines recommending targeted hypothermia in this patient population. Multiple studies have sought to explore and compare the benefit of hypothermia in various subgroups of patients, such as survivors of out-of-hospital cardiac arrest versus in-hospital cardiac arrest, and survivors of an initial shockable versus non-shockable rhythm. Larger and more recent trials have shown no statistically significant difference in neurological outcomes between patients with targeted hypothermia and targeted normothermia; further, aggressive cooling is associated with a higher incidence of multiple systemic complications. Based on this data, temporal trends have leaned towards using a lenient temperature target in more recent times. Current guidelines recommend selecting and maintaining a constant target temperature between 32 and 36 °C for those patients in whom TTM is used (strong recommendation, moderate-quality evidence), as soon as possible after return of spontaneous circulation is achieved and airway, breathing (including mechanical ventilation), and circulation are stabilized. The comparative benefit of lower (32-34 °C) versus higher (36 °C) temperatures remains unknown, and further research may help elucidate this. Any survivor of cardiac arrest who is comatose (defined as unarousable unresponsiveness to external stimuli) should be considered as a candidate for TTM regardless of the initial presenting rhythm, and the decision to opt for targeted hypothermia versus targeted normothermia should be made on a case-by-case basis.
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Affiliation(s)
- Agastya D Belur
- Division of Cardiology, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Yub Raj Sedhai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Kentucky College of Medicine, Bowling Green, KY, USA
| | | | - Ashish K Khanna
- Section of Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Outcomes Research Consortium, Cleveland, OH, USA.,Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
| | - Joseph D Mishkin
- Section of Advanced Heart Failure and Transplant Cardiology, Atrium Health Sanger Heart and Vascular Institute, Charlotte, NC, USA
| | - P Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, 306 Westwood Avenue, Suite 401, High Point, Winston-Salem, NC, 27262, USA
| | - David X Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, 306 Westwood Avenue, Suite 401, High Point, Winston-Salem, NC, 27262, USA
| | - Saraschandra Vallabhajosyula
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA. .,Section of Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, 306 Westwood Avenue, Suite 401, High Point, Winston-Salem, NC, 27262, USA. .,Department of Implementation Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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Soldozy S, Dalzell C, Skaff A, Ali Y, Norat P, Yagmurlu K, Park MS, Kalani MYS. Reperfusion injury in acute ischemic stroke: Tackling the irony of revascularization. Clin Neurol Neurosurg 2023; 225:107574. [PMID: 36696846 DOI: 10.1016/j.clineuro.2022.107574] [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: 04/07/2022] [Revised: 12/12/2022] [Accepted: 12/23/2022] [Indexed: 01/06/2023]
Abstract
Reperfusion injury is an unfortunate consequence of restoring blood flow to tissue after a period of ischemia. This phenomenon can occur in any organ, although it has been best studied in cardiac cells. Based on cardiovascular studies, neuroprotective strategies have been developed. The molecular biology of reperfusion injury remains to be fully elucidated involving several mechanisms, however these mechanisms all converge on a similar final common pathway: blood brain barrier disruption. This results in an inflammatory cascade that ultimately leads to a loss of cerebral autoregulation and clinical worsening. In this article, the authors present an overview of these mechanisms and the current strategies being employed to minimize injury after restoration of blood flow to compromised cerebral territories.
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Affiliation(s)
- Sauson Soldozy
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA; Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Christina Dalzell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Anthony Skaff
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Yusuf Ali
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Pedro Norat
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Kaan Yagmurlu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Min S Park
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - M Yashar S Kalani
- Department of Surgery, University of Oklahoma, and St. John's Neuroscience Institute, Tulsa, OK, USA.
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You JS, Kim JY, Yenari MA. Therapeutic hypothermia for stroke: Unique challenges at the bedside. Front Neurol 2022; 13:951586. [PMID: 36262833 PMCID: PMC9575992 DOI: 10.3389/fneur.2022.951586] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/08/2022] [Indexed: 12/24/2022] Open
Abstract
Therapeutic hypothermia has shown promise as a means to improving neurological outcomes at several neurological conditions. At the clinical level, it has been shown to improve outcomes in comatose survivors of cardiac arrest and in neonatal hypoxic ischemic encephalopathy, but has yet to be convincingly demonstrated in stroke. While numerous preclinical studies have shown benefit in stroke models, translating this to the clinical level has proven challenging. Major obstacles include cooling patients with typical stroke who are awake and breathing spontaneously but often have significant comorbidities. Solutions around these problems include selective brain cooling and cooling to lesser depths or avoiding hyperthermia. This review will cover the mechanisms of protection by therapeutic hypothermia, as well as recent progress made in selective brain cooling and the neuroprotective effects of only slightly lowering brain temperature. Therapeutic hypothermia for stroke has been shown to be feasible, but has yet to be definitively proven effective. There is clearly much work to be undertaken in this area.
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Affiliation(s)
- Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong Youl Kim
- Department of Anatomy, Yonsei University College of Medicine, Seoul, South Korea
| | - Midori A. Yenari
- Department of Neurology, The San Francisco Veterans Affairs Medical Center, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Midori A. Yenari
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Horn M, Diprose WK, Pichardo S, Demchuk A, Almekhlafi M. Non-invasive Brain Temperature Measurement in Acute Ischemic Stroke. Front Neurol 2022; 13:889214. [PMID: 35989905 PMCID: PMC9388770 DOI: 10.3389/fneur.2022.889214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Selective therapeutic hypothermia in the setting of mechanical thrombectomy (MT) is promising to further improve the outcomes of large vessel occlusion stroke. A significant limitation in applying hypothermia in this setting is the lack of real-time non-invasive brain temperature monitoring mechanism. Non-invasive brain temperature monitoring would provide important information regarding the brain temperature changes during cooling, and the factors that might influence any fluctuations. This review aims to provide appraisal of brain temperature changes during stroke, and the currently available non-invasive modalities of brain temperature measurement that have been developed and tested over the past 20 years. We cover modalities including magnetic resonance spectroscopy imaging (MRSI), radiometric thermometry, and microwave radiometry, and the evidence for their accuracy from human and animal studies. We also evaluate the feasibility of using these modalities in the acute stroke setting and potential ways for incorporating brain temperature monitoring in the stroke workflow.
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Affiliation(s)
- MacKenzie Horn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- *Correspondence: MacKenzie Horn
| | - William K Diprose
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Samuel Pichardo
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Andrew Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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8
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Angus SA, Henderson WR, Banoei MM, Molgat‐Seon Y, Peters CM, Parmar HR, Griesdale DEG, Sekhon M, Sheel AW, Winston BW, Dominelli PB. Therapeutic hypothermia attenuates physiologic, histologic, and metabolomic markers of injury in a porcine model of acute respiratory distress syndrome. Physiol Rep 2022; 10:e15286. [PMID: 35510328 PMCID: PMC9069168 DOI: 10.14814/phy2.15286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/29/2022] [Accepted: 04/02/2022] [Indexed: 06/14/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a lung injury characterized by noncardiogenic pulmonary edema and hypoxic respiratory failure. The purpose of this study was to investigate the effects of therapeutic hypothermia on short-term experimental ARDS. Twenty adult female Yorkshire pigs were divided into four groups (n = 5 each): normothermic control (C), normothermic injured (I), hypothermic control (HC), and hypothermic injured (HI). Acute respiratory distress syndrome was induced experimentally via intrapulmonary injection of oleic acid. Target core temperature was achieved in the HI group within 1 h of injury induction. Cardiorespiratory, histologic, cytokine, and metabolomic data were collected on all animals prior to and following injury/sham. All data were collected for approximately 12 h from the beginning of the study until euthanasia. Therapeutic hypothermia reduced injury in the HI compared to the I group (histological injury score = 0.51 ± 0.18 vs. 0.76 ± 0.06; p = 0.02) with no change in gas exchange. All groups expressed distinct phenotypes, with a reduction in pro-inflammatory metabolites, an increase in anti-inflammatory metabolites, and a reduction in inflammatory cytokines observed in the HI group compared to the I group. Changes to respiratory system mechanics in the injured groups were due to increases in lung elastance (E) and resistance (R) (ΔE from pre-injury = 46 ± 14 cmH2 O L-1 , p < 0.0001; ΔR from pre-injury: 3 ± 2 cmH2 O L-1 s- , p = 0.30) rather than changes to the chest wall (ΔE from pre-injury: 0.7 ± 1.6 cmH2 O L-1 , p = 0.99; ΔR from pre-injury: 0.6 ± 0.1 cmH2 O L-1 s- , p = 0.01). Both control groups had no change in respiratory mechanics. In conclusion, therapeutic hypothermia can reduce markers of injury and inflammation associated with experimentally induced short-term ARDS.
