1
|
Wang P, Yang X, Yang F, Cardiff K, Houchins M, Carballo N, Shear DA, Scultetus AH, Bailey ZS. Intravenous Administration of Anti-CD47 Antibody Augments Hematoma Clearance, Mitigates Acute Neuropathology, and Improves Cognitive Function in a Rat Model of Penetrating Traumatic Brain Injury. J Neurotrauma 2024. [PMID: 38874230 DOI: 10.1089/neu.2024.0047] [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: 06/15/2024] Open
Abstract
Traumatic brain injury (TBI)-induced intracerebral hematoma is a major driver of secondary injury pathology such as neuroinflammation, cerebral edema, neurotoxicity, and blood-brain barrier dysfunction, which contribute to neuronal loss, motor deficits, and cognitive impairment. Cluster of differentiation 47 (CD47) is an antiphagocytic cell surface protein inhibiting hematoma clearance. This study was designed to evaluate the safety and efficacy of blockade of CD47 via intravenous (i.v.) administration of anti-CD47 antibodies following penetrating ballistic-like brain injury (PBBI) with significant traumatic intracerebral hemorrhage (tICH). The pharmacokinetic (PK) profile of the anti-CD47 antibody elicited that antibody concentration decayed over 7 days post-administration. Blood tests and necropsy analysis indicated no severe adverse events following treatment. Cerebral hemoglobin levels were significantly increased after injury, however, anti-CD47 antibody administration at 0.1 mg/kg resulted in a significant reduction in cerebral hemoglobin levels at 72 h post-administration, indicating augmentation of hematoma clearance. Immunohistochemistry assessment of glial fibrillary acidic protein (GFAP) and ionized calcium-binding adaptor molecule 1 (IBA1) demonstrated a significant reduction of GFAP levels in the lesion core and peri-lesional area. Based on these analyses, the optimal dose was identified as 0.1 mg/kg. Lesion volume showed a reduction following treatment. Rotarod testing revealed significant motor deficits in all injured groups but no significant therapeutic benefits. Spatial learning performance revealed significant deficits in all injured groups, which were significantly improved by the last testing day. Anti-CD47 antibody treated rats showed significantly improved attention deficits, but not retention scores. These results provide preliminary evidence that blockade of CD47 using i.v. administration of anti-CD47 antibodies may serve as a potential therapeutic for TBI with ICH.
Collapse
Affiliation(s)
- Ping Wang
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Xiaofang Yang
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Fangzhou Yang
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Katherine Cardiff
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Melonie Houchins
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Noemy Carballo
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Deborah A Shear
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Anke H Scultetus
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Zachary S Bailey
- Brain Trauma Neuroprotection, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| |
Collapse
|
2
|
Milewski K, Orzeł-Gajowik K, Zielińska M. Mitochondrial Changes in Rat Brain Endothelial Cells Associated with Hepatic Encephalopathy: Relation to the Blood-Brain Barrier Dysfunction. Neurochem Res 2024; 49:1489-1504. [PMID: 35917006 PMCID: PMC11106209 DOI: 10.1007/s11064-022-03698-7] [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: 08/31/2021] [Revised: 02/17/2022] [Accepted: 07/14/2022] [Indexed: 12/06/2022]
Abstract
The mechanisms underlying cerebral vascular dysfunction and edema during hepatic encephalopathy (HE) are unclear. Blood-brain barrier (BBB) impairment, resulting from increased vascular permeability, has been reported in acute and chronic HE. Mitochondrial dysfunction is a well-documented result of HE mainly affecting astrocytes, but much less so in the BBB-forming endothelial cells. Here we review literature reports and own experimental data obtained in HE models emphasizing alterations in mitochondrial dynamics and function as a possible contributor to the status of brain endothelial cell mitochondria in HE. Own studies on the expression of the mitochondrial fusion-fission controlling genes rendered HE animal model-dependent effects: increase of mitochondrial fusion controlling genes opa1, mfn1 in cerebral vessels in ammonium acetate-induced hyperammonemia, but a decrease of the two former genes and increase of fis1 in vessels in thioacetamide-induced HE. In endothelial cell line (RBE4) after 24 h ammonia and/or TNFα treatment, conditions mimicking crucial aspects of HE in vivo, we observed altered expression of mitochondrial fission/fusion genes: a decrease of opa1, mfn1, and, increase of the fission related fis1 gene. The effect in vitro was paralleled by the generation of reactive oxygen species, decreased total antioxidant capacity, decreased mitochondrial membrane potential, as well as increased permeability of RBE4 cell monolayer to fluorescein isothiocyanate dextran. Electron microscopy documented enlarged mitochondria in the brain endothelial cells of rats in both in vivo models. Collectively, the here observed alterations of cerebral endothelial mitochondria are indicative of their fission, and decreased potential of endothelial mitochondria are likely to contribute to BBB dysfunction in HE.
Collapse
Affiliation(s)
- Krzysztof Milewski
- Department of Neurotoxicology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego St. 5, 02-106, Warsaw, Poland.
| | - Karolina Orzeł-Gajowik
- Department of Neurotoxicology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego St. 5, 02-106, Warsaw, Poland
| | - Magdalena Zielińska
- Department of Neurotoxicology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego St. 5, 02-106, Warsaw, Poland.
| |
Collapse
|
3
|
Pierzchala K, Hadjihambi A, Mosso J, Jalan R, Rose CF, Cudalbu C. Lessons on brain edema in HE: from cellular to animal models and clinical studies. Metab Brain Dis 2024; 39:403-437. [PMID: 37606786 PMCID: PMC10957693 DOI: 10.1007/s11011-023-01269-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/24/2023] [Indexed: 08/23/2023]
Abstract
Brain edema is considered as a common feature associated with hepatic encephalopathy (HE). However, its central role as cause or consequence of HE and its implication in the development of the neurological alterations linked to HE are still under debate. It is now well accepted that type A and type C HE are biologically and clinically different, leading to different manifestations of brain edema. As a result, the findings on brain edema/swelling in type C HE are variable and sometimes controversial. In the light of the changing natural history of liver disease, better description of the clinical trajectory of cirrhosis and understanding of molecular mechanisms of HE, and the role of brain edema as a central component in the pathogenesis of HE is revisited in the current review. Furthermore, this review highlights the main techniques to measure brain edema and their advantages/disadvantages together with an in-depth description of the main ex-vivo/in-vivo findings using cell cultures, animal models and humans with HE. These findings are instrumental in elucidating the role of brain edema in HE and also in designing new multimodal studies by performing in-vivo combined with ex-vivo experiments for a better characterization of brain edema longitudinally and of its role in HE, especially in type C HE where water content changes are small.
Collapse
Affiliation(s)
- Katarzyna Pierzchala
- CIBM Center for Biomedical Imaging, Lausanne, Switzerland.
- Animal Imaging and Technology, EPFL, Lausanne, Switzerland.
| | - Anna Hadjihambi
- The Roger Williams Institute of Hepatology London, Foundation for Liver Research, London, SE5 9NT, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jessie Mosso
- CIBM Center for Biomedical Imaging, Lausanne, Switzerland
- Animal Imaging and Technology, EPFL, Lausanne, Switzerland
- Laboratory for Functional and Metabolic Imaging (LIFMET), EPFL, Lausanne, Switzerland
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain
| | - Christopher F Rose
- Hépato-Neuro Laboratory, Centre de Recherche du Centre Hospitalier de l', Université de Montréal (CRCHUM), Montreal, QC, H2X 0A9, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, QC, Montreal, H3T 1J4, Canada
| | - Cristina Cudalbu
- CIBM Center for Biomedical Imaging, Lausanne, Switzerland.
- Animal Imaging and Technology, EPFL, Lausanne, Switzerland.
| |
Collapse
|
4
|
Huang NX, Huang HW, Dong QY, Wen YL, Li D, Li JQ, Chen HJ. Metabolic alterations in the right anterior insula among patients with cirrhosis without overt hepatic encephalopathy: a magnetic resonance spectroscopy study. Front Neurol 2024; 14:1291478. [PMID: 38283679 PMCID: PMC10811796 DOI: 10.3389/fneur.2023.1291478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Purpose We investigated metabolic alterations in the right anterior insula (rAI) in cirrhotic patients and determined its association with patients' cognitive dysfunction. Methods In this study, 31 healthy controls (HCs) and 32 cirrhotic patients without overt hepatic encephalopathy participated. Both blood ammonia level and Child-Pugh score were measured. The psychometric hepatic encephalopathy score (PHES) was used to evaluate cognitive function. 1H-magnetic resonance spectroscopy (MRS) data located in the rAI were recorded on a commercially available 3T magnetic resonance imaging scanner. The ratios of metabolites were measured, including N-acetylaspartate (NAA)/total creatine (tCr), glutamate plus glutamine (Glx)/tCr, myo-inositol (mI)/tCr, and total choline (tCho)/tCr. We adopted the non-parametric Mann-Whitney U-test for intergroup comparison of metabolic ratios. To determine the association between metabolite concentration and clinical parameters, we performed Spearman correlation analyses. Results Patients with cirrhosis performed worse on PHES in comparison with HCs (P < 0.001). Patients with cirrhosis had significantly decreased mI/tCr (0.87 ± 0.07 vs. 0.74 ± 0.19, P = 0.025) and increased Glx/tCr (1.79 ± 0.17 vs. 2.07 ± 0.29, P < 0.001) in the rAI. We did not observe any significant between-group differences in tCho/tCr and NAA/tCr. The blood ammonia level was correlated with Glx/tCr (r = 0.405, P = 0.022) and mI/tCr (r = -0.398, P = 0.024) of the rAI. In addition, PHES was negatively correlated with Glx/tCr of the rAI (r = -0.379, P = 0.033). Conclusion Metabolic disturbance of the rAI, which is associated with ammonia intoxication, might account for the neural substrate of cirrhosis-related cognitive dysfunction to some extent.