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Affiliation(s)
- Sarah A. Angus
- Department of KinesiologyUniversity of WaterlooWaterlooOntarioCanada
| | - William R. Henderson
- Division of Critical Care MedicineDepartment of MedicineFaculty of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Mohammad M. Banoei
- Department of Critical Care MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Yannick Molgat‐Seon
- Department Kinesiology and Applied HealthUniversity of WinnipegWinnipegManitobaCanada
| | - Carli M. Peters
- School of KinesiologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Hanna R. Parmar
- School of KinesiologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Donald E. G. Griesdale
- Division of Critical Care MedicineDepartment of MedicineFaculty of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Department of AnesthesiologyPharmacology & TherapeuticsUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Mypinder Sekhon
- Division of Critical Care MedicineDepartment of MedicineFaculty of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Andrew William Sheel
- School of KinesiologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Brent W. Winston
- Department of Critical Care MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Departments of Medicine and Biochemistry & Molecular BiologyUniversity of CalgaryCalgaryAlbertaCanada
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Cooling and Sterile Inflammation in an Oxygen-Glucose-Deprivation/Reperfusion Injury Model in BV-2 Microglia. Mediators Inflamm 2021; 2021:8906561. [PMID: 34776788 PMCID: PMC8589512 DOI: 10.1155/2021/8906561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/02/2021] [Indexed: 12/26/2022] Open
Abstract
Objective Cold-inducible RNA-binding protein (CIRBP) has been shown to be involved not only in cooling-induced cellular protection but also as a mediator of sterile inflammation, a critical mechanism of the innate immune response in ischemia/reperfusion (I/R) injury. The role of microglia and its activation in cerebral I/R injury warrants further investigation as both detrimental and regenerative properties have been described. Therefore, we investigated the effects of cooling, specifically viability, activation, and release of damage associated molecular patterns (DAMPs) on oxygen glucose deprivation/reperfusion- (OGD/R-) induced injury in murine BV-2 microglial cells. Methods Murine BV-2 microglial cells were exposed to 2 to 6 h OGD (0.2% O2 in glucose- and serum-free medium) followed by up to 19 h of reperfusion, simulated by restoration of oxygen (21% O2) and nutrients. Cells were maintained at either normothermia (37°C) or cooled to 33.5°C, 1 h after experimental start. Cultured supernatants were harvested after exposure to OGD for analysis of DAMP secretions, including high-mobility group box 1 (HMGB1), heat shock protein 70 (HSP70), and CIRBP, and cytotoxicity was assessed by lactate dehydrogenase releases after exposure to OGD and reperfusion. Intracellular cold-shock proteins CIRBP and RNA-binding motif 3 (RBM3) as well as caspases 9, 8, and 3 were also analyzed via Western blot analysis. Furthermore, inducible nitric oxide synthase (iNOS), ionized calcium-binding adaptor molecule 1 (Iba1), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-1β (IL-1β), interleukin-1α (IL-1α), monocyte chemotactic protein 1 (MCP-1), transforming growth factor β (TGFβ), CIRBP, and RBM3 gene expressions were assessed via reverse transcription polymerase chain reaction, and TNF-α, IL-6, and IL-1β releases into the cultured supernatants were assessed via enzyme-linked immunosorbent assays (ELISA). Results Prolonged exposure to OGD resulted in increased BV-2 necrotic cell death, which was attenuated by cooling. Cooling also significantly induced cold-shock proteins CIRBP and RBM3 gene expressions, with CIRBP expression more rapidly regulated than RBM3 and translatable to significantly increased protein expression. DAMPs including HMGB-1, HSP70, and CIRBP could be detected in cultured supernatants after 6 h of OGD with CIRBP release being significantly attenuated by cooling. Exposure to OGD suppressed cytokine gene expressions of IL-1β, TNF-α, MCP-1, and TGFβ independently of temperature management, whereas cooling led to a significant increase in IL-1α gene expression after 6 h of OGD. In the reperfusion phase, TNF-α and MCP-1 gene expressions were increased, and cooling was associated with significantly lower TGFβ gene expression. Interestingly, cooled Normoxia groups had significant upregulations of microglial activation marker, Iba1, IL-1β, and TNF-α gene expressions. Conclusion BV-2 microglial cells undergo necrotic cell death resulting in DAMP release due to OGD/R-induced injury. Cooling conveyed neuroprotection in OGD/R-injury as observable in increased cell viability as well as induced gene expressions of cold shock proteins. As cooling alone resulted in both upregulation of microglial activation, expression of proinflammatory cytokines, and cold shock protein transcript and protein expression, temperature management might have ambiguous effects in sterile inflammation. However, cooling resulted in a significant decrease of extracellular CIRBP, which has recently been characterized as a novel DAMP and a potent initiator and mediator of inflammation.
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10
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Rosahl SC, Covarrubias C, Wu JH, Urquieta E. Staying Cool in Space: A Review of Therapeutic Hypothermia and Potential Application for Space Medicine. Ther Hypothermia Temp Manag 2021; 12:115-128. [PMID: 33617356 DOI: 10.1089/ther.2020.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite rigorous health screenings, medical incidents during spaceflight missions cannot be avoided. With long-duration exploration flights on the rise, the likelihood of critical medical conditions with no suitable treatment on board will increase. Therapeutic hypothermia (TH) could serve as a bridge treatment in space prolonging survival and reducing neurological damage in ischemic conditions such as stroke and cardiac arrest. We conducted a review of published studies to determine the potential and challenges of TH in space based on its physiological effects, the cooling methods available, and clinical evidence on Earth. Currently, investigators have found that application of low normothermia leads to better outcomes than mild hypothermia. Data on the impact of hypothermia on a favorable neurological outcome are inconclusive due to lack of standardized protocols across hospitals and the heterogeneity of medical conditions. Adverse effects with systemic cooling are widely reported, and could be reduced through selective brain cooling and pharmacological cooling, promising techniques that currently lack clinical evidence. We hypothesize that TH has the potential for application as supportive treatment for multiple medical conditions in space and recommend further investigation of the concept in feasibility studies.
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Affiliation(s)
- Sophie C Rosahl
- Faculty of Medicine, Ruprecht-Karls-Universität, Heidelberg, Germany
| | - Claudia Covarrubias
- School of Medicine, Universidad Anáhuac Querétaro, Santiago de Querétaro, México
| | - Jimmy H Wu
- Department of Medicine and Center for Space Medicine, Baylor College of Medicine, Houston, Texas, USA.,Translational Research Institute for Space Health, Houston, Texas, USA
| | - Emmanuel Urquieta
- Translational Research Institute for Space Health, Houston, Texas, USA.,Department of Emergency Medicine and Center for Space Medicine, Baylor College of Medicine, Houston, Texas, USA
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11
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Kulesh AA. The modern concept of neuroprotective therapy in the acute period of ischemic stroke. ACTA ACUST UNITED AC 2020. [DOI: 10.21518/2079-701x-2020-11-82-91] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In recent years, significant successes have been achieved in the treatment of acute ischemic stroke. Given the trend towards an increase in the proportion of patients undergoing intravenous thrombolysis and / or mechanical thrombectomy, the question justifies: is there place for neuroprotective therapy (NT) in the era of active introduction of reperfusion treatment? The review discusses the main mechanisms of brain damage in ischemia / reperfusion and the leading neuroprotective strategies studied in clinical trials. Neuroprotective approaches to suppress excitotoxicity, oxidative and nitrosative stress are presented. The clinical efficacy of magnesium sulfate, uric acid, and edaravone is discussed. Non-pharmacological methods of neuroprotection have been characterized, including remote ischemic conditioning, therapeutic hypothermia and neurostimulation. NT in a situation of impossibility of cerebral reperfusion is discussed. The results of randomized clinical trials and meta-analyzes on citicoline (ceraxon) are analyzed. A clinical case is presented illustrating the management of a patient for whom reperfusion therapy was not feasible due to the course of the disease. In the era of the active development of reperfusion methods for the treatment of ischemic stroke, the goal-setting of NT has changed: it is intended to expand the possibilities of application and increase the effectiveness of intravenous thrombolysis and/or mechanical thrombectome, as well as neutralize their negative reperfusion effects. The main targets for NT remain excitotoxicity, oxidative and nitrosative stress. On the other hand, the real clinical situation associated with the low frequency of reperfusion technology in our country necessitates the use of neuroprotectors effective in this category of patients. In this regard, the administration of ceraxon increases the chances of achieving functional independence. The most effective use of the drug from the first day of the disease at a dose of 2000 mg per day intravenously for at least 4-6 weeks with further long-term oral administration at a dose of 1000 mg per day.
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Affiliation(s)
- A. A. Kulesh
- E.A. Vagner Perm State Medical University; City Clinical Hospital No. 4
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12
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Wu D, Chen J, Hussain M, Wu L, Shi J, Wu C, Ma Y, Zhang M, Yang Q, Fu Y, Duan Y, Ma C, Yan F, Zhu Z, He X, Yao T, Song M, Zhi X, Wang C, Cai L, Li C, Li S, Zhang Y, Ding Y, Ji X. Selective intra-arterial brain cooling improves long-term outcomes in a non-human primate model of embolic stroke: Efficacy depending on reperfusion status. J Cereb Blood Flow Metab 2020; 40:1415-1426. [PMID: 32126876 PMCID: PMC7308521 DOI: 10.1177/0271678x20903697] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Nearly all stroke neuroprotection modalities, including selective intra-arterial cooling (SI-AC), have failed to be translated from bench to bed side. Potentially overlooked reasons may be biological gaps, inadequate attention to reperfusion states and mismatched attention to neurological benefits. To advance stroke translation, we describe a novel thrombus-based stroke model in adult rhesus macaques. Intra-arterial thrombolysis with tissue plasminogen activator leads to three clinically relevant outcomes - complete, partial, and no recanalization based on digital subtraction angiography. We also find reperfusion as a prerequisite for SI-AC-induced benefits, in which models with complete or partial reperfusion exhibit significantly reduced infarct volumes, mitigated neurological deficits, improved upper limb motor dysfunction in both acute and chronic stages; however, no further neuroprotection is observed in those without reperfusion. In summary, we discover reperfusion as a crucial regulator of SI-AC-induced neuroprotection and provide insights of long-term functional benefits in behavior and imaging levels. Our findings could be important not only for the translational prerequisite and potential molecular targets, but also for this thrombus-thrombolysis model in monkeys as a powerful tool for further translational stroke studies.
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Affiliation(s)
- Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mohammed Hussain
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Longfei Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China
| | - Jingfei Shi
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China
| | - Yanhui Ma
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mo Zhang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qi Yang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongjuan Fu
- Department of Pathology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yunxia Duan
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Cui Ma
- Interdisciplinary Innovation Institute of Medicine and Engineering, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Feng Yan
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zixin Zhu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaoduo He
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianqi Yao
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ming Song
- Interdisciplinary Innovation Institute of Medicine and Engineering, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Xinglong Zhi
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chunxiu Wang
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lipeng Cai
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shengli Li
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongbiao Zhang
- Brainnetome Center, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Yuchuan Ding
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xunming Ji
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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13
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Rouzbahani A, Khodadadi E, Fooladi M. Impact of Mild Hypothermia on Final Outcome of Patients with Acute Stroke: A Randomized Clinical Trial. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Background and Aim Stroke is a sudden neurological disorder caused by disturbances in the brain blood flow and loss of normal brain function. Stroke is also the second leading cause of death worldwide. In the last two decades, among the various treatment options for stroke, hypothermia has shown the promise of improving the final outcome. This study aimed to investigate the effect of noninvasive hypothermia on the final outcome of patients with an acute stroke in Iran.
Methods In a randomized clinical trial, 60 Iranian patients diagnosed with acute stroke were enrolled in 2018. Patients were selected by convenience sampling method and then randomized in two groups as experimental (n = 30) and control (n = 30). Mild hypothermia was applied using a cooling device for 72 hours on the patients’ heads and intervention results were compared with the control group. Data were collected by using Acute Physiology and Chronic Health Evaluation III (APACHE III), Full Outline of Un-Responsiveness (FOUR), and National Institutes of Health Stroke Scale (NIHSS), and later analyzed by Statistical Package for the Social Sciences (SPSS) software version 22.
Results No significant difference was found in the mean scores of all three scales before and after the intervention in control group (p > 0.05) but statistically significant difference was found in the mean scores of all three scales for the intervention group (p < 0.05). The intervention group had an increased mean score in FOUR, while APACHE and NIHSS values dropped. Researchers found statistically significant difference between the mean scores after the intervention in the experimental group compared with the control group in all three scales (p < 0.05).
Conclusion The findings of this study indicate that hypothermia has a significant statistical and clinical effect on the acute stroke outcome and it can be argued that hypothermia therapy can increase the level of consciousness and reduce the risk of death in stroke patients.
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Affiliation(s)
- Abbas Rouzbahani
- Nursing and Midwifery School, Islamic Azad University, Urmia, Iran
| | | | - Marjaneh Fooladi
- World Wide Nursing Service Network, PLLC, El Paso, Texas, United States
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14
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Wu L, Wu D, Yang T, Xu J, Chen J, Wang L, Xu S, Zhao W, Wu C, Ji X. Hypothermic neuroprotection against acute ischemic stroke: The 2019 update. J Cereb Blood Flow Metab 2020; 40:461-481. [PMID: 31856639 PMCID: PMC7026854 DOI: 10.1177/0271678x19894869] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023]
Abstract
Acute ischemic stroke is a leading cause of death and disability worldwide. Therapeutic hypothermia has long been considered as one of the most robust neuroprotective strategies. Although the neuroprotective effects of hypothermia have only been confirmed in patients with global cerebral ischemia after cardiac arrest and in neonatal hypoxic ischemic encephalopathy, establishing standardized protocols and strictly controlling the key parameters may extend its application in other brain injuries, such as acute ischemic stroke. In this review, we discuss the potential neuroprotective effects of hypothermia, its drawbacks evidenced in previous studies, and its potential clinical application for acute ischemic stroke especially in the era of reperfusion. Based on the different conditions between bench and bedside settings, we demonstrate the importance of vascular recanalization for neuroprotection of hypothermia by analyzing numerous literatures regarding hypothermia in focal cerebral ischemia. Then, we make a thorough analysis of key parameters of hypothermia and introduce novel hypothermic therapies. We advocate in favor of the process of clinical translation of intra-arterial selective cooling infusion in the era of reperfusion and provide insights into the prospects of hypothermia in acute ischemic stroke.
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Affiliation(s)
- Longfei Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tuo Yang
- Department of Neurology, Pittsburgh Institute of Brain Disorders and Recovery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jin Xu
- Department of Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Luling Wang
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shuaili Xu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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15
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Katica-Mulalic A, Suljic E, Begic E, Mukanovic-Alihodzic A, Straus S, Feto A, Dedovic Z, Gojak R. Effect of Therapeutic Hypothermia on Liver Enzymes in Patients With Stroke. Med Arch 2020; 74:470-473. [PMID: 33603273 PMCID: PMC7879342 DOI: 10.5455/medarh.2020.74.470-473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: A promising strategy that can lead to longer brain cell survival after an acute stroke is therapeutic hypothermia. It represents a controlled decrease in body temperature for therapeutic reasons. It is increasingly represented as a therapeutic option and is one of the most challenging treatments that improves neurological recovery and treatment outcome in patients with acute stroke. Aim: To examine the effect of therapeutic hypothermia on liver enzymes in patients with diagnosis of stroke. Methods: A total of 101 patients diagnosed with acute stroke were treated. The first group (n=40) were treated with conventional treatment and therapeutic hypothermia, while the second group (n=61) only with conventional treatment. Cooling of the body to a target body temperature of 34°C to 35°C was performed for up to 24 hours. Outcome (survival or death) of treatment was monitored, degree of disability was determined by National Institutes of Health Stroke Scale (NIHSS) and assessment of consciousness using the Glasgow Coma Scale (GCS). Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values were taken at admission, after 24 hours, and were monitored upon discharge. Results: There was a significant difference in AST values at admission relative to disease outcome (p = 0.002), as well as for ALT (p = 0.008). In patients treated with therapeutic hypothermia, mean AST values decreased after 24 hours (32.50 to 31.00 IU/mL) as well as ALT values (27.50 to 26.50 IU/mL), without statistical significance. In the group of subjects who survived with sequela, AST values correlated with GCS (rho = -0.489; p = 0.002) and NIHSS (rho = 0.492; p = 0.003), ALT values correlated with GCS (rho = -0.356; p = 0.03) but not with NIHSS. Conclusion: AST and ALT values at admission correlate with the severity of the clinical picture. Therapeutic hypothermia is hepatoprotective and lowers AST and ALT values.
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Affiliation(s)
- Amela Katica-Mulalic
- Clinic Anesthesiology and Resuscitation, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Enra Suljic
- Department for Science, Teaching and Clinical Trials, Clinical Centre University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Edin Begic
- Department of Cardiology, General Hospital «Prim. dr. Abdulah Nakas», Sarajevo, Bosnia and Herzegovina
| | - Azra Mukanovic-Alihodzic
- Clinic Anesthesiology and Resuscitation, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Slavenka Straus
- Clinic for Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Amila Feto
- Clinic Anesthesiology and Resuscitation, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Zenaida Dedovic
- Clinic Anesthesiology and Resuscitation, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Refet Gojak
- Clinic for Infectious Diseases, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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16
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Huber C, Huber M, Ding Y. Evidence and opportunities of hypothermia in acute ischemic stroke: Clinical trials of systemic versus selective hypothermia. Brain Circ 2019; 5:195-202. [PMID: 31950095 PMCID: PMC6950508 DOI: 10.4103/bc.bc_25_19] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/28/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022] Open
Abstract
Stroke is the second leading cause of death globally and the third leading cause disability. Acute ischemic stroke (AIS), resulting from occlusion of major vessels in the brain, accounts for approximately 87% of strokes. Despite this large majority, current treatment options for AIS are severely limited and available to only a small percentage of patients. Therapeutic hypothermia (TH) has been widely used for neuroprotection in the setting of global ischemia postcardiac arrest, and recent evidence suggests that hypothermia may be the neuroprotective agent that stroke patients desperately need. Several clinical trials using systemic or selective cooling for TH have been published, reporting the safety and feasibility of these methods. Here, we summarize the major clinical trials of TH for AIS and provide recommendations for future studies.
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Affiliation(s)
- Christian Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Mitchell Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
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17
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Vaughan BC, Jones MER, Browne IL, Olshavsky JM, Schultz RD. Selective retrograde cerebral cooling in complete cerebral circulatory arrest. Brain Circ 2019; 5:234-240. [PMID: 31950100 PMCID: PMC6950516 DOI: 10.4103/bc.bc_60_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 12/09/2019] [Accepted: 12/16/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE: Cerebral hypothermia is a known neuroprotectant with promising applications in the treatment of ischemic events. Although systemic cooling is standard in post-cardiac arrest care, the deleterious effects of whole-body cooling have precluded it from translation into a viable treatment option for acute ischemic stroke (AIS). Selective cerebral cooling has been proposed as a method to minimize these risks while granting the neuroprotection of therapeutic hypothermia in AIS. METHODS: In a porcine model (n = 3), the efficacy of selective retrograde cerebral cooling through the internal jugular vein was evaluated in the setting of complete cerebral circulatory arrest. Furthermore, a novel endovascular device and cooling system enabling selective retrograde cerebral cooling were studied in a normothermic perfused cadaver. RESULTS AND CONCLUSION: Neurologic assessment of animals receiving this therapy reflected substantial neuroprotection in animals undergoing both 15 min and 30 min of otherwise catastrophic complete cerebral circulatory arrest. The novel endovascular device and cooling system were validated in human anatomy, demonstrating successful cerebral cooling, and feasibility of this mechanism of selective retrograde cerebral cooling.