Collapse
Affiliation(s)
- Nao-Xin Huang
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hui-Wei Huang
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qiu-Yi Dong
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yu-Lin Wen
- Shanghai Key Laboratory of Magnetic Resonance, School of Physics and Electronic Science, East China Normal University, Shanghai, China
| | - Dan Li
- Department of Gastroenterology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jian-Qi Li
- Shanghai Key Laboratory of Magnetic Resonance, School of Physics and Electronic Science, East China Normal University, Shanghai, China
| | - Hua-Jun Chen
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| |
Collapse
|
5
|
Mehtani R, Premkumar M, Garg S, Kajal K, Kulkarni AV, Duseja AK, Dhiman RK, De A, Verma N, Taneja S, Rathi S, Singh V, Chakma J, Soni SL, Kakkar A, Kapila AT, Ahuja CK, Divyaveer S, Praharaj D. Intravenous BCAA Infusion Does Not Lead to a Sustained Recovery From Overt HE in ACLF - An Open Label Randomized Clinical Trial. J Clin Exp Hepatol 2023; 13:977-988. [PMID: 37975059 PMCID: PMC10643498 DOI: 10.1016/j.jceh.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/28/2023] [Indexed: 11/19/2023] Open
Abstract
Background Hepatic encephalopathy (HE) in acute-on-chronic liver failure (ACLF) is associated with significant morbidity and mortality. We conducted a prospective, randomized controlled clinical trial to study the efficacy of intravenous branched chain amino acids (IV-BCAA) with lactulose versus lactulose alone for improvement in HE at 24 h, day 3, and day 7. The primary outcome was an improvement in encephalopathy by ≥ 1 grade at 72 h. Patients and methods European association for study of liver (EASL) defined ACLF patients with overt HE were assessed and randomized into the experimental arm (IV-BCAA - 500 mL/day for 3 days + Lactulose; n = 39) and the comparator arm (Lactulose alone; n = 37). Six patients developed COVID-19 after randomization and were excluded (4-experimental arm and 2-comparator arm). Results Of 222 screened patients, 70 (35 in each arm) were included in the analysis. Baseline characteristics, including HE grade (2.9 ± 0.7 vs 2.8 ± 0.7; P = 0.86) and (chronic liver failure) CLIF-C ACLF score (54.2 ± 5.6 vs 54.8 ± 5.7; P = 0.65), were similar. Overall survival was 40% at 28 days (48.5% vs 31.4%; P = 0.14). Improvement in hepatic encephalopathy scoring algorithm (HESA) by ≥ 1 grade at 24 h occurred in 14 patients (40%) in the BCAA arm and 6 patients (17.1%) in the control group (P = 0.03) which translated to a shorter intensive care unit (ICU) stay. The median change in HESA at 24 h was greater in the BCAA arm than the control arm (P = 0.006), which was not sustained at days 3 or 7. Ammonia levels did not correlate with the grade of HE (Spearman's correlation coefficient (ρ) = - 0.0843; P = 0.29). Conclusion Intravenous BCAA does not lead to a sustained improvement in HE grade in ACLF. Trial registration no NCT04238416 (clinicaltrials.gov).
Collapse
Affiliation(s)
- Rohit Mehtani
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shankey Garg
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kamal Kajal
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anand V. Kulkarni
- Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Ajay K. Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha K. Dhiman
- Department of Hepatology, Sanjay Gandhi Post Graduate Institute, Lucknow, Uttar Pradesh, India
| | - Arka De
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nipun Verma
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahaj Rathi
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Joy Chakma
- Scientist ‘E', Indian Council of Medical Research, New Delhi, India
| | - Shiv L. Soni
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Kakkar
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aastha T. Kapila
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag K. Ahuja
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Smita Divyaveer
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Dibyalochan Praharaj
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
| |
Collapse
|
6
|
Nakadate K, Sono C, Mita H, Itakura Y, Kawakami K. Severe Acute Liver Dysfunction Induces Delayed Hepatocyte Swelling and Cytoplasmic Vacuolization, and Delayed Cortical Neuronal Cell Death. Int J Mol Sci 2023; 24:ijms24087351. [PMID: 37108515 PMCID: PMC10139143 DOI: 10.3390/ijms24087351] [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: 02/01/2023] [Revised: 04/10/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
Liver dysfunction is the main cause of hepatic encephalopathy. However, histopathological changes in the brain associated with hepatic encephalopathy remain unclear. Therefore, we investigated pathological changes in the liver and brain using an acute hepatic encephalopathy mouse model. After administering ammonium acetate, a transient increase in the blood ammonia level was observed, which returned to normal levels after 24 h. Consciousness and motor levels also returned to normal. It was revealed that hepatocyte swelling, and cytoplasmic vacuolization progressed over time in the liver tissue. Blood biochemistry also suggested hepatocyte dysfunction. In the brain, histopathological changes, such as perivascular astrocyte swelling, were observed 3 h after ammonium acetate administration. Abnormalities in neuronal organelles, especially mitochondria and rough endoplasmic reticulum, were also observed. Additionally, neuronal cell death was observed 24 h post-ammonia treatment when blood ammonia levels had returned to normal. Activation of reactive microglia and increased expression of inducible nitric oxide synthase (iNOS) were also observed seven days after a transient increase in blood ammonia. These results suggest that delayed neuronal atrophy could be iNOS-mediated cell death due to activation of reactive microglia. The findings also suggest that severe acute hepatic encephalopathy causes continued delayed brain cytotoxicity even after consciousness recovery.
Collapse
Affiliation(s)
- Kazuhiko Nakadate
- Department of Basic Science, Educational and Research Center for Pharmacy, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose 204-8588, Tokyo, Japan
| | - Chiaki Sono
- Department of Basic Science, Educational and Research Center for Pharmacy, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose 204-8588, Tokyo, Japan
| | - Homura Mita
- Department of Basic Science, Educational and Research Center for Pharmacy, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose 204-8588, Tokyo, Japan
| | - Yuki Itakura
- Department of Basic Science, Educational and Research Center for Pharmacy, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose 204-8588, Tokyo, Japan
| | - Kiyoharu Kawakami
- Department of Basic Science, Educational and Research Center for Pharmacy, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose 204-8588, Tokyo, Japan
| |
Collapse
|
7
|
A mouse model of hepatic encephalopathy: bile duct ligation induces brain ammonia overload, glial cell activation and neuroinflammation. Sci Rep 2022; 12:17558. [PMID: 36266427 PMCID: PMC9585018 DOI: 10.1038/s41598-022-22423-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/14/2022] [Indexed: 01/13/2023] Open
Abstract
Hepatic encephalopathy (HE) is a common complication of chronic liver disease, characterized by an altered mental state and hyperammonemia. Insight into the brain pathophysiology of HE is limited due to a paucity of well-characterized HE models beyond the rat bile duct ligation (BDL) model. Here, we assess the presence of HE characteristics in the mouse BDL model. We show that BDL in C57Bl/6j mice induces motor dysfunction, progressive liver fibrosis, liver function failure and hyperammonemia, all hallmarks of HE. Swiss mice however fail to replicate the same phenotype, underscoring the importance of careful strain selection. Next, in-depth characterisation of metabolic disturbances in the cerebrospinal fluid of BDL mice shows glutamine accumulation and transient decreases in taurine and choline, indicative of brain ammonia overload. Moreover, mouse BDL induces glial cell dysfunction, namely microglial morphological changes with neuroinflammation and astrocyte reactivity with blood-brain barrier (BBB) disruption. Finally, we identify putative novel mechanisms involved in central HE pathophysiology, like bile acid accumulation and tryptophan-kynurenine pathway alterations. Our study provides the first comprehensive evaluation of a mouse model of HE in chronic liver disease. Additionally, this study further underscores the importance of neuroinflammation in the central effects of chronic liver disease.
Collapse
|
8
|
Bai X, Zhou M. The benefit of bevacizumab therapy in patients with refractory vasogenic edema caused by brain metastasis from lung and colon cancers. Front Oncol 2022; 12:838670. [PMID: 36249059 PMCID: PMC9559828 DOI: 10.3389/fonc.2022.838670] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 09/06/2022] [Indexed: 11/28/2022] Open
Abstract
Objective This retrospective study investigated the efficacy of bevacizumab in refractory brain edema caused by brain metastasis from lung cancer and colon cancer. Methods A total of 72 patients with refractory brain edema were divided into the lung cancer and colon cancer groups according to their primary tumor. All patients received a single bevacizumab treatment for refractory brain edema. MRI was performed 1 week before the treatment and 4 weeks after the treatment. The edema and tumor volumes were calculated using imaging modalities. Results After a single bevacizumab treatment, the refractory brain edema of 61 patients was controlled, and the clinical symptoms of 65 patients were improved. The average edema volume before treatment was 201,708.97 ± 61,426.04 mm3, which has decreased to 116,947.01 ± 43,879.16 mm3 after treatment (P < 0.05). After treatment, the edema index decreased from 25.97 ± 7.15 to 17.32 ± 5.24 (P < 0.05).We found that brain edema was controlled in 40 patients (93.02%) in the lung cancer group and 21 patients (72.41%) in the colon cancer group (P<0.05). In addition, 22 patients (88.00%) in the radiotherapy group achieved edema control, compared to 39 (82.98%) in the non-radiotherapy group (P>0.05). Nine patients experienced hypertension after treatment, two patients exhibited decreased platelet counts, and no hemorrhage cases were observed. Conclusion Bevacizumab can significantly alleviate refractory brain edema, and there is a significant difference in the efficacy of bevacizumab on refractory brain edema caused by brain metastasis from lung and colon cancers.
Collapse
|
9
|
Zielińska M, Albrecht J, Popek M. Dysregulation of Astrocytic Glutamine Transport in Acute Hyperammonemic Brain Edema. Front Neurosci 2022; 16:874750. [PMID: 35733937 PMCID: PMC9207324 DOI: 10.3389/fnins.2022.874750] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022] Open
Abstract
Acute liver failure (ALF) impairs ammonia clearance from blood, which gives rise to acute hyperammonemia and increased ammonia accumulation in the brain. Since in brain glutamine synthesis is the only route of ammonia detoxification, hyperammonemia is as a rule associated with increased brain glutamine content (glutaminosis) which correlates with and contributes along with ammonia itself to hyperammonemic brain edema-associated with ALF. This review focuses on the effects of hyperammonemia on the two glutamine carriers located in the astrocytic membrane: Slc38a3 (SN1, SNAT3) and Slc7a6 (y + LAT2). We emphasize the contribution of the dysfunction of either of the two carriers to glutaminosis- related aspects of brain edema: retention of osmotically obligated water (Slc38a3) and induction of oxidative/nitrosative stress (Slc7a6). The changes in glutamine transport link glutaminosis- evoked mitochondrial dysfunction to oxidative-nitrosative stress as formulated in the “Trojan Horse” hypothesis.
Collapse
|
10
|
Mehtani R, Garg S, Kajal K, Soni SL, Premkumar M. Neurological monitoring and sedation protocols in the Liver Intensive Care Unit. Metab Brain Dis 2022; 37:1291-1307. [PMID: 35460476 DOI: 10.1007/s11011-022-00986-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/10/2022] [Indexed: 11/25/2022]
Abstract
Patients with liver disease often have alteration of neurological status which requires admission to an intensive care unit. Patients with acute liver failure (ALF), acute-on-chronic liver failure (ACLF) and rarely cirrhosis are at risk of cerebral edema. These patients require prompt assessment of neurological status including assessment of intra-cranial pressure (ICP) and monitoring metabolic parameters like arterial/venous ammonia levels, serum creatinine and serum electrolytes so that timely specific therapy for raised ICP can be instituted to prevent permanent neurological dysfunction. The overall aims of neuromonitoring and sedation protocols in a liver intensive care unit are to identify the level of multifactorial metabolic encephalopathy, individualize sedation and analgesia requirements for patients on mechanical ventilation, institute specific therapy to correct the neurological insult in ALF and ACLF, provide clear physiological data for guided therapy of drugs like muscle relaxants, antiepileptics, and cerebral edema reducing agents, and assist with overall prognostication. In this review article we will outline the clinical scenarios related to liver disease requiring intensive care and neuromonitoring, current techniques of neurological assessment, sedation protocols and point of care tests which enable the treating physician and intensivist guide therapy for raised ICP.
Collapse
Affiliation(s)
- Rohit Mehtani
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Shankey Garg
- Department of Anesthesiology and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Kamal Kajal
- Department of Anesthesiology and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Shiv Lal Soni
- Department of Anesthesiology and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| |
Collapse
|
11
|
Brain magnetic resonance imaging radiomics features associated with hepatic encephalopathy in adult cirrhotic patients. Neuroradiology 2022; 64:1969-1978. [PMID: 35488097 PMCID: PMC9474333 DOI: 10.1007/s00234-022-02949-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/05/2022] [Indexed: 10/28/2022]
Abstract
PURPOSE Hepatic encephalopathy (HE) is a potential complication of cirrhosis. Magnetic resonance imaging (MRI) may demonstrate hyperintense T1 signal in the globi pallidi. The purpose of this study was to evaluate the performance of MRI-based radiomic features for diagnosing and grading chronic HE in adult patients affected by cirrhosis. METHODS Adult patients with and without cirrhosis underwent brain MRI with identical imaging protocol on a 3T scanner. Patients without history of chronic liver disease were the control population. HE grading was based on underlying liver disease, severity of clinical manifestation, and number of encephalopathic episodes. Texture analysis was performed on axial T1-weighted images on bilateral lentiform nuclei at the level of the foramina of Monro. Diagnostic performance of texture analysis for the diagnosis and grading of HE was assessed by calculating the area under the receiver operating characteristics (AUROC) with 95% confidence interval (CI). RESULTS The final study population consisted of 124 patients, 70 cirrhotic patients, and 54 non-cirrhotic controls. Thirty-eight patients had history of HE with 22 having an HE grade > 1. The radiomic features predicted the presence of HE with an AUROC of 0.82 (95% CI: 0.73, 0.90; P < .0001; 82% sensitivity, 66% specificity). Radiomic features predicted grade 1 HE (AUROC 0.75; 95% CI: 0.61, 0.89; P < .0001; 94% sensitivity, 60% specificity) and grade ≥ 2 HE (AUROC 0.82; 95% CI: 0.71, 0.93; P < .0001, 95% sensitivity, 57% specificity). CONCLUSION In cirrhotic patients, MR radiomic is effective in predicting the presence of chronic HE and in grading its severity.
Collapse
|
12
|
Severe Acute Hepatic Dysfunction Induced by Ammonium Acetate Treatment Results in Choroid Plexus Swelling and Ventricle Enlargement in the Brain. Int J Mol Sci 2022; 23:ijms23042010. [PMID: 35216129 PMCID: PMC8879736 DOI: 10.3390/ijms23042010] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/08/2022] [Accepted: 02/10/2022] [Indexed: 02/04/2023] Open
Abstract
Hepatic encephalopathy is a major cause of liver failure. However, the pathophysiological role of ventricle enlargement in brain edema remains unclear. Here, we used an acute hepatic encephalopathy mouse model to examine the sequential pathological changes in the brain associated with this condition. We collected tissue samples from experimental animals treated with ammonium acetate at 3 and 24 h post-injection. Despite the normalization of the animal’s ammonia levels, samples taken at 24 h after injection exhibited distinct enlargement of lateral ventricles. The choroid plexus samples obtained at 3 h post-ammonium acetate treatment indicated enlargement; however, this swelling was reduced at the later timepoint. The aquaporin-1 proteins that regulate the choroid plexus were localized both in the apical membrane and the cytoplasm of the epithelia in the control; however, they translocated to the apical membranes of the epithelia in response to ammonia treatment. Therefore, severe acute hepatic encephalopathy induced by ammonium acetate administration caused enlargement of the ventricles, through swelling of the choroid plexus and aquaporin-1 transport and aggregation within the apical membranes.
Collapse
|
13
|
Kim YK, Song J. Therapeutic Applications of Resveratrol in Hepatic Encephalopathy through Its Regulation of the Microbiota, Brain Edema, and Inflammation. J Clin Med 2021; 10:jcm10173819. [PMID: 34501267 PMCID: PMC8432232 DOI: 10.3390/jcm10173819] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/22/2021] [Accepted: 08/24/2021] [Indexed: 02/07/2023] Open
Abstract
Hepatic encephalopathy is a common complication in patients with liver cirrhosis and portosystemic shunting. Patients with hepatic encephalopathy present a variety of clinical features, including neuropsychiatric manifestations, cognitive dysfunction, impaired gut barrier function, hyperammonemia, and chronic neuroinflammation. These pathogeneses have been linked to various factors, including ammonia-induced oxidative stress, neuronal cell death, alterations in the gut microbiome, astrocyte swelling, and blood-brain barrier disruptions. Many researchers have focused on identifying novel therapeutics and prebiotics in the hope of improving the treatment of these conditions. Resveratrol is a natural polyphenic compound and is known to exert several pharmacological effects, including antioxidant, anti-inflammatory, and neuroprotective activities. Recent studies suggest that resveratrol contributes to improving the neuropathogenic effects of liver failure. Here, we review the current evidence describing resveratrol's effects in neuropathogenesis and its impact on the gut-liver axis relating to hepatic encephalopathy. We highlight the hypothesis that resveratrol exerts diverse effects in hepatic encephalopathy and suggest that these effects are likely mediated by changes to the gut microbiota, brain edema, and neuroinflammation.
Collapse
Affiliation(s)
- Young-Kook Kim
- Department of Biochemistry, Chonnam National University Medical School, Hwasun 58128, Jeollanam-do, Korea;
| | - Juhyun Song
- Department of Anatomy, Chonnam National University Medical School, Hwasun 58128, Jeollanam-do, Korea
- Correspondence: ; Tel.: +82-61-379-2706; Fax: +82-61-375-5834
| |
Collapse
|
14
|
DeMorrow S, Cudalbu C, Davies N, Jayakumar AR, Rose CF. 2021 ISHEN guidelines on animal models of hepatic encephalopathy. Liver Int 2021; 41:1474-1488. [PMID: 33900013 PMCID: PMC9812338 DOI: 10.1111/liv.14911] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/05/2021] [Accepted: 04/01/2021] [Indexed: 02/07/2023]
Abstract
This working group of the International Society of Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) was commissioned to summarize and update current efforts in the development and characterization of animal models of hepatic encephalopathy (HE). As defined in humans, HE in animal models is based on the underlying degree and severity of liver pathology. Although hyperammonemia remains the key focus in the pathogenesis of HE, other factors associated with HE have been identified, together with recommended animal models, to help explore the pathogenesis and pathophysiological mechanisms of HE. While numerous methods to induce liver failure and disease exist, less have been characterized with neurological and neurobehavioural impairments. Moreover, there still remains a paucity of adequate animal models of Type C HE induced by alcohol, viruses and non-alcoholic fatty liver disease; the most common etiologies of chronic liver disease.
Collapse
Affiliation(s)
- S DeMorrow
- Division of Pharmacology and Toxicology, College of Pharmacy, The University of Texas at Austin, Texas, USA; Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Texas, USA; Research division, Central Texas Veterans Healthcare System, Temple Texas USA.,Correspondance: Sharon DeMorrow, PhD, ; tel: +1-512-495-5779
| | - C Cudalbu
- Center for Biomedical Imaging, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - N Davies
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom
| | - AR Jayakumar
- General Medical Research, Neuropathology Section, R&D Service and South Florida VA Foundation for Research and Education Inc; Obstetrics, Gynecology and Reproductive Sciences, University of Miami School of Medicine, Miami FL, USA
| | - CF Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montreal, Canada
| |
Collapse
|
15
|
Ochoa-Sanchez R, Tamnanloo F, Rose CF. Hepatic Encephalopathy: From Metabolic to Neurodegenerative. Neurochem Res 2021; 46:2612-2625. [PMID: 34129161 DOI: 10.1007/s11064-021-03372-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/31/2021] [Accepted: 06/03/2021] [Indexed: 12/15/2022]
Abstract
Hepatic encephalopathy (HE) is a neuropsychiatric syndrome of both acute and chronic liver disease. As a metabolic disorder, HE is considered to be reversible and therefore is expected to resolve following the replacement of the diseased liver with a healthy liver. However, persisting neurological complications are observed in up to 47% of transplanted patients. Several retrospective studies have shown that patients with a history of HE, particularly overt-HE, had persistent neurological complications even after liver transplantation (LT). These enduring neurological conditions significantly affect patient's quality of life and continue to add to the economic burden of chronic liver disease on health care systems. This review discusses the journey of the brain through the progression of liver disease, entering the invasive surgical procedure of LT and the conditions associated with the post-transplant period. In particular, it will discuss the vulnerability of the HE brain to peri-operative factors and post-LT conditions which may explain non-resolved neurological impairment following LT. In addition, the review will provide evidence; (i) supporting overt-HE impacts on neurological complications post-LT; (ii) that overt-HE leads to permanent neuronal injury and (iii) the pathophysiological role of ammonia toxicity on astrocyte and neuronal injury/damage. Together, these findings will provide new insights on the underlying mechanisms leading to neurological complications post-LT.
Collapse
Affiliation(s)
- Rafael Ochoa-Sanchez
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, 900, rue Saint-Denis Pavillon R, R08.422, Montreal, QC, H2X-0A9, Canada
| | - Farzaneh Tamnanloo
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, 900, rue Saint-Denis Pavillon R, R08.422, Montreal, QC, H2X-0A9, Canada
| | - Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, 900, rue Saint-Denis Pavillon R, R08.422, Montreal, QC, H2X-0A9, Canada.
| |
Collapse
|
16
|
Bosoi CR, Vandal M, Tournissac M, Leclerc M, Fanet H, Mitchell PL, Verreault M, Trottier J, Virgili J, Tremblay C, Lippman HR, Bajaj JS, Barbier O, Marette A, Calon F. High-Fat Diet Modulates Hepatic Amyloid β and Cerebrosterol Metabolism in the Triple Transgenic Mouse Model of Alzheimer's Disease. Hepatol Commun 2021; 5:446-460. [PMID: 33681678 PMCID: PMC7917280 DOI: 10.1002/hep4.1609] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/09/2020] [Accepted: 08/20/2020] [Indexed: 12/19/2022] Open
Abstract
Obesity and diabetes are strongly associated not only with fatty liver but also cognitive dysfunction. Moreover, their presence, particularly in midlife, is recognized as a risk factor for Alzheimer's disease (AD). AD, the most common cause of dementia, is increasingly considered as a metabolic disease, although underlying pathogenic mechanisms remain unclear. The liver plays a major role in maintaining glucose and lipid homeostasis, as well as in clearing the AD neuropathogenic factor amyloid-β (Aβ) and in metabolizing cerebrosterol, a cerebral-derived oxysterol proposed as an AD biomarker. We hypothesized that liver impairment induced by obesity contributes to AD pathogenesis. We show that the AD triple transgenic mouse model (3xTg-AD) fed a chow diet presents a hepatic phenotype similar to nontransgenic controls (NTg) at 15 months of age. A high-fat diet (HFD), started at the age of 6 months and continued for 9 months, until sacrifice, induced hepatic steatosis in NTg, but not in 3xTg-AD mice, whereas HFD did not induce changes in hepatic fatty acid oxidation, de novo lipogenesis, and gluconeogenesis. HFD-induced obesity was associated with a reduction of insulin-degrading enzyme, one of the main hepatic enzymes responsible for Aβ clearance. The hepatic rate of cerebrosterol glucuronidation was lower in obese 3xTg-AD than in nonobese controls (P < 0.05) and higher compared with obese NTg (P < 0.05), although circulating levels remained unchanged. Conclusion: Modulation of hepatic lipids, Aβ, and cerebrosterol metabolism in obese 3xTg-AD mice differs from control mice. This study sheds light on the liver-brain axis, showing that the chronic presence of NAFLD and changes in liver function affect peripheral AD features and should be considered during development of biomarkers or AD therapeutic targets.