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Affiliation(s)
| | - Melissa E R Jones
- Voyage Biomedical Inc., Berkeley, CA, United States.,Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ikennah L Browne
- Voyage Biomedical Inc., Berkeley, CA, United States.,Department of Surgery, Division of General Surgery, University of Calgary, Calgary, AB, Canada
| | | | - Robert D Schultz
- Voyage Biomedical Inc., Berkeley, CA, United States.,Section of Cardiac Surgery, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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18
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Chen Y, Quddusi A, Harrison KA, Ryan PE, Cook DJ. Selection of preclinical models to evaluate intranasal brain cooling for acute ischemic stroke. Brain Circ 2019; 5:160-168. [PMID: 31950091 PMCID: PMC6950506 DOI: 10.4103/bc.bc_20_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/28/2019] [Indexed: 01/12/2023] Open
Abstract
Stroke accounts for a large proportion of global mortality and morbidity. Selective hypothermia, via intranasal cooling devices, is a promising intervention in acute ischemic stroke. However, prior to large clinical trials, preclinical studies in large animal models of ischemic stroke are needed to assess the efficacy, safety, and feasibility of intranasal cooling for selective hypothermia as a neuroprotective strategy. Here, we review the available scientific literature for evidence supporting selective hypothermia and make recommendations of a preclinical, large, animal-based, ischemic stroke model that has the greatest potential for evaluating intranasal cooling for selective hypothermia and neuroprotection. We conclude that among large animal models of focal ischemic stroke including pigs, sheep, dogs, and nonhuman primates (NHPs), cynomolgus macaques have nasal anatomy, nasal vasculature, neuroanatomy, and cerebrovasculature that are most similar to those of humans. Moreover, middle cerebral artery stroke in cynomolgus macaques produces functional and behavioral deficits that are quantifiable to a greater degree of precision and detail than those that can be revealed through available assessments for other large animals. These NHPs are also amenable to extensive neuroimaging studies as a means of monitoring stroke evolution and evaluating infarct size. Hence, we suggest that cynomolgus macaques are best suited to assess the safety and efficacy of intranasal selective hypothermia through an evaluation of hyperacute diffusion-weighted imaging and subsequent investigation of chronic functional recovery, prior to randomized clinical trials in humans.
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Affiliation(s)
- Yining Chen
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Ayesha Quddusi
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | | | - Paige E Ryan
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Douglas J Cook
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Department of Surgery, Division of Neurosurgery, Kingston General Hospital, Kingston, ON, Canada
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19
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Hypothermia in the Neurocritical Care Unit: Physiology and Applications. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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20
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Duan H, Huber M, Ding JN, Huber C, Geng X. Local endovascular infusion and hypothermia in stroke therapy: A systematic review. Brain Circ 2019; 5:68-73. [PMID: 31334359 PMCID: PMC6611196 DOI: 10.4103/bc.bc_9_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/03/2019] [Accepted: 05/16/2019] [Indexed: 01/01/2023] Open
Abstract
Ischemic stroke is a leading cause of death and disability worldwide, but there are no effective, widely applicable stroke therapies. Systemic hypothermia is an international mainstay of postcardiac arrest care, and the neuroprotective benefits of systemic hypothermia following cerebral ischemia have been proven in clinical trials, but logistical issues hinder clinical acceptance. As a novel solution to these logistical issues, the application of local endovascular infusion of cold saline directly to the infarct site using a microcatheter has been put forth. In small animal models, the procedure has shown incredible neuroprotective promise on the biochemical, structural, and functional levels, and preliminary trials in large animals and humans have been similarly encouraging. In addition, the procedure would be relatively cost-effective and widely applicable. The administration of local endovascular hypothermia in humans is relatively simple, as this is a normal part of endovascular intervention for neuroendovascular surgeons. Therefore, it is expected that this new therapy could easily be added to an angiography suite. However, the neuroprotective efficacy in humans has yet to be determined, which is an end goal of researchers in the field. Given the potentially massive benefits, ease of induction, and cost-effective nature, it is likely that local endovascular hypothermia will become an integral part of endovascular treatment following ischemic stroke. This review outlines relevant research, discusses neuroprotective mechanisms, and discusses possibilities for future directions.
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Affiliation(s)
- Honglian Duan
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Mitchell Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Jessie N Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Christian Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
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21
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Choi JH, Pile-Spellman J. Reperfusion Changes After Stroke and Practical Approaches for Neuroprotection. Neuroimaging Clin N Am 2019; 28:663-682. [PMID: 30322601 DOI: 10.1016/j.nic.2018.06.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Reperfusion is the first line of care in a growing number of eligible acute ischemic stroke patients. Early reperfusion with thrombolytic drugs and endovascular mechanical devices is associated with improved outcome and lower mortality rates compared with natural history. Reperfusion is not without risk, however, and may result in reperfusion injury, which manifests in hemorrhagic transformation, brain edema, infarct progression, and neurologic worsening. In this article, the functional and structural changes and underlying molecular mechanisms of ischemia and reperfusion are reviewed. The pathways that lead to reperfusion injury and novel neuroprotective strategies with endogenous properties are discussed.
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Affiliation(s)
- Jae H Choi
- Center for Unruptured Brain Aneurysms, Neurological Surgery PC, 1991 Marcus Avenue, Suite 108, Lake Success, NY 11042, USA; Department of Neurology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, USA; Hybernia Medical LLC, 626 RexCorp Plaza, Uniondale, NY 11556, USA.
| | - John Pile-Spellman
- Center for Unruptured Brain Aneurysms, Neurological Surgery PC, 1991 Marcus Avenue, Suite 108, Lake Success, NY 11042, USA; Hybernia Medical LLC, 626 RexCorp Plaza, Uniondale, NY 11556, USA
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22
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King ZA, Sheth KN, Kimberly WT, Simard JM. Profile of intravenous glyburide for the prevention of cerebral edema following large hemispheric infarction: evidence to date. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:2539-2552. [PMID: 30147301 PMCID: PMC6101021 DOI: 10.2147/dddt.s150043] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Glyburide (also known as glibenclamide) is a second-generation sulfonylurea drug that inhibits sulfonylurea receptor 1 (Sur1) at nanomolar concentrations. Long used to target KATP (Sur1–Kir6.2) channels for the treatment of diabetes mellitus type 2, glyburide was recently repurposed to target Sur1–transient receptor potential melastatin 4 (Trpm4) channels in acute central nervous system injury. Discovered nearly two decades ago, SUR1–TRPM4 has emerged as a critical target in stroke, specifically in large hemispheric infarction, which is characterized by edema formation and life-threatening brain swelling. Following ischemia, SUR1–TRPM4 channels are transcriptionally upregulated in all cells of the neurovascular unit, including neurons, astrocytes, microglia, oligodendrocytes and microvascular endothelial cells. Work by several independent laboratories has linked SUR1–TRPM4 to edema formation, with blockade by glyburide reducing brain swelling and death in preclinical models. Recent work showed that, following ischemia, SUR1–TRPM4 co-assembles with aquaporin-4 to mediate cellular swelling of astrocytes, which contributes to brain swelling. Additionally, recent work linked SUR1–TRPM4 to secretion of matrix metalloproteinase-9 (MMP-9) induced by recombinant tissue plasminogen activator in activated brain endothelial cells, with blockade of SUR1–TRPM4 by glyburide reducing MMP-9 and hemorrhagic transformation in preclinical models with recombinant tissue plasminogen activator. The recently completed GAMES (Glyburide Advantage in Malignant Edema and Stroke) clinical trials on patients with large hemispheric infarctions treated with intravenous glyburide (RP-1127) revealed promising findings with regard to brain swelling (midline shift), MMP-9, functional outcomes and mortality. Here, we review key elements of the basic science, preclinical experiments and clinical studies, both retrospective and prospective, on glyburide in focal cerebral ischemia and stroke.
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Affiliation(s)
- Zachary A King
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - W Taylor Kimberly
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA,
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Drieu A, Levard D, Vivien D, Rubio M. Anti-inflammatory treatments for stroke: from bench to bedside. Ther Adv Neurol Disord 2018; 11:1756286418789854. [PMID: 30083232 PMCID: PMC6066814 DOI: 10.1177/1756286418789854] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/19/2018] [Indexed: 12/11/2022] Open
Abstract
So far, intravenous tissue-type plasminogen activator (tPA) and mechanical
removal of arterial blood clot (thrombectomy) are the only available treatments
for acute ischemic stroke. However, the short therapeutic window and the lack of
specialized stroke unit care make the overall availability of both treatments
limited. Additional agents to combine with tPA administration or thrombectomy to
enhance efficacy and improve outcomes associated with stroke are needed.
Stroke-induced inflammatory processes are a response to the tissue damage due to
the absence of blood supply but have been proposed also as key contributors to
all the stages of the ischemic stroke pathophysiology. Despite promising results
in experimental studies, inflammation-modulating treatments have not yet been
translated successfully into the clinical setting. This review will (a) describe
the timing of the stroke immune pathophysiology; (b) detail the immune responses
to stroke sift-through cell type; and (c) discuss the pitfalls on the
translation from experimental studies to clinical trials testing the therapeutic
pertinence of immune modulators.