Collapse
Affiliation(s)
- Cristina R Bosoi
- Centre De Recherche De L'institut De Cardiologie Et Pneumologie De QuébecQuébecCanada.,Faculté De MédecineUniversité LavalQuébecCanada.,Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada
| | - Milène Vandal
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada.,Faculté De PharmacieUniversité LavalQuébecCanada
| | - Marine Tournissac
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada.,Faculté De PharmacieUniversité LavalQuébecCanada.,OptiNutriBrain International Associated LaboratoryQuébecCanada
| | - Manon Leclerc
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada.,Faculté De PharmacieUniversité LavalQuébecCanada
| | - Hortense Fanet
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada.,Faculté De PharmacieUniversité LavalQuébecCanada.,OptiNutriBrain International Associated LaboratoryQuébecCanada
| | - Patricia L Mitchell
- Centre De Recherche De L'institut De Cardiologie Et Pneumologie De QuébecQuébecCanada
| | - Mélanie Verreault
- Laboratoire de Pharmacologie MoléculaireAxe Endocrinologie et NéphrologieCentre de Recherche du CHU de Québec (Pavillon CHUL)QuébecCanada
| | - Jocelyn Trottier
- Laboratoire de Pharmacologie MoléculaireAxe Endocrinologie et NéphrologieCentre de Recherche du CHU de Québec (Pavillon CHUL)QuébecCanada
| | - Jessica Virgili
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada.,Faculté De PharmacieUniversité LavalQuébecCanada
| | - Cynthia Tremblay
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada
| | - H Robert Lippman
- Central Virginia VA Health Care SystemRichmondVA.,Virginia Commonwealth UniversityRichmondVA
| | - Jasmohan S Bajaj
- Central Virginia VA Health Care SystemRichmondVA.,Virginia Commonwealth UniversityRichmondVA
| | - Olivier Barbier
- Faculté De PharmacieUniversité LavalQuébecCanada.,Laboratoire de Pharmacologie MoléculaireAxe Endocrinologie et NéphrologieCentre de Recherche du CHU de Québec (Pavillon CHUL)QuébecCanada
| | - André Marette
- Centre De Recherche De L'institut De Cardiologie Et Pneumologie De QuébecQuébecCanada.,Faculté De MédecineUniversité LavalQuébecCanada
| | - Frédéric Calon
- Axe NeurosciencesCentre De Recherche du CHU de Québec-Université LavalQuébecCanada.,Faculté De PharmacieUniversité LavalQuébecCanada.,OptiNutriBrain International Associated LaboratoryQuébecCanada
| |
Collapse
|
17
|
Clément MA, Bosoi CR, Oliveira MM, Tremblay M, Bémeur C, Rose CF. Bile-duct ligation renders the brain susceptible to hypotension-induced neuronal degeneration: Implications of ammonia. J Neurochem 2021; 157:561-573. [PMID: 33382098 DOI: 10.1111/jnc.15290] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 12/11/2022]
Abstract
Hepatic encephalopathy (HE) is a debilitating neurological complication of cirrhosis. By definition, HE is considered a reversible disorder, and therefore HE should resolve following liver transplantation (LT). However, persisting neurological complications are observed in as many as 47% of LT recipients. LT is an invasive surgical procedure accompanied by various perioperative factors such as blood loss and hypotension which could influence outcomes post-LT. We hypothesize that minimal HE (MHE) renders the brain frail and susceptible to hypotension-induced neuronal cell death. Six-week bile duct-ligated (BDL) rats with MHE and respective SHAM-controls were used. Several degrees of hypotension (mean arterial pressure of 30, 60 and 90 mm Hg) were induced via blood withdrawal from the femoral artery and maintained for 120 min. Brains were collected for neuronal cell count and apoptotic analysis. In a separate group, BDL rats were treated for MHE with the ammonia-lowering strategy ornithine phenylacetate (OP; MNK-6105), administered orally (1 g/kg) for 3 weeks before induction of hypotension. Hypotension 30 and 60 mm Hg (not 90 mm Hg) significantly decreased neuronal marker expression (NeuN) and cresyl violet staining in the frontal cortex compared to respective hypotensive SHAM-operated controls as well as non-hypotensive BDL rats. Neuronal degeneration was associated with an increase in cleaved caspase-3, suggesting the mechanism of cell death was apoptotic. OP treatment attenuated hyperammonaemia, improved anxiety and activity, and protected the brain against hypotension-induced neuronal cell death. Our findings demonstrate that rats with chronic liver disease and MHE are more susceptible to hypotension-induced neuronal cell degeneration. This highlights MHE at the time of LT is a risk factor for poor neurological outcome post-transplant and that treating for MHE pre-LT might reduce this risk.
Collapse
Affiliation(s)
- Marc-André Clément
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Cristina R Bosoi
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Mariana M Oliveira
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Mélanie Tremblay
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Chantal Bémeur
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| |
Collapse
|
18
|
Reynolds AS, Liang J, Raiss M, Dangayach NS, Schiano TD. Fatal cerebral edema in patients with decompensated cirrhosis: A case series. J Crit Care 2020; 61:115-118. [PMID: 33157306 DOI: 10.1016/j.jcrc.2020.10.020] [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: 07/08/2020] [Revised: 10/15/2020] [Accepted: 10/19/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Unlike patients with acute liver failure, patients with cirrhosis are not traditionally thought to be at risk for developing cerebral edema. In the largest case series to date, we document clinical characteristics of cirrhotic patients who develop cerebral edema. MATERIALS AND METHODS In this retrospective case series, seventeen adult patients with acute-on-chronic liver failure (ACLF) were identified using Morbidity & Mortality data. Neurological decompensation was defined by focal neurological deficits or abnormal movements. Elevated ICP was diagnosed clinically by pupillary reflex change improving with hyperosmolar therapy, or by herniation on CT. Pulsatility indices >1.2 on transcranial Dopplers (TCDs) and/or optic nerve sheath diameter (ONSD) >0.5 cm were acceptable alternatives. RESULTS Median MELD-Na was 36 (IQR 31.5,43) compared with 20 (IQR 19,23) prior to admission. Neurological decompensation was associated with abnormal pupil reactivity in 76% and abnormal movements in 65%. Cerebral edema was diagnosed by CT (n = 14). For those too ill to transport, elevated ICP was confirmed with TCDs for three patients and ONSD for two. Mortality was 100% a median of 3 days (IQR 1.5,5) from neurologic decompensation. CONCLUSIONS ACLF patients with neurological decompensation exhibit distinct clinical changes. Noninvasive bedside techniques may serve as surrogate measures for ICP.
Collapse
Affiliation(s)
- Alexandra S Reynolds
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States of America; Department of Neurology, Mount Sinai Hospital, New York, NY, United States of America.
| | - John Liang
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States of America; Department of Neurology, Mount Sinai Hospital, New York, NY, United States of America
| | - Monica Raiss
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States of America
| | - Neha S Dangayach
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States of America; Department of Neurology, Mount Sinai Hospital, New York, NY, United States of America
| | - Thomas D Schiano
- Department of Medicine, Mount Sinai Hospital, New York, NY, United States of America
| |
Collapse
|
19
|
Weiss N, Rose CF. Plasmatic osmolality and hepatic encephalopathy: A new player on the field? Liver Int 2020; 40:1826-1828. [PMID: 33135858 DOI: 10.1111/liv.14549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/21/2020] [Accepted: 05/23/2020] [Indexed: 02/13/2023]
Affiliation(s)
- Nicolas Weiss
- Département de Neurologie, Unité de réanimation neurologique, Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Assistance Publique - Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Sorbonne Université, Paris, France
| | - Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Québec, Canada
| |
Collapse
|
20
|
Tran TT, Wei K, Cole S, Mena E, Csete M, King KS. Brain MR Spectroscopy Markers of Encephalopathy Due to Nonalcoholic Steatohepatitis. J Neuroimaging 2020; 30:697-703. [PMID: 32705733 DOI: 10.1111/jon.12728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE In hepatic encephalopathy (HE), osmotic stressors promoting brain edema result in a compensatory drop in the astrocyte metabolite myo-inositol (mI). Identifying differences between nonalcoholic steatohepatitis (NASH) with and without HE and healthy controls using proton magnetic resonance spectroscopy (MRS) and evaluating hypoalbuminemia and hyperammonemia as osmotic stressors that predict the reduction of mI allow further understanding of mechanisms that promote brain edema in HE. The aim of this study was to assess brain edema in HE using characteristic MRS markers and serum albumin. METHODS We evaluated between group differences among 19 NASH cirrhosis without HE (Crhs-HE) (age = 63 ± 8.7), 9 NASH cirrhosis with HE (Crhs+HE) (age = 63 ± 9.2), and 16 controls (age = 57.8 ± 11.7) using 1 H MRS. Glutamine (Gln/tCr) and serum albumin were evaluated as predictors of myo-inositol (mI/tCr) using linear regression. Statistical significance was set at P < .05 with adjustment for multiple comparisons. RESULTS Brain mI/tCr was decreased, and Gln/tCr increased in Crhs+HE compared to Crhs-HE and controls in both brain regions (P < .001 for all). Evaluated together as joint predictors, serum albumin but not Gln/tCr significantly predicted mI/tCr in GM (P = .02 and P = .2, respectively) and PWM (P = .01 and P = .1, respectively). CONCLUSION Low mI/tCr and increased Gln/tCr were characteristics of Crhs+HE. Low serum albumin was the strongest predictor of brain osmotic stress indicated by reduced mI/tCr, with no residual independent association seen for brain Gln/tCr concentration. This suggests that hypoalbuminemia in chronic liver disease may promote brain edema in HE.
Collapse
Affiliation(s)
| | - Ke Wei
- HMRI Imaging Center, Pasadena, CA
| | | | - Edward Mena
- California Liver Research Institute, Pasadena, CA
| | | | | |
Collapse
|
21
|
Liotta EM, Kimberly WT. Cerebral edema and liver disease: Classic perspectives and contemporary hypotheses on mechanism. Neurosci Lett 2020; 721:134818. [PMID: 32035166 DOI: 10.1016/j.neulet.2020.134818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 02/01/2020] [Accepted: 02/03/2020] [Indexed: 02/07/2023]
Abstract
Liver disease is a growing public health concern. Hepatic encephalopathy, the syndrome of brain dysfunction secondary to liver disease, is a frequent complication of both acute and chronic liver disease and cerebral edema (CE) is a key feature. While altered ammonia metabolism is a key contributor to hepatic encephalopathy and CE in liver disease, there is a growing appreciation that additional mechanisms contribute to CE. In this review we will begin by presenting three classic perspectives that form a foundation for a discussion of CE in liver disease: 1) CE is unique to acute liver failure, 2) CE in liver disease is only cytotoxic, and 3) CE in liver disease is primarily an osmotically mediated consequence of ammonia and glutamine metabolism. We will present each classic perspective along with more recent observations that call in to question that classic perspective. After highlighting these areas of debate, we will explore the leading contemporary mechanisms hypothesized to contribute to CE during liver disease.
Collapse
Affiliation(s)
- Eric M Liotta
- Northwestern University-Feinberg School of Medicine, Department of Neurology, United States; Northwestern University-Feinberg School of Medicine, Department of Surgery, Division of Organ Transplantation, United States; Northwestern University Transplant Outcomes Research Collaboration, United States.
| | | |
Collapse
|
22
|
Hunt A, Tasker RC, Deep A. Neurocritical care monitoring of encephalopathic children with acute liver failure: A systematic review. Pediatr Transplant 2019; 23:e13556. [PMID: 31407855 DOI: 10.1111/petr.13556] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/14/2019] [Accepted: 07/04/2019] [Indexed: 12/15/2022]
Abstract
Research on non-invasive neuromonitoring specific to PALF is limited. This systematic review identifies and synthesis the existing literature on non-invasive approaches to monitoring for neurological sequelae in patients with PALF. A series of literature searches were performed to identify all publications pertaining to five different non-invasive neuromonitoring modalities, in line with PRISMA guidelines. Each modality was selected on the basis of its potential for direct or indirect measurement of cerebral perfusion; studies on electroencephalographic monitoring were therefore not sought. Data were recorded on study design, patient population, comparator groups, and outcomes. A preponderance of observational studies was observed, most with a small sample size. Few incorporated direct comparisons of different modalities; in particular, comparison to invasive intracranial pressure monitoring was largely lacking. The integration of current evidence is considered in the context of the clinically significant distinctions between pediatric and adult ALF, as well as the implications for planning of future investigations to best support the evidence-based clinical care of these patients.
Collapse
Affiliation(s)
- Adam Hunt
- University College Hospital, London, UK
| | - Robert C Tasker
- Harvard Medical School, Chair in Neurocritical Care, Boston Children's Hospital, Boston, MA
| | - Akash Deep
- Paediatric Intensive Care, King's College Hospital, London, UK
| |
Collapse
|
23
|
Down-regulation of microRNA-138 improves immunologic function via negatively targeting p53 by regulating liver macrophage in mice with acute liver failure. Biosci Rep 2019; 39:BSR20190763. [PMID: 31152110 PMCID: PMC6639459 DOI: 10.1042/bsr20190763] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/08/2019] [Accepted: 05/21/2019] [Indexed: 12/23/2022] Open
Abstract
MicroRNAs (miRNAs) have been frequently identified as key mediators in almost all developmental and pathological processes, including those in the liver. The present study was conducted with aims of investigating the role of microRNA-138 (miR-138) in acute liver failure (ALF) via a mechanism involving p53 and liver macrophage in a mouse model. The ALF mouse model was established using C57BL/6 male mice via tail vein injection of Concanamycin A (Con A) solution. The relationship between miR-138 and p53 was tested. The mononuclear macrophages were infected with mimic and inhibitor of miR-138 in order to identify roles of miR-138 in p53 and levels of inflammatory factors. Reverse transcription quantitative polymerase chain reaction (RT-qPCR), Western blot analysis and ELISA were conducted in order to determine the levels of miR-138, inflammatory factors, and p53 during ALF. The results showed an increase in the levels of miR-138 and inflammatory factors in ALF mice induced by the ConA as time progressed and reached the peak at 12 h following treatment with ConA, while it was on the contrary when it came to the level of p53. Dual-luciferase reporter gene assay revealed that p53 was a target gene of miR-138. Furthermore, the results from the in vitro transfection experiments in primary macrophages of ALF mouse showed that miR-138 down-regulated p53 and enhanced levels of inflammatory factors; thus, improving immune function in ALF mice. In conclusion, by negatively targeting p53, the decreased miR-138 improves immunologic function by regulating liver macrophage in mouse models of ALF.
Collapse
|
24
|
Cudalbu C, Taylor-Robinson SD. Brain Edema in Chronic Hepatic Encephalopathy. J Clin Exp Hepatol 2019; 9:362-382. [PMID: 31360029 PMCID: PMC6637228 DOI: 10.1016/j.jceh.2019.02.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 01/15/2019] [Accepted: 02/06/2019] [Indexed: 02/07/2023] Open
Abstract
Brain edema is a common feature associated with hepatic encephalopathy (HE). In patients with acute HE, brain edema has been shown to play a crucial role in the associated neurological deterioration. In chronic HE, advanced magnetic resonance imaging (MRI) techniques have demonstrated that low-grade brain edema appears also to be an important pathological feature. This review explores the different methods used to measure brain edema ex vivo and in vivo in animal models and in humans with chronic HE. In addition, an in-depth description of the main studies performed to date is provided. The role of brain edema in the neurological alterations linked to HE and whether HE and brain edema are the manifestations of the same pathophysiological mechanism or two different cerebral manifestations of brain dysfunction in liver disease are still under debate. In vivo MRI/magnetic resonance spectroscopy studies have allowed insight into the development of brain edema in chronic HE. However, additional in vivo longitudinal and multiparametric/multimodal studies are required (in humans and animal models) to elucidate the relationship between liver function, brain metabolic changes, cellular changes, cell swelling, and neurological manifestations in chronic HE.
Collapse
Key Words
- 1H MRS, proton magnetic resonance spectroscopy
- ADC, apparent diffusion coefficient
- ALF, acute liver failure
- AQP, aquaporins
- BBB, blood-brain barrier
- BDL, bile duct ligation
- CNS, central nervous system
- CSF, cerebrospinal fluid
- Cr, creatine
- DTI, diffusion tensor imaging
- DWI, diffusion-weighted imaging
- FLAIR, fluid-attenuated inversion recovery
- GM, gray matter
- Gln, glutamine
- Glx, sum of glutamine and glutamate
- HE, hepatic encephalopathy
- Ins, inositol
- LPS, lipopolysaccharide
- Lac, lactate
- MD, mean diffusivity
- MRI, magnetic resonance imaging
- MRS, magnetic resonance spectroscopy
- MT, magnetization transfer
- MTR, MT ratio
- NMR, nuclear magnetic resonance
- PCA, portocaval anastomosis
- TE, echo time
- WM, white matter
- brain edema
- chronic hepatic encephalopathy
- in vivo magnetic resonance imaging
- in vivo magnetic resonance spectroscopy
- liver cirrhosis
- mIns, myo-inositol
- tCho, total choline
- tCr, total creatine
Collapse
Affiliation(s)
- Cristina Cudalbu
- Centre d'Imagerie Biomedicale (CIBM), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Simon D. Taylor-Robinson
- Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, St Mary's Hospital Campus, Imperial College London, London, United Kingdom
| |
Collapse
|
25
|
Ochoa-Sanchez R, Rose CF. Pathogenesis of Hepatic Encephalopathy in Chronic Liver Disease. J Clin Exp Hepatol 2018; 8:262-271. [PMID: 30302043 PMCID: PMC6175755 DOI: 10.1016/j.jceh.2018.08.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 08/09/2018] [Indexed: 12/12/2022] Open
Abstract
Hepatic encephalopathy (HE) is a complex neuropsychiatric syndrome that occurs during chronic liver disease (CLD). While ammonia and other precipitating factors in liver disease including inflammation, bile acids, oxidative stress, and lactate play a role in the pathogenesis of HE, the exact mechanism that leads to HE is not fully understood. Notably, accumulating evidence points toward a synergic effect rather than independent actions among precipitating factors that contributes to the development and severity of HE in CLD. Hence, this review is aimed to briefly discuss the single and synergic interplay of pathological factors in the progression and severity of HE.
Collapse
Key Words
- AQP4, Aquaporin 4
- BAs, Bile Acids
- BBB, Blood-Brain Barrier
- BDL, Bile Duct Ligation
- CLD, Chronic Liver Disease
- CSF, Cerebrospinal Fluid
- GABA, Gamma-Aminobutyric Acid
- GAMSAs, GABAA Receptor Modulating Steroid Antagonists
- GFAP, Glial Fibrillary Acid Protein
- GLAST, Glial Glutamate-Aspartate Transporter
- GPR81, G-Protein-Coupled Receptor 81
- GS, Glutamine Synthetase
- HE, Hepatic Encephalopathy
- ICP, Intracranial Pressure
- ILs, Interleukins
- MRI, Magnetic Resonance Imaging
- NF-?B, Nuclear Factor Kappa B
- NMDA, N-Methyl-d-Aspartate Glutamate Receptor
- NO, Nitric Oxide
- PCA, Portacaval Anastomosis
- ROS, Reactive Oxygen Species
- TJ, Tight Junction
- TNF-a, Tumor Necrosis Alpha
- ammonia
- astrocyte swelling
- bile acids
- brain edema
- cGMP, Cyclic Guanosine Monophosphate
- cirrhosis
- hepatic encephalopathy
- inflammation
- lactate
- mGluR, Metabotropic Glutamate Receptor
- neurotransmission
- oxidative stress
Collapse
Affiliation(s)
| | - Christopher F. Rose
- Address for correspondence. Christopher F. Rose Professor, Dept. Medicine, Université de Montréal, CRCHUM, 900 Saint-Denis Street, Montréal, Québec, H2X 0A9, Canada.
| |
Collapse
|
26
|
Abstract
Acute liver failure (ALF) is a life-threatening condition of heterogeneous etiology. Outcomes are better with early recognition and prompt initiation of etiology-specific therapy, intensive care protocols, and liver transplantation (LT). Prognostic scoring systems include the King's College Criteria and Model for End-stage Liver Disease score. Cerebral edema and intracranial hypertension are reasons for high morbidity and mortality; hypertonic saline is suggested for patients with a high risk for developing intracranial hypertension, and when it does, mannitol is recommended as first-line therapy. Extracorporeal liver support system may serve as a bridge to LT and may increase LT-free survival in select cases.