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Affiliation(s)
- Antoine Drieu
- Pathophysiology and Imaging of Neurological Disorders, Normandy University, Caen, France
| | - Damien Levard
- Pathophysiology and Imaging of Neurological Disorders, Normandy University, Caen, France
| | - Denis Vivien
- Pathophysiology and Imaging of Neurological Disorders, Normandy University, Caen, France Pathophysiology and Imaging of Neurological Disorders, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Marina Rubio
- Pathophysiology and Imaging of Neurological Disorders, Normandy University, Boulevard Henri Becquerel BP 5229, Caen Cedex, 14000, France
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Park HS, Choi JH. Safety and Efficacy of Hypothermia (34°C) after Hemicraniectomy for Malignant MCA Infarction. J Korean Neurosurg Soc 2018. [PMID: 29526071 PMCID: PMC5853190 DOI: 10.3340/jkns.2016.1111.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The beneficial effect of hypothermia after hemicraniectomy in malignant middle cerebral artery (MCA) infarction has been controversial. We aim to investigate the safety and clinical efficacy of hypothermia after hemicraniectomy in malignant MCA infarction. METHODS From October 2012 to February 2016, 20 patients underwent hypothermia (Blanketrol III, Cincinnati Sub-Zero, Cincinnati, OH, USA) at 34°C after hemicraniectomy in malignant MCA infarction (hypothermia group). The indication of hypothermia included acute cerebral infarction >2/3 of MCA territory and a Glasgow coma scale (GCS) score <11 with a midline shift >10 mm or transtentorial herniation sign (a fixed and dilated pupil). We retrospectively collected 27 patients, as the control group, who had undergone hemicraniectomy alone and simultaneously met the inclusion criteria of hypothermia between January 2010 and September 2012, before hypothermia was implemented as a treatment strategy in Dong-A University Hospital. We compared the mortality rate between the two groups and investigated hypothermia-related complications, such as postoperative bleeding, pneumonia, sepsis and arrhythmia. RESULTS The age, preoperative infarct volume, GCS score, National institutes of Health Stroke Scale score, and degree of midline shift were not significantly different between the two groups. Of the 20 patients in the hypothermia group, 11 patients were induced with hypothermia immediately after hemicraniectomy and hypothermia was initiated in 9 patients after the decision of hypothermia during postoperative care. The duration of hypothermia was 4±2 days (range, 1 to 7 days). The side effects of hypothermia included two patients with arrhythmia, one with sepsis, one with pneumonia, and one with hypotension. Three cases of hypothermia were discontinued due to these side effects (one sepsis, one hypotension, and one bradycardia). The mortality rate of the hypothermia group was 15.0% and that of the control group was 40.7% (p=0.056). On the basis of the logistic regression analysis, hypothermia was considered to contribute to the decrease in mortality rate (odds ratio, 6.21; 95% confidence interval, 1.04 to 37.05; p=0.045). CONCLUSION This study suggests that hypothermia after hemicraniectomy is a viable option when the progression of patients with malignant MCA infarction indicate poor prognosis.
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Affiliation(s)
- Hyun-Seok Park
- Department of Neurosurgery, Busan-Ulsan Regional Cardio-Cerebrovascular Center, Medical Science Research Center, Dong-A University College of Medicine, Busan, Korea
| | - Jae-Hyung Choi
- Department of Neurosurgery, Busan-Ulsan Regional Cardio-Cerebrovascular Center, Medical Science Research Center, Dong-A University College of Medicine, Busan, Korea
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Abstract
Therapeutic hypothermia (TH) is a potent neuroprotective therapy in experimental cerebral ischemia, with multiple effects at several stages of the ischemic cascade. In animals, TH is so powerful that all preclinical stroke studies require strict temperature control. In humans, multiple clinical studies documented powerful protection with TH after accidental neonatal hypoxic-ischemic injury and global cerebral ischemia with return of spontaneous circulation after cardiac arrest. National and international guidelines recommend TH for selected survivors of global ischemia, with profound benefits seen. Recently, a study comparing target temperature 33-36°C failed to demonstrate significant effects in cardiac arrest patients. Additionally, clinical trials of TH for head trauma and stroke have so far failed to confirm benefit in humans despite a vast preclinical literature. Therefore, it is now critical to understand the fundamental explanation for the success of TH in some, but famously not all, clinical trials. TH in animals appears to work when used soon after ischemia onset; for a short duration; and at a deep target temperature.
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Muengtaweepongsa S, Srivilaithon W. Targeted temperature management in neurological intensive care unit. World J Methodol 2017; 7:55-67. [PMID: 28706860 PMCID: PMC5489424 DOI: 10.5662/wjm.v7.i2.55] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/12/2017] [Accepted: 05/18/2017] [Indexed: 02/06/2023] Open
Abstract
Targeted temperature management (TTM) shows the most promising neuroprotective therapy against hypoxic/ischemic encephalopathy (HIE). In addition, TTM is also useful for treatment of elevated intracranial pressure (ICP). HIE and elevated ICP are common catastrophic conditions in patients admitted in Neurologic intensive care unit (ICU). The most common cause of HIE is cardiac arrest. Randomized control trials demonstrate clinical benefits of TTM in patients with post-cardiac arrest. Although clinical benefit of ICP control by TTM in some specific critical condition, for an example in traumatic brain injury, is still controversial, efficacy of ICP control by TTM is confirmed by both in vivo and in vitro studies. Several methods of TTM have been reported in the literature. TTM can apply to various clinical conditions associated with hypoxic/ischemic brain injury and elevated ICP in Neurologic ICU.
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Babadjouni RM, Walcott BP, Liu Q, Tenser MS, Amar AP, Mack WJ. Neuroprotective delivery platforms as an adjunct to mechanical thrombectomy. Neurosurg Focus 2017; 42:E4. [PMID: 28366053 DOI: 10.3171/2017.1.focus16514] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Despite the success of numerous neuroprotective strategies in animal and preclinical stroke models, none have effectively translated to clinical medicine. A multitude of influences are likely responsible. Two such factors are inefficient recanalization strategies for large vessel occlusions and suboptimal delivery methods/platforms for neuroprotective agents. The recent endovascular stroke trials have established a new paradigm for large vessel stroke treatment. The associated advent of advanced mechanical revascularization devices and new stroke technologies help address each of these existing gaps. A strategy combining effective endovascular revascularization with administration of neuroprotective therapies is now practical and could have additive, if not synergistic, effects. This review outlines past and current neuroprotective strategies assessed in acute stroke trials. The discussion focuses on delivery platforms and their potential applicability to endovascular stoke treatment.
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Affiliation(s)
| | - Brian P Walcott
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Matthew S Tenser
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Arun P Amar
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - William J Mack
- Zilkha Neurogenetic Institute and.,Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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28
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Karsy M, Brock A, Guan J, Taussky P, Kalani MYS, Park MS. Neuroprotective strategies and the underlying molecular basis of cerebrovascular stroke. Neurosurg Focus 2017; 42:E3. [DOI: 10.3171/2017.1.focus16522] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Stroke is a leading cause of disability in the US. Although there has been significant progress in the area of medical and surgical thrombolytic technologies, neuroprotective agents to prevent secondary cerebral injury and to minimize disability remain limited. Only limited success has been reported in preclinical and clinical trials evaluating a variety of compounds. In this review, the authors discuss the most up-to-date information regarding the underlying molecular biology of stroke as well as strategies that aim to mitigate this complex signaling cascade. Results of historical research trials involving N-methyl-d-aspartate and α-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptor antagonists, clomethiazole, antioxidants, citicoline, nitric oxide, and immune regulators have laid the groundwork for current progress. In addition, more recent studies involving therapeutic hypothermia, magnesium, albumin, glyburide, uric acid, and a variety of other treatments have provided more options. The use of neuroprotective agents in combination or with existing thrombolytic treatments may be one of many exciting areas of further development. Although past trials of neuroprotective agents in ischemic stroke have been limited, significant insights into mechanisms of stroke, animal models, and trial design have incrementally improved approaches for future therapies.
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Lyden P, Hemmen T, Grotta J, Rapp K, Ernstrom K, Rzesiewicz T, Parker S, Concha M, Hussain S, Agarwal S, Meyer B, Jurf J, Altafullah I, Raman R. Results of the ICTuS 2 Trial (Intravascular Cooling in the Treatment of Stroke 2). Stroke 2016; 47:2888-2895. [PMID: 27834742 DOI: 10.1161/strokeaha.116.014200] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 09/13/2016] [Accepted: 10/05/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Therapeutic hypothermia is a potent neuroprotectant approved for cerebral protection after neonatal hypoxia-ischemia and cardiac arrest. Therapeutic hypothermia for acute ischemic stroke is safe and feasible in pilot trials. We designed a study protocol to provide safer, faster therapeutic hypothermia in stroke patients. METHODS Safety procedures and 4°C saline infusions for faster cooling were added to the ICTuS trial (Intravascular Cooling in the Treatment of Stroke) protocol. A femoral venous intravascular cooling catheter after intravenous recombinant tissue-type plasminogen activator in eligible patients provided 24 hours cooling followed by a 12-hour rewarm. Serial safety assessments and imaging were performed. The primary end point was 3-month modified Rankin score 0,1. RESULTS Of the intended 1600 subjects, 120 were enrolled before the study was stopped. Randomly, 63 were to receive hypothermia plus antishivering treatment and 57 normothermia. Compared with previous studies, cooling rates were improved with a cold saline bolus, without fluid overload. The intention-to-treat primary outcome of 90-day modified Rankin Score 0,1 occurred in 33% hypothermia and 38% normothermia subjects, odds ratio (95% confidence interval) of 0.81 (0.36-1.85). Serious adverse events occurred equally. Mortality was 15.9% hypothermia and 8.8% normothermia subjects, odds ratio (95% confidence interval) of 1.95 (0.56-7.79). Pneumonia occurred in 19% hypothermia versus 10.5% in normothermia subjects, odds ratio (95% confidence interval) of 1.99 (0.63-6.98). CONCLUSIONS Intravascular therapeutic hypothermia was confirmed to be safe and feasible in recombinant tissue-type plasminogen activator-treated acute ischemic stroke patients. Protocol changes designed to reduce pneumonia risk appeared to fail, although the sample is small. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01123161.