Collapse
Affiliation(s)
- Chalermrat Bunchorntavakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Rajavithi Road, Ratchathewi, Bangkok 10400, Thailand; Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| |
Collapse
|
27
|
Rousseau G, Signolet I, Denis MC, Chao de la Barca JM, Mahieu R, Letournel F, Reynier P, Simard G. 5-Oxoprolinuria in hyperammonemic encephalopathy: Coincidence or worsening factor? Clin Biochem 2017; 50:1115-1117. [PMID: 28974423 DOI: 10.1016/j.clinbiochem.2017.09.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 09/29/2017] [Accepted: 09/29/2017] [Indexed: 01/09/2023]
Affiliation(s)
- Guillaume Rousseau
- Department of Biochemistry and Genetics, University Hospital, Angers, France
| | - Isabelle Signolet
- Department of Biochemistry and Genetics, University Hospital, Angers, France
| | | | | | - Rafaël Mahieu
- Department of Medical Intensive Care and Hyperbaric Medicine, University Hospital, Angers, France
| | - Franck Letournel
- Department of Neuropathology, University Hospital, Angers, France
| | - Pascal Reynier
- Department of Biochemistry and Genetics, University Hospital, Angers, France
| | - Gilles Simard
- Department of Biochemistry and Genetics, University Hospital, Angers, France.
| |
Collapse
|
28
|
Dhanda S, Sandhir R. Blood-Brain Barrier Permeability Is Exacerbated in Experimental Model of Hepatic Encephalopathy via MMP-9 Activation and Downregulation of Tight Junction Proteins. Mol Neurobiol 2017; 55:3642-3659. [PMID: 28523565 DOI: 10.1007/s12035-017-0521-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 04/06/2017] [Indexed: 12/27/2022]
Abstract
The present study was designed to investigate the mechanisms involved in blood-brain barrier (BBB) permeability in bile duct ligation (BDL) model of chronic hepatic encephalopathy (HE). Four weeks after BDL surgery, a significant increase was observed in serum bilirubin levels. Masson trichrome staining revealed severe hepatic fibrosis in the BDL rats. 99mTc-mebrofenin retention was increased in the liver of BDL rats suggesting impaired hepatobiliary transport. An increase in permeability to sodium fluorescein, Evans blue, and fluorescein isothiocyanate (FITC)-dextran along with increase in water and electrolyte content was observed in brain regions of BDL rats suggesting disrupted BBB. Increased brain water content can be attributed to increase in aquaporin-4 mRNA and protein expression in BDL rats. Matrix metalloproteinase-9 (MMP-9) mRNA and protein expression was increased in brain regions of BDL rats. Additionally, mRNA and protein expression of tissue inhibitor of matrix metalloproteinases (TIMPs) was also increased in different regions of brain. A significant decrease in mRNA expression and protein levels of tight junction proteins, viz., occludin, claudin-5, and zona occluden-1 (ZO-1) was observed in different brain regions of BDL rats. VCAM-1 mRNA and protein expression was also found to be significantly upregulated in different brain regions of BDL animals. The findings from the study suggest that increased BBB permeability in HE involves activation of MMP-9 and loss of tight junction proteins.
Collapse
Affiliation(s)
- Saurabh Dhanda
- Department of Biochemistry, Basic Medical Science Block-II, Sector-25, Panjab University, Chandigarh, 160014, India
| | - Rajat Sandhir
- Department of Biochemistry, Basic Medical Science Block-II, Sector-25, Panjab University, Chandigarh, 160014, India.
| |
Collapse
|
29
|
Piazza M, Munasinghe J, Murayi R, Edwards N, Montgomery B, Walbridge S, Merrill M, Chittiboina P. Simulating vasogenic brain edema using chronic VEGF infusion. J Neurosurg 2017; 127:905-916. [PMID: 28059647 DOI: 10.3171/2016.9.jns1627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To study peritumoral brain edema (PTBE), it is necessary to create a model that accurately simulates vasogenic brain edema (VBE) without introducing a complicated tumor environment. PTBE associated with brain tumors is predominantly a result of vascular endothelial growth factor (VEGF) secreted by brain tumors, and VEGF infusion alone can lead to histological blood-brain barrier (BBB) breakdown in the absence of tumor. VBE is intimately linked to BBB breakdown. The authors sought to establish a model for VBE with chronic infusion of VEGF that can be validated by serial in-vivo MRI and histological findings. METHODS Male Fischer rats (n = 182) underwent stereotactic striatal implantation of MRI-safe brain cannulas for chronic infusion of VEGF (2-20 µg/ml). Following a preinfusion phase (4-6 days), the rats were exposed to VEGF or control rat serum albumin (1.5 µl/hr) for as long as 144 hours. Serial MRI was performed during infusion on a high-field (9.4-T) machine at 12-24, 24-36, 48-72, and 120-144 hours. Rat brains were then collected and histological analysis was performed. RESULTS Control animals and animals infused with 2 µg/ml of VEGF experienced no neurological deficits, seizure activity, or abnormal behavior. Animals treated with VEGF demonstrated a significantly larger volume (42.90 ± 3.842 mm3) of T2 hyper-attenuation at 144 hours when compared with the volume (8.585 ± 1.664 mm3) in control animals (mean difference 34.31 ± 4.187 mm3, p < 0.0001, 95% CI 25.74-42.89 mm3). Postcontrast T1 enhancement in the juxtacanalicular region indicating BBB breakdown was observed in rats undergoing infusion with VEGF. At the later time periods (120-144 hrs) the volume of T1 enhancement (34.97 ± 8.99 mm3) was significantly less compared with the region of edema (p < 0.0001). Histologically, no evidence of necrosis or inflammation was observed with VEGF or control infusion. Immunohistochemical analysis demonstrated astrocyte activation, vascular remodeling, and increased claudin-5 expression in juxtacanalicular regions. Aquaporin-4 expression was increased in both control and VEGF animals in the juxtacanalicular regions. CONCLUSIONS The results of this study show that chronic brain infusion of VEGF creates a reliable model of VBE. This model lacks necrosis and inflammation that are characteristic of previous models of VBE. The model allows for a precise investigation into the mechanism of VBE formation. The authors also anticipate that this model will allow for investigation into the mechanism of glucocorticoid action in abrogating VBE, and to test novel therapeutic strategies targeting PTBE.
Collapse
Affiliation(s)
- Martin Piazza
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, and
| | | | - Roger Murayi
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, and
| | - Nancy Edwards
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, and
| | - Blake Montgomery
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, and
| | - Stuart Walbridge
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, and
| | - Marsha Merrill
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, and
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, and
| |
Collapse
|
30
|
Palenzuela L, Oria M, Romero-Giménez J, Garcia-Lezana T, Chavarria L, Cordoba J. Gene expression profiling of brain cortex microvessels may support brain vasodilation in acute liver failure rat models. Metab Brain Dis 2016; 31:1405-1417. [PMID: 27406245 DOI: 10.1007/s11011-016-9863-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 06/19/2016] [Indexed: 12/13/2022]
Abstract
Development of brain edema in acute liver failure can increase intracranial pressure, which is a severe complication of the disease. However, brain edema is neither entirely cytotoxic nor vasogenic and the specific action of the brain microvasculature is still unknown. We aimed to analyze gene expression of brain cortex microvessels in two rat models of acute liver failure. In order to identify global gene expression changes we performed a broad transcriptomic approach in isolated brain cortex microvessels from portacaval shunted rats after hepatic artery ligation (HAL), hepatectomy (HEP), or sham by array hybridization and confirmed changes in selected genes by RT-PCR. We found 157 and 270 up-regulated genes and 143 and 149 down-regulated genes in HAL and HEP rats respectively. Western blot and immunohistochemical assays were performed in cortex and ELISA assays to quantify prostaglandin E metabolites were performed in blood of the sagittal superior sinus. We Identified clusters of differentially expressed genes involving inflammatory response, transporters-channels, and homeostasis. Up-regulated genes at the transcriptional level were associated with vasodilation (prostaglandin-E synthetase, prostaglandin-E receptor, adrenomedullin, bradykinin receptor, adenosine transporter), oxidative stress (hemoxygenase, superoxide dismutase), energy metabolism (lactate transporter) and inflammation (haptoglobin). The only down-regulated tight junction protein was occludin but slightly. Prostaglandins levels were increased in cerebral blood with progression of liver failure. In conclusion, in acute liver failure, up-regulation of several genes at the level of microvessels might suggest an involvement of energy metabolism accompanied by cerebral vasodilation in the cerebral edema at early stages.
Collapse
Affiliation(s)
- Lluis Palenzuela
- Servei de Medicina Interna-Hepatologia, Valld'Hebron Institut de Recerca (VH-IR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marc Oria
- Servei de Medicina Interna-Hepatologia, Valld'Hebron Institut de Recerca (VH-IR), Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Center for Fetal, Cellular and Mollecular Therapy, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA.
| | - Jordi Romero-Giménez
- Servei de Medicina Interna-Hepatologia, Valld'Hebron Institut de Recerca (VH-IR), Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Teresa Garcia-Lezana
- Servei de Medicina Interna-Hepatologia, Valld'Hebron Institut de Recerca (VH-IR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laia Chavarria
- Servei de Medicina Interna-Hepatologia, Valld'Hebron Institut de Recerca (VH-IR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Cordoba
- Servei de Medicina Interna-Hepatologia, Valld'Hebron Institut de Recerca (VH-IR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| |
Collapse
|
31
|
Bémeur C, Cudalbu C, Dam G, Thrane AS, Cooper AJL, Rose CF. Brain edema: a valid endpoint for measuring hepatic encephalopathy? Metab Brain Dis 2016; 31:1249-1258. [PMID: 27272740 DOI: 10.1007/s11011-016-9843-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 05/19/2016] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy (HE) is a major complication of liver failure/disease which frequently develops during the progression of end-stage liver disease. This metabolic neuropsychiatric syndrome involves a spectrum of symptoms, including cognition impairment, attention deficits and motor dysfunction which eventually can progress to coma and death. Pathologically, HE is characterized by swelling of the astrocytes which consequently leads to brain edema, a common feature found in patients with acute liver failure (ALF) as well as in cirrhotic patients suffering from HE. The pathogenic factors involved in the onset of astrocyte swelling and brain edema in HE are unresolved. However, the role of astrocyte swelling/brain edema in the development of HE remains ambiguous and therefore measuring brain edema as an endpoint to evaluate HE is questioned. The following review will determine the effect of astrocyte swelling and brain edema on neurological function, discuss the various possible techniques to measure brain edema and lastly to propose a number of neurobehavioral tests to evaluate HE.