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Affiliation(s)
- Patrick Lyden
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.).
| | - Thomas Hemmen
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - James Grotta
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Karen Rapp
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Karin Ernstrom
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Teresa Rzesiewicz
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Stephanie Parker
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Mauricio Concha
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Syed Hussain
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Sachin Agarwal
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Brett Meyer
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Julie Jurf
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Irfan Altafullah
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
| | - Rema Raman
- From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.); Department of Neurosciences (T.H., K.R., B.M.) and Sanford Stem Cell Clinical Center (T.R.), University of California, San Diego; Department of Neurology, Memorial Health Care System, Houston, TX (J.G.); Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego (K.E., R.R.); Department of Neurology, University of Texas McGovern Medical School, Houston (S.P.); Department of Neurosciences, Sarasota Memorial Health Care System, FL (M.C.); Department of Neurology, Michigan State University, Kalamazoo (S.H.); Department of Neurology, Columbia University, New York, NY (S.A.); Performance Improvement Patient Safety Department, UC San Diego Health System, CA (J.J.); and Department of Neurology, North Memorial Medical Center, Minneapolis, MN (I.A.)
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Abstract
Hypothermia is the most potent neuroprotective therapy available. Clinical use of hypothermia is limited by technology and homeostatic mechanisms that maintain core body temperature. Recent advances in intravascular cooling catheters and successful trials of hypothermia for cardiac arrest revivified interest in hypothermia for stroke, resulting in Phase 1 clinical trials and plans for further development. Given the recent spate of neuroprotective therapy failures, we sought to clarify whether clinical trials of therapeutic hypothermia should be mounted in stroke patients. We reviewed the preclinical and early clinical trials of hypothermia for a variety of indications, the putative mechanisms for neuroprotection with hypothermia, and offer several hypotheses that remain to be tested in clinical trials. Therapeutic hypothermia is promising, but further Phase 1 and Phase 2 development efforts are needed to ensure that cooling of stroke patients is safe, before definitive efficacy trials.
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Affiliation(s)
- Patrick D. Lyden
- Neurology and Research Services of the San Diego Veteran's Administration Medical Center and the Department of Neurosciences, University of California, San Diego, CA, USA
| | - Derk Krieger
- Section of Stroke and Neurological Critical Care, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Midori Yenari
- Department of Neurology, University of California San Francisco School of Medicine, San Francisco, CA, USA
- Neurology Department of the San Francisco Veteran's Administration Medical Center, San Francisco, CA, USA
| | - W. Dalton Dietrich
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL, USA
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31
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Tahir RA, Pabaney AH. Therapeutic hypothermia and ischemic stroke: A literature review. Surg Neurol Int 2016; 7:S381-6. [PMID: 27313963 PMCID: PMC4901811 DOI: 10.4103/2152-7806.183492] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/18/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Ischemic stroke is the fifth leading cause of death in the US. Clinical techniques aimed at helping to reduce the morbidity associated with stroke have been studied extensively, including therapeutic hypothermia. In this study, the authors review the literature regarding the role of therapeutic hypothermia in ischemic stroke to appreciate the evolution of hypothermia technology over several decades and to critically analyze several early clinical studies to validate its use in ischemic stroke. METHODS A comprehensive literature search was performed using PubMed and Google Scholar databases. Search terms included "hypothermia and ischemic stroke" and "therapeutic hypothermia." A comprehensive search of the current clinical trials using clinicaltrials.gov was conducted using the keywords "stroke and hypothermia" to evaluate early and ongoing clinical trials utilizing hypothermia in ischemic stroke. RESULTS A comprehensive review of the evolution of hypothermia in stroke and the current status of this treatment was performed. Clinical studies were critically analyzed to appreciate their strengths and pitfalls. Ongoing and future registered clinical studies were highlighted and analyzed compared to the reported results of previous trials. CONCLUSION Although hypothermia has been used for various purposes over several decades, its efficacy in the treatment of ischemic stroke is debatable. Several trials have proven its safety and feasibility; however, more robust, randomized clinical trials with large volumes of patients are needed to fully establish its utility in the clinical setting.
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Affiliation(s)
- Rizwan A Tahir
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Aqueel H Pabaney
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA
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Wu Z, Zhu SZ, Hu YF, Gu Y, Wang SN, Lin ZZ, Xie ZS, Pan SY. Glibenclamide enhances the effects of delayed hypothermia after experimental stroke in rats. Brain Res 2016; 1643:113-22. [PMID: 27134036 DOI: 10.1016/j.brainres.2016.04.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 04/24/2016] [Accepted: 04/27/2016] [Indexed: 11/25/2022]
Abstract
In order to evaluate whether glibenclamide can extend the therapeutic window during which induced hypothermia can protect against stroke, we subjected adult male Sprague-Dawley rats to middle cerebral artery occlusion (MCAO). We first verified the protective effects of hypothermia induced at 0, 2, 4 or 6h after MCAO onset, and then we assessed the effects of the combination of glibenclamide and hypothermia at 6, 8 or 10h after MCAO onset. At 24h after MCAO, we assessed brain edema, infarct volume, modified neurological severity score, Evans Blue leakage and expression of Sulfonylurea receptor 1 (SUR1) protein and pro-inflammatory factors. No protective effects were observed when hypothermia was induced too long after MCAO. At 6h after MCAO onset, hypothermia alone failed to decrease cerebral edema and infarct volume, but the combination of glibenclamide and hypothermia decreased both. The combination also improved neurological outcome, ameliorated blood-brain barrier damage and decreased levels of COX-2, TNF-α and IL-1β. These results suggest that glibenclamide enhances and extends the therapeutic effects of delayed hypothermia against ischemia stroke, potentially by ameliorating blood-brain barrier damage and declining levels of pro-inflammatory factors.
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Affiliation(s)
- Zhou Wu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shu-Zhen Zhu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ya-Fang Hu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yong Gu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Sheng-Nan Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhen-Zhou Lin
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zuo-Shan Xie
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Su-Yue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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Forreider B, Pozivilko D, Kawaji Q, Geng X, Ding Y. Hibernation-like neuroprotection in stroke by attenuating brain metabolic dysfunction. Prog Neurobiol 2016; 157:174-187. [PMID: 26965388 DOI: 10.1016/j.pneurobio.2016.03.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 03/02/2016] [Accepted: 03/03/2016] [Indexed: 11/24/2022]
Abstract
Many mammalian species naturally undergo hibernation, a process that is associated with drastic changes in metabolism and systemic physiology. Their ability to retain an undamaged central nervous system during severely reduced cerebral blood flow has been studied for possible therapeutic application in human ischemic stroke. By inducing a less extreme 'hibernation-like' state, it has been hypothesized that similar neuroprotective effects reduce ischemia-mediated tissue damage in stroke patients. This manuscript includes reviews and evaluations of: (1) true hibernation, (2) hibernation-like state and its neuroprotective characteristics, (3) the preclinical and clinical methods for induction of artificial hibernation (i.e., therapeutic hypothermia, phenothiazine drugs, and ethanol), and (4) the mechanisms by which cerebral ischemia leads to tissue damage and how the above-mentioned induction methods function to inhibit those processes.
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Affiliation(s)
- Brian Forreider
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - David Pozivilko
- Michigan State University College of Human Medicine, East Lansing, MI, USA
| | - Qingwen Kawaji
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xiaokun Geng
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA; China-America Institute of Neuroscience, Luhe Hospital, Capital Medical University, Beijing, China.
| | - Yuchuan Ding
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA; China-America Institute of Neuroscience, Luhe Hospital, Capital Medical University, Beijing, China.
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Su Y, Fan L, Zhang Y, Zhang Y, Ye H, Gao D, Chen W, Liu G. Improved Neurological Outcome With Mild Hypothermia in Surviving Patients With Massive Cerebral Hemispheric Infarction. Stroke 2016; 47:457-63. [PMID: 26696645 DOI: 10.1161/strokeaha.115.009789] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 11/16/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Yingying Su
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Linlin Fan
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Yunzhou Zhang
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Hong Ye
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Daiquan Gao
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Weibi Chen
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Gang Liu
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
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Novel Interventions for Stroke: Nervous System Cooling. Transl Neurosci 2016. [DOI: 10.1007/978-1-4899-7654-3_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Callaway CW, Elmer J, Guyette FX, Molyneaux BJ, Anderson KB, Empey PE, Gerstel SJ, Holquist K, Repine MJ, Rittenberger JC. Dexmedetomidine Reduces Shivering during Mild Hypothermia in Waking Subjects. PLoS One 2015; 10:e0129709. [PMID: 26237219 PMCID: PMC4523180 DOI: 10.1371/journal.pone.0129709] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/12/2015] [Indexed: 12/20/2022] Open
Abstract
Background and Purpose Reducing body temperature can prolong tolerance to ischemic injury such as stroke or myocardial infarction, but is difficult and uncomfortable in awake patients because of shivering. We tested the efficacy and safety of the alpha-2-adrenergic agonist dexmedetomidine for suppressing shivering induced by a rapid infusion of cold intravenous fluids. Methods Ten subjects received a rapid intravenous infusion of two liters of cold (4°C) isotonic saline on two separate test days, and we measured their core body temperature, shivering, hemodynamics and sedation for two hours. On one test day, fluid infusion was preceded by placebo infusion. On the other test day, fluid infusion was preceded by 1.0 μg/kg bolus of dexmedetomidine over 10 minutes. Results All ten subjects experienced shivering on placebo days, with shivering beginning at a mean (SD) temperature of 36.6 (0.3)°C. The mean lowest temperature after placebo was 36.0 (0.3)°C (range 35.7-36.5°C). Only 3/10 subjects shivered on dexmedetomidine days, and the mean lowest temperature was 35.7 (0.4)°C (range 35.0-36.3°C). Temperature remained below 36°C for the full two hours in 6/10 subjects. After dexmedetomidine, subjects had moderate sedation and a mean 26 (13) mmHg reduction in blood pressure that resolved within 90 minutes. Heart rate declined a mean 23 (11) bpm after both placebo and dexmedetomidine. Dexmedetomidine produced no respiratory depression. Conclusion Dexmedetomidine decreases shivering in normal volunteers. This effect is associated with decreased systolic blood pressure and sedation, but no respiratory depression.
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Affiliation(s)
- Clifton W. Callaway
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jonathan Elmer
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Francis X. Guyette
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Bradley J. Molyneaux
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Kacey B. Anderson
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Philip E. Empey
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Stacy J. Gerstel
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Kate Holquist
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Melissa J. Repine
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jon C. Rittenberger
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- * E-mail:
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Jinka TR, Combs VM, Drew KL. Translating drug-induced hibernation to therapeutic hypothermia. ACS Chem Neurosci 2015; 6:899-904. [PMID: 25812681 DOI: 10.1021/acschemneuro.5b00056] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Therapeutic hypothermia (TH) improves prognosis after cardiac arrest; however, thermoregulatory responses such as shivering complicate cooling. Hibernators exhibit a profound and safe reversible hypothermia without any cardiovascular side effects by lowering the shivering threshold at low ambient temperatures (Ta). Activation of adenosine A1 receptors (A1ARs) in the central nervous system (CNS) induces hibernation in hibernating species and a hibernation-like state in rats, principally by attenuating thermogenesis. Thus, we tested the hypothesis that targeted activation of the central A1AR combined with a lower Ta would provide a means of managing core body temperature (Tb) below 37 °C for therapeutic purposes. We targeted the A1AR within the CNS by combining systemic delivery of the A1AR agonist (6)N-cyclohexyladenosine (CHA) with 8-(p-sulfophenyl)theophylline (8-SPT), a nonspecific adenosine receptor antagonist that does not readily cross the blood-brain barrier. Results show that CHA (1 mg/kg) and 8-SPT (25 mg/kg), administered intraperitoneally every 4 h for 20 h at a Ta of 16 °C, induce and maintain the Tb between 29 and 31 °C for 24 h in both naïve rats and rats subjected to asphyxial cardiac arrest for 8 min. Faster and more stable hypothermia was achieved by continuous infusion of CHA delivered subcutaneously via minipumps. Animals subjected to cardiac arrest and cooled by CHA survived better and showed less neuronal cell death than normothermic control animals. Central A1AR activation in combination with a thermal gradient shows promise as a novel and effective pharmacological adjunct for inducing safe and reversible targeted temperature management.
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Affiliation(s)
- Tulasi R. Jinka
- University of Alaska Fairbanks, 902 North Koyukuk Drive, Fairbanks, Alaska 99775-7000, United States
- University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Velva M. Combs
- University of Alaska Fairbanks, 902 North Koyukuk Drive, Fairbanks, Alaska 99775-7000, United States
| | - Kelly L. Drew
- University of Alaska Fairbanks, 902 North Koyukuk Drive, Fairbanks, Alaska 99775-7000, United States
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Han Z, Liu X, Luo Y, Ji X. Therapeutic hypothermia for stroke: Where to go? Exp Neurol 2015; 272:67-77. [PMID: 26057949 DOI: 10.1016/j.expneurol.2015.06.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 05/16/2015] [Accepted: 06/04/2015] [Indexed: 01/08/2023]
Abstract
Ischemic stroke is a major cause of death and long-term disability worldwide. Thrombolysis with recombinant tissue plasminogen activator is the only proven and effective treatment for acute ischemic stroke; however, therapeutic hypothermia is increasingly recognized as having a tissue-protective function and positively influencing neurological outcome, especially in cases of ischemia caused by cardiac arrest or hypoxic-ischemic encephalopathy in newborns. Yet, many aspects of hypothermia as a treatment for ischemic stroke remain unknown. Large-scale studies examining the effects of hypothermia on stroke are currently underway. This review discusses the mechanisms underlying the effect of hypothermia, as well as trends in hypothermia induction methods, methods for achieving optimal protection, side effects, and therapeutic strategies combining hypothermia with other neuroprotective treatments. Finally, outstanding issues that must be addressed before hypothermia treatment is implemented at a clinical level are also presented.
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Affiliation(s)
- Ziping Han
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Xiangrong Liu
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Yumin Luo
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100053, China
| | - Xunming Ji
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100053, China; Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China.
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Andresen M, Gazmuri JT, Marín A, Regueira T, Rovegno M. Therapeutic hypothermia for acute brain injuries. Scand J Trauma Resusc Emerg Med 2015; 23:42. [PMID: 26043908 PMCID: PMC4456795 DOI: 10.1186/s13049-015-0121-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 04/29/2015] [Indexed: 02/07/2023] Open
Abstract
Therapeutic hypothermia, recently termed target temperature management (TTM), is the cornerstone of neuroprotective strategy. Dating to the pioneer works of Fay, nearly 75 years of basic and clinical evidence support its therapeutic value. Although hypothermia decreases the metabolic rate to restore the supply and demand of O₂, it has other tissue-specific effects, such as decreasing excitotoxicity, limiting inflammation, preventing ATP depletion, reducing free radical production and also intracellular calcium overload to avoid apoptosis. Currently, mild hypothermia (33°C) has become a standard in post-resuscitative care and perinatal asphyxia. However, evidence indicates that hypothermia could be useful in neurologic injuries, such as stroke, subarachnoid hemorrhage and traumatic brain injury. In this review, we discuss the basic and clinical evidence supporting the use of TTM in critical care for acute brain injury that extends beyond care after cardiac arrest, such as for ischemic and hemorrhagic strokes, subarachnoid hemorrhage, and traumatic brain injury. We review the historical perspectives of TTM, provide an overview of the techniques and protocols and the pathophysiologic consequences of hypothermia. In addition, we include our experience of managing patients with acute brain injuries treated using endovascular hypothermia.
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Affiliation(s)
- Max Andresen
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta, 367, Santiago, Chile.
| | - Jose Tomás Gazmuri
- Hospital de Urgencia Asistencia Pública, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Arnaldo Marín
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta, 367, Santiago, Chile.
| | - Tomas Regueira
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta, 367, Santiago, Chile.
| | - Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta, 367, Santiago, Chile.
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Feketa VV, Marrelli SP. Induction of therapeutic hypothermia by pharmacological modulation of temperature-sensitive TRP channels: theoretical framework and practical considerations. Temperature (Austin) 2015; 2:244-57. [PMID: 27227027 PMCID: PMC4844121 DOI: 10.1080/23328940.2015.1024383] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/25/2015] [Accepted: 02/25/2015] [Indexed: 12/22/2022] Open
Abstract
Therapeutic hypothermia has emerged as a remarkably effective method of neuroprotection from ischemia and is being increasingly used in clinics. Accordingly, it is also a subject of considerable attention from a basic scientific research perspective. One of the fundamental problems, with which current studies are concerned, is the optimal method of inducing hypothermia. This review seeks to provide a broad theoretical framework for approaching this problem, and to discuss how a novel promising strategy of pharmacological modulation of the thermosensitive ion channels fits into this framework. Various physical, anatomical, physiological and molecular aspects of thermoregulation, which provide the foundation for this text, have been comprehensively reviewed and will not be discussed exhaustively here. Instead, the first part of the current review, which may be helpful for a broader readership outside of thermoregulation research, will build on this existing knowledge to outline possible opportunities and research directions aimed at controlling body temperature. The second part, aimed at a more specialist audience, will highlight the conceptual advantages and practical limitations of novel molecular agents targeting thermosensitive Transient Receptor Potential (TRP) channels in achieving this goal. Two particularly promising members of this channel family, namely TRP melastatin 8 (TRPM8) and TRP vanilloid 1 (TRPV1), will be discussed in greater detail.