Collapse
Affiliation(s)
- Chantal Bémeur
- Département de nutrition, Université de Montréal, Montréal, Québec, Canada
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Québec, Canada
| | - Cristina Cudalbu
- Centre d'Imagerie Biomédicale (CIBM), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Gitte Dam
- Department of Medicine V (Hepatology and Gastroenterology), Aarhus, Denmark
| | - Alexander S Thrane
- Department of Ophthalmology, Haukeland University Hospital, 5012, Bergen, Norway
- Division of Glial Disease and Therapeutics, Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, 14642, USA
| | - Arthur J L Cooper
- Department of Biochemistry and Molecular Biology, New York Medical College, Valhalla, New York, 10595, USA
| | - Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Québec, Canada.
| |
Collapse
|
32
|
Zhang J, Zhang L, Sun X, Yang Y, Kong L, Lu C, Lv G, Wang T, Wang H, Fu F. Acetylcholinesterase Inhibitors for Alzheimer's Disease Treatment Ameliorate Acetaminophen-Induced Liver Injury in Mice via Central Cholinergic System Regulation. J Pharmacol Exp Ther 2016; 359:374-382. [PMID: 27535978 DOI: 10.1124/jpet.116.233841] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 08/12/2016] [Indexed: 01/30/2023] Open
Abstract
Acetaminophen (APAP) is widely used as an analgesic and antipyretic agent, but it may induce acute liver injury at high doses. Alzheimer's disease patients, while treated with acetylcholinesterase inhibitor (AChEI), may take APAP when they suffer from cold or pain. It is generally recognized that inhibiting acetylcholinesterase activity may also result in liver injury. To clarify whether AChEI could deteriorate or attenuate APAP hepatotoxicity, the effects of AChEI on APAP hepatotoxicity were investigated. Male C57BL/6J mice were administrated with the muscarinic acetylcholine receptor (mAChR) blocker atropine (Atr), or classic α7 nicotine acetylcholine receptor (α7nAChR) antagonist methyllycaconitine (MLA) 1 hour before administration of AChEIs-donepezil (4 mg/kg), rivastigmine (2 mg/kg), huperzine A (0.2 mg/kg), or neostigmine (0.15 mg/kg)-followed by APAP (300 mg/kg). Eight hours later, the mice were euthanized for histopathologic examination and biochemical assay. The results demonstrated that the tested AChEIs, excluding neostigmine, could attenuate APAP-induced liver injury, accompanied by reduced reactive oxygen species formation, adenosine triphosphate and cytochrome C loss, c-Jun N-terminal kinase 2 (JNK2) phosphorylation, and cytokines. However, Atr or MLA significantly weakened the protective effect of AChEI by affecting mitochondrial function or JNK2 phosphorylation and inflammation response. These results suggest that central mAChR and α7nAChR, which are activated by accumulated acetylcholine resulting from AChEI, were responsible for the protective effect of AChEIs on APAP-induced liver injury. This indicates that Alzheimer's patients treated with AChEI could take APAP, as AChEI is unlikely to deteriorate the hepatotoxicity of APAP.
Collapse
Affiliation(s)
- Jianqiao Zhang
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Leiming Zhang
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Xue Sun
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Yanting Yang
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Liang Kong
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Chengwen Lu
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Guangyao Lv
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Tian Wang
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Hongbo Wang
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Fenghua Fu
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| |
Collapse
|
33
|
Multifactorial Effects on Different Types of Brain Cells Contribute to Ammonia Toxicity. Neurochem Res 2016; 42:721-736. [PMID: 27286679 DOI: 10.1007/s11064-016-1966-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 05/20/2016] [Accepted: 05/24/2016] [Indexed: 12/12/2022]
Abstract
Effects of ammonia on astrocytes play a major role in hepatic encephalopathy, acute liver failure and other diseases caused by increased arterial ammonia concentrations (e.g., inborn errors of metabolism, drug or mushroom poisoning). There is a direct correlation between arterial ammonia concentration, brain ammonia level and disease severity. However, the pathophysiology of hyperammonemic diseases is disputed. One long recognized factor is that increased brain ammonia triggers its own detoxification by glutamine formation from glutamate. This is an astrocytic process due to the selective expression of the glutamine synthetase in astrocytes. A possible deleterious effect of the resulting increase in glutamine concentration has repeatedly been discussed and is supported by improvement of some pathologic effects by GS inhibition. However, this procedure also inhibits a large part of astrocytic energy metabolism and may prevent astrocytes from responding to pathogenic factors. A decrease of the already low glutamate concentration in astrocytes due to increased synthesis of glutamine inhibits the malate-aspartate shuttle and energy metabolism. A more recently described pathogenic factor is the resemblance between NH4+ and K+ in their effects on the Na+,K+-ATPase and the Na+,K+, 2 Cl- and water transporter NKCC1. Stimulation of the Na+,K+-ATPase driven NKCC1 in both astrocytes and endothelial cells is essential for the development of brain edema. Na+,K+-ATPase stimulation also activates production of endogenous ouabains. This leads to oxidative and nitrosative damage and sensitizes NKCC1. Administration of ouabain antagonists may accordingly have therapeutic potential in hyperammonemic diseases.
Collapse
|
34
|
Lester C, Cooper J, Peters RM, Webster CRL. Retrospective evaluation of acute liver failure in dogs (1995-2012): 49 cases. J Vet Emerg Crit Care (San Antonio) 2016; 26:559-67. [DOI: 10.1111/vec.12482] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 05/18/2015] [Accepted: 05/31/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Carrie Lester
- Departments of Clinical; Cummings School of Veterinary Medicine at Tufts University; Grafton MA 01536
| | - Johanna Cooper
- Departments of Clinical; Cummings School of Veterinary Medicine at Tufts University; Grafton MA 01536
| | - Rachel M. Peters
- Biomedical Science; Cummings School of Veterinary Medicine at Tufts University; Grafton MA 01536
| | - Cynthia R. L. Webster
- Departments of Clinical; Cummings School of Veterinary Medicine at Tufts University; Grafton MA 01536
| |
Collapse
|
35
|
Reversal of Low-Grade Cerebral Edema After Lactulose/Rifaximin Therapy in Patients with Cirrhosis and Minimal Hepatic Encephalopathy. Clin Transl Gastroenterol 2015; 6:e111. [PMID: 26378384 PMCID: PMC4816249 DOI: 10.1038/ctg.2015.38] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 07/14/2015] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES: Decreased magnetization transfer ratio (MTR) in the brain characterizes cerebral edema (CE) in patients with liver cirrhosis, but the role of treatment on its reversibility has not been studied in patients who have minimal hepatic encephalopathy (MHE). This study was carried to evaluate the reversibility of CE with lactulose and rifaximin treatment in patients with MHE and role of ammonia, pro-inflammatory interleukins (IL-1, IL-6) and tumor necrosis factor (TNF)-α in its pathogenesis. METHODS: Twenty-three patients with cirrhosis (14 with MHE, 9 without MHE (NMHE)) and 6 healthy controls underwent ammonia, IL-1, IL-6, TNF-α estimation, and MTR in frontal white matter (FWM), parietal white matter (PWM), internal capsule (IC), and basal ganglia (BG). RESULTS: Ammonia was significantly higher in the cirrhosis group compared with controls and in MHE compared with the NMHE group. Ammonia correlated positively with IL-1 and IL-6. MTRs in FWM, PWM, IC, and BG were significantly lower in the MHE group compared with controls and in PWM, IC, and BG compared with the NMHE group. MHE patients showed significant MTR increase in FWM, PWM, and IC with treatment. IL-6 and ammonia had significant negative and significant positive psychometric hepatic encephalopathy score (PHES) correlation with MTR in various regions. CONCLUSIONS: This study, for the first time, demonstrated the reversibility of low-grade CE with treatment in patients with MHE. Negative correlation between ammonia, IL-6 levels, and MTR and positive correlation between PHES and MTR in MHE patients suggests the role of inflammation and ammonia in the genesis of low-grade CE.
Collapse
|
36
|
Wu X, Lv XF, Zhang YL, Wu HW, Cai PQ, Qiu YW, Zhang XL, Jiang GH. Cortical signature of patients with HBV-related cirrhosis without overt hepatic encephalopathy: a morphometric analysis. Front Neuroanat 2015; 9:82. [PMID: 26106307 PMCID: PMC4458689 DOI: 10.3389/fnana.2015.00082] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 05/26/2015] [Indexed: 12/21/2022] Open
Abstract
Previous studies have shown that patients with hepatitis B virus-related cirrhosis (HBV-RC) without overt hepatic encephalopathy (OHE) are associated with a varying degree of cognitive dysfunction. Several resting-state functional magnetic resonance imaging (fMRI) studies have been conducted to explore the neural correlates of such cognitive deficits, whereas little effort has been made to investigate the cortical integrity in cirrhotic patients without OHE. Here, using cortical thickness, surface area and local gyrification index (lGI), this study performed a comprehensive analysis on the cortical morphometry of patients with HBV-RC without OHE (HBV-RC-NOHE) vs. matched healthy controls. Compared with healthy controls, we found significantly increased cortical thickness in the bilateral lingual and parahippocampal gyrus, right posterior cingulate cortex, precuneus, peri-calcarine sulcus and fusiform gyrus in patient with HBV-RC-NOHE, which may closely relate to be the low-grade brain edema. Cortical gyrification analysis showed significantly increased lGI in the left superior and inferior parietal cortex as well as lateral occipital cortex, which was speculated to be associated with disruptions in white matter connectivity and sub-optimal intra-cortical organization. In addition, the mean cortical thickness/lGI of the regions with structural abnormalities was shown to be negatively correlated with psychometric hepatic encephalopathy score (PHES) of the patients with HBV-RC-NOHE. These morphological changes may serve as potential markers for the preclinical diagnosis and progression of HBV-RC-NOHE.
Collapse
Affiliation(s)
- Xiu Wu
- Key Laboratory for NeuroInformation of Ministry of Education, School of Life Science and Technology, University of Electronic Science and Technology of China Chengdu, China ; Department of Medical Imaging, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine Guangzhou, China
| | - Xiao-Fei Lv
- Department of Medical Imaging, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine Guangzhou, China
| | - Yu-Ling Zhang
- Key Laboratory for NeuroInformation of Ministry of Education, School of Life Science and Technology, University of Electronic Science and Technology of China Chengdu, China
| | - Hua-Wang Wu
- Key Laboratory for NeuroInformation of Ministry of Education, School of Life Science and Technology, University of Electronic Science and Technology of China Chengdu, China ; Department of Medical imaging, Guangzhou Brain Hospital, The Affiliated Hospital of Guangzhou Medical University Guangzhou, China
| | - Pei-Qiang Cai
- Department of Medical Imaging, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine Guangzhou, China
| | - Ying-Wei Qiu
- Department of Medical Imaging, Guangdong No. 2 Provincial People's Hospital Guangzhou, China
| | - Xue-Lin Zhang
- Medical Imaging Centre, Nanfang Hospital, Southern Medial University Guangzhou, China
| | - Gui-Hua Jiang
- Department of Medical Imaging, Guangdong No. 2 Provincial People's Hospital Guangzhou, China
| |
Collapse
|
37
|
Pathogenesis of brain edema and investigation into anti-edema drugs. Int J Mol Sci 2015; 16:9949-75. [PMID: 25941935 PMCID: PMC4463627 DOI: 10.3390/ijms16059949] [Citation(s) in RCA: 194] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 04/15/2015] [Accepted: 04/27/2015] [Indexed: 12/18/2022] Open
Abstract
Brain edema is a potentially fatal pathological state that occurs after brain injuries such as stroke and head trauma. In the edematous brain, excess accumulation of extracellular fluid results in elevation of intracranial pressure, leading to impaired nerve function. Despite the seriousness of brain edema, only symptomatic treatments to remove edema fluid are currently available. Thus, the development of novel anti-edema drugs is required. The pathogenesis of brain edema is classified as vasogenic or cytotoxic edema. Vasogenic edema is defined as extracellular accumulation of fluid resulting from disruption of the blood-brain barrier (BBB) and extravasations of serum proteins, while cytotoxic edema is characterized by cell swelling caused by intracellular accumulation of fluid. Various experimental animal models are often used to investigate mechanisms underlying brain edema. Many soluble factors and functional molecules have been confirmed to induce BBB disruption or cell swelling and drugs targeted to these factors are expected to have anti-edema effects. In this review, we discuss the mechanisms and involvement of factors that induce brain edema formation, and the possibility of anti-edema drugs targeting them.