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Key Words
- DMH, dorso-medial hypothalamus
- MPA, medial preoptic area of hypothalamus
- TRP, Transient Receptor Potential
- TRPA1, Transient Receptor Potential cation channel, subfamily A, member 1
- TRPM8, Transient Receptor Potential cation channel, subfamily M, member 8
- TRPV1, Transient Receptor Potential cation channel, subfamily V, member 1
- TRPV2, Transient Receptor Potential cation channel, subfamily V, member 2
- TRPV3, Transient Receptor Potential cation channel, subfamily V, member 3
- TRPV4, Transient Receptor Potential cation channel, subfamily V, member 4
- ThermoTRPs
- ThermoTRPs, Thermosensitive Transient Receptor Potential cation channels
- body temperature
- core temperature
- pharmacological hypothermia
- physical cooling
- rMR, rostral medullary raphe region
- therapeutic hypothermia
- thermopharmacology
- thermoregulation
- thermosensitive ion channels
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Affiliation(s)
- Viktor V Feketa
- Department of Molecular Physiology and Biophysics Graduate Program; Cardiovascular Sciences Track; Baylor College of Medicine , Houston, TX, USA
| | - Sean P Marrelli
- Department of Molecular Physiology and Biophysics Graduate Program; Cardiovascular Sciences Track; Baylor College of Medicine, Houston, TX, USA; Department of Anesthesiology; Baylor College of Medicine, Houston, TX, USA
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Vaity C, Al-Subaie N, Cecconi M. Cooling techniques for targeted temperature management post-cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:103. [PMID: 25886948 PMCID: PMC4361155 DOI: 10.1186/s13054-015-0804-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2015 and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/annualupdate2015. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Bai J, Lyden PD. Revisiting Cerebral Postischemic Reperfusion Injury: New Insights in Understanding Reperfusion Failure, Hemorrhage, and Edema. Int J Stroke 2015; 10:143-52. [DOI: 10.1111/ijs.12434] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 11/14/2014] [Indexed: 01/11/2023]
Abstract
Cerebral postischemic reperfusion injury is defined as deterioration of ischemic brain tissue that parallels and antagonizes the benefits of restoring cerebral circulation after therapeutic thrombolysis for acute ischemic stroke. To understand the paradox of injury caused by treatment, we first emphasize the phenomenon in which recanalization of an occluded artery does not lead to tissue reperfusion. Additionally, no-reflow after recanalization may be due to injury of the neurovascular unit, distal microthrombosis, or both, and certainly worsens outcome. We examine the mechanism of molecular and sub-cellular damage in the neurovascular unit, notably oxidative stress, mitochondrial dysfunction, and apoptosis. At the level of the neurovascular unit, which mediates crosstalk between the damaged brain and systemic responses in blood, we summarize emerging evidence demonstrating that individual cell components play unique and cumulative roles that lead to damage of the blood–brain barrier and neurons. Furthermore, we review the latest developments in establishing a link between the immune system and microvascular dysfunction during ischemic reperfusion. Progress in assessing reperfusion injury has also been made, and we review imaging studies using various magnetic resonance imaging modalities. Lastly, we explore potential treatment approaches, including ischemic preconditioning, postconditioning, pharmacologic agents, and hypothermia.
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Affiliation(s)
- Jilin Bai
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Patrick D. Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Anastasian Z. Anaesthetic management of the patient with acute ischaemic stroke. Br J Anaesth 2014; 113:ii9-ii16. [DOI: 10.1093/bja/aeu372] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Gao XY, Huang JO, Hu YF, Gu Y, Zhu SZ, Huang KB, Chen JY, Pan SY. Combination of mild hypothermia with neuroprotectants has greater neuroprotective effects during oxygen-glucose deprivation and reoxygenation-mediated neuronal injury. Sci Rep 2014; 4:7091. [PMID: 25404538 PMCID: PMC4665348 DOI: 10.1038/srep07091] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 10/29/2014] [Indexed: 12/02/2022] Open
Abstract
Co-treatment of neuroprotective reagents may improve the therapeutic efficacy of hypothermia in protecting neurons during ischemic stroke. This study aimed to find promising drugs that enhance the neuroprotective effect of mild hypothermia (MH). 26 candidate drugs were selected based on different targets. Primary cultured cortical neurons were exposed to oxygen-glucose deprivation and reoxygenation (OGD/R) to induce neuronal damage, followed by either single treatment (a drug or MH) or a combination of a drug and MH. Results showed that, compared with single treatment, combination of MH with brain derived neurotrophic factor, glibenclamide, dizocilpine, human urinary kallidinogenase or neuroglobin displayed higher proportion of neuronal cell viability. The latter three drugs also caused less apoptosis rate in combined treatment. Furthermore, co-treatment of those three drugs and MH decreased the level of reactive oxygen species (ROS) and intracellular calcium accumulation, as well as stabilized mitochondrial membrane potential (MMP), indicating the combined neuroprotective effects are probably via inhibiting mitochondrial apoptosis pathway. Taken together, the study suggests that combined treatment with hypothermia and certain neuroprotective reagents provide a better protection against OGD/R-induced neuronal injury.
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Affiliation(s)
- Xiao-Ya Gao
- 1] Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China [2] Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Jian-Ou Huang
- 1] Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China [2] Department of Neurology, the 421 Hospital, Guangzhou, Guangdong, P. R. China
| | - Ya-Fang Hu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Yong Gu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Shu-Zhen Zhu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Kai-Bin Huang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Jin-Yu Chen
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Su-Yue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
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Jeon SB, Koh Y, Choi HA, Lee K. Critical care for patients with massive ischemic stroke. J Stroke 2014; 16:146-60. [PMID: 25328873 PMCID: PMC4200590 DOI: 10.5853/jos.2014.16.3.146] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 09/03/2014] [Accepted: 09/04/2014] [Indexed: 01/29/2023] Open
Abstract
Malignant cerebral edema following ischemic stroke is life threatening, as it can cause inadequate blood flow and perfusion leading to irreversible tissue hypoxia and metabolic crisis. Increased intracranial pressure and brain shift can cause herniation syndrome and finally brain death. Multiple randomized clinical trials have shown that preemptive decompressive hemicraniectomy effectively reduces mortality and morbidity in patients with malignant middle cerebral artery infarction. Another life-saving decompressive surgery is suboccipital craniectomy for patients with brainstem compression by edematous cerebellar infarction. In addition to decompressive surgery, cerebrospinal fluid drainage by ventriculostomy should be considered for patients with acute hydrocephalus following stroke. Medical treatment begins with sedation, analgesia, and general measures including ventilatory support, head elevation, maintaining a neutral neck position, and avoiding conditions associated with intracranial hypertension. Optimization of cerebral perfusion pressure and reduction of intracranial pressure should always be pursued simultaneously. Osmotherapy with mannitol is the standard treatment for intracranial hypertension, but hypertonic saline is also an effective alternative. Therapeutic hypothermia may also be considered for treatment of brain edema and intracranial hypertension, but its neuroprotective effects have not been demonstrated in stroke. Barbiturate coma therapy has been used to reduce metabolic demand, but has become less popular because of its systemic adverse effects. Furthermore, general medical care is critical because of the complex interactions between the brain and other organ systems. Some challenging aspects of critical care, including ventilator support, sedation and analgesia, and performing neurological examinations in the setting of a minimal stimulation protocol, are addressed in this review.
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Affiliation(s)
- Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - H Alex Choi
- Departments of Neurology and Neurosurgery, The University of Texas Medical School at Houston, Houston, Texas, USA
| | - Kiwon Lee
- Departments of Neurology and Neurosurgery, The University of Texas Medical School at Houston, Houston, Texas, USA
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Orlowski P, McConnell FK, Payne S. A mathematical model of cellular metabolism during ischemic stroke and hypothermia. IEEE Trans Biomed Eng 2014; 61:484-90. [PMID: 24058013 DOI: 10.1109/tbme.2013.2282603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Stroke is a major cause of death and disability worldwide. Therapeutic hypothermia is a potentially useful neuroprotective treatment. A mathematical model of brain metabolism during stroke is extended here to simulate the effect of hypothermia on cell survival. Temperature decreases were set to reduce chemical reaction rates and slow diffusion through ion channels according to the Q10 rule. Heat delivery to tissues was set to depend on metabolic heat generation rate and perfusion. Two cooling methods, scalp and vascular, were simulated to approximate temperature variation in the brain during treatment. Cell death was assumed to occur at continued cell membrane depolarization. Simulations showed that hypothermia to 34.5 °C induced within 1-1.5 h of stroke onset could extend cell survival time by at least 5 h in tissue with perfusion reduced by 80% of normal. There was good agreement between simulated metabolite dynamics and those reported in rat model studies.
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Maze R, Le May MR, Froeschl M, Hazra SK, Wells PS, Osborne C, Labinaz M, Hibbert B, So DYF. Endovascular cooling catheter related thrombosis in patients undergoing therapeutic hypothermia for out of hospital cardiac arrest. Resuscitation 2014; 85:1354-8. [PMID: 24978111 DOI: 10.1016/j.resuscitation.2014.05.029] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 05/20/2014] [Accepted: 05/23/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Therapeutic hypothermia improves neurologic outcome and survival in patients following out-of-hospital cardiac arrest (OHCA). Endovascular cooling devices are commonly used to rapidly achieve and maintain hypothermia. The use of these devices may be associated with catheter related thrombosis. The objective of this study was to determine the risk of catheter related thrombosis associated with the use of an endovascular cooling catheter in patients referred for therapeutic hypothermia following OHCA. METHODS AND RESULTS We conducted a retrospective cohort study on consecutive patients, referred for therapeutic hypothermia following OHCA, between February 2012 and May 2013. Of 80 patients initially treated with therapeutic hypothermia, 61 completed the cooling protocol using an endovascular cooling device. The primary outcome was catheter related thrombosis defined as evidence of thrombus in the inferior vena cava, deep vein thrombosis or pulmonary embolism during the index hospitalization. We further evaluated the incidence of the primary outcome between patients on dose adjusted intravenous unfractionated heparin compared to those on a subcutaneous prophylactic regimen alone. Catheter related thrombosis was observed in 9/61 (14.7%), with nine events in the prophylaxis group compared to none in the full dose unfractionated heparin group (22.0% vs. 0.0%, p=0.02). CONCLUSIONS The use of endovascular catheters for induction of therapeutic hypothermia is associated with a high rate of catheter related thrombosis. This risk appears to be abrogated with dose adjusted unfractionated heparin infusion.
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Affiliation(s)
- Ronnen Maze
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Michel R Le May
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Michael Froeschl
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Samir K Hazra
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Philip S Wells
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, ON, Canada
| | - Christina Osborne
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Marino Labinaz
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Derek Y F So
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada.
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