Collapse
|
38
|
Bosoi CR, Rose CF. Elevated cerebral lactate: Implications in the pathogenesis of hepatic encephalopathy. Metab Brain Dis 2014; 29:919-25. [PMID: 24916505 DOI: 10.1007/s11011-014-9573-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 05/28/2014] [Indexed: 01/31/2023]
Abstract
Hepatic encephalopathy (HE), a complex neuropsychiatric syndrome, is a frequent complication of liver failure/disease. Increased concentrations of lactate are commonly observed in HE patients, in the systemic circulation, but also in the brain. Traditionally, increased cerebral lactate is considered a marker of energy failure/impairment however alterations in lactate homeostasis may also lead to a rise in brain lactate and result in neuronal dysfunction. The latter may involve the development of brain edema. This review will target the significance of increased cerebral lactate in the pathogenesis of HE.
Collapse
Affiliation(s)
- Cristina R Bosoi
- Hepato-Neuro Laboratory, Centre Hospitalier de l'Université de Montréal (CRCHUM), 900, rue Saint-Denis - Tour Viger R08.422, Québec, H2X 0A9, Canada,
| | | |
Collapse
|
39
|
Abstract
INTRODUCTION Hepatic encephalopathy (HE) is a serious neuropsychiatric complication that is seen in patients with liver failure. The pathogenesis of HE is not entirely understood, but several hypotheses have emerged and persisted during the years. Despite the many prevalent hypotheses, most of the existing evidence point to ammonia as the main culprit behind primary and secondary symptoms making it the center of potential therapeutic options for the treatment of HE. Most treatments of hyperammonemia target the organs and metabolic processes involved in ammonia detoxification. AREAS COVERED This article provides a review of the current targets of therapy as well as the drugs used for hyperammonemia treatment. EXPERT OPINION Lactulose and rifaximin have a proven role as measures to use for secondary prophylaxis and are the mainstay of current therapy. The use of molecular adsorbent recirculating system in patients with severe HE has been proven to be efficacious, but through mechanisms that appear to be independent of ammonia. The main challenge that faces the further development of treatments for HE is finding appropriate end points, and the next step would be to provide evidence of the effectiveness of established treatments and define the role of emerging new treatments.
Collapse
Affiliation(s)
- Anna Hadjihambi
- UCL Institute for Liver and Digestive Health, UCL Medical School , Upper Third Floor, Royal Free Campus, Pond Street, NW3 2PF, London , UK +44 207 4332 794 ;
| | | | | |
Collapse
|
40
|
Bosoi CR, Tremblay M, Rose CF. Induction of systemic oxidative stress leads to brain oedema in portacaval shunted rats. Liver Int 2014; 34:1322-9. [PMID: 25354203 DOI: 10.1111/liv.12414] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 11/16/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The pathogenesis of hepatic encephalopathy (HE) is multifactorial and often associated with the development of brain oedema. In addition to ammonia playing a central role, systemic oxidative stress is believed to aggravate the neuropsychological effects of ammonia in patients with chronic liver disease (CLD). The aim of this study was to (i) induce systemic oxidative stress in hyperammonaemic portacaval anastomosed (PCA) rats by inhibiting the antioxidant glutathione using Dimethyl maleate (DEM) and (ii) investigate whether a synergistic relationship between ammonia and oxidative stress contributes to the pathogenesis of brain oedema in CLD. METHODS Four-week PCA and sham-operated rats received DEM (0.4-4 mg/kg/day) for the last 10 days before sacrifice when oxidative stress markers [reactive oxygen species (ROS) and malondialdehyde (MDA)] were assessed in blood and frontal cortex. Brain water content was measured using a specific gravimetric technique. RESULTS Dimethyl maleate induced an increase in ROS and MDA in the blood, but not in the brain, of the PCA rats, compared with non-treated PCA rats. This was accompanied with an increase in brain water content (PCA+DEM: 78.45 ± 0.13% vs. PCA: 77.38 ± 0.11%, P < 0.001). Higher doses of DEM induced systemic oxidative stress in sham-operated controls, but brain oedema did not develop. CONCLUSIONS Dimethyl maleate provoked systemic, not central, oxidative stress in PCA rats, resulting in the development of brain oedema. Independently, hyperammonaemia and systemic oxidative stress do not precipitate brain oedema; therefore, our findings sustain that a synergistic effect between hyperammonaemia and systemic oxidative stress is responsible for the development of brain oedema in HE.
Collapse
Affiliation(s)
- Cristina R Bosoi
- Neuroscience Research Unit, Hôpital Saint-Luc (CRCHUM), Université de Montréal, Québec, Canada
| | | | | |
Collapse
|
41
|
Hertz L, Peng L, Song D. Ammonia, like K(+), stimulates the Na(+), K(+), 2 Cl(-) cotransporter NKCC1 and the Na(+),K(+)-ATPase and interacts with endogenous ouabain in astrocytes. Neurochem Res 2014; 40:241-57. [PMID: 24929663 DOI: 10.1007/s11064-014-1352-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/31/2014] [Accepted: 06/03/2014] [Indexed: 12/12/2022]
Abstract
Brain edema during hepatic encephalopathy or acute liver failure as well as following brain ischemia has a multifactorial etiology, but it is a dangerous and occasionally life-threatening complication because the brain is enclosed in the rigid skull. During ischemia the extracellular K(+) concentration increases to very high levels, which when energy becomes available during reperfusion stimulate NKCC1, a cotransporter driven by the transmembrane ion gradients established by the Na(+),K(+)-ATPase and accumulating Na(+), K(+) and 2 Cl(-) together with water. This induces pronounced astrocytic swelling under pathologic conditions, but NKCC1 is probably also activated, although to a lesser extent, during normal brain function. Redistribution of ions and water between extra- and intracellular phases does not create brain edema, which in addition requires uptake across the blood-brain barrier. During hepatic encephalopathy and acute liver failure a crucial factor is the close resemblance between K(+) and NH4(+) in their effects not only on NKCC1 and Na(+),K(+)-ATPase but also on Na(+),K(+)-ATPase-induced signaling by endogenous ouabains. These in turn activate production of ROS and nitrosactive agents which slowly sensitize NKCC1, explaining why cell swelling and brain edema generally are delayed under hyperammonemic conditions, although very high ammonia concentrations can cause immediate NKCC1 activation.
Collapse
Affiliation(s)
- Leif Hertz
- Laboratory of Brain Metabolic Diseases, Institute of Metabolic Disease Research and Drug Development, China Medical University, No. 92 Beier Road, Heping District, Shenyang, People's Republic of China
| | | | | |
Collapse
|
42
|
Robinson CA, Adiele RC, Tham M, Lucchinetti CF, Popescu BFG. Early and widespread injury of astrocytes in the absence of demyelination in acute haemorrhagic leukoencephalitis. Acta Neuropathol Commun 2014; 2:52. [PMID: 24887055 PMCID: PMC4035095 DOI: 10.1186/2051-5960-2-52] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 05/02/2014] [Indexed: 01/22/2023] Open
Abstract
Acute hemorrhagic leukoencephalitis (AHL) is a fulminant demyelinating disease of unknown etiology. Most cases are fatal within one week from onset. AHL pathology varies with the acuteness of disease. Hemorrhages, vessel fibrinoid necrosis, perivascular fibrin exudation, edema and neutrophilic inflammation are early features, while perivascular demyelination, microglial foci and myelin-laden macrophages appear later. Reactive astrocytosis is not present in early hemorrhagic non-demyelinated lesions, but is seen in older lesions. This case report presents the pathology of an AHL case with fulminant course and fatal outcome within 48 hours from presentation. Severe hemorrhages, edema and neutrophilic inflammation in the absence of circumscribed perivascular demyelination affected the temporal neocortex and white matter, hippocampus, cerebellar cortex and white matter, optic chiasm, mammillary bodies, brainstem, cranial nerve roots and leptomeninges. Perivascular end-feet and parenchymal processes of astrocytes exhibited impressive swelling in haemorrhagic but non-demyelinated white matter regions. Astrocytes were dystrophic and displayed degenerating processes. Astrocytic swellings and remnants were immunoreactive for aquaporin-4, aquaporin-1 and glial fibrillary acidic protein. These morphological changes of astrocytes consistent with injury were also observed in haemorrhagic and normal appearing cortex. Our findings reinforce that perivascular demyelination is not present early in AHL. This is the first study that highlights the early and widespread astrocytic injury in the absence of demyelination in AHL, suggesting that, similarly to neuromyelitis optica and central pontine myelinolysis, demyelination in AHL is secondary to astrocyte injury.
Collapse
|
43
|
Spence SC, Strobel NHP, Beckmann NM, Kumaravel M. Traumatic portacaval shunt: a case report and literature review. J Radiol Case Rep 2013; 7:1-6. [PMID: 24421924 DOI: 10.3941/jrcr.v7i11.1817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Computed tomography (CT) evaluation of the acute polytrauma patient has become well established as a mainstay of ER triage in hemodynamically stable patients. The radiologist plays a pivotal role in directing management by identifying and appropriately categorizing the severity of a patient's injuries. High-grade liver injuries have undergone an increasing trend of nonoperative management over the last several decades, with concurrent decrease in mortality. However, we present a case of a patient with a grade V liver laceration, in whom a rare portacaval shunt was also present. In the setting of this rare injury, the radiologist will likely be the first person to recognize and categorize a severe complication, which may indicate the need for a fundamental change in patient management.
Collapse
Affiliation(s)
- Susanna C Spence
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston Houston, USA
| | - Nathaniel H P Strobel
- Department of Pediatrics, Division of Critical Care, University of Texas Health Science Center at Houston Houston, USA
| | - Nicholas M Beckmann
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston Houston, USA
| | - Manickam Kumaravel
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston Houston, USA
| |
Collapse
